Transcript JCAHO Core Measure Project

Acute Myocardial Infarction
(AMI)
JCAHO Core Measure Project
Team Membership
Clinical Departments: Cardiology, Cardiovascular Surgery,
Emergency Medical Services
Hospital Departments: 3 NEWS, Cardiac Cath Lab, Cardiac Rehab,
Emergency Department, Medical Records, Quality and Resource
Management, Center for Clinical Effectiveness
Opportunity for Improvement
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LUHS began reporting AMI core measures to JCAHO
beginning in July, 2002 and to the Center for Medicaid and
Medicare Services (CMS) in July, 2003.
AMI core measures are based on AHA/ACC Coronary Heart
Disease guidelines
Full FY 05 Medicare reimbursement requires reporting of
AMI and other quality measures to CMS
Data will be reported on the CMS website and in the media.
LUHS performs well on most measures, but our goal is to
achieve excellent performance on all measures
Most Likely Causes for the
Improvement Opportunity
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AMI patients are complex and the care is
often emergent
Care involves many different units and
teams during a patient’s stay
Clinicians lack tools (forms, reminders,
order sets) needed to follow guidelines
Hospitals have previously not addressed
prevention like smoking cessation
JCAHO AMI Core Measures
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Aspirin within 24 hours
before or after arrival
Aspirin prescribed at
discharge
Beta blocker within 24
hours after arrival
Beta blocker
prescribed at discharge
Time to PTCA in
patients with an ST
elevation AMI
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ACE-Inhibitor
prescribed at discharge
in patients with left
ventricular systolic
dysfunction (LVSD)
Adult smoking
cessation advice to all
patients who have
smoked within the last
12 months
Inpatient mortality
Solutions Implemented
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2002 and 2003
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Formed AMI Core Measure committee
Implemented AMI Discharge Progress Note Addendum
Educated attendings, residents and nursing staff
Developed chart stickers to designate AMI patients
Established process with Cath Lab to obtain precise
wire cross times for PTCA
Developed draft of pre-printed unstable angina/non-ST
elevation MI physician order set
Implemented hospital-wide smoking cessation program
Solutions Implemented (con’t)
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2004
Implemented pre-printed unstable angina/nonST elevation MI orders
 Revised Nursing Database to accurately collect
smoking history
 Revised Patient Education Record to include
documentation of smoking cessation advice
 Formed a sub-committee and began data
collection to study the admission process for
patients presenting with an ST elevation AMI
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AMI Core Measure - Aspirin at Arrival
Rate of Eligible AMI Patients Receiving Aspirin within 24 hours of Arrival
UCL
100%
LUHS Mean = 97%
National Mean = 93% Q12003
90%
LCL
80%
70%
60%
50%
Rate of Eligible AMI Patients Receiving Aspirin Prescription at Discharge
AMI Core Measure - Aspirin at Discharge
UCL
100%
Mean
National Mean = 89% Q12003
90%
LCL
80%
70%
60%
50%
LUHS Mean = 97%
Percent of AMI Smokers Receiving Smoking Cessation Counseling
Acute Myocardial Infarction - Smoking Cessation Advice
UCL
100%
100%
80%
LUHS Mean = 69%
National Mean = 66% Q12003
60%
40%
20%
LCL
0%
Acute Myocardial Infarction Inpatient Mortality
25%
20%
Percent Mortality of AMI Patients
UCL
15%
National Mean = 13% Q12003
LUHS Expected Mean
10%
LUHS Mean = 7%
5%
0%
LCL
AMI Core Measure - Median Time to PTCA
Median Time (minutes) to PTCA of Eligible AMI Patients
360
300
UCL
240
National Mean = 192 minutes Q12003
180
LUHS Mean = 137 minutes
120
60
LCL
0
Next Steps
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Continue with establishing a comprehensive
system-wide smoking cessation program
Present findings to physician and nurse groups to
promote their participation and obtain their input
and suggestions
Develop and implement AMI care pathway,
discharge protocol form and patient education
materials
Develop and implement ST elevation MI preprinted order set