action registry-gwtg workshop #20

NCDR 13 Annual Conference

ACTION Registry-GWTG

Workshop #20

Disclosures• Dr. Fonarow, MD, FACC, FAHA

– Boston Scientific, Takeda, Amgen,

Johnson&Johnson, Medtronic, Gambro,

NIH/NIAID, Novartis, NHLBI

• Mary Anne Elma, MPH

No Disclosures

• Kim Hustler RN

No Disclosures

• Susan Rogers RN, MSN, NE-BC

No Disclosures

Friday, March 8, 2013

NCDR.13 Annual Conference

San Francisco, CA

Presenter Disclosure

MaryAnne Elma, MPH

Director, Quality Innovation and Implementation

American College of Cardiology

In the next 15 minutes you will:

1. Get an overview on ACC QI initiatives

2. Learn about the evidence supporting SAMI -

what makes it unique and applicable to all QI

3. Learn about SAMI’s goal, timeline, features

4. Know what to do next – when, how…

From Priorities to ProgramsHigh priority improvement opportunities

become national quality initiatives because…

There is a recognized gap/variation

in care

= Proven clinical need

= Proven patient need (patient-centered

care)

There are evidence-based

strategies that are proven to

improve the problem

= Proven interventions

The most affected target

audiences want to fix the problem

= Individual internal motivation

The financial and regulatory

environment support or promote

improvement

= Environmental motivation and support

= Operational sustainability (funding)

GAP 1999-2001

• AMI in MI (30+ hospitals)

• HF in OR (8 hospitals)

• SA in AL (planning)

• www.acc.org

• Tools

D2B 2006-now

•AMI PCI patients

•1100 hospitals

•D2balliance.org

•Partners

•Active listserv•Toolkit with 6 strategies

•Webinar series

H2H 2009-now

• HF and MI 30-d readmission

• 1700 hospitals

• www.h2hquality.org

• Partners

• Active listserv

• 3 challenges including ~45 tools +

ACC National Quality Initiatives Timeline

Lessons Learned from GAP, D2B, H2H

� Leadership comes from local physician AND non-

physician ACC members AND local partners

� Adoption of a NQI locally requires both proof that

it works AND resources to support it

� Start with a 1-2 local success stories, share these,

and adapt the “packaged options” along the way

� Clearly define the role and support of ACC

national – relationship building, consulting,

resources

Features of a successful national quality initiative

1. An evidence-based goal

2. Proven environmental need and demand

3. Evidence-based interventions (strategies/tools)

4. Learning events

5. Local implementation outreach

6. Pre/post measurement capabilities (data)

7. Pre/post evaluation activities (surveys)

8. Participant recognition (including MOC IV)

9. Publishable results (lives saved, dollars saved)

10. Patient-centered

ACC National Quality Initiatives Model

Website

Toolkits

Consultation, local support for QI

E-Community

Webinars

H2H SAMID2B

The Evidence BaseDr. Leslie Curry

To identify hospital-level factors that

may be associated with better performance

in AMI care as measured by RSMR

Survival after Acute Myocardial Infarction Study)

Identify

‘positive deviants’

Study them using

qualitative methods

Generate and test

hypotheses

quantitatively

Partner with

stakeholders for

dissemination

Hospitals in top/bottom 5%

performance in RSMR (n=11)

In depth interviews with key

staff in AMI care (n=158)

Cross sectional survey

(n=537; 91% response rate)

National quality initiative

using both qualitative and

quantitative data

Feature Examples

Hospital practices and

protocols to improve AMI

care

Clinical guidelines and order sets; rapid response

teams; quality improvement committees

Organizational values and goals Shared values to provide exceptional, high quality

care; alignment of quality and financial goals

Senior management

involvement

Provision of adequate resources; holding staff

accountable for quality; use of quality data in

management decisions

Broad staff presence and

expertise in AMI care

Sustained physician champions; empowered

nurses; involved pharmacists; high standards

Communication and

coordination among groups

Diverse skills and roles; recognizing

interdependencies; smooth information flow

among groups

Problem solving and learning Adverse events opportunities to learn; innovation

and creativity in trial and error; learn from outside

Differentiating features of top performers

Strategies associated with lower AMI mortality

Strategy% Points Decrease

in RSMR

Cardiologists always on site 0.54

Foster organizational culture where clinicians are

encouraged to solve problems creatively

0.84

Not cross training nurses from ICU for the cardiac

catheterization laboratory

0.44

Having physician and nurse champions

(rather than nurse champions alone)

0.88

Holding monthly meeting with EMS providers to review

AMI cases

0.70

Pharmacists rounding on all patients with AMI

(secondary analysis excluding cardiologist 24/7)

0.41

Bradley EH, Curry LA, Spatz ES, Herrin J, Cherlin EJ, Curtis JP, et al. Hospital strategies for reducing risk-standardized mortality rates in acute myocardial infarction. Ann Intern Med. 2012;156:618-26.

Percent of hospitals using each strategy

Strategy% Hospitals using

each strategy

Cardiologists always on site 14

Foster organizational culture where clinicians are

encouraged to solve problems creatively

40

Not cross training nurses from ICU for the cardiac


82

Having physician and nurse champions

(rather than nurse champions alone)

43

Holding monthly meeting with EMS providers to review

AMI cases

15

Pharmacists rounding on all patients with AMI

(secondary analysis excluding cardiologist 24/7)

35

Bradley EH, Curry LA, Spatz ES, Herrin J, Cherlin EJ, Curtis JP, et al. Hospital strategies for reducing risk-standardized mortality rates in acute myocardial infarction. Ann Intern Med. 2012;156:618-26.

The opportunity:

Fewer than 10% of hospitals

are using at least 4 of the 5

strategies

SAMI Goal

To reduce risk standardized 30-day

mortality rates for patients

hospitalized with acute myocardial

infarction by 20% by December 2016.

SAMI – Unique Features

1. Blended education and quality

interventions addressing process and

culture

2. Hospital-targeted and team-based change,

inclusive of different roles and functions

3. Leadership team of varied expertise and

experience

4. Diversity of collaborating organizations

Actions and Behaviors of Top Performers

1. Having both a physician and nurse champions (rather

than nurse champion alone)

2. Fostering an organizational culture where clinicians

are encouraged to solve problems creatively

3. Holding monthly meetings with Emergency Medical

Services providers to review AMI cases

4. Cardiologists always on site 24/7

5. Not cross training nurses from ICU for the cardiac


6. Pharmacists rounding on all patients with AMI

“On the acute MI side, XXX is a huge logistic champion,

process champion. She has a background that earned her

place…she has done quality outcomes and a lot of our

process improvement. So it was a very easy transition to

her being the acute MI champion. Her background is such

that she has a great relationship with the emergency

room, with the nursing community upstairs in the CSU,

and with the interventional cardiologists, so that’s been

terrific.” -- Interventional Cardiologist

Have BOTH physician and nurse champions

"We took a couple of the cath lab nurses and techs

and said we've got a problem here…So you look at

where the root problem is and you look at the people

who do that for a living, the techs and the nurses. We

didn’t tell them what to do. We said this is the

problem, how can we do it better and they figured out

how to do it better.” -- Interventional cardiologist/cath lab director

Support creative problem solving

“First it was just the cath lab folks…and then we started

including the ED folks and then we expanded it even

more and now we have the paramedic team come in

and sit in with us. It’s very interesting to see how much

more they feel involved now and when the door-to-

balloon time feedback reports go out you get this blitz

of feedback from them and, and they want to know

how the patient did.” -- Cardiology Program Quality Manager

Active collaboration between

ED clinicians and EMS

“…when we float staff amongst the different units, there are

certain competencies that everyone has to have… we are

looking at competence of that individual when we float

them. We’re not going to give them an assignment that

doesn’t match their competence.” -- Nurse Manager

Develop nurses with expertise in cath lab

…the nurses on the cardiac units…maintain very high

levels of competence and professionalism…part of [our]

success is the caliber and strength of the nursing, either

as individuals or as a department and a team that

works together. -- Nurse Manager

“Pharmacy will come up onto the unit…for questions about

interactions with medications…like these are the meds the

patient is on at home but he’s taking these additional over-the-

counter herbal medications…One of our pharmacists, that’s her

doctorate work…So it’s really helpful, you have access to

pharmacy right away.” -- Nurse Clinician

“I am the Director of Pharmacotherapy…we have three clinical

pharmacy clinicians who round with a medical team…So we

have, including myself, four full-time clinical pharmacy

specialists on the floor.” -- Pharmacist

Have pharmacy staff round on all AMI patients

Next Steps

1. Complete the SAMI pre-survey -

http://learn.med.yale.edu/sami//login.asp

2. Go to CardioSource and submit the online

interest form to get more information

3. Know your 30-day RSMR for AMI

Where to get it, why, who should know

about it…

Thank You

NCDR. 13 Case Scenario Presentation


Kim Hustler, RN

Clinical Quality Consultant

Case Scenarios

• Unique sessions for beginners to experts

• Real case scenarios

• Coding based on the current data definitions

with information related to version 2.3

• ARS participation

Objectives for the ACTION Registry-

GWTG

Case Scenario Presentation

Describe specific data collection instructions for the


Demonstrate knowledge of data abstraction

through participation with ARS

Discuss the data points that will be changing for

version 2.3

Section E- Medications

UFH administered- no PCI

Documentation:

• Presents with N/V, left arm pain

• 12 lead ECG- STEMI

• To cath lab for primary PCI- 5000 units UFH in cath

lab

• Coronary arteries- clean

• No PCI is performed


The data collection form would be completed as:

• PCI Seq. #7100 as “no”

• No other fields (until #7200) are able to be answered- all are

children to PCI #7100


The data collection form would be completed as:

• Reperfusion Candidate #8000 “yes”

• Primary PCI #8015 “no” Reason no PCI #8030- Anatomy not

suitable to primary PCI

• Thrombolytic “no”, reason #8035- Expected DTB <90 min- if

was expected

ARS Question #1

Would this patient be included in the UFH Excessive

dosing report as we are currently entering it?

1. No

2. Yes

UFH administered- no PCIDocumentation:



• To cath lab for primary PCI- 5000 units UFH in cath

lab



Would this patient be included in the UFH Excessive

dosing report as we are currently entering it?

1. No

2. Yes


New medication Xarelto

Documentation:

• History of Atrial fibrillation

• Presents with symptoms of ACS

• Positive Troponins- NSTEMI

• Physician discharges patient on

Xarelto/Rivaroxaban

ARS Question #2

How would you enter the Xarelto in the data

collection tool?

1. Do not include

2. Answer Warfarin at discharge Seq. #6220 as

“contraindicated”

3. Answer Warfarin at discharge Seq. #6220 as “yes”


New medication XareltoDocumentation:

• History of Atrial fibrillation

• Presents with symptoms of ACS

• Positive Troponins- NSTEMI

• Physician discharges patient on Xarelto/Rivaroxaban

How would you enter the Xarelto in the data

collection tool?

1. Do not include

2. Answer Warfarin at discharge Seq. #6220 as

“contraindicated”

3. Answer Warfarin at discharge Seq. #6220 as “yes”


Brilinta/Tricagrelor v2.3

Documentation:

• STEMI- Primary PCI with stent

• Discharge- Brilinta/ Tricagrelor

• Software vendors have until October to include

• Q4 2013- 1st Outcomes Report Ticagrelor included

• Screen shot v2.3 DCF

ARS Question #3

How would you enter the Brilinta/ Tricagrelor into

the v2.3 data collection form with the delay in

reporting? The Brilinta/Ticagrelor should be:

1. Blank until October & answer Clopidogrel,

Ticlopidine, and Prasugrel as “contraindicated”

2. Blank until October & answer Clopidogrel,

Ticlopidine, & Prasugrel as “no”

3. “Yes” & answer Clopidogrel, Ticlopidine, and

Prasugrel as “contraindicated”

4. “Yes” & answer Clopidogrel, Ticlopidine, & Prasugrel

as “no”


Brilinta/Tricagrelor v2.3

Documentation:

• STEMI- stent- Discharge- Brilinta/ Tricagrelor

• Entering v2.3- vendors have until October to include

• Q4 2013- 1st Outcomes Report Ticagrelor included

How would you enter the Brilinta/ Tricagrelor into the v2.3 data

collection form with the delay in reporting? The

Brilinta/Ticagrelor should be:

1. Blank- P2Y12 as “contraindicated”

2. Blank- P2Y12 as “no”

3. “Yes”- P2Y12 as “contraindicated”

4. “Yes”- P2Y12 as “no”

Section B- Admission

First Medical Contact time Seq. #3106

Documentation:

• Presented to physician office at 10:30 with 3 hours of

“burning” chest pain- radiating to left arm-

diaphoresis & nausea- ECG- STEMI

• EMS contact time 10:45- transported by ambulance

to PCI hospital

• Immediate Primary PCI

ARS Question #4

What time would you enter in for First Medical

Contact time Seq. #3106?

1. 10:30 Physician Office contact time

2. 10:45 EMS contact time

3. Leave time blank

First Medical Contact time Seq. #3106

Documentation:

• Presented to physician office at 10:30 with 3 hours of

“burning” chest pain- radiating to left arm- diaphoresis &

nausea- ECG- STEMI

• EMS contact time 10:45- transported by ambulance to PCI

hospital

• Immediate Primary PCI

What time would you enter in for First Medical Contact time

Seq. #3106?

1. 10:30 Physician Office contact time

2. 10:45 EMS contact time

3. Leave time blank

Section G- Reperfusion Strategy

No PCI & no Thrombolytic

Documentation:



• To cath lab for primary PCI



• This site is submitting into limited tool

ARS Question #5

Does limited report in the same manner as

premier for reperfusion therapy?

1. No

2. Yes

Section G- Reperfusion Strategy

No PCI & No ThrombolyticDocumentation:



• To cath lab for primary PCI



• This site is submitting into limited tool

Does limited report in the same manner as premier

for reperfusion therapy?

1. No

2. Yes

V2.4 Additions

Documentation:

You asked for:

• Non-system reason for delay for First Medical

Contact

• Non-system reason for delay for ECG’s

• LVEF measured after discharge

• Geographic concerns with D2B patients

• Initial & peak or lowest lab values same check box

ARS Question #6

What did we include in the process to

determining what fields to add?

1. Email suggestions

2. RSM calls

3. Focused RSM teleconferences

4. Physician committee meetings

5. All of the above

V2.4 Additions Documentation:

• Non-system reason for delay for First Medical Contact

• Non-system reason for delay for ECG’s

• LVEF measured after discharge

• Geographic concerns with D2B patients

• Initial & peak or lowest lab values same check box

What did we include in the process to determining what

fields to add?

1. Email suggestions

2. RSM calls

3. Focused RSM teleconferences

4. Physician committee meetings

5. All of the above

V2.4 Removed fields

Documentation:

• With addition of v2.4 fields

• Other fields must be removed

• Heavy work loads in your facilities

• Changes in practice

ARS Question #7

How did we determine what fields to remove?

1. Frequency of fields being answered

2. Current practice

3. Need for data- research, guidelines

4. Enough data already captured

5. All of the above

V2.4 Removed fields

Documentation:

• With addition of v2.4 fields

• Other fields must be removed

• Heavy work loads in your facilities

• Changes in practice

How did we determine what fields to remove?

1. Frequency of fields being answered

2. Current practice

3. Need for data- research, guidelines

4. Enough data already captured

5. All of the above

Showcase hospital Variance Report

Outcome Report-Metric #10

Statin at Discharge

Documentation:

• Presents with STEMI

• History of dyslipidemia

• Last lipid panel- 5 mos prior arrival-LDL 105 mg/dL

• No lipid panel during this episode of care

• To cath lab- no PCI

• No statin at home and no statin at discharge

ARS Question #8

Would this patient be included in the

Performance Measure Statin at Discharge?

1. No

2. Yes

Outcome Report-Metric #10

Statin at Discharge

Documents:

• Presents with STEMI

• History of dyslipidemia

• Last lipid panel- 5 mos prior arrival-LDL 105 mg/dL

• No lipid panel during this episode of care

• To cath lab- no PCI

• No statin at home and no statin at discharge

Would this patient be included in the Performance Measure

Statin at Discharge?

1. No

2. Yes

Outcomes Report Metric #12

ACE/ARB at Discharge

Documentation:

• 62 year old presented ED-symptoms of ACS

• ECG was negative for STEMI- Troponin positive

• History of HTN, HF, DM, Dyslipidemia, MI, PCI

• Echo- 1 month prior- LVEF 40%

• Cath lab- day after arrival- EF 35%

ARS question #9

Would this patient be included in the

denominator for Performance Measure

ACE/ARB at discharge?

1. No

2. Yes


ACE/ARB at Discharge

Documents:

• 62 year old presented ED-symptoms of ACS

• ECG was negative for STEMI- Troponin positive

• History of HTN, HF, DM, Dyslipidemia, MI, PCI

• Echo- 1 month prior- LVEF 40%

• Cath lab- day after arrival- EF 35%

Would this patient be included in the denominator for

Performance Measure ACE/ARB at discharge?

1. No

2. Yes


Cardiac rehabilitation patient referral from an

inpatient setting

Documentation:

• 35 yo presented to ED 3 hours of “burning” chest pain-

radiating to arms & back- diaphoresis & nausea

• Risk factors- dyslipidemia, obesity

• ECG- STEMI

• Angiography results: Normal coronary arteries, normal systolic

function, mild elevated end-diastolic pressure, EF 55%

ARS Question #10

Would this patient be included in the metric cardiac

rehabilitation at discharge?

1. No

2. Yes

Cardiac rehabilitation patient referral from an

inpatient settingDocumentation:

• 35 yo presented to ED 3 hours of “burning” chest pain-

radiating to arms & back- diaphoresis & nausea

• Risk factors- dyslipidemia, obesity

• ECG- STEMI

• Angiography results: Normal coronary arteries, normal systolic

function, mild elevated end-diastolic pressure, EF 55%

Would this patient be included in the metric cardiac

rehabilitation at discharge?

1. No

2. Yes

Details for Rosemary’s report

How facility uses these variance reports:

• Monthly reports are sent to Cardiologists, PA’s, NP’s,

Internal medicine, Hospitalists

• Reports include physicians- unblinded

• Reports include the Performance measures & all

clinical events

• Include performance measure- definitions &

exclusions

• Clinical events definitions- Cardiogenic shock, HF,…

• Physicians report the results at quarterly meetings

that include up to 50 members- Physicians,

Administrators, Pharmacy, Managers, Cardiac Rehab

Details for Rosemary’s report

Outcomes from the use of the variance reports:

• Physician satisfaction with benchmarking

• Trusting relationship with abstractors

• Formalized locations for specific documentation

• Created electronic record smart tools- fields with

required thresholds

• Improving data scores- cardiac rehab- <50% to >90%

• Created information cards including criteria for

ACE/ARB at discharge

• Registration can order ECG’s, increased # of ECG

machines in ED- improve D2ECG times

Email sent to Cardiologists

If Variances: (to Cardiology)

“Greetings from Rosemary and Annette,

We have completed abstracting the patient records for

December 2012. I have attached the variance report for the

month. We have included 2 new categories, statin at discharge

and LVEF measurement. This was done as a reminder to ensure

that we do not drop below the parameters for the registry. As

always, if you have any questions regarding the information,

please call or e-mail Annette or me. We greatly appreciate your

efforts in delivering quality care to our patients. You all do

excellent work which makes our job so much easier. Keep it up!

Have a Great Day!”

ARS Question #11

How receptive do you think your physicians would be

to a variance report?

1. Very receptive

2. Moderately receptive

3. Not receptive

4. Already provide this

Contact information

Questions?

Contact Rosemary.Rose or

[email protected]