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IHS Best of the Best Series: Acute Myocardial Infarction

Mercy Des Moines AMI 2005 % of Cases

All or Nothing 609/612 patients
Aspirin at Discharge 100
B-blocker Discharge 100
Smoking Advice 100
%PCI w/in 120 Min. arr Mean <60 98% ’04
• Established multidisciplinary steering team and standardized physician order sets 1999
• Developed strategic plans, Ev-Based targets and monthly performance to targets reporting
• Moved from ‘Project in a Box’ to ‘Get with the Guidelines’ 2002
• Educated physicians on AMI core measures and Participated in Trinity Health AMI
initiative 2003
• Piloted defect reporting to identify patterns/trends 2004
– 1:1 physician and nurse coaching/mentoring
– Level 1 Heart Attack Protocols for time to PCI
• Piloted “perfect care methodology” 2005

Mercy Cedar Rapids AMI 2005 % of Cases

Aspirin at Discharge 99
B-blocker Discharge 99
Smoking Advice 100
• Support of senior leaders and highly engaged physician champions
• Management expectation to use tools
• Planned, monitored project phases
• Replaced care map for care of AMI patient
• Standardized Evidence-based risk stratification for all potential acute coronary syndrome
• Evidence-based flip charts distributed to all ED & primary care physicians, family practice
residents and faculty
• ACC/AHA Class I recommendations for AMI:
– Highlighted on each order set (continually revised and discussed with physicians)
– Adherence monitored for ED and Cardiology physicians’ for all AMI, PCI patients
• Review AMI core measures data at meetings:
– Monthly: Cardiology medical directors = % usage each set type
– Cardiac nursing and cath lab staff
– Quarterly: Internal Medicine
– Monthly: ED physicians and nursing staff
• Case studies on extreme deviations from Class I recommendations
Best of the Best in AMI Mortality

AMI Mortality: Abbott Northwestern 2005

(Barbara Tate Unger RN BS FAACVPR)
• 2% “AMI direct” mortality rate (3rd year of improvement work)
• 4% for overall mortality; LOS = 2 days
– 850 patients in 30 months (56 last month) – majority not metro area
• 95% of patients alive one year later (contact them all)
• 90% referral rate to cardiac cath – all are set up in the patient’s home community
• Time to PCI = 66 minutes (Down from 98 minutes)
– daytime 44 minutes
• 75% of patients come by ambulance compared with American Heart’s 50%

IHI calls this type of work “Extending the Chain” – moving upstream in a process to
improve quality, safety and efficiency.
Attributes success to rapid ‘in-processing’ all patients from the metro or rural
• Developed system to process patients faster en route to hospital (ground and air)
• Reduced air transport flight time max to 30 minutes (for helicopter one way)
– TAT skids to skids at pick up point is 10 minutes (don’t shut the rotors off)
• Fully assessed 30 community and rural hospitals in network:
– helped them set up the program,
– spent a whole day in the ED to see their processes and
– helps them streamline everything to minimize time spent on processing patients
• No handoff verbal report
– Quick-use forms allow physicians to quickly verify all needed information
• Keep track of all AMI drugs used
– Abbott Compliance is high
– Debriefs each case with all hospitals
• Ambulance or flight teams identify smokers and the Cath Lab includes float wires during cath
• 16 slice CT remote when possible; OR team sets up based on readings shipped electronically
• Use STEMI reaction protocol in the ED
• Hardest to streamline is ordering blood;
– currently working to allow ordering 20 units with one simple order in computer