Safer Healthcare Now! Acute Myocardial Infarction

1. Safer Healthcare Now! Acute Myocardial Infarction Presented by Amanda Thompson, Safer Healthcare Now Facilitator

2. Safer Healthcare Now! Background • Largest patient safety initiative in Canadian history • Adopted form IHI • Over 600 teams registered across Canada • Goal to improve health care delivery through 6 initiatives

3. Safer Healthcare Now! Initiatives • Acute Myocardial Infarction (AMI) • Ventilator Associated Pneumonia (VAP) • Central Line Associated Infection (CLI) • Prevention of adverse drug events through Medication Reconciliation (Med. Rec) • Prevention of Surgical Site Infection (SSI) • Rapid Response Teams (RRT)

4. AMI – Goal • Decrease mortality rate for AMI by 20% by implementing all 6 elements • NDBMH will have all 6 elements implemented by May 18th 2007

5. Six Elements of AMI • Timely initiation of thrombolytics • Early administration of aspirin • Smoking cessation counseling/nicotine replacement • Aspirin at discharge • ACE or ARB at discharge • Beta Blocker at discharge

6. Acute MI “Canadian Cardiologists & experts who were consulted when developing …this kit agree, that these six care components should be provided to all patients with an AMI. Unless a clear contraindication exists and is documented in the medical record.”

7. Timely Initiation of Reperfusion with Thrombolytics • Defined as percent of AMI patients who received thormbolytics within 30 minutes of arrival • A goal of 85% of patients with ST elevation or new LBBB on ECG ST Elevation LBBB

8. Statistics on Thrombolytics TNKase • ST elevation of 1mm or more, in two or more contiguous standard limb leads Or… • Elevation of 2 mm or more, in two or more contiguous precordial leads • New or presumed new LBBB

9. Thrombolytics within 30 Minutes Where we are now…

10. Early Administration of Aspirin • Defined as percent of AMI patients who received ASA within 24 hours before or after hospital arrival. • Prompt aspirin administration results in a 15% reduction in vascular events • A study by the RAND corporation showed 61% of AMI patients received early administration of aspirin • Goal is 90%

11. Early Administration of Aspirin cont’d Where we are now…

12. Smoking Cessation/Counseling/ Nicotine Replacement/Pharmacological Therapy • Percent of AMI patients who received smoking cessation advice or counseling • Any patient who has smoked in the past year • Recommended: counseling combined with pharmacological therapy and cessation programs. • Goal is 100%

13. Smoking Cessation/Counseling/ Nicotine Replacement/Pharmacological Therapy cont’d Where we are now…

14. Beta Blockers at Discharge • Reduces AMI mortality in the first week by 13% and long-term mortality by 23% • IHI 100K Lives Campaign has used early administration of Beta Blockers • May be better to start Beta Blockers when patient is stable & then continue long term • Studies show risk for cardiogenic shock increased by 11 per 1000 on days 0-1 post MI • Goal 90%

15. Beta Blockers at Discharge cont’d Where we are…

16. Common Beta Blockers Timolol Betaxolol Propranolol Metoprolol Labetalol Atenolol

17. Aspirin at Discharge One study showed that after 5 weeks, patients who had aspirin , had a decreased risk of vascular mortality (23%), non fatal reinfarction (49%) and non fatal stroke (46%).

18. Aspirin at Discharge • Goal 90% Where we are….

19. ACE or Angiotension Receptor Blockers (ARB) at Discharge • ACE = proven to decrease mortality after an MI particularly in PTS with LV dysfunction, heart failure or both. • ARB = can improve heart failure, and is usually used when and ACE can not be tolerated.

20. Common ACE & ARB • Goal 85%

21. ACE or Angiotension Receptor Blockers (ARB) at Discharge cont’d Where we are….

22. “Perfect AMI Care” • Perfect AMI care = patient who receives all six elements within the time frame

23. Admission Standing Orders AMI Order Set AMI Diagnostic Criteria ST elevated MI: Y___ N___ New LBBB: Y ___ N ___ Thrombolysis with 30 minutes Time Administered ________Contraindication _________ EKG Post TNK ________ 4 hrs Post TNK ________ Common LABS ___________ Early Measures Aspirin within 24 hours Dose _______ Route _______ Time _______

24. “How to Improve Care” • Discharge Medication Program Includes key AMI care components • Aspirin: Y___ N___ Reason not given ___ • Beta Blocker: Y ___ N ___ Reason not given ___ • ACE/ARB: Y ___ N ___ Reason not given ___ Smoking Counseling Provided Y ___ N ___ Not Applicable ___ • If “Yes”, Zyban Prescribed Y ___ N ___ Reason not given___ Referral to Cardiac Rehab Program Y ____ N _____

25. “How to Improve Care” cont’d • This method has contributed to greater than 90% compliance with Aspirin and Beta Blocker guidelines • To be compliant, documentation must exist • Documentation of contraindication must exist • If documentation for any one area is missing patient is not considered as having perfect care

26. Statins at Discharge

27. Mortality Rate Where we are….

28. Education on AMI • Posters on AMI care • Education sessions • Increase public awareness • Change in policy and procedures

29. Questions?

30. Contact Information Amanda Thompson 709-292-2647 athompson@cwhc.nl.ca www.saferhealthcarenow.ca

31. Thank You!

32. Questions?