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Acute Myocardial Infarction	Medication Reconciliation (ADE)
Boards on Board	Pressure Ulcers
Catheter-Associated UTI	Rapid Response Teams
Central Line Infections	Surgical Complications
Congestive Heart Failure	Surgical Safety Checklist
High-Alert Medications	Surgical Site Infections
MRSA	Ventilator-Associated Pneumonia

Use this table to quickly find a mentor for improving Acute Myocardial Infarction care with demographics similar to your own, or use 'ctrl+f' in your web browser to search for specific key words on this page.

Aiken Regional Medical Centers – Aiken, SC
Availability Status: Available to answer requests
Licensed Beds: 225
Teaching / Non-Teaching Status: Non-Teaching
Setting: Urban
Start Date of Intervention Work: January 2005
Mentor Contact Name: Marilyn Thomas, RN
Mentor Contact Email: marilyn.thomas@uhsinc.com
Mentor Contact Phone: 803-641-5773

Additional Information:

• Key to success has been consistent and enthusiastic support from the Board of Governors and Senior Adminitrative level.  Direct knowledge of changes and goal by top level sets standard.

• Aiken Regional has the advantage of having one cardiology group, making physician education and follow-up relatively easy.  This has also allowed us to achieve "one voice" in the expected management of the AMI patient.

• We found that in most cases, patients were receiving evidence based care.  Documentation of that care, however, was missing.  “Physician champions” were identified who promoted the cause amoung peers.

• Identified “nurse champions” for each of the departments who are critical to the success of these initiatives.  This has promoted the concept of teamwork in achieving success by including those at the bedside in the development of solutions and education.  We are quick to recognize departmental improvements by offering various rewards and recognition.

• As a result of joing the ACC's D2B initative, we provided immeadiate data feedback to the key players in easy to read, relevent formats for all STEMI patients.  Varried the data formats of data presentation to keep it new to the staff.

Percent AMI patients who received ASA within 24 hours before or after hospital arrival:
2005 - 80%
2006 - 100%
2007 - 97%
2008 - 100%
2009 Q1-Q3 - 100%

Percent AMI patients prescribed ASA at discharge:
2005 - 96%
2006 - 100%
2007 - 100%
2008 - 98%
2009 Q1-Q3 - 100%

Percent of AMI patients prescribed beta-blocker at discharge:
2005 - 97%
2006 - 100%
2007 - 100%
2008 - 100%
2009 Q1-Q3 - 100%

Percent of AMI who were prescribed for ACEI or ARB at discharge:
2005 - 100%
2006 - 100%
2007 - 100%
2008 - 97%
2009 Q1-Q3 - 93%

Percent of AMI patients who received Percutaneous Coronary (PCI) within 90 minutes of hospital arrival:
2005 - 52%
2006 - 52%
2007 - 66%
2008 - 78%
2009 Q1-Q3 - 88%

Average door-to-balloon time:
2005 - 151
2006 - 123
2007 - 100
2008 - 83
2009 Q1-Q3 - 65

Percent of AMI patients (cigarette smokers) who received smoking cessation advice or counseling during hospital stay
2005 - 95%
2006 - 100%
2007 - 100%
2008 - 100%
2009 Q1-Q3 - 100%

Percent of AMI Patients with "Perfect Care":
2005 - 82%
2006 - 92%
2007 - 86%
2008 - 90%
2009 Q1-Q3 - 95%

AMI Inpatient Mortality
2005 - 11%
2006 - 2%
2007 - 5%
2008 - 2%
2009 Q1-Q3 - 5%

Mentor designation - 6/2/06
Information updated - 3/2/10

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AnMed Health – Anderson, SC
Availability Status: Available to answer requests
Licensed Beds: 533
Teaching / Non-Teaching Status: Non-Teaching
Setting: Urban
Start Date of Intervention Work: January 2005, renewed 10/12/09
Mentor Contact Name: Leigh Miller, Director of Clinical Outcomes
Mentor Contact Email: leigh.miller@anmedhealth.org
Mentor Contact Phone: 864-512-2480

Additional Information:

AnMed Health began a physician-led process improvement initiative in January 2005 to improve rapid diagnosis and treatment of the Acute Myocardial Infarction (AMI) patient.  The Medical Executive Committee endorsed a system-wide approach to improvement of AMI care after AnMed Health dropped to the 8th decile from the 5th in the CMS/Premier Hospital Quality Incentive Demonstration Project.  Two physician led teams were formed to improve general care of AMI patients and to improve rapid diagnosis and treatment of STEMI’s (ST elevation myocardial infarctions).

Changes included development of an AMI Alert process in which the ED physician diagnoses the STEMI and pages the cardiologist and cath lab at the same time.  Goals were set around door-to-ECG ( < 10 minutes), door-to-cath lab (< 45 minutes), door-to-balloon inflation (first < 120 minutes, since July 2006, < 90 minutes).  Order templates were developed in Emstat for the Emergency Department physicians to facilitate ordering quickly and accurately.  New alpha-numeric beepers were obtained for the cardiologists to facilitate Alert paging.

The cath lab changed many of their processes.  Prep for emergency caths was minimized by leaving the cath lab equipment table ready for an emergency case at the end of the day.  Call teams were rearranged to ensure no team included more than one member on any team had more than a 30 minute response time.  One person was designated to go straight to the ED to assist with prep for the cath lab as well as assist with transportation, while the other three team members went to the cath lab to get the equipment ready. 

Preprinted orders were revised to include all AMI indicators as well as other evidence-based guidelines.  The orders were built in our CPOE system for those physicians trained on that system.  The electronic template of the paper version was added to the home page of the physician portal to ensure that any physician not using CPOE could easily print a copy.  Plans of care were revised and added to electronic nursing documentation to ensure all AMI patients were receiving needed treatments and education.  Preprinted discharge orders were developed and printed to ensure the physician did not miss any needed discharge medications.  Those orders have also been built in our CPOE system.  We've worked with the cardiologists to develop an electronic i-form to facilitate ordering electronically and to ensure indicators do not get missed.

Every AMI alert is reviewed by a multi-disciplinary team from the Emergency Department, the Cath Lab, Clinical Outcomes and Process Improvement.  In the past year, we've also added EMS to those meetings so we can look at problems in the field.  The educator from the ED has attended the EMS chiefs meeting to provide positive feedback for those who made it quickly to the cath lab.

Any patient not meeting established goals is examined carefully for breaks in process.  Feedback is given to the individual physician by the CV Services medical director with assistance of the AMI case manager.  Reports are given at bimonthly Cardiology Department meeting, as well as Internal Medicine Department.  Outcomes are reviewed monthly at the Quality Coordinating Council, as well as at the Quality Committee of the Board of Trustees.  We have begun to recevie ECG's from the field to initiate the alert to the team more quickly.

Our health system is involved in a state-wide initiative to regionalize cardiac care in South Carolina, working with EMS systems to transport AMI patients directly to a PCI center.  Anderson also has a group called Heart and Stroke Safe Community that involves not only the hospital and EMS, but the Red Cross, American Heart Association, the United Way and other community groups to increase community awareness of risk factors, symptoms, and what to do in the case of emergency.

Our improvements have been possible due to every person involved in the process knowing what has to happen, why it's important, and how that person fits in making it work.  We have celebrated our successes with staff in all involved departments: ED, Cath lab, CCU, telemetry, Clinical Outcomes, and the physicians.  The true winners have been the persons in our community who present at AnMed Health with Acute Myocardial Infarctions.

Percent AMI patients who received ASA within 24 hours before or after hospital arrival:
100%
Have missed one patient in Q 4 2005, otherwise have been 100% since Q3 2005.

Percent AMI patients prescribed ASA at discharge: 
100%
Have been 100% since Q4 2005.

Percent of AMI patients prescribed beta-blockers:
Beta-blocker use on admission was 93.5% in Q1 2005.  Missed one patient in Q4 2007, but otherwise has been 100% since Q4 2005. 
On discharge, beta-blockers were given 91.67% in Q1 2005.  We missed 1 patient in Q4 2007, but otherwise, have been 100% since Q4 2005.

Percent of AMI who were prescribed for ACEI or ARB at discharge:
In Q1 2005, only 77% of those patients with left ventricular systolic dysfunction received an ACE-I or ARB.  We have been at 100% since Q4 2005.

Percent of AMI patients who received either thrombolytics within 30 minutes of hospital arrival or Percutaneous Coronary (PCI) within 120 minutes of hospital arrival:
At the beginning of the initiative, only 45% of the STEMI patients received PCI in less than 120 minutes and only 37.5% in less than 90 minutes.  Since Q4 2008, we have been at 100% in less than 90 minutes.

Average door-to-balloon time for the last 10 months is 62 minutes.

Percent of AMI patients (cigarette smokers) who received smoking cessation advice or counseling during hospital stay:
We have been at 100% since Q2 2005.  When it is documented in our electronic nursing documentation, it triggers a message to respiratory therapy to educate the patient.

The Perfect Care Score 67.83% in Q1 2005, but had been consistently between 65 and 70% since Q4 2003.  It has steadily increased since we began the process improvement.  Since Q4 2008, we have missed only two indicators, bringing us to 99.58%.

AMI Inpatient Mortality:
In Q1 2005, mortality for AMI patients was 13%.  Mortality for AMI patients has run 1.96-5.71%.  Since Q4 2007, mortality has been 3-4%.

Mentor designation - 6/26/07
Information updated - 3/2/10

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Avera Heart Hospital of South Dakota – Sioux Falls, SD
Availability Status: Available to answer requests
Staffed Beds: 55
Teaching / Non-Teaching Status: Teaching
Setting: Rural
Start Date of Intervention Work: July 2002
Mentor Contact Name: Peggy Goos
Mentor Contact Email: peggy.goos@medcath.com
Mentor Contact Phone: 605-977-7025

Additional Information:

Avera Heart Hospital of South Dakota (AHHSD) has been actively working to improve AMI care since July 2002.  In October 2005, AHHSD adopted the IHI 100,000 Lives Campaign initiative related to improved care for acute myocardial infarction patients.

The focus of the improvement process related to the 100,000 Lives Campaign has been to maintain high compliance rates with all measures and specifically to decrease door-to-balloon time.  Our work on this intervention includes:

• Development and implementation of AMI admission order sets, with continual evaluation and modification as needed
• Campaign to increase awareness of intervention among physicians and clinical staff
• Development and implementation of a hospital Code STEMI team
• Collaboration with the local ambulance service and referring hospitals to improve care of the AMI patient prior to AHHSD receiving patient 
• The improvement process has led to a much greater awareness of appropriate and timely AMI care among all physicians and clinical staff with all working as a team toward a common goal

Improvement efforts since mid-2002 have resulted in nearly 100% compliance with all measures.  An intensive improvement process focused on door-to-reperfusion time has led to vast improvement in timeliness.

Average Door-to-Reperfusion Times:

Fiscal Year 2005 (October 2004-September 2005)       205 minutes
Fiscal Year 2006 (October 2005-September 2006)       120 minutes
Fiscal Year 2007 (October 2006-September 2007)       52 minutes

Through March 2008:

• Smoking Cessation education 100% compliance for 31 consecutive months
• Aspirin at Arrival 100% compliance for 16 consecutive months
• Beta Blocker at Arrival 100% compliance for 19 consecutive months
• Aspirin Prescribed at Discharge 99.7% for last 12 months
• ACE-I/ARB for LVSD  96% for last 12 months
• Beta Blocker Prescribed at Discharge 99.7% for last 12 months
• Average Door-to-Balloon Time for last 12 months: 64 minutes where 92% of patients (1 fallout) with time < 90 minutes (compared to 22% in 2005)

According to Thomson Top 100 and HealthGrades, Avera Heart Hospital of South Dakota's risk-adjusted AMI mortality rate is significantly lower (statistically) than the peer and benchmark groups.  AHHSD has been named a Thomson Top 100 Cardiovascular Hospital for two consecutive years and Top 5% in Cardiovascular Services by HealthGrades for five consecutive years.

[5/1/08]

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Baystate Medical Center – Springfield, MA
Availability Status: Available to answer requests
Licensed Beds: 636
Teaching / Non-Teaching Status: Teaching
Setting: Urban
Start Date of Intervention Work: January 2000
Mentor Contact Name: Jan Fitzgerald, RN
Mentor Contact Email: janice.fitzgerald@bhs.org
Mentor Contact Phone: 413-794-2531

Additional Information:

Baystate Medical Center has been successful in incorporating key AMI evidence-based components/interventions into clinical care through use of CPOE (Computerized Physician Order Entry), CPG, real time cue/prompt, standardization of care, ongoing performance monitoring/feedback and engaging clinical champions in leading the process review, change and ownership.

We achieved top 10th decile performance in PY 1 of the HQID (CMS/Premier Hospital Quality Incentive Demonstration).  High levels of primary and secondary interventions (such as - but not limited to - ASA on admission/discharge, beta blockers on admission/discharge - consistently at > 95%) are consistently in place through use of the 3 tier design system.  Focus of our work has been on door-to-balloon time as well as regionalization of heart care.  D2B work has resulted in top sustained CMS top 10th precentile rates for primary angioplastly.  Our AMI mortality has consistently been well below the national, state and comparative rates.

See graphs of their results.

Mentor designation - 1/31/06
Information updated - 2/24/10

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Berkshire Medical Center – Pittsfield, MA
Availability Status: Available to answer requests
Licensed Beds: 309
Teaching / Non-Teaching Status: Teaching
Setting: Urban
Start Date of Intervention Work: 2001
Mentor Contact Name: Rick Glasener
Mentor Contact Email: rglasener@bhs1.org
Mentor Contact Phone: 413-447-2383

Additional Information:

Implementation of the American Heart Association's Get With The Guidelines program at Berkshire Medical Center using a multifaceted approach including multidisciplinary rounds was associated with improved treatment rates.

Patient centered multidisciplinary rounds occur 4 times per week in 1 hour sessions provide concurrent feedback using realtime data.  Multifaceted approach also includes CPOE order set, cardiovascular disease checklist, documentation tool, and physician reminders.  System of Care is adaptable to changing and new measures.  Significant increase in treatment utilization compared to pre-intervention which has been sustained for over 4 years.

Smoking cessation advice counseling has improved from 43% baseline to 100% (Q1 03 – Q2 05) sustained performance.

Aspirin at discharge has improved from 96% baseline to 100% sustained performance (Q3 03 – Q2 05).

Beta-blocker at discharge has sustained 100% performance (Q1 03 – Q2 05).

ACEI at discharge has sustained performance (Q3 04 – Q2 05) at 97%.

Lipid lowering medication in eligible patients has improved from 59% baseline to 100% (Q3 04 – Q2 05).

Cardiac Rehab referral rates have increased from 14% baseline to 98% (Q3 04 – Q2 05).

[2/14/06]

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Centra Health – Lynchburg, VA
Availability Status: Available to answer requests
Licensed Beds: 403
Teaching / Non-Teaching Status: Non-teaching
Setting: Urban
Start Date of Intervention Work: 2002
Mentor Contact Name: Cindi Cole, BSN, RN, AMI Coordinator
Mentor Contact Email: cindi.cole@centrahealth.com
Mentor Contact Phone: 434-200-6701

Additional Information:

Centra Health has led the way in door-to-device time since we started tracking it in NRMI in 2002.  The guideline for discharge therapy showed its most remarkable improvement in 2004 with the initiation of discharge contracts.

In 2007, Centra implemented a door-to-balloon form that is inititated in the Emergency Department.  This document tracks the door-to-device time, along with door-to-EKG, and door-to-cath lab, allowing us to report to all staff involved the patient's process times and outcomes.

We also developed a form to track the first responders Arrival-to-Device (E2B) and report patient successes to our EMS personnel.

Overall, strong physician champions and teamwork with emergency department first responders and cath lab staff  have been instrumental in achieving these improvements.

2006 - 2009 data:
• Since 2006, ASA on arrival and ASA on discharge has maintained a 98% to 100% success rate for all MI patients
• Beta blocker on discharge improved with the contracts to 95% or greater
• ACEI on discharge compliance went from 81% to 95% or greater
• Smoking cessation education went from 93% to 100% compliance
• Door-to-device median time has steadily decreased:

2006 - 66 minutes
2007 - 63 minutes
2008 - 54 minutes
2009 - 51 minutes

We attribute this decrease to the introduction of Centra's pre hospital EKG program.

Mentor designation - 3/30/06
Information updated - 3/4/10

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Christiana Care Health Systems – Newark, DE
Availability Status: Available to answer requests
Licensed Beds: 675
Teaching / Non-Teaching Status: Teaching
Setting: Urban
Start Date of Intervention Work: Before 2003
Mentor Contact Name: Maria Albert RN, PI Program Manager
Mentor Contact Email: malbert@christianacare.org
Mentor Contact Phone: 302-733-5417

Additional Information:

The American Heart Association’s “Get With The Guidelines” program is a quality-improvement program that helps hospitals insure that patients consistently receive cardiac care in accordance with best practice guidelines and recommendations.

An interdisciplinary team at Christiana Care recognized the importance of engaging and stimulating conversation between our staff and patients on best practice guidelines for myocardial infarction (MI).  A team of nurses and physicians assessed direct care nurses' current knowledge of best practice interventions for patients with acute MI using a pre-test/post-test method and focus groups.

Innovative educational tools developed included:
Creative acronym “BLAAST” for best practice interventions
B = Beta blocker
L = Lipid lowering therapy
A = Aspirin
A = ACE/ARB
S = Smoking cessation
T = Talk to your doctor or health care provider

• “ASK ME ABOUT BLAAST” button to encourage dialogue among the health care team as well as between staff and  patients/families

•  Standardized BLAAST script card

Christiana Care was able to roll out the initiative on the pilot unit very quickly and with great results and have expanded to a hospital-wide rollout.  The BLAAST those MI's team is viewed as a very positive resource in the hospital, as the medical staff/cardiology fellows have joined in providing education sessions.  This project has won an award for clinical excellence at our hospital's annual "Focus on Excellence" awards.  Results show that the BLAAST button provided engagement of staff and stimulation of conversation between staff and patients.

To assess the impact of the program on secondary prevention, core measures on MI patients were compared pre- implementation and after each phase of implementation of the “BLAAST” program.  Compliance with all core measures improved and the hospital received a Get with the Guidelines sustained performance achievement (Gold) award.

Phase 2 was initiated on ten inpatient units with a high population of MI patients.  Again, a pre-test, post-test format was used.  However, the methodology was improved to ensure that the same nurses that completed a pre-test, also completed a post-test.  There was a significant increase in the percentage of correct answers to all five test questions.  The variance of different nursing units with varying levels of cardiac expertise was virtually zero and did not affect results.

BLAAST Those MI’s uses a creative acronym that contains all the core measures for MI.  The team identified the need to educate creatively, teach consistently and engage staff.  This innovative approach improved staff nurses’ knowledge, ultimately improving the quality of patient education and adherence to secondary prevention guidelines for CAD.

Publicly reported core measures for acute MI were less than 100% at base line for 4 out of 5 measures with a range of 91.5% to 97%.  Post data showed 100% for all 5 measures.  The “BLAAST THOSE MI's” initiative may have influenced staff knowledge resulting in 100% compliance in core measures.
                     
FY 2010 for December 09 data:

100% percent AMI patients who received ASA within 24 hours before or after hospital arrival compared to 99.8%  (FY 09) and 93% (FY08).

100% Percent AMI patients prescribed ASA at discharge compared to 99.2% (FY09) and 97.8% (FY08).

100% Percent of AMI patients prescribed beta-blocker at discharge compared to 99.7% (FY09) and 99% (FY08).

100% Percent of AMI who were prescribed for ACEI or ARB at discharge compared to 97.3% (FY09) and 94.9% (FY08).

98% Percent of AMI patients of Percutaneous Coronary (PCI) within 90 minutes of hospital arrival compared to 81.8% (FY09) and 85.5% (FY08).

67 minutes average door-to-balloon time compared to 77 minutes (FY09) and 85 minutes (FY08).

100% Percent of AMI patients (cigarette smokers) who received smoking cessation advice or counseling during hospital stay compared to 100% (FY09) and 99.6% (FY08).

98.3% percent of AMI Patients with "Perfect Care" compared to 92% (FY09) and 92.6% (FY08).

3.7% AMI Inpatient Mortality for FY10YTD compared to 4.3% for FY09 YTD.

Mentor designation - 2/6/07
Information updated - 3/10/10

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Cleveland Regional Medical Center – Shelby, NC
Availability Status: Available to answer requests
Licensed Beds: 241
Teaching / Non-Teaching Status: Non-Teaching
Setting: Rural
Start Date of Intervention Work: 2005
Mentor Contact Name:  Cindy Proctor, Director of Quality Management
Mentor Contact Email: cynthia.proctor@carolinashealthcare.org
Mentor Contact Phone: 980-487-3721

Additional Information:

CRMC implemented a concurrent chart review and intervention process.  This process includes active intervention and follow up among the Quality Management staff and direct care givers.  Weekly monitoring of our processes as well as "All-or-none/perfect process" indicators have improved mortality as well as process indicator compliance.

Mortality reduction from 8.74% to 6.9%.
Perfect process compliance is greater than 95% for 1 year and 6 months.
Process compliance for all indicators is 95% or higher.
ASA on arrival and DC, beta blocker on arrival and discharge, ACEI or ARB and Smoking Cessation have been 100% for over a year.

[2/7/07]

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Community Hospital Anderson – Anderson, IN
Availability Status: Available to answer requests
Licensed Beds: 207
Teaching / Non-Teaching Status: Non-teaching
Setting: Rural
Start Date of Intervention Work: ?
Mentor Contact Name: Cleo Ann Burgard
Mentor Contact Email: cburgard@ecommunity.com
Mentor Contact Phone: 317-621-5329

Additional Information:

This intervention is spread throughout our five (5) Network hospitals:  Community Hospital Anderson, Community Hospital East, Community Hospital North, Community Hospital South, and the Indiana Heart Hospital

• The Community Health Network utilized the National Registry for Myocardial Infarction (NRMI) as a means to collect our data
• Best practices were identified and implementation of these quality improvement measures have been undertaken
• Development of standard order sets, pathways and discharge instructions sheets occurred to facilitate best practice
• Education regarding best practice standards to all staffing members
• Development of Code STEMI team to facilitate process improvement

• Process redesign has resulted in a significant reduction of lytic administration to an average of 18.4 minutes for 2005
• Process redesign has resulted with an overall improvement of medication administration with > 90% compliance for all of our patients admitted with a primary diagnosis of AMI
• 100% of patients within the Community Health Network receive smoking cessation information
• Overall mortality reduction of > 1%
• Decreased door to balloon times by 20% since initiation of Code STEMI

[2/14/06]

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Doylestown Hospital – Doylestown, PA
Availability Status: Available to answer requests
Staffed Beds: 196
Teaching / Non-Teaching Status: Non-teaching
Setting: Urban
Start Date of Intervention Work: February 2005
Mentor Contact Name: Michele Clugston, RCIS
Mentor Contact Email: mclugston@dh.org
Mentor Contact Phone: 215-345-2554

Additional Information:

Following a review of the hospital processes related to acute myocardial infarction (AMI) care, Doylestown Hospital felt we had an opportunity to improve the care provided and to have the various hospital departments work more cohesively as a team to ensure that all AMI patients for which PCI was indicated received the intervention in 90 minutes or less upon arrival.

LESSONS LEARNED

The development of a team philosophy among the members of the ED and cardiac cath lab (CCL) staffs (including strong interdepartmental and interdisciplinary communication and problem-solving) was critical to our success.  This team came up with a number of enhancements, including development of an ACS form, physician champions, case management prompts to improve documentation, and utilizing real-time chart review. 

Simple solutions helped save time, such as utilizing pacer pads instead of the traditional 3-lead system for patient transport, ensuring a 500 mL bag of normal saline was running on all patients, and taking time to remove trousers on the front end.  ED staff would also stay in the CCL to ensure that the CCL staff had time to set up the room, supplies and other activities, especially in the off hours, and CCL staff would come to the ED to pick up patients during increased census and acuity times in the ED.

One of the things our team is most proud of is an innovative and simple solution that helped keep this initiative in the forefront of all health care team members' minds.  Bulletin boards (in both the CCL and ED) provide a simple pictorial depiction of the AMI process so staff can better visualize the process, identify where there are delays, and suggest changes.  Physicians, nurses, patients, families, administrators, and many others find this spurs discussion.  Pictures illustrate the steps in the process including a door to indicate time of arrival, an EKG strip to depict time of first EKG, a phone to indicate time the CCL was notified, and, finally, a whimsical balloon to indicate successful reperfusion.  At the end, a football referee indicates "GOAL" at the 90-minute mark.  A change identified early on was to have the ED physician alert the CCL of the AMI patient in the ED.  This has cut 10 minutes off of our mean D2B times.

Recently, we performed a mock STEMI drill with our EMS, ED and cath lab in which a real patient and his wife participated.  We had a separate team critique all those participating in order to be objective and we met afterward to review processes.  (The D2B time was 38 minutes.) One of the key things we learned was the need to increase communication to the patient and family during treatment.  We are working to enhance our relationship with all EMS squads by meeting with them quarterly to review MI cases and by having them observe in the ED and the cath lab so that we can incorporate them in the team goals.

There is still room for improvement by capitalizing on use of pre-hospital EKGs and utilizing in-house cardiothoracic physician assistants to set up the Cardiac Catheterization Laboratory during off hours.

• The baseline door-to-balloon time at the start of the project (July 2004 - June 2006) was 84.3 minutes, but only 70 percent of the patients eligible for PCI were receiving the intervention in 90 minutes or less. 
• Current door-to-balloon time (July 2007 - March 2008) averages 62.5 minutes, an approximately 22 minute improvement in mean time to PCI. 
• For the period July 2007 - June 2008, remeasurement demonstrated that 93.9 percent of all AMI patients eligible for PCI received the intervention in 90 minutes or less. 
• Permitting the Emergency Department physicians to call the Cardiac Catheterization Laboratory team reduced on average 10 minutes of the mean door-to-balloon time.

Here is the data (mean, median, %):

Phase                              Mean time to PCI             Median time to PCI     % < 90 min.
Baseline (Jul 04–Jun 06)    84.3 min.                         79.2 min.                    70.3
After improvements           65.6 min.                         60.5 min.                    91.7
(July 06– Mar 08)

Most recent performance measures (July 2007 - March 2008):

Percent AMI patients who received ASA within 24 hours before or after hospital arrival: 99.4%
Percent AMI patients prescribed ASA at discharge: 99.2%
Percent of AMI patients who received beta-blockers within 24 hours after hospital arrival: 99.3%
Percent of AMI patients prescribed beta-blocker at discharge: 100%
Percent of AMI who were prescribed for ACEI or ARB at discharge: 100%
Percent of AMI patients (cigarette smokers) who received smoking cessation advice or counseling during hospital stay: 100%

Percent of AMI Patients with "Perfect Care": 97.8%

AMI Inpatient Mortality
2005: 1.8%
2006: 1.5%
2007 & 1Q 2008: 0.6%

[8/15/08]

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Houston Northwest Medical Center – Houston, TX
Availability Status: Available to answer requests
Staffed Beds: 300
Teaching / Non-Teaching Status: Non-teaching
Setting: Urban
Start Date of Intervention Work: June 2006
Mentor Contact Name: Marianne Morse
Mentor Contact Email: marianne.morse@tenethealth.com
Mentor Contact Phone: 281-631-8927

Additional Information:

Achieving best care for our clients with an Acute Myocardial Infarction begins with enthusiastic support from senior hospital and nursing management and physician champions.  Nursing administration identified the need for a Core Measure Coordinator who would assist with quality improvement with Core Measures.  Daily meetings were initiated to review patients in the facility with diagnosis of AMI and possible AMI.  Subsequently, concurrent reviews continue until an AMI is ruled out or diagnosis of an AMI is made.  Cardiac discharge orders and standardized orders regarding ACEI/ARB contraindications are utilized.  Concurrent reviews by the Core Measure Coordinator or Quality Improvement Coordinator occur.  At discharge, a concurrent review occurs with the staff nurse and the Core Measure Coordinator.  If the appropriate medication is not ordered at discharge and no contraindication is documented, the nurse will call the physician to discuss the medication.

Our hospital’s collaborative effort with our community Emergency Medical System (EMS) has been phenomenal.  The paramedics utilize a protocol to identify patients with STEMI.  If the EKG indicates the patient is experiencing a STEMI, the paramedic calls the Emergency Department while in transport.  The Emergency Department charge nurse immediately notifies the cardiac cath lab and interventional cardiologist after receiving the call.  The Emergency Department Physician sees the patient on arrival to the ED, verifies the EKG, and discusses treatment the patient received from paramedics.  The patient is then transported directly to the cardiac cath lab.  Coordinated team effort beginning with the EMS, the Emergency Department physicians and nurses, our interventional cardiologists and the staff in the Cardiac catheterization lab make it happen every day.

Percent AMI patients who received ACEI or ARB (with LVSD) at discharge:
For the first three quarter of 2008, 100% of patients with AMI and LVSD were discharged on an ACE inhibitor or ARB.  In 2007, comparing the same 3 quarters, 97.2% and in 2006, 91.4% were discharged on an ACE inhibitor or ARB with LVSD. 

Percent of patients who received primary PCI within 90 minutes of arrival:
For the first three quarters of 2008, our facility had an average door-to-balloon time with patients with STEMI, of less than 60 minutes (mean of 57.1 minutes) and 98% of STEMI patients had primary PCI in less than 90 minutes.  In 2007, the time from door-to-balloon was a mean of 65 minutes and 88% of patients with a STEMI had PCI within 90 minutes of arrival.  In 2006, the first two quarters of the year the mean time for PCI after arrival was 177 minutes.  After June 2006, with implementation of the above interventions, the mean time decreased in the last two quarters of 2006 to a mean of 79.5 minutes.

Percent AMI patients who received ASA within 24 hours before or after hospital arrival:
For 2005, the percent of AMI patients who received ASA within 24 hours before or after hospital arrival was 93.6%; 2006 = 96.2%; 2007 = 99.3% and the first 3 quarters of 2008 = 96.4%. 

Percent AMI patients prescribed ASA at discharge:
For 2005, the percent AMI patients prescribed ASA at discharge was 92.5%; 2006 = 96.5%;  2007 = 98.7%: and the first 3 quarters of 2008 = 99.6%. 

Percent of AMI patients who received beta-blockers within 24 hours after hospital arrival:
For 2005, the percent of AMI patients who received beta-blockers within 24 hours after hospital arrival was 87.9%; 2006 = 92.9%; 2007 = 95.7%; and the first 3 quarters of 2008 = 97.6%.  

Percent of AMI patients prescribed beta-blocker at discharge:
For 2005, the percent of AMI patients prescribed beta-blocker at discharge was 92.3%; 2006 = 98.7%; 2007 = 99.4%; and for the first 3 quarters of 2008 = 98.8%.  

Percent of AMI patients (cigarette smokers) who received smoking cessation advice or counseling during hospital stay:
For 2005, the percent of AMI patients (cigarette smokers) who received smoking cessation advice was 88.6%; 2006 = 99.3%; 2007 = 100% and the first 3 quarters of 2008 = 100%. 

Percent of AMI Patients with Perfect Care: In 2007, percent of AMI with perfect care  was 92.2%.  In 2008, for the first 3 quarters the percent of AMI with "Perfect Care" was 94.7%.

AMI Inpatient Mortality: In 2006, observed mortality was 4.3% and risk adjustment was 3.99%.  In 2007, observed mortality was 3.27% and risk adjusted was 3.52%.  In 2008, for the first 3 quarters, observed mortality is 4.3%.

[2/10/09]

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Kapiolani Medical Center at Pali Momi – Aiea, HI
Availability Status: Available to answer requests
Licensed Beds: 116
Teaching / Non-Teaching Status: Non-Teaching
Setting: Rural
Start Date of Intervention Work: June 2005
Mentor Contact Name: Richard Giardina, Director of Quality
Mentor Contact Email: Richard.giardina@kapiolani.org
Mentor Contact Phone: 808-485-4683

Additional Information:

• Within first 6 months physician education
• Hand written cards of thanks and public recognition of compliance rates occurred
• Individual physicians were shown their compliance rates when they were under achieving
• Joint chart review between Quality Dept and physician began at 6 months and continue to present
• Nursing education and buy in to audit for compliance
• Physician to physician accountability of bundle elements began at 12 months
• 100% chart audit is ongoing
• New physician orientation to process and expectations began at 18 months

• Pre-intervention (retrospective) measurement: January to October 2004 gave value of 35% compliance.  Our AMI mean composite score at this time was only 26%.
• After 1st six months: reduction in mortality of 47%
• After 18 months: reduction in mortality of 87%
• 1st six months: < 50% compliance by physicians involved in care of the AMI patient
• After 12 months: 100% compliance
• Pali Momi has now achieved 17 months of 100% compliance to bundle for all AMI patients

[2/7/07]

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McLeod Regional Medical Center – Florence, SC
Availability Status: Unavailable to answer requests
Licensed Beds: 371
Teaching / Non-Teaching Status: Non-Teaching
Setting: Urban
Start Date of Intervention Work: October 2004
Mentor Contact Name:
Mentor Contact Email:
Mentor Contact Phone:

Additional Information:

The following Quality Indicators have been utilized to improve care: Aspirin on arrival and at discharge.  Beta Blockers on arrival and at discharge.  ACE/ARB for EF < 40%. Smoking Cessation Counseling.  PCI within 90 minutes.  Thrombolysis within 30 minutes.

We have utilized evidence-based practice and physician-led teams to accomplish a composite score of 96.99% from Oct 04 to June 05.

[2/14/06]

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Mercy Medical Center – Cedar Rapids, IA
Availability Status: Available to answer requests
Licensed Beds: 445
Teaching / Non-Teaching Status: Teaching
Setting: Urban
Start Date of Intervention Work: January 2004
Mentor Contact Name: Sue Dawson, MA, RN, CCRP
Mentor Contact Email: sdawson@mercycare.org
Mentor Contact Phone: 319-221-8536 or 319-533-8869

Additional Information:

Mercy developed the "ABCDs of Care” concept as a quick and easy way to highlight all Class I recommendations for the care of the AMI patient:
A - Aspirin on admission and discharge AND ACE- I or ARB for an EF < 40%
B - Beta-Blockers on admission and discharge
C - Cholesterol assessment and treatment
D - Dysphagia screening on admission to the unit
S - Smoking cessation education (if the patient has smoked within the previous year)

Additionally, all cardiac order sets highlight the Class I recommendations for the care of the AMI patient.
Developed the "Evidence-Based Risk Stratification Tool" for any patient that presents as a potential acute coronary syndrome patient.
In June 2005, convened the first STAT (STEMI Time to PTCA Action Team) meeting. This is a multidisciplinary team approach to improving the care of the ST-Segment Elevation MI (STEMI) patients.

Percent AMI patients who received ASA within 24 hours before or after hospital arrival
2007, 2008 & First 3 Q 2009: 100%

Percent AMI patients prescribed ASA at discharge
2007, 2008 & First 3 Q 2009: 100%

Percent of AMI patients prescribed beta-blocker at discharge
2007, 2008 & First 3 Q 2009: 100%

Percent of AMI who were prescribed for ACEI or ARB at discharge
2008 & First 3 Q 2009: 100%

In June 2005, Mercy's average door-to-balloon time was 125 minutes and by March 2006 our average time had decreased to 80 minutes.  By the 2nd Q 2009, our overall average is 59 minutes.

Percent of AMI patients (cigarette smokers) who received smoking cessation advice or counseling during hospital stay
2007, 2008 & First 3 Q 2009: 100%

In the 4th Q 2005, Mercy had 100% compliance in ASA on admission and discharge, Beta-blockers on admission and discharge, ACE-I/ARB for LVSD, and smoking cessation education.

Percent of AMI Patients with "Perfect Care": 95-100% every quarter for over 2 years

*AMI Inpatient Mortality
Hospital-wide mortality reduction of 5.29%
• STEMI mortality decrease from 2004 to 2006: 82%
• STEMI mortality decrease from 2005 to 2006: 77%
The 2nd Q 2009 demonstrated a 0% mortality rate in the overall AMI population.

We have had no serious adverse events in our STEMI population since Jan of 2007.  This equates to:
• Return on QI investment: $182,545
• Cost vs. aggregate return on QI investment: 420%

Mentor designation - 3/17/07
Information updated - 10/19/09

*                *                  *

North Suburban Medical Center – Thornton, CO
Availability Status: Available to answer requests
Licensed Beds: 157
Teaching / Non-Teaching Status: Non-Teaching
Setting: Urban
Start Date of Intervention Work: July 2004
Mentor Contact Name: Eileen Caden
Mentor Contact Email: eileen.caden@healthonecares.com
Mentor Contact Phone: 303-450-4559

Additional Information:

Initiated North Metro Cardiac Alert involving 5 EMS agencies.  EMS interpret 12 lead EKG in field and notify ED physician of acute MI.  Cardiac alert is called in house.  The cardiac alert team consists of cardiologists and cardiovascular lab staff.

Implemented new order sets for early administration of aspirin and beta blocker and added documentation area for contraindications.

Constant feedback to physicians on compliance with the bundle through congratulatory certificates, letters, graphics, posters and department meetings.

Current PCI time of 61 minutes and and overall 97% compliance with the bundle.

[5/12/06]

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Northwestern Memorial Hospital – Chicago, IL
Availability Status: Available to answer requests
Licensed Beds: 811
Teaching / Non-Teaching Status: Teaching
Setting: Urban
Start Date of Intervention Work: December 2003
Mentor Contact Name: Bob Costello
Mentor Contact Email: rcostell@nmh.org
Mentor Contact Phone: 312-926-4714

Additional Information:

Successful Implementation Strategies
(1) Collaboration of ED, Cardiology and Cath Lab clinicians
(2) Dedicated EKG room in the ED
(3) Algorithm for patients with signs and symptons of AMI based on AHA guidelines
(4) Standardized protocol for care
(5) Continuous review of outliers

Performance continues to exceed 95% compliance with AMI guidelines.

[1/31/06]

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Our Lady of Lourdes Memorial Hospital – Binghamton, NY
Availability Status: Available to answer requests
Licensed Beds: 267
Teaching / Non-Teaching Status: Non-teaching
Setting: Rural
Start Date of Intervention Work: March 2004
Mentor Contact Name: Terry Harris, RN-C, CPHQ Quality Specialist
Mentor Contact Email: tharris@lourdes.com
Mentor Contact Phone: 607-798-5778

Additional Information:

Keys to our success:

The AMI team developed and tested pre-printed physician orders.  The orders were tested in the Emergency Department and on the telemetry unit.  Over the years, these have been revised and updated.

The ED Staff also have a Chest Pain Progress Note which steers the ED staff toward documenting the required "time frames" and required core measures which helps with compliance with the measures.  The team also added the indicators to the patient care path, patient teaching guide and the discharge instructions.

To improve measures and to gain individual knowledge of each variance and to gain individual acountability, monthly variance reports are generated and shared with CMO, CNO, Nurse Directors, and ED Medical Director for knowledge and follow throughs as necessary.  Also, each individual provider or nurse receives a Core Measure letter documenting the variance. Most of our documentation is electronic at this point which also helps steer compliance with the required core measures.

Our hospital does not have a cardiac cath lab.  We worked collaboratively with the other hospital in town to transfer our AMI patients in need of an urgent cardiac cath within 60 - 90 minutes, so the patient can have the PCI within the 120 minutes as recommended by JCAHO and CMS.

                                            2004     2005      2006      2007      2008      2009
ASA @ Arrival:                       94%     96%       98%      95%       100%     100%
ASA @ Discharge:                  94%     95%       100%     99%      100%      100%
ACEI / ARB LVSD:                  82%     94%       85%      100%     100%     100%
Smoking Cessation Advice:     62%     100%     100%     100%     100%     100%
Beta Blocker @ Arrival:           95%     95%       98%      97%       100%     98%    
Beta Blocker @ Discharge:      93%     96%       96%      99%       99%       99%
Inpatient Mortality:                 8.4%    7.4%      8%        12%       13%       14% 

Mentor designation - 1/31/06
Information updated - 3/16/10

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Parkview Medical Center – Pueblo, CO
Availability Status: Available to answer requests
Licensed Beds: 305
Teaching / Non-Teaching Status: Non-teaching
Setting: Urban
Start Date of Intervention Work: July 2003
Mentor Contact Name: Judy Sikes, PhD, CPHQ
Mentor Contact Email: jsikes@parkviewmc.com
Mentor Contact Phone: 719-584-4650

Additional Information:

Parkview Medical Center has chosen to participate in all of the AMI measures and we believe the overall process has contributed to the lowering of our AMI mortality rate.

We have found that constant communication between the staff and physicians contributes to our success in lowering our AMI mortality rate.  We continue to work on PCI timing and we have established an interdisciplinary team with the ER physicians, cardiologists and staff.

Percent AMI patients who received ASA on Arrival: 
100% for the past 43 months except 3/09 when it was 93% due to one missed patient.

Percent AMI patients prescribed ASA at discharge: 
100% for the past 43 months except 91% for 1/09 and 95% for 4/09 due to one missed patient each month.

Percent of AMI patients prescribed beta-blocker at discharge:   
100% for the past 30 months

Percent of AMI who were prescribed for ACEI or ARB at discharge:
100% since April 2005

Average door-to-balloon time for 2009 is 98 minutes.

Percent of AMI patients (cigarette smokers) who received smoking cessation advice or counseling during hospital stay:
100% since June 2004

Percent of AMI Patients receiving "Perfect Care":
93% average for the the first nine months of 2009.

JCAHO AMI mortality rate for 2009 is 4.0%
Parkview Medical Center AMI mortality rate for same period: 0%

Mentor designation - 3/13/07
Information updated - 2/22/10

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Ridgeview Medical Center – Waconia, MN
Availability Status: Available to answer requests
Licensed Beds: 129
Teaching / Non-Teaching Status: Non-Teaching
Setting: Urban
Start Date of Intervention Work: January 2003
Mentor Contact Name: Melissa Pitts
Mentor Contact Email: melissa.pitts@ridgeviewmedical.org
Mentor Contact Phone: 952-442-2191 ext. 5142

Additional Information:

Ridgeview implemented an acute cardiac care program in partnership with a tertiary care facility in 2003, utilizing evidence-based protocols.  The protocols have become the standard of care for all cardiac patients in the ED, regardless of disposition. Current work is underway to build the principles of reliability into the AMI order set.

Ridgeview has achieved seven months of ‘perfect care’ for the AMI patients.

[2/14/06]

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River's Edge Hospital & Clinic – St. Peter, MN
Availability Status: Available to answer requests
Licensed Beds: 22
Teaching / Non-Teaching Status: Non-teaching
Setting: Rural
Start Date of Intervention Work: March 2005
Mentor Contact Name: Benjamin W. Chaska, M.D., MBA, CPE, FACPE, Chief Medical Officer and Patient Safety Officer
Mentor Contact Email: bchaska@riversedgehealth.org
Mentor Contact Phone: 507-934-8416

Additional Information:

Adaptation: Reliable and timely treatment, stabilization and transfer for acute MI patients seen in the Emergency Department.

Actions Taken:
• Standardized chest pain protocol
• Incorporated into order set
• Adopted Mayo Clinic Fast Track for ST elevation MI
• Communicated expectations for time and process

Results: Reliable AMI care provided for all patients with AMI.

ASA administered at discharge within 10 minutes 100% of the time.

Beta Blockers at discharge administered 100% of the time.

Patients transferred in 30 to 60 minutes to definitive AMI care.

Mentor designation - 1/31/06
Information updated - 2/22/10

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Saint Agnes Medical Center – Fresno, CA
Availability Status: Available to answer requests
Licensed Beds: 434
Teaching / Non-Teaching Status: Non-Teaching
Setting: Urban
Start Date of Intervention Work: October 2004
Mentor Contact Name: Carolyn Okamoto RN
Mentor Contact Email: carolyn.okamoto@samc.com
Mentor Contact Phone: 559-450-3381

Additional Information:

• Saint Agnes has an active multi-disciplinary performance improvement team for AMI care, with a specific focus on the STEMI/PCI process starting with EMS to when the patient reaches the cath lab for intervention.
• Excellent times have been achieved as a result of the collaborative efforts between EMS, Emergency Department staff and physicians, EKG technicians, cath lab staff and Cardiologists.
• Use of a simultaneous paging system to activate the Cath lab team and Cardiologist has helped to cut down on unnecessary phonecalls.
• Valuable time has been saved by empowering our Emergency Department physicians to activate the Cath Lab team and Cardiologist as soon as a STEMI patient is identified in the ED, or when EMS call in a positive ST elevation EKG performed in the field. 
• Concurrent data is collected on all STEMI patients and reviewed monthly with the AMI performance improvement team.  Outlying cases (cases lasting > 90 minutes) are reviewed immediately by our Outcomes Physician and feedback is provided to the appropriate department or physician.  Unblinded data on all cases is reviewed regularly at the Cardiology Committees.
• Early identification of AMI patients in the Emergency Department, use of standardized order sets, and concurrent data collection to feedback real-time performance to clinical staff has consistently resulted in meeting the core measures for ASA, Beta-blocker and ACEi/ARB therapy for AMI patients.
• The process for ensuring patients receive Smoking Cessation Counseling has been hardwired in to our system.  Process changes started in 2006 included the patient being asked questions regarding their smoking history at the time of registration, appropriate smoking cessation counseling literature being provided at that time, and subsequent follow-up being done by the respiratory therapy department for specific patient needs. 

• Mean "door-to-balloon" time improved at Saint Agnes from 100 minutes in 2006 to 61 minutes in 2007.
• STEMI cases at Saint Agnes meeting the "door-to-balloon" standard of < 90 minutes improved from 66% in 2006, to 94% in 2007.
• Remarkable "door-to-balloon" times of < 40 minutes (fastest time 24 minutes) have been achieved by many of our community-based cardiologists.
• AMI core measures for ASA & Beta-blocker within 24 hrs and at discharge have consistently been met 97-100% of the time in the last 2 years.
• AMI patients needing ACEi/ARB therapy at discharge have received it 100% of the time for the last year.
• In 2005, compliance with the smoking cessation measure for our AMI patients was at 88%.  Process changes resulted in our compliance improving to 100% for 2006 and 2007.

As process improvements have been implemented for AMI care at Saint Agnes, this has been reflected in our in-patient mortality rates.  In 2005, when our mean door-to-balloon time was 163 minutes and "perfect care" for our AMI patients was at 78%, our in-patient mortality rate was at 11.6%.  In 2006, mean door-to-balloon time improved to 99.7 minutes, "perfect care" was provided for AMI patients 96% of the time, and mortality was 7.4%.  We are excited that during 2007, as our mean door-to-balloon times have dropped significantly to 63 minutes, "perfect care" is at 97%, and in-patient mortality is down to 3.4%.

(Note: this is raw mortality data, not risk-adjusted.)

[3/24/08]

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St. Elizabeth Medical Center – Edgewood, KY
Availability Status: Available to answer requests
Licensed Beds: 639
Teaching / Non-Teaching Status: Teaching
Setting: Urban
Start Date of Intervention Work: April 2002
Mentor Contact Name: Jean Smith
Mentor Contact Email: jsmith@stelizabeth.com
Mentor Contact Phone: 859-301-3858

Additional Information:

St. Elizabeth strives to be one of the top heart hospitals in the nation.  Administration and the Medical Staff have worked closely with the quality improvement team to accomplish this goal.  Through monitoring, analyzing and changing the patterns of care we have successfully implemented best practices by improving processes and outcomes.

Smoking cessation education improvement was accomplished by taking the approach that all patients - not only AMI patients - should be educated.  Smoking cessation packets are now placed in all admission packets and education begins at that time.  It has also been included on the discharge instruction form to reiterate the importance of smoking cessation prior to discharge.

ACEI/ARB at discharge improved through continual communication with the Medical Staff.  Stickers were developed to remind staff of the need for ACEI/ARB, standing orders were revised, educational sessions were held outside the medical staff lounge and informational letters were sent to physicians not following the protocol.

A multidisciplinary team was developed and multiple improvement initiatives were developed, including but not limited to: data collection tool that would look at every measurable time frame, EKG's given directly to physician for reading, education provided to ED physicians and staff, procedure for notifiying on call staff changed, and reinservicing was done when variances were identified.

Through process changes and continual feedback to staff St. Elizabeth has been successful in improving care in several areas:
• Smoking cessation education has improved from 77% in the 3rd quarter of 02 to 100%.
• ACEI/ARB at discharge for EF < 40% has improved from 67% to 100%.  This was accomplished through continual communication with the Medical Staff.

Mean time to PCI has improved from 92.9 minutes to 82.4 minutes.

[6/2/06]

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St. Luke’s Hospital – Cedar Rapids, IA
Availability Status: Available to answer requests
Licensed Beds: 560
Teaching / Non-Teaching Status: Non-Teaching
Setting: Urban
Start Date of Intervention Work: January 2005
Mentor Contact Name: Peg Bradke
Mentor Contact Email: BradkeMM@crstlukes.com
Mentor Contact Phone: 319-369-7269

Additional Information:

Interdepartmental team used Six Sigma to elevate the process.  Significant data collection drove the process.

2008 and 2009 key improvement processes:

1) Frontline Emergency Department and Cath Lab staff involved in review of all cath lab alerts twice a month.  This facilitated finding solutions to issues that presented themselves.  It has also led to the staff being proactive in discussing interdepartmental issues outside the twice monthly meetings.

2) Feedback to Emergency Department, Cath Lab and physicians involved in each case regarding the D2D times.  We include the breakdown of each of the components of the time.  This information is emailed to those involved.  This has provided helpful feedback from all regarding barriers that they encounter or issues that have come up.

3) Continual work on the ED door-to-EKG time.

4) Frontline staff suggestions for various process improvements, e.g., one of the cath lab staff on the case is sent to the ED to help get the patient transported to the cath lab in a timely manner.

5) Work with outlying hospitals on STEMI transfer patients.  Working a process to facilitate taking the patient directly to the cath lab.  Also working on the initiation of a "one call" system for the transferring hospital and transmission of patient paperwork by fax after the patient is enroute to our facility and feedback loop to the sending facility regarding times and outcomes in the cath lab.

AMI patients who received ASA within 24 hours before or after hospital arrival:

July to December 2006  98/98  100%
2007  204/204  100%
2008  179/179  100%
2009  207/207  100%

AMI patients prescribed ASA at discharge:

July to December 2006  108/110  98.2%
2007  225/227  99.1%
2008  222/222  100%
2009  245/245  100%

AMI patients prescribed beta-blocker at discharge:

July to December 2006  123/125  98.4%
2007  230/230  100%
2008  226/226  100%
2009  237/237  100%

AMI patients prescribed ACEI or ARB at discharge:

July to December 2006  13/15  86.7%
2007  27/28  96.4%
2008  20/20  100%
2009  30/33  90.9%

AMI patients who received thrombolytics within 30 minutes of hospital arrival:

July to December 2006  1/1  100%
2007   0  0  NA
2008   -  -   NA
2009   1/1  100%

AMI Patients who received Percutaneous Coronary Intervention PCI within 90 minutes of hospital arrival:

July to December 2006  21/33  63.6%
2007   44/52  84.6%
2008   32/35  91.4%
2009   47/49  95.9%

Average door-to-balloon time:

July to December 2006  89 minutes
2007   76 minutes
2008   68 minutes
2009   61 minutes

AMI patients (cigarette smokers) who received smoking cessation advice or counseling during hospital stay:

July to December 2006  49/49  100%
2007  79/79  100%
2008  96/98  98%
2009  85/87  97.7%

Percent of AMI Patients with "Perfect Care"

Q1 2007  91%
Q2 2007  96%
Q3 2007  94%
Q4 2007  99%
Q1 2008  99%
Q2 2008  96%
Q3 2008  94%
Q4 2008  99%
Q1 2009  87%
Q2 2009  99%
Q3 2009  99%

AMI Inpatient Mortality

July to December 2006  2/138  1.4%
2007  10/259  3.9%
2008  5/214  2.3%
2009  2/209  1.0%

Mentor designation - 8/31/06
Information updated - 3/15/10

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Saint Luke's Hospital – Kansas City, MO
Availability Status: Available to answer requests
Licensed Beds: 576
Teaching / Non-Teaching Status: Teaching
Setting: Urban
Start Date of Intervention Work: February 2005
Mentor Contact Name: Geri Seavey
Mentor Contact Email: gseavey@saint-lukes.org
Mentor Contact Phone: 816-932-5692

Additional Information:

Patients presenting to SLH ED with ST-elevation MI receive reperfusion in less than 120 minutes.  Goal shifts to 90 minutes in 2006 and process will be extended to ST-elevation patients received in transfer.

% of patients who presented with ST-elevation MI who received reperfusion in less than 120 minutes went from 55% in 2004 to 100% in 2nd quarter 2005.

[1/31/06]

*                *                  *

St. Mary Medical Center – Apple Valley, CA
Availability Status: Available to answer requests
Staffed Beds: 186
Teaching / Non-Teaching Status: Non-Teaching
Setting: Urban
Start Date of Intervention Work: September 2003
Mentor Contact Name: Teresa Brown, RN, ED Director; Staci Brady, RN, Cath Lab Team Leader
Mentor Contact Email: Teresa.Brown@stjoe.org; Staci.Brady@stjoe.org
Mentor Contact Phone: 760-242-2311 ext. 6525 (Brown); 760-242-2311 ext. 8793 (Brady)

Additional Information:

2009 Data:

MI patients who received ASA within 24 hours before or after hospital arrival: failure rate for rolling 12 months
Only one failure for 2009
AMI patients prescribed ASA at discharge: failure rate for rolling 12 months
4 failures for 09
AMI patients prescribed beta-blocker at discharge: We are currently at a % failure rate for rolling 12 months
3 failures for 2009
AMI patients who were prescribed for ACEI or ARB at discharge: % failure rate for rolling 12 months
One failure for 2009
AMI patients who received either thrombolytics within 30 minutes of hospital arrival
or PCI < 90 minutes: Rare use of lytics and no fallouts; only one PCI fallout for 2009 at 92 minutes

We failed to give smoking cessation advice 50% of the time in 2004.  We are currently at a zero failure rate for over two years.

Percent of AMI Patients with Perfect Care: When we began the HQID Project five years ago, we were in the 9th decile; we have received most improved status.  Our current 2009 aggregate failure rate is 1.3%. 

AMI Inpatient Mortality: Non-risk adjusted mortality was 5% two years ago and is currently 3% for the rolling 12 months (40% reduction).

2008 Data:

AMI patients who received ASA within 24 hours before or after hospital arrival: 1% failure rate for rolling 12 months

AMI patients prescribed ASA at discharge: 2% failure rate for rolling 12 months

AMI patients who received beta-blockers within 24 hours after hospital arrival: 1% failure rate for rolling 12 months

AMI patients prescribed beta-blocker at discharge: We were identified previously as an outlier by the Joint Commission for failing to prescribe beta-blockers at discharge.  We are currently at a 2% failure rate for rolling 12 months

AMI patients who were prescribed for ACEI or ARB at discharge: 2% failure rate for rolling 12 months

AMI patients who received either thrombolytics within 30 minutes of hospital arrival or PCI within 120 minutes of hospital arrival: For 2008 YTD for all STEMI patients, 92% of cases in 2008 were under 90 minutes.  (8% failure rate)

We failed to give smoking cessation advice 50% of the time in 2004.  We are currently at a zero failure rate for over a year.

Percent of AMI Patients with Perfect Care: When we began the HQID Project five years ago, we were in the 9th decile; we are currently at a 3.33% failure rate.

AMI Inpatient Mortality: Observed to expected mortaltiy O/E is .66 for 2009

• The project began as a quality department project and has now become integrated into the organizational work we do each day.  The care has become standardized with minimal variation.
• We have spread our successes with AMI to other areas of patient safety and quality.  We learned by working locally with our St. Joseph Health-system’s Perfect Care calls, statewide with our state’s Quality Improvement Organization (QIO) and internationally with the Institute for Healthcare Improvement.
• Everyone knows their role and is engaged from the CEO, to middle management to the frontline staff.
• Perfect care is one of our St. Joseph Health-system goals and it is not just something written on a piece of paper, it is real and achievable.
• We work as a team with a common purpose, not in silos. 
• Our partnership with EMS has improved our Door-to-Balloon Times.  We recognize not only our frontline staff for great Door-to-Balloon Times (D2B) but our EMS partners as well.
• We are now a regional STEMI Receiving (SRC) Center.
• Our EMS pre-hospital positive EKG to balloon time consistently under 90 minutes (E2B).
• Our average D2B time is 62 minutes.  The average Pre-hospital EKG to balloon time (E2B) is 95 mintues.  We have  long transport times.
• The process for obtaining EKG in less than 10 minutes is hardwired.
• Our ED physicians activate the cath lab (this has improved our times dramatically).
• Our Cardiac Cath Lab has won the highest patient satisfaction scores three of the last four years.
• A perfect care check list at discharge mitigates failure.

2010:

SMMC has two members of AHA Western States STEMI taskforce.

We are improving transfer times for inter-facility STEMI patients and have gone from the first quarter of 2009 transport times of 6 hours 5 minutes to current transfer time of 92 minutes with a significant decline in mortality.

We provide feedback to referral facilities 100% of the time.

We recognize our EMS partners with a wall of recognition and use this to teach them about 12 lead changes.  SMMC developed regional EMS cardiac classes a year ago.  Medical simulation process used for improving STEMI care with a scenerio involving our EMS partners.  Using Toyota lean tools and the St. Mary Way to improve cardiac quality involving EMS partners.

Standardized roles for Code STEMI. Developed a STEMI box with all needed medications.  Overhead page Code STEMI now and ancillary departments such as lab and radiology come emergently like a trauma.  Trialing pre-hospital activation of cath lab.

SMMC is part of a panel discussion on Medical Simulation at 2010 ACC Scientific Sessions in Atlanta.

Piloting pre-hosptial EKG transmission and spreading it this year to a new broadband EKG receiving station.

Mentor designation - 10/23/08
Information updated - 2/10/10

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Southwestern Vermont Medical Center – Bennington, VT
Availability Status: Available to answer requests
Licensed Beds: 99
Teaching / Non-Teaching Status: Non-Teaching
Setting: Rural
Start Date of Intervention Work: January 2001
Mentor Contact Name: Mark Novotny, MD
Mentor Contact Email: mnn@phin.org
Mentor Contact Phone: 802-447-5006

Additional Information:

• We have imbedded triggers for medications on the CCU order set.  If physicians do not order these medications, they have to state why in their documentation.
• We have two cardiologists who end up seeing the majority of our AMI patients – either as the admitting physician or consulting (cardiology consult is a part of everyone’s care).
• The cardiologists know the guidelines and help to ensure patients are on the appropriate meds.
• We provide consistent communication (via clinical nurse specialist responsible for following AMI patient population) back to all disciplines through outcomes reports that look at compliance with interventions and outcomes of care.
• AMI care is discussed in many different arenas including: nursing meetings, ICU daily rounds, physician team meetings, ICU Committee, etc. such that everyone collectively is working on it.

In FY 2005, 97% of patients diagnosed with MI received ‘perfect care’ – meaning that they received all key interventions for treatment of MI.

AMI in-patient risk-adjusted mortality index (Delta Data) has dropped 60% since 2000.

[2/14/06]

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Tacoma General/Allenmore Hospital – Tacoma, WA
Availability Status: Available to answer requests
Licensed Beds: 521
Teaching / Non-Teaching Status: Non-Teaching
Setting: Urban
Start Date of Intervention Work: July 2005
Mentor Contact Name: Christi McCarren, RN, MBA, Administrator, Cardiovascular Services
Mentor Contact Email: christi.mccarren@multicare.org
Mentor Contact Phone: 253-403-1617

Additional Information:

On July 5, 2005, Tacoma General and Allenmore hospitals implemented an improvement process to provide rapid diagnosis and treatment of patients presenting with a myocardial infarction (heart attack).  The redesigned process was dubbed “Code STEMI” (ST-elevation myocardial infarction) and provides the means for all necessary healthcare professional to converge in the emergency department, facilitate consistent adherence to published clinical guidelines, while decreasing the time to treatment and saving precious heart muscle.

Through the Cardiology Clinical Practice Committee and the Ad Hoc Code STEMI working sub-group, all necessary team members were identified.  Part of our success was due to the development of a very specific treatment algorithm where roles, duties and expectations were delineated, and treatments and timeframes were established.

Prior to the process redesign, our time to treatment was consistently greater than 110 minutes – well above the ACC/AHA 90 minute target.  The best heart centers around the country have been able to achieve time to treatment of 60 minutes.  Our entire team felt our community deserved nothing but the best, so we established the same 60 minute goal.  The most significant change to our process was having the emergency department physicians activate the cardiac call team if it was determined a heart attack was underway.  This single process change shaved a minimum of 30 minutes off the total time to treatment.  Our team approach and the adoption of the ACC/AHA clinical guidelines have dramatically improved the care provided to these critically ill patients.  We are proud to report that our mean time to treatment at the end of 2005 was 73 minutes, a 33% improvement in the first six months of this important process redesign.

Overall 2005 year end interval averages are as follows:

Door to ECG:	5.0 minutes	(target=5)
Door to Transport:	39.5 minutes	(target=40)
Door to Stick:	58.0 minutes	(target=50)
Stick to Balloon:	16.6 minutes	(target=10)
Door to Balloon/Flow:	73.8 minutes	(target=60)

Relative to state averages:
Under 90 minutes 81% of the time (state average = 51%)
Under 60 minutes 26% of the time (state average = 21%)

Time to Treatment by shift:

Days	62.4 minutes
Evenings	75.4 minutes
Nights	85.8 minutes

Focus for 2006:
Increase percentage of patients receiving treatment under 60 minutes to 35%.
Increase percentage of patients receiving treatment under 90 minutes to 90%.
Implement in-house Code STEMI process by March 1, 2006

[3/30/07]

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United Hospital Center – Clarksburg, WV
Availability Status: Available to answer requests
Licensed Beds: 318
Teaching / Non-Teaching Status: Teaching
Setting: Rural
Start Date of Intervention Work: July 2003
Mentor Contact Name:  Mark Povroznik, PharmD, Director, Quality Initiatives
Mentor Contact Email: povroznikm@uhcwv.org
Mentor Contact Phone: 304-624-2088

Additional Information:

Over the past four years, UHC has gone from a predominantly manual process to a more streamlined electronic abstraction process.  The first step in our success was the implementation of Horizon Patient Folder.  This system allows abstractors to review charts that are electronically triggered for review seven days after discharge.  This allows official data to be available quicker and provide more timely feedback to providers on specific cases that have missed opportunities.

UHC's success specifically related with AMI is largely attributed to building redundancies into the patient care processes. Smoking cessation is incorporated both on the admission assessment, as well as on the Respiratory Therapy assessment.  The Patient Discharge Instructions were also revised to include ACEI/ARB, Aspirin, Beta Blockers, and Smoking Cessation.  Recent implementation of a computerized nursing documentation system has also greatly increased compliance by building the required data elements into the system.

Since January 2007, there has been an increased focus on PCI throughput times.  The Emergency Department and Cardiovascular Department have teamed with local EMS personnel to trigger the call initiation while the patient is still enroute to the hospital.  UHC is in a rural area and it can take 30 to 60 minutes to even transport a patient to this facility.  Despite this obstacle, UHC has been able to reduce median PCI time to 59 minutes in the 1st  Quarter of 2007, with 100% being less than 90 minutes.

UHC has had great success with the AMI process and outcomes measures over the past several years:

	2003	2004	2005	2006
Aspirin at Arrival	85.4%	91.4%	99.2%	100%
Aspirin at Discharge	77.9%	90.6%	97.9%	100%
Beta Blocker at Arrival	83.0%	100%	99.1%	100%
Beta Blocker at Discharge	86.2%	100%	97.9%	100%
Smoking Cessation/Counseling	54.8%	75.0%	100%	100%
Mortality	14.9%	12.1%	6.8%	7.9%
% PCI < 120 minutes	40.0%	84.6%	88.6%	1st Half 2006 - 88.9%

% PCI < 90 minutes (measure changed to 90 minutes 7/1/2006)
2nd Half 2006 - 84.2%, 1Q2007 - 100%

Median PCI Times over the past 5 quarters has improved dramatically:
1Q06 = 85 minutes, 2Q06 = 72 minutes, 3Q06 = 78 minutes, 4Q06 = 71 minutes, 1Q07 = 59 minutes

[12/3/07]

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University of California, San Diego Medical Center – San Diego, CA
Availability Status: Available to answer requests
Licensed Beds: 552
Teaching / Non-Teaching Status: Teaching
Setting: Urban
Start Date of Intervention Work: July 2002
Mentor Contact Name: Andrea Snyder
Mentor Contact Email: agsnyder@ucsd.edu
Mentor Contact Phone: 619-543-6475

Additional Information:

Percent AMI patients who received ASA within 24 hours before or after hospital arrival
Apr 2008 - Mar 2009 = 99%

Percent AMI patients prescribed ASA at discharge
Apr 2008 - Mar 2009 = 100%

Percent of AMI patients prescribed beta-blocker at discharge
Apr 2008 - Mar 2009 = 100%

Percent of AMI who were prescribed for ACEI or ARB at discharge
Apr 2008 - Mar 2009 = 100%

Percent of AMI patients who received either thrombolytics within 30 minutes of hospital arrival or Percutaneous Coronary Intervention (PCI) within 120 minutes of hospital arrival
Apr 2008 - Mar 2009 = 64.5%

Percent of AMI patients (cigarette smokers) who received smoking cessation advice or counseling during hospital stay
Apr 2008 - Mar 2009 = 100%

Percent of AMI Patients with "Perfect Care"
Jul 2008 - Mar 2009 = 96%

AMI Inpatient Mortality
Our inpatient mortality is consistently below expected (based on UHC risk adjustment).
Apr 2008 - Mar 2009 = 1.95% compared to UHC expected of 4.89%

We have implemented standardized order sets, including admission and discharge orders and patient education.  We've gotten Respiratory Therapy involved in smoking cessation and provided physician/staff education and feedback.  We're also participating in a county-wide STEMI project, involving 12-lead EKGs in the field.  This valuable information gives us time to prepare our cath lab before the heart attack patient ever reaches our door.  We also have a STEMI kit with all the necessary equipment, so that staff are ready to provide care when the patient arrives.  In the end, great physician leadership and staff participation have been the key to our success.

Mentor designation - 6/10/06
Information updated - 10/19/09