Michael Mihara, MD
Shayne Castanera, MD
David Saito, MD
David Swanson, MD
Robert Canonico, MD
Michael Chan, MD
William Dang, MD
Hiro Makino, MD
Joel Kobayashi, MD
Louis Ragunton, MD
Kevin Hara, MD
Eric Smedegaard, MD
Nurses from Emergency Room, ICU, and Telemetry Units
Kelly Kawasaki, RN, Quality Management Coordinator
Steven H. Shaha, PhD, DBA
Kelle Payne, RN, Director of Quality, Patient Safety and Risk
Jen Chahanovich, Chief Operating Officer, Kapiolani Medical Center at Pali Momi
Brigitte McKale, Chief Nurse Executive
Bonnie Castonguay, RN, MBA
Hareesh Mavoori, PhD, MBA

Percentage of AMI eligible patients who received all 7 components of recommended and appropriate AMI care (as identified in the Centers for Medicare and Medicaid Services 7th Scope of Work and Joint Commission Core Measures):

1. Aspirin within 24 hours of arrival or within 24 hours prior to arrival
2. Beta-blocker within 24 hours of arrival
3. Thrombolytic agent received within 30 minutes of hospital arrival
4. Aspirin at discharge
5. Beta-blocker at discharge
6. ACEI inhibitor at discharge for LVEF < 40%
7. Patients with a history of cigarette use within the past year who receive smoking cessation advice or counseling during the hospitalization

Strategies

• Project charter approved by leadership and Quality Council October 2004 – with anticipated end date June 2005.
• Physicians caring for patients with the diagnosis of Chest Pain r/o MI, ACS, AMI, CHF, and any other similar diagnosis code were interviewed individually. Discussion included:
  • Best practice evidence-based medicine
  • Individual beliefs regarding care of patients with identified diagnoses
  • Barriers to providing best care
  • Methods to achieve best practice measures
• Nursing staff were interviewed both at staff meetings and on a 1:1 basis. Best practice was discussed and information exchanged regarding evidence-based protocols for treating patients with AMI and ACS.
• Order sets were created based on the discussion and monitoring was performed on aggregate physician compliance with order set utilization.
• Signed up for the IHI 100,000 Lives Campaign.

Changes

• Developed a care plan that can be individualized for patients with AMI/ACS.
• Provided education and training to both physicians and nursing staff regarding delivering evidenced-based practice.
• Ongoing data collection (concurrent chart review) and reporting of an overall AMI composite score as well as individual AMI measures. The use of composite or summary measures reduces the amount of information that consumers must process when making a decision.
• Placed laminated Best Practice Guidelines next to each dictation phone and provided pocket cards for the physicians.
• Routine meetings with physicians and nursing daily for the first six months to offer support and education.
• Compiled data using a risk stratification tool which included encounters with all physician areas (emergency department (ED), internal medicine, nephrologists, family practice, cardiology); then provided feedback to individual physicians with respect to how he/she was doing in providing desired measures for his/her patients.
• Compiled data for nursing regarding discharge education, medication reconciliation, smoking cessation counseling, activity recommendations, signs and symptoms to report to physician, as well as education regarding disease process. This information was presented at monthly staff meetings and on an individual basis.
• Personal and public recognition to both physicians and nursing staff that provided evidence-based, best practice care guidelines.
• Regularly monitored and shared with medical staff the compliance to Core Measures Data through JCAHO.
• Collaborated with Medical Staff Dept to create a privileging and credentialing packet to educate and inform physicians about facility expectations regarding documentation and treatment of patients that fall into this category.
• Enlisted help from physician champions from Cardiology, ED, Hospitalists, Internal Medicine, Nephrology, as well as from Quality Council, Critical Care and Cardiology Committee, and the Department of Medicine and posted results via poster boards.
• Validation of data abstracted from 3 sources (QM, CDAC, and other RN).
• Holding the gains: Use positive reinforcement to encourage ongoing excellence.

• Baseline data from Jan-Oct 2004 showed a mean AMI Composite Compliance Score of 26.3 percent, interpreted as 26.3 percent of cases for which all 7 measures were complete and correct. 
• Post-intervention showed a mean AMI Composite Score of 84.2 percent which rose to 100 percent compliance for nine consecutive months and counting. 
• Implementing the 7 components of AMI care significantly decreased our AMI mortality rate by 39.4 percent (p=0.0339), and our AMI-associated death rates were significantly reduced by 47 percent (p=0.0267).

Lesson Learned

• It is possible to achieve and maintain 100 percent compliance on Core Measures for AMI and experience the clinically beneficial impacts promised. 
• Though education is important, we found that clear communication of not just the goals, but also dissemination of the clinically-pertinent results that were achieved along the way was critical, and not merely shared in meetings, but one on one. This made it personal.

Kelle Payne, RN
Director of Quality, Patient Safety, and Risk
Kapiolani Medical Center at Pali Momi
kpayne@kapiolani.org