Clinical pathway: helicopter scene STEMI protocol to facilitate long-distance transfer for primary PCI.

BACKGROUND: The latest American College of Cardiology/American Heart Association guidelines recommend primary percutaneous coronary intervention (PCI) in acute ST-elevation myocardial infarction (STEMI) patients within 90 minutes from presentation to the emergency room. For interhospital transfers, the most recent PCI guidelines recommend first medical contact-to-device times ≤120 minutes. Although PCI-capable hospitals have improved door-to-balloon times, many patients present to non-PCI-capable facilities and have been excluded from national quality measures. METHODS: In our acute myocardial infarction network, not only do we enable non-PCI hospitals to transfer STEMI patients but empower outside emergency medical services (EMS) to activate the catheterization laboratory team with a burst page and transfer STEMI patients directly from the scene. Data on patient characteristics, outcomes, and time elements were collected for "scene STEMI" patients who circumvented outlying rural non-PCI hospitals and are presented in this case series. RESULTS: From December 2007 to November 2010, 22 STEMI patients with higher than average acuity were transported by helicopter directly to our medical center for primary PCI. Median distance from the scene to our medical center was 47 miles [25th to 75th interquartile range (IQR) = 39-71 miles]. Median EMS-to-balloon time was 120 minutes (IQR = 111-134 minutes). There were no false activations by EMS. In comparison, our median time for interhospital STEMI transfers (N = 335) was 145 minutes (IQR = 121-186 minutes) from 2007 to 2009. CONCLUSIONS: In our single-center experience, 22 scene STEMI patients were diagnosed and appropriately triaged by EMS to our center for primary PCI. Our data show feasibility of an EMS-activated STEMI network over long distances with good reperfusion times.

Learning curve in transradial cardiac catheterization: procedure-related parameters stratified by operators' transradial volume.

OBJECTIVE: To determine whether radial artery access is associated with a reduction in fluoroscopy time, procedure time, and other procedural variables over a 27-month period during which the radial artery approach was incorporated in a single academic Medical Center. BACKGROUND: Although previous studies have demonstrated a relationship between increased volume and decreased procedural time, no studies have looked at the integration of radial access over time. METHODS: Data were collected from consecutive patients who presented to the Vanderbilt University Medical Center cardiac catheterization laboratory from January 1, 2009 to April 1, 2011. Patients who underwent radial access diagnostic catheterization with and without percutaneous coronary intervention were included in this study. A total of 1112 diagnostic cardiac catheterizations through the radial access site were analyzed. High-volume, intermediate-volume, and low-volume operators were grouped based on the percentage of procedures performed through a radial approach. RESULTS: From 2009 to 2011, there was a significant decrease in fluoroscopy time in all operator groups for diagnostic catheterization (P=.035). The high-volume operator group had 1.88 and 3.66 minute reductions in fluoroscopy time compared to the intermediate- and low-volume operator groups, respectively (both P<.001). Likewise, the intermediate-volume operator group had a 1.77 minute improvement compared to the low-volume operator group, but this did not reach statistical significance (P=.102). The improvement in fluoroscopy time and other procedure-related parameters was seen after approximately 25 cases with further improvement after 75 cases. CONCLUSIONS: The incorporation of the radial access approach in the cardiac catheterization laboratory led to a decrease in fluoroscopy time for each operator and operator group over the last 3 years. Our data demonstrated that higher-volume radial operators have better procedure, room, and fluoroscopy times when compared to intermediate- and low-volume operators. However, lower-volume operators have a reduction in procedure-related parameters with increased radial cases. Number of procedures needed to become sufficient was demonstrated in the current study.

Effect of a pharmacist intervention on clinically important medication errors after hospital discharge: a randomized trial.

BACKGROUND: Clinically important medication errors are common after hospital discharge. They include preventable or ameliorable adverse drug events (ADEs), as well as medication discrepancies or nonadherence with high potential for future harm (potential ADEs). OBJECTIVE: To determine the effect of a tailored intervention on the occurrence of clinically important medication errors after hospital discharge. DESIGN: Randomized, controlled trial with concealed allocation and blinded outcome assessors. (ClinicalTrials.gov registration number: NCT00632021) SETTING: Two tertiary care academic hospitals. PATIENTS: Adults hospitalized with acute coronary syndromes or acute decompensated heart failure. INTERVENTION: Pharmacist-assisted medication reconciliation, inpatient pharmacist counseling, low-literacy adherence aids, and individualized telephone follow-up after discharge. MEASUREMENTS: The primary outcome was the number of clinically important medication errors per patient during the first 30 days after hospital discharge. Secondary outcomes included preventable or ameliorable ADEs, as well as potential ADEs. RESULTS: Among 851 participants, 432 (50.8%) had 1 or more clinically important medication errors; 22.9% of such errors were judged to be serious and 1.8% life-threatening. Adverse drug events occurred in 258 patients (30.3%) and potential ADEs in 253 patients (29.7%). The intervention did not significantly alter the per-patient number of clinically important medication errors (unadjusted incidence rate ratio, 0.92 [95% CI, 0.77 to 1.10]) or ADEs (unadjusted incidence rate ratio, 1.09 [CI, 0.86 to 1.39]). Patients in the intervention group tended to have fewer potential ADEs (unadjusted incidence rate ratio, 0.80 [CI, 0.61 to 1.04]). LIMITATION: The characteristics of the study hospitals and participants may limit generalizability. CONCLUSION: Clinically important medication errors were present among one half of patients after hospital discharge and were not significantly reduced by a health-literacy-sensitive, pharmacist-delivered intervention. PRIMARY FUNDING SOURCE: National Heart, Lung, and Blood Institute.

Quality improvement initiatives improve hypertension care among veterans.

BACKGROUND: We implemented a quality improvement initiative to improve hypertension care at Veterans Affairs-Tennessee Valley Healthcare System. METHODS AND RESULTS: We implemented multiple interventions among 2 teaching hospitals, 5 community-based outpatient clinics, and 4 contract clinic sites. Goals of the program were to (1) improve measurement and documentation of blood pressure (BP), (2) initiate outpatient patient education, (3) emphasize VA/Department of Defense hypertension treatment algorithms to providers, (4) emphasize external peer review program performance goals, and (5) initiate feedback of each clinic's performance. The primary outcome was the proportion of patients seen each week with a diagnosis of hypertension who had their last available BP in control (< or =140/90 mm Hg). Observation time was 40 weeks (14 weeks preintervention, 8 weeks intervention implementation, and 18 weeks postintervention), during which there were 55 586 unique clinic visits for hypertension. After intervention deployment, there was an absolute improvement of 4.2% in BP control (preintervention 61.5% [12 245/19 908] versus postintervention 65.7% [15 809/24 059], P<0.0001). Teaching hospital A had an absolute improvement of 1.4% (63.4% [3544/5591] versus 64.8% [4581/7073], P=0.108). Teaching hospital B showed a 0.8% absolute improvement in BP control (59.7% [2577/4315] versus 60.5% [3416/5650], P=0.456). The community-based outpatient clinics had a combined absolute improvement of 8.6% (60.2% [5252/8728] versus 68.8% [6895/10025], P<0.0001). The contract clinics had a combined improvement of 1.5% (68.4% [872/1274] versus 69.9% [917/1311], P=0.409). Results were sustained 1 year after intervention. CONCLUSIONS: After implementing small, focused, and inexpensive interventions, BP control improved 4.2%, thereby improving the quality of hypertension care.

An algorithm to identify incident myocardial infarction using Medicaid data.

PURPOSE: Studies of non-steroidal anti-inflammatory drugs (NSAIDs) and cardiovascular events using administrative data require identification of incident acute myocardial infarctions (AMIs) and information on whether confounders differ by NSAID status. METHODS: We identified patients with a first AMI hospitalization from Tennessee Medicaid files as those with primary ICD-9 discharge diagnosis 410.x and hospitalization stay of > 2 calendar days. Eligible persons were non-institutionalized, aged 50-84 years between 1999-2004, had continuous enrollment and no AMI, stroke, or non-cardiovascular serious medical illness in the prior year. Of 5524 patients with a potential first AMI, a systematic sample (n = 350) was selected for review. Using defined criteria, we classified events using chest pain history, EKG, and cardiac enzymes, and calculated the positive predictive value (PPV) for definite or probable AMI. RESULTS: 337 of 350 (96.3%) charts were abstracted and 307 (91.1%), 6 (1.8%), and 24 (7.1%) events were categorized as definite, probable, and no AMI, respectively. PPV for any definite or probable AMI was 92.8% (95% CI 89.6-95.2); for an AMI without an event in the past year 91.7% (95% CI 88.3-94.2), and for an incident AMI was 72.7% (95% CI 67.7-77.2). Age-adjusted prevalence of current smoking (46.4% vs. 39.1%, p = 0.35) and aspirin use (36.9% vs. 35.9%, p = 0.90) was similar among NSAID users and non-users CONCLUSIONS: ICD-9 code 410.x had high predictive value for identifying AMI. Among those with AMI, smoking and aspirin use was similar in NSAID exposure groups, suggesting these factors will not confound the relationship between NSAIDs and cardiovascular outcomes.

Using quality improvement methods to improve door-to-balloon time at an academic medical center.

OBJECTIVES: 1) Describe a quality improvement (QI) process to decrease door-to-balloon time (D2B); 2) Explain implementation of evidence-based strategies to improve D2B. BACKGROUND: The ACC/AHA 2006 guideline target for ST-elevation myocardial infarction (STEMI) is a D2B of 90 minutes (min). QI methods can be used to identify areas for improvement, measure current processes, and provide rapid-cycle feedback about which strategies are effective. METHODS: We studied all STEMI patients presenting to Vanderbilt University Medical Center from July 2005 through November 2006. A process flow chart was created and all D2B process steps were analyzed. In February 2006, evidence-based strategies were implemented to address bottlenecks and decrease D2B. Statistical process control (SPC) was used to monitor D2B time in real-time. RESULTS: Targeted changes led to a 44 min decrease (p < 0.001) in overall median D2B time from 108 min (interquartile range [IQR] = 94-122 min) to 64 min (IQR = 56-94 min). Subinterval time periods for emergency department (ED)-to-electrocardiogram (ECG) time decreased by 7 min (p = 0.008), ECG-to-cardiac catheterization laboratory (CCL) time decreased by 18 min (p = 0.01), and CCL-to-balloon time decreased by 4 min (p = 0.19). After implementation, SPC charts revealed a 50% decrease in the central mean line and narrower control limits indicating more reliable performance. CONCLUSIONS: Using QI methods of flow-charting, identifying bottlenecks, targeting strategies to bottleneck areas, and real-time monitoring with SPC and rapid-cycle feedback, D2B processes can be systematically redesigned for improvement. QI methods can be used by individual institutions to customize and implement strategies for their particular context.

Beta-blocker therapy for heart failure: should the therapeutic target be dose or heart rate reduction?

Therapeutic target with beta blockers in heart failure, i.e., target heart rate reduction or beta-blocker dose, is controversial. To resolve this controversy, the authors studied 152 heart failure patients on beta blockers who were divided into four groups based on median peak exercise heart rate reduction as compared with predicted and prescription of at least 50% recommended beta-blocker dose. Event-free survival (vs. death or assist device placement or urgent transplantation) was compared. Baseline and peak exercise heart rates were 74 +/- 14 and 116 +/- 21 bpm, respectively. Median heart rate reduction at peak exercise was 35%. When median or higher peak heart rate reduction was achieved, there were no significant survival differences noted between patients on different beta-blocker doses. With below-median peak heart rate reduction, there was a strong trend toward better event-free survival with higher beta-blocker doses. In conclusion, the results suggest that higher heart rate reduction is associated with better outcomes for heart failure patients overall and, for patients with persistently elevated heart rates, higher beta-blocker doses provided additional benefit.