Streamlined Quality Improvement a Focus of ACC Accreditation Services’ 20th Annual Congress Nearly 200 nurses, cardiovascular care coordinators, data abstractors and cardiologists convened in Las Vegas in October as part of ACC Accreditation Services 20th annual Congress to learn about the tools needed to provide the best patient outcomes across the continuum of care. Attendees also had opportunities to network with colleagues from across the country about best practices on creating and maintaining a multi-disciplinary team focused on data-driven, quality improvement efforts within their hospitals and in the community. David Winchester, MD, FACC, congress chair, opened the conference by providing a brief overview of the hottest topics and latest accreditation offerings, particularly Chest Pain Center Version 6. Additionally, the late Joseph Lee Garvey, Jr., MD, FACC, was recognized as the 2017 Raymond D. Bahr Award of Excellence winner. Among his many accomplishments, Garvey was co-founder of the North Carolina Regional Approach to Cardiovascular Emergencies (RACE) program, a founding member of the Society of Cardiovascular Patience Care (SCPC) Board of Directors and a crucial player in transitioning the SCPC into the ACC family as ACC Accreditation Services. Phillip Levy, MD, FACC, chair of ACC’s Accreditation Management Board, also provided attendees with a quick history lesson, noting ACC Accreditation Services’ expansion from a primarily Chest Pain Center focus to today’s variety of accreditation options, ranging from Atrial Fibrillation to Cardiac Cath Lab to Heart Failure. He also touched on future projects, particularly how ACC Accreditation Services will continue to uncover ways to ease the data burden. “Working with the NCDR registries is going to be an important point for us. Right now, we rely on hospitals to pull data for accreditation separately. Moving forward, we’re going to be one big happy ACC family, focused on quality improvement and transforming patient care,” he noted. New this year, NCDR leaders provided insights on how metrics in the ACTION Registry and the CathPCI Registry will support Chest Pain Center Accreditation and Cardiac Cath Lab Accreditation, respectively. Based on feedback from hospitals and other stakeholders, it was announced that the next version of ACTION Registry will overlap with the data submission populations in Chest Pain Center Version 6 Accreditation. “I love the idea of being able to compare ourselves to other facilities,” said Laura McGuire, RN, cardiovascular patient care program manager at NorthBay Medical Center in Fairfield, CA. “This will also make it easier to collaborate across the cardiovascular care team, especially since the ACTION Registry is so well-known and understood by physicians.” Breakout sessions focused on hot topics in acute coronary syndrome (ACS), such as cardiovascular screening for teenage athletes, considerations when caring for female cardiovascular patients, applying hypothermia guidelines recommendations to clinical practice; the ABCs of the accreditation process, including what to expect from a site visit, how to better engage and collaborate with emergency medical services (EMS), and how to present Accreditation Conformance Database data; and the management of observation services, including a look at the c-suite billing and coding perspective, ACS risk stratification methodology and strategies, and the benefits of using the HEART Pathway app. Other sessions looked at the evolution of the Atrial Fibrillation Clinic; troponin strategies; business aspects of medicine, with special sessions on MACRA, the future of healthcare, millennials’ role in the workplace and physician engagement; and how EMS can assist in expanding Early Heart Attack Care (EHAC) education in the community. The Congress also provided an opportunity to recognize those going above and beyond in the accreditation space. Jamie Moore, RN, acute myocardial infarction coordinator at CHRISTUS Trinity Mother Frances Tyler in Tyler, TX, was recognized as the EHAC Person of the Year for her work in gathering more than 800,000 pledges to beat heart attack. Sara Hansen, executive director of the heart and vascular service line at University Health System in San Antonio, TX, and Casey Bridge, regional cardiac service coordinator at CHRISTUS Santa Rosa Health in New Braunfels, TX, were named honorees. To close out the conference, 2017 Process Improvement Pioneer Award winners, Jan Hartness, RN, and Leah Hite, RN, cardiovascular services coordinator and director of cardiovascular services at Cartersville Medical Center in Cartersville, GA, were joined on stage by the first ACC Accreditation recipient in South America, Sala Mercado, MD, of Modelo de Cardiologia Privado, SRL, in Córdoba, Argentina. They took turns to discuss how each system successfully listened to the data gathered for accreditation to drive change, strengthen teamwork and improve patient care. Stay updated on news and updates coming from ACC Accreditation Services by following @ACCCVQuality on Twitter and using the hashtag #ACCAccreditation. STEMI ACCELERATOR-2: Intensive Regional Approach Between EMS and Hospitals Results in Better STEMI Care Emergency medical services (EMS) and hospitals that coordinate emergency cardiovascular care on a regional basis may result in optimized treatment and better outcomes for STEMI patients, according to results of the STEMI ACCELERATOR-2 trial presented at AHA 2017 and simultaneously published in Circulation. Between April 2015 and March 2017, James G. Jollis, MD, FACC, et al., worked with 12 metropolitan regions across the U.S. to further reduce time to reperfusion and mortality in patients with STEMI. Key elements of the project included pre-hospital activation of catheterization laboratories and bypassing the emergency department when appropriate; pre-specified treatment protocols; measurement and feedback in regional reports; broad regional leadership; and ongoing implementation of quality improvement efforts by a dedicated regional coordinator. Participating hospitals were enrolled in ACC’s ACTION Registry, from which data was collected quarterly. The study’s primary endpoint was the change, from baseline to final quarter, in the proportion of EMS transported patients with first medical contact to device (FMC2D) time )90 minutes. Over the course of the study period, 10,730 patients were transported by EMS directly to PCI-capable hospitals; 4,546 patients were transferred from hospitals without PCI to PCI-capable ones; and 5,884 patients were self-transported to PCI-capable hospitals. Of those transported to PCI-capable hospitals, 974 patients received PCI in the baseline quarter and 972 in the final quarter. Between the two quarters, demographic and clinical characteristics were similar. Data showed both the baseline and final quarters had the same symptom onset to first medical contact time (50 minutes). “There were reductions in every time interval analyzed, reflecting increased coordination between EMS providers, [emergency department] physicians, cardiologists, and catheterization laboratory staff,” the authors explain. “Over the span of less than 18 months, using established methods to organize emergency cardiac care, hundreds of health professionals across the United States collaborated to successfully improve the care of patients with STEMI.” For example, the proportion of patients with a FMC2D time of )90 minutes increased from 67 percent to 74 percent (p < 0.002), while the proportion of those with first medical contact to catheterization laboratory activation of <20 minutes increased from 38 percent to 56 percent (p < 0.0001). The emergency department dwell time of <20 minutes also increased from 33 percent to 43 percent (p < 0.0001). Furthermore, the study authors also noted a decrease in the in-hospital mortality (4.4 percent to 2.3 percent; p = 0.001) and heart failure complications (7.4 percent to 5.0 percent; p = 0.031) among patients brought to PCI-capable hospitals by EMS. “This small infrastructure added to the significant resources dedicated to cardiovascular care at the individual hospital level has the potential to expedite care and improve outcomes for acute coronary syndrome patients across entire regions,” the authors conclude. “STEMI Accelerator-2 is the first large-scale study showing striking improvements in multiple treatment times to speed reperfusion for heart attack patients by implementing coordinated regional systems of care in 12 large population metro centers In the U.S. (including New York, Philadelphia, Houston, Las Vegas and Seattle among others). Over the nearly two years of supervision, STEMI in-hospital mortality dropped by nearly one-half and heart failure by one-third. These results will inform, strengthen and promote the guidelines for further implementation of coordinated regional systems of STEMI care in the U.S. and internationally,” says B. Hadley Wilson, MD, FACC. New Risk-Standardization Model Validated for IMPACT Registry The creation of a risk-standardization model for adverse outcomes following congenital cardiac catheterization will lay another brick in the path towards quality improvement for participants in ACC’s IMPACT Registry, according to a study published in Circulation. Natalie Jayaram, MD, MSB, FACC, et al., note that the IMPACT Registry collects data on over 200 different types of interventional procedures. Given the lack of feasibility to adjust for each procedure individually, a committee of eight subject matter experts were convened to review the IMPACT case report form and determine the adverse events that constituted a major adverse event (MAE). Cardiac arrest requiring CPR, embolic stroke within 72 hours of cardiac catheterization and subsequent cardiac catheterization due to complication were among the more than 15 defined events. Using the IMPACT Registry, researchers identified 39,725 patients who underwent cardiac catheterization at 74 centers in the United States between January 2011 and March 2014. They randomly selected 70 percent of the total study population for the derivation cohort and 30 percent for the validation cohort. The mean patient age was 9.7 years and the most common comorbidity was chronic lung disease (6 percent of patients). One in 10 had a reportable genetic condition, while one in five had single ventricle physiology. The study authors note that a MAE occurred in 7 percent of cases, and a similar occurrence rate was found in both derivation and validation cohorts (7.1 percent vs. 7.2 percent, p = 0.84). Six procedure-type risk categories and six independent indicators of hemodynamic vulnerability were identified. Procedure-type risk category, number of hemodynamic vulnerability indicators, renal insufficiency, single-ventricle physiology and coagulation disorder were all included in the final risk adjustment model. Results showed the most common events were bleeding (1.4 percent), an arrhythmia requiring antiarrhythmic medication (1 percent) and death during hospital admission following cardiac catheterization (2 percent). Neonates were more likely to experience a MAE compared with children or adults (22.2 percent vs. 4.3 percent), as were those with a genetic condition compared with those without a documented syndrome (10 percent vs. 6.8 percent). Building upon prior efforts (Boston Children’s Hospital and the CHARM model), the risk-standardization methodology can be incorporated into the registry’s quarterly metric reports. The study authors write this will “lay the foundation for comparing outcomes across institutions participating in IMPACT, while accounting for both the types of patients they treat and the types of procedures they perform.” “In an era where transparency and public reporting of outcomes is becoming increasingly embraced, the ability to report risk-standardized rates of major adverse events is crucial,” they continue. “Individual practitioners and institutions are much more likely to support public reporting if they feel that these data represent a fair and accurate assessment of their performance and reflects the acuity of their patient population.”
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