Performance Improvement for Chest Pain - PowerPoint PPT Presentation

Loading...

PPT – Performance Improvement for Chest Pain PowerPoint presentation | free to view - id: 26b45f-YWQ3Y



Loading


The Adobe Flash plugin is needed to view this content

Get the plugin now

View by Category
About This Presentation
Title:

Performance Improvement for Chest Pain

Description:

These patients usually have a non-specific pattern ... NEW ERA ... Blood drawn was used for rapid bedside Troponin I and Myoglobin by TRIAGE assay. ... – PowerPoint PPT presentation

Number of Views:467
Avg rating:3.0/5.0
Slides: 82
Provided by: shahriard
Category:

less

Write a Comment
User Comments (0)
Transcript and Presenter's Notes

Title: Performance Improvement for Chest Pain


1
Performance Improvement for Chest Pain Heart
FailureUsing Bed Side Cardiac Markers
  • S. Dadkhah MD.MBA.FACP.FACC
  • Director Section of Cardiology Research
  • Co-Director of Chest Pain Center
    Saint Francis Hospital, Evanston , IL
  • Assistant Professor of Medicine
  • University of Illinois

2
Disclosure
  • Sanofi Synthelabo
  • Bristol-Myers Squibb
  • Aventis
  • Novartis
  • AstraZeneca
  • GlaxoSmithKline
  • Scios
  • Biosite

3
8 Million Adults Visit Hospital Emergency
Departments Complaining of Chest Pain Annually
  • 15-20 Experience AMI
  • 600,000 Admitted/Discharged without CAD
  • Diagnosing AMI costs the Nations
    HealthcareSystem about 10 Billion Annually

4
In the Emergency Department
  • Approximately 5 of AMI Patients are Released
    Unintentionally
  • 20 of Malpractice Claims are associated with the
    missed Diagnosis and Management of AMIs

5
Acute Coronary Syndromes Risk of Mortality
Cumulative 6-Month Mortality
25
(N 21,761)
20
15
Death (100/Pts/Month)
Acute MI Unstable Angina Stable Angina
10
5
0
0
1
2
3
4
5
6
Months After Hospital Admission
Theroux P et al. Circulation. 19989711951206.
6
Philosophy
  • Remaining years of life are usually less
    important than the quality of remaining life.

7
Cardiac Milestones at Saint Francis Hospital
  • First cardiac catheterization 1959
  • First open heart surgery 1962
  • First PTCA 1981
  • First laser angioplasty 1987
  • First accredited chest pain center in the state
    of Illinois 2003

8
Milestones in developing a Chest Pain Center
  • 1991 established Chest Pain Committee
  • 1992 developed chest pain pathways
  • 1992 interventional call roster/ PCP preferred
    cardiologist List
  • 1993 ED stress test after 4 hours observation
  • 1994 Stress test by cardiology fellows or
    cardiologist
  • 1997 qualitative bedside markers diagnose MI
  • 1998 qualitative markers and ECG in the
    ambulance
  • 1999 NSTEMI to cath lab from ED
  • 2000 community outreach program
  • 2002 rapid quantitative bedside markers/BNP
  • 2002 stress test by third year Internal
    Medicine residents
  • 2003 stress test by Emergency Physicians

9
Chest Pain Center
  • A Chest Pain Center in not a section of the
    Hospital that treats Acute Myocardial Infarction
  • A Chest Pain Center is a process that starts
    from the time a patient activates EMS until that
    patient discharges from the hospital

10
Chest Pain Committee Functions
  • Collaboration between Emergency Medicine,
    Cardiology and laboratory
  • Meets monthly
  • Performs data collection and review
  • Reviews Process Improvement initiatives
  • Cost of Care and Reimbursement
  • Education of Staff
  • Recommendations to Administration

11
Patient enters the CPC having ACS STEMI/NSTEMI
Laboratory turnaround time
Notification to cath lab staff of AMI
Delayed arrival to the CPC
Time from ECG to diagnosis
Time to ECG
Time from diagnosis to transportation to cath
lab
12
Patient enters the CPC having ACS
Delayed arrival Of cardiologist
D/C instruction
Delayed arrival of heart team
CCU LOS
Time to wire cross
Time from Admission to D/C
13
Critical PathwaysMyocardial Infarction - Track I
Possible Solutions
  • Formation of Heart Center Code Team and the Code
    42
  • Cardiology call roster
  • PMD preferred cardiologist roster
  • Rapid Blood Markers in the Emergency Department
    and in the Emergency Medical System (EMS)

14
WHO Criteria for AMI
  • Definite AMI is Diagnosed in the Presence of
    Unequivocal ECG Changes and/or Unequivocal Enzyme
    Changes, History of Pain may be Typical or
    Atypical
  • Definite AMI requires 2 of the 3 Criteria

Circulation 1979 59607-609
15
Within the clinical spectrum of acute chest pain
is a subset of patients in whom the quality,
duration, associated systems and precipitating
factors are not characteristic for cardiac
pain.These patients usually have a non-specific
pattern of chest discomfort, normal ECG and a
low likelihood of cardiac disease often are
classified as having atypical chest pain
16
ECG and MI
  • In a multi-center emergency department study,
    only 39 of 108 patients (36) with AMI had a
    diagnostic ECG.1

As many as 40 of individuals with
autopsy-proven AMIs have non-diagnostic ECGs
initially.2
1 Chest 19942 Annals of Emergency Medicine 1987
17
The Ideal Marker of Myocardial Injury/Ischemia
  • Found in High Concentration within the Myocardium
  • Not Found in other Tissues, even in Trace Amounts
    or under Pathological Conditions
  • Released Rapidly and Completely after Ischemia
  • Released in Direct Proportion to the Extent of
    Ischemia
  • Persists in Plasma for Several Hours

18
Characteristics
19
Myoglobin in the Early Evaluation of Chest Pain
89 Patients
  • 13 of 25 patients (52) had positive myoglobins
    prior to an increase in CKMB or CK.One patient
    discharged home with positive myoglobin.

56 100
83 100
Montaque, Colorado, American Journal of Chest
Physicians Oct 1995
20
Negative Predictive Value
  • The negative predictive value if the serum
    Myoglobin did not double within 2 hours . . .
  • . . . in patients who presented within 6 hours
    of the onset of their symptoms . . .
  • . . . was 97.

Tucker, Annals of Emergency Medicine 1994
21
Myoglobin Cost Savings
  • Cost of Single Myoglobin 20
  • 25,000 Missed AMIs Discharged from the ED
    Annually(Atypical Presentations)
  • Total Malpractice Loss for Missed AMI60
    Million (20 of ED Claims)
  • Cost of Two Myoglobin Tests in ED for 25,0001
    million/year

Potential Cost Savings - 53 Million/year
Selective use in 250,000 Atypical
Presentations(1 of 10 AMIs) - Cost Savings of
44 Million/year
Brogan,Annals of Emergency Medicine Oct 1994
22
Troponin I
  • Part of the Thin Filament Regulatory Complex that
    Confers Calcium Sensitivity to the ATPase
    Activity of the Striated Muscle Actin-Myosin
    Complex
  • Identified as Three Isoforms expressed in a
    Muscle Fiber Type-Specific-Manner - Troponin
    I Fast - Troponin I Slow (both expressed
    exclusively in fast twitch and slow twitch
    skeletal fiber muscles, respectively) -
    Troponin I Cardiac with an extra 30 residues at
    the N-terminal (expressed
    exclusively in atrium and ventricle)

Clin. Chem. 1993
23
SERUM MARKERS POST AMI
24
Rapid Evaluation Of Chest Pain In The Emergency
Department
25
Chest Pain
Track I AMI
ST Elevation With Reciprocal Changes
CODE 42
Cath Lab
Thrombolytic
Surgery
PTCA
Admit to CCU
Medical TX
Angiography?
Stress Test?
Home in 5 Days
26
Chest Pain
Track III a Atypical CP
Non-diagnostic ECG without Exclusion Criteria
POC Myoglobin/CKMB/Troponin I on admission. POC
Myoglobin/CKMB/Troponin I at 2 4 hours
Cardiac Markers Positive
Cardiac Markers Negative
Admit TX per protocol
Exercise Stress Test in ED
Negative Test
Positive Test
Discharge home
Admit TX per PMD
27
(No Transcript)
28
The 68th Scientific Sessions AHA 1995 California
Circulation Volume 92,No 8.1995
29
Case 90
  • ES - 61 Male physician for elective surgical
    repair of quadricep torn after a fall. In the
    holding area he became hypotensive after IV
    sedation. He had chest pain with increasing
    fatigue 3 days prior to that admission
  • Risk Factors Hypertension, smoker
  • Physical Exam Unremarkable
  • ECG/Angiogram

30
Case 90
ES
31
Case 90
Rapid Myoglobin
Rapid CKMB
Rapid Troponin I
Myoglobin
Troponin I
  • Surgery cancelledemergency angiogram performed

32
Case 90
Dadkhah
33
(NEW ERA)Now Evaluate Chest Pain with 12 Lead
Electrocardiograms and Rapid Assays for Early
Recognition of Myocardial Infarctions in the
Ambulance(IJEM volume1, N3 2005)
34
NEW ERA
Methods
  • Multi-Centered Trial
  • 5 Hospitals- 4 with Emergency PTCA
    Capabilities(St. Francis, Evanston, Holy
    Family, Rush North Shore) Glenbrook
  • 5 Ambulance ServicesEvanston, Lincolnwood,
    Skokie, Wheeling, Glenview
  • Performed prior to arrival in ED
  • 12 Lead ECGs (Life-pack 11)
  • Rapid CK-MB
  • Rapid Myoglobin
  • Rapid Troponin I performed

35
NEW ERA
Results
  • 252 Patients enrolled
  • 247 Patients had completed follow-up
  • 44 (18) Patients diagnosed with AMI before being
    discharged from the hospital
  • 7 Patients had negative ECG and Markers ED
    markers were negative but AMI occurred during
    course of hospitalization
  • 37 (15) Patients positive for AMI in the ED

36
NEW ERA
Results
  • 5 (2) Patients transferred to other institutions
    with diagnosis of AMI 2 out of the 5 patients
    with positive ECGs did not have markers
    performed in the ambulance
  • 28 (11.3 ) Patients had either positive ECGs or
    Markers pre-hospital

37
NEW ERA, Phase II
  • 203 Consecutive Patients
  • 160 Patients had completed follow-up
  • - 23 Ambulances
  • - 7 Hospitals
  • Findings
  • 8.4 (17/203) Positive markers in the field vs.
    7.7 Positive markers in Phase I

38
Case 91
  • BH - 75 WM Complaining of sharp, stuttering chest
    pain on and off for 12 hours was seen in his
    PMDs office. 911 was called and in the field
    12-Lead ECG and Rapid Cardiac Markers were
    performed
  • Risk factors Hypertension, smoker
  • Physical Exam Unremarkable
  • Field ECG/Angiogram

39
Case 91
40
Case 91
Rapid Myoglobin
Rapid CKMB
Rapid Troponin I
Myoglobin
Troponin I
41
Case 91
Rapid Myoglobin
Rapid CKMB
Rapid Troponin I
Myoglobin
Troponin I
42
Case 91
Dadkhah
43
Chest Pain Centers
Level I
Level II
Level III
EMS
44
Action Plan of the 4 Ds
  • Door
  • Data
  • Decision
  • Drug

45
SCPC Benefits
  • The Heart Attack Act of 2005 was introduced by
    Senator Mike DeWein of Ohio ( on Judiciary
    Committee, Appropriations Committee, and others.)
    It was accompanied by a letter signed by Senators
    Arlen Specter, John McCain, Orin G. Hatch, Mary
    L. Landrieu, Mike DeWine and Sam Brownback. The
    act stipulates that in order to receive Medicare
    funds a facility that self designates as a Chest
    Pain Center must be accredited.

46
The Triage System (POC)BEDSIDE SYSTEM
  • Rapid, Whole Blood Testing
  • 15 Minute Time to Result
  • Hand Held, Portable System
  • Markers Available
  • Triage Cardiac Panel
  • Troponin I
  • Myoglobin
  • CK-MB
  • BNP
  • D-Dimer
  • Stored memory, printed results, Hospital
    Information System Interface

47
Abstract (SCPCP2004)
Critical Pathway in Cardiology V3,N3 Sept. 2004
48
Introduction
  • Troponin I and Myoglobin are cardiac markers
    released from myocardium and are routinely used
    in the diagnosis of myocardial injury.They are
    released within hours of cardiac injury in the
    blood.
  • We wanted to compare the levels of rapid bedside
    Troponin I and Myoglobin by TRIAGE assay with
    laboratory values by STRATUSDade.

49
Method
  • 72 consecutive patients with chest pain or
    shortness of breath who come to the emergency
    department were enrolled in the study.
  • Mean age was 68 (27 to 94)

50
Method
  • 0.25 c.c. of blood was used for the analysis.
  • Blood drawn was used for rapid bedside Troponin I
    and Myoglobin by TRIAGE assay.
  • Same blood sample was sent to laboratory to be
    analyzed by STRATUSDade.

51
Results
  • Troponin I levels by rapid bedside TRIAGE assay
    and laboratory STRATUS Dade correlates when
    STRATUSDade cutoff at 1.0ng/ml and TRIAGE at
    0.4ng/ml with diagnostic agreement of 97.2.

52
Results
53
Results
  • When Myoglobin levels by STRATUS Dade cutoff at
    82ng/ml and TRIAGE assay cutoff at170ng/ml and
    220ng/ml the diagnostic agreement was 77.8 and
    83.3 respectively

54
Results
55
Results
56
Conclusion
  • Our results conclude that rapid bedside TRIAGE
    assay for Troponin I and Myoglobin in the
    emergency department can be done faster and are
    accurate

57
Significant Clinical and Economic Burden of HF
  • Persons with HF in US 5.0 million
  • Overall prevalence 2.2
  • Incidence 550,000/yr
  • Mortality in 2001 52,828
  • Cost 25.8 billion

AHA. Heart Disease and Stroke Statistics2004
Update
58
Outcomes in Patients Hospitalized With HF
Mortality
Hospital Readmissions
100
100
75
75
50
50
50
50
33
20
25
12
25
0
0
30 Days
6 Months
30 Days
12 Months
5 Years
Median LOS 6 days
N 38,702 Aghababian RV. Rev Cardiovasc Med.
20023(suppl 4)S3 Jong P et al. Arch Intern Med.
20021621689
59
Symptoms and signs in the diagnosis of heart
failure
Eur Heart J, Vol. 22, issue 17, September 2001
60
BNP vs. NYHA Classification

95th 43.1 673 1148 1956 3725 N 419 42 98 114 50
Wieczorek S, Wu A, et al..
61
Early Initiation of Vasoactive Therapy Clinical
Outcomes
ADHERE National registry, gt250 US hospitals, N
46,559
Emerman C et al. Ann Emerg Med.
200342S36 Fonarow GC for ADHERE Scientific
Advisory Committee. Rev Cardiovasc Med.
20034(suppl 7)S21
62
Impact of ED vs In-patient Initiation of
IV Vasoactive Therapy on LOS
P?0.0001
LOS (days)
7.0
4.5
ED Initiation (n 4096)
In-patient Unit Initiation (n 3499)

Peacock WF et al. Ann Emerg Med. 20034292
63
Abstract (SCPCP2004)
  • Utility of B-Type Natriuretic Peptide for the
    diagnosis of congestive heart failure in
    geriatric population in the emergency department
  • Syed N.Ghani M.D, Shahriar Dadkhah M.D, Debbie
    Bishop R.N, Martin Fedko, Saint Francis Hospital,
    Evanston IL
  • Introduction B-Type Natriuretic Peptide (BNP) is
    released from cardiac ventricles in response to
    increased wall tension. It is helpful in
    differentiating dyspnea due to congestive heart
    failure (CHF) and non-cardiac causes.
  • Method 100 consecutive patients who came to
    emergency department of a community hospital with
    dyspnea in a two month period were enrolled in
    the study. 67 patients were with age 65 or older.
    Each patient had a rapid bedside assay of BNP by
    BIOSITE? at the time of arrival to the emergency
    department. Patient hospitalizations were
    reviewed and primary discharge diagnosis of
    pneumonia and heart failure were used as the
    basis for the analysis.
  • Results Out of 67 patients who were 65 or older,
    43 patients had BNP ? 150 pg/ml. 40 patients had
    BNP ? 150 pg/ml and clinical and
    echocardiographic evidence of CHF. Three patients
    had BNP ? 150 pg/ml and no clinical but
    echocardiographic evidence of CHF. One patient
    had BNP ? 150 pg/ml with diagnosis of pneumonia
    and no clinical evidence of CHF.
  • Conclusion Our results showed that rapid
    diagnosis of heart failure can be made in
    geriatric population by using the bedside marker
    BNP upon arrival to emergency department. We have
    found BNP levels of ? 150 pg/ml and above are
    highly consistent with discharge diagnosis of
    congestive heart failure.

Critical Pathway in Cardiology V3,N3 Sept. 2004
64
Method
  • 100 consecutive patients who came to emergency
    department of a community hospital with dyspnea
    in a two month period were enrolled in the study.
  • 67 patients were with age 65 or older.
  • Each patient had a rapid bedside assay of BNP by
    BIOSITE? at the time of arrival to the emergency
    department.
  • Patient hospitalizations were reviewed and
    primary discharge diagnosis of pneumonia and
    heart failure were used as the basis for the
    analysis.

65
Results
  • Mean BNP was 666 for diagnosis of CHF median BNP
    was 268.
  • 79 of patients had 2D echo during their hospital
    stay.
  • 60 of patients were diagnosed with CHF at time
    of discharge.
  • 71 of patients had a BNP gt 150.
  • 100 of patients with a diagnosis of CHF had a
    BNP gt 150.

66
Results
Positive predictive value 93.02 Negative
predictive value 100
Sensitivity 100 Specificity 89
67
August 29, 2005 1201 p.m. EDT  
 
 
  • Dr. Shahriar Dadkhah, director of cardiology
    research at St. Francis Hospital in Evanston,
    Ill., said offering BNP testing in physician
    offices can save money. The test costs less than
    40 - much less than admission of a patient to
    the hospital for heart failure.
  • "The test gives you an idea if you should
    increase treatment," Dadkhah said. If a patient
    has heart failure, the physician can prescribe
    medications such as diuretics to ease symptoms,
    and potentially keep the patient out of the
    hospital. "The No. 1 money loser for any hospital
    is admission for heart failure,"

68
Average Length of Stay
2002 MedPar data
69
Average Per Patient Medicare Reimbursement
2002 MedPar data
70
If you always dowhat youve always doneyoull
always getwhat you always got
71
  • You are as good as
  • the people you work for and
  • the people you work with

72
  • You are as good as
  • Your Arteries

73
(No Transcript)
74
  • THE END

75
Chest Pain Center Committee
Active members of Chest Pain Committee include
Ø      Chairman of Department of
Cardiology Ø      Chairman of Department of
Emergency Medicine Ø      Directors of Chest
Pain Center Ø       Director of Pharmacy Ø     
Director of laboratory Ø      Representative from
Performance Improvement
Ø      Chest Pain Center Coordinator Ø      VP of
Nursing/Operations Ø      Manager of Emergency
Department Ø      Manager of Heart Center Ø     
Data Collector for ACS
76
Current Treatments for ADHF
Natriuretic Peptide
Diuretics
Vasodilators
Inotropes
Decrease Preload and Afterload Reduce Fluid
Volume
Decrease Preload and Afterload
Reduce Fluid Volume
Augment Contractility
77
ASA on Arrival
Before implementation of pathways
78
B-blocker on Arrival
79
ACE
80
Door To ECGMinute
81
(No Transcript)
About PowerShow.com