Quality Cardiovascular Care at Hamilton Medical Center

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Quality Cardiovascular Care at Hamilton Medical
Center
Meeting and Exceeding Best Practice Expectations

• Therese White, RN
• Clinical Resource Nurse Cardiovascular Services

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Hamilton Medical Center Dalton, Georgia
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About Hamilton Medical Center

• Centered in the heart of the Hamilton Health Care
  System is Hamilton Medical Center, a 282-bed
  hospital dedicated to providing quality care and
  service excellence. Twice named one of the Top
  100 Hospitals in the United States by HCIA and
  Mercer Consulting, Hamilton Medical Center
  continually receives the maximum accreditation by
  the Joint Commission on Accreditation of
  Healthcare Organizations (JCAHO).

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About Hamilton Medical Center

• The Level II trauma center, among the states
  busiest, provides outstanding immediate and
  ambulatory emergency care with an integrated
  chest pain center.
• Its centers for excellence include psychiatry and
  substance abuse, diabetes treatment, cancer care
  and maternal and infant care.
• Hamiltons technologically advanced diagnostic
  facility includes a fully-accredited laboratory,
  a fully equipped imaging center and outpatient
  neurodiagnostic center. The medical center is
  also home to an advanced computer radiology
  system, an ambulatory Surgery Center and
  outpatient womens pavilion featuring
  mammography, ultrasound and bone densitometry
  capabilities.

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Cardiovascular Services

• Cardiovascular Services at Hamilton Medical
  Center include
• Chest Pain Center
• Medical Intensive Care Unit
• Cardiac Short Stay Unit
• General Cardiac Care Unit
• Diagnostic Cardiology Department
• Cardiac Catheterization Laboratory\
• New E.P. Lab Coming Soon

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Cardiovascular Services

• The Cardiovascular Service Line Team has been
  instrumental in the continual identification and
  implementation of measures to improve
  Cardiovascular care at Hamilton Medical Center.
  The multidisciplinary team is represented by

Clinical Resource Nurse Cardiovascular Service
Associates from each CV unit PI
Director Laboratory Respiratory Radiology
7 Cardiologists ECD Medical Director Hospitalist
Director 2 Organizational Vice Presidents Chief
Nursing Officer Cardiovascular Director
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Identifying and Implementing Best Practice
Compliance Tools

• Pathways in Cardiovascular Care
• Chest Pain Center Pathway
• Acute Myocardial Infarction Pathway
• Congestive Heart Failure Pathway
• Acute Coronary Syndrome/NSTEMI Pathway

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Identifying and Implementing Best Practice
Compliance Tools

• Universal Smoking Cessation Counseling
• Every patient admitted to Hamilton Medical Center
  receives smoking cessation counseling.
• Counseling includes a written booklet taken from
  Clinical Practice Guideline on Smoking Cessation
  developed by a non-Federal panel of experts
  sponsored by the Agency for Health Care Policy
  and Research.
• The booklet is included in all admission packets
  and counseling is completed at the time of
  admission or as soon as feasibly possible.

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Identifying and Implementing Best Practice
Compliance Tools

• Discharge Instructions
• Patient discharge instruction were revised and
  formatted to prompt nursing associates to
  document the required educational components to
  assure Best Practice Compliance, including diet,
  activity, weight monitoring, indicators for
  physician follow up and home medications.

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Identifying and Implementing Best Practice
Compliance Tools

• Best Practice Prompt Forms
• AMI
• CHF
• ACS
• In addition to CMS requirements, all Best
  Practice Prompt forms include indicators for
  early identification of Chronic Kidney Disease in
  the Cardiovascular Disease patient population.
  (CKD/CVD Collaborative Georgia Pilot Project of
  GMCF and The National Kidney Foundation)

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Implementation of the Best Practice Prompt Tool

• Education in Best Practice Expectations and
  Awareness of Best Practice Prompt Initiative
• Physicians
• Nursing Associates
• Clerical Staff
• Supplying Best Practice Expectations and
  Reporting Practices
• Introduction of form and appropriate utilization
• Empowering Nursing Associates to identify and
  address areas of non-compliance

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Best Practice Prompt Tools
This alert is included for health care providers
on each prompt tool specified by diagnosis.
Attention All Health Care Providers, This
patient has been admitted on the ___ Clinical
Pathway. The following BEST PRACTICE GUIDELINES
have been identified in the most appropriate
course of treatment for ___ by one or more of the
following organizations the ACC, AHA, NCEP, or
NKF. This form is a tool, intended to help our
facility comply with best practice standards and
evidenced based practice reviews by this
institution as well as other agencies including
CMS and JCAHO. Compliance data from these
reviews may be subject to publication. HMC data
is available upon request. This form will not be
included in the permanent Medical Record.
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Best Practice Prompt Tools

• Acute Myocardial Infarction CORE MEASURE STUDY
• Acute Care
• Aspirin on Arrival (or documented
  contraindication)
• Beta-blocker on Arrival (or documented
  contraindication)
• Thrombolysis within 30 minutes of Arrival
• Smoking Cessation Counseling
• Documented Estimation of Left Ventricular (LV)
  Function
• Discharge
• Aspirin at Discharge (or documented
  contraindication)
• Beta-blocker at Discharge (or documented
  contraindication)
• ACE-Inhibitor prescribed at Discharge for
  patients with LVSD (or documented
  contraindication)
• Is LDL gt 70? (LDL Goal is lt70 for CHD risk or
  CHD risk equivalents per NCEP)
• Statin Therapy (or documented contraindication)
• Patient Education for Therapeutic Lifestyle
  Changes (TLC)
• Renal Assessment Participation in CKD/CVD
  Collaborative
• IS GFR LESS THAN 60? GFR lt 60 NECESSITATES

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Best Practice Prompt Tools

• Congestive Heart Failure CORE MEASURE STUDY
• Documented Estimation of Left Ventricular (LV)
  Function
• ACE-I or ARB prescribed at Discharge for patients
  with LVSD (or documented contraindication)
• Smoking Cessation Counseling
• Complete Discharge Instructions
• Renal Assessment Participation in CKD/CVD
  Collaborative
• IS GFR LESS THAN 60? GFR lt 60 NECESSITATES
• Documented Assessment of Hypertension
• ACE-I / ARB Therapy (or documented
  contraindication)
• Dietary Consult
• Dietary Discharge Teaching
• GFR lt 60 with HGB lt 12 indicates
• Evaluation for Anemia
• Treatment of Anemia

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Best Practice Prompt Tools

• ACS/NSTEMI BEST PRACTICE INITIATIVE (CRUSADE)
• Acute Care (within 24 hours of presentation)
• Aspirin on Arrival (or documented
  contraindication)
• Low molecular weight or Unfractionated Heparin
  (or documented contraindication)
• Beta Blocker (or documented contraindication)
• GP IIB-IIIA Inhibitor (or documented
  contraindication)
• Discharge
• Smoking Cessation Counseling
• Dietary Modification Counseling
• ACE-Inhibitor prescribed for patients with LVSD
  lt40, HTN, CHF or DM. (or documented
  contraindication)
• Aspirin at Discharge (or documented
  contraindication)
• Combination ASA and Clopidogrel for 9 months
  after UA/NSTEMI. Clopidogrel for 9 months after
  PCI (or documented contraindication)
• Beta-blocker at Discharge (or documented
  contraindication)
• Documentation for Cardiac Rehabilitation Plan
• Is LDL gt 70? (LDL Goal is lt70 for CHD risk or
  CHD risk equivalents per NCEP)
• Statin Therapy (or documented contraindication)
• Patient Education for Therapeutic Lifestyle
  Changes (TLC)

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Reporting Best Practice in Cardiovascular Services

• Performance Improvement Committee
• Quarterly reports indicating Best Practice
  Compliance reported by CMS are provided for
  Cardiovascular Services by the Service Line
  Facilitator.
• Ongoing communication between the PI Department
  and Service Line Facilitator to evaluate data on
  a more concurrent basis.
• Restructure of Case Management Department to
  further improve compliance by providing real
  time data.

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Reporting Best Practice in Cardiovascular Services

• Disseminating data to physicians and associates
  in an effort to highlight areas of success and
  identify areas for improvement
• Service Line Team Meetings
• Monthly Staff Meetings
• All Cardiovascular Units
• Cardiovascular Services Newsletter, Heart Murmurs
• Written notice in the event of non-compliance

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Plan for Further Improvement

• Pre-Printed Discharge Orders as an addition to
  each Cardiovascular Pathway prompting discharge
  compliance for Best Practice measures
• Restructuring of the Case Management Dept. to
  each nursing unit to further improve compliance
  by providing real time data and more efficiency
  in patient placement and length of stay.

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Plan for Further Improvement

• Ongoing Pathway Revisions
• Prompted Shift Assessments to ensure consistency
  in documentation
• Shift assessments will include an early warning
  score and the discharge plan

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Quality Cardiovascular Care at Hamilton Medical
Center
Meeting and Exceeding Best Practice Expectations

• Therese White, RN
• Clinical Resource Nurse Cardiovascular Services

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Thank You