Cardiothoracic Department October 9, Deborah Winters, RN BSN Clinical Excellence

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1 Cardiothoracic Department October 9, 2013 Deborah Winters, RN BSN Clinical Excellence

2 Quarterly Executive Summary CathPCI Registry PCI Performance Measures PCI Process/Outcome Metrics Diagnostic Cath Process/Outcome Metrics PCI Appropriate Use Criteria Metrics ICD Registry Device Based Therapy Guidelines Metrics Process Metrics Outcome Metrics

3 Use of ACC-NCDR Data Performance Improvement Focus on metrics with below average performance on benchmarked areas Improve Patient Outcomes CMS Requirement for Initial AICD implants Advancement of CV Care 276+ Abstracts/160+ manuscripts in major medical journals Public Reporting Leapfrog Hospital Compare PCI 30 Day Readmissions Insurance Companies Request for Information Preferred Status

4 Risk Adjusted Mortality Rate 4.0% 3.5% 3.58% ACC-NCDR PCI In-Hospital Risk Adjusted Mortality Rate (all patients) % 3.0% 2.5% 2.14% 2.17% 2.0% 1.65% 1.67% 1.5% 1.0% 1.44% 1.54% 0.5% SJMC Mortality Rate 3.58% 1.44% 2.14% 1.54% 3.56% 1.65% 1.67% 2.17% ACC-NCDR 10th Percentile 2.63% 2.40% 2.76% 2.77% 2.76% 2.78% 2.85% 2.99% ACC-NCDR Vol Grp Mean 1.42% 1.34% 1.51% 1.54% 1.59% 1.62% 1.66% 1.71% ACC-NCDR 90th Percentile 0.79% 0.72% 0.78% 0.81% 0.84% 0.86% 0.86% 0.91% 1: NCDR Risk Adjustment Model endorsed by the National Quality Forum

5 Time (min) 90.0 ACC-NCDR Median Time to Immediate PCI for STEMI Patients SJMC Median Time ACC-NCDR 10th Percentile ACC-NCDR Vol Grp Mean ACC-NCDR 90th Percentile : Excludes patients transferred in from another acute care facility; Reasons for delay does not equal

6 Proportion of Patients ACC-NCDR Proportion of PCI Procedures with Acute Kidney Injury 1 7.0% 6.0% 5.0% 4.0% 3.0% 2.0% 1.0% 1.5% Q2 '11 Q3 '11 2.7% Q4 '11 SJMC Proportion 1.5% 2.7% 6.2% 1.7% 2.4% 2.7% ACC-NCDR 10th Percentile 4.3% 4.4% 4.4% 4.1% 4.1% 4.1% 4.1% ACC-NCDR Vol Grp Mean 2.4% 2.4% 2.5% 2.2% 2.4% 2.2% 2.3% 2.5% ACC-NCDR 90th Percentile 1.0% 0.9% 1.0% 0.9% 0.9% 0.9% 1.0% 1: Proportion of patients who had a rise of serum creatinine of >50% over the pre-procedure baseline (excluding patients on dialysis pre-procedure). Includes >= 90% of patients with a pre and post creatinine 6.2% Q1 '12 1.7% Q2 '12 2.4% Q3 '12 Q4 '12 Q1 '13 2.7% Post PCI Acute Kidney Injury SJMC: 2011 R4Q 3.8% 2012 R4Q 1.1% Improvement Strategies Adequate preparatory Hydration STEMI cases Order Sets Minimizing Contrast in patients w/ known CKD Summary of Findings cases of AKI post PCI Documentation by MD acknowledging of patients at risk for AKI and providing adequate hydration as well as planned judicious use of contrast UPDATE: Risk Adjusted AKI Increase of 0.3mg/dL or increase of 50% in Creatinine

7 Proportion of Patients 4.5% 4.0% 3.5% 3.0% 2.5% 2.0% 1.5% 1.0% 0.5% SJMC Proportion 3.70% 4.14% 3.79% 3.33% 2.48% 3.15% 1.64% 0.90% ACC-NCDR 10th Percentile ACC-NCDR Vol Grp Mean ACC-NCDR 90th Percentile ACC-NCDR PCI Procedures with Transfusion of Whole Blood or RBC's % 4.14% 3.79% 3.33% 2.48% 3.15% 1.64% 4.0% 4.0% 3.7% 3.7% 3.6% 3.4% 3.4% 3.3% 2.2% 2.1% 1.9% 1.6% 1.9% 1.4% 1.4% 1.8% 1: Proportion of patients who received a transfusion of whole blood or red blood cells after a PCI procedure. Includes patients with a pre-procedure hemoglobin >8 g/dl and patients with no CABG, and 0.90% Post PCI PRBC SJMC : 2011 R4Q 4.9% 2012 R4Q 2.7% Improvement Strategies: Communication w/ Director of Critical Care Cath Lab Outcomes Board SJMC Blood Component Transfusion Criteria updated August 2012 Meditech PRBC rationale upon order of blood transfusion prompts updated Summary of Findings PCI pt receiving PRBC documentation of rationale

8 Proportion of Patients ACC-NCDR Proportion of PCI Procedures with Vascular Access Site Injury Requiring Treatment or Major Bleeding 1 5.0% 4.5% 4.0% 3.5% 3.0% 2.92% 2.76% 2.5% 2.0% 1.5% 1.56% 1.0% 0.76% 0.83% 0.5% 0.00% 0.00% 0.00% Quarterly Comp Cases (Num) Quarterly Eligible Cases (Den) SJMC Proportion 2.92% 2.76% 0.76% 0.83% 0.00% 1.56% 0.00% 0.00% ACC-NCDR Vol Grp Mean 1.2% 1.2% 1.1% 1.1% 1.10% 1.10% 1.00% 1.03% 1: Proportion of patients with major access site related injury requiring treatment or major bleeding. Excludes patients with CABG during admission.

9 Risk Adjusted Rate of Bleeding Events ACC-NCDR PCI In-Hospital Risk Adjusted Rate of Bleeding Events (all patients) 1 Q2 CY 2011 Q1 CY % 8.0% 7.0% 6.0% 5.0% 4.0% 3.0% 2.0% 5.03% 7.85% 6.78% 5.02% 3.51% 4.47% 1.42% 1.80% Metric Includes : Bleeding Event w/in 72 hours Hemorrhagic Stroke Tamponade Post PCI PRBC transfusion (Hbg >8g/dL) Improvement Secondary to Decrease in Post PCI transfusions and Decrease in Post PCI Vascular Complications 1.0% SJMC Rate 5.03% 7.85% 6.78% 5.02% 3.51% 4.47% 1.42% 1.80% ACC-NCDR 10th Percentile ACC-NCDR Vol Grp Mean ACC-NCDR 90th Percentile 7.83% 7.53% 7.37% 7.21% 6.32% 6.00% 4.90% 4.65% 4.36% 4.30% 3.67% 3.78% 2.21% 2.07% 1.96% 1.86% 1.61% 1.50% 1: Risk adjusted rate of bleeding events for patients with PCI procedures using the NCDR PCI bleeding risk adjustment model.

10 Proportion of Patients 3.0% ACC-NCDR Proportion of Diagnostic Cath procedures with Vascular Access Site Injury Requiring Treatment or Major Bleeding 1 2.5% 2.0% 1.5% 1.0% 0.5% 0.35% 0.52% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% Quartery Comp Cases (Num) Quartery Eligible Cases (Den) SJMC Proportion 0.35% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.52% ACC-NCDR Vol Grp Mean 0.3% 0.3% 0.3% 0.2% 0.2% 0.2% 0.2% 0.2% 1: Proportion of patients with major access site related injury requiring treatment or major bleeding. Excludes patients with CABG or other major surgery during admission.

11 Updates Acute Kidney Injury changing to a Risk Adjusted Metric with more sensitive to creatinine changes Acute Kidney Injury Network (AKIN Stage 1 +) *Mehta RL, Kellum JA, Shah SV, Molitoris BA, Ronco C, Warnock DG, Levin A. Acute Kidney Injury Network: report of an initiative to improve outcomes in acute kidney injury. Crit Care. 2007;11(2):R31) PCI 30 Day Readmissions CMS Hospital Compare: 30 Day Risk Standardized Readmission Rates following PCI (Jan Nov. 2011): SJMC No Different than NCDR Registry RSRR 10.6% Reviewing all SJMC PCI readmissions % Unadjusted Readmission Rate (all cause)

12 Proportion of Patients ACC-NCDR ICD Proportion of Patients for Class I, IIa, and IIb Guideline Indications % 96.3% 95.0% 93.8% 92.3% % % No. Patients Meeting Guideline Indications No. Eligible Patients SJMC Proportion 96.3% 95.0% 93.8% 92.3% ACC-NCDR Vol Grp Mean 85.9% 86.0% 88.5% 89.3% 88.5% 89.2%

13 Proportion of Patients 10 ACC-NCDR ICD Composite Discharged Medications (ACE/ARB and Beta Blockers) 1 Opportunity for Improvement: 95.0% % % 87.5% 93.1% 93.3% 85.7% 82.6% 90.5% 93.3% Need for Improved Documentation of Contraindication to ACE/ARB and Beta Blocker for eligible patients (EF <40%) % 65.0% 6 No. of Patients Received Composite Discharge Meds No. Eligible Patients SJMC Proportion 87.5% 93.1% 93.3% 85.7% 82.6% 90.5% 93.3% 72.7% ACC-NCDR Vol Grp Mean 76.6% 76.9% 76.6% 76.8% 77.6% 78.8% 1. Therapy with ACE/ARB and Beta Blocker at discharge following ICD implantation in eligible patients.

14 Updates New Metrics (test metrics): Metric 15-All ICD and CRT-D Initial Implants that meet class I, IIa, IIb ICD or CRT- D guideline indications Metric 16- Initial Single/Dual chamber ICDs that meet any class I, IIa, IIb ICD guideline indications Metric 17- Initial CRT-Ds implant procedures that fulfill class I, IIa, or IIb guideline indications 8 new CRT recommendations Tracy CM, Epstein AE, Darbar D, et al ACCF/AHA/HRS focused update of the 2008 guidelines for device-based therapy of cardiac rhythm abnormalities: a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines. J Am Coll Cardiol 2012;60: Epstein AE, Dimarco JP, Ellenbogen KA, et al. ACC/AHA/HRS 2008 Guidelines for device-based therapy of cardiac rhythm abnormalities. Heart Rhythm. J Am Coll Cardiol 2008;51:e1-62. Complications Risk Model

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