2022 Quality Summit ePosters (Non-CE) - CathPCI Registry-16. Using Data to Drive Improvement: UPMC Altoona’s Journey to Renewing Cardiac Cath Lab Accreditation and Improving CathPCI Registry® Metrics

16. Using Data to Drive Improvement: UPMC Altoona’s Journey to Renewing Cardiac Cath Lab Accreditation and Improving CathPCI Registry® Metrics

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This case study discusses how UPMC Altoona utilized clinical registry data to drive improvement in their Cardiac Cath Lab Accreditation process. By partnering with the UPMC Cardiovascular Registries Data Team (UCRDT), UPMC Altoona was able to focus on improving their CathPCI Registry® metrics and achieve successful accreditation renewal. <br /><br />The study highlights several areas of improvement:<br /> <br />1. Composite Discharge Medications (M38) Compliance: The 2-year medication compliance rate increased from 96.93% to 98.45% in 2020-2021, consistently exceeding the NCDR 50th percentile.<br /><br />2. Cardiac Rehab Referral (M45): The 2-year cardiac rehab referral rate increased from 44.14% to 85.59% in 2020-2021, with no month in 2021 falling below a 95% referral rate.<br /><br />3. In-Hospital Bleed (M40): The bleed rate decreased from 2.48% to 1.14% in 2020-2021.<br /><br />4. Door-to-Balloon Median Minutes (D2B) (M3): The median D2B time improved from 56 minutes to 48 minutes in 2020-2021.<br /><br />The study suggests that the improvements in D2B time and bleed rate may be attributed to an increased focus on care improvement efforts in the cath lab and improved knowledge of the CathPCI Registry® metrics.<br /><br />UPMC Altoona sustained the improvement in these metrics by establishing a review process, employing diagnostic analytics to identify areas for improvement, providing education to healthcare providers, and integrating cath lab staff into the cardiac rehab referral process.<br /><br />By implementing data-driven improvements and leveraging the expertise of the UCRDT, UPMC Altoona achieved above-average performance in NCDR metrics and provided higher quality care to patients undergoing cardiac catheterization.

Keywords

UPMC Altoona

clinical registry data

Cardiac Cath Lab Accreditation

UPMC Cardiovascular Registries Data Team

CathPCI Registry metrics

accreditation renewal

Composite Discharge Medications Compliance

Cardiac Rehab Referral

In-Hospital Bleed

Door-to-Balloon Median Minutes