Hello everyone, first we would like to thank the American College of Cardiology for allowing us to share our quality improvement project with the group. It is truly an honor to be part of this summit. And before we start with our presentation, I would like to share with you a quick background of Riverview Medical Center. Our hospital is part of the Hackensack Meridian Health Network located in Red Bank, New Jersey. We are a heart care designated hospital holding chest pain center, heart failure, and cath lab with PCI accreditation. We had been participating with the NCDR registry since 2012 and a platinum status recipient from the chest pain MR registry since 2015. We have a multidisciplinary committee that continuously monitor our NCDR registry metric performance, create process improvement projects to improve outcomes, as well as to ensure that our processes are aligned with the industry and accreditation standards. Today, we would like to share a project that help improve the compliance in the utilization of risk scores for our NSTEMI patients and how it impacts the identification of high risk NSTEMI patients that receive early invasive strategy. Approach to risk stratify NSTEMI patients utilizing a validated risk score is part of a process that impacts the initial treatment strategy for our NSTEMI patients. The utilization of risk scores helps identify the selection process and identifies the high risk patients for early invasive strategy, which is usually within 12 to 24 hours, or delayed invasive strategy, which is usually between 24 to 72 hours. It also helps prioritize patients for early coronary angiography and possible revascularization. The utilization of risk scores also aids in predicting outcomes following an NSTEMI diagnosis. The NCDR chest pain MR registry metrics, number 50 and 51, are two quality metrics that is related to risk score stratification. Metric number 50 measures the percentage of patients hospitalized with NSTEMI who had a risk stratification score documented during hospitalization. Excluded from this metrics are those NSTEMI patients who left against medical advice, deceased during hospitalization, and NSTEMI patients who are on comfort measures only on hospice care, and for those transferred to other acute care hospital. Metric number 51 measures the percentage of patients hospitalized with acute NSTEMI who were at high risk and who received an early invasive strategy within 24 hours of hospital arrival. NSTEMI patients with high risk scores, which is usually a TMI risk score of above 4, or a heart score of above 7, and received early invasive strategy, which is less than 24 hours of hospital arrival, are included in this metric. After reviewing the NCDR chest pain MR registry report, metric number 50 that addresses the presence of risk score stratification for NSTEMI patients, our data showed that our compliance this metric is below the 50th percentile. The above published report showed that for 2021 quarter 2, our compliance for the last rolling four quarters was at 33.33% and is below the 50th percentile when compared to the rest of the nation's performance in the same hospital group. So performing below the 50th percentile is an opportunity that the ACS committee has identified for improvement. So if we look closely, the historical performance for metric number 50, our quarterly trends showed a continued decline in compliance. The ACS committee is aware that underperforming on this quality metric will not affect our platinum performance award status, however, compliance to this metric are proven to predict cardiovascular outcomes and it is imperative that the ACS committee will set a goal to improve the compliance for this metric, at least above the 50th percentile. When we look at our data that reports the percentage of high risk NSTEMI patients who receive early invasive strategy, our NCDR metrics came out that we have no data to show at all. Absence of the data doesn't mean that Riverview Medical Center does not treat high risk NSTEMI patients. It is related to the low compliance in the documentation that led to the data not being captured. So we know that improved compliance to metric number 50, which is the documentation of the risk stratification score, will aid in identifying the high risk patients and will allow us to evaluate our performance and how optimal the timing of the invasive procedure was done. As you can see from this slide, that metric number 51's historical performance since 2019 of quarter two, we have no data to show that there were high risk NSTEMI patients that received early invasive strategy. So without the data, there's nothing to measure and we cannot address any gaps in the care of our NSTEMI patients. With these questions in mind, we set our goals for the project. Our goals for the project includes improving the compliance to the documentation of a risk stratification scores for NSTEMI patients and have it at least above the 50th percentile, identify the high risk NSTEMI patients that are candidates for early invasive strategy and investigate the timing of their coronary angiography. We also want to determine the volume of high risk NSTEMI patients that we get and identify any associated reasons for any procedural delays that might be encountered. The design for our project is a retrospective review of cases. The scope includes all NSTEMI patients enrolled in the NCDR Chest Pain MI Registry at Riverview Medical Center, inclusively between 2021 quarter one to 2021 quarter four and identified high risk NSTEMI patients include those patients that had a heart score of above seven or TIMI score above four. Our process improvement methodology is a plan to study act. Our interventions include developing a project charter and identifying the champions for the project. The champions include departmental leaders, such as the ED medical director, the cardiology section chief, who is also our chest pain medical director, the cath lab medical director, and also a meeting with the head of the hospital's group was facilitated by the chest pain coordinator to increase awareness of the importance of the risk stratification scores for ACS patients. And they were also empowered that they can do the risk stratification scores themselves without waiting for cardiology referrals. During our monthly ACS meetings, providers were selected to provide a variety of meetings. Providers were surveyed and asked for input as to the factors that might contribute to non-compliance. And definitely we did a patient level drill down of the metric number 50 and metric number 51. To determine why we have low metric compliance, we start looking into the different areas that influence them. We come to realize that the providers that are involved in risk stratifying and semi-patients are not familiar with the metrics and are not aware that the metrics are being captured. Not being aware of the requirements to meet the metric, and in some cases, reluctance to adapt to the process are factors that contribute to the low metric compliance. We also learned that there was no templates available that providers can use with ease. And there are varied expectations as to who is involved and expected to document the risk scores. After examining the factors that influence the low compliance to our metrics, our interventions include sharing epic smart phrases among providers, real-time capture of missing risk scores was addressed by the cardiology NP, and a risk score was documented in real-time. Cardiologists were encouraged and reminded that the risk scores were documented in real-time. And a risk score was documented in real-time. Cardiologists were encouraged and reminded to document the risk scores during their initial consults, and compliance to the risk score documentation was reported monthly to the ACS committee. To identify the gaps associated with the timing of early invasive strategy for high-risk and end-stemmy patients, an individual retrospective review of the cases was done. A total of 65 charts were reviewed, and for those patients with no documented risk scores, the cardiology NP retrospectively assigned a risk score to risk stratify the end-stemmy patients. To limit variances and facilitate consistency, the cardiology NP, who is also the chest pain care coordinator, is one that is solely assigning the risk scores. Once the high-risk patients were identified, we further reviewed the timing of the invasive strategy. For those patients that are high-risk and who went for early invasive strategy after 24 hours, the chart was further reviewed to determine if there are patient-related reasons for the delay, or is it non-patient related and is process or system related. We then attempt to identify non-patient-related reasons for the delay. So these are the results of our retrospective data review. A total of 63 charts were reviewed. Out of those 63 charts, 25 of those patients were identified as high-risk end-stemmy patients. The average time to angiography was 32.6 hours, and 64% received angiography within the first 24 hours of hospital arrival. There was a portion, about 38% of those high-risk end-stemmy patients that were delayed, and 50% were related and 50% were patient-related, which includes hydration, because their creatinine was elevated, and they were on anticoagulation that needed to get washed before the procedure. The 50% of those cases that we identified that were delayed was a non-patient-related reason, and we attempt to identify the reasons and a common denominator with all those cases, and it seems like it all happened on those patients that were admitted on the weekend, on a holiday, and when the cath lab staff is off-site. So knowing and having an idea as to reasons for procedural delay that we can intervene, we communicated and tried to make some initiatives involving the cath lab administrators to accommodate these high-risk end-stemmy cases. In the next slides, I want to introduce our cath lab administrators, Stephanie Minervini, who's the manager of Riverview Cath Lab, and her assistant nurse manager, Jessica Altshuler, who is also played a key role in staffing the cath lab. Hello, my name is Stephanie Minervini. I'm the nurse manager of the Cardiac Cath Lab here at Riverview. I would like to discuss our interventions to improve our compliance and accommodate emergency cases in the Cardiac Cath Lab. The process to timely accommodate high-risk non-stemmy patients is a need that we anticipate in the cath lab. Resources can be a challenge and requires flexibility. Open communication among providers and cath lab management is essential. Our interventions include open communication among providers, departmental leaders, and staffing coordinators to facilitate accommodation of cases that need early coronary angiography. Patient-related issues that contribute to delayed invasive strategy is hard to control. However, system and process-related issues are things that, as a group, we can have a continuous discussion. So after we did our initiatives and checked our data, our project started in October of 2021, and when the 2022 quarter one report was published, metric number 50, which was the compliance to risk score certification for n-stemmy patients, a rolling four-quarter report showed that our compliance is still below the 50th percentile, which is not a goal. However, if we look at the next slide, in this slide, despite our rolling four-quarter results staying below the 50th percentile, when we look into our historical performance, we notice that our quarterly performance is trending to the right direction. From 16.67 when we started, we are now at 50 percent compliance. For our metric 51, which is the percentage of high-risk n-stemmy patients who receive early invasive strategy, from zero percent, we are now at 50 percent, which demonstrated an improved compliance. And if you look at our metric 51 quarterly trends, we are heading at the right direction. We started with no data to show, and then in 2021 quarter three, we had identified an n-stemmy high-risk patients, but that patient did not go to the lab within 24 hours. And by 2022 quarter one published report, the identified high-risk n-stemmy patients that we have all went to the lab within less than 24 hours of hospital admission. The cost of pursuing early versus delayed strategy for high-risk n-stemmy patients has been seen to be valuable. From the study conducted by Bailey in 2014, the implications regarding the cost of pursuing an early versus delayed strategy for high-risk n-stemmy patients was lower with an average total cost to be minus $1,100. Early invasive intervention reduces length of stay, which further reduces costs that positively impacts our patients, payers, and healthcare system spending. For the next slide, I would like to introduce to you Dr. Ravi Dhawan, who is our Chest Pain Center medical director, and he is also our cardiology section chief of Riverview Medical Center. Improving risk score documentation compliance provided Riverview the information of how timely the invasive strategy was done for high-risk patients. Retrospective review, patient level drill down, and discussions of data trends and benchmarks during the meetings helped identify opportunities for improvement. Initiatives such as real-time data capture and intervention, creating smart phrases in the EMR, collaboration among providers, and continuous data monitoring helped improve metric compliance. The process to timely accommodate high-risk n-stemmy patients is a need that must be anticipated by the cardiac cath lab. Resources can be a challenge and require flexibility to help open communications among providers and cardiac cath lab management is essential. Real-time data monitoring of our compliance and validating our performance internally empowered our team to continuously strive for top quality care. Capturing the variables associated with calculating the risk scores for the EMR and automation is being considered, but demands for further discussion between committee members and providers. So for our next steps, the need to continuously discuss the availability of cath lab resources to accommodate the high-risk n-stemmy patients demands commitment from all departments. Collaboration is the key. We don't stop when the results improve, but rather continue to innovate ideas that can help our process. We are a small lab with limited resources and on-call teams, so it is essential that open communications among providers and cath lab management must happen. Real-time data monitoring of our compliance will validate our performance internally, and as we mentioned, we need to facilitate discussions for the possibility of automating our risk scores by capturing the variables from the electronic medical records. However, it is a discussion that we continuously need to do as a group, and we will be looking into the possibilities of this initiative. This is the end of our presentation, and we thank everyone for your time, and if you have any questions, you could always email us and we will be more than happy to communicate and share our initiatives with you. Thank you. you

quality improvement project

risk score documentation

NSTEMI patients

early invasive strategies

risk score stratification

metric compliance