Good morning. Happy Friday, everyone. It's good to see your faces again. And on our last day of Quality Summit, I hope that you're learning something new in every session and finding at least a few takeaways to bring back to your facility and have some good internal discussion. And just to make sure everyone's in the right track, this is the CAHPS PCI Registry track. And today, I am thrilled to have two different hospitals with us who will be sharing some of their processes that they've put in place to improve patient care. We have both Hackensack University Medical Center and Rush University Medical Center here with us today who will be presenting. And first up, we are going to have Hackensack presenting. And from Hackensack, we have both Kristen Murrah and Tammy Russo. And once they finish, then Julie Meurs and Megan Hartman from Rush will come up. And then at the end of their presentations, we'll take questions and answers. So without further ado, we're going to have Tammy come up. And thank you very much. »» Thank you. Good morning, everyone. We like to thank the American College of Cardiology for the opportunity to share our approach to risk assessments and our Risk Here, Risk There, Risk Everywhere initiative. Kristen and I have no disclosures. A little bit about us and our program. Kristen and I are from Hackensack University Medical Center, which is part of the Hackensack Meridian Health Network. We're a large academic hospital with approximately 800 beds located in the northeastern portion of New Jersey, just over the bridge from New York City. Hackensack has achieved multiple ACC accreditations, raising the bar and elevating our programs. Today we're going to be walking you through how we tackled risk assessments for our cardiac cath patients. This was truly a labor of love. It came to light during our accreditation process. When we evaluated our program, it was like opening Pandora's box. We're excited to give you an overview and highlight how we identified risk to be an opportunity. And then Kristen is going to share with you the tools that we rolled out for our clinical teams. So a little bit about our cath lab. It supports a high volume of both inpatients and outpatients with five different specialties. We have eight procedural rooms and 19 bays for same-day admissions, same-day discharges and direct admissions, four of which are radio lounges. We utilize a multidisciplinary approach to care with our nurse practitioners being at the core of the coverage model. They are the key drivers behind our pre- and post-procedure care and the connecting piece between our physicians and our multidisciplinary team. Our care team structure will be important later when we dive into the standardization of risk documentation. Our partnership with the ACC and the cath lab accreditation was truly a reflective process. We used a microscope to examine our entire program. And with this bigger lens, we realized we were no longer setting our own standards, but rather being benchmarked by the gold standard, one that is driven by best practices and guidelines. It became a domino effect for us. So whether we were looking at our program's governance, quality or phases of procedural care, they all had one common theme. The attention to risk was a priority everywhere. So when it came time to choosing our quality metrics for our quality improvement projects, risk found its way back in the spotlight again with our choice of AKI and bleeding. So we let the accreditation take us on the journey and the idea of risk here, risk there, risk everywhere was created. So we started by looking at our current approach to risk. Initially it seemed like we had all the pieces in place. Every patient has a history in physical, nursing assessments, consult notes, and perhaps even previous hospital admissions and office visits were available in our electronic health record. But where exactly was the risk? HMPs carried a piece, nursing assessments captured another, but there was varying degrees based on the provider. We were not able to find one patient who had all the needed risk assessments. So we had our clinical practice guidelines. We have our risk assessment tools. But we did not have a way to tie it all together. Individually these tools are good. They provide value. They help guide our clinical care. But one piece alone does not tell the whole story. Risk evaluation is no different. Individual tools are good, but having them work together collectively would be the most impactful for care. It's at this point we realized we had a tremendous opportunity to fix our fragmented approach and replace it with something more cohesive. We identified the need. We had the tools. But we needed to close the loop to centralize the documentation, location, location, location. Centralization was key to complete the assessments. But equally important, we needed to ensure that the entire healthcare team had access to these tools so they could be utilized as the patient transcended through care. So hardwiring the process and the communication tools into our electronic health record was the link to reduce variations and allow us to track compliance. This redefined focus would help us provide the individualized care that our patients deserved. So I'm going to fast forward. We're going to look at our numbers. Our risk-adjusted metrics provide us valuable insight on our clinical practices and our documentation. So after launching the centralized risk assessment, we waited patiently for the next NCDR published report so we could ask ourselves the question, did all our hard work make a difference? And I'm happy to say it did. We were able to make significant improvements in not only our outcome metrics but also our observed over expected ratios. But this initiative was so much bigger than the results you see. It was not a simple fix. It was not a one and done. Because as we all know, risk is everywhere. So I'm going to now hand it over to Kristen, and she's going to walk you through all the moving parts and the tools that we gave to our clinical teams. It's not working. Thank you, Tammy. Good morning, everyone. As you just saw, we made some really great strides in a very small amount of time. Now we're going to get into the nitty gritty, how and the why behind our numbers, and how we were able to identify and mitigate our risk. So starting with the basics, we developed three tools that we integrated into our electronic health record. But they just weren't any three tools. They were designed to work together to make sure that all of our processes were intertwined. Each piece was a building block that created accountability for our clinical teams as a whole. It started with the pre-procedure checklist, completed by our nursing team, continued with our nurse practitioners, evaluating risk assessments, and then ended with the communication process by our intra-procedure team, really to bring everything full circle. So now we're going to take a look at exactly how we put all of these pieces together to mitigate our risk. So the first building block was our pre-procedure checklist. So our original checklist, it was fine, it was simple, it was basic, but we raised the bar to be able to align with SCI guidelines. The checklist is owned by our nursing team to capture patient-specific information that's most impactful to our procedures, with a secondary targeted focus on AKI and bleeding, since risk assessments are so important for both of these potential complications of PCI. The checklist lives in the front of every patient chart. It's used as a quick reference. And the updates we made were really intended to guide handoff discussions between our pre-procedure teams and our intra-procedure teams, because for us, those teams aren't interchangeable. So it really served as that reminder to be sure that we've asked all the right questions and we've raised all of the red flags prior to putting our patients on the procedure table. The second layer of our building blocks was our risk assessment form. So this is our hub for risk evaluation, the home of our centralized collection of risk. So the form was designed with three sections. Not only do we need those risk scores, those raw values, but we also included an interpretation section to bucket each one of these risks into high, medium, or low, and really to help guide us as we begin to prioritize our various risks. And then most importantly, an intervention section to focus on what we did about it all, all the actions that we took to keep our patients safe and to minimize our risk. So in terms of responsibility, our APN team, as Tammy had mentioned earlier, was really top of our list when we began to look at process ownership. They play an integral role in our pre-procedure process and serve as that consistent piece to make sure that there's reliability within our program. Their commitment as our clinical experts was truly instrumental. They play a critical role in identifying our risk, intervening when appropriate, and then communicating back with our physician team. So this specific image here really focuses primarily on risk that's associated with a scale or a value, but the note template in its entirety was really built to align with multiple NCDR metrics. And the next two slides are going to look at how we use this template to both impact our clinical care as well as our data requirements. So I know there's a lot going on here, but my goal is to give you a more granular look at the components of our risk assessment form. So first and foremost, the focus was to support our end users, so this is a glimpse into exactly what they see. It's an easy point-and-click process with definitions and guidance that we baked right into our build. All the responses, they were designed to file to flowsheets, and we did this for two reasons. So first, I think we can all relate to flowsheets. They're easily accessible and a useful tool for our teams to be able to follow as our patients transition through our care system. And then secondly, because they're all discrete data fields, so that means when it's time to start crunching those numbers, they were easily leveraged for monitoring and for analytics. All of the risk scores that you see here on the left side of the screen appear by default for all of our patients, and they're used based on clinical presentation. NCDR elements such as indications, appropriateness, and other classification categories were also included in our form. So our clinical teams can really continue to put those pieces together to see the bigger picture, and at the same time, the abstraction process is more streamlined, more efficient, and more accurate for our data team. So one last piece that we built into our risk assessment form was our risk model elements. So specifically, I'm talking about all four NCDR mortality risk models, as well as the AKI and bleeding risk models, to really ensure that each one of those elements are assessed and addressed from a clinical perspective, and then available to our data abstraction team for accuracy. This approach that we used to capture patient acuity and risk actually provided a dual benefit. It helped us to improve our clinical care in real time, and then also address that mismatch of our observed over-expected ratios. And ultimately, putting all these pieces into one form really helped contribute to our success. So we've talked a lot about the first two building blocks. The first one was the pre-procedure checklist. The second one was our risk assessment form. Now we're going to talk about the last, which is really the glue that held all of this together, and brought our process really full circle. And that's our briefing, debriefing, and intervention safety huddle. This series of checks was designed to be performed with our entire procedure team present to really focus on various aspects of safety, make sure that everyone in the same room is on the same page and has the same information. So the procedure briefing, it's a best practice. It was brand new for our cath lab and included an ABCD check, allergies, bleeding, clotting, and dye. The debriefing, we modified to guide best practice discussions related to things such as risk scores, contrast, volume, radiation threshold. And then the intervention safety huddle was just that, a quick huddle prior to a diagnostic procedure becoming an intervention. So putting it all together, each of our teams really own a small piece of that building block through those individual building blocks, but none of them really can function at their highest potential without all of the others. As we know, there's many decisions made during a cath lab procedure, whether it's our access approach, our stent choice, our drug choice, just to name a few. And with each one of those decisions comes its own set of risks and benefits. So this intertwined process really keeps the team focused through discussion, through accountability, to make sure we're providing that top-notch care with risk at the heart of every decision. So we've talked about all the great tools that make up our risk assessment process, but what's next? All of us who've rolled out initiatives know that the compliance rate, it usually starts pretty strong. Then, over time, it can fizzle out. So what do we do? One of my colleagues recently shared a quote that resonated with me, mostly because it's so relevant to our everyday life. And the quote goes, you get what you inspect, not what you expect. And I thought this was very powerful. As we all know, expectations sometimes can have a funny way of turning upside down. It's kind of like driving down the road, you see this amazing-looking restaurant. Fancy signage, beautiful greenery, lit up so nicely, and you automatically assume it's going to be a great place to eat dinner. So you walk in, you sit down, you order your dinner, you take that first bite, ugh, falls a million miles short of your expectations. And you think, well, I guess it was my own fault. I probably should have inspected the restaurant's reviews. Perhaps I should have looked at the menu, because now I'm totally disappointed. It's the same with our initiatives. People don't always do things exactly how we have set out and envisioned in our minds. There's room for error, there's misinterpretation, and there are certainly going to be bumps in the road. And sometimes, when we rely solely on those expectations, we overlook the important details that can really make or break our plans. But reality is, we're all being pulled in a million directions. This inspection thing, well, it sounds like a winner, but who has the time and the resources to devote to digging into every patient chart to look at compliance? So this is where our flow sheet rows and those discrete data fields really become so impactful for our sustainability. So we were able to create a quality dashboard that pulled discrete data from each one of our risk scores, as well as some other fields within our risk assessment form. And this allowed us to see where we were going, what our trends were, simply with the click of a button. They say, anything worth doing is worth doing right. And this quality dashboard really kept us climbing in the right direction towards our goal. So if your head's spinning and you feel like we did, like you have a little bit of risk over here and a little more risk over there, and gosh, your risk is everywhere, you're probably right. That small, little, four-letter word really has big consequences, whether it's outcomes or whether it's cost of care. And in the end, it's really about bringing it back to our patients, providing that individualized, evidence-based care that they deserve. So why not take a risk and invest in setting your clinical teams up with the tools they need to succeed? It just might pay off for you, like it did for us. Hello, everyone. Good morning. Thank you, ACC, for allowing us to present today. We're really excited to share what we've been doing at our organization. My name is Megan Hartman, and I am a clinical nurse specialist at Rush University Medical Center working in the interventional procedure space, going over cath lab, and then also interventional radiology. This is Julie Merz. She is the quality manager over the heart and vascular line at Rush University Medical Center. We are here to present on a multidisciplinary cardiac cath committee that we created at our organization, and we're really dedicated to improving our patient outcomes. And we're going to go through what those are throughout our presentation and how we actually developed the quality cath meeting. So before we get started into how we developed the quality cath meeting, I just wanted to give you a little glance at our organization. It is an academic medical center of about 671 beds. It's three hospitals within the system. As you can see on the slide, some of the facts that we have up there, we're really dedicated in producing quality. And some of the quick cath lab facts, because that's what our focus is going to be on during this presentation, we are two full-time labs. We are staffed five days a week with nurses and technologists and physicians, 10-hour days, 10 hours per day, and then with 24-7 on-call coverage as well. And then some of our FY23 volumes listed there too, about 1,800 procedures within the last FY year. So I want to start off with a little bit of a timeline to set the foundation of how we actually got to the quality cath lab committee. So back in 2015, that's when we started in the cath lab to do the register for NCDR and participate in the cath lab registry. We were participating, but we didn't really do anything with the data. And it wasn't because we didn't want to. We just didn't really have the bandwidth to be able to do that. We didn't have the resources in place. We didn't have the process in place to come together and really look at the data and understand what our opportunities are and what we were doing well. So fast forward a little bit to the end of 2021. We started to get a little bit of leadership changes and additions to the leadership, such as Julie starting in her role as the quality manager and leveraging some roles such as my role as the clinical nurse specialist and working together to really review these registries that we're participating in and understanding where some of the opportunities are that we have. So that started back in March 2022. And then our first project that really sparked all of this was cardiac rehab referral project. We noticed that this was kind of a low-hanging fruit, but something that we can really leverage and do better on and implement some of the quality improvements. So Julie's going to kind of go over that later in the presentation of how we made improvements on that project specifically. But because we found such success in that project, we talked with the cath lab physician director and said, you know, I think there's a big opportunity to hear that we can come together and really collaborate on a lot of these initiatives that we're seeing within the registry data of where we can make improvements. So let's come together and let's see who needs to be at that table. So on the next few slides, we'll kind of talk about who is part of that committee and how we set that foundation. So this is what we started with for some of the foundation. This was adapted from the Institute for Healthcare Improvement. We needed to define what is quality? What are we going to look at within this committee? And this is what we decided on. Safety obviously is our number one priority. We want to make sure that all of our quality initiatives and changes are safe for patients and safe for our team members as well. But all of these affect quality. So effectiveness, patient-centeredness, timeliness, especially working in a procedural space, we are always looking at how do we avoid delays? How do we make our process efficient? And then of course equity as well and closing the gap in justice and in healthcare. So I'm going to pass it over to Julie now, who's going to be talking more about our foundation of how we set up the Cardiac Cath Lab Quality Committee. Thank you, Megan. So we started with defining quality, and then the next thing that we needed to do was create a pathway of, okay, we know what quality is now. How do we get to getting quality improvements? And we started by understanding the data, by looking at our submission process, make sure we were confident in what we were submitting and what it was, and also understanding the data definitions because nobody really knew what those were. Once we were confident in that, then we brought it to our team. We were transparent, brought it to the staff, our faculty, physicians, fellows, everyone who impacts the outcomes of interventions to say, here's where we're at, this is what we're doing, here's where we need to be to get that transparency out there. And then we wanted to collaborate together, creating that quality committee, as Megan said, including having a physician chair that who had protected time to do so. And once we felt like we had that structure, that foundation, then we could actually go into quality improvements. So this is, again, the framework that we're going to walk you all through of how we did this to actually make some improvements this past year. So starting with the data, where were we at? Let's build some trust. In reviewing our data in 2021, we started this, we had a lot of room for improvement. Our STEMI mortality rate, risk adjusted, was over 9.5 compared to the 75th percentile benchmark, which is where we wanted to be performing at, was less than 6. Our major adverse events were fine, a couple of emergency revascularizations, and as well as the mortalities are included in there. Our bleedings, transfusions, again, right around that mark, we were doing all right, but our AKIs and our referrals to phase two rehab, again, significant room for growth. We were at 8, everyone else was less than 6. We had 70 percent referral rate, everyone else was almost at 100 percent. So we knew we needed to start there. All right, so we knew where we were at, we knew what we could do, how do we get to some quality improvement projects? From just our data deep dives, we felt like we could attack the STEMI mortalities and the cardiac rehab approaches. STEMI mortality is understanding the metrics. We realized we weren't documenting well. We weren't capturing exactly how sick our patients were, which is really impacting our expected ratio. And just by reviewing retrospective data and educating the physicians, we were able to make some improvements there. I'll get into the phase two rehab project, but there was a broader institution interest, so that kind of went beyond the cath lab. Some learnings there then led us to the structure of the quality committee and able to tackle a couple improvements, which we'll talk through, our bed rest and hydration protocols as well. Okay, so starting with the cardiac rehab phase two project. As you saw, our opportunity is that we are at 70% and we wanted to be much closer to 100%. So what did we do? We started by bringing together a multidisciplinary team to define the problem, led by our cardiac rehab physician. We brainstormed what the ideal patient pathway should be for a patient who is appropriate for cardiac rehab, and then I identified the gaps of how do we then get from point A to point B. We created protocols, pathways, and education material to help us get to this ideal pathway that we are at. So we actually created phase one cardiac rehab education material and pathways, which is essentially just education of patients in-house about what cardiac rehab is and how it could benefit them. We updated our PCI and structural, actually, post-procedure order sets to make sure they included requirements for phase two referrals, and then updated that pathway and education not only for our patients, but for our staff. So this three-pronged approach, again, went beyond the cath lab. It started there by reviewing our metrics and expanded to a broader hospital-wide project as that actually was the root cause of what was going on. Want to give some detail of what these order sets looked like. So when patients are admitted to our ICU, we kept it to the ICU. It was a little bit easier to control on the admission order sets and how our structure is at rush. They have to select if a patient potentially is appropriate for cardiac rehab or not. If they are, then this order set comes up that automatically involves our case management, PTOT, dieticians, and nursing to have them educate the patient on cardiac rehab, lifestyle changes, as well as their recommendations if they would be appropriate for cardiac rehab. This then is our phase two order set, which is separate than the phase one. It can be ordered at any time during a patient's stay and will be released upon discharge. But this is also what's embedded in our post-procedure order sets. So it's a reminder of what patients are indicated for cardiac rehab phase two, and then also a list of registry-appropriate reasons why they might not be indicated for cardiac rehab, such as patient preference or inability to be able to perform rehab. So did it work? Yes, and we have a long way to go. So we ended up actually implementing this toward the end of the year due to needing to get some of that education material in place. And we did see an uptick in referrals, which is that blue bar, as well as appointments created from those referrals, which is the orange bar, in the following two months, which was encouraging. But then we kind of took a turn for the worse and definitely had a large decrease, which is actually OK for us because this came from our QI project. We realized that our barrier was not just inpatient referrals. There was a broader operational issue in us getting patients actually to cardiac rehab. So it's great that you'll see our metric really increased in the percentage of cardiac rehab referrals that were entered. But we still want our patients to actually go to rehab, right? That's the point of this metric. So this was actually transitioned to our operational team, who is diving into this and looking into virtual programs and other ways that we can improve our operations to actually increase the patients who are completing cardiac rehab. But the other thing that we learned from this is that it was really helpful to have a focused multidisciplinary team working on this larger problem. And as Megan mentioned, that's why then we brought in the Cath Lab Quality Committee. We wanted a team for structure and accountability so we could continue implementing protocols that were going to benefit our patients and improve the amount of quality that we could bring. So I'm going to pass it back over. Oh, the Quality Committee, we did with the purpose of essentially being a problem-solving center. As I mentioned, it's a multidisciplinary group with our physicians, fellows, nurses, techs, and quality. We meet monthly for about one hour to discuss an agenda set by the chair, usually coming from a lot of our metrics. And we do use the Cath PCI Registry, as well as Visient Data, and lots of other literature that can inform what we should be doing. And our staff can also come and bring anything that they've observed or they think should be an area for improvement for us to review and address. OK, so now we have a couple of initiatives under our belt. We've done cardiac rehab. I briefly talked about our semi-mortalities. We realized that we need to create a structure, so we did. And now we're going to talk through a couple of protocols, or Megan's going to walk us through a couple of protocols we were able to implement now with that structure. OK, so our first protocol that we started with is around our bedrest standards. This one was pretty unique in the fact that this didn't come directly from the NCDR Registry. There was nothing to say we need to improve on our bedrest standards. This really came from our staff members that came in to the quality meeting and said, this is something we've noticed. We've noticed that there's inconsistencies around bedrest orders. The same procedure could be done. One physician likes two-hour bedrest. Another physician likes up to eight hours bedrest. What can we do to really standardize this process and align it with best practice? So that was our opportunity. So we, for our work step groups, the first thing we did was go to the literature. What is the literature saying currently about bedrest standards? And there's actually a lot of literature currently on specifically coronary procedures and bedrest orders post-op, and how can we implement some of that literature into our current practice. And mostly, the literature looks at a variety of different things. It compares bedrest hour times. It compares sheath sizes, anticoagulation that's used during the procedure. It compares closure devices versus manual devices. So we really just compiled all of the literature together to look at how we can create our own protocol. And the literature did show that it is safe and it is feasible to reduce bedrest times. I think sometimes we're so focused on the three hours for closure devices and six hours for manual compression. So how can we adapt some of this? So we looked at it. We designed an order set. We reviewed it with the committee. We do have fellows and attendings on the committee, staff on the committee, and they were all in agreeance. This looks great. But before we actually went live with it throughout the entire platform, we decided to do a pilot. Let's pilot this for three months. The physicians that are in our quality cath lab were agreeable to do the pilot along with some other physicians. So we wanted to pilot, and we just really wanted to make sure that, again, this was safe for our patients. We weren't going to do harm. And we wanted to keep track of our access site complications during this pilot, make sure we don't have any increased complications during this. So we piloted it. The pilot went great. We didn't see any increased complications in site access. So we then took the next step to let's embed this into the order set and have everyone on board. So we disseminated the education to the team, built the order sets. And then some of our outcomes that we saw, like I mentioned, even post-pilot, we did not see any change in post-procedure bleeding rates, which was what we wanted to see. We weren't trying to improve, although we did have some improvement after our implementation. But we really just wanted to make sure we weren't causing complications because of this. And then we also saw a decreased outpatient recovery length of stay by 43 minutes. And that was specifically for interventional coronary procedures. Diagnostic, we didn't see a huge change, only because of the sheet size that's used. And that was more so on the lower end of bed rest times, more around the two-hour bed rest. But our interventional procedures is where we had the biggest drop in recovery length of stay because of the change in how many hours the patient had to lay flat. I do want to mention this was only femoral access. This was not including radial access because we had a completely different protocol. It's already set in place for radial. So this is just femoral access talking about bed rest times. So now I want to walk you through what the actual order sets look like. We embedded it into the electronic health care record. When we're doing new protocols and rolling out new initiatives, I'm a firm believer that education is, of course, one piece of the rollout and making sure everyone's educated on this new process. I like to focus on the why. Why are we doing this part of the education? Because that helps people buy into the new implementation. Why are we doing this? We're doing this because. So we really focused our education more around that. The literature shows that if you have lower bed rest times, patient satisfaction rates can go up. They're happier about that. They have less back pain. We can get patients out quicker also, but safe as well. So we did take a little bit more conservative approach with our new bed rest standards, and that was because we wanted buy-in from all of the physicians. So some physicians were OK with what was seen in the literature. Others were a little bit more conservative and wanted not to decrease it too drastically and kind of a stepwise approach. So right now, we're in the phase one of this of decreasing our bed rest times. But the great thing is everyone's on the same page. We're all standardized now. So this is what it looks like. It's a mandatory stop embedded into the order set. So to help improve compliance, I'm also a firm believer of working it into the process and making sure the process is there to prevent people from forgetting to order it. So it's a mandatory field. They have to pick diagnostic or interventional. So if they pick diagnostic, it populates with two different options, either manual compression or a closure device. And based on what they choose is the bed rest time. And for interventional, if it's an interventional procedure, they also have a couple options. But this is broken out by more of the sheath size. So if they use a 6-front sheath or less, it's broken out into different times, along with if it's greater than 7-front sheath or equal to, it's broken out in those different times. So this is our overall bed rest standards that we implemented. We've seen great compliance with it. Our recovery nurses are also very happy with it. They're able to plan the schedule a little easier now, knowing that it's not physician-based. It's more, this is the procedure done. This is what we can expect for the recovery time. The next protocol I'm going to discuss is our hydration protocol, which seems to be a pretty hot topic right now. Looking at a lot of the e-posters from yesterday, a lot on AKI right now. And through our registry data, we did see that we had improvement to make in our AKIs for PCI patients. So this was directly from the registry data that we saw an opportunity. How can we standardize our pre- and post-procedural IV fluid sets for patients that are at an elevated risk of contrast-induced AKI? So going through the work steps again, we went to the literature. What is the literature saying? Did an extensive literature review to really develop an evidence-based practice approach to what we want our protocol to be for patients with renal insufficiency at risk of the AKI. So we focused more on the Poseidon study that I did see some posters reference as well. And so we designed it based off of that and collaborated again with our EHR team to really embed this into the order set to help increase compliance. We of course did education too on the why of why are we doing this. This is our data. Like Julie mentioned earlier, we want to be transparent with our entire team. The care does not stop within the cath lab. The patient moves on from there and goes to recovery, goes home. What are our metrics looking like for these patients? So after we did all of that, these were some of the outcomes that we saw. We saw an increased awareness of patient identification pre-procedure. And that's because the residents and fellows were having to look at the patient's GFR prior to the procedure, understand is this a patient that's going to be at risk and do we need to order pre-fluid hydration on these patients. And then intra-op, we embedded it into our timeout process that the GFR was discussed so the whole procedure room knows the risk for the patient at that time. They might have received fluid intra-op based on that LVDP, which I'll get to at the next slide. And then post-op, making sure in our post-op huddle that we discuss if this patient needs fluid continued for the rest of their recovery stay. And then we saw a reduction in risk-adjusted AKI from 8.04 to 6.65, which was within the 75th percentile range. So we still have work to do, but we were very happy with the decline in that in a short period of time. This was about two quarters worth since implementing. And then we saw a decrease in absolute number of AKIs as well. So going through the order set, this was embedded into the electronic healthcare record. We have our pre-procedure order set for all of our pre-procedures before going into CAFLA. And we have an inclusion and exclusion criteria. The inclusion criteria is patients with renal insufficiency, GFR less than 60. And exclusion criteria is really the patients that are at risk for fluid overload. So like pulmonary edema, acute decompensated heart failure. If they're on dialysis or end-stage renal disease, they also were excluded from this protocol. And then we did a post-hydration protocol. And this is embedded into our order set for every coronary procedure post-op. So they had the same inclusion-exclusion criteria. And this is where it was driven by the LVEDP that was measured in the procedure room. If an LVEDP was unable to be measured, then we also had an option for that. And based on what they chose is the amount of fluid the patient would receive during that post-op time. The fluid would run for about four hours post-op. And we were able to work with our healthcare record team to make sure that the healthcare record is doing the calculation based on the patient weight because this is based on kilograms. So there's no math involved for the fellow that's ordering this. It's all pre-populated within Epic just based on what they choose. So those are two of the biggest order sets that we have come up with so far within the quality meeting. We've done many other initiatives, but these were two that we wanted to share with you today. And Julie is now going to discuss what the impact's been on our volume of the cardiac cath with doing all of these quality initiatives. Yeah, as you guys can see, we grew our volumes by 13%, which has less to do with the quality and more just the goal of the program, right? We always want to grow our program, be able to work with more patients. But we don't want our quality or our growth, I should say, to come at the expense of quality. So that's why it's really important for us to monitor this, our growth, but also how are our quality outcomes going. And we're proud to say that we can do both at the same time. So again, did any of this work? Where are we sitting now compared to the metrics when we first started looking at this at the end of 2021? Our STEMI mortalities have decreased drastically. And as I mentioned, that was simply by understanding the data, simply understanding what we were doing and what our documentation looked like. We do have work to do. Our overall mortality rate we wish would be better. And so we know that's one of our next steps that we'll bring to the lab. But we're really happy that the STEMI mortality rate has decreased. Our major adverse events have increased a little bit, but that's all from those mortalities. So overall, those have maintained the same. But then the things that we really were looking at were where our interventions could have made a difference. So as Megan mentioned, our bleeding and transfusion rate has stayed essentially the same, which is great. With our bedrest protocols, we didn't want that to change at all. We were already performing well. We wanted to make sure there was no additional complications. Our AKIs dropped by almost a point and a half, and we're much closer to that 75th percentile, which is really where we're looking to be. And this only includes, as Megan said, two quarters of our interventions. So we're hoping that this will continue to drop as we get some more of those risk-adjusted numbers. And our referrals to phase two rehab, from 70% to almost 100%, which again is that not only education, but building it into the system. So we have a lot of opportunities yet to learn, and a lot of things that we can still take to our quality committee that we'll continue to improve on. But we're really excited about the structure that we do have to be able to continue to implement protocols, educate, and problem-solve together. Thank you for your time, for listening to all of us speak. I believe we have time for Q&A now, so we'll happily take any of your questions. Thank you. Thank you so much to both teams for sharing this wonderful information and these great quality initiatives you've implemented. We do have a few questions to go through. The first question is a general question for the HACNSAC team. And this was around how you document your risk scores. This is specific to the clinical frailty, and more of a question of how you ensure that all of your APPs understand the definition and are capturing the clinical frailty score appropriately based on those definitions. Is there some sort of formal education or process around ensuring that? We definitely had some education with our both our we have APNs that are specific to our cardiac unit, and then we have inpatient APNs as well. So everybody throughout our heart and vascular service line are completing this form prior to our patients going for their procedure. So it was a large education amongst those groups. And then when they fill out that frailty scale within the risk assessment form, all of the definitions are baked right in there. So they follow the same definition for each. And if there is a question, they have their own group chat that they're able to get on and talk and make sure that everybody is understanding and interpreting the same way. That's wonderful. Okay. Next question is, are your checklists available in the EPIC library that other EPIC users could use and or modify to fit their institution? So the checklist, if you're talking about the pre-procedure checklist, that is a paper form. So that obviously is not available in EPIC. The debriefing briefing and intervention safety huddle we did put into EPIC, I would assume that they could, if you told them about our institution, would be able to find it. It's not part of their, I guess what they call their foundational build through EPIC. So it's not available for anybody. But if you let them know Hackensack is using such a form, your analysts are then able to talk behind the scenes and they'd probably be able to pull that information. Or we could share it with you. I guess I would say the same for any of the drop downs and pieces that you've implemented from the Rush perspective as well. I guess, are you, who are you using for your EPIC as well? Yes. And similarly, we built those on our own, but would be happy to share any of that detail. Next question is asking about, and I'm assuming based on some of the protocol, this would be a Rush question. Do you do same day PCI discharges? And if you do, how do you get those patients educated and seen about the phase two rehab prior to discharge? Yeah, it's a great question. We do do some same day PCI discharges, not as many as we would like, but we have worked with not only our, I guess, recovery nurse team, but also our ICUs and some of the other floors. So a lot of different areas have been educated on the rehab. And especially if they're going home same day, that phase two referral is entered as an order right post procedure, so they will have that. And if they're going home same day, the recovery nurses have been educated on how to talk to them about cardiac rehab and have the same education materials. So although there's not an official phase one order for that group, they will still be able to provide that material to the patients, and they will still have that phase two referral. Next question is, how did you get physician buy-in for your intervention safety huddle? Well, they really had no choice. The intervention safety huddle is driven by our team. So that was built into Epic, and our nurses, when a procedure is turning into an intervention, they just start going through. It's not quite like a time-out where everybody's standing completely still. So it's not as formal as a time-out, but they are talking through all of those pieces, what your contrast threshold is, how much contrast we've used, where we are with our radiation. And they really have no choice but to listen, because if the nurse isn't doing anything else besides talking about this stuff, what else are they going to do? It's always good to have a captive audience. Yeah. I guess, well, a similar question along the same lines of your committee or multidisciplinary teams to Julie and Megan. Who were the participants on that committee? The participants on the committee are a variety of different people. So we have nurse representation, technologist representation, fellows that come as well, attending physicians, our cath lab director, and nursing leadership, myself and Julie are on it as well. And then if we need to bring anyone in as ad hoc, we will do that too, or work offline with different team members, and then come back to the quality committee to discuss further. I'd add to the how did you get some buy-in. Our cath lab director actually was the one who came to us, and we discussed this together. I have never seen an improvement be successful where there is not a physician bought into it. So that is super important. But even if he wouldn't have come to us, the SCAI best practices list out that a quality committee should be part of the quality that you are bringing to the lab. And so again, bringing evidence-based best practices has been really helpful for us. And now we have a setting to do that, to say, hey, this is the best practice, or hey, this is where our data is at. We're not meeting that. We're not hitting that. What do you want to do about that? They tend to be a little more responsive in those situations than anecdotal stories, or I think that we should do this, but instead bringing objective facts of why we should be doing something. And do you have data abstractors participating, or solely clinical practitioners? I guess I would be the data representation. We actually have a third party do our abstraction for us, but I own all the, I guess I'm accountable for all of the data that we do submit, and so I'm the one closest to that reviewing it, pulling out fallouts and different things like that. So there is that representation then. And if we had an abstractor, I think that would be a really good addition to the team. For your outcomes, the AKI and bleeding, do you focus on observed over expected, and how do you benchmark that? Yeah, so we do. We use the risk-adjusted metric. We also kind of in the interim, because of course we have a couple of months that we have to wait to actually see the risk-adjusted metrics, we will look at raw percentage of where we're at quarter over quarter. So it is most helpful. I'm sure as you guys are familiar, every hospital takes care of the sickest patients, and our physicians take care of the sickest patients. So that risk-adjusted measure is very helpful for us to be able to talk through that. But looking in the meantime at the raw numbers could also give us an idea of the trends of where we're at, and if some of those interventions are helping. Agree. And I think we answered this, Hackensack's form is electronic, not paper. One form is paper, and then the rest is on electronic. Your pre-checklist. Pre-checklist. That's correct. Yes, that's on paper. It's just a quick reference tool for our teams, our pre-procedure teams and our inter-procedure teams. It just serves as that piece on the front of the paper chart to give them a little bit of reference and a reminder of what those important values are. And it helps to drive that intervention safety huddle and our discussions at the end of the procedure with our debriefing. All of the values and the scores are copied there as well. Are you also rounding the cardiac rehab phase to whichever facility the patient selects? And if yes, is that automated, or who finishes that piece? Yeah, that's a great question. It's kind of patient-dependent. The automatic way that it works in our system is it goes directly to our cardiac rehab facility. We have our patient access and reach out to the patient once they've been discharged, and either tries to schedule them an appointment, or if they would prefer another facility, then at that time they can kind of give them to the appropriate facility. If from the forefront, that's kind of why case management is involved in the phase one rehab, if they know from the beginning that this patient lives far away, or they're not going to make it to our facility, then they can try and change that, especially in the interim. But all of that would be manual, done by our care transitions and case management team. Otherwise, it is all automated to our own in-house rehab. Thank you. Of course, everyone wants you to share all of your resources. So just know that. Another question. How are you capturing the post-creatinine level on your same-day discharge PCIs? That is an opportunity for us. We are not capturing it very well for our same-day discharge. So what we're looking at through the data is mainly our inpatient population for PCIs. We have to do a better job about doing the same-day discharge. »» I think you answered this, but just to clarify for the HAC and SAC team, the checklist process is used for all patients including STEMI or just for scheduled cases? »» The pre-procedure checklist, we try to use it for every patient. It's maybe not as comprehensively filled out for those STEMI patients because we don't ‑‑ sometimes they're coming in hot and we don't have all of the details to be able to fill it out completely. Sometimes we don't have lab scores back so we can't ‑‑ we don't have a GFR to be able to calculate a contrast threshold. So we do the best we can. On-hours are definitely a little bit easier. There's more resources to help gather that information. But yes, we try to do it consistently with all of our patients to the best we can. »» We keep it in place just to keep a standard so that there's not different levels of care. »» For AKI and hydration protocol, was this only for inpatient or was it both inpatient and outpatient? And do you have a separate post‑CAF recovery team? »» Yes, we have a separate CAF. We're all one platform. But the PrEP recovery team is their own team. So CAF Lab team doesn't go out to the PrEP and recovery areas. And our biggest focus is on the inpatient side of the hydration protocol. We did track outpatient and inpatient. And it's meant for both. But we really are focusing more on the inpatient side of it. »» And we're even doing different iterations of the hydration protocol, talking about when does it make sense for an outpatient to come in, for example, for their procedure. Do we want them to come in an hour earlier for that? »» We've talked about, too, just kind of giving a bolus right as they enter the room. So there's opportunity there. But our inpatients tend to be sicker, right, and a higher risk of AKI. So that's what we tend to track and do more auditing on to make sure that those patients are actually following the protocol for sure. »» And we did collaborate with the inpatient side as well when we were rolling this out to let them know your nurses are going to be seeing these orders pre-procedure prior to the call down to CAF Lab. And they're going to be seeing these post-op procedures as well to continue the hydration for four hours. So we really had to collaborate on the inpatient side, too. »» I know we said this, but I'm just clarifying it out loud because it's a question. Both of you use Epic EHRs, correct? »» Correct. »» Do you have a Level 1 recovery and a Level 2 recovery, or share your recovery team with a PACU unit that recovers OR, ENDO, EP, IR? »» So we do have a level, we do have Phase 1 and Phase 2 and a PACU interventional space. But the staff that staffs that is all the same. So all of our staff go to Phase 1, Phase 2, or PACU. It just kind of depends where they're assigned for that day. But it's all within the same platform as our CAF Lab. So our interventional platform also includes our interventional rheology team, our neuro-endovascular team, our electrophysiology team, and CAF Lab. It's all just one platform. So they recover all of those patients in the recovery area. »» Well thank you so much. We are at the full hour. So we will be respectful of time and wrap up this session. We really appreciate you being here and sharing all this wonderful information. Thank you. »» Thank you.

quality improvement initiatives

risk assessments

standardization

centralized risk assessment form

interventions

outcome metrics

multidisciplinary cardiac cath committee

data analysis

physician buy-in