Hello, everyone. My name is Susan Ball, and I am the chest pain and STEMI coordinator at Baptist Health Louisville in Kentucky. The topic for this session is how to navigate rough waters and find smooth sailing. Our learning objectives are to explore the accreditation detail lines within the facility reports and to leverage facility data to identify process improvement initiatives and advance cardiac care. This slide just shows a picture of our hospital, Baptist Health Louisville, which was founded in 1975. We are a part of the Baptist Health System, which is one of Kentucky's largest non-for-profit healthcare providers. We have 519 licensed beds, 468 are acute care, 29 are rehab beds, and 22 are psychiatric. We have 695 active physicians on staff, 132 of which are employed. We have 213 privileged allied healthcare professionals, including nurse practitioners, physician assistants, and CRNAs. We have 3,189 employees, of which 1,218 are registered nurses. Our data for fiscal year 2020 showed emergency department patient visits at 52,146. Probably much like the rest of the country, our emergency department visits were down by almost 2,000 due to the pandemic. Our inpatient admissions were at 23,189, which was down by 3,000. Our surgeries, both inpatient and outpatient, were down to 29,465, which was down by 7,000. And we had 1,112 and 601 total patient days. We started tracking heart risk scores by our emergency department physicians back in 2019 with our previous accreditation, but here is the more recent data. These heart risk scores were performed on non-STEMIs, unstable angina patients, and low-risk chest pain populations. In quarter two of 2020, we were at 42.29%, which is 72 out of 154 patients. In quarter three of 2020, we were at 43.78%, which was 86 out of 177 patients. In quarter four of 2020, we were up to 49.3%, which was 100 out of 153 patients. We did make some progress in quarter one of 2021, and we were at 67.3%, which was 113 out of 168 patients. This slide is just for anyone who is not familiar with heart score for risk stratification of chest pain patients in the emergency department. As the legend indicates, the patient receives points for each category from history to ECG to age to troponin and other risk factors such as diabetes, smoking, hypertension, hyperlipidemia, obesity, and positive family history for coronary artery disease. When we started reviewing heart score documentation for risk stratification in quarter three of 2019, we were only documenting it 26% of the time. We implemented process improvement initiatives, which included the following. We provided education to our emergency department physicians regarding the rationale for heart score documentation. We developed a BPA alert for heart score documentation in EPIC for non-STEMIs, unstable angina, and low-risk chest pain patients to prompt the ED physician to document. We were tracking heart score documentation and gave that feedback to our chest pain center ED physician leader who relayed that to his colleagues. We created a risk stratification flowchart in collaboration with the ED physician leadership so that our current status as of quarter one of 2021, the documentation of heart score was up to 67.3%. And although there is much room for improvement, we are definitely tracking in the right direction. The next slide shows our acute coronary syndrome risk stratification flowchart. We start with symptoms suggestive of acute coronary syndrome and follow the early heart attack care model, which includes both typical and atypical signs and symptoms of acute coronary syndrome. Our goal is to have the ECG read within 10 minutes, establish an IV, apply O2 if SATs are less than 90% or the patient's in respiratory distress, do a STAT troponin, a set of vital signs, and continuous cardiac monitoring. The heart risk score is then documented by our ED physician and clinical judgment is utilized to determine next steps. The flowchart is divided into low risk heart scores of zero to three, moderate heart risk score of four to six, and high risk heart scores of greater than six. You can see on the right side of the flowchart, if there is a positive ECG for STEMI, we go straight to the cath lab, or if it's an out of hospital cardiac arrest, we check the ECG for positivity and then go straight to the lab. Further delineation of the heart risk scores will determine whether the patient is admitted, if they go to our cardiac evaluation center as an outpatient, if they go to observation, or what testing is indicated. The next slide shows our NCDR performance trend for first medical contact to device. You can see back in 2019, we were clicking along at 90% or greater in meeting first medical contact to device times of 90 minutes or less. But when COVID hit, we started to trend downward. In quarter two of 2020, we were down to 68.8%. We, at that time, we were no longer allowing our EMS agencies to bypass our emergency department and go straight to the cath lab. We required them to make a pit stop in our emergency department for COVID swab and chest x-ray. That's when we saw the decline in our percentages. In addition, our STEMI volume for quarter two of 2020 plummeted, as so many patients were afraid to come to the hospital due to the pandemic out of fear. So, when we did have outliers, they had a much bigger impact on our overall percentages. As the pandemic progressed, however, our overall STEMI volume increased, and we became more efficient in our COVID screening procedures. So, that by quarter one of 2021, we were back up to 95.5%. This slide shows our process improvement plan for first medical contact to device. The issue was a decline in the percentage of STEMI patients meeting the first medical contact to device time of less than or equal to 90 minutes during COVID when EMS bypass of ED was no longer allowed. In quarter two of 2020, we were at 68.8% that met the metric. Our process change had been to have EMS pit stop in the ED for COVID swab and chest x-ray of the patient. We educated the ED staff regarding the importance of rapid COVID screening. We dedicated a pod in the emergency department for rapid COVID screening. We notified the radiology department a stat chest x-ray needed upon arrival. Q3 2021, we allowed STEMI bypass of the ED when EMS COVID screening was negative once again. So, that by Q1 of 2021, we were back up to 95.5% of STEMI patients that met the goal of first medical contact to device times of less than or equal to 90 minutes, which were pre-pandemic percentages. The next slide shows the patient flow from the 911 call to EMS, to our emergency department, and then to cath lab arrival. A 911 call is made, EMS is dispatched, they arrive on the scene and perform a patient assessment. If the patient complains of chest pain or other signs and symptoms of ACS, the goal is to have the ECG obtained within 10 minutes. EMS is to attempt to transmit the ECG when possible. We do not require that the ECG has to be transmitted in order to activate our cath lab. We have so many rural EMS agencies that they cannot always transmit, and some are poorly funded, so they do not even have the software for transmission. If there is ST elevation, cath lab is activated through our STEMI one-call system. That calls in all the cardiac cath lab staff, as well as the interventionalist. If the staff is present by the time of EMS arrival, the patient will go straight to the cath lab and bypass our ED with our new ED bypass when EMS screens for COVID. If the staff is not available in cath lab at the time of EMS arrival, then they make a pit stop in our emergency department prior to proceeding to our cath lab. The next slide shows our flow of EMS bypass of our emergency department for STEMI patients during COVID. If the EMS ECG is positive for STEMI, EMS completes the initial screen for COVID, assessing for fever, chills, persistent cough, loss of taste or smell, or exposure to someone with COVID in the last 14 days. If the answer to any of those questions is yes, they will make a pit stop in our emergency department for a quick COVID swab and chest x-ray, and our staff will follow our PPE precautions for COVID, and rapid transfer to the cath lab will then be done. If the answer to the COVID screening questions are negative, we will bypass our ED and go direct to the cath lab, then the COVID swab and chest x-ray are done in the post-cath unit. The next slide shows our performance trend from NCDR for cardiac rehab referrals. In quarter three of 2019, our ambulatory referrals to cardiac rehab for STEMIs and non-STEMIs was only at 64%. There had been a definition change by NCDR, and we implemented a number of process improvement steps that led to the overall improvement in our trend line. In Q3 of 2020, we were up to 95.6%, which was 109 out of 114 patients. For Q4 of 2020, we were at 98.8%, which was 80 out of 81 patients. In Q1 of 2021, we were at 95.1%, which was 78 out of 82 patients. And in Q2 of 2021, we were at 96.5%, which was 111 out of 115 patients. This slide shows the bar graph review we use in our chest pain process improvement committee meeting, and it gives us a more in-depth look at the breakdown of STEMI and non-STEMI patient populations for cardiac rehab referrals. We tend to have more outliers in our non-STEMI patient population who had no intervention completed, either because they were not a candidate for PCI or they had small vessel disease or chronic occlusions. The majority of the time, it is a lack of documentation from our physicians. We follow up on each of these outliers with our physicians or physician extenders. You can see in Q2 of 2021, our STEMI non-STEMI composite for cardiac rehab referrals was at 96.5%. This slide shows our process improvement plan for cardiac rehab referrals. The issue was a decline in the ambulatory referrals for cardiac rehab in Q3 of 2019, when we dropped to 66.4% after the NCDR definition change for ambulatory referrals to cardiac rehab. The process changes that we made included adding ambulatory referral to cardiac rehab to cardiac post-procedure order sets. We developed a BPA alert in Epic to prompt the provider to order or select a contraindication for cardiac rehab. We educated all cardiologists, nurse practitioners, and nurse extenders regarding the change and all the documentation requirements. We developed a type 2 MI clinical documentation tip sheet. We then educated all of our coders and all of our providers regarding documentation of type 2 MIs. More currently, we have added concurrent review of non-STEMIs in addition to STEMIs, which have always been reviewed concurrently. This was not started until July of this year, so will not be reflected until our Q3 2021 data. But our current status as of Q2 2021, our STEMI, non-STEMI cardiac rehab referrals were up to 96.5%. The next slide shows the education that we did for our coders and all of our cardiology providers and extenders. It delineates all of the etiologies, suggested documentation, and core measures associated with type 1 STEMIs, type 2, and non-MI troponin elevation. The biggest emphasis for education was on type 2 MIs. We went in extensive detail about all the different reasons you might have a non-MI troponin elevation. The next slide shows an extension of the education that we did for elevated troponins not caused by STEMI. We reviewed cardiac causes as well as systemic causes and the rationale for specific documentation related to elevated troponin. We guided them on terms to avoid and what terms to use, such as tachyarrhythmias, sepsis, pulmonary embolism, renal failure, rhabdomyolysis, or DKA. All physician providers and extenders were provided with this education documentation for their future reference. This slide shows our NCDR trend for ACE inhibitors or ARBs for LV systolic dysfunction at discharge for both STEMIs and non-STEMIs. You can see back in quarter three of 2019, we were at 80%. In quarter one of 2020, we dropped to 60%. In quarter three of 2020, we were up to 90%, which was nine out of 10 patients. In quarter four of 2020, we were at 83.3%, which was 10 out of 12 patients. In quarter one of 2021, we were at 81.1%, nine out of 11 patients. And by quarter two of 2021, we were at 91.7%, which was 11 out of 12 patients. This slide shows the bar graph we utilize in our Chest Pain Center process improvement meetings to further review the breakdown of both STEMIs and non-STEMIs for ACE inhibitors or ARBs prescribed at discharge for LV systolic dysfunction. As you can see in quarter one of 2021, our STEMI non-STEMI composite dropped to 81.8%. There were two outliers that quarter. The first was a patient whose ARB had been discontinued for acute kidney injury and hyperkalemia. However, the ACE inhibitor was never mentioned in documentation, nor was any correlation made. The second outlier was an acute kidney injury patient with low blood pressure, but no documentation was provided as to the rationale for not prescribing. In quarter two of 2021, our STEMI non-STEMI composite was up to 91.7%. We had one outlier, which was a STEMI, whose cath showed an ejection fraction of 40%. However, a TEE done closer to discharge showed an EF of 30%. There was documentation of quote-unquote lowish blood pressure, but no correlation mentioned as to the reason for not prescribing an ACE inhibitor or ARB. This slide shows the NCDR performance trend graph for high intensity statins prescribed at discharge for both STEMIs and non-STEMIs. You can see back in quarter three of 2019, we were at a low of 80%. We have gradually trended upward so that by quarter three of 2020, we were at 96.9%, which was 94 out of 97 patients. In quarter four of 2020, we were at 97.3%, which was 72 out of 74 patients. Quarter one of 2021, we were at 98.7%, which was 74 out of 75 patients. And in quarter two of 2021, we were at 99% compliance, which was 96 out of 97 patients. This slide represents a more in-depth look at the breakdown of STEMIs and non-STEMIs for high intensity statins prescribed at discharge that we review in our chest pain process improvement meetings. In quarter three of 2020, our STEMI non-STEMI composite was at 96.4%, which is below the ACC 75th percentile goal of 97.7%. A quarter one of 2021, our STEMI non-STEMI composite had risen to 98.7% after our process improvement initiatives. We did have one non-STEMI outlier that quarter where no statin was prescribed and there was no rationale for not prescribing. In quarter two of 2021, our STEMI non-STEMI composite was at 99%. There was one non-STEMI outlier where the initial troponin was negative, but within 24 hours, it rose to 0.257. The cath only showed mild obstructive disease. However, the cardiac MRI showed infarct of the septum. As a consequence, this coded out as a non-STEMI. This slide reflects our process improvement steps to address the specific discharge medications for both STEMI and non-STEMI patients where we were not meeting the ACC's 75th percentile goals. Starting on the left, the issues were as follows. Number one, ACE inhibitors or ARBs prescribed for LV systolic dysfunction at discharge. In quarter three of 2019, we were at 86%. Number two, high intensity statins prescribed at discharge for the same patient population. In quarter three of 2019, we were at 80%. The process improvement changes that we implemented were as follows. For ACE inhibitors or ARBs, we developed a BPA in Epic to alert the provider to prescribe when the EF was less than 40%. We educated all cardiologists, nurse practitioners and nurse extenders regarding the discharge medication requirements for all STEMI and non-STEMI patients. We also educated all pharmacists hospital-wide regarding the same discharge medication requirements for that patient population. We added a dot phrase in Epic for pharmacy documentation of those required medications for STEMI and non-STEMI patients. We also developed a badge card listing all of those discharge medication requirements and distributed to all cardiologists, nurse practitioners, nurse extenders and nurses on the cardiac units. More recently in July of this year, we added concurrent review of non-STEMIs to assess discharge medication requirements and ensure that we are meeting those in a timely fashion. The current status as of quarter two of 2021, ACE inhibitors or ARBs prescribed for STEMIs and non-STEMIs at discharge with an EF of less than 40%, we were at 91.7%. Pardon the error on this next note, in quarter two of 2021, our high intensity statins prescribed at discharge has nothing to do with the EF here, but we were at 99%. Here is the laminated badge card we developed and distributed to our cardiologists, nurse practitioners, nurse extenders, and nurses taking care of the STEMI and non-STEMI patient population. The discharge medication checklist is included here as well as the ambulatory referral to cardiac rehab. Aspirin, P2Y12 inhibitors, high intensity statins, beta-BACR, ACE inhibitor or ARB for LV systolic dysfunction. And we also added in the aldosterone antagonist for LV systolic dysfunction to help with our heart failure requirements. On the backside of the badge card, our vascular pre-op medications and discharge medication requirements to assist our vascular team in meeting their requirements. Like all of you, our healthcare system experienced some additional challenges early in the pandemic with a decrease in both STEMI and non-STEMI patient volume, which made the impact of any outliers more prominent. Also ensuring patient and staff safety during COVID contributed to increased times for first medical contact to device. There was definitely a learning curve for us with this, but our times have gradually improved. Currently, our overall patient volume has markedly increased with approximately 20 to 30 holds per day in our emergency department, stretching our staffing capabilities. All of these issues have an impact on meeting goal times for our cardiac program. And we are striving to address each issue as we encounter them. As you know, process improvement is an ongoing effort, but utilizing the NCDR data and tools, we can identify opportunities quickly and implement the appropriate changes for improvement. I am happy to answer any questions you may have.

Susan Ball

cardiac care

Baptist Health Louisville

pandemic impact

process improvement

NCDR tools