Good morning, everyone. We're going to go ahead and get started. My name is Julie Mobate. I'm the product manager for the chest pain of my registry, and I'm super excited to introduce these ladies here on stage today. First is Liz Toledo. She is the chest pain coordinator from Hackensack University Medical Center, and I'm going to actually just bring her on up, and she's going to introduce her colleagues, and we'll get started. Thank you. Good morning, everyone. Thank you for having us here today. Thank you for joining us right before lunch. I walked by. They're really yummy. So I want to start by thanking the ACC for having us here today and letting us walk you through our journey. Today we will be presenting our process improvement project, Am I Hitting All the Benchmarks? Advanced Practice Nurses Paving the Way for Data-Driven Quality Initiatives. We will be discussing how our team was able to impact everyday guideline-driven care that we provide to our patients and also turn around the metrics in our chest pain in my registry. Our presentation today is actually twofold. We will walk you through everything that we did, all the challenges that we had, and how we approached those challenges. As Julie mentioned, I am the chest pain coordinator at Hackensack University Medical Center. I've been in this role since 2020. I graduated with my RN in 1995. That really dates me, huh? From Molloy College in New York. And then in 2006, I graduated as a nurse practitioner, spent eight years as a surgical NP, and then went into electrophysiology and then general and interventional cardiology. I also want to introduce two of my colleagues, Veronica Rupinian and Lynn Sauer, who this whole project would have never been possible. They were vital people that did a lot of things to move this along. Veronica? Good morning. Can you hear me? My name is Veronica Rupinian. I've been a nurse practitioner for about eight years. I graduated from Fairleigh Dickinson University in 2016 with my MSN as an adult gerontology nurse practitioner and currently pursuing my MBA in healthcare administration from William Patterson University. I previously worked in both internal medicine and neurology and have been in cardiology for the past two years in the cardiac cath lab seeing cardiovascular, vascular, and electrophysiology patients with a strong focus on cardiac cath and our AMI population. Good morning. I'm Lynn Sauer. I've been employed at Hackensack Medical Center for the last 30 years, been a nurse practitioner for 22 of those years, started initially in our anticoagulation clinic, moved on to be a unit-based surgical APN, and for the last 18 years, I've joined our cardiac cath lab team and worked in interventional cardiology. I received my undergraduate degree from the University of Scranton in Pennsylvania and my master's degree in William Patterson University in New Jersey. Thank you. So now a little bit about who we are. Hackensack University Medical Center is an 853-bed nonprofit teaching and research hospital located in Bergen County, New Jersey. We are the largest provider of inpatient and outpatient services within the state. We were first founded in 1888 and as you can see on the picture on the left, that was where we started. That little house depicts who we were back in 1888. The picture on the right shows who we are today. That tower was a recent addition we had in 2022 and houses our surgical suites and our critical care areas. Hackensack University Medical Center is part of Hackensack Meridian Health. We are comprised of 18 hospitals. We have three academic hospitals, one located in the northern region, which is us, Hackensack. We are eight miles from New York City. In the middle, in the central region, we have JFK University Medical Center and then in the southern region, we have Jersey Shore University Medical Center. We have 4,714 licensed beds, over 36,000 team members, and over 500 patient care areas. We at Hackensack have a mission, vision, and beliefs. Our mission is to be nationally recognized as a top integrated network of advanced cardiovascular care across the continuum, providing exceptional service, clinical excellence with innovation, and state-of-the-art advanced technologies. Our vision is to transform cardiovascular care and be recognized as a leading center of excellence. We believe in the five C's, to be creative, to be courageous, to be compassionate, to be collaborative, and most of all, to be connected. At Hackensack, we offer state-of-the-art invasive and non-invasive services. Our cardiac service line includes a robust heart failure program, cardiac surgery program and structural heart, and an ACS program. We offer state-of-the-art patient care areas and a top-notch team to take care of our patients. We were the number one hospital in the state of New Jersey, recognized by U.S. News and World Reports, number 41 for cardiovascular services with U.S. News and World Reports. We have the Heart Care Center of Excellence Award. We also have chest pain with PCI, ACC accreditation, heart failure, cath lab, and most recently, TAVR. We are also Go Plus recipients for the Get With The Guidelines as a stroke center. These are just some of our little, some of our accolades. Once a patient comes into our care, they become our primary focus, whether it's a STEMI, NSTEMI, or an ACS patient. I put this slide in here because it really shows how many people really it does take to partake in the patient's care, whether it's the physician, the nurse practitioner, EMS services, nutrition, or the data abstractor. Somebody partakes in their care. Not only is Hackensack the busiest emergency room in the state of New Jersey, but it is the fourth busiest emergency room in the nation. In 2023, they saw over 88,000 visits. Our ER is comprised of 70 beds with a separate observation unit that houses 20 patients. In 2023, just to give you a little bit of a background, we had over 4,500 chest pain visits, over 3,200 of those were discharged right from our emergency room. 930 of them went to our observation unit, 185 of them were STEMI's, 246 of them were NSTEMI's, and we also received transfers. We had 114 AMI transfers in 2023. At Hackensack, we use our Plan, Do, Study, Act model. This is our four-stage problem-solving system that allows us to establish, process, and implement changes. At HUMC, we are fortunate to have a quality council committee that plays a pivotal role in aligning us with hospital-identified metrics and provides us with benchmarking for discussion, allowing us to take a multidisciplinary approach. When applying this PDSA model, we always ask ourselves, what are we trying to accomplish? How will we know that a change is an improvement? And what changes can we make that will result in an improvement? So I review this model because this is the model that we really use, and I'm going to walk you through the first part of our journey. So in 2016, Hackensack embarked on a journey with Legacy Meridian and joined forces to form our network of hospitals that today is known as Hackensack Meridian Health. This venture called for harmonization among all of our hospitals. So in that harmonization, one of the things that we realized was that our cardiovascular service line needed to align with the way we reported to our NCDR chest pain MI. So we knew that at Hackensack, we were only reporting a basic data set, while all of our other sister hospitals were reporting a full data set. So we were tasked with going in and starting to report a full data set and entering basically our NSTEMI patients. So in September of 2022, we entered retrospective data for quarter one through quarter three. Once we started doing that, what we found was that there were gaps between the clinical picture and the documentation of these patients. So we did a deeper dive and found that we had entered 96 NSTEMI patients, and we were finding that, oh wow, these patients are really not type one NSTEMI patients, but they're really type two MIs. So out of those 96 patients that we had already entered, 46 of them were not true type one MIs. So again, we went back again and did a deeper dive once more, realizing that documentation was our biggest opportunity. So now we have this information, and where do we go from here? What do we do? How do we fix this? Now I'm going to take us through the different implementation phases that we went through to really tune up our documentation between NSTEMI versus type two MIs. First I'll talk a little bit about our planning phase. We knew we had this data. 47.9 of those patients that we had entered into our registry were type two MIs. They were really not type one MIs. So we have the data. We then went on to identify a physician champion who was our quality cardiology physician, and he reviewed all the cases with us. We met with our coding team and our billing team. We needed to understand, how were these patients being coded? What are they looking for in the charts? We needed to understand, how are they being billed? How come this is going right through there, right through the cracks? So some of the common themes that we found were that a lot of our attendings were documenting NSTEMI. A lot of our patients get admitted to hospitalists and internal medicine doctors. So they were documenting NSTEMI, while our cardiologists were documenting very nonspecific language or non-codable language. The other thing we found was that our attendings were documenting NSTEMI, despite cardiology documenting codable language or reflecting not true type one MIs. Or both of them, the attending and the cardiologist, were documenting incorrectly, saying these patients were NSTEMIs. So phase one, the awareness was generated and education was initiated. So the process change began. Educational sessions were put together for all of our providers. We went to workshops. We had workshops. We had huddles. We had meetings. We attended grand rounds. We went to chair meetings. We were all over the place. Anyone who would listen to us, we were there. It wasn't just cardiology. It was every department within our hospital. We also used the ACC tools available to us, and we took those tools, we laminated them, we put them up in our nursing stations, our physician lounges, our physician workstations, everywhere. And here on the screen, you can see, these were our take-home educational areas. Type one versus type two MI. And then we also put on there the documentation that we wanted to see within the chart. Phase two. Now, we had done a lot of education. We had some barriers. One of those barriers was really getting a clean list of our NSTEMI patients, the ones that were live in the hospital. How are we going to do this? So we teamed up with our IT department. And then we developed a list within our, we use Epic as our electronic medical record. And we developed a list within there to really find these patients in real time. And then we also were able to get access from our coding team on a list that they use for patients that they're coding as NSTEMI patients. One of the biggest things as well that we did during this phase was we initiated a work queue. This work queue allowed us to look at patients post-coding and pre-billing. It gives us 72 hours to look at those patients that had been coded as NSTEMI. And if they really truly didn't fit the bill of being a type one MI, we got the opportunity within those 72 hours to go back and get that documentation changed and made appropriate. And this is just the workflow process of what that looked like for development of the work queue and using the coding list. Phase three. So now we had done the education. We had an NSTEMI list. And it brought us to this phase, which was kind of a little bit more of an advancement for us. We started using our secure chat. So if all these patients were in the hospital in real time, those that were getting coded as NSTEMIs that really didn't fit the picture of type one, we were able to use the secure chat and contact our hospitalists, our cardiologists, whatever APP, whatever team member was on the case and make sure that the appropriate documentation got put into place. We also developed smart phrases. So this smart phrase consisted of a dropdown menu. We worked with our coding team and made it available to all those hospital-wide for all those who document within the chart. And our biggest accomplishment was in our hospital, the coding team is only allowed to query the attending of record. So we went to executive leadership and asked that this rule be changed and we would be allowed to query cardiologists because they were the ones who were really determining, is this really a type one of mine or a type two? So that was a huge accomplishment for us. So in the end, we had established a pretty solid process that we were able to review our charts for appropriate documentation. So where are we today? We had made our workflow process. And as you can see here, in 2022, we only were at 57% for appropriate documentation. Now in quarter one of 2024, we are at 78%. We still have 22% to tackle, but we continue with our educational sessions. We do have new team members that come on board. So we try to always capture that population as well. If you're going to take anything away from this today, what drove our process was education, education, education. And not only that, but this also impacted our 30 day mortality, our 30 day readmission, our AMI length of stay, our NCDR registry data, but our story doesn't end there. This was just the first step that put us on a path of many discoveries. What did we find? We had entered this data into our registry. Our performance within the chest pain MI registry was between the 25th and 50th percentile. Put the brakes on. That's what they said. Let's go back. Let's go back to the drawing board and use our plan, do study act model once again. So we knew we were falling below the 50th percentile. So we did a gap analysis and we knew we fell short between medications, diagnostic testing, possibly charting by exclusion. So these were the areas that we knew we could improve. As nurse practitioners, this team up here, we put our heads together and we went to our leadership and proposed an APN driven initiative. We wanted to make sure that our patients were getting quality care and evidence based practice that was delivered to all of our AMI patients. So now I'm going to invite Veronica, who's going to walk us through everything that was done to improve these metrics. »» Good morning. I'm going to go into a little bit more detail about our APN-AMI Quality Initiatives Project. Some of the topics I'm going to discuss include our gap analysis, our proposal, our methodology, the Hackensack University Medical Center Care Pathway, our NSEMI and Semi-Clinical Pathways, our everyday workflow, patient education, our Meds to Beds Program and a little bit about our Cardiac Rehab Program. Before initiating our pilot, we conducted a gap analysis and looking at the 2022 data, we saw that our overall defect-free care was at 51%, placing us in the 25th percentile. Our semi-composite was at 96 percent, placing us in the 50th percentile, and our N semi-composite was at 85 percent, placing us in the 10th percentile. After seeing these numbers, we met with our leadership team to propose our initiative to increase the percentages in each of these metrics. We made a proposal to increase our overall defect-free care to 77 percent from 51 percent, which would place us in the 50th percentile, our semi-composite to 97 percent from 96 percent, which would keep us in the 50th percentile, and our N semi-composite to 95 percent from 85 percent, which would also put us into the 50th percentile. How did we do this? We came together as a group and started rounding on all the AMI patients, noticing that not all of our population was receiving the same care, whether it be that they were on a non-cardiac unit based on bed availability or whether they were not on a unit-based cardiac APN on their floor. In order to improve the care of our AMI patient population, our cardiology APNs proposed the initiative to round on all of our AMI patients Monday through Friday, documenting a short progress note to align with our AMI care pathway goals. Prior to initiating our study, we met with multidisciplinary teams, including physicians, nurse practitioners, nurses, and case managers on the inpatient units to educate them on our AMI pathway metrics and goals. We worked with these teams to ensure correct documentation, medication compliance, and follow-up after discharge was established. A consistent cardiology nurse practitioner was assigned to a patient from admission to discharge to allow for better provider-patient relationship and continuity of care, while also ensuring timely diagnostic testing and, in turn, decreasing the length of stay. We facilitated follow-up appointments scheduling within seven days of discharge with either the patient's primary cardiologist or at our APN AMI clinic, which Lim will get a little bit more into detail about later. All of our AMI patients were referred to cardiac rehab, and we provided cardiovascular risk factor modification education to all of this population. Hackensack University Medical Center developed an AMI care pathway, which standardized the care for all of our AMI patients, helping to initiate and review orders, clinical documentation, and expected patient outcomes, which, in turn, would reduce AMI mortality's length of stay and readmissions, as well as track patients' progress along the way. We did this by including all the multidisciplinary teams, as well as relevant transitions between levels of prevention and levels of care, promoting standardization through identification of variants in care, which, in turn, improved patient experience and outcomes. We did this through education at our HPH APN meetings to educate our hospital-wide APNs, as well as the nurses on our inpatient units, and posted the care pathways to inpatient units to provide as a guide for staff on the floor for our AMI ACS patient population. Each care pathway includes current evidence-based practice, treatment guidelines, real-time clinical decision support, standardized orders, flow sheets, and care plans, and targeted quality measure reports. This is our N-Semi clinical pathway, which pretty much documents roadmaps of patients' stay from admission to discharge. On day of admission, the initial workup is done, which includes routine blood work, lipid panel, hemoglobin A1c, serial troponins, EKG, echocardiogram, nuclear stress test versus coronary CTA, with plan for left heart cath on day one of admission. If any intervention is performed, the cardiology APN ensures that the patient is on the correct medication, including aspirin, P2I-12, a beta blocker, ACE, ARB, or ARNI, and a high-dose statin. With plan for discharge by day two, after the patient is seen by the cardiologist, as well as the cardiology APN, an education is provided, including education on diagnosis, medications, the echocardiogram results, post-PCI procedure site care, cardiac rehab, and smoking cessation. This is our semi-clinical pathway, which is pretty similar to the N-Semi clinical pathway, with the biggest difference being Hackensack's goal of 60 minutes from the ED to the cath lab. Initial workup is again done on day of admission, including all of the blood work, EKG, echocardiogram. If any intervention is performed in the cath lab, again ensuring the patient's on the correct medications. With plan for discharge by day one, after once again being seen by the cardiologist and the cardiology APN, education is given, and follow-up appointment is made within seven days of discharge. I'm going to talk a little bit about our process and everyday workflow. Our APNs work collaboratively with our inpatient care teams to institute best practices and align with our ACS quality measures. We round daily to ensure that patients are on the appropriate medications and are compliant with the medications. One of the issues that we found in terms of medication was that some patients, especially patients that were hospitalized for a prolonged period of time, whether being acutely sick due to other comorbidities, being in the ICU in cardiogenic shock, for example, some of the medications would expire and fall off the chart if they were not renewed by the provider. By our APN's daily rounding and daily chart reviews, we were able to spot any expiring medications and renew them before they had fallen off the chart, which would, sorry, which would make sure that the patient had the medications throughout their stay and were discharged home with them. Some other metrics that our daily rounding helped to improve was timely diagnostic testing. Another issue that we saw was in terms of our echocardiograms. Although for the most part they were ordered on day of admission, sometimes there was a delay in the testing, sometimes to the next day, even later in the day, which would cause patients to stay an extra night, increasing the length of stay. By daily rounding, our APN's were able to ensure that the orders were placed stat and with priority discharge and call the department if necessary to expedite the testing. Daily rounding also helped to call any internal medicine or social work consults if needed, ensure that the blood work was done and call any dietician referrals, especially for new diagnosis diabetes or exceptionally high lipid panels, ensure that the patient was referred to cardiac rehab, receive meds to beds, which I'll talk a little bit about shortly, provide education on our cardiovascular risk factor modification, and once again, ensure that there's follow-up appointment with the cardiologist or at our AMI clinic within seven days of discharge. This is an example of our APN quality metrics progress note, which basically touches on each of the metrics to make sure they're all addressed. We have any overnight events, the telemetry, EKG, echocardiogram, their blood work results, their current medications, the physical exam, including the post-procedure site assessment, our risk factor modifications that we educate the patient on, including hypertension, hyperlipidemia, diabetes, obesity, and smoking cessation, as well as the core measures and the medications that the patient should be on and any contraindications if they are not. Education was a huge part of our pilot study. This is one of the tools that we used to help educate our AMI population. This is our risk assessment guide for a healthy heart. This guide shows a picture of the heart with all the coronary arteries, so the APN is able to show the patient exactly where their MI occurred or where any stents were placed, as well as go over a little bit of background of the anatomy of the heart. We're also able to write in the patient's blood pressure, lipid panel, hemoglobin A1c, their BMI, physical activity goals, smoking cessation plan if needed, heart healthy eating plan, and there's an area for cardiovascular rehab where we can place the patient's appointments so they have everything organized for them on discharge. On the back of the pamphlet is just some facts about heart disease and some of the steps to improve patient's cardiovascular health. Just some statistics. We started this pilot in June of 2023 and have since seen 449 AMI patients, 275 of those in STEMI and 174 STEMI. A little bit about our Meds to Beds program. Medication was an area that we had fallen short on in terms of compliance of our AMI and ACS population. Our Meds to Beds program is a hospital-wide program in which the provider prescribes the patient's medication to our hospital pharmacy and it's delivered to the patient's bedside prior to discharge. By using Meds to Beds, we can ensure that any of the doses are available, avoid any potential insurance barriers, and in some cases, especially with new dual antiplatelet therapy, some allow for a free 30-day supply which we would ensure that the patients had received. Some challenges with our Meds to Beds program was due to our high nurse turnover rate and new nurses not being educated. We collaborated with our pharmacy department to provide education on the nursing units and worked effectively with our multidisciplinary teams to ensure the medications were delivered to the patient's bedside prior to discharge. Weekend discharge was another challenge that we faced. As of right now, our Meds to Beds program is open Monday through Saturday, but the hospital is currently working to open on Sunday as well to help improve with this metric. Cardiac rehab. Prior to our pilot, our initial referral compliance was 46%, and since the rollout has increased to 92%. What are some of the ways that we increased the number of cardiac rehab referrals? We added a pre-click choice to our post-PCI order set. At Hackensack, we have two order sets, post-PCI and a diagnostic order set, which we noticed were being used interchangeably, which was leading to missed cardiac rehab orders. Another challenge regarding the two order sets was that in terms of patients who were diagnostic but, for example, had multivessel disease and were referred to surgery, the diagnostic order set was ordered, which does not include the cardiac rehab referral, and if it was not placed manually, it would sometimes be missed. Some other interventions that we rolled out to improve the number of referrals was adding the instructions to our patient's after-visit summary and providing the interventional cardiologist with prescriptions in the cath lab prior to the patient going to the inpatient unit. One of the challenges with our cardiac rehab referrals was our lack of weekend APN coverage. The hospital is currently working to provide coverage, especially on the cardiology units, seven days a week, to help improve with this metric. Although the cardiology APNs are not able to write for the cardiac rehab prescription, having an APN there seven days a week will help to notice if any of the patients are missing the prescription and can reach out to the cardiologist if need be. I'm now going to turn it over to Lynn, who's going to talk a little bit about our barriers and results of our pilot. I'm now going to shift our discussion a bit and provide a comprehensive overview on some barriers we encountered, our value proposition, our AMI readmission and length of stay, our MI performance improvement, our patient satisfaction, transitions of care, and our next steps. Our team is involved in the care of our cath PCI patients, both pre- and post-procedure, and have been involved in a number of projects throughout the years. Last year, we had the good fortune of teaming up with Liz, our chest pain coordinator, to tackle our MI patient population, not just in the cath lab during the time at which they received their stent, but throughout their inpatient stay at Hackensack. Prior to this project's rollout, we identified gaps in care for our STEMI, non-STEMI patient population and formulated a plan to close those gaps. Although our project has been successful, we have encountered some barriers along the way. One of the barriers that we have identified and has accounted for areas that we have fallen short in the past has been in regard to our medical attendings. In our hospital, most of our patients are admitted to a hospitalist and not necessarily a cardiologist. Although our cardiology service is well-versed on dual antiplatelet therapy, beta blockade, and max statin therapy, our hospitalist physicians often are not. Our hospitalist physicians also work on a rotating system of coverage, which often presents challenges and gaps in continuity of care. We've worked closely with our hospitalists, familiarizing them with our goals, and it has been well-received. Like anything else, we continue to educate our nursing staff, as they are the front line and constant in the care of our MI patients. A second barrier we encountered was our weekend discharges. As we all can probably attest to, weekends at hospitals are different than Monday through Friday. There's often less staff and often physicians are covering. We have been working with our unit-based APNs and teams, the inpatient teams, throughout this project, and we'll continue that moving forward. Our project has had positive outcomes, not only in our metrics, but also improvements in our key indicators, such as length of stay and readmissions. STEMI, non-STEMI patients are at an increased risk of readmission during their recovery. APNs play a vital role in providing efficient and consistent care, regardless of the inpatient care unit. This involves conducting timely testing, prescribing appropriate medications, and ensuring follow-up care after discharge, all of which are crucial to reducing readmissions and length of stay. It has historically been challenging to arrange follow-up appointments for patients within one week of discharge. The establishment of an advanced practice-run cardiology clinic has helped to provide timely follow-up to our patients after discharge. In pursuing these quality initiatives, we have achieved superior outcomes through various measures, including enhanced patient care, improved patient compliance, increased patient satisfaction, reduced length of stay, and reduced readmissions. I'm now going to shift our focus and review our AMI readmissions. When we started to review our readmissions, our strategy was simple, find out where we fell short, and find solutions. We initiated many strategies, one of which was having post-discharge follow-up phone calls within four days of discharge. This allows for open dialogue and opportunity to clarify any medication questions patients may have and ensure timely outpatient follow-up. We have one person dedicated to appointment scheduling for our follow-up appointments, whether at the clinic or with their private cardiologist. We have a shared spreadsheet for tracking and a chat space for communication. The realization that most of our readmissions are related to heart failure, we now keep closer surveillance on those patients with reduced ejection fractions and work closely with our heart failure team. To the right of your screen, you can see a sample of our follow-up phone call note, which is a permanent part of our electronic medical record. As it currently stands, our strategies have proven successful, and I'm happy to report our readmission rate year-to-date is 6.55%, which is less than our hospital goal set at 8.54%. This was a tremendous accomplishment and a reflection of a lot of hard work and collaboration. We have incorporated a number of strategies to improve our MI length of stay. The AMI care pathway has been the model we have followed throughout this process. We ran daily on patients. We've started using the TIMI score to risk stratify and see patients within 24 hours and sooner, if appropriate. Our hospital has just started a new initiative, Hospital at Home Program, with the hopes that patients can at times be managed appropriately at home, and we are hoping in the future to include our MI population when appropriate. We closely follow for appropriate ICD-10 coding. We work closely with our post-cath care unit, along with their managers, and have initiated a number of great strategies for their patients. There are senior leadership huddles, volunteers three days a week to work with nurses and patients, and a focus on getting patients up and out of bed sooner. Our length of stay data in our uncomplicated STEMI is currently 1.88 days, which meets our goal of less than two days. And in our non-STEMI patient population, we are currently at 2.29 days, which is slightly higher than our goal set of less than 2.15 days. Although we didn't meet that goal, we have come close and will continue to work hard to meet it in the future. In terms of our metrics, I'm proud to share that we have moved from between the 25th and 50th to between the 75th and 90th percentile in all three metrics, overall defect-free care, STEMI, and non-STEMI composite. We are pleased with our progress and will continue to work hard to maintain our standing. We have also seen improvement in patient satisfaction scores, and just wanted to mention a few of them to review. They include patients feeling that their educational needs were met, there are more likely to recommend Hackensack, and overall, more pleased with the care received. The purpose of a care pathway initiative is to develop and implement network-wide and evidence-based care pathways. Our chest pain ACS care pathway has become the gold standard and has provided a tool for staff and providers that often sets a standard, offers a set of standards and a timeline for MI patients. Although we have had an impact on our patients during their inpatient stay, we hope to extend good care to patients while at home. We continue to refer our patients to cardiac rehab, we start the discussion on day of admission and continue throughout their stay, and again on the day of discharge. Many patients are encouraged to attend our outpatient wellness center as well. They can get involved socially by participating in cooking classes, they can learn more about overall risk factor modification, diabetes, cholesterol, get an overall better handle on their health and well-being, and set reasonable goals. So where do we go from here? We are thrilled to have made such an impact, but continue to evolve and look toward the future. What we have proposed is expanding our APN-1 clinic in days and hours covered, and hopefully see many more patients. We are looking to expand our APN coverage on weekends to a more consistent model. We are also looking to change our rounding to more of a team huddle approach, to include the APN, the chest pain coordinator, cardiac rehab, case management, and our cardiac fellow. Our larger goal is to move our MI pilot from just that to a standard of care for all MI patients through the use of our ACS Care Pathway network-wide. The biggest take-home for our team is that all MI patients should receive the same care, whether they have their heart attack on a weekend, at night, are admitted to a cardiologist or a primary care doctor, and more importantly, whether our patients have their MI in northern New Jersey and are hospitalized at Hackensack or at the beach, and have their MI there and are hospitalized at Jersey Shore, one of our network sister hospitals. This is a picture of our APN team that I have the privilege to work with each and every day. Without our team, none of this would be possible. Liz, Veronica, and I would like to take a minute to thank you all for attending our presentation. We hope you found our presentation helpful and hope you were able to incorporate some of our ideas into your practice. We'd now like to open up for questions. »» Thank you all so much. That was fantastic. We do have some questions, so I'll just start by asking them. How did you identify the patients in real-time to secure during the Mission for Improved Documentation? »» Okay. I just wanted to make sure it was working. So we work with our coding team. They provide us with a list that belongs to the coding team, and those are patients that are being currently coded as NSTEMI patients. We use that list, and then we have an EPIC list that was created for us with the ICD-10 codes that pulls in the patients in real-time as well. Using those two lists, Veronica, really, who leads this project, will then go through those patients daily and ensure that those patients are really Type 1 MIs. »» And I know you showed the picture up there, but how many APNs are on your team? »» We currently have six APNs. »» Correct. »» Okay. Is your cardiac APN employed by the hospital or cardiology group, and would they round with the quality coordinator? »» So we're all employed by HAC and SAC. We round on our AMI patients daily, pretty much it's just APN-based rounding as of right now. But we're trying to open it up to a bigger team to include the case manager, cardiologists and kind of do a daily rounding with everyone. »» Yeah. One of the things that I want to add too, one of the challenges that we were having with the rounding is that we don't have one sole unit, one sole telemetry cardiac unit. Our patients go to three different units. So we were attending, there's multidisciplinary rounds that take place every day, and we were attending those. However, we were hearing about every other patient that really was not a cardiac patient and didn't really need our care. So what we plan on and what we have proposed to leadership, and we're hoping it's going to be approved, is that we can form a multidisciplinary team, that's what Lynn spoke about, that would involve our fellow, our cardiac rehab, the APN, to really come up with a good plan and follow those patients through. »» Who does the AMI follow-up, who does the AMI follow-up phone calls? »» The unit has an assigned person that does that follow-up phone call within four days of discharge. »» How did you get your Physician Champion to assist you with a review of the NSEMI cases that were incorrectly entered? »» We showed those numbers to leadership. And we actually, we have a very robust quality team within the hospital. And they are very big on making sure that everyone's on board. So yeah, we do have an assigned quality cardiologist for reviewing these cases. »» How do you handle the patients who are referred to cardiac rehab but don't have insurance that would cover the services? »» Our cardiac rehab team works with social service and that sort of thing. Patients can apply for charity care and at times can still enroll in cardiac rehab. »» And then along with cardiac rehab, with regard to that cardiac rehab, who is talking with them, with the patient, providing the education, the options, is it the whole team, is it specific people? »» We do have cardiac rehab nurses that actually round on patients, the MI patients every day. And what we found and what Liz spoke about moving forward in the future, a lot of us are seeing the patients at a lot of different times and talking about similar things. We reinforce cardiac rehab from the start to the finish. So what we're hoping is to bring us all together and do it together as a team. I think it's less overwhelming for patients to see three or four people throughout the day all touching on similar topics. »» And one of the other things that we've added with cardiac rehab is we've also created a chat space with the cardiac rehab team so we can capture all the AMI patients that are actively admitted. »» What is your plan or was your plan to educate and introduce your process to new staff, new physicians? »» We came up with an actual proposal for our leadership team. We actually had a formal meeting, had a formal written proposal, and then began our education. Our education, we have an APN council. So we started with that team. A lot of our care to our patients is provided by a lot of nurse practitioners within the institution, be it private practice or employed by the hospital. So we started with that team providing the educational sessions within our APN council meetings as well as our heart and vascular hospital meetings also. »» Are the NPs required to be involved in QI? And how do they balance the time between clinic, patient care, QI? »» We are responsible. Each of us are involved in multiple projects. We're fortunate enough to have a strong team. We cover five days a week currently from 6 a.m. to 7.30. We work well. We collaborate. We're all allowed sufficient time to work on projects and follow through. »» Do the NPs cover clinics and hospital? »» Yes. One of our nurse practitioners follows the clinic throughout the week and then returns back to the inpatient side. »» How did you or will you incorporate shared decision-making into your process improvement? »» Yes. That's part of our next steps. We just actually met about that as a team, as a network, to talk about how we're going to incorporate that. »» Any challenges for your Meds to Bed program and patients not wanting to use the hospital pharmacy versus their own? »» Yeah. So some patients want their own pharmacy, of course. It's not required that they use the Meds to Bed program. It's just a better program in terms of getting their patients, making sure they're available. But we can prescribe them to their own pharmacy if they want them to be. »» And to add as well to that, when they get that four-day follow-up phone call, we make sure that they have picked up their P2Y12 and they're taking their aspirin and so forth. So that's part of the phone call piece. »» Another thing that was helpful for us, we prescribe aspirin. They actually are given and have the prescription filled. We have had issues in the past with patients assuming that they were on Berlinter or Plavix and no longer required aspirin. So our physician team insisted that we provide aspirin on discharge for all of our patients as well. »» So how long did it take to work on this project from start to finish? And knowing you're not finished yet, you have next steps. »» We started this in 2022, I think, in September of 2022. And we've been working and working and working. And every time we take two steps forward, there's always something new that we learn. And we're like, okay, now we got to go back and rethink how we're going to do this. So a lot of challenges. »» And knowing that inherently people are resistant to change, how do you identify that? How did you overcome any of those challenges? And do you go back and have to regroup? »» I think many times we do. We have to go back, regroup. One of the things I think that we're all fortunate of is that we do have, we work with physicians who really respect us. We're out there, especially these guys more so than I am nowadays, but they're out there at the bedside providing that great care. And I think that gives them a lot of respect. I think as nurse practitioners, that's what we're always looking for. We're fortunate to work with great leadership and wonderful physicians that were very receptive to this. It only helps them and their patients. »» And I know you're talking about the multidisciplinary team. Have you or will you identify champions within those departments or sections that you want to work with so that they can assist in going forward? »» Yes, definitely. We have already started identifying champions in different areas. We have a STEMI champion, we have an NSTEMI champion, a cardiac rehab champion, and they're all within the different clinical areas to be able to make sure that this patient does go home with cardiac rehab. And we work with the nursing team very closely because those are our champions. »» How did you arrange to have the same provider to follow each patient with regard to the weekends and off time? »» We've done our best. We do try to provide consistent coverage. The weekends was one of the barriers. We do have unit-based APNs on two of the units that we currently follow patients on. They do have intermittent coverage on weekends that the hospital is looking to make more of a 24-7 model. So moving forward, our hope is that we will continue to connect with them and work together and kind of report off on Fridays of potential patients for the weekend to ensure that they still get discussions about cardiac rehab, meds to beds, and that sort of thing. »» How long did it take for you to be able to get epic changes in the order set, smart phrases, et cetera, and how did you overcome any barriers in that? »» Since we are a network of hospitals, it sometimes does become a little bit of a challenge for us because we can't just make a change for a hack and sack. Everyone in the network needs to, we're big believers on harmonization. So it has to be something that works for everyone. So sometimes it does become a little bit of a challenge. But again, the things that we are proposing are not unreasonable. So a lot of times we can get the network hospitals to agree. »» Can you elaborate on the hospital at home program from the readmission rate portion? »» I can speak a little bit to the program. It is new. It's just rolled out, I would say probably three or four months now. I know they've seen upwards of 100 patients so far. They're hoping to grow that program as well. And we're looking to get involved, our team as well. Especially for those MI patients with a potentially longer length of stay, many comorbidities, that we can hopefully facilitate them returning home and providing coverage there. »» How frequently are you meeting with the QI team? Is this on a regular basis? I'm assuming you're the liaisons between the MDs and the quality coordinators. And then do you also include the hospitalists on the team when you're doing this? »» Yeah. So we meet monthly with a bigger group, which includes the hospitalists, cardiologists, QI. But then we also have weekly meetings with a subcommittee that consists of the QI person, APNs, myself, to just go over the ongoing issues and the challenges we're having. »» Do you have multiple chest pain center coordinators? What is the staffing model for APNs and the CPC coordinators? »» I am the only chest pain coordinator at Hackensack. And just recently we had an ACS coordinator who's an RN join the team as well. »» Can you elaborate a little bit on the chat space with the cardiac rehab team, the creation, location, use? »» Yes. So the chat space is located in Google Drive within our email. And we communicate through there on patients that need to be seen. If there's a new patient, somebody who's up for, that came in later in the day, and cardiac rehab rounds very early in the morning, the nurses from there, will see the patients very early on in the morning because they need to get back to cardiac, to their area for the patients that are coming in. So we go within that chat space. We will identify patients throughout the day and let them know so that they can come by and do their education. »» I think we can do maybe one or two more. Who is assuring that dischargements are prescribed according to guidelines? And is the pharmacist involved, et cetera? »» We do. The pharmacists are very involved. And certain pharmacists are assigned to certain units for coverage. And they're big in the initial admission process, med rec, as well as discharge. For any issues or reactions between two medications, they'll reach out to us or the physician. Overall it's us that are working with the inpatient team to assure that, you know, medications are continued throughout their stay, especially for those patients that have a prolonged length of stay. »» Are the unit-based phone calls being escalated to an NP, if needed? Are the 6NP cardiology based for AMI or heart failure or other specialties? »» We're interventional cardiology. Our heart failure team has a separate team. And in terms of escalating up, yes. If there's any issues within follow-up phone calls, they do reach out to us. For symptomology, lower extremity edema, weight gain, something that comes up. And we always can discuss and take that up with their physician. »» Last one. How do you incorporate your data teams into your process? »» They are involved with us every day. They review patients on a daily basis as well. We actually, our data team will send out an email with all the cases that went through our cath lab daily and let us know who had a PCI, even an elective PCI as well, just to let us know and make sure that we're following up and making sure if they did stay overnight, whether their P2Y12 was ordered, the guideline therapy is on board as well. They send an email to us. They send it to a pharmacist as well. »» And that is it. Thank you so much. Wonderful information. Good luck on the next phase. »» Thank you, everyone.

Hackensack University Medical Center

process improvement

chest pain care

myocardial infarction

advanced practice nurses

data accuracy

Epic systems

AMI Care Pathway

patient outcomes