Welcome to part one, lesson one, of this learning activity module, the CATH PCI Registry, metric 39, PCI in-hospital risk-adjusted acute kidney injury, all patients. My name is John Giroud, and I will be narrating this lesson. Acute kidney injury after PCI is a common and serious complication of the procedure and is associated with an increased risk of myocardial infarction, dialysis, and death. Even small increases in serum creatinine have been associated with increased hospital length of stay. Acute kidney injury prediction and prevention should be a priority for participants because therapeutic options are limited once AKI develops. Metric 39 is helpful in providing risk-adjusted feedback on AKI, informing clinical decision-making, and directing the use of strategies to avoid AKI and improve the safety of PCI procedures. The objectives for this learning module are to discuss and define what is post-PCI acute kidney injury, analyze and apply a systematic approach in understanding metric 39, and to utilize the eReports dashboard metric feedback. Lesson 1 will include a general overview of metric 39, the definition of acute kidney injury, patient eligibility, and patient variables utilized by metric 39, as well as key resources that are available to assist in understanding metric 39. Lesson 1 will also include case scenarios. PCI in-hospital risk-adjusted acute kidney injury is defined as the patient having any one of the following, an increase in serum creatinine from pre-procedure to post-procedure of greater than or equal to 0.3 milligrams per deciliter, or an increase in serum creatinine of greater than 50% from the baseline, or the new requirement for dialysis. At the patient level, the model will include patients with a PCI procedure attempted and or performed during the episode of care. When patients have multiple PCI procedures during their episode of care, metric 39 will only review the procedure variables from the first PCI. Subsequent PCI procedures during the same episode of care are excluded. Metric 39 will exclude patients with a missing pre- or post-procedure creatinine and new requirement for dialysis is coded no. When yes is coded to sequence number 4560 currently on dialysis, the patient is excluded from metric 39. Metric 39 will also exclude patients who are discharged on the same day as their PCI procedure. Some patient characteristics or variables can make patients sicker and more likely to experience AKI. Some characteristics reviewed by metric 39 include the presence of cardiovascular instability, specifically cardiogenic shock, as well as the use of intra-aortic balloon pump, and more specifically when that intra-aortic balloon pump is in place at the start of procedure. Other patient variables reviewed by metric 39 include recent heart failure or cardiovascular instability that has been identified as acute heart failure. The CATH PCI Registry Executive Summary Measures and Metrics Companion Guide, located on the Resource Documents page, provides the user the comprehensive and complete patient variables used by metric 39. The CATH PCI Registry Enhanced Data Collection Form, also located on the Resource Documents page, informs us of the data elements reviewed by metric 39. At the patient detail level, the participant can view the patient variables and patient characteristics reviewed by metric 39. The patient level detail also informs us of the patient eligibility and when the outcome, post-PCI acute kidney injury, occurs. The patient level detail also provides us with what was coded for pre-procedure creatinine, post-procedure creatinine, and new requirement for dialysis. A blank field indicates that not drawn was coded for a creatinine value, or that the data field was left blank. All eligible patients receive a predicted probability value of AKI, based on the coding and the capturing of patient variables used by the risk model. This is displayed on the patient level detail report patient drill down page. Each eligible patient's predicted probability of AKI is then used to provide the hospital's overall expected AKI rate. We will discuss this in Lesson 2. Understanding individual patient risk factors may help in preventing AKI. Identifying patients who have higher risk factors may be helpful to avoid additional injury and reduce the risk of AKI. The patient's risk factors should be assessed prior to the procedure to reduce the risk of AKI. For our first case scenario, a 65-year-old male with a history of coronary artery disease, hypertension, diabetes mellitus, and heart failure presents to the cath lab as a preoperative evaluation for a planned aortic valve replacement. His pre-procedure creatinine is 0.4 milligrams per deciliter. During the diagnostic cath, the patient experiences chest pain and ST elevation, and an emergent PCI is performed to the proximal LAD. The highest post-procedure creatinine value obtained is 0.6 milligrams per deciliter. Three days after his emergent PCI to the proximal LAD, he experiences recurring chest pain and is taken back to the cath lab, where he receives balloon angioplasty for instant thrombosis. Our first question is, is this patient eligible for metric number 39? Number one, no, or number two, yes. Please take some time to review the documentation and consider your selection. And the answer is number two, yes. The patient had a PCI procedure during their episode of care. While this patient went on to undergo a second PCI during their episode of care, the second PCI does not impact their model eligibility. It is simply just the procedure variables from subsequent PCIs that are excluded from the risk model, as only the index or first PCI procedure is included. Our next question for this case scenario is, is this patient an observed AKI? Number one, no, or number two, yes. Please review the documentation before making your selection. And the answer is number two, yes. The rise in this patient's creatinine from 0.4 milligrams per deciliter pre-procedure to 0.6 milligrams per deciliter post-procedure is representative of a 50% increase, and therefore meets outcome number two. For our next case scenario, we have Helen, a 70-year-old female who is a current smoker with a history of coronary artery disease and diabetes mellitus. She presents to the emergency department complaining of generalized weakness, nausea, vomiting, shortness of breath, and chest pressure and palpitations that have been going on for the past several days. Her ECG is negative for STEMI, but shows peaked T waves. A point-of-care creatinine is obtained, and the result is 5.5 milligrams per deciliter. Emergent treatment of hyperkalemia is initiated, and Helen agrees to temporary dialysis. During her dialysis, Helen begins to experience chest pain, and the ECG shows STEMI. She is taken emergently to the cath lab for immediate PCI. Our question for this scenario is, is Helen eligible for metric number 39? And the selections are no, Helen is currently on dialysis, or yes, Helen had a PCI procedure during her episode of care, which makes her eligible for metric 39. Please take some time to review the details of this case scenario before making your selection. And the answer is number one, no. Helen is currently on dialysis, and per the patient-level model eligibility Part D, she is therefore excluded from the metric. For our final case scenario, we have Tim, who is a 72-year-old male with a history of stage 5 chronic kidney disease and has refused dialysis. Tim also has a history of unstable angina, coronary artery disease, and a prior PCI to his proximal CERC and OM1 that was treated with a drug-eluting stent. He is now experiencing ongoing angina and has been noncompliant with his medications. A recent stress test is indeterminate, and the patient agrees to a diagnostic cath with a possible PCI. His pre-procedure creatinine is 4.0 milligrams per deciliter. The interventionalist is unable to cross Tim's 90% proximal LAD, and because of his chronic kidney disease, the procedure is stopped. Post-procedure, Tim's highest creatinine value is coded accordingly at 4.3 milligrams per deciliter. Our question here, is the patient eligible for metric 39? Number one, no. The patient has stage 5 chronic kidney disease and elevated pre-procedure creatinine. Number two, no. The PCI procedure is aborted. Or number three, yes. The patient has a PCI procedure performed during the episode of care. Please take time to review the following documentation before making your selection. And the answer is number three, yes. The patient has a PCI procedure performed during the episode of care. Any PCI procedure that is attempted and or performed qualifies as a PCI procedure. Additionally, Tim will also be considered an observed AKI because he experiences a greater than or equal to 0.3 milligrams per deciliter increase in serum creatinine from pre-procedure to post-procedure. This concludes lesson number one of cath PCI metric 39, PCI in-hospital risk-adjusted acute kidney injury, all patients. Now that you have completed this education, please click on the next lesson. Thank you for your participation.

CATH PCI Registry

Metric 39

acute kidney injury

PCI

AKI prediction