Welcome everyone and thank you for joining this quality summit hot topic session focused on the updated patient population of the chest pain and my registry. My name is Connie and as the chest pain and my registry product manager on moderate our discussion today, beginning with introducing our speakers. Kristen young is a clinical quality advisor to the chest pain and my registry sts ACC dbt registry the calf PCI registry and I CD registry. And a recent graduate of George mason university's master's in nursing program. As well we're joined by carry Morris, she is the chest pain Center accreditation clinical product manager with a wealth of experience in emergency medicine cardiology and quality. These ladies share a passion for ensuring quality patient care is delivered and together have over 30 years of nursing experience. I hope you take a moment to read their bios and get to know them a little bit better Thank you Kristen and carry for preparing this content for us let's get started. Thank you so much Connie for that great introduction and, yes, my name is Kristen young and i'm going to take you through a portion of the. The beginning of this presentation and the followed by carry to close it out, so we are going to get started. Because there is a lot to learn, but while there is a lot to learn, we do have some learning objectives that we are going to focus on by the end of this presentation. That we hope you will be able to define the chest pain at my registry patient populations also discuss how hospital care practices are impacted by data from all patient types. and identify how the chest pain and my registry data can support hospital credentialing. Formerly known as the acute coronary treatment and intervention outcomes network or action registry. The chest pain and my registry version three offers the ability to include data on unstable angina low risk chest pain and now the in hospital STEMI patient population. But we also have the oldies but goodies the end STEMI is and the pre admit STEMI patient populations as well, but this broader scope will aid in reducing variations in care through risk stratification using collaborative options for a wider cardiovascular team, including pre hospital patient populations, as well as the in hospital STEMI patient populations, so we hope you will be able to define the chest pain at my registry patient populations and identify how the chest pain and my registry data can support hospital credentialing. Including pre hospital providers EMTs ER providers and others caring for the at risk patients with chest pain. The complete picture of chest pain and my care starts in the Community or at the outpatient provider level, and that includes our EMS folks, then it moves into the hospital care and the procedures that are performed in the hospital, all the way up until the patient goes home or discharge. Evaluation of hospital performance and delivering guideline recommended care is visible and the accompanying accompanying executive summary measures and metrics and the detail lines. The data set was created with greater flexibility in mind by providing fewer data fields and different ways to evaluate and benchmark your data, including appropriate use criteria or a UC anticipated in the coming year. Additionally, we collaborated with our accreditation colleagues to bring a single data source with streamline data entry and monitoring and trending for chest pain Center accreditation. Many goals were in mind when developing the chest pain and my registry, as mentioned previously, we expanded our patient populations to include low risk chest pain unstable Angela and in hospital STEMI patients to our current and STEMI and patient and STEMI patient types. Next, we look to increase the relevance of the registry by collecting data elements to support hospital level reporting on the updated 2017 AMI performance measures. We also sought to accurately capture risk model variables to ensure meaningful risk models data variables include risk factors present on arrival, as well as data elements, such as troponin and the associated troponin assay used at the hospital. We anticipate that the dashboard will report appropriate utilization of cardiovascular imaging emergency department patients with low risk chest pain. Longitudinal or follow up reporting provides the hospital an opportunity to receive reporting on patient outcomes post discharge. Every effort has been made to ensure that the interaction of elements between cat PCI version five and chest pain in my version three was seamless so for hospitals to be able to provide a seamless report on patient outcomes. Understanding your patient populations that is greater than the sum of what you might receive through single participation in a single registry. And lastly, local, regional and state efforts around STEMI care continue to be a priority, where we provide support. For the focus of this presentation, we are going to focus on these three course objectives. Moving into the first one, the American College of Health and Human Services. And lastly, local, regional and state efforts around STEMI care continue to be a priority, where we provide support. For the focus of this presentation, we are going to focus on these three course objectives. Moving into the first one, the American College of Cardiology and the American Heart Association performance measure sets, they serve as vehicles to accelerate translation of scientific evidence into clinical practice measure sets developed by the ACC AHA are intended to provide practitioners and institutions that deliver cardiovascular services with tools to measure the quality of care. And lastly, local, regional and state efforts around STEMI care continue to be a priority, where we provide support. This document has served as a foundation for the reporting of six composite performance measures, 15 individual performance measures and six quality metrics. Appropriate use criteria, or AUC, are decision support quality improvement tools are intended to help clinicians select the right patients for the right diagnostic tests and provide a practical standard upon which to assess and better understand variability. AUC can serve to improve the utilization of cardiovascular procedures in an efficient and contemporary fashion. Clinicians, payers and patients are interested in the incremental value offered by imaging to both a diagnosis and clinical management disease conditions. Alternatively, when imaging does not offer this value, this document addresses the appropriate use of imaging in patients who present to an EV chest pain. ACC has endorsed the reporting of appropriate use criteria in the NCDR registries as a means for hospitals to evaluate interventions related to specific outcomes, such as financial, clinical and others of the like. The chest pain MI registry captures data on STEMI, pre-admit and in-hospital, NSTEMI, unstable angina and low-risk chest pain patients, which we will now review. MI caused by atherothrombotic coronary artery disease and usually precipitated by atherosclerotic plaque disruption is designated as a type 1 MI, which the registry has molded their inclusion criteria based upon using the fourth universal definition. It is essential to integrate the ECG findings with the aim of classifying type 1 MI into STEMI or NSTEMI in order to establish the appropriate treatment according to current guidelines. Pre-admit STEMI and NSTEMI should demonstrate a rise or fall and or fall of cardiac troponin values with at least one value above the 99% URL or upper reference level. With at least one of the following, which include symptoms of acute myocardial ischemia, new ischemic ECG changes, development of Q waves, imaging evidence of new loss of viable myocardium or an abnormality in the wall in a pattern consistent with an ischemic etiology or by seeing it, such as during coronary angiography. One exception to the definition is in the scenario of a STEMI where we accept a clinical diagnosis with immediate revascularization, whether it be PCI, lytics or cabbage in lieu of a rise and or fall of troponins. So we're not going to spend too much time on the pre-admit or the NSTEMI patient populations because we want to talk a little bit about the new kids on block. And we're going to start with the in-hospital STEMI. So in-hospital STEMI outcomes are not well documented or tracked and represent an important population for data capture. From what we do know from about this patient population, they're older. They have more comorbidities and more frequent coagulopathies. And contraindications for anti-coagulation or lytic therapy. Additionally, there are usually three areas of delay in the treatment of patients within hospital STEMI that merit attention. And these are getting the ECG, interpreting the ECG, and then activating the STEMI systems of care. Thus, quality improvement programs, sorry, thus quality improvement programs targeted at decreasing delays of streamlining treatment of such patients may improve treatment and outcome, which can be done using the chest pain MI registry. ACS, acute coronary syndrome, has evolved as a useful operational term that refers to a spectrum of conditions compatible with acute myocardial ischemia and or infarction that are usually due to an abrupt, abrupt reduction in coronary blood flow. The absence of persistent ST elevation is suggested of an NSTEMI, which can be further subdivided based on cardiac biomarkers of necrosis, which we're familiar with our troponins. Cardiac biomarkers are elevated and the clinical context is appropriate. The patient is considered to have an NSTEMI. Otherwise, the patient is then considered to have unstable angina. We're going to spend a little bit of time talking about the low risk chest pain population, because in 2010 the National Hospital Medical Care Survey reported nearly 130 million emergency department visits, with the second largest component being patients who came to the ER with complaints of chest pain. Thus, we've labeled these patients ER cloggers. The spectrum of potential etiologies can range from serious to life threatening pathologies, such as an acute coronary syndrome, PE, or acute aortic syndromes, to relatively benign illnesses without long term consequences, such as your costochondritis. And they pose a great challenge to a caregiving physician. Initial strategies of these patients focus on rapidly and accurately excluding diagnoses with the greatest short term mortality risk. Much of the initial diagnosis is determined by the clinical presentation, as assessed by the history, physical examination, basic ancillary testing. However, diagnostic imaging may be used to identify or exclude a potential life threatening condition. The clinical presentation does not reveal an obvious cause. This aided in the development of the broader scope to expand our patient population type to include these low risk chest pain patients, which are defined as patients who present with chest pain. It can be pressure, tightness, burning, squeezing, indigestion, anything that can represent myocardial ischemia. The evaluation must include at a minimum an ECG and one troponin and the definition of unstable angina and STEMI or STEMI must not be met. Patients may have subsequent testing, but cannot have undergone PCI during the same episode of care. When talking about these low risk chest pain patients and in regards to their importance into the registry and being under evaluated or under researched, it comes at a time when I remember an article that was by the New York Post published in 2015, I believe. And I can't recite the title of the article at this time, but the gist of it was that these patients were better served whenever they were in the hospital and had chest pain. If they ran outside and started to complain of chest pain versus being in the hospital and complaining of it, they get treated quickly. All right, well, that concludes my portion of the chest pain. registries, vision and goals. I am now going to hand it off to Carrie Morris with accreditation, who is going to bring us home with some useful insight into the accreditation process and kind of expand upon the new patient populations as well in regards to bringing value to understanding at your hospital. Great, thank you, Kristen. So as she said, I'm Carrie Morris. I am the accreditation clinical product manager for chest pain center accreditation. And so we're just going to dig a little deeper into managing this new kids on the block, so to speak. And so looking at these populations for that in hospital STEMI and stable angina as well as the low risk chest pain patient. So just as previously stated, historically, the chest pain in my registry did look at just the AMI populations with that STEMI and non STEMI and now with these expanded populations, you're going to be able to see the metrics related to the low risk patient to the unstable angina and inpatient STEMI populations. But the management of these populations are often met with misunderstanding and quite honestly inconsistencies. And so here is where the chest pain center accreditation strategically provides clarity and a streamlined approach to manage the ambiguity. It helps close delays or gaps in care that you might identify at your hospital. It also helps to mitigate the risk for your facility as well as the patient and the provider and help to avoid unnecessary cost of care. So ultimately, we have this goal of the right care at the right time. So let's look at the low risk patient a little bit deeper. So sometimes it can seem like a busy interstate and there's not really clear direction. So how do you navigate for this most appropriate exit ramp for each of those patients that show up in the low risk category? Well, you're going to start with that initial workup, of course. And risk stratification is certainly key to develop a clear method to deliver care. And everyone's not necessarily on the same pathway. So you need to be able to define the low risk patient. Is that patient at sufficient risk, whether by history, by presentation, ECG changes, troponin levels, results? Is that patient fit into the high risk, the intermediate risk, the low risk category? And then that ultimately helps you in the clinical decision making to appropriately disposition that patient. Is it appropriate for the patient to go home from the ER? Or do they need outpatient stress testing? Or do they need to have a little bit more time and observation to really get serial strategy of your ECGs, of your troponins and be able to allow that patient to rule themselves out? And then identify if that patient needs stress testing. So now let's look at the unstable angina patient. So this can certainly be a challenge to navigate. So they don't have clear ST elevation on an ECG, nor positive troponin, yet they can still be an ACS patient. We know from the non-STE ACS guidelines, the non-STEMI and unstable angina populations are discussed together in order of management. So again, risk stratification is certainly key. And it's helpful to determine that appropriate pathway. We want to see, is this patient going to rule themselves in as a non-STEMI? Are they going to have a rise and fall of their troponins? Is there going to be a delta change between the serial troponins? Are there going to be ECG changes when you get their serial ECGs? So we want to look at this patient according to the guidelines and truly manage them through the ischemia-driven strategy. So is this patient appropriate for the cath lab? If so, what is the timing of that cath lab visit? Are they low on the TIMI or GRACE score? Are they absent of high-risk features such as those ischemic ECG changes? Signs of heart failure? New or worsening mitral regurg? Low ejection fraction? Is this patient a non-STEMI major? Or is maybe non-invasive stress testing more appropriate to determine the likelihood of ACS? Certainly having a solid roadmap to follow will enable optimal and timely management of this population. So as I mentioned earlier, historically, the STEMI patient has received faster reperfusion and better care outside the hospital for their presentation rather than inside the hospital. Often what we see is that the process is not clearly defined. So the hospital response team really should act like first responders. So what is the imperative for early recognition? So we know about 60% of inpatient STEMIs have atypical presentations. So these are often related to the patient's maybe presentation or admitting diagnosis or procedure. Maybe they had a surgery in this visit, but these patients are already sick and they're in the hospital. Often they have those comorbidities and all of these items can confound those symptoms. So certainly early recognition and clinical decision for reperfusion is critical. A robust discussion between providers managing the patient's episode of care, the cardiologist and the patient is vital to ensure that the patient is certainly appropriate for cath lab. So there's great value in having a hardwired plan. We wanna create a multidisciplinary flow chart, drill the process. These will help eliminate delays in care when a patient converts to a STEMI in-house. Ensure you are reviewing each case for efficiency and identifying process revisions that may be necessary. We want to mirror the proven process for STEMI patients presenting through EMS or the ED because it's vital to hardwire that in order to salvage the heart muscle. So now let's take a little sneak peek into the accreditation tool, what it looks like, how the content is laid out, what resources are there to provide for those hospitals going through accreditation. So version seven, this is version six, but version seven will be coming out probably the end of this year, maybe first quarter of 2021, but for those not familiar, so here's how the tool appears. It has resources, clear guidance, shared practices embedded, and then the version seven will be very similar, but there will be a few enhancements. Here you'll see where the essential components, how these are laid out. So here we're looking at the early stabilization and each line item has a dropdown caret. And so within the dropdown caret, you'll see that the references are built in. So you know exactly what the writing committee was thinking when they determined that that item was gonna be a mandatory item. Again, early stabilization, but this time looking at troponin. So there are several sections to early stabilization. So really being able to look into all of the components of care and ensuring your troponin strategy is agreed upon and standardized across your departments. Also looking and making sure that your troponin is actually at the 99th% cut point of the coefficient of variation. Looking at your interpretive comments, what's available to this provider's managing care? How do they know that that is what your cutoff is and that patient's troponin result is indicative of myocardial damage? Also looking for delta changes. How is that written into your processes and then standardization, like I said, across all departments. And so you'll see here these references and the references are so important to look at your troponin analyzer very critically. So whether you're using point of care testing in the emergency department or observation areas or your lab-based testing. And so version seven of accreditation will dive a little bit deeper and highlight high-sensitivity troponin and making the distinction between contemporary and high-sensitivity troponins as well. Here, we're gonna look at acute care. So looking at that non-STE ACS patient. So looking at specifically like an unstable angina patient and the ischemia-guided management process. So once more, risk stratification is a critical component and here's references to provide you with the guidelines as well as the appropriate use criteria for coronary revascularization as well. Here, we'll look at the designation. Within the designation tabs, you have the inpatient STEMI process. This is where it's embedded and it's important to have a clinical response team for the potential STEMI patient, whether they're an observation or an inpatient unit as well. The value of flow charting out the process to evaluate efficiency used, and these can be used as education to staff that may not be familiar with the process. Often facilities will post these on their crash carts within the facility, which serves as a great resource for staff. Again, references here to support this EC. And then finally, we're gonna look at the shared practice library. So oftentimes we get asked by hospitals going through accreditation, what does that look like operationally? And so this is a fantastic resource that was new to version six and we've carried it forward within version seven as well for facilities to see how to truly operationalize processes that they may not currently have at this time. And so you can see where the shared practices house or attached to the central component it supports. So you'll see where they have the dropdown caret and then where it's attached as well. So overall, this is an overview of how accreditation assist and implementing guidelines and best practices that translate into improved collaboration and processes, creating a multidisciplinary team approach to ensure departments and providers are not operating in silos. Through the accreditation registry, we drive science to the bedside, accountability and increase efficiency. This ignites a strategy to focus on meaningful metrics. A reduced variation of care translates to lower cost of care and improve bottom line. So together we optimize patient outcomes and financial performance. I'd like to thank you for your commitment through these challenging times of furloughs and shifting responsibilities from data abstraction to the bedside and back. We appreciate your time and joining us in this session today and Connie, I will turn it back over to you. Thank you, Kristen and Keri. That was an informative and enlightening presentation even for myself as the product manager. So thank you for all the work you put into it. So Kristen and Keri have some questions for you. Kristen, I'd like to start with you. So Keri talked a lot about accreditation and the value that the registry holds for clients who are seeking accreditation. If a hospital is not engaged in accreditation, can you share how the registry data alone can help hospitals understand the care they are providing to the expanded patient population in the registry? Yeah, sure. And that is a great question. And sometimes it's often one that we see, especially submitted to the NCDR because sites want to know if I participate in chest pain or not, do I have to participate in accreditation and vice versa? And so the answer is, no, you don't have to participate. But you get a really good perception of what is going on in both measures. But if you choose not to, you do get accreditation detail lines and you may not know that they are there, but if you go on the dashboard and filter down the detail lines, you will see them titled accreditation detail lines. And you will still get results, you will still get benchmarking and you will still get compared to the US registry comparison in those detail lines. Also, you don't have it now, but sites will have a better understanding of their low risk chest pain population whenever we do implement the AUC for the cardiovascular imaging for those patients in the ER. And also we're gonna be coming out with the, I wanna say they're gonna be detail lines, we're not gonna do metrics for the in-hospital STEMI, but you will get some more information in regards to your in-hospital STEMI population as well. So the reason I asked you to answer that question is because I have queried the registry to see the percentage of hospitals that have opted to give us all patients, and it is 70%. So that's phenomenally high, I thought. It impressed me, right? Because it seemed very much a risk of the chest pain MI version three to expand that population. It felt like it was more data collection burden, but we gave hospitals the option not to submit all patients and to just stick with their STEMI and NSTEMI. And then there's also the option to do only the basic data set and submit only STEMI, and yet 70% of participants have opted to give us all their patients, which is really incredible. And the metrics that are on the dashboard now that are to support accreditation absolutely can support our participants as well. All right, so Kerry, my question for you is, what are the challenges to delivering guideline-directed care? For the low-risk chest pain patient and the unstable angina patient? Oftentimes, that's a great question. Oftentimes what we see when we're navigating hospitals through accreditation is that they don't have an agreed-upon risk stratification method. So they don't have physicians speaking the same language. Whether it's you have providers that have been clinicians for 25 years next to providers that maybe haven't practiced as much or as long as they have. And so their experience level is a little bit different and they manage those patients a little bit different. And so really being able to help them determine what that same language is going to be and define the pathways. And so that the patient gets the optimal level of care regardless of what day of the week they present, which providers are working that day. And so it's a much more streamlined approach in ensuring that the guidelines are met, the patient is getting evidence-based care and they are being treated appropriately. And at the right time. I think it's funny that you say that, Carrie, in regards to presenting. Shouldn't matter what time you come and shouldn't matter who the provider is whenever you get there. And in my clinical experience as well, it was like whenever I did ER nursing, for us it was anything from the groin up, we were doing an ECG. If there was a symptom from the groin up, they got a quick ECG, just threw them in the bed, slapped it on a triage and then sent them back out to the waiting room. But we do find that even when collecting the registry data, we're like, well, this was an atypical symptom. They came in complaining of abdominal pain, so we didn't do an ECG. So it just drives home the point that you're making, it shouldn't matter, it should be a standard in regards to when they and why they present. Definitely. And Carrie, what you said in your presentation that I thought was, that really resonated with me was when you said the guidelines for low risk chest pain and unstable angina should mirror that of the STEMI guidelines. And I mean, across the country, it almost doesn't matter which hospital you go to anymore, there is an established and clearly understood process for handling a STEMI patient. So we have to get there with our low risk and unstable angina patients. So it's nice to know that accreditation could give a helping hand, but as Kristen said, I think the registry also puts the data in your hands if you're willing to use it and improve that process of care. So Carrie, one of the things that you mentioned as well was you referenced avoiding unnecessary costs of care. So that sounds like the secret sauce that everybody wants. Can you elaborate on how the accreditation program actually improves the cost of care? It seems sort of like you're focused on guideline care and everything, but how does that also improve the cost of care? Great question. We have countless hospitals that have shown great improvement, just looking at the low risk patient in and of themselves. So if that patient presents and the providers don't have a clear pathway of managing that patient, identifying is this a very low risk patient? Are they not likely having an ACS event or at risk of having an ACS event in the very near future? But sometimes physicians will want to kind of cover themselves and absolutely completely understand. They don't want to put the hospital at risk or themselves at risk or the patients at risk. And so of sending them home too early, but with having an established pathway, then they're able to identify which ones actually do need to go into observation and maybe complete a stress test versus those that don't. And so we have hospitals that have built this definition of the very low risk chest pain patient to the intermediate risk chest pain patient. And it's typically those very low risks that are able to go home from the emergency department. So they're not using up and tying up the last inpatient bed or observation bed for a patient that is not likely having an acute event or having ACS symptoms. And so then they are able to actually preserve those beds for those patients that truly do need to have some extra time to rule themselves in or rule themselves out. And so we have hospitals that, just for one example, we had a hospital that implemented our accreditation standards and guideline-based care for their low risk patients. Well, they ended up shaving 10 hours off of their observation patients and length of stay. And in doing so, they recognize a cost savings of $600,000 per quarter. Wow, that's impressive. I mean, it goes back to what Kristen was saying about the ER cloggers. I mean, I worked in the ER for nine years and definitely we had our process, but everything always is worth re-evaluating and improving on it. So that's impressive. So Kristen, back to the version three dataset upgrade. You also mentioned that there is a synergy with the cath PCI version five. So can you just tell us a little bit about what some of those might be? So it was built with, of course, the interoperability in mind as well. So you will find that there's almost close, I want to say to 100 data elements at this point that are interoperable with cath PCI version five. But in regards to being a synergy, it's that even though you have these interoperable data elements, they're still essentially telling a different story in the metrics that each registry is reporting. So even though you may be coding something the same way, it can appear differently in the metrics in cath PCI version five and just my version three. So you're kind of getting an entire story in regards to procedure-based versus process-based care. And I'm not going to get too much into that because I know that there is a presentation that goes over or talk about the similarities and differences in cath PCI and chest pain in mind. And I'm pretty sure Connie, you're on that one. Yeah, I did that, but I wish I had said the phrase that you just said. There are a lot of synergies, but they absolutely tell a unique story. So that's quite true. So we probably should wind this down. I know we could talk about this all day because we're all passionate about it and the registry and accreditation and seeing hospitals really utilize the data to improve care for these lower risk chest pain patients. Also the in STEMI patients, we haven't talked a lot about those, but to your point, Kristen, you mentioned how there's definitely been research that has demonstrated that patients might be better off walking outside the door and coming in than being processed in-house. And obviously I think now that the registry of both chest pain and my registering cath PCI are focused on that in-house STEMI, I think we'll see care really change and the research retrospective story about that really change in the future. But before we close, Carrie, I was wondering if you could give us another example of how accreditation has helped a hospital really improve the care that they're providing. I'm putting you on the spot, but. Oh, no, that's fine. Yeah, so we just recently had a hospital. In fact, they're given a presentation within the quality summit as well. And so they went through accreditation using the cath, I mean, the chest pain and my registry and they looked at their cardiac rehab referrals and they saw that they were extremely low. And so through process improvement and implementing guidelines and getting it built into order sets and such and getting all the physicians and the advanced nurse practitioners and everybody on board with this, they were able to expand their cardiac rehab program so much so that they created new FTEs and it even supported, they are at max capacity. And so now they're also referring patients to competitors in the area. And so they're actually getting patients plugged into cardiac rehab whereas those weren't being plugged in previously. And so it's truly working, the synergy of the chest pain in my registry and the accreditation. So lots of great stories there. Well, those are the ones we like to hear. Of course. Yeah. So on that note, we'll close out this session. And if anyone who is listening still has questions, please email us at ncdr.org. And thank you again, Kristen and Carrie for such a great job and all the information you shared. Thank you. Thank you.

Chest Pain and My Registry

Patient Population

Clinical Quality Advisor

Chest Pain Center Accreditation

Learning Objectives

Low-risk Chest Pain

Unstable Angina

In-hospital STEMI