Hello, I'm Jennifer Varner. I'm the STEMI coordinator for West Tennessee Health Care and I'm the clinical manager for our cardiology data registries. West Tennessee Health Care is a public not-for-profit organization serving over 500,000 residents throughout 19 counties in West Tennessee. We have six inpatient hospitals and emergency departments. We treat over 185,000 people per year. West Tennessee Health Care has three acute care facilities that hold chest pain center accreditation. Jackson-Madison County General Hospital is considered the flagship in where I work. It is a 640-bed tertiary care center. Our cardiac cath lab performs 1,200 to 1,500 PCIs per year. We do this without any cardiology residency or fellowship. In the fall of 2018, we actually opted into the PCI Reduce the Risk Fleet campaign. This did take several conversations with stakeholders and eventually we were able to bring our campaign into an already existing cardiac interventional modality group and we were able to present some information to the Department of Cardiology. From here, we began educating these groups on metrics and definitions. We presented the hospital data and how we compared to other facilities and the benchmarks. We were able to also drill down on our hospital data and show specific aspects of care which increased the risk of bleeding for patients here at Jackson General. Upon doing that, we were then able to recommend a process change based on findings using the toolkit. There are several items within the toolkit and campaign that we were able to implement here at Jackson General. One of these was a bleed avoidance strategy that we found within the toolkit and watched a webinar and were able to develop a bleed avoidance strategy specific to the needs of our organization. Hi, I'm Dylan Wilson and I am the cardiology pharmacist at Jackson Madison County General Hospital. I was a member of the modality team that Jennifer referenced earlier that looked at trying to improve our outcomes specific to bleeding for our patients that had PCI. One of my jobs is looking at the data and analyzing and assessing it and trying to identify opportunities for improvement for our patients and to see who was experiencing bleeding in the first place. Like she said, we implemented this bleed avoidance strategy which you can see here on this slide. The cath lab staff would enter certain patient characteristics into a calculator. Based on that calculator, the patient was determined to either be low, moderate, or high risk for bleeding. Then we asked the cardiologist to either consider or encourage them to implement one or two of the bleed avoidance strategies which are listed on the bottom. From our data, we saw that patients were most likely to bleed if they had femoral as opposed to radial access, if they were given a GP2B3A inhibitor or Tyrofiband or Eptifibatide. Also, they seemed to be more likely to bleed if they had the MINX closure device used. We tried to encourage the use of PERT-CLOSE closure device. After we implemented the bleed avoidance strategy policy, we looked back at practice changes as well as outcomes that our patients experienced both before and then after the policy was implemented. We presented the results of our study or of our process changes at last year's quality summit. What we saw was there was a significant reduction in the usage of MINX closure devices, a significant reduction of femoral access, and we did not however see any real movement in the usage of our glycoprotein 2B3A inhibitor usage. But as a result of all of this, we ultimately saw a reduction in our bleeding events which was really what we were shooting for. So after presenting the results in our poster, we were voted by fellow meeting attendees as the People's Choice Award winners. And so we want to thank the NCDR for that special honor as well as our fellow meeting goers last year. However, we weren't really satisfied with that. We wanted to continue to improve, make sure that we maintained the success that we had, and continue to look for opportunities to improve the care for our patients. So this slide is copied and pasted from our cath PCI registry and looking at metric 40. And as you can see, in just before quarter one of 2019, we implemented our bleed avoidance strategy policy. And after that, we saw a decline in our bleeding event rates. Once we saw a decline in our bleeding event rates, we then analyzed the data, presented it as the poster last year. And so the data that we presented then was through quarter one of 2020. So after presenting the data that we had from last year, we've continued to maintain a relatively low bleeding event rate for our institution at least. And we've maintained that success. However, we still continue to hover just slightly above the 50th percentile. And we want to continue to improve the care for our patients. And so we continue to dig deeper into the data, go into the cath PCI registry, and try to find what was going on with our patients that we could continue to improve. So when we looked at who is actually receiving the care recommended by the bleed avoidance strategy, we found that when we broke it down into low, moderate, and high-risk patients, the low and moderate bleed risk patients were almost always receiving the recommendations of the bleed avoidance strategy policy. However, the high-risk patients, the patients who needed it the most, were far and away the least likely to follow that protocol. And so less than 50% of our high risk bleeding or high bleed risk patients actually had two of those three bleed avoidance strategies followed throughout their cath. So once we started to look at our patients who bled, we broke it into patients who were moderate risk and experienced a bleeding event, and patients who were high risk and experienced a bleeding event. We then compared that to just the total PCI patient population. And what we saw was that in the dark blue bar, you can see those are our high risk patients who experienced a bleeding event. And when it comes to femoral access, they were far more likely if they were high risk patients to have femoral access than just our total population. PERT-CLOS didn't seem to make a difference with our overall population and then our two others. And then again, when we looked at patients who had a GPI, our glycoprotein inhibitor used during their PCI, our moderate risk patients were much higher than the total population. And then our high risk patients who had a bleeding event were even higher than that in terms of usage of a glycoprotein inhibitor during their PCI. So once I saw that glycoprotein inhibitor usage was used so much more often in patients who experienced a bleeding event, whether that was moderate risk or high risk patients, I looked a little further just to kind of see what our overall usage was. And as you can see in this slide, our usage was 15% in PCI patients, whereas our like volume group was significantly lower at 10%. So the usage of glycoprotein inhibitors in similar size cath labs was two thirds of that of ours. Now, glycoprotein inhibitors being associated with increased bleeding, certainly not news to anyone, but really trying to drill down on what patients are getting them and really trying to figure out what the true impact of glycoprotein inhibitor usage was for our patients. I sat down with one of our cardiologists and kind of showed him the different ways I've been looking at bleeding events and patient characteristics and what could lead to increased bleeding and what characteristics were associated with increased bleeding. And I'd looked at radial versus femoral, GPI versus no GPI, and he recommended maybe even looking at it within both of those groups together. And so when I looked at radial bleeding events, you see that our rate was only about two and a half percent, whereas femoral was 3.2%. But once you added a glycoprotein inhibitor to either of those, our radial bleeding event rate went up twofold and our femoral bleeding rate went up almost fivefold simply by adding a glycoprotein inhibitor to that case. Now, there were certainly higher risk patients because usually that's who receives the glycoprotein inhibitors, but seeing the event rate nearly quintuple definitely caught our attention. So on this slide, we looked at just bleeding and different patient characteristics and what effect those characteristics had on our overall bleeding rates. And so you can see on the left-hand column are the different patient characteristics. The second column is an unadjusted bleeding rate based on those characteristics. And then the third column is the relative risk. And you see even with just glycoprotein inhibitor usage, regardless of access site, resulted in nearly fivefold increased risk of bleeding, which was a statistically significant increase. And then you can see even though those patients might have been higher risk, when we look at our observed-to-expected in the next two columns, the observed-to-expected ratio on the far right column shows that glycoprotein inhibitor usage, even when normalized for the patient's baseline risk, resulted in a 70% increased risk with glycoprotein inhibitor usage by itself. And then even when broken down into radial and femoral with the glycoprotein inhibitor usage, again, about a 60% to 77% increased risk of bleeding simply by adding a glycoprotein inhibitor usage to their care. So this slide really just highlights the points that I was making on the previous slide, where glycoprotein inhibitor usage added to either by itself or added to either radial or femoral access. So it consistently increases the patient's likelihood of having a bleeding event. So what did we do with all this information? Well, we continued to educate both our cath lab staff and cardiologists, present that data, make sure it gets in front of them as often as possible. We really want to try to sustain the success that we've had so far. Like I said, we've identified that high-risk patients were not getting the bleed avoidance strategy, and so we're really trying to highlight that and encourage the use of bleed avoidance strategies for our high-risk patients, the patients who need it the most. This isn't a problem that's unique to our institution. It's been reported in the literature and even described as a treatment risk paradox, and that the patients who need it the most are least likely to get it. We also, like I said, we noticed that our glycoprotein inhibitor usage was higher than the national average for like-volume hospitals, and that usage was really associated with significantly increased risk for our patients. And so this was all presented to our cardiology department, put in front of all of the cardiologists, and hopefully with the continued encouragement and information getting in front of them, that can help to really inform their practice patterns. So for next steps are moving forward in an attempt to try and keep this as a focus for our physicians and cardiac cath lab team. We have implemented a few things. The first one is a template from the LISTSERV for clinician feedback, and I'll show you that in just a moment. We actually obtained this from the PCI LISTSERV. This is from another facility. There's also a template in the toolkit that's very similar, and I'll talk about that in just a minute. We were also very excited to get this added to our quality community board, which aligns with our facility's mission regarding quality and safety. Our department of quality actually works with each individual department for your quality goals, your safety goals, patient satisfaction goals, and for the cardiac cath lab, some of your more common PSI safety initiatives, such as falls, reduced skin falls, pressure ulcer, those type things don't necessarily apply to our cardiac cath lab. So we were able to add our PCI bleed risk initiative and our acute kidney injury initiative under our safety goals for the coming year, and our department of quality approved that. So we're very excited about that because that is backed by our administration. Our physicians will be in tune to that, and our cath lab staff will be engaged with those goals. We will report those monthly to the quality department and quarterly to our department of cardiology. So we're very excited about that and think that will keep us continued on our role for our goal for improving these patients and reducing the number of patients that we have. So as I mentioned, this is the feedback letter template that we will provide for clinicians that do have a patient that fall out for a bleed. Like I said, I got this from the listserv as part of the PCI campaign, and I think that is still available. The middle section, which includes the risk factors, is also in the toolkit, and this is probably something that some hospitals are already using since this was shared in our listserv. So we're excited about this and to begin using it, and it's pretty self-explanatory. You can see you would put the date at the top, the reason the patient was taken to the cath lab, there a little summary of the patient, if they had a hemoglobin drop, their risk factors, and at the bottom in the feedback is where we were going to suggest some of the bleed avoidance strategies. If they didn't go radial, you know, suggest could you have gone radial maybe in this patient, could you have used a glycoprotein inhibitor, just a bolus instead of a drip, or could you have used the perclose instead of a minks, things like that, just reminding them of why the patient had a bleed and things that they could have done to avoid it, and then at the bottom you can see there we will list the patient's risk, so they'll know if they were low, moderate, or high. So we would like now to offer some time to see what questions you might have for us, and if you would like to call or email Dylan or myself, we have our contact information listed here, our email and phone number, and we would be happy to help you or answer any questions that you may have had about this presentation today. Thank you.

bleeding events

percutaneous coronary intervention

reduce the risk fleet campaign

patient characteristics

educating staff