DMACS Discharge Management of patients with Acute Coronary Syndromes (DMACS) – a quality...

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DMACS DMACS D ischarge M anagement of patients with A cute C oronary S yndromes (DMACS) – a quality improvement initiative Feedback A quality improvement initiative in collaboration with: NPS: Better choices, Better health

Transcript of DMACS Discharge Management of patients with Acute Coronary Syndromes (DMACS) – a quality...

Page 1: DMACS Discharge Management of patients with Acute Coronary Syndromes (DMACS) – a quality improvement initiative Feedback A quality improvement initiative.

DMACS DMACS

Discharge Management of patients

with Acute Coronary Syndromes

(DMACS) – a quality improvement

initiative

Feedback

A quality improvement initiative in collaboration with:NPS: Better choices, Better health

Page 2: DMACS Discharge Management of patients with Acute Coronary Syndromes (DMACS) – a quality improvement initiative Feedback A quality improvement initiative.

DMACS

Insert hospital logo here

Hospital DMACS contacts

Local coordinator

– Insert name here

Local DMACS team

– Insert names here

Page 3: DMACS Discharge Management of patients with Acute Coronary Syndromes (DMACS) – a quality improvement initiative Feedback A quality improvement initiative.

DMACS

Overview

Aims and methods

Best practice in discharge management of patients with Acute

Coronary Syndromes (ACS)

Feedback on audit of current practice

Discussion

Education and ongoing monitoring

Page 4: DMACS Discharge Management of patients with Acute Coronary Syndromes (DMACS) – a quality improvement initiative Feedback A quality improvement initiative.

DMACS

Aims

To improve management of ACS at discharge by targeting:

1. Prescription of guideline-recommended* cardiovascular medicines following an ACS event (antiplatelets, ACE-inhibitor, beta blocker, statin, short-acting nitrate)

2. Provision of education on lifestyle modifications following an ACS event (incl. smoking cessation, cardiac rehab)

3. Communication to patient/carer & general practitioner (GP) regarding ACS management post-discharge

*NHF & CSANZ ACS Guidelines working group. National Heart Foundation ACS Guidelines.

Med J Aust 2006:184(Supp):S1-32

Page 5: DMACS Discharge Management of patients with Acute Coronary Syndromes (DMACS) – a quality improvement initiative Feedback A quality improvement initiative.

DMACS

Quality improvement initiative steps

1. Gain support

2. Collect data (insert month/year here)

Data entered into NPS* DMACS e-DUE audit tool

- ‘x’ patients (inpatient data)

- Patient post-discharge telephone survey (delete if not applicable)

3.Evaluate data (insert month/year here)

- Reports generated

4. Feedback data (insert month/year here)

5. Action - Intervention/education

Methods

NPS an independent organisation promoting quality use of medicines, funded by the Commonwealth

Page 6: DMACS Discharge Management of patients with Acute Coronary Syndromes (DMACS) – a quality improvement initiative Feedback A quality improvement initiative.

DMACS

Best practice for discharge management of patients with ACS*

Initiate long-term management plan for ACS patients

Consider guideline-recommended medicines for all ACS patients

Identify risk factors and refer all ACS patients to secondary

prevention programs

Communicate management plan to the patient, carers & the

community healthcare providers

*Based on the National Heart Foundation of Australia, Cardiac Society of Australia and New Zealand Guidelines for the management of acute coronary syndromes 2006, and Therapeutic Guidelines: Cardiology, Version 5, 2008.

Page 7: DMACS Discharge Management of patients with Acute Coronary Syndromes (DMACS) – a quality improvement initiative Feedback A quality improvement initiative.

DMACS DMACS

Inpatient medical record review

Page 8: DMACS Discharge Management of patients with Acute Coronary Syndromes (DMACS) – a quality improvement initiative Feedback A quality improvement initiative.

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Demographics and risk factors

Audit 1(n =)

Audit 2(n =)

Median age (years)

Male

Documented cardiac risk factors at admission:

Previous ACS event

Diabetes

Current smokers

Page 9: DMACS Discharge Management of patients with Acute Coronary Syndromes (DMACS) – a quality improvement initiative Feedback A quality improvement initiative.

DMACS

Discharge diagnosis

Audit 1(n =)

Audit 2(n =)

STEMI*

Non-STEMI†

Unstable Angina

Unspecified ACS

*STEMI = ST-segment-elevation myocardial Infarction, †Non-STEMI=non-ST-segment-elevation myocardial infarction

Page 10: DMACS Discharge Management of patients with Acute Coronary Syndromes (DMACS) – a quality improvement initiative Feedback A quality improvement initiative.

DMACS

Best practice: Consider guideline-recommended* medicines for all ACS patients

The combination of antiplatelet agents, a beta blocker, a statin and an

angiotensin-converting enzyme inhibitor are recommended for most patients.

All 4 drug classes have been proven to reduce subsequent cardiac events and

death.

If therapy is not indicated for an individual, document the reason(s) why in the

patient’s medical record and management plan.

*NHF & CSANZ ACS Guidelines working group. National Heart Foundation ACS Guidelines.

Med J Aust 2006:184(Supp):S1-32 and 2011 Addendum. Heart, Lung and Circulation 2011: Vol 20, 1-16

Page 11: DMACS Discharge Management of patients with Acute Coronary Syndromes (DMACS) – a quality improvement initiative Feedback A quality improvement initiative.

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ACS discharge medicines

  

Audit 1(n =)

Audit 2(n =)

Antiplatelet agents (aspirin and/or clopidogrel/prasugrel/ticagrelor)

Angiotensin blockade (ACE inhibitor and/or angiotensin ll-receptor antagonist)

Beta blocker

Statin

Short-acting nitrate

Guideline-recommended ACS medicines prescribed at discharge (4 classes)*

*Combination of aspirin and/or clopidogrel/prasugrel/ticagrelor, ACE inhibitor and/or Angiotensin II-receptor antagonist, beta blocker and statin

(adjusted for contraindication, lack of indication & patient refusal)

Page 12: DMACS Discharge Management of patients with Acute Coronary Syndromes (DMACS) – a quality improvement initiative Feedback A quality improvement initiative.

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Patients prescribed ACS medicines by discharge diagnosis

  

STEMI Non-STEMI Unstable Angina Unspecified ACS

Audit 1 Audit 2 Audit 1 Audit 2 Audit 1 Audit 2 Audit 1 Audit 2

Antiplatelet agents (aspirin and/or clopidogrel/ prasugrel/ticagrelor)

Angiotensin blockade(ACE inhibitor and/or angiotensin II-receptor antagonist)

Beta blocker

Statin

All guideline-recommended ACS medicines

(adjusted for contraindication, lack of indication & patient refusal)

Page 13: DMACS Discharge Management of patients with Acute Coronary Syndromes (DMACS) – a quality improvement initiative Feedback A quality improvement initiative.

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Best practice: Identify risk factors

Therapeutic Guidelines: Cardiovascular, Version 5. 2008.

Provide patients with a self-management plan before discharge

- Plan should include advice on lifestyle changes such as good nutrition, moderating alcohol intake, regular physical activity and weight management as appropriate.

- Patients should be provided with adequate counselling regarding medicines to enable self-management.

Provide smoking-cessation advice and support to all patients who smoke

- There is a rapid reduction in the risk of coronary heart disease within one year of quitting smoking.

- For patients who would like assistance to quit smoking a combination of pharmacotherapy and support programs are appropriate.

Page 14: DMACS Discharge Management of patients with Acute Coronary Syndromes (DMACS) – a quality improvement initiative Feedback A quality improvement initiative.

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Patient education - documentation

  

Audit 1(n =)

Audit 2(n =)

Discharge medicines counselling

Current smokers

Smoking cessation counselling provided to current smokers

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DMACS

Best practice: Refer all patients with ACS to secondary prevention programs

Actively refer to, and encourage attendance at secondary prevention and cardiac rehabilitation programs.

Cardiac rehabilitation is a proven effective intervention

Attendance at cardiac rehabilitation outpatient programs reduces risk for further cardiac events

Patients participating in cardiac rehabilitation can achieve improvements in:

- Physical activity, weight loss, smoking cessation, blood lipid levels and blood pressure control

NHF and CSANZ ACS Guidelines working group. Med J Aust 2006:184(Supp):S1-32NHF and CSANZ. Reducing risk in heart disease, 2007. Taylor RS, et al. Am J Med 2004;116:882-92. Vale MJ, et al. Arch Intern Med 2003;163:2775-83. NHF , Australian Cardiac Rehabilitation association. Recommended framework for cardiac rehabilitation, 2004.

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Patient referral to cardiac rehabilitation

  

Audit 1(n =)

Audit 2(n =)

Referral to cardiac rehab (total)

Referral by discharge diagnosis: 

STEMI

Non-STEMI

Unstable Angina

Unspecified ACS

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DMACS

Best practice: Communicate management plan to the patient, carers and community healthcare providers

Communicate the long-term management plan, including treatment

goals, to the community healthcare providers

Adherence to long-term therapy improves patient survival

Discontinuation of medicines after MI is common and occurs soon

after discharge

Ho PM, et al. Arch Intern Med 2006;166:1842-7

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Documented ACS management plan

  Audit 1(n =)

Audit 2(n =)

Documented ACS management plan:

% of plans that included:

a list of current medicines

a chest pain action plan

risk factor modification

all of the above

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Best practice: Provide a discharge letter/summary

Include:

Complete list of all medicines

Any changes to pre-admission medicines

Plan for any dose titration

Recommendations for monitoring

Treatment goals

Recommendation for attendance at cardiac rehabilitation

Advice regarding lifestyle modifications

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Documented ACS management plan communicated to GP

  Audit 1(n =)

Audit 2(n =)

ACS management plans communicated to GP:

% of GPs where a plan was communicated that included:

a list of current medicines

a chest pain action plan

risk factor modification

all of the above

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DMACS

Documented ACS management plan communicated to patient

  Audit 1(n =)

Audit 2(n =)

ACS management plans communicated to patient

% of patients where a plan was communicated that included:

a list of current medicines

a chest pain action plan

risk factor modification

all of the above

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Communication of documented ACS plans

Audit 1(n =)

Audit 2(n =)

 ACS management plans communicated to:

General practitioner

patient

both GP and patient

neither GP and patient

Page 23: DMACS Discharge Management of patients with Acute Coronary Syndromes (DMACS) – a quality improvement initiative Feedback A quality improvement initiative.

DMACS DMACS

Patient telephone survey at ‘x’ days post-discharge

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Survey response rates

Audit 1(n =)

Audit 2(n =)

Survey Participation (%)

Page 25: DMACS Discharge Management of patients with Acute Coronary Syndromes (DMACS) – a quality improvement initiative Feedback A quality improvement initiative.

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Patient report usage of ACS medicines at time of survey

*Includes aspirin and/or clopidogrel / prasugrel / ticagrelor plus those on warfarin†combination of aspirin and/or clopidogrel / prasugrel / ticagrelor, ACE inhibitor and / or angiotensin II-receptor antagonist, beta blocker & statin

  

Audit 1(n =)

Audit 2(n =)

Antiplatelet agents*

Angiotensin blockade(ACE inhibitor and/or angiotensin ll-receptor antagonist)

Beta blocker

Statin

Short-acting nitrate

Guideline-recommended ACS medicines available at time of survey (4 classes)†

(% of patients completing telephone survey)

Page 26: DMACS Discharge Management of patients with Acute Coronary Syndromes (DMACS) – a quality improvement initiative Feedback A quality improvement initiative.

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Patient report of adherence

  

Audit 1(n =)

Audit 2(n =)

All of the time

Most of the time

Some of the time

None of the time

Page 27: DMACS Discharge Management of patients with Acute Coronary Syndromes (DMACS) – a quality improvement initiative Feedback A quality improvement initiative.

DMACS

Cardiac rehabilitation

Audit 1(n =)

Audit 2(n =)

Inpatient documentation of referral

Patient-reported advice to attend

Of those who were advised:

Patients reporting completion

Patients reporting still attending or scheduled to attend

Patients who did not attend or complete

:

Page 28: DMACS Discharge Management of patients with Acute Coronary Syndromes (DMACS) – a quality improvement initiative Feedback A quality improvement initiative.

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Patient reported reasons for non-attendance at follow-up

You may wish to create a graph like the one opposite or insert a table

(% of patients who did not attend/complete cardiac rehab)

Page 29: DMACS Discharge Management of patients with Acute Coronary Syndromes (DMACS) – a quality improvement initiative Feedback A quality improvement initiative.

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Patients’ report on type of cardiac rehabilitation / education sessions attended

Audit 1(n =)

Audit 2(n =)

Group, outpatient at hospital (centre-based program)

One-on-one with a nurse at the hospital (centre-based program)

Private cardiac rehabilitation clinic

(centre-based program not attached to hospital)

One-on-one telephone follow-up

(home-based program supported by telephone)

Other

Page 30: DMACS Discharge Management of patients with Acute Coronary Syndromes (DMACS) – a quality improvement initiative Feedback A quality improvement initiative.

DMACS

Preferred times for cardiac rehabilitation / education sessions

Audit 1(n =)

Audit 2(n =)

Weekday morning

Weekday afternoon

Weekday evening

Weekend

Reported by those patients who were unable to attend due to time / work commitments or session availability

Page 31: DMACS Discharge Management of patients with Acute Coronary Syndromes (DMACS) – a quality improvement initiative Feedback A quality improvement initiative.

DMACS

Patient’s report on smoking status

Audit 1(n =)

Audit 2(n =)

Patients who reported being smokers at the time of admission*

Patients who smoked at admission who continued to smoke at time of survey

Patients who were smokers at the time of survey who are using a program to help quit smoking

*As a percentage of patients who answered this question.

Page 32: DMACS Discharge Management of patients with Acute Coronary Syndromes (DMACS) – a quality improvement initiative Feedback A quality improvement initiative.

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Discussion: Areas where we did well

Customise this slide for your hospital by adding bullet points on areas where your hospital is doing well

An example could be the % of patients with all guideline-recommended medicines prescribed at discharge

Page 33: DMACS Discharge Management of patients with Acute Coronary Syndromes (DMACS) – a quality improvement initiative Feedback A quality improvement initiative.

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Discussion: Areas we can build upon

Customise this slide for your hospital by adding bullet points on areas that your hospital project team has identified as an area of interest/focus of education

An example could be: current level of communication at discharge

Page 34: DMACS Discharge Management of patients with Acute Coronary Syndromes (DMACS) – a quality improvement initiative Feedback A quality improvement initiative.

DMACS

Action: the next step

Strategies to raise awareness of best practice in discharge management of patients with ACSCustomise this slide for your hospital by adding bullet points on how you will implement some change.

Examples of educational resources include:

Bookmark reminder

- Discharge ACS management plan reminder

Discharge templates/checklists

Group education sessions on current practice and comparison to ‘best practice’

Educational visits (academic detailing using the DMACS information summary card)

Page 35: DMACS Discharge Management of patients with Acute Coronary Syndromes (DMACS) – a quality improvement initiative Feedback A quality improvement initiative.

DMACS

After the educational intervention

Collect data on ‘x’ ACS cases (similar to Audit 1):

Evaluate post-intervention (Audit 2) data

Feedback data and compare with baseline and ‘best practice’

Highlights of achievements in the post-intervention presentation

Page 36: DMACS Discharge Management of patients with Acute Coronary Syndromes (DMACS) – a quality improvement initiative Feedback A quality improvement initiative.

DMACS

Acknowledgements

Congratulations and thanks to the team involved in this DUE:

Insert name

Insert name

Insert name

NPS together with QLD, VIC, NSW, TAS & SA state DUE groups and state DMACS project committees

Page 37: DMACS Discharge Management of patients with Acute Coronary Syndromes (DMACS) – a quality improvement initiative Feedback A quality improvement initiative.

DMACS

Questions?

Contact your DMACS coordinator for further information if required

Hospital contact person (insert name)

Ph: (insert contact number)

Email: (insert email address)

THANK YOU