Developing a Treatment Quality Monitoring Program for Patients with Acute Coronary Syndrome in Western Slavonia

    Authors

    Abstract

    A well-organized network for primary percutaneous coronary intervention (pPCI) is of paramount importance in providing optimal healthcare for patients with acute coronary syndrome (ACS). Organizing a pPCI network is a lengthy and logistically complex task. The purpose of gathering, analyzing, and sharing data on the functioning of the network is to improve the system. Monitoring everyday work and gathering, analyzing, and sharing data are the key elements of continuous improvement. This article describes the efforts to develop a quality monitoring program for the treatment of patients with ACS in western Slavonia – a region in Croatia. We also explain the diagnostic, treatment, and destination protocols used and the types of data we will monitor as indicators of quality and comprehensiveness of care for patients with ACS.

    Keywords

    acute myocardial infarction, primary percutaneous intervention network, reperfusion therapy, pharmacoinvasive strategy, primary percutaneous coronary intervention

    DOI

    https://doi.org/10.15836/ccar.2015.263

    Full Text

    ## Introduction When a diagnosis of ST segment elevation myocardial infarction (STEMI) has been established or is suspected, the most important treatment is quick reperfusion of the occluded blood vessel. Primary percutaneous coronary intervention (pPCI) is the preferred revascularization method for patients with STEMI ( 1 , 2 ); a pharmacoinvasive strategy is recommended for patients where a timely pPCI is not feasible ( 3 , 4 ). Timely reperfusion requires timely diagnosis, transport, and treatment, but the timeliness of the intervention is measured in minutes, not hours or days. A well-organized network of primary percutaneous coronary intervention is of paramount importance in providing optimal healthcare for patients in the acute phase of myocardial infarction. Guidelines for treating patients with STEMI ( 1 , 2 ) stress the importance of organizing a pPCI network between hospitals and emergency medical services that takes into account the specifics of the region, but also includes continuous control of the quality of the system. Professional organizations exist both in Europe (Stent for Life Initiative) ( 5 ) and in the USA (Mission: Lifeline®; The Door-to-Balloon Alliance) ( 6 - 8 ) that work on the implementation of programs designed to improve pPCI networks with the goal of achieving timely pPCI interventions. ## Developing a network of primary percutaneous coronary intervention in western Slavonia The invasive cardiologic laboratory in the Slavonski Brod General Hospital in Slavonia was opened in 2003. Even at its conception, we envisaged a regional center that would eventually organize a network for the treatment of patients with ACS, a network which would make pPCI treatment available to every patient with acute myocardial infarction (AMI) in western Slavonia. Due to insufficient numbers of invasive cardiologists on hire, pPCI treatment started being performed only in 2010 and even then only during working hours. On January 1, 2014, our laboratory with 24-hour readiness was introduced into the Croatian pPCI network ( 9 ). Approximately 140 pPCI procedures are performed annually in the laboratory, as well as a comparable number of interventions with non-ST elevation acute coronary syndrome (NSTE-ACS). ( 10 ) The goal of improving organization is to achieve the aims set out by the Stent for Life initiative of the European Society of Cardiology ( 5 ): performing more than 600 pPCI per million inhabitants or using pPCI to treat more than 70% patients with STEMI. We also want to increase the number of pPCI performed to over 180 annually and make timely invasive diagnostics and percutaneous coronary intervention (PCI) available to all patients with NSTE-ACS. Organizing a pPCI network is a lengthy and logistically complex task demanding a dedicated interdisciplinary team. Such a team is comprised of physicians, nurses, and technicians in emergency medicine (EM) teams, merged emergency hospital admissions (MEHA) in Požega, Nova Gradiška, Pakrac, and Slavonski Brod, and the cardiologic departments of these hospitals along with the intervention team of the laboratory in the Slavonski Brod General Hospital. This interdisciplinary team is dedicated to the expressly stated goal of improving the treatment of patients with ACS in the region, through cooperation and mutual respect, dedication, and tenaciousness in the pursuit of this goal. Better organization will allow us to monitor our own work as well as the efficacy of the system, analyze data and both successes and failures, identify problems, and find avenues of improvement. To attain these goals, it is necessary to develop a comprehensive and standardized diagnosis, treatment, and destination protocol for the whole region, while also developing an official program of quality monitoring for treatment of patients with ACS. ## A comprehensive and standardized diagnosis, treatment, and destination protocol The most important and basic task is to clearly define a team-based approach and create a comprehensive and standardized diagnosis, treatment, and destination protocol for the whole region, based on current guidelines set by modern medicine ( 1 , 2 ) that also takes into account the specific characteristics of the region. These joint protocols must clearly define “geographical areas of responsibility” and implement and encourage all measures proven to reduce delays in providing timely reperfusion. ( 11 , 12 ) These measures include: Having as many patients as possible enter the system through EM services Triage of patients with STEMI outside the hospital and transportation to a hospital where a PCI procedure is available while avoiding hospitals where it is not, and direct admission to the Coronary Care Unit in the Slavonski Brod General Hospital. Prehospital 12-lead electrocardiogram (ECG) administration with quick and correct interpretation and establishment of a STEMI diagnosis, followed by the activation of the PCI team while the patient is in transit to the hospital. For patients entering the healthcare system through merged emergency hospital admissions in hospitals where PCI treatment is unavailable, the door-in to door-out interval should be brought down to less than 30 minutes, and the door-to-balloon time in MEHA of the Slavonski Brod General Hospital should be brought below 60 minutes. A PCI team must arrive in the intervention laboratory within 20 minutes of the call. One phone-call from the first physician interpreting the ECG should be sufficient to activate the PCI team to accept all referred patients (no refusal policy). In creating these protocols, our goal was to cover all entry-points for patients with ACS into the system, and create protocols that would function as diagnostic and treatment guidelines that would be simple to fulfill, but would at the same time be a source of as much data on the functioning the system as possible. We formed protocols from physicians in EM and MEHA ambulances, protocols for choosing reperfusion treatments for physicians in non-PCI hospitals, and a general statistical sheet that follows the patient from their entry to the system to their discharge from the hospital. The protocols can be found in the Appendix (online, only in Croatian). ## The treatment quality monitoring program for patients with acute coronary syndrome The goal of this program is to bring the treatment quality for these patients as close as possible to the ideal level of care they should receive. Such a program must be comprehensive and include not only patients that received an intervention, but also those that were diagnosed with ACS but were not treated with any form of reperfusion – the program should provide the total number of patients with ACS and the number of cases where reperfusion was indicated but not performed (eligible-untreated patients). In creating this program, we aimed to measure and monitor all aspects of belated treatment, i.e. the timeframes of timely reperfusion, at all levels of patients care from entry to the system to the final angiogram, as well as measure quality and comprehensiveness indicators in the treatment of patients with ACS. ## Parameters for timely administration of reperfusion treatment For EM services: Time elapsed from symptom onset to telephone call Time elapsed from call to arrival on scene Time spent on the scene Transport time For MEHA: Time elapsed from arrival to ECG recording Time elapsed from recording to ECG interpretation Time needed to call the PCI team Time to transport commencement (for hospitals where PCI is unavailable) Adding up the above time gives the door-in to door-out (DIDO) time for hospitals where PCI is unavailable Transport time for patients from hospitals where PCI is unavailable Hospital performing PCI procedures: Same parameters as with MEHA Separate monitoring of transported and walk-in patients Monitoring the percentage of patients that go directly to the operation hall and those that go to the coronary care unit PCI team: time to arrival in the operating hall, time to lead insertion, time of wire passing through the relevant lesion For the entire network: Total time of ischemia (from symptom onset to passing through the relevant lesion, stratified according to the site of entry into the system and transfer, as well as the time delay at each level). Quality and comprehensiveness indicators in the treatment of patients with acute coronary syndrome How and where the patient entered the system The percentage of patients that recorded a 12-lead ECG which was interpreted within 10 minutes from first medical contact (FMC) The percentage of cases in which the 12-lead ECG was adequately interpreted The percentage of patients in whom reperfusion (PCI or fibrinolysis) is indicated, and the percentage of cases where it was achieved The percentage of patients that received timely reperfusion treatment: pPCI: from FMC to wire passing: within 90 minutes, 120 minutes being acceptable; for patients with early presentation (time from pain onset to FMC less than 120 minutes) the target time is 60 min, and 90 min is acceptable Fibrinolysis: time from FMC to fibrinolysis – less than 30 min Pharmacoinvasive approach: coronarography within 24 hours, undelayable transfer for rescue PCI pPCI successfulness: the percentage of patients in whom a thrombolysis in myocardial infarction (TIMI) grade 3 flow was achieved Percentage of patients with suspected ACS who received invasive processing, eliminating the diagnosis of coronary heart disease Clinical outcomes: Hospital mortality, mortality after 1 month, mortality after 1 year In-hospital bleeding, stroke Treatment by EM or MEHA: With aspirin Additional antithrombotic treatment (clopidogrel, ticagrelor, prasugrel) Anticoagulation treatment (unfractionated heparin, enoxaparin, or fondaparinux) -Patients with NSTE-ACS: Documented risk stratification for ischemic events and bleeding risk Documented times and types of treatment In patients chosen for invasive strategies: documented catheterization time Therapy at discharge: High-dose statin therapy Beta-blockers Aspirin Additional antithrombotic treatment (clopidogrel, ticagrelor, prasugrel) Referral to rehabilitation and a dietician, inclusion in a smoking cessation program ## Conclusion The goal of gathering, analyzing, and sharing data on the treatment network for patients with ACS is to improve the system as a whole. Monitoring everyday work performance is necessary to provide insight on the direction we are going in and on what can be improved, whereas getting feedback is a key element in continuous improvement for all the members of the team that participate in patient treatment. Monitoring and analyzing all the above-mentioned data is a momentous task that can only be achieved with the full participation of all members of the team. We hope that our quality monitoring program will be successful in west Slavonia, in which case we hope to set up a national registry of patients with ACS, which would include all interested parties – professional societies, the Ministry of Health, and the Croatian Health Insurance Fund.

    Cardiologia Croatica
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    Developing a Treatment Quality Monitoring Program for Patients with Acute Coronary Syndrome in Western Slavonia

    Review Article
    Issue11-12
    Published
    Pages263-268
    PDF via DOIhttps://doi.org/10.15836/ccar.2015.263
    acute myocardial infarction
    primary percutaneous intervention network
    reperfusion therapy
    pharmacoinvasive strategy
    primary percutaneous coronary intervention

    Authors

    Đeiti Prvulović*ORCIDCroatia

    Abstract

    A well-organized network for primary percutaneous coronary intervention (pPCI) is of paramount importance in providing optimal healthcare for patients with acute coronary syndrome (ACS). Organizing a pPCI network is a lengthy and logistically complex task. The purpose of gathering, analyzing, and sharing data on the functioning of the network is to improve the system. Monitoring everyday work and gathering, analyzing, and sharing data are the key elements of continuous improvement. This article describes the efforts to develop a quality monitoring program for the treatment of patients with ACS in western Slavonia – a region in Croatia. We also explain the diagnostic, treatment, and destination protocols used and the types of data we will monitor as indicators of quality and comprehensiveness of care for patients with ACS.

    Full Text

    ## Introduction When a diagnosis of ST segment elevation myocardial infarction (STEMI) has been established or is suspected, the most important treatment is quick reperfusion of the occluded blood vessel. Primary percutaneous coronary intervention (pPCI) is the preferred revascularization method for patients with STEMI ( 1 , 2 ); a pharmacoinvasive strategy is recommended for patients where a timely pPCI is not feasible ( 3 , 4 ). Timely reperfusion requires timely diagnosis, transport, and treatment, but the timeliness of the intervention is measured in minutes, not hours or days. A well-organized network of primary percutaneous coronary intervention is of paramount importance in providing optimal healthcare for patients in the acute phase of myocardial infarction. Guidelines for treating patients with STEMI ( 1 , 2 ) stress the importance of organizing a pPCI network between hospitals and emergency medical services that takes into account the specifics of the region, but also includes continuous control of the quality of the system. Professional organizations exist both in Europe (Stent for Life Initiative) ( 5 ) and in the USA (Mission: Lifeline®; The Door-to-Balloon Alliance) ( 6 - 8 ) that work on the implementation of programs designed to improve pPCI networks with the goal of achieving timely pPCI interventions. ## Developing a network of primary percutaneous coronary intervention in western Slavonia The invasive cardiologic laboratory in the Slavonski Brod General Hospital in Slavonia was opened in 2003. Even at its conception, we envisaged a regional center that would eventually organize a network for the treatment of patients with ACS, a network which would make pPCI treatment available to every patient with acute myocardial infarction (AMI) in western Slavonia. Due to insufficient numbers of invasive cardiologists on hire, pPCI treatment started being performed only in 2010 and even then only during working hours. On January 1, 2014, our laboratory with 24-hour readiness was introduced into the Croatian pPCI network ( 9 ). Approximately 140 pPCI procedures are performed annually in the laboratory, as well as a comparable number of interventions with non-ST elevation acute coronary syndrome (NSTE-ACS). ( 10 ) The goal of improving organization is to achieve the aims set out by the Stent for Life initiative of the European Society of Cardiology ( 5 ): performing more than 600 pPCI per million inhabitants or using pPCI to treat more than 70% patients with STEMI. We also want to increase the number of pPCI performed to over 180 annually and make timely invasive diagnostics and percutaneous coronary intervention (PCI) available to all patients with NSTE-ACS. Organizing a pPCI network is a lengthy and logistically complex task demanding a dedicated interdisciplinary team. Such a team is comprised of physicians, nurses, and technicians in emergency medicine (EM) teams, merged emergency hospital admissions (MEHA) in Požega, Nova Gradiška, Pakrac, and Slavonski Brod, and the cardiologic departments of these hospitals along with the intervention team of the laboratory in the Slavonski Brod General Hospital. This interdisciplinary team is dedicated to the expressly stated goal of improving the treatment of patients with ACS in the region, through cooperation and mutual respect, dedication, and tenaciousness in the pursuit of this goal. Better organization will allow us to monitor our own work as well as the efficacy of the system, analyze data and both successes and failures, identify problems, and find avenues of improvement. To attain these goals, it is necessary to develop a comprehensive and standardized diagnosis, treatment, and destination protocol for the whole region, while also developing an official program of quality monitoring for treatment of patients with ACS. ## A comprehensive and standardized diagnosis, treatment, and destination protocol The most important and basic task is to clearly define a team-based approach and create a comprehensive and standardized diagnosis, treatment, and destination protocol for the whole region, based on current guidelines set by modern medicine ( 1 , 2 ) that also takes into account the specific characteristics of the region. These joint protocols must clearly define “geographical areas of responsibility” and implement and encourage all measures proven to reduce delays in providing timely reperfusion. ( 11 , 12 ) These measures include: Having as many patients as possible enter the system through EM services Triage of patients with STEMI outside the hospital and transportation to a hospital where a PCI procedure is available while avoiding hospitals where it is not, and direct admission to the Coronary Care Unit in the Slavonski Brod General Hospital. Prehospital 12-lead electrocardiogram (ECG) administration with quick and correct interpretation and establishment of a STEMI diagnosis, followed by the activation of the PCI team while the patient is in transit to the hospital. For patients entering the healthcare system through merged emergency hospital admissions in hospitals where PCI treatment is unavailable, the door-in to door-out interval should be brought down to less than 30 minutes, and the door-to-balloon time in MEHA of the Slavonski Brod General Hospital should be brought below 60 minutes. A PCI team must arrive in the intervention laboratory within 20 minutes of the call. One phone-call from the first physician interpreting the ECG should be sufficient to activate the PCI team to accept all referred patients (no refusal policy). In creating these protocols, our goal was to cover all entry-points for patients with ACS into the system, and create protocols that would function as diagnostic and treatment guidelines that would be simple to fulfill, but would at the same time be a source of as much data on the functioning the system as possible. We formed protocols from physicians in EM and MEHA ambulances, protocols for choosing reperfusion treatments for physicians in non-PCI hospitals, and a general statistical sheet that follows the patient from their entry to the system to their discharge from the hospital. The protocols can be found in the Appendix (online, only in Croatian). ## The treatment quality monitoring program for patients with acute coronary syndrome The goal of this program is to bring the treatment quality for these patients as close as possible to the ideal level of care they should receive. Such a program must be comprehensive and include not only patients that received an intervention, but also those that were diagnosed with ACS but were not treated with any form of reperfusion – the program should provide the total number of patients with ACS and the number of cases where reperfusion was indicated but not performed (eligible-untreated patients). In creating this program, we aimed to measure and monitor all aspects of belated treatment, i.e. the timeframes of timely reperfusion, at all levels of patients care from entry to the system to the final angiogram, as well as measure quality and comprehensiveness indicators in the treatment of patients with ACS. ## Parameters for timely administration of reperfusion treatment For EM services: Time elapsed from symptom onset to telephone call Time elapsed from call to arrival on scene Time spent on the scene Transport time For MEHA: Time elapsed from arrival to ECG recording Time elapsed from recording to ECG interpretation Time needed to call the PCI team Time to transport commencement (for hospitals where PCI is unavailable) Adding up the above time gives the door-in to door-out (DIDO) time for hospitals where PCI is unavailable Transport time for patients from hospitals where PCI is unavailable Hospital performing PCI procedures: Same parameters as with MEHA Separate monitoring of transported and walk-in patients Monitoring the percentage of patients that go directly to the operation hall and those that go to the coronary care unit PCI team: time to arrival in the operating hall, time to lead insertion, time of wire passing through the relevant lesion For the entire network: Total time of ischemia (from symptom onset to passing through the relevant lesion, stratified according to the site of entry into the system and transfer, as well as the time delay at each level). Quality and comprehensiveness indicators in the treatment of patients with acute coronary syndrome How and where the patient entered the system The percentage of patients that recorded a 12-lead ECG which was interpreted within 10 minutes from first medical contact (FMC) The percentage of cases in which the 12-lead ECG was adequately interpreted The percentage of patients in whom reperfusion (PCI or fibrinolysis) is indicated, and the percentage of cases where it was achieved The percentage of patients that received timely reperfusion treatment: pPCI: from FMC to wire passing: within 90 minutes, 120 minutes being acceptable; for patients with early presentation (time from pain onset to FMC less than 120 minutes) the target time is 60 min, and 90 min is acceptable Fibrinolysis: time from FMC to fibrinolysis – less than 30 min Pharmacoinvasive approach: coronarography within 24 hours, undelayable transfer for rescue PCI pPCI successfulness: the percentage of patients in whom a thrombolysis in myocardial infarction (TIMI) grade 3 flow was achieved Percentage of patients with suspected ACS who received invasive processing, eliminating the diagnosis of coronary heart disease Clinical outcomes: Hospital mortality, mortality after 1 month, mortality after 1 year In-hospital bleeding, stroke Treatment by EM or MEHA: With aspirin Additional antithrombotic treatment (clopidogrel, ticagrelor, prasugrel) Anticoagulation treatment (unfractionated heparin, enoxaparin, or fondaparinux) -Patients with NSTE-ACS: Documented risk stratification for ischemic events and bleeding risk Documented times and types of treatment In patients chosen for invasive strategies: documented catheterization time Therapy at discharge: High-dose statin therapy Beta-blockers Aspirin Additional antithrombotic treatment (clopidogrel, ticagrelor, prasugrel) Referral to rehabilitation and a dietician, inclusion in a smoking cessation program ## Conclusion The goal of gathering, analyzing, and sharing data on the treatment network for patients with ACS is to improve the system as a whole. Monitoring everyday work performance is necessary to provide insight on the direction we are going in and on what can be improved, whereas getting feedback is a key element in continuous improvement for all the members of the team that participate in patient treatment. Monitoring and analyzing all the above-mentioned data is a momentous task that can only be achieved with the full participation of all members of the team. We hope that our quality monitoring program will be successful in west Slavonia, in which case we hope to set up a national registry of patients with ACS, which would include all interested parties – professional societies, the Ministry of Health, and the Croatian Health Insurance Fund.