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New QI Tool Helps Systems Improve Emergency Care for Cardiac Patients

A multicenter project funded by a $3 million grant from the Agency for Healthcare Research and Quality is measuring the effectiveness of a new EMS cardiac care quality improvement system in reducing errors in the care of patients with acute coronary syndrome and delays in appropriate patients receiving either thrombolytics or percutaneous cardiac intervention (i.e., angioplasty).

Tufts-New England Medical Center's Institute for Clinical Research and Health Policy Studies is in the concluding stage of a successful project to demonstrate the use of two predictive instruments and a retrospective feedback system to improve clinician treatment decision-making. The Acute Cardiac Ischemia-Time Insensitive Predictive Instrument (ACI-TIPI) and the Thrombolytic Predictive Instrument (TPI) are being used with the TIPI-Information System (TIPI-IS) to provide detailed reports about patient care at all levels to drive continuous quality improvement. These tools also are being used by EMS systems across the United States that are participating in the IMMEDIATE trial. (See ˙$36 NIH Prehospital Study to Assess Promising Low-Cost AMI Treatment,Ó November 2006 EMS Insider.)

˙Our interest is in measuring the quality of care of patients with possible ACS in the prehospital setting and continuing into the emergency department and treatment within the hospital,Ó said Project Director Denise Daudelin, RN, MPH, an investigator with Tufts-NEMC/ICRHPS. (The project's principal investigator is ICRHPS Executive Director Harry Selker, MD.)

ACI-TIPI works with standard 12-lead ECGs, using the patient's age, sex, chest-pain status and ECG findings to calculate a simple-to-read 0Ï100% probability that the patient has ACS. That prediction is printed on the resulting ECG strip. If the ACI-TIPI determines the patient likely is having an ST-elevation myocardial infarction, the TPI provides the predicted 30-day mortality for the patient with and without reperfusion and also prints that probability on the ECG.

During the pilot, the 81 paramedics with Worcester (Mass.) EMS and 48 paramedics with American Medical Response in Brockton, Mass., identify patients with possible ACS through assessment and 12-lead interpretation, notify the receiving emergency department as quickly as possible and provide the ED physician with the ECG upon hospital arrival.

After reviewing the ECG, the ED physician provides feedback to the paramedics and alerts the cath lab when appropriate. In some cases, however, the cath lab is activated when the paramedic identifies a STEMI in the field and issues a STEMI Alert according to a protocol developed by the EMS agency and hospitals in the community.

TIPI-IS collects a wide variety of information about the patients' prehospital care, their ECGs, their in-hospital care and their outcomes and combines it in a database to generate quality-measure reports for both prehospital and ED caregivers. QI teams review those reports with the paramedics and ED staff to identify areas for improvement and implement actions to make those improvements.

˙From all the information gathered, we compile performance measures specifically about patients with ACS, including the proportion of patients who had 12-leads performed and the percentage who got aspirin, oxygen and IVs placed, but also the proportion of cases in which there was complete compliance with the protocols or error-free care (e.g., nothing omitted),Ó Daudelin said. ˙On the hospital side, we are looking at door-to-first ECG time, door-to-thrombolytics, door-to-balloon or door-to-transfer time. When there's a transfer for angioplasty, we look at the time from the door of hospital A to the door of hospital B to balloon time.

˙We also look at the continuum of time of the patients' first encounter with EMS, on-scene time and door-to-balloon time so we can see which patients are treated with thrombolytics or PCI within recommended timeframes. Paramedics receive feedback on the number of patients they correctly identified as ACS in the field and on their outcomes,Ó she said. ˙We've had impressive results with our EMS agencies and hospitals, and we're moving ahead to expand use of the system in this state.Ó

The TIPI-IS software is available via a subscription or purchase from Clinical Care Systems Inc., according to President and CEO Matthew Kristin. The ACI-TIPI and the TPI predictive instruments are available from the major 12-lead ECG/defibrillator manufacturers as a software upgrade.

˙There have been a number of studies published that clearly demonstrate the effectiveness of these decision support tools,Ó Kristin said.1Ï3

1. Selker HP, Beshansky JR, Griffith JL, for the TPI Trial Investigators. ˙Use of the electrocardiograph-based thrombolytic predictive instrument to assist thrombolytic and reperfusion therapy for acute myocardial infarction: A multicenter randomized clinical effectiveness trialÓ. Annals of Internal Medicine 2002;137:87-95.„

2. Selker HP, Beshansky JR, Griffith JL. ˙Use of the acute cardiac ischemia time-insensitive predictive instrument (ACI-TIPI) to assist emergency department triage of patients with chest pain or other symptoms suggestive of acute cardiac ischemia: A multicenter controlled clinical trialÓ. Annals of Internal Medicine 1998;129:845-855.

3. Daudelin DH, Selker HP. ˙Medical error prevention in ED triage for ACS: Use of cardiac care decision support and quality improvement feedbackÓ. Cardiology Clinics 2005;23:601-614.

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