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CRUSADE: A National Quality Improvement Initiative. C an R apid Risk Stratification of U nstable Angina Patients S uppress AD verse Outcomes with E arly Implementation of the ACC/AHA Guidelines. Aspirin Aspirin + Clopidogrel Beta-Blockers Heparin ( UFH or LMWH )

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CRUSADE: A National

Quality Improvement Initiative

Can Rapid Risk Stratification of Unstable Angina Patients

Suppress ADverse Outcomes with Early Implementation

of the ACC/AHA Guidelines

Aha acc treatment recommendations


Aspirin + Clopidogrel


Heparin (UFH or LMWH)

GP IIb/IIIa Inhibitors

For high-risk patients

For early cath/PCI


Aspirin + Clopidogrel




Cardiac Rehab

Smoking Cessation

AHA/ACC Treatment Recommendations

Acute Therapies

Discharge Therapies

Crusade objectives
CRUSADE Objectives

  • Determine current state of awareness of and adherence to the ACC/AHA Non-ST-Elevation (NSTE) ACS Guidelines

  • Implement quality improvement initiatives to promote ACC/AHA NSTE ACS recommendations

  • Improve clinical outcomes for NSTE ACS patients via early risk stratification and implementation of evidence-based care

Inclusion criteria high risk nste acs
Inclusion Criteria: High-Risk NSTE ACS

  • Ischemic symptoms lasting  10 minutes < 24 hours and at least one of the following:

  • Positive cardiac markers

    • CK-MB or TnI / TnT above ULN

    • Positive bedside troponin assay

  • Dynamic ST-segment ECG changes:

    • ST-segment depression  0.5 mm

    • Transient ST-segment elevation of 0.6-1.0 mm (lasting < 10 mins)

  • Transfer patients - must arrive at CRUSADE hospital within 24 hrs of symptoms

Study design
Study Design

  • Nationwide quality improvement initiative

    • 400+ participating hospitals

  • Collaborative effort between Emergency Medicine, Cardiology, Hospital QI, Academia, and Industry

    • Optimize risk stratification for NSTE ACS patients

    • Promote adherence to ACC/AHA treatment guidelines for NSTE ACS

    • Implement quality improvement interventions

Data collection
Data Collection

  • Concise, 3-page data collection form

    • Retrospective data collection

    • Payment of $20 per DCF returned

  • Data collected includes:

    • Pt risk factors/presenting symptoms

    • Use of medications/ Use of invasive procedures/In-hospital clinical outcomes

  • Institutional Review Boards:

    • Should not require informed consent

    • Should be viewed by local IRB as QI

Quality improvement initiative primary endpoints
Quality Improvement Initiative:Primary Endpoints

  • Effectiveness of QI initiatives measured by changes in adherence to AHA/ACC treatment guidelines

    • Early / Discharge aspirin and clopidogrel use

    • Early / Discharge beta-blocker use

    • Discharge ACE-Inhibitor and statin use

    • GP IIb/IIIa Inhibitors: Early use and during PCI

    • Early invasive management - use of cath/PCI/CABG

    • Appropriate secondary prevention measures

      • Smoking cessation

      • Cardiac rehabilitation

Patient identification strategies screening in the emergency department
Patient Identification StrategiesScreening in the Emergency Department

  • Prospectively identify patients in the ED

    • Elevated cardiac markers, dynamic ECG changes

    • Rapid, bedside Troponin I assays in the ED

  • Review daily ED admission logs

    • Unstable angina, chest pain, R/O MI, or acute MI

  • Review admissions to chest pain units

  • Develop triggers for ED nursing staff to identify patients for CRUSADE

  • Work with research coordinators who are screening patients for ACS clinical trials

Patient identification strategies screening after admission
Patient Identification StrategiesScreening After Admission

  • Review daily CCU or telemetry floor admission logs

    • Unstable angina, chest pain, R/O MI, or acute MI

  • Review daily cath lab schedule

    • Unstable angina, acute MI

  • Develop triggers for CCU / telemetry floor nurses to identify patients for CRUSADE

  • Screen all patients with elevated cardiac marker levels from local laboratory records

Patient identification strategies screening after discharge
Patient Identification StrategiesScreening After Discharge

  • Review discharge diagnoses for chest pain

    • Unstable angina, chest pain, R/O MI, or acute MI

    • New ICD-9 codes for acute MI: + TnT/TnI

  • Review all patients with elevated cardiac marker levels from local laboratory records

  • Pull charts after identification of patients to fill out items on the data collection form

Quality improvement initiatives
Quality Improvement Initiatives:

  • Regional educational meetings

    • ACC/AHA Guidelines recommendations

    • Review CRUSADE and QI Initiatives

  • Site Survey

    • Understand site beliefs and practice environment

  • Educational / QI materials

    • ED Risk Stratification Algorithm/ Sample orders

    • Guidelines Posters/pocket cards

    • Discharge MD and patient check lists

  • Quarterly Feedback Reports

Quality improvement initiatives hospital survey component
Quality Improvement Initiatives:Hospital Survey Component

  • Baseline understanding of and concurrence with AHA/ACC NSTE ACS treatment guidelines

    • Is it an education versus adherence issue?

  • Identify local features which may serve to promote quality improvement initiatives

    • Survey “structure and culture” of institution

    • Do institutional characteristics predict improved adherence to guidelines-based care?

Quality improvement initiatives data reporting to sites
Quality Improvement Initiatives:Data Reporting to Sites

  • Quarterly feedback reports to sites regarding their adherence to ACC/AHA treatment guidelines

    • Focused on AHA/ACC Guidelines treatments

    • Site confidentiality maintained - data supplied back to sites in a secure fashion

    • Provides sites with benchmark performance data

Sample quarterly report gp iib iia inhibitor use in first 24 hours
Sample Quarterly Report:GP IIb/IIa Inhibitor Use in First 24 Hours

Site participants and responsibilities
Site Participants and Responsibilities

  • Emergency Medicine and Cardiology Co-Advocates

    • Develop strategies to identify high-risk NSTE ACS patients early during hospitalization

    • Implement QI tools to promote ACC/AHA Guidelines

  • QI nurse or research coordinator

    • Completion of case report forms

    • Assist in local educational/QI efforts to increase adherence to ACC/AHA Guidelines

Promoting a new paradigm of evidence based cardiovascular care
Promoting a New Paradigm of Evidence-Based Cardiovascular Care

  • The CRUSADE national quality improvement initiative will teach us much about:

    • Why current ACC/AHA treatment guidelines for ACS are not followed

    • What initiatives can improve adherence

    • How to promote EM-Cardiology collaboration

    • Will improved early adherence to treatment guidelines lead to better acute outcomes?