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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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Presentation Transcript

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
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?