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Acute Myocardial Infarction. Committee Membership : K. McLean, MD, M. Jarotkiewicz MBA, Administrative Director Cardiovascular Service Line, Mary Morrow, APRN, Barbara Majcher, APRN, Cynthia Mulhall, APRN, Nursing Staff of 3NEWS, CCU, 3 ITV and Emergency Room, Cardiac Cath Lab,
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Acute Myocardial Infarction Committee Membership: K. McLean, MD, M. Jarotkiewicz MBA, Administrative Director Cardiovascular Service Line, Mary Morrow, APRN, Barbara Majcher, APRN, Cynthia Mulhall, APRN, Nursing Staff of 3NEWS, CCU, 3 ITV and Emergency Room, Cardiac Cath Lab, Medical Records Department, Center for Clinical Effectiveness.
Process for Evaluation Since July 2002 Loyola University Medical Center (LUMC) has been extracting data on AMI Patients for the National Hospital Quality Measures (NHQM) / Core Measures. These measures are based on guidelines established by the American Heart Association and the American College of Cardiology for management of patients with coronary heart disease and AMI. To help with this process the AMI Discharge ProgressNote Addendumwas designed to help physician and nurses key into the areas that needed to be addressed before discharge.
Opportunity for Improvement Review of AMI NHQM data has shown that LUMC is at or better than the University HealthSystem Consortium (UHC) and national rates for most AMI measures. LUMC mortality was below national averages but above expected, according to the Joint Commission on Accreditation of Healthcare Organizations’ (JCAHO) risk adjustment methodology.
Most Likely Causes for the Improvement Opportunity Cases may have been inappropriately included in measure set, which is based on the priority of diagnoses that are determined after discharge Opportunities existed for additional physician involvement during the post-admission coding of diagnoses JCAHO risk adjustment methodology may not fully appreciate the typically complex LUMC patient population
Solutions Implemented AMI NHQM Committee meets monthly to review and to discuss mortality cases in order to understand and improve AMI care Following patient discharge, all AMI charts are co-reviewed by a cardiac case manager and medical records coding team for appropriate inclusion in the measure set based on priority of diagnoses. Physician review is included when a conclusion is not clear. To understand the effectiveness of the JCAHO risk-adjustment, NHQM AMI cases were analyzed using the APR-DRG (All patient refined diagnosis related group) risk adjustment methodology through UHC. APR-DRG is trusted way to risk-adjust complex patient cases to determine risk of mortality.
Acute Myocardial Infarction Inpatient Mortality 20% 18% Initiation of case manager and physician review LUMC Observed Rate LUMC Expected Rate 16% National Mean Rate 14% 12% Mortality 10% 8% 6% 4% 2% 0% 2002 Q2 (n=50) 2002 Q3 (n=71) 2003 Q1 (n=79) 2003 Q2 (n=69) 2003 Q3 (n=69) 2003 Q4 (n=79) 2004 Q1 (n=83) 2004 Q2 (n=67) 2004 Q3 (n=67) 2004 Q4 (n=74) 2005 Q1 (n=85) 2005 Q2 (n=60) 2005 Q3 (n=47) 2005 Q4 (n=55)
Outcomes Observed mortality has returned to JCAHO’s expected levels in the most recent quarter. This appears to be due to improved processes to ensure that cases are appropriately included in this measures. Mortality analysis using APR-DRG risk adjustment showed a below expected mortality rate. This is due to differences between the JCAHO and APR-DRG risk-adjustment models.
Next Steps The NHQM AMI committee will continue meeting on a monthly basis to address additional opportunities for improving the care of the MI patient at Loyola. Perform case level review at monthly NHQM AMI committee meeting. Notify JCAHO of additional diagnoses and co-morbidities absent from the JCAHO risk-adjustment formula which can influence mortality risk.
