HeartBeat

Age standardised CHD mortality rates per 100,000 for Males and Femalesin Ireland and EU-15(Source WHO HFA database)Male Female EU-15 Male EU-15 Female450Age standardised mortality per100,0004003503002502001501005001969 1974 1979 1984 1989 1994 1999 2004Year

Snapshot picture…………..INDICATORAspirin onadmissionAspirin ondischargeBeta-blocker ondischargeEuroHeartEUROASPIRESurvey (2002) CCU 2003 1 111, 2006 (Irish data) 293% 85%88.1% 81% 99%75.2% 66% 84%Thrombolysis55.8%

HeartBeat ProgrammeAIMTo save lives from Acute Myocardial Infarction (AMI) byimplementing and assuring best practice - using the IHImethodologyOBJECTIVESTo help hospitals– increase % patients receiving the 8 evidenced basedcomponents of AMI care (unless unless contraindicated )– reduce in-hospital mortalityFOCUS– Information– Techniques in managing change

Initiative included :• Structure– Steering Group, Core team, 5 hosps to start,Agreement with IHF, ICS, ISQSH• Process– Clarifying objective, gelling of core team, consideringbarriers and their solutions– Irish ‘Kit, Data set and collection– Feedback (Academic involvement , confidentiality)– Getting ready Invited Dr N Devaney, IHI Fellowin Belfast to discuss approach.– Hospital visits to all 5 hospitals• Outcome

AMI Care : Key Components ofEvidenced Based CarePre-hospital/Admission1. Early aspirin2. Early beta-blocker3. Timely initiation ofreperfusion(thrombolysis or primaryPCI)On Discharge4. Aspirin5. Beta-blocker6. ACE-inhibitor orARB for patients withsystolic dysfunction7. Smoking cessationcounselling8. Lipid lowering agent

HeartBeat BulletinCare on admission (% eligible received)Oct 06 – Sept 09 (3 years)1008097.50 100.00 100.0094.5080.0072.8587.506050.004036.84200AspirinAll Hosp N=680Beta blocker (BB)All Hosp N=599Timely reperfusionAll Hosp N=523Lowest Average (All Hospitals) Highest

HeartBeat BulletinCare on discharge (% eligible received)Oct 06 – Sept 09 (3 years)%100908070605040302010098.0 100 97.1 10010092.394.5 95.8 100 97.2 10090.981.875.066.7AspirinAll HospN=571BBAll HospN=553ACEI/ARBAll HospN=521Smoke cessAll HospN=220LLDAll HospN=566Lowest Average (All Hospitals) Highest

Three monthly trend in % eligible patientsreceiving timely reperfusion

HeartBeat% Thrombolysed

Annual in-hospital mortality (STEMI)for the first 3 years of HeartbeatYear Deaths Death rate(95% Conf Intervals)Year 1(Oct 06-Sept 07)Year 2(Oct 07-Sept 08)Year 3(Oct 08-Sept 09)24(193 patients)15(205 patients)12(223 patients)12.44%(10.9 - 14)7.32%(6.4 - 8.2)5.38%(4.7 – 6.05)

What changed within Hospitals?• Speedier communication– between ED and Medical/cardiology SpR– between Cath Lab and ED• Promoted action– Consultant in ED studied data and discussed withcolleagues– Audit showed contributing factors in each step of thecare pathway in 1 hosp– Inclusion of HeartBeat in regular meetings• Education of SpRs and protocols adjusted• OtherwiseSynchronising ED clocks!

IndicatorHeartBeat36 monthsOct 2006 -Sept 2009MINAP-EnglandApr 2008 –Mar 2009Improving USHospitalsJan – Dec 2007Early ASA 97.5% NA 97.4%Early Beta Blockers 94.5% NA 94.7%TimelyReperfusionThrom 75.9%PPCI 70.2%Throm 83%PPCI 84%Throm 51%PPCI 72.3%ASA on discharge 98.0% 98% 97.2%Beta Blockers ondischarge97.1% 93% 97.2%ACEI/ARB for LVF 94.5% 92% 91.5%Smoke cess. advice 95.8% NA 98.2%Lipid loweringmeds97.2% 97% 96%

Summary points• AMI death rates are dropping but Ireland could dobetterbetter - evidence is that improved process of care couldsave even more lives• We have initiated a quality improvementprogramme– We are clear on care carried out to high degree in these hospitals– Timely reperfusion has improved since inception of Heartbeat– In-hospital mortality has improved• Issues now involve– expansion of programme to all hospitals (and to NSTEMI)– addressing primary PCI, pre-hospital triage and thrombolysis– Addressing patient delay in seeking help

Questions/comments/observations• Challenge of set-up, buy-in• Hosp.variation – in interest, commitment• Sustainability and growth factors??– Corporate– At hospital level– ACS programme– IT environment– Spreading change management experience

HeartBeatImproving Heart Attack Care inIreland(Case study 2)Dr Siobhan Jennings,Consultant in Public Health Medicine

Age standardised CHD mortality rates per 100,000 for Males and Femalesin Ireland and EU-15(Source WHO HFA database)Male Female EU-15 Male EU-15 Female450Age standardised mortality per100,0004003503002502001501005001969 1974 1979 1984 1989 1994 1999 2004Year

Snapshot picture…………..INDICATOREuroHeartSurvey (2002)CCU 2003 1EUROASPIRE111, 2006 (Irish data) 2Aspirin onadmission93%85%Aspirin ondischarge88.1%81%99%Beta-blocker ondischarge75.2%66%84%Thrombolysis55.8%

HeartBeat ProgrammeAIMTo save lives from Acute Myocardial Infarction (AMI) byimplementing and assuring best practice - using the IHImethodologyOBJECTIVESTo help hospitals– increase % patients receiving the 8 evidenced basedcomponents of AMI care (unless contraindicated )– reduce in-hospital mortalityFOCUS– Information– Techniques in managing change

Initiative included :• Structure– Steering Group, Core team, 5 hosps to start,Agreement with IHF, ICS, ISQSH• Process– Clarifying objective, gelling of core team, consideringbarriers and their solutions– Irish ‘Kit, Data set and collection– Feedback (Academic involvement , confidentiality)– Getting ready Invited Dr N Devaney, IHI Fellowin Belfast to discuss approach.– Hospital visits to all 5 hospitals• Outcome

AMI Care : Key Components ofEvidenced Based CarePre-hospital/Admission1. Early aspirin2. Early beta-blocker3. Timely initiation ofreperfusion(thrombolysis or primaryPCI)On Discharge4. Aspirin5. Beta-blocker6. ACE-inhibitor orARB for patients withsystolic dysfunction7. Smoking cessationcounselling8. Lipid lowering agent

HeartBeat BulletinCare on admission (% eligible received)Oct 06 – Sept 09 (3 years)1008097.50 100.00 100.0094.5080.0072.8587.506050.004036.84200AspirinAll Hosp N=680Beta blocker (BB)All Hosp N=599Timely reperfusionAll Hosp N=523Lowest Average (All Hospitals) Highest

HeartBeat BulletinCare on discharge (% eligible received)Oct 06 – Sept 09 (3 years)%100908070605040302010098.0 100 97.1 10010092.394.5 95.8 100 97.2 10090.981.875.066.7AspirinAll HospN=571BBAll HospN=553ACEI/ARBAll HospN=521Smoke cessAll HospN=220LLDAll HospN=566Lowest Average (All Hospitals) Highest

Three monthly trend in % eligible patientsreceiving timely reperfusion

What changed within Hospitals?• Speedier communication– between ED and Medical/cardiology SpR– between Cath Lab and ED• Promoted action– Consultant in ED studied data and discussed withcolleagues– Audit showed contributing factors in each step of thecare pathway in 1 hosp– Inclusion of HeartBeat in regular meetings• Education of SpRs and protocols adjusted• OtherwiseSynchronising ED clocks!

IndicatorHeartBeat36 monthsOct 2006 -Sept 2009MINAP-EnglandApr 2008 –Mar 2009Improving USHospitalsJan – Dec 2007Early ASA 97.5% NA 97.4%Early Beta Blockers 94.5% NA 94.7%TimelyReperfusionThrom 75.9%PPCI 70.2%Throm 83%PPCI 84%Throm 51%PPCI 72.3%ASA on discharge 98.0% 98% 97.2%Beta Blockers ondischarge97.1% 93% 97.2%ACEI/ARB for LVF 94.5% 92% 91.5%Smoke cess. advice 95.8% NA 98.2%Lipid loweringmeds97.2% 97% 96%

Summary points• AMI death rates are dropping but Ireland could dobetterbetter - evidence is that improved process of care couldsave even more lives• We have initiated a quality improvementprogramme– We are clear on care carried out to high degree in these hospitals– Timely reperfusion has improved since inception of Heartbeat– In-hospital mortality has improved• Issues now involve– expansion of programme to all hospitals (and to NSTEMI)– addressing primary PCI, pre-hospital triage and thrombolysis– Addressing patient delay in seeking help

Questions/comments/observations• Challenge of set-up, buy-in• Hosp.variation – in interest, commitment• Sustainability and growth factors??– Corporate– At hospital level– ACS programme– IT environment– Spreading change management experience