Transcript Getting to know the Acute Myocardial Infarction (AMI) Core Measures

Developed by: Kathy Wonderly RN, BSPA, CPHQ
Performance Improvement Coordinator
Developed:
October 2009
Most recent update: November 2013
 For
the first time, there are significant
differences in the requirements for Centers
for Medicare and Medicaid Services (CMS)
and The Joint Commission (TJC) AMI measure
set requirements.
 CMS only has two indicator in their measure
set while TJC requires seven measures.
 Please follow your hospital plan of care for
the AMI patient.
 To
know the value of administering aspirin
at arrival for patients with an AMI.
 To be able to identify the recommended
timeframe for fibrinolytic therapy and
primary PCI for qualifying AMI patients.
 Note:
changes for January 1, 2014 through
September 30, 2014 are in italics.

For TJC hospitals there are 7 required
indicators in the AMI measure set.
 For
hospitals only submitting data to CMS,
the last two measure sets apply however the
last measure applies to those facilities that
can provide primary coronary intervention
(primary angioplasty) on site for the AMI
patient.

Patients discharge to Hospice whether with home care or
to another facility for hospice care are excluded from the
requirements for this measure set.
 We
will cover the measures that are reported
to both agencies in the beginning of this
presentation then move to the Joint
Commission only measures.
The national guidelines recommend that
fibrionolytic therapy be given within 30 minutes of
hospital arrival for patients with ST-elevation or
Left Bundle Branch Block myocardial infraction.
 Research shows that nearly 2 lives per 1000 patients
are lost per hour of delay (Fibrinolytic Therapy,
1994).
 Remember the time of arrival is the very first time
documented on the medical record it could be the
triage time, first note, vitals document time or
registration time.

 Patients
who did not receive fibrinolytic
therapy within 30 minutes and have a
documented Reason for Delay of
Fibrinolytic Therapy will be excluded
from this measure.
CMS
understands this may not be
possible in the case of a transfer from
another facility so those patients are
excluded from this indicator. That
said, it is still very important to start
fibrinolytic therapy as soon as possible
after the transferred patient arrives.
These drugs include:

Abbokinase

Activase
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Alteplase
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Anistreplase
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Anisoylated Plasminogen-Streptokinase Activator Complex
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APSAC
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Eminase
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Kabikinase
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Retavase
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Reteplase
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rPA (RPA)
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Streptase

Streptokinase

Tenecteplase

Tissue plasminogen activator

TNKase

tPA (TPA)
Specifications Manual for National Hospital Inpatient
Quality Measures Discharges
01-01-14(1Q14) through 9-30-14 (3Q14) Appendix C
 To
meet this recommendation, the ED staff and
ancillary services must work together and make
the AMI patient a top priority. The nurse and
practitioner must assess the patient, the EKG
must be done, the necessary lab tests drawn and
IV lines established before the fibrinolytic
therapy is started.
 There is usually a consultation with a cardiologist
either live, via phone or using telemedicine.
 Respiratory therapy may also play a role in this
patients care.
Understandably,
this measure is a
challenge for all hospitals to meet.
The nurse assigned to the AMI
patient must coordinate the care
to assure that anyone with a ST
segment elevation or LBBB on the
EKG gets the ordered therapy
within the 30 minute window.
 If
a patient does not receive the fibrinolytic
therapy within 30 minutes because of one of
the following reason; social or religious
issues, initial concern or refusal by the
patient or family, cardiopulmonary arrest,
balloon pump insertion or respiratory failure
requiring intubation and the physician, PA or
CRNP documents the reasons the indicator is
met.
 The
next indicator for the AMI core measure
set focuses on the time from hospital arrival
to primary PCI for patients who present with
ST-segment elevation or LBBB.
 The
early use of primary angioplasty for
patients with ST-segment MI (STEMI) has
resulted in a significant reduction in
mortality and morbidity. CMS has determined
the prompt initiation of PCI for the
qualifying AMI patients is 90 minutes or less.
Patients
who did not receive PCI
within 90 minutes and have a
documented Reason for Delay of
PCI will be excluded from this
measure.
 CMS
understands this may not be possible in
the case of a transfer from another facility
so those patients are excluded from this
indicator. It is still very important to do the
primary angioplasty as soon as possible
after the transferred patient arrives.
 As
with the administration of the fibrinolytic
therapy, getting the patient from arrival to
primary PCI within 90 minutes requires very
exact coordination between all members of the
team. The ED and Cath Lab/OR must have good
coordination and all the necessary ancillary
staff must work together to be sure the patient
gets the most timely and safe care possible.
 The
data collected for these measures start with
the arrival time (the first time documented in
the medical record which could be registration
time, triage time or the first note in the medical
record) and the time the fibrinolytic therapy is
started.
 This data is compiled and the public report
includes the median (the point where half of the
cases fall below and half above) time for each
facility.
A
recent CMS study reports the following results
correlating with the National campaigns—the
CMS' Hospital Compare, the American College of
Cardiology's D2B Alliance and the American Heart
Association's Mission: Lifeline demonstrate that
in 2010 90% of patients received the procedure
within 90 minutes compared to 50% in 2005.
 This
represents a median decrease of 32minutes from 2005 to 2010 in the time from
hospital admission to angioplasty. That is a
decrease from 96 minutes to 64 minutes.

Reference: ModernHealthcare.com August 23,2011

Please note: Many hospitals comply with the
Joint Commission AMI measure set in total
even though they are not TJC accredited.

You will need to become familiar with and
follow the plan of care for the AMI patient as
approved by your facility.
 It
has been well documented that the early use
of aspirin (ASA) in patients with an AMI results in
a significant reduction in adverse events and
mortality.
 To meet this indicator the patient must have
received ASA within 24 hours before or after
arrival.
 This information can be obtained from the
patient history, EMT (ambulance) record or the
MAR.

While the drug Aggrenox contains
aspirin, the amount is sub-therapeutic
therefore does not meet the criteria for
either of the aspirin measures for a
patient diagnosed with an AMI.
 Studies
have demonstrated that long term aspirin
therapy for patients who have suffered an AMI
can reduce the risk of a future adverse event or
mortality by 20%.
 This core measure requires that AMI patients are
prescribed ASA when discharged.
 The practitioner must make the decision
regarding the discharge medications but nursing
and case management reminders as well as the
use pre-printed discharge instruction guides can
improve compliance.
 If
the patient has a contraindication to taking
ASA, such as a true allergy or recent GI
bleed, this reason must be clearly
documented in the medical record.
 Any
patient with documented left ventricular
systolic dysfunction (LVSD) should have an ACEI or
ARB prescribed at discharge.
 LVSD is defined as a left ventricular ejection
fraction of less than 40% or a narrative
description of moderate or severe systolic
dysfunction by the practitioner.
 This indicator appears in both the AMI and CHF
core measure sets.
 While
the practitioner is responsible for
ordering medications, nurses should remind
him/her that the patient has LVSD especially if
it was in found on a recent echocardiogram.
 As
with all other medication requirements, if
the patient cannot take an ACEI or ARB, the
reason must clearly be documented in the
medical record.
ALLERGY
to ACEI
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Accupril
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Accuretic
Fosinopril
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Aceon
Fosinopril Sodium/hydrochlorothiazode
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Altace
Lisinopril
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Benazepril
Lisinopril/hydrochlorothiazide
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Benazepril Hydrochloride
Lotensin
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Benazepril/amlodipine
Lotensin HCT
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Benazepril/hydrochlorothiazide
Lotrel
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Capoten
Mavik
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Capozide
Moexipril
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Captopril
Moexipril Hydrochloride
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Captopril HCT
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Captopril/hydrochlorothiazide
Moexipril/hydrochlorothiazide
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Enalapril
Monopril
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Enalapril Maleate/hydrochlorothiazide
Perindopril
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Enalapril/hydrochlorothiazide
Perindopril Erbumine
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Enalaprilat
Moexipril Hydrochloride/hydrochlorothiazide
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Prinivil
Prinzide
Quinapril
Quinapril HCL
Quinapril HCL/HCT
Quinapril Hydrochloride/hydrochlorothiazide
Quinapril/hydrochlorothiazide
Quinaretic
Ramipril
Tarka
Trandolapril
Trandolapril/verapamil
Trandolapril/verapamil hydrochloride
Uniretic
Univasc
Vaseretic
Vasotec
Zestoretic
Zestril
Specifications Manual for National Hospital Inpatient
Quality Measures Discharges 01-01-14(1Q14) through
9-30-13 (3Q14) Appendix C
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Atacand
Atacand HCT
Avalide
Avapro
Azilsartan
Azor
Benicar
Benicar HCT
Candesartan
Candesartan/hydrochlorothiazide
Cozarr
Diovan
Diovan HCT
Edarbi
Eprosartan
Eprosartan/hydrochlorothiazide
Exforge
Hyzaar
Irbesartan
Irbesartan/hydrochlorothiazide
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Losartan
Valsartan
Losartan/hydrochlorothiazide
Valsartan/amlodipine
Micardis
Valsartan/hydrochlorothiazide
Micardis HCT
Valtuma
Olmesartan
Verdia
Olmesartan/amlodipine
Olmesartan/amlodipine/hydrochlorothiazide
Olmesartan Medoxomil
Olmesartan Medoxomil/amlodipine
Olmesartan/hydrochlorothiazide
Tasosartan
Telmisartan
Telmisartan/amlodipine
Telmisartan/hydrochlorothiazide
Teveten
Teveten HCT
Specifications Manual for National Hospital Inpatient
Tribenzor
Quality Measures Discharges 01-01-14(1Q14)
Twynsta
through 9-30-14 (3Q14) Appendix C
 The
Smoking Cessation indicator has been
retired from the AMI measure set starting
January 1, 2012. CMS feels this should occur
for all patients and are considering this as a
global measure set for future use.
 That said, each hospital will need to
determine how they will address this change.
 If your facility chooses to continue to offer
smoking cessation the requirements are on
the next slide.
 Any
patient admitted who is a current
smoker or has smoked within the past 12
months should be offered smoking cessation
advice/counseling.
 It is the patient’s right to refuses such advice
or counseling. Such a refusal must be
documented in the medical record.
 This is a nursing driven measure.
 This
is another practitioner driven indicator.
 The long-term use of a beta-blocker for
patients who have suffered an AMI can reduce
mortality and morbidity by about 20%.
 The national guidelines from the American
College of Cardiology/American Heart
Association Task Force strongly recommend
long-term beta blocker therapy for the
secondary prevention of cardiovascular events
in patients discharged after an AMI. (Antman, 2004 &
2008, Anderson, 2007 and Smith, 2011).
 Despite
the strong recommendations, betablockers remain under-utilized in eligible older
patients discharged after suffering an AMI.
 As with the other medication measures, if beta
blockers are not ordered at discharge the
practitioner must document a clinical valid
reason for the decision.
 There are many drugs that are classified as betablockers.
 The next slides contain a list of these approved
beta-blockers.

Acebutolol
Atenolol
Atenolol/chlorthalidone
Betapace
Betapace AF
Betaxolol
Bisoprolol
Bisoprolol/fumarate
Bisoprolol/hydrochlorothiazide
Brevibloc
Bystolic
Carvedilol
Coreg
Corgard
Corzide 40/5
Corzide 80/5 c
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Esmolol
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Inderal
Inderal LA
Inderide
Inderide LA
InnoPran XL
Labetalol
Levatol
Lopressor
Lopressor HCT
Lopressor/hydrochlorothiazide
Metoprolol
Metoprolol/hydrochlorothiazide
Metoprolol Tartrate/hydrochlorothiazide
Nadolol
Nadolol/bendroflumethiazide
Nebivolol
Nebivolol HCL
Nebivolol Hydrochloride
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Penbutolol
Pindolol
Propranolol
Propranolol HCL
Propranolol Hydrochloride
Propranolol/hydrochlorothiazide
Sectral
Sorine
Sotalol
Sotalol HCL
Tenoretic
Tenormin
Tenormin I.V.
Timolol
Toprol
Toprol-XL
Trandate
Trandale HCL
Visken
Zebeta
Ziac
Specifications Manual for National Hospital Inpatient Quality
Measures Discharges 01-01-14(1Q14) through 9-31-14 (3Q14) Appendix C
 This
measure requires that a statin
medication be prescribed at the time of
hospital discharge.
 Patients
with LDL less than 100mg/dL within
the first 24 hours after hospital arrival or 30
days prior to arrival are excluded from this
indicator.
 Research
shows that the use of these drugs
for AMI patients reduced the risk of death
and recurrent cardiovascular events.
 If
a statin is not ordered at discharge, the
practitioner must document the reason for
not ordering one.
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Advicor
Lovastatin/niacin
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Altoprev
Mevacor
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Atorvastatin
Pitavastatin
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Atorvastatin/amlodipine
Pravastatin
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Caduet
Rosuvastatin
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Crestor
Simcor
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Fluvastatin
Simvastatin
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Fluvastatin XL
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Juvisync
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Lescol
Vytorin
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Lescol XL
Zocor
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Lipitor
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Livalo
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Lovastatin
Simvastatin/ezetimibe
Simvastatin/ niacin
Specifications Manual for National Hospital Inpatient Quality Measures Discharges
01-01-13(1Q13) through 12-31-13 (4Q12) Appendix C
 While
there have been many improvements
in the care of the patient with an AMI, the
American Heart Association reports that
approximately 800,000 patients suffer an AMI
annually. Of these 20% (160,000) are STEMI
and should follow these AMI recommended
measures.
1. To reduce the risk of mortality the
recommended time from hospital arrival to the
administration of a fibrinolytic medication is
___________ minutes.
A. 15
B. 30
C. 60
2. The recommended time from hospital arrival
to primary angioplasty is within 90 minutes.
A. True
B. False
3. Aspirin given by the paramedic and
documented prior to arrival at the hospital
does not meet the CMS requirement ASA on
arrival for a patient with an AMI.
A. True
B. False
4. If the patient is allergic to aspirin and the
practitioner documents this allergy in the
medical record the measure is met.
A. True
B. False

Fibrinolytic Thearpy Trialists’ Collaborative Group.
Indications for fibrinolytic therapy in suspected AMI:
collaborative overview of early mortality and major
morbidity results form all randomized trials of more than
1000 patients. Lancet. 1994;343:311-22.