GWTG- CAD Transcript

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Darlene Carney: That's devotion.

Loni: That is.

Darlene Carney: Is there a website that we should be on or anything like that?

Loni: No. So if you preregistered for the discussion then you would have received the materials ahead of time. Primarily, what we're going to focus on is the recognition and how to get to recognition -

Darlene Carney: I didn't get anything.

Loni: Oh, you didn't? Okay. So, who's speaking?

Darlene Carney: This is Darlene Carney from Conrow.

Speaker 3: It should be in your ... You should have gotten an email, Darlene. I got one.

Darlene Carney: I didn't get an email.

Speaker 3: I got one.

Darlene Carney: I didn't get anything.

Speaker 4: I didn't get anything either.

Loni: No? Okay, if you send ... Larissa, are you on?

Larissa: Yes, I'm on. It depends on when they registered, when they got the email. So if you registered a little late you probably didn't receive it. If you could email me at larissa.deluna@heart, I could forward you that.

Darlene Carney: Okay. Can you say that again?

Larissa: Larissa L-A-R-I-S-S-A.

Darlene Carney: L-A-R-R-I-S-S-A?

Larissa: One R.

Darlene Carney: Oh, one R?

Cybil: Darlene, I just ... Darlene, this is Cybil, I just ... I forwarded it to you.

Darlene Carney: Oh, okay thanks.

Loni: Okay. And there was somebody else on the line who didn't receive the information. Okay, I thought there was more than one of you.

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So we'll be focusing on recognition. The only thing that you might want to have in front of you is the recognition criteria. Other than that, it's just open forum time. So before we get started talking about the specifics of recognition, is there anything that anyone wants to talk about in particular on today's call? Any burning questions?

Speaker 4: I have a question.

Loni: Uh-huh?

Speaker 4: Has there been any indication of how soon they think that the CAD tool may be expanded or, I guess, maybe deviating from actions tools?

Loni: So, I think what you're referring to is the addition of all of the Chest Pain Center Accreditation fields, or data elements, that you would need for Version 6 or Cycle 6 Chest Pain Center Accreditation. Is that what you're referring to?

Speaker 4: Well actually, I know that with our Chest Pain Center Accreditation, we're going through the ACC accreditations, and they're able to pull all that information except like your low-risk population and all that. But I'm just wondering if ... Which elements may become further developed in the CAD tool that is not currently captured in Action. Meaning, for example, like your risk for sudden cardiac death, your low-risk chest pain, your hypothermia protocols. Is there any other kinds of questions that are going to be added to the tool to deviate further from Actions, to make it its own separate, more distinguished type registry, as opposed to just basically copying a lot of the Action element?

Loni: Yeah, so we ... The build out, we're anticipating it is scheduled for February or March. The addition of low-risk elements and your chest pain elements. Now you can enter a lot of that into the tool, but we're going to have all of those elements that are currently in the ACD tool, if you're participating in that, so that you have everything in one place. You'll have all of your NSTEMI, your non-STEMI, and all the things that you need for your Chest Pain Center accreditation in the guidelines CAD tool. So what we're hoping to do, is to make it easier for hospitals to just house everything in one place and not have to have everything in multiple locations. And we do have, in our contract with the ACC, that get with the coronary artery disease data is accepted for the Chest Pain Center accreditation. So our IT team is working with ACC staff to make sure that we have all of the data elements that are needed for Version 6.

So a way that I think your question is as well is like when is that gonna happen? The schedule is for February/March timeline and that's if everything goes as planned.

Speaker 4: Okay. And will be begin to get snippets or updates to see it before it rolls out likely, or do you think it'll like we'll just discover what's in there?

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Loni: No, I think we'll have an opportunity to take a look at the elements that are in there. We've already been provided with just kind of a pre-look and I'm not able to show that out yet. But I know that if they're working on the build out, they'll provide information so that we can give our partners a heads up so you can see what you're going to need to start collecting before it actually goes live.

Speaker 4: Okay, thank you.

Loni: You're welcome.

Speaker 3: This may be a little off subject a little bit, but yesterday is when I submitted our application at Kingwood for the AHACAD, and I didn't have the actual member of hospital beds. I put 368 and we're actually 373. Is there a way that I can correct that or does that really matter?

Loni: I think you're close enough. You're only five patients off, but you're close enough with the number that you provided.

Speaker 3: Okay.

Loni: Thanks for submitting that. You got it in under the wire. If there's anyone else on the line that submitted their enrollment -

Larissa: Yes.

Loni: - or missed the deadline and plan to within the next two weeks.

Did I hear somebody say yes, you're in that situation too?

Larissa: No, I submitted mine yesterday.

Loni: Okay.

Larissa: Oh, and this is Conrow.

Loni: Conrow, okay. So I'm just gonna send a note over to make sure ... our leadership heads up a bit. So Kingwood and Conrow, so you guys just ... For those hospitals that are kinda close to the deadline, we wanna make sure you will receive that, the discount next year.

Cybil: My hospital hasn't made a decision yet. If they make it in the next week, would we still be eligible for the discount or not?

Loni: If it's underway, like if you're in discussion with your administration and they're working, if we can say that you're working on the enrollment form, I'll submit your hospital name as well so that if it comes through by the fifteenth, you know that you would still be eligible.

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Cybil: Okay.

Loni: Which hospital?

Cybil: Texas Health Arlington Memorial.

Loni: Okay. Alright, I'll add you to the list.

Cybil: There's a discussion going on between corporate and the individual hospitals on who's gonna do what. You know that takes an act of Congress, right?

Loni: Yes, it does.

Cybil: See, everyone goes, "Yes!"

Loni: Okay, I'll add you. I'll add you to the list. Very good. Any other enrollment questions or ... module questions?

Okay, we, in the future, hope to highlight some best practices on the call, so if you're a facility who has been recognized in the past, do you wanna just kinda highlight how you made a specific measure. We want for you to be able to share that information and for us to all learn from one another, so let us know if that's something you'd be interested in doing on this call. Moving forward, we hoped to have somebody talk about how they took one of those hard recognition measures and was able to meet it at their facility and the steps they took to make that happen. So just keep that in mind. People are making it into the recognition criteria, did wanna mention that scientific session is in two weeks and we do ... we are still accepting RSVPs. If you were recognized in 2017 for Mission Lifeline, and you want to attend sessions and you want to go to the awards ceremony, please let us know so we can get you on the list. It's in Anaheim, California and we have a really, really lovely recognition event for our hospitals. It's complimentary if you can get out there, forward it, it's a really fun evening where we can just celebrate your quality work with you.

So keep that in mind for next year as well. We do it every year. So what ...

Speaker 3: You said it's in Anaheim what date?

Loni: It is. The recognition ceremony is on the fourteenth. It's on a Monday evening.

Speaker 3: January?

Loni: Or thirteenth. No, in November.

Speaker 3: Oh, November. Sorry.

Loni: Yeah, this month. So it's in only, I think, ten days or eleven days or so, but we do that every year for our hospitals that are recognized and it's just a really nice

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opportunity for you to celebrate your achievement. If you're still able to go even though it's late notice, we'll work to get you on the list for the ceremony. This year is supposed to, they're doing a nursing track as well, so I'm excited about that.

Okay, let's hop into recognition. So it sounds like everybody on the line is a receiving facility. Is that right? Do we have any STEMI referring hospitals?

Cybil: Well, my circumstances are a little different. I have the ... heart and vascular hospital is actually inside my hospital.

Loni: Okay.

Cybil: So they actually come into my ER, but they're transferred to the heart and vascular hospital. So even though it's in the same building, I would not be considered a receiving facility.

Loni: Okay.

Cybil: It's crazy.

Loni: No, we have a number of facilities that are in that exact same situation. So for you, your recognition criteria would be different and we wanna make sure that we're evaluating your performance on referring center metrics. So I just want to make sure ... We'll touch on that then, referring center metrics.

So for those of you, I think you all have been involved with Mission:Lifeline in the past. Is there anyone who is not involved with Mission:Lifeline?

Okay. So you know how it works. We, at American Heart Association, we have all the guidelines and the science and we are very laser focused on helping hospitals implement the guidelines in their facilities, and we pull out some of the most, the very essential guideline based practices and those are our recognition criteria. We help hospitals focus on them. The reports that we provide out to you every quarter just pull your recognition out in that report so we can see how you're performing. For, and this is for if you have the documents in front of you, you'll wanna pull out the document that's labeled 2018 Mission:Lifeline Recognition Receiving Criteria, and we'll go over the referring criteria next.

The receiving criteria, we have two different awards programs, a STEMI awards program and an N STEMI recognition program. You can, and I have several hospitals this year this year who got N STEMI recognition without getting STEMI recognition. You can get one without the other or you can get both. So let's go over the STEMI recognition measures first.

The percentage of STEMI patients with door to device time, so door sets your basic door to balloon, unless the ninety minutes for your non transfer patients. And then the really difficult one is that EMS first medical contact to balloon

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within ninety minutes. So it's a little bit confusing, but people ask, "Well, why would both of those be ninety minutes, like why wouldn't door to balloon be sixty or something." You know, we've heard that rumor for many years that door to balloon is gonna be shortened from ninety minutes, it just never happened. So that one remains at ninety minutes because it remains that way in the guidelines. But we do set that goal of EMS from the time that their eye to eye with their patient to balloon to all happen within ninety minutes. And we'll hope that there that is EMS is giving you a heads up. You know that they're on their way, it can help shorten your door to balloon time and I would say that it's very, very difficult to meet that measure unless you're activating your team based on sales calls from EMS.

And then we do have this year something that we're gonna be looking at and we're gonna be adding to the tool is an actual transfer time or not transfer time, but the time that ... From the time that the EMS picks up, you should [inaudible 00:15:40] gets into your facility. If that drive time is prolonged greater than forty five minutes and you're able to get the patient from your door to balloon within thirty minutes or less, that would be something that would be provided an allowance or an exclusion for you.

Darlene Carney: Okay, so you're saying that they'll be using that as an exclusion now?

Loni: Yes, yes, so we are ... So one of the things about Mission:Lifeline, the platform's changing. I bet we can be very nimble with the types of things that we're able to add and things that we're able to manipulate within the tool, and so this one thing that we really wanted for a long time and that's where ... And we have, I think everyone who's on is from Texas, and you know that sometimes those rural patients, they're coming in from EMS that's several counties away and may or may not be an option for whatever their reason. Either they're not available or it's a favorite and they just can't fly, which we have. So if this grand transportation is extended, that time is extended, that you are still getting your team. So you get the heads up, you're getting your team so you can get that patient from door to balloon within thirty minutes. Those patients will no longer fall out of the first medical contact to device measure. We feel like that's a fair exclusion for those patients that are coming from a long way away, but we do have that caveat that then you've got to have them balloon that [inaudible 00:17:37] within thirty minutes.

Darlene Carney: Okay.

Loni: Yep, yeah, that's new this year.

Darlene Carney: That's great.

Loni: I know, we're excited about it.

Okay, the next one is Aspirin within twenty four hours of arrival if EMS is giving the Aspirin you can ... you know, that's something you can take into consideration

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and that patient will fall into the measure room. You want them to have Aspirin at discharge as well. Beta blocker, at discharge and ... There should have been another, online there's another line in between these two but maybe there isn't on yours. I just need one out of mine, the percentages of so many patients that have a high LBL, greater than a hundred, that receiving staff use are lipid medications, that they go home on those. And then we've got patients with LV systolic dysfunction that are on ace and arb at discharge. And percentage of STEMI patients that smoke that get smoking cessation counseling. Then we have a plus measure, so it's not gonna keep you from recognition if you don't need it, but you get kind of like a gold star or an added plus. Recognition if you need it, and that's for your transfer patients and it's for everything happening within a hundred and twenty minutes. So the clark starts at the outlaying hospital door and then unstops when the balloon is up at your facility.

Darlene Carney: Can I ask one question?

Loni: Sure.

Darlene Carney: Since they're American Heart and American Stroke, why is it that the LBL for Stroke is ... They need it on lipid therapy, or anti ... a statant at discharge for their LBL being greater than seventy, but for the heart it's still one hundred. Why is there a difference still?

Loni: Yeah, so it's completely guidelines based. It's what the science writers have written into the guidelines. So it's just based on the different studies for the [inaudible 00:19:58] and on different patient populations and we have new STEMI guidelines that we anticipate probably will be released next year and so, who knows, maybe it'll change and if it does, then we'll follow the new STEMI guidelines and lower it for our STEMI population as well, but it's just a difference in what the science and what has been written into the guidelines for strokes versus STEMI.

Darlene Carney: Okay. Alright, thank you.

Loni: Good question.

And then there's another volume criteria that you need to meet for your STEMI patients. You will need an average of nine per quarter, nine patients per quarter, and that average just means that if you, say you have twelve in one quarter and you dropped to six in the next quarter, that'll all be taken into consideration. So when the date is annualized, you'll just need a thirty six or more in order to have a silver or a gold level achievement. And then we do have those hospitals that weren't recognized, say in 2017 or they're new to the program, and we want to be able to give them a bronze level award if they are able to meet just one quarter of the achievement measures. So they just need nine in that one quarter and they meet all the recognition measures to get recognized. Each individual measure needs to be seventy five percent or greater, and then the composite score of eighty five percent or greater.

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This year we have a really different situation in that registry changes. We weren't anticipating, you were not anticipating, and so we want to make sure that our hospitals that have been recognized previously are able to continue to do so without a disruption or with the least amount of headaches possible. So we are allowing hospitals to, if you get one quarter of data in for this year and the new tool and you meet the criteria, we want to be able to ... for you to continue at your recognition level. So let's say you were gold or silver last year, we want you to be able to continue at that level just by entering one quarter of data and you want an increase in an award level. So let's say you were silver for one year's worth of meeting the measures and you wanna move up to gold, you will want to enter two quarters of data in to get with the guideline CAD for this year and meet the criteria to be eligible to move up to gold.

So any questions about that? And also a little bit confusing, but we are allowing you to continue your award if you just get one quarter's of data worth in and if you wanna move up, we ask that you enter two quarters of data to send in a different year, I'm sure it won't continue to be this year, but we wanted to make that allowance for hospitals that wanna continue to keep their recognition or move up and it's minimal disruption or minimal data entry requirements. We just are asking that you show that you have continued to perform at those higher recognition levels.

Any questions about any recognition? Okay, let's move to NSTEMI. So I'm loving the NSTEMI focus and the measures that we have for NSTEMI. The guidelines are newer and so I think it's, you know, a lot of people feel like, "Okay, we got STEMI down. We're ready to take on a new challenge," and the NSTEMI program, I think, provides an opportunity for hospitals to really focus on NSTEMI and get their staff educated and their docs educated about the guideline based criteria for NSTEMI. We have five that we have pulled out that we feel are most important for your NSTEMI patients in terms of providing better outcome, so cardiac rehab, referral for your NSTEMI patients. Then we have the ace and arb for the LV, folks who have LV less than forty percent, and then dual antiplatelet therapy, which is a really challenging one. It's one that I just came from at GCG conference in Denver and ... there's so much interest in the dual antiplatelet therapy and so many of the docs are really interested in what the guidelines are telling us and what they need to be ordering in order to be in compliance, so this is one that's very difficult for hospitals right now because it's new, but it would feel really essential for that patient to have a good outcome.

So this one, because it is so challenging right now and you have a lot of different docs in your hospital right now aside from cardiologists taking care of these patients that may not be as familiar with the guidelines, this one is, we've set the bar at sixty five percent. And then ... Oh, and for NSTEMI, all the other ones are eighty five percent instead of seventy five percent in STEMI. So eighty five percent on the other four, sixty five for the DAT, the dual antiplatelet therapy measure.

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And then, excuse me, and then we also have the LV that you've evaluated, the systolic dysfunction and ... that it was done during that patient's admission or it's planned for after discharge. And then we have the percentage of NSTEMI patients that put out get caught [inaudible 00:26:16] counseling at discharge.

Speaker 3: Can I ask one thing about the ... Excuse me, can I ask one thing about the ES? Is it okay if they document, say that they have an echo done in the doctor's office or a previous admission, is there ... Like we did with heart failure, as long as it's documented in the record, the last ES, would that be used or did they have to have a new one? Because that's gonna be a learning curve. It's because so many people, we've educated so many people for heart failure that they need to have it documented whether, it didn't matter how long ago, as long as there's an ES document in the record, they didn't have to have a new one.

Loni: Right. I believe that's the case, but I need to double check that one. I'll ... take a look at that.

Speaker 3: Yeah, so many of these patients come back. They may have been in the hospital a week ago and they did the echo then or the cast and now they're back a week ago. It doesn't make sense [crosstalk 00:27:27] that they have to redo it again.

Loni: Exactly, it's an unnecessary expense. I am almost certain there's an allowance for that, but I need to take a look at the data [crosstalk 00:27:41]

Speaker 3: And I have another question, on the cardiac rehab, I know that the guidelines say that they have to have a cardiac rehab referral and note prior to discharge, right. And so I know this is a problem for us, some of these come in on a Friday and our discharge is on a Sunday, so our cardiac rehab department calls them Monday and talks to them about cardiac rehab and tries to sign them up and all that kind of stuff. But right now, that count, that's still a no and they fall out on that because it's supposed to be done prior to discharge.

Loni: So you will wanna look for, do you have in your order set upon discharge that patient go to cardiac rehab and so [crosstalk 00:28:34]

Speaker 3: These two, yes.

Loni: Okay.

Speaker 3: That's on our orders.

Loni: So that's, okay, that's what you need is that the physician is ordering it and that kinda triggers that follow up phone call from your cardiac rehab department, so that's acceptable. That's fine.

Speaker 3: Okay.

Loni: And I will say that the only, that cardiac rehab is the other really challenging ...

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measure and I will say that the only hospitals I've seen meet that measure are the ones that really have that just written right in the order set, so it automatically happens for every patient so it gets discussed. If not the case, somebody's gonna be calling you and following up on Monday or next week to talk to you about cardiac rehab that that is just in that automatic order set. The division can't go any further in. The discharge orders [crosstalk 00:29:26]

Speaker 3: Right, it's in our orders, but the way it is now for the STEMIs is that they're counting that as not counting because it didn't happen prior to them being discharged.

Loni: So that, we do not have cardiac in our STEMI recognition measures for Mission:Lifeline.

Speaker 3: I get that's your CDR. Yeah.

Loni: So what you're referring to, yeah, that's MCDR. And their roles ...

Speaker 3: But for this one you're saying that so long they get at least a phone call, you know, when they're discharged we give them the address, the phone number of our cardiac rehab and tell them that they should get a phone call but if they can't, they can call us. And then cardiac rehab then follows up with them by phone.

Loni: Yep. That's a referral. They're getting the information before they lead your doctor's, checking the box that, yep, you want this patient or she wants this patient to go to cardiac rehab and the intent is there to get that patient in. So they're getting the information and that's fine. That's what you have to do when they're coming in on the weekend and that's fine.

Speaker 3: Yeah, because ... Okay, thank you.

Loni: You're welcome.

Okay, any other ... The volume is the same for NSTEMI, actually you need to have an average of nine STEMI records per quarter and must have at least nine NSTEMI records in the quarter to receive bronze. Same rules apply if you were an NSTEMI award winner last year and you wanna maintain your status, you get one quarter's of data in where you're able to meet the criteria and if you wanna move up, enter two quarters of data. We run all of your 2017 data in the spring for recognition. What's really nice about the new tool is that you can run at any time you want. In the old system, we waited for those Mission:Lifeline reports to drop, those static reports to drop and it was ... You, a long time, sometimes after the quarter. Now, as soon as you grab those patients in, you can enter or you can run these recognition measures and you can see exactly how you're performing and whether you're falling in or out and which record you need to look at to make sure that you know they don't require any edit, so.

Maybe we can focus on that on a subsequent call, how to run those reports or if

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you wanna start doing that now, reach out to your director and myself and we can help you get going on that.

Speaker 4: So you said that the twenty seven ... 2017 data reports are gonna be available in spring of 2018, is that what you said?

Loni: No, that's when we run your recognition, your eligibility for awards, is in the spring. So after you've entered all your 2017 data, we could actually do it on January first. I just know after the, you will know on January first if you're gonna meet the criteria or not because as soon as your patients are entered, you can run those reports, but we'll have an official awards criteria and your data will all be run after the end of the year, so we took the first day in the spring, we'll be able to start letting hospitals know about [crosstalk 00:33:05]

Speaker 3: Okay, are the reports available now?

Loni: They are!

Speaker 3: Okay.

Loni: Yeah, if you're entering patients in, you can run a report as soon as you enter the patients.

Speaker 3: Okay.

Loni: Thirty seconds, five seconds after you enter your patient, you can run this recognition. All the criteria that we just talked about, you can run your report and they'll, you know, if you're falling in or out of each of the measures. Once you get started on the registry, your regional director will say to you, sometimes you get busy and you're not thinking about it and so we want you to have those reports, we will run those for you and send those to you every quarter. But you can run them any time you want. If you want to be looking at them more frequently, if you wanna use the data in more real time. What's nice about this tool is that you can run anything you want and to get into your meetings, so then you're not creating separate reports for your cardiology meetings and such.

Jennifer: This is Jennifer from south. I have a question, when is the data deadline to enter these quarters in if we wanna qualify for spring. Is there an actual date set for when the data needs to be entered or completed by?

Loni: Yeah, so we're ... Because we ... If you're involved in a regional report, let me say this, if you're involved in a regional report where you have in some hospitals in your area all entering data and you wanna run the data at the same time and look at all the hospitals at the same time, it's whatever deadline the region comes up with. So it's flexible in that way, the regions that we want real time data, we want the deadline to be one month after past discharge, then that's what you would follow, but right now we're just kind of loosely following the MCDR data deadline, but honestly with this tool, because we can run reports as soon as the

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patients are entered, we are not following a hard deadline.

If you ... So let's see, Jennifer, if you enter a patient right now in for July or you enter something in for February, there is not that hard data deadline. That patient will still be included in that quarter's data. So unlike MCDR, you know how you enter your patient and you submit it to see whether the patient, you get the the red light, green light, yellow light. But all of that is done in real time as you're entering a patient. So for those of you that have started entering patients, you know your errors as soon as you enter the information. They will start to pop up, if you have an error, it will pop up on your screen. You correct it right then while you've go the chart open. There's not like, "Oh, I have to submit this data and then it's gonna come back to me and it needs to be fixed." You know instantly whether the ... You know the patient's ... There's something that needs to be edited. So it's different in that way.

[crosstalk 00:36:38] So no hard line.

Jennifer: For recognition, in order to be recognized, we have to have it in at what, the beginning of March?

Loni: No, just one. So were you recognized in 2017?

Jennifer: No.

Loni: Okay. So you could receive a bronze recognition level if you get one quarter's worth of data in in 2017 and it doesn't matter which quarter. It's up to you. You could qualify for a bronze level award. If you enter two quarters of data in in 2017, you could qualify for a silver level award and that silver award is for this year only because the two only became available in April or May, so it doesn't matter which quarter, any one quarter within this year where you would meet the criteria, the volume criteria and the measure criteria, and you could become a bronze level award winner.

Steph: And Loni, it's Steph. So for, but the data has to be in the system in order to be analyzed, we're asking for that by the end of February.

Loni: Oh, sorry.

Steph: So 2017 data after that, once we run the file, we only have one opportunity to run the file and have everyone recognized. So if data's entered in April, then we've passed that window and we wouldn't be able to recognize the hospital.

Loni: Right.

Darlene Carney: This is Darlene from Conrow.

Loni: Thank you for that. Uh-huh?

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Darlene Carney: Since we, I know Kingwood and I just signed up yesterday and we do participate in action. We were told that we could upload our data from action into this tool.

Loni: You can.

Darlene Carney: Will we be contacted by somebody to help us get that accomplished now that we've just signed up, so we don't even know how to get into this tool, we have not really gotten like an orientation, I guess.

Loni: Yeah, you will receive [crosstalk 00:39:00]

Allison: I started ...

Loni: Go ahead.

Allison: This is Allison, so I will be your person to contact you.

Darlene Carney: Oh, good! Yay! Hello.

Allison: Yeah, hello. That is wonderful news, I'm so glad to hear you guys signed up.

Darlene Carney: Yes.

Allison: You will get an email from me and from Quintiles and I'll work with you guys on how to get that whole sorted data uploaded from action registry to Quintiles.

Darlene Carney: Okay.

Allison: There's a specific criteria we can give you to get by that.

Darlene Carney: Okay, right.

Speaker 4: So we could get something in the next week or two?

Allison: Yes, I can actually email you over the coding instructions for that and it's something you'll probably wanna work with your IT department on because it does require you to get some specific coding of certain data.

Darlene Carney: Okay.

Allison: Is that right, Loni? Did I say that, right?

Loni: Yeah, so we have the instructions that we can send over to you already and we are doing this as a one time batch upload. So because you signed up when you did ... Actually I think anybody that signs up by, I need to check and make sure, but we're offering that free, one time batch upload of your historical and CDR data, so it could all be just moved over. What you do is put it in a specific file like Allison was saying, your IT department might need to help you to be able to do

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that and you then you send that to Quintiles, which is the data platform, and they will upload it for you into the guideline CAD.

Darlene Carney: Okay.

Loni: So one time batch upload for free of your historical data to make it easier for you to make that transition.

Darlene Carney: Alrighty.

Thank you.

Loni: You're welcome.

So I wanna make sure we've covered the receiving hospital information. There was somebody on the line who is in the referring hospital situation.

Speaker 3: Yeah, I've got that information and I've looked at it so I pretty well understand that all because we've been doing it anyway, so.

Loni: Oh, good. Okay.

Speaker 3: I got it.

Loni: Perfect. Alright, we won't go over the criteria one by one, but please let us know if you have any questions about -

Speaker 3: Sure.

Loni: Any of the criteria ...

So any other comments, questions ...

Anything that you want us to cover on the next quality exchange?

Speaker 4: We'll probably have to just work our way through this and as we go, we could probably jot down some questions that come up for our next call because I can't think of anything right off the top of my head what ... what to ask. This is typical of Kingwood.

Loni: Yeah, just send us a note, you can send it to Allison or you can send it to me directly. Either way, welcome any suggestions, anything that will be helpful to you.

Speaker 4: Mm-kay.

Speaker 3: Larissa, did you become our contact person? I know that I've been dealing with the Dallas office, Taqiyya, so or is it still Taqiyya for me? If I have a question,

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someone ...

Larissa: Which hospital were you with again?

Speaker 3: Texas Health Arlington.

Larissa: It would still be Taqiyya.

Speaker 3: Okay.

Larissa: Yeah, and we can pass your information along to her to make sure that she knows to round back with you.

Speaker 3: She knows. I've talked to her a couple of times, I just wanted to make sure it was still here, so okay.

Larissa: Yeah, it's still her.

Speaker 3: Okay.

Cybil: And Allison, you're ours, right? In Conrow and Kingwood?

Allison: Yes, ma'am, I have Conrow and Kingwood. Those fall under the same single code territory.

Cybil: Okay.

Allison: All things get with the guidelines, I'm your girl.

Cybil: Okay. Alright.

Loni: Okay, anything else before we close out?

Thank you for starting your morning with us. We appreciate all of you and please, feel free to reach out if you need help with anything or if you think of any additional questions.

Thanks so much, everybody.

Speaker 4: Thanks so much, I appreciate the info.

Loni: Great.

Darlene Carney: Thank you, appreciate it.

Speaker 4: Alright, talk to you next time. Bye-bye.

Larissa: Thanks, Loni.

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Speaker 3: Buh-bye.

Loni: Buh-bye.

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GWTG- Stroke Transcript

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Deb Motz: Okay, I think we'll go ahead and get started. This the quality exchange call for strokes. First of all, I want to wish everybody a happy Halloween. Good afternoon. My name is Deb Motz, and I am the Senior Director for Stroke and AFib for our six-state Southwest Affiliate. I'm joined by Allison Capetilo. She's the Director of Quality and System Improvement for Houston, and she's also our affiliate lead for stroke.

We would like to welcome you to the second stroke quality exchange. This is a quarterly call that ... This is actually the second one, but it's a quarterly call to allow our hospital teams to come together and learn from each other, share, identify resources needed, and just kinda help one another out with process improvements and things that you're doing in your hospital to improve stroke care. I hope you'll invite your colleagues to join us. Everyone is welcome on the call, whether you're Get With the Guidelines, or not. We are also holding quality exchange calls. This morning we had heart failure, which was an excellent presentation. Tomorrow we have resuscitation at 8:00 in the morning. We have atrial fib at noon, and then coronary artery disease will be presented as an exchange call on Wednesday morning at 8:00.

For now, everyone's been placed on mute, but to join the conversation, just select *6. We wanted this to be interactive, so don't hesitate to unmute and speak up. We really want to be able to help one another and answer questions. The topics for today's call, we're gonna start with a brief overview of the Get With the Guidelines Stroke Release that was released on October 19. We're gonna have a couple of the Houston hospitals share best practices for stroke management and group discussion and questions. We also may have a presentation from Baylor Scott White in Grapevine to talk a little bit about a process that they have implemented. Then we'll just briefly go over the Comprehensive Stroke Center measure updates. We'll talk a little bit about the intensive statin, and then we're going to identify the top three measures that most frequently fall out below the 85% goal, and then we'll end with some resources and handouts.

There were some handouts that were sent out this morning. If you did not receive them, then please email larissa.deluna@heart.org. That's L-A-R-I-S-S-A-dot-D-E-L-U-N-A-@heart.org, and she can send those to you. Let's go ahead and get started as. As I don't know if you'll recall, but from our last call, what we decided to implement through the American Heart Association and quality systems improvement areas, we decided to provide you all with an update, a snapshot of where you are with your quality achievement awards and the Plus awards and also Target Stroke.

Hopefully you've all received that report, and please note that this is just a snapshot. The Get With the Guidelines PMT is a fluid tool, and so every time somebody enters in, then things change. This is just a one-time snapshot of where you are in the first three quarters, and also there is a date on your email that tells you the last patient that was entered, so you kinda have an idea where this is at. These reports can be read by you at any time using your configurable

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report. If you don't know how to do that, then please contact your AJ representative, QSI representative, and they can actually help you walk through how to run those reports.

Now to kick us off, I'm gonna turn it over to Allison, and she's gonna discuss the brief review of the stroke release and also the Houston hospitals and the intensive statin measure. Allison?

Allison Capetillo: Hi, everyone. I hope you all can hear me okay. I apologize. I just got interrupted by a phone call that came through, and it kind of messed up my notes here. Let me just get back to it. The first thing I'm gonna go over today with everyone is to talk about the most recent revision to the PMT, so Get With the Guidelines Stroke. If you all recall, there might've been an email that came out to you directly from Quntile with an attachment that had the release note. You all probably also got an email from Larissa De Luna, who would've sent it out from our quality email as well. If you have gotten a chance to look through that, great. If not, we're gonna just do a high-level highlight right here.

First off, there were a couple of things added for sites that are enrolled in our MaRISS and ARAMIS programs. These are both research programs that some of our hospitals are working on. There are new components that have been added to the PMT directly for those hospitals. If you are signed on and you have those items enabled for those two research projects, then you should see there are a couple of new items that are probably going to have to be included in your abstraction, so just be on the lookout for that. If you are not seeing these times and you are an ARAMIS or MaRISS participant, please, please let your director know so that they can help you get that stuff activated.

The next thing that was released was the addition of a new Telestroke tab. This is for both providers of Telestroke and receivers of Telestroke. If you are a hospital that that pertains to, you might want to listen up to this part. If you are interested in turning this on -- this is a free feature of Get With the Guidelines you will be able to have added into your PMT to track your Telestroke metrics -- this is for you. I'm just gonna go quickly over kind of how to do that, but we can definitely provide you some more detailed instruction in writing if you're needing that. But if you are interested, listen up for this.

If you are a provider of Telestroke consultation and you are looking to add this to your tool, you're going to want to enable this under your stroke site characteristics. On your home page, you're going to look down towards kinda the middle on the left hand side. There's a section that says, "abate stroke site characteristics." You would click on that, and you'll be able to see a place that indicates where you want to enable or disable Telestroke consultation. Once that's done, you're going to have to log in after the update takes place, and it'll have you agree to a new terms and conditions of agreement for Get With the Guidelines. Once that's done, you should begin to see the new components added into your PMT. You would see a brand new tab added into your tool. As a site, you will have to indicate where you are primarily a provider or a recipient of

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Telestroke consultation.

The next thing I want to go over are a couple of issues that we've noticed that have come up since this release of updates. There have been a couple of issues with folks that have had difficulty saving their abstraction because of errors in either the arrival method, or I've seen a couple of people have had difficulties with some PPA components as well that are not saving. If you're having difficulty with these, please, please know, we are working on this diligently. Quintiles is aware of the problem, and they are working on a fix for this, so we're hoping to have a resolution to that here in the next few days. If you have not seen a resolution in the next week, please let us know that you're still encountering these problems. It's difficult for us sometimes to see whether or not these are still happening, since we're not the ones putting the data in, so please just let us know.

I would also like to talk quickly about a couple of our presenters today. We're gonna have a couple of hospitals presenting on a best practice that they've implemented to improve some of their measures, and specifically the time to treatment for TPA. Of course we know this is important to everybody, and this is definitely at the forefront of a lot of our programs, so it's great to hear some of the things that hospitals are doing to improve their timing.

First up, I'm gonna introduce Ms. Marcia Carlton. She is from Clear Lake Regional Hospital here in the Houston area. She has a background in ER nursing and education as well. She has worked for about 20 years in the nursing field before she switched over to the coordination side, and has now been in the coordinator role for a little over a year, I believe, and has done some really great things, including helping get her hospital to its first comprehensive stroke designation. Marcia, if you are ready, I'm gonna let you go ahead and jump in and talk about what you guys have implemented at Clear Lake.

Marcia Carlton: Okay.

Allison Capetillo: Unless there was like ... Oh. Go ahead.

Marcia Carlton: Hi, Allison. Okay. Again, I'm Marcia Carlton from Clear Lake, and yes, I've been in this role for about a yeah, so I'm still new, still learning things. I do have a background in ER, so I have a great reputation, great conversations with our ER people. So they've been very generous. They've done everything we've asked them to do.

A couple of things that we started just trying to change, one thing at a time. We started with changing our EMS patients that call prior to arrival and let us know their coming. We would take them directly to CT, get the CT done first, and then they would go to a patient care room. We started that in April and had great success with that. One concern when we went to this practice was, we were concerned that the lab draw times were gonna get extended since we were focusing more on the CT times.

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What we found out, surprisingly, was it made the whole practice better. Our lab times got extremely low. They were wonderful. Our lab tech actually comes to all of our code neuros, which is what we call code strokes here. They need us when the patient arrives, and most of the time they will just do a direct stick on the patient, just do a butterfly and draw the labs and go. Before that, we had been waiting to draw the blood from an EMS line or starting a line of our own, those kind of things. But just to get lab to do a direct stick and go has really helped their times.

The other thing, when we sent that out, we also started having EMS draw blood for us. We've tried this a couple of times. I've been at Clear Lake for about 10 years. We've tried this a couple times, and it's not really worked too well. We decided to try it again. We have bags in the EMS room for them to take and stock on their ambulances, and if they're able to, if they have the ability to, is to go ahead and draw the labs for us when they're en route to the hospital. That way our lab tech just has to walk in, pick up the blood, make sure it's labeled, and go.

We started this with EMS, and we had great response. Our numbers dropped really well. Then we moved it into the walk-in patients. We know whenever people would bring people in, they'd stop at the front desk. They'd ask a bunch of questions. They get recepted into the computer. Before you turned around twice, you were there 20 minutes and you haven't gotten anything done. We also started this straight to CT. If the patient arrives, they get recepted into the system and they go straight to the CT scanner. Then they'll go back to the patient care room and finish everything there. We actually started that full-blown about the middle of September, so we don't have a lot of numbers on that, but it has definitely helped our times.

The big thing that we're working on right now, which we've been talking about for a few months, and everybody's processes are different. But here, earlier this year, earlier in 2017, the pharmacy part of this changed. Instead of just pulling the TPA of the Alteplase, mixing it, and giving it, our pharmacists had to stop and do a thing called compound verification, which is going through multiple screens on a computer and scanning the bottles. It takes between five and seven minutes just for that process. That was really extending our times, and we were frustrated because we're standing there looking at the medicine, but we couldn't give it yet.

We are getting ready to start trialing using Alteplase as an emergency drug, because that's what it is, and being able to have the pharmacists mix it with a ER nurse at the bedside, give the bolus, start the infusion, and then they will go back in through the EMAR and they will full document the actual time that the gave the bolus and the infusion. We are hoping to shave off anywhere between five and ten minutes of our times on each patient, because time is brain cells. That's something that we're starting to try. We actually almost did it today right before this call, but the patient refused. Hopefully that also will help.

If that comes to fruition and it seems like something that everybody's going to do,

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I can put that out there again, our process that we're using for that. We did have a patient that we just gave TPA to over the weekend in 23 minutes, even with that process, but that's not the norm. That's where we're at. That's really all I have, unless anybody has a question about it. Allison, are you still on?

Susie Mitchell: This is Susie Mitchell, stroke coordinator at Covenant Medical Center in Lubbock. I have a question for you. Have you thought about the nurses mixing the TPA?

Marcia Carlton: We have, and that's always been a question. For our program to survey when we were getting ready for that, there was a lot of questions about that. The problem with our nurses ... We have a pretty large ER. We're a level two trauma as well. So we have about 80 nurses. To be able to have competencies on everyone, we went to having the pharmacists mix it because that's a lower number of people that you have to have competencies on and that you know they know exactly what they're doing. We have pharmacists in the ER 12 hours a day, so from 10:00 a.m. to 10:00 p.m., and then we have the backup pharmacists that are actually in the pharmacy will actually respond to our code neuros in the ER on the off times when we do not have a pharmacist. That helps us. I know a lot of places don't have that, but we did that for the quality aspect of being able to have competencies on a smaller number of people than trying to get everybody doing the right thing.

Susie Mitchell: So you're similar then to what we have too, the 12 hours we have the pharmacists available. Our times for TPA are just over 60 minutes, and I was trying to shave off some time by having nurses mix, but that is an issue, competency.

Marcia Carlton: Right. Do y'all have to do the compound verification or any other billing issue things before it's given?

Susie Mitchell: Yes. Yes, I will look into that as well. Thank you.

Marcia Carlton: Yeah, because we've been arguing this. Because as an ER nurse for 20 years, when we're doing a code, we're giving all these drugs and we're not scanning. We're not doing anything. We're saving this person's life, and then we're going back and full documenting the actual time that we gave it. That's kinda the hurdle we're trying to cross right now.

Susie Mitchell: Correct. Okay, thank you so much.

Marcia Carlton: Sure.

Allison Capetillo: Thank you, Marcia. I'm so sorry. I must have been on mute and didn't realize it. That is wonderful information and really, really good to know about the compound verification. I actually didn't even know that, so thank you for sharing. If anyone comes up with questions in the meantime, we're gonna go ahead and let Donald present. I will definitely take more questions at the end, and we'll let both of these wonderful coordinators jump in and answer questions for you guys.

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Real quick, I'm gonna kick it over to Donald Garrett, who is the stroke coordinator at one of our other facilities here in the Houston area. This is a facility that is actually going to be pursuing comprehensive certification, I believe, this year or next year, right, Donald? I think that's what we talked about. Donald also has a background in ER nursing as well and has been a paramedic for a number of years, so he actually bring a unique perspective to the stroke coordinator role, and I'm excited to have him share with you guys a little bit about how he's created a culture of stroke care in his hospital. With that, Donald, I will go ahead and let you jump on, if you want to do *6 to unmute.

Donald Garrett: Okay, excellent. Hello there. All right, hello, everybody from Houston, Texas. Yeah, I just want to start off with the attachments they sent for this conference call, the 12 Key Best Practice Strategies form that they sent. We have basically adopted just about all of those, except for mixing the Alteplase ahead of time and having a time or clock attached to the chart. I'm sort of that person, because I respond to all the code strokes in our facility. They know when I'm standing there that I'm ticking the time off as we're there, so that's sorta the substitute for that. But definitely the 12 best practices that they have are things that will definitely cut time out for the door-to-needle times for your stroke patients. I definitely recommend any of those, and if you have questions later on as to how we implement some of those things, again, you can let me know or you can email as well.

But one of the things ... there's a lot of practices and processes we can put in place, but really we have to have the people in the ED to actually follow them and do them and accept what we're wanting them to do for the stroke patients. The way I approached the ED staff in the very beginning when I first came was letting the nurses know that they are the patient's advocate for stroke, that while the patient's there as a stroke patient. The ED nurses are constantly being bombarded with having to meet certain metrics or different type of patients they care for. We have to market our service to stroke patients of saying our patients are just as important as all the other ones.

My philosophy of the ED nursing staff was, they're the ones running the code stroke. The physician's there to order the medication and confirm what the nurses are saying for that particular patient. But when we look at the code stroke pathway, almost everything is nurse-dependent. Nurse recognition of the stroke symptoms in triage, calling a code stroke immediately, getting the patient straight to CT, getting the IV access, labs, quick assessment, and having someone holding the TPA medications so they can mix it immediately when told by the physician, and having all the supplies needed to mix and administer TPA in the CT suite. While mix and administering the TPA, the CT techs are prepping the patient for a CTA to rule out a large vessel occlusion, possibly.

And of course, documenting all that happens in the EMR and getting all the times correct for us, so when stroke coordinators go back and abstract the case, that we can sorta pinpoint if there's any time we could've made up, possibly. What I

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say to the ED nurses is, "Look, we need to find a reason why we shouldn't give TPA, rather than why we should." Trying to turn around their thinking a little bit. It's just a different way of thinking about giving the TPA.

I also advocate that a stroke coordinator respond to all the code strokes in the ED when available, not to assume patient care or direct what the nurses are doing, but rather be a spectator that may ask why they are not doing something along the stroke pathway, and support them and let them know they're doing a great job if they are following that, of course. If the ED team veers off the normal course, we can redirect if needed and offer that support.

The last thing every ED team needs is feedback. Within 48 hours after a patient's given TPA or goes through, they'll them back to me. I send a breakdown to the ED, lab staff, CT techs, neurologists, stroke leaders, on how these cases went along with the time metrics. The team has to know what the goals are and how they're doing as a team. Setting realistic goals and giving them time to improve. Some of the time metrics that we've had. Basically over the past two years or so, we've gone from door-to-needle times of 60 minutes or less around 40% of the time, to this year so far we're at 60 minutes or less around 96.2% of the time. We've cut the 45 minutes down to 82.7% of the time. Our goal actually is 30 minutes or less in the ED. If we hit 45, that's okay too. Between 30 to 45 are our door-to-needle times we're trying to meet, and a lot of times they even meet that. Just changing that philosophy and the ED nurses' thinking of, "It's just another patient. [inaudible 00:22:36]" They're the ones who are impacting each of those patients' outcomes when they get those type patients.

Allison Capetillo: Thank you, Donald. That's really, really great. Really actually love y'all's philosophy of trying the thought process about giving TPA, and thinking of it more like looking for reasons not to give the TPA rather than trying to find a reason to give it. It really does change the way you're thinking about it and opens up the realm of possibilities of the number of patients that would be able to get TPA. Does anyone have questions for Donald or Marcia about their processes or anything that they've implemented in their hospitals?

Susie Mitchell: I would ask that.

Allison Capetillo: You wanted ... Go ahead.

Susie Mitchell: Oh. I was gonna ask Donald -- this is Susie again -- if the nurses mix the TPA at his facility.

Donald Garrett: We also have the pharmacists during the 12 hours during the day. If they're available, they usually mix it. But then again, if they're in a meeting that particular morning, guess what. The nurses have to do it. All the ED nurses are hands-on competency mixing and administering TPA. [inaudible 00:23:47] and all the ICU nurses as well.

Susie Mitchell: Thank you.

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Allison Capetillo: Great questions. Anyone else have any questions? Okay. I will jump in, I guess, real quick with one more thing I was gonna add to our PMT updates list that I forgot to mention earlier. If anyone is having difficulty with any of the elements that have been added to the advanced stroke care tab, if you'll recall, this was to replace what used to be called the MER tab for hospitals that were collecting data on thrombectomy patients. All of those elements and some of the neurosurgery elements have been rolled into what's now called the advanced stroke care tab. If you are a site prescribing to the CSTK layer for Get With the Guidelines, you were automatically given the advanced stroke care tab. You won't have to do anything to activate that.

Some of your data elements that used to be in the hospitalization tab have been moved to that new advanced stroke care tab. Really, this was just to streamline the data collection process a little bit more, to put all of those elements that did not pertain to primary stroke centers into one place, and then to put all of the elements that would pertain to a higher level of stroke care in one area of the PMT. If you are a site that is collecting data on large vessel occlusion patients because you're planning to pursue comprehensive level certification or you're planning to go for the new thrombectomy capable site certification that's gonna be coming next year, please let us know if you need help to get these elements added to your PMT. We can certainly help you get these activated, and I believe that should not be at cost to you. The only thing that has a cost associated with it is the addition of the CSTK layer, which would automatically pull your data elements for Joint Commission's management for C hospitals.

That's all I had to provide - I'm sorry - on the PMT updates. I am going to kick it back now to Deb to talk a little bit more about the CFB performance measures. Deb, if you want to jump in.

Deb Motz: Thanks, Allison. I think before we talk about the CFB measures, we have Jamie [Gessmeyer 00:26:22] on the line. She's from Baylor Scott White in Grapevine. Jamie spoke just briefly on our last call about a new smartphone technology that they're using to improve stroke and [STEMI 00:26:37] care. I'm gonna ask Jamie to share a little bit about their processes, how it's working out for them, and what kind of improvements that they've seen as a result. Jamie, *6 to unmute your line if you're available.

Jamie Gessmeyer: Okay. Thank you. Yes, I'm here. We've been using Pulsar since last November, and I think the last time I talked a little bit about it, and we're using it for both our STEMI and stroke program. We're really excited to be ... we are working on comprehensive stroke, and we'll be able to use another part of the technology, and that is in activating our IR team, which will be really neat because the pagers definitely are kinda old school. What we've noticed is, that two-way communication that P allows has been really valuable between our staff. We're noticing in the code stroke, when EMS activate it in the field, we all know right away who's acknowledged it and who's going to be coming down to the ED. We have a neuro hospitalist who is sometimes up on the units, and he's able to get

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the notification, and then we can tell that he's on his way coming to the ED. Having that neurologist almost there as soon as EMS pulls in has been really invaluable.

The people that are in on it with us right now is, we have pharmacy pulled in. We've got our neuro hospitalist. We have our ED physician, our nursing staff, radiology, and I think I said pharmacy as well. Our whole team is all on that, and we can communicate. We are in the process of rolling out to the inpatient side as well. There again, the communication is really nice between if we want to know which CT we're gonna be taking the patient too, we can text that and know where we're going. The physician knows what room they're going to and can find out very quickly where the staff is. In the past, sometimes it would be, the physician was up on a different floor and didn't even know where the patient was, if they were in CT or on their way to the hallway. But it's just a really nice way to keep in touch.

The neat things for stroke coordinators is, all of the information that's in the app is exported in a spreadsheet, so you're able to track all of your false activations, your activations, all your door-to-needle times, everything like that. But all the steps in between are also captured, and so you can break down processes that may be taking too long and then know where to kinda shave time off. Our pharmacy is probably one of the most active on it. As soon as we know what the patient's weight is, we can enter that, and then the pharmacy can be precalculating the mix on TPA. Then as soon as we know that the physician has assessed the patient and says, "Yes, go ahead and mix it," we text the pharmacy and say, "Per Dr. So-and-so, mix TPA. Bring to room such-and-such." All those pieces that were phone calls, stepping out of the patient's room, having to tell the unit secretary to contact the pharmacy or call the doctor, things like that, those have all been broken out of the process, and we can see it on Pulsara and do it from the app.

We have actually decreased our door-to-needle time from a average of about 60 minutes last year to 44 minutes this year. I think it's been a great way for us to reduce some of the door-to-needle times, just by zeroing in on processes that were a little bit broken. Does anybody have any questions on that? I'm trying to thinking of some other things that we've done. It also provides feedback to EMS right away, if the case was stopped for whatever reason. Or if we gave TPA, they get that door-to-needle time. Pretty cool process.

On the flip side, there's always some cons to things. Some of the things that we're finding out what are difficult is, people don't like change. Getting everyone on board and changing the process that they have has been challenging. We don't really encourage our ED nurses and our staff to pull out their phones and use them in front of people, so we had to be creative and we purchased a couple iPads. We use those in the units rather than ask people to use their cell phone. One, we don't want to have to pay for their cell phone. Everything is HIPAA protected, but the iPads have been kinda nice answer to that. The other piece that's kind of a con is that no, the data does not merge into the medical records

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yet. We're hoping that it does do some merging at some point, so that we're not having double-charting. But all in all, I think the process itself has helped us tremendously.

Deb Motz: Jamie, are you able to print from the Pulsara app so that you can just add that to the chart, or you need to double-chart?

Jamie Gessmeyer: Yes. No, actually, we are. When you go into the website and you start exporting your dat, because it exports all into spreadsheets, you can actually, if there's a EKG there or a picture of something or any type of documentation in there that you want to capture, you can export it, or sometimes I'll even do a little snippet and do a screenshot. Then I can actually label that with the patient's information and get it scanned into the chart. A lot of our inpatient RRTs, some of [inaudible 00:32:13] record that we have access to, doesn't always allow you to chart the specifics that we need on a code stroke on the inpatient side. The information is actually on the Pulsara website, and I can go in and print that, put a patient sticker on it, and then scan it in. It is able to be recaptured. It's just a little extra step. But I think at some point, it may be where it merges.

Deb Motz: Great, thank you. Anybody else have any questions for Jamie? *6 if you have a question.

Allison Capetillo: Hey, Jamie. This is Allison.

Jessica: I have a question. Sorry. This is Jessica.

Allison Capetillo: No problem.

Jessica: At Lutheran in Colorado. Did I also hear that the Pulsara allows for communication about patient information when EMS in en route, like name, age, that kind of thing as well?

Jamie Gessmeyer: Yes, actually, Pulsara is completely HIPAA protected. It goes through the Cloud, so there's no breach of patient confidential information. What we're working on is getting EMS to, if they do a picture of the monitor and it shows the vital signs and things like that, some of them have even laid the driver's license up there. We're able to preregister these-

Jessica: Preregister, yeah.

Jamie Gessmeyer: Before they even get here. But yes, you have access to that information. They can do up to three images on the app itself at this point.

Jessica: Great, thank you. Do I *6 to back mute?

Jamie Gessmeyer: Yeah, thanks for that.

Allison Capetillo: Jamie, this is Allison. Can you guys hear me?

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Jamie Gessmeyer: Yep.

Allison Capetillo: Oh, okay, perfect. I just had a quick question about the implementation. Were you guys the first to adopt the Pulsara platform, or was EMS, in your area?

Jamie Gessmeyer: I was actually the first one to adopt it in our area. The fee actually comes from the hospital, and then it's free to the EMS agencies that you pull on board. It was actually something that I initiated and instigated from our end.

Allison Capetillo: Okay. Did you feel like it was pretty easy to get the EMS agencies on board and collaborate with you guys?

Jamie Gessmeyer: Absolutely, yeah. They actually took to it a little bit better than some of our hospital staff did. I don't know if they're a younger crowd and more techy or what it was, but EMS bought into it very easy.

Allison Capetillo: Awesome. Thank you.

Deb Motz: Great information. Thank you, Jamie.

Jamie Gessmeyer: You're welcome.

Deb Motz: Okay, so now we're gonna switch gears a little bit and talk about comprehensive stroke measures. Starting January 1st of 2018, there's a few changes that are gonna be made to the performance measure requirements for comprehensive stroke for the joint commission. Now there will be 10 mandatory comprehensive stroke measures as of January 1, 2018 for meeting the performance measure requirements.

The changes to the CSTK2 measure, modified rank-in score, at 90 days. Originally this was intended as an outcome measure, and it was modified prior to its 2015 implementation to focus on the process of obtaining the score at 90 days. The modified rank-in has become the most widely used clinical outcome measure for the stroke clinical trials. Comprehensive stroke centers now have processes in place to collect 90-day [inaudible 00:35:54] data and aggregate the performance, is nearly at 90%. That is no longer gonna be followed.

Also effective ... let's see. Favorable ... okay. Also effective ... hold on. With the effective January 1 stroke 10 modified rank-in score at 90 days, the favorable outcome will be added to the CSTK measure. This outcome measure captures the percentage of stroke patients that are treated with the reperfusion therapy, whether it be IV or IA or mechanical reperfusion. It's looking for the good outcomes for the modified rank-in of zero, one, or two at 90 days. Stroke 10 will replace the CSTK2 measure.

Then also effective on the 1st, the CSTK measure will include the new measure, number 11, which is timeliness of reperfusion. It'll be a rival time to the [tiki

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00:37:04] 2B or higher, and the stroke ... our STK 12 is timeliness of reperfusion, so skin puncture to the tiki 2B or higher. These are robust measures of mechanical reperfusion effectiveness, and like I said, they will be effective January 1. If you need more details about that, it is on the specification manual for the joint commission national quality measures on their website. Any questions about that, that I can answer?

Susie Mitchell: Yes, if you are an ... This is Susie again, from Lubbock. If you're an advanced primary stroke center, and we do thrombectomy, and we don't have 24 IR coverage, so we're an advanced primary, do we still collect that data? When-

Deb Motz: Only if you are going to be reporting it as a comprehensive stroke.

Susie Mitchell: Okay, thank you.

Deb Motz: If you do want to add this online-

Michelle Rogers: This is Michelle Rogers. I'm the stroke coordinator at Methodist Dallas Medical Center. I was just wondering if you're going to start putting in some of the DNV measures into Get With the Guidelines instead of all just Joint Commission.

Deb Motz: That, we have been working with the DNV and also with Quintiles, trying to get those measures married up. I'm not sure at what point that's gonna happen, but we are looking into it and working on it. Most likely, the DNV measures will probably match up because they're all based on the clinical practice guidelines, so eventually it will probably match up with the recommendations for the clinical practice guidelines. But that's what I can answer for you right now.

Michelle Rogers: Thank you.

Deb Motz: Any [inaudible 00:38:54] Any other questions? Okay. I think I'm gonna turn it back to Allison just to talk very briefly about the intensive statin measure. Allison?

Allison Capetillo: Well, hi, everybody again. I'm gonna tell you all some exciting news, exciting and probably some work ahead for everybody, but we are gonna be making some changes to the achievement measures for 2018, and the effect will be fully in effect by 2019. 2018 will be a transition year, and I'll explain a little bit in a minute what that means.

For the first time in quite a number of years, we are gonna be adding a new measure, or actually replacing one of the current achievement measures. These are the measures that get you the gold and silver award for quality for your stroke program. If that's something that is important to you, you definitely want to [inaudible 00:40:02] to this. In 2018, we are going to be changing the current statin measure to what is currently called the intensive statin measure under the quality measure section. Right now, intensive statin is not a required measure. It's one of that group of eight that you need to get five out of the eight in order to get your Plus. We are gonna be moving that up to the achievement quality

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measures, which means you would need to get all of the measures at 85% or higher in order to maintain your status as a silver or gold facility.

What that means. In 2018, it'll be a transition year, so as a hospital, you will have the option to choose if you are gonna abide by the old measure, the old statin measure, or if you're going to be adhering to the new intensive statin measure guidelines. The reason we're doing this, the intensive statin measure falls more in line with what the recommendations are from ACC out of the 2013 guidelines update. That is where we're headed, and we are trying to push this into the achievement measure section so that hospitals will begin to work on getting that more ingrained into their practice. Of course, you'll have the year of 2018 to start making that transition and getting your team on board and getting everybody caught up to speed.

I will also note that the coding instructions for this measure will be updated to reflect the guidelines. And of course, like all of our measures, you will always have exclusion criteria. Absolutely, we're not saying that every single person is gonna have to go home on a statin. There's definitely gonna be exclusion criteria, and there will be patients that do not meet that ... that that will not be applicable to. Just bear in mind that will be there for you. We should be getting some more information about what the exclusion criteria will be probably closer to the end of the year, maybe around December, so be on the lookout for webinars and announcements coming from AHA to let you know when these things are coming.

More to come on that measure, and I will answer questions as I can. I don't have much more information on that right now, but I am happy to try to answer your questions if you have any. Okay. If there aren't any questions, I will go back to Deb.

Deb Motz: Thanks, Allison. We're gonna switch gears again now, and just kinda go over ... what I did was review all of the reports that were sent out to everybody. We looked for the top three measures that are most frequently fallouts for the 85% of the achievement award. Just wanted to share what the top three are. And also, if anybody in the group, if you've run into any of these issues, if you have, how did you deal with it? Any PI measures that you've put in place to address these measures would be really helpful if you would like to share those with the group.

The first one is probably not a surprise. It is arrive by 2:00, treat by 3:00. Of course, that goes hand in hand with the door-to-needle time. Now, we've already had three different little presentations, and sharing processes from some of the hospitals that have done a great job of improving these. I don't know if there's anybody else that has anything to share, but we are happy to listen to those. I did include in the handouts ... and again, if you need them, Larissa De Luna, L-A-R-I-S-S-A-dot-D-E-L-U-N-A@heart.org, and she will send you the handouts. But these are also all on the internet.

As Donald had talked to before, we have the stroke best practices, and there's

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the 12 strategies. Along with that, if you go to the resources, the SWA Quality at heart.org, there's a really cute video that's about four to five minutes, that go over all of these strategies. It might be fun just to show those to your ER and to some of your, maybe, stroke committee members, just to kinda reinforce what the strategies are and how to implement those. Again, that's on the website for SWA Quality at heart.org. The banners will come across, and if you just click on the banner, then it will take you to the site.

The second measure that I saw that seemed to have the most fallouts was smoking cessation. I think a lot of the fallouts with the smoking cessation are related to ... we are seeing less and less people that are smoking. The one rule that we have for the quality achievement measure is that there has to be at least one patient in each of the measures in order to qualify. If there's no patient, then you would not be able to qualify for the achievement award. It's really important to be very diligent in asking the patients about smoking, whether it was current, recent within the last 12 months, so that those can be addressed and be included.

Then the third one is the AFib, so the anticoagulation, if the patient has history or current AFib or a-flutter. Those seem to be the highest three that are fallouts. Also, probably the lowest volume of patients are in these measures, so that makes it even a little more difficult to achieve those measures. Does anybody have anything that they can share with us on any of those, arrive by 2:00, treat by 3:00, door-to-needle, smoking cessation, or AFib, that you would like to share for your preface improvement? *6 if you have something to share.

I know in previous positions that I've had, the smoking cessation one, we made sure and added that to all of our educational material with some links as far as where to go to find more information. That kinda helped us to achieve that measure. We also had, the respiratory therapists were notified when a patient was a smoker, current or within the last 12 months, so that RT could visit with the patient and do some of that education. That was one way to handle that one.

The AFib measure, I know another thing that we've done in the past was included all the documented reasons for possibly not starting the patient on a anticoagulation, so it was just a checkbox. If the patient had AFib or a-flutter, then it was a checkbox if they weren't on anticoagulate, why not. That really did seem to help improve performance measures in my previous position. Anybody else have anything that they've tried or done to help with that? Okay. I know there's, like, 50 or 60 people on here, so a lot of information can be shared on this quality exchange.

Next, I can-

Allison Capetillo: Deb, I'll jump in. I'm sorry. I'll jump in and share. I know one thing at my previous facility we did was ... I know a lot of people are against these, but in things like smoking cessation where that's actually a metric that applies to so many different disease phased across the hospital, and it's really important that it's captured on

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admission, is to make that a hard stop. I know that's not something that everyone loves to hear, but on admission, it's definitely something that can be incorporated into the admission note for the nurse to address. I believe probably a lot of places are already doing that. I don't think that's unique by any means, but it's definitely something to consider if it's something that you are having a difficult time capturing. That's all I got.

Deb Motz: Okay, thank you. Ope, go ahead. No? Anybody else have anything to share? If not, then we're gonna move on to some resources that are available for you. First of all, the two handouts that were given to you or sent to you, the one with the target stroke best practices, and then there also was a time tracker that may be helpful for you to use while you're working on your process improvement, to help you to identify where there may be issues as far as timing goes and how to improve that process.

Another thing just to mention is, I know that while a lot of times ... or several places have missed that show all for the counterindication. For the TPA inclusion-exclusion criteria, some of the hospitals have selected "yes," there was a reason documented. But then you have to select "show all" down below that in order to open up the inclusion-exclusion criteria so that you can mark what the exclusion reason was. That has been missed by some hospitals. If you are falling out in the arrive by 2:00, treat by 3:00, you may want to take a look back at those patients and see if that's the case.

You can run that report, just the arrive by 2:00, treat by 3:00, in the Get With the Guidelines configurable measures. Then if you hit instead of "bar charts," select "patient list." Then that will provide the patient's name so that you can easily just click on the patient number, which will take you directly into the records, so you can take a look and make sure that those reasons were documented. The other thing is an NI stroke scale of zero is a stand-alone reason for not giving TPA. If there's an NI stroke scale of zero documented, then you're good as well.

Those are a couple of handouts that were provided. Another thing when I was looking into ... I saw that some people are asking about cryptogenic stroke. There is a website. Actually, if you go again to the SWA Quality at heart.org website, there's a place. It's down on the lower corner. It says, "Anyone can have a stroke. Everyone should be ready." Then it's got a [inaudible 00:52:02] and cryptogenic, the link, under there. If you go to that cryptogenic link, there is a whole bunch of information about. There's tool kits. There's resources for healthcare professionals. There's patient education resources. There's a lot of information on cryptogenic stroke, because that's being looked at more and more to try to identify what type or what could be possible causes of those that we have not been able to identify with the routine tests. If you're interested in learning more about that, then please go to that website. I think that you'll find some very valuable information.

Another thing that was provided was the stroke resources. Stroke resources has just a bunch of links in it. There's a stroke video, treatment video. That's just a

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short one that may be helpful for you. There's a new fast music video that goes with the music YMCA, and that's available per that link to YouTube so that you can take a look at that one as well. There's a stroke simulation event. If you click on that link, it will take you to a bunch of information. Then acute ischemic stroke treatment kits for the hospitals have all kinds of links to information that might be helpful for you. There's also a severity-based stroke triage algorithm, so if you click on that link, it will take you to there.

Another thing is, we're always looking for stroke heroes, so any hero stories. There's a link to a stroke hero online submission form. If there's any particular patients that you would like to provide his link to, that they can tell their story. Then there's a campaign tool kit, actually, for World Stroke Day, which happened to be last Sunday, but there's a lot of campaign information and educational information for you to share. Even though it's past World Stroke Day, there's still strokes occurring every day, as we know, so there is some helpful information there. Then there's also the Fast Act alerts. Members of Congress, you can send information or letters to your representatives that are provided to help with the legislation that's being passed.

Those are all great stroke resources for you. Feel free to take a look at those. There also is the stroke fact list. That's a, actually, Get With the Guidelines stroke fact sheet that was developed in February 2017. This sheet actually provides an overview of all the achievement awards, the currently quality awards, the description, and then reporting measures. When you take a look at that, I believe it's, like, six pages long, and there's all kinds of reports that you can run. If you're looking for process improvement, or you think that there may be something that you're seeing, but you're not really sure, you can really take a look at any one of those fields and try to drill down to see. That just kinda gives you an overview of most of the information that you can glean from your PMT.

Let's see. Additional resources. Again, the SouthWest Affiliate Quality@heart.org, there's a banner there that has the AHA-recognized hospitals in the US News and World Report for the 2018 Guidebook. Those are out. Those are available. Many of you have probably already received a copy from your director or your QSI director, but if not, then contact them and they can get you a hard copy. But you can go online, and actually you can search by state. You can see what hospitals have achieved the silver and gold plus in the target stroke measures. That is available for you online as well. On that website, there's also a link to the acute stroke ready recommendations. That was a recording that happened about a month ago. If you want to go back and take a listen to that webinar, then you certainly can listen to that recording by accessing it on that site.

On January 8th of 2018, there's a stroke research. We have, actually, a series of webinars that we are presenting through the SouthWest Affiliate Stroke Committee. The next one will be held January 8th, and that will be talking about Lone Star Stroke Consortium with Dr. Mark Goldberg and Dr. Steven Warach. There is a link to register for that webinar as well, if you're interested in that. I already talked about the 12 Key Strategies for Success video, and it's really cool,

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so take a look at that one if you have a chance.

Last, you can expect a invitation for the SouthWest Affiliate reception that will take place at the International Stroke Conference in January. The reception will be held on Tuesday, January 23 from 5:30 to 7:30. You should be receiving a invite for that in the next week or so. Please respond to that. It should be really fun. We have some fun things scheduled, and I think you'll enjoy meeting some of your colleagues at the reception.

Just remember, we really want to hear from you. Let us know what you're struggling with, what resources you need, and anything like that, because that's what we're here for, is sharing and helping one another to provide the best stroke care that we can. Before I close, is there any last questions to be answered? If you have a question, *6 and we'll be happy to try to answer your question.

Okay, there's no further questions. Thank you so much for joining us today. Our next quality exchange for stroke will be held on January 30th at noon. That's Central time, 11:00 on Mountain time. This brings us to the end of our quarterly gate exchange. If you didn't preregister, then please email swaquality@heart.org, or larissa.deluna@heart.org, and let us know that you attended, and then you will receive the resource mailing packet and a short survey so that we can hear about what you want to hear next.

Just in closing, a huge thank you to our presenters, Allison, Marcia, Donald, and Jamie, for sharing your best practices. We really appreciate your time and hope that this has been helpful to all of you. Have a great day.

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GWTG- Resus

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Speaker 1: Example reporting using get with the guideline's resuscitation and resource availability. Now I'm going to turn it over to Cherie and she's going to talk about [inaudible 00:00:17] data.

Announcer: The conference is now in silent mode.

Cherie: Sorry everybody, I'm playing with my mute. Can you hear me Julie?

Julie: We can hear you Cherie.

Cherie: Okay, thank you. Sorry, I didn't wanna start talking if no one could hear. All right, prior to today's session, some of you pre-registered, and you received a data, power point, I guess it's in PDF, but a power point presentation. On our last call many of you said that some of the numbers that we looked at you wanted to be able to have a visual. So that was sent out to you and that's what I'm gonna be going through in this part of the session. However, if you did not receive that or you joined without pre-registering, which is just fine, will you send an email now to swaquality@heart.org and Audrey who is helping us with the call today, she'll send out the presentation that I'm going to review. So if you did not pre-register or you don't have that in your email, just send an email to swaquality@heart.org. Thanks so much.

Let's take a look. The document that you have, on the first line says resuscitation trends for the nation and for the southwest affiliates. I wanted us to be able on this call, to be able to look ... I know that you all have received a report from your director in the last week or so, indicating what your current performance level is on the achievement and on the quality achievement measures.

I wanted to be able to show you how we are looking as an affiliate, and just as a reminder, you'll see it on slide two, our affiliate includes Arkansas, Colorado, Oklahoma, New Mexico, Texas and Wyoming. That is who is represented on this call and so I wanted you to be able to see what our performance is compared to those get with the guidelines resuscitation participants across the country. I think this also will give us an idea where we need to focus ... I know you each have your own [inaudible 00:03:02] improvement groups working but this'll give you some idea where you wanna focus. I also might mention the areas that people indicated that they wanted to learn a little more about, of course, included several of these measures as strategies to reduce the time to shock, strategies on the airway confirmation, were two that came up in the pre-registration.

Let's look at the slide two. When we're looking at 4CPA the time to shock being two minutes or less and you can see that this is an area, where even across the country, if you look at an average, we are not meeting that guideline. That's what that line across the top, that 85% number there is the goal to be recognized. You can see even across the nation as well as for us in the southwest affiliate, that we're falling a bit short on that area. I would like to open the line in a little bit to talk about those of you who have implemented strategies to reduce that time, how you're doing that.

As you look at our time to epinephrine in five minutes or less, we're doing well and

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dead even with performance on a national level, as well as the percentage of our cardiac arrest patients that are witnessed or monitored. Then we have the measure that was adjusted this year, and is airway confirmation, and remember the adjustment that was made was that it no longer just includes those folks that were intubated at this time and this incident, but also those patients who were intubated earlier and so they've come to us and were needing to confirm that airway.

We'll talk a little more about these specifically after we go through. This chart is the adult measures. We don't have enough hospitals doing pediatric and neonatal ... it wouldn't be private ... there's not enough to demonstrate the [inaudible 00:05:10] so I did wanna show you our performance nationally as it relates to the pediatric achievement measures. Remember they're a little bit different. Again we have airway confirmation, but we do have time to compression in less than one minute, as well as the epinephrine measure, and then whether the patient's who had these pulses rhythms, did those occur in an ICU setting, so that we're making sure that our high risk children are in a higher monitored setting.

Then your next slide is slide four, is our neonatal achievement measures where again, nationally, we are exceeding the recommended levels for that for time to compression, for time to epi, and also where those patients are that these pulses and rhythms are occurring in an ICU setting. Still having difficulty as it relates to the airway confirmation, so that seems to be a trend that goes through all of those.

I might open it up. I know we're gonna have some best practices and we're gonna have them come now. As it relates to the time to shock, for those of you on the phone, is there anyone who would like to just come off mute, star six, and tell us what strategies you've used to be able to accomplish that. Anyone willing this bright and early to share with us? Just star six and tell us what you've been doing.

All right well think about it, those of you are on the phone 'cause we'd like to hear ... even if you wanna share it in writing, we'd be glad to send it out.

As we talk about our data, we are nearing the end of 2017 so I know you'll start asking us when do you need to have your 2017 data completed. We know that you can't finish the data 12/31. You don't have those discharge, you don't have those coded out, etc ... but we would like for you to use ... your director may give you a specific deadline that he or she would like you to do but we would like you to finish your data abstraction for 2017 no later than the end of February. If you can do it earlier that would be great, but if we finish at the end of February, then we are able to be able to look back at that data, see if there looks like there's discrepancies, go back into charts if necessary to confirm documentation did or didn't occur. That kind of thing. Please be diligent in getting your abstraction up to date so that when the award season comes, which we submit those awards in March, that you are completely done with your abstraction and don't have to do any late nights on that. If you have any questions, speak to your quality improvement director, and if you're not sure who you're working with, just email swaquality@heart.org.

We do have some feedback on a couple of questions that came up in our pre-

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registration, so be thinking what your hospital has done related to hot and cold code evaluation. We're wanting to kinda hear what folks are doing as it relates to looking at the code immediately after it occurs, and then how you're addressing that in a longer term session. Also, if anybody has any feedback as it relates to strategies you put in place related to the NT, the time to ... not time but, the place and confirmation when you have intubation. Because that is an important measure so Julie, do you want me to share what Sarah shared with us from St. Mary Corwin and then I believe Nancy's on the phone and she might talk about that also.

We do not hear you.

Julie: Can you hear me now, Cherie?

Cherie: Yes.

Julie: Okay, I apologize. I've been working with one of my hospitals here in Colorado, and unfortunately they were unable to join this morning but in regards to hot and cold evaluation and debriefing, they have been struggling with their debriefing for post CPA in that event. It appeared that since they transitioned to a different electronic medical record program in April, the hot debriefing had fallen by the wayside. They noticed that when they did a root cause analysis, they were not ... that was about the time that it had stopped. They found that the nurses and staff were a bit overwhelmed by the new paperless system, but the debrief has not been properly documented recently. However, we were having a skills fair next week, for critical care telemetry in ED nursing staff in the education department. They had plans on having a station that highlighted the importance of team debriefing, and how we can once again adopt this practice back into their codes for patients safety and improved outcome.

The cold debriefing will now be discussed in a monthly code blue, and a rapid response subcommittee, made up of staff from the above three departments that are quality department. They're really making sure that they loop their quality department back into the debriefing efforts. They're gonna discuss cases that have been abstracted and have been highlighted for discussion. Their first official meeting will be held this Thursday prior to the skills fair.

That's an example of what this one hospital is doing, and we would love to hear ... does anyone else have any examples that are working, or maybe even examples that aren't working so well, but you're really working to try to perfect?

Cherie: Don't be shy. Well Nancy, I think we have Nancy Caf on the line from Baylor Scott & Light, Round Rock. They are a high performing hospital and I had asked her to share a little bit about what they've been working on and some strategies that have worked for them. Nancy, can you join us?

Just star six and you'll be on.

Are you there, Nancy?

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Well she may have had something come up. While we're waiting for her, I've had quite a lot of questions as it relates to the, [inaudible 00:12:33] the old tube confirmation, and so thought I might just give a little background as to that measure. There was a webinar given on the new measures in May of 2017 and if you were on our last call, I actually sent out the link after that, so that you could hear about the new measures and why it was so important to add this airway confirmation. Not only for the patients that were intubated at this time but those who were brought in who'd been intubated previously. I thought that it might help you, we also ... they did that discussion based on 13 pieces of literature that indicated, and so I thought I would share a little bit with you about that. Let me get to the correct page here.

Of course, it is not only the American Heart Association that's made this recommendation, if you look at the American College of Emergency Physicians, this is also an updated guideline for the patients that are being cared for in the emergency department. I'll just read from their policy a little bit.

Confirmation of proper endotracheal tube placement should be completed in all patients, both in hospital and out of hospital settings, and of course that's not only initially, but also to cross confirm that it is there correctly. The recommendation as with the AHA guideline is to use end-tidal carbon dioxide detector and we suggest a continuous wave form technography for this purpose, to evaluate and confirm endotracheal tube position in patients, to make sure they have adequate tissue perfusion.

This is such a foundational ... and I know for some reason I think I have a feeling this is being done but it is not being documented, and I'd be interested in some confirmation of that ... it is so vital when you think about oxygen being able to get, so that everything that you're working on depends on oxygenation. If that is not properly placed, then all the other things that you were doing simply aren't going to be as effective. I think there had been some concerns so I'd be interested in hearing from you, if your physicians have [inaudible 00:15:02] on this or questioned if it was going to take additional time, or what. This really is a foundational element.

There are a few timeframes when technography will not work for you, if there's a huge pulmonary embolism of course, that will be an indication that there is something else going on because the numbers are not going up or there's had a severe reduction. The other benefit of using the wave form technography is to determine ROC because when you have an immediate increase there, it gives you early detection that you do have a return to circulation. There's many benefits, so I've been a little bit surprised that we're not seeing higher numbers on that but again I think it's something where the documentation is not there for the abstractors.

Do I have any comments as it relates to, as you've looked at your data, on this measure as to what the situation is? Anyone? Star six.

Nancy, if you've gotten on the phone feel free to star six and hop on.

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Well we're gonna move along and talk a little bit about accreditation and how your resuscitation database really does impact what sections of the standards ... I did provide on your slide ... these happen to be joint commission standards, and I am not being biased to those of you who use other accrediting organizations but you will have very similar standards that apply.

This is slide five for those of you who received the slides. This is why it's so important and why we feel like it was the guidelines resuscitation, is such an awesome tool to have the data and be working with the data as you're accrediting organization requires. Certainly when we looked on page five, and we're talking about the standards. On this slide I mentioned this is under the chapter 'Provision of Care Treatment Services'. This chapter's maybe named slightly different with your other crediting organizations but I assure you this is there. For standard PC9.30, that resuscitation of services are available throughout the hospital. That's not gonna only include that you have policies, procedures, processes, to make sure that the resuscitation services are available, but also is the equipment there and available? How much time would it take to get the appropriate equipment there? Is it placed strategically? By using your get with the guidelines reports, and I'll show you some ways to do that, you can certainly be able to determine if there are places in your organization where the equipment is too far. Do you have an evidence based training program to train the staff? That's also a good use of your get with the guidelines, is you can run reports by units if you capture those to see where you might need additional training. Because wherever you have anything related to variations, you might wanna do a root cause analysis.

On slide six, again still in the chapter 'Provision of Care Treatment and Services' we have the issues related to medications and certainly the medications that are involved in a code need to be properly and safely stored. They need to be consistently available. There's other issues your work on related to control and security, but having them available is critical and you can prove that is one way to use your database for that purpose.

Slide seven. This is a different chapter. This is your PI chapter. Your improving organizational performance chapter. It's got several really important standards that get with the guidelines resuscitation or however you're collecting your data can be used. That is standard PI1.10 that the hospital collects data to monitor the performance of potentially high risk processes. Certainly everything that we look at as it relates to MET, ARC and CPA is considered a high risk process. And that that data is systematically aggregated and analyzed. If you are just putting data in to get with the guidelines resuscitation and certainly for the purpose of recognition, that is fine but it does not meet the standard. The beauty of get with the guidelines resuscitation is how to run your reports. If you're not sure how to slice and dice that data ... and I'm gonna show you a couple examples, please call your quality improvement director today. If you're not sure who that is, email swaquality@heart.org and we want to show you the power of the reporting side of get with the guidelines resuscitation. It's really neat and it will allow you to systematically aggregate and analyze your data and be able to show that to your surveyors.

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Slide eight. Look at undesirable patterns or trends in performance. That is part of what you want to do to your process improvement. Again, I'll show you an example slide coming up. Then to use that information to make changes to improve performance. If you have implemented changes, make sure you run your get with the guidelines data for the related measures, before and after that implementation to confirm that what you're trying to change has worked. This is a great way to run a chart and you can even have an arrow for your surveyors. This is where we implemented. You can put another chart ... this is where it didn't work, so we redesigned, we implemented, and you can use your data in get with the guidelines resuscitation for that to make that decision process.

Slide nine. This is the standard ... this is under the chapter, 'Information Management' and I did not put that on here, I apologize. The hospital has processes in place to effectively manage information including the capturing, reporting, processing, storing, retrieving, so on and so forth, of data. This certainly is an area where get with the guidelines resuscitation can help you.

I think I had this later in the webinar, but I think I'll go ahead. This is an example of how to use your report. As you know, when there is variation, and you don't have high quality, and what you're able to do is to take your data, and that's what the blue line is ... it is a particular hospital. I don't even remember who I used, but a hospital that had a pretty decently high volume. Looking at their time to first shock, less than or equal to two minutes for VS pulse less than VTAC, as the first documented rhythm. Then comparing it to that large number of patients across the country.

As you look, and this happens to be quarterly, as you look, and I did it July 15 through August 2017. So it's a way for you to see the variations that occur. You can also perhaps ... I could've run this monthly to see if there were annual trends. We see that in teaching hospitals where we have a brand new set of residents on July first, and if you will run their reports across the continuum for a few years, you will see that there is a variation that is immediately after the whole new group of residents comes in. This is a great way to look at that. I would encourage you ... I included an article, that's a link on that page, an article about the variation in code blue at a big hospital. This is kind of a very interesting article ... they don't tell you which hospital it is, but it shows all of the various things that impact code blue. Everything from a delay in CPR, a delay activation of the team, that they're not getting a good bag bowel [inaudible 00:23:46] seal. Inadequate ventilations, inadequate compressions, medication errors ... it just goes through every one of the things that cause variants in a code blue. I would encourage you to look at that article. It was kinda eye opening when you think about that. This is an example of how you can slide and dice your data.

On slide 11, look at things based on the day of the week. This also, and I don't have it on here, but this is also time to shock for a particular hospital, and it is done by the day of the week. So while this hospital has a 73% in this measure, 11 of 15, you can using your tools, look at your performance by the day of the week and compare it. While this is a very low number of patients, you can still see that it's pretty interesting that two of two on Tuesday, two of two on Wednesday, one of three on Thursday ... they got everybody on Friday, but interesting it was only 33% on Saturday. Note they

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didn't have any codes on a Sunday, 'cause this was a small volume facility. That's interesting that out of the three, of these rhythms, that occurred on a Saturday, that only one of three received the shock in two minutes or less.

I do encourage you to look at different measures by the day of the week. That is a good way to get on top of training and educational needs. I also included an article on that page, and for those of you who didn't get these slides, we'll send them out afterwards and for everyone who pre-registers, you always get the slides in advance. I put an article on that slide that's called 'Code Blue for Code Blue' and so it's kind of an interesting article on how to get on top of some of these elements related to how to use your data, how to determine where the problem is ... kind of a root cause analysis.

Our emails are on the last slide, those Julie and I, as well as the swaquality so you certainly should always be speaking with your director, but if you don't know who that is, feel free to ask any of us your questions.

Let's see. Julie's gonna talk about a few resources that we have for you out there.

Julie: Hi Cherie, can you hear me?

Cherie: Loud and clear.

Julie: Thank you. I think that you've made some great points, Cherie, and I know in working with my hospital that it seems as though many of these measures are being done but it's just being able to go in and actually find the documentation if the documentation is there. I think most often the hospitals don't have a good process in place to get it documented. So once they streamline that, it looks like their measure scores are coming up substantially. So I think that's a great point.

Some of the resources that we have available is we are frequently getting asked to add abstractors to various modules. And we're gonna speak specifically just to resuscitation. For resuscitation, an abstractor must actually pass a test before they come become what we call a certified abstractor and be added to the approved used list. If you have an abstractor, or a person who wants to become an abstractor, notify your director in the state of which you live, and we'll tell you how to do that here at the end to send an email. Then that director can kinda help you go through the process that must be gone through ... there's a link that we'll send you out to, to where you will do some training, and do kind of a practice test, and then there'll be a pre-test, and then there will be your official test that you get to do, and once you pass that, then we will work with you to get you signed on with a username and password, and you can begin abstracting. Please know that your director in the state you live in is there to kind of work with you step by step, and help you through the processes to make this as seamless and painless and possible. And get you up and running just as quickly as we can. Also make sure ...

Cherie: Hey Julie. I might just jump in there. Just to reminder that if you are not an abstractor but you wanna have access to the data, to slice and dice it, you don't have to take the test. Many of you on the phone, maybe you're an abstractor but maybe you're an

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abstractor and a leader, or maybe you're just the leader. You can become an observation only user of your data without taking the abstraction test. So think about who in your organization you might want to get on board, as one of those types of users, so that we can really use this data well. Maybe someone in your quality department, maybe somebody higher up in cardiovascular, or an accreditation. I think sometimes people think oh I have to take that test, I'm not gonna do it. Well you can get access to just view your data without taking the test. I just thought I'd throw that out there.

Julie: Perfect. Thank you so much, Cherie. Then also you do have the availability to run your 2016 risk standardized survival report. Make sure you're using those and comparing those, and if you are uncertain how to do that, please reach out to one of us directors in the state that you live in, and we're always glad to walk you through that. That's the beautiful thing about the get with the guidelines resuscitation module is that the reporting function is so robust that we can slice and dice data in ways that you could never imagine. I think that that was very true in where Cherie was able to point out that certain days of the week are going to effect patient outcomes and I think that if it was one of your loved ones ... certainly those Saturdays are something that is very concerning. So how can you work with your quality director to improve outcome for those patients that are having events on Saturdays or the weekend?

Our resuscitation conference, at scientific sessions, is soon coming up. There will be a separate resuscitation conference that will be November 11th and 12th. Then scientific sessions directly following that November 12th through the 15th. So if you've not registered for that, please do so and you can reach out to one of us or we'll give you an email address, here at the end and we'll get you connected that way.

December 12th is a resuscitation sciences webinar, and be watching your email for that promotion to come out very soon.

So Cherie, I'm gonna pass it back to you.

Cherie: I might just add either that list standardize survival report, this is so important. There's really no other place you can get that information. When we run in the database, when you run survival, it is not risk adjusted. So when you're doing it inside the configurable report, it's just what I consider just a baseline. It doesn't take any factors into consideration. However, when you go to your home page, and it's kinda halfway down the page to the right, and it says 'Risk Standardized Survival Report' and you open that up. That is for your hospital alone. It has taken into consideration ... I forget if it's 11 different [inaudible 00:32:09], I don't have the number but many number of elements to determine if you had sicker patients, so that you really are looking at an apples to apples comparison, because taking a community hospital survival rate, and then taking an academic center or research organization and then comparing those is not really a good way to go. We don't know what the expected survival was.

By looking at that risk standardized survival report, or you can call it 'Risk Adjusted' you are finally getting that number. You know, we have talked over and over, at least to American Heart and through the groups that I interact with, about the survival rate

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from cardiac arrest. With that being under 30%, actually we've gone up from 19%, but in hospital survival from cardiac arrest remains consistently below 30% across the country. It is really important, all the things that you're doing, to improve that survival rate and have a good number for it. If you have not looked at that, open it up now. The unfortunate part is because it is so involved, you only get it annually, but it is scientifically developed by our clinical work team by the physicians who work with us, and it is something that is only really available through get with the guidelines resuscitation. In fact, probably one reason to even have it is the availability of that report. So if you haven't seen it, go find it or call your director or let us know at swaquality@heart.org.

I don't know if Nancy had a chance to join us from Baylor Scott & White, Round Rock. Are ya on?

All right, no problem. We know how it happens in nursing. Things come up. I don't know if I can get ... I haven't been very successful getting you guys to talk up, but I'd just be interested ... I have a few questions I'm hoping you might be willing to share. Can folks on the line ... can anyone tell me, are you all abstracting your own data or do you have some abstraction help? If you can come off mute, star six, tell us who you are and your hospital, and who is abstracting your data. Is anyone willing to share?

It's an easy question.

All right, well I might put this out in a little survey. I'm just interested in who's abstracting, getting a feel for what PI's you're working on currently, and then there's gonna be a little question if you could change one thing about your performance, what is the thing that you're really working on, what that would be. So in the post participation survey, I will put those in there.

Unless we've got some contribution from the group, I'll pass it over to Julie.

Julie: Anyone have anything they would like to share? Or not? I think this is also a great opportunity and a safe place that if you have something that is not working well in your hospitals, we find in our other groups that sharing things that are not working well, and then having others there that can make suggestions, has been kind of a life saver for many people.

All right, well thank you so much for attending. We really do appreciate it. Our next quality exchange for resuscitation will be held January 31st at 8 am, Central time. This brings us to the end of our quarterly data exchange. If you didn't pre-register, please email swaquality@heart.org and let us know that you did attend. All attendees will receive a resource mailing and a short survey so that we know what you want to hear about next quarter. We can make sure that we tailor these to the specific needs of the hospital because we do want it to be about you and improving patient outcomes. Unless anyone has any further questions or comments, we will go ahead and adjourn for today. Thank you so much.

Cherie: Thanks everyone.

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Announcer: Thank you.

GWTG- Heart Failure

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Katie B.: All right. Looks like it's just a little after 8:00 a.m. We are so excited to have everyone here. Good morning. I'm Katie Butterfield, the Director of Quality System and Improvement for the State of Oklahoma and the heart failure lead for the [inaudible 00:00:14] affiliate. I'm joined by Cherie Boxbergerr. I just called Cherie Cherie. Her name is Cherie, the Regional VP for Heart Failure and Resuscitation for the affiliate.

Welcome to the second installment of the Heart Failure Quality Exchange. This is a quarterly phone call to allow hospital teams who are working diligently to improve care for our heart failure patients. We come together, learn, share, and identify resource needs. I hope you'll invite your colleagues to join us for these calls. Everyone that is passionate about heart failure is welcome on this call. We're also holding quality exchange calls for resuscitation, atrial fibrillation, stroke, and coronary artery disease.

Those of you who pre-registered should have received some slides that serve as a foundation for our meeting today. If you did not receive this email or the slides, please just send an email to Larissa DeLuna. Her email is larissa.deluna@heart.org, and she will send those slides to you.

Everyone has been placed on mute. If you would like to join the conversation, which this is a very informal call, please just press *6 and I will unmute your line. To mute the line back, please press *6. We want this to be interactive. Please don't hesitate to unmute, speak up whenever you have a question or a comment.

The topic for today's call, and we have some really exciting ones, an Introduction to the Cardiovascular Center of Excellence, which is including the heart failure pillar. We're going to speak a little bit about the Heart Failure Society of America Highlights, which was just recently held in Grapevine, Texas, a look at the performance by our affiliate, our six states. Two hospitals are going to share best practices for heart failure management and group discussion. Then the demonstration of our brand new the resources. Let's get started.

Here are some things that are new. We are actually going to ask Joyce Wright, who is part of our American Heart family, she's going to jump in and give an overview and what's new and how the heart failure is the pillar of our Cardiovascular Center of Excellence. Joyce, if you would like to press *6, come off, and give us your overview.

Joyce Wright: Thanks, Katie. Cherie and Katie asked me to speak to you today about the Cardiovascular Center of Excellence accreditation. This accreditation is the collaboration between the American Heart Association and the American College of Cardiology. As you know, we're the two leaders in cardiac care.

The original requirements for the Cardiovascular Center of Excellence ... And you're going to hear me say CVCOE, that is the Cardiovascular Center of Excellence. The original requirements for CVCOE were that a hospital needed to have three ACC cornerstones and then apply for the Cardiovascular Center of

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Excellence.

We found that there were many hospitals that had stellar cardiac programs, but not necessarily the three cornerstones in place, so we developed a limited time offering for early adopters. This offering is available through January 1, 2018, and it does not require you to have the cornerstones in place at this time. The hospitals can become CVCOE-accredited and they'll then go back and put their cornerstones in place.

Let's quickly talk about the cornerstones. They are administered by the American College of Cardiology. The marketing you will see, even though it's a co-branded product, but on the cornerstones, the marketing that you will see is ACC/AHA. There is one mandatory cornerstone, and that is the chest pain center module. Then you will need to choose between two of the following three: heart failure, aFib, or cath lab.

Anyone who is doing Get With the Guidelines CAD, Get with the Guidelines Heart Failure, or Afib, this is a great tool because there is a free layer that you can add with the guidelines tool that can be turned on in Quintiles and will meet the daily requirements that ACC requires for their data registry.

The AHA IT department has gotten the data elements from ACC and they have matched them to the Get with the Guidelines measures. The items that are not included in the Get with the Guidelines Heart failure or afib or CAD, are put into a layer so that you can just turn that on and you will meet the data requirements for ACC.

Let's talk about the capstone. You'll hear capstone or CBCOE. Those are the same thing. This is a portion of the accreditation that is administered by the American Heart Association. The marketing that you will see will be AHA/ACC. This is a cardiac service line accreditation that looks at systems of care starting for when the patient is picked up by EMS, brought to the hospital, entire way to the hospital, out into the community, back into their home or cardiac rehab or nursing home, and then on to preventative medicine.

The benefits of this accreditation include making the hospitals as a driver of change for health in their community to improve health. Public recognizes the hospital for their commitment to high quality care. The accreditation provides standardized cohesive, consistent multidisciplinary care. The quality improvement data from the data that we collect allow the hospitals to identify disparities and gaps in care and implement quality improvement programs.

This is a great recruitment tool for physicians and other healthcare staff. It allows patients and families increased participation in their care decisions. This is really the cornerstone here for us is how to make the patient care better and how to make outcomes better for patients and to improve their quality of life, or allow them to have the best quality of life possible.

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This accreditation also ensures that multidisciplinary teams are talking with the patients, again, to coordinate care. It provides education out in the community so that patients have early access to care. It shows dedication to quality of care close to home. We also look at patient safety.

Let's just look at maybe one of your heart failure patients. It would be a comfort to know that if they came in for heart failure and ended up needing a valve replacement, that all those systems in your hospital were communicating and making decisions that were in the best interest of the patient and would follow them through the entire hospital stay.

The requirements for the CVCOE are those three cornerstones, but we are not going to be looking at those cornerstones again. ACC has already helped your facility achieve those cornerstones so we are going to be looking at other things like the entire cardiac service line like your cardiac surgery areas, or the lab, or the echo people, but looking at the entire cardiac service line not just individual disease states.

We want to make sure that the patients are getting timely information about their disease state and making sure they understand and are making the best decisions for their care.

Let me talk about the early adopter limited time offering just a little bit more. We really want to meet you where you're at and help you meet your goals, so the early adopter limited offering is you do not have to have the three cornerstones in place. We will be sending you readiness assessments. The readiness assessment will just take a look at what systems you already have in place in your facility that might be equivalent to what needs to be there for CVCOE.

There is a cost for the readiness assessment. It is $9,000. Let me just back up for just a minute. The cost for the CVCOE during the limited time offering is $57,000 for a three-year accreditation. The first year is just a little bit different because of the readiness assessment. The readiness assessment is $9,000 to cover the fees for that. First what you would do is submit your application, get your PHA, Participating Hospital Agreement, completed and signed then submit your readiness assessment. We'll invoice you for the $9,000. There's a committee in AHA that will take a look at your readiness assessment. Once they make a decision as to whether you would be able to sustain a CVCOE, we'll let you know, let's do the positive first here, you are approved to move forward. What you would do is move on to the desk survey.

The desk survey looks at all your supporting documentation that supports the CVCOE standards in the standards manual. We have a reviewer that you'd be working with. You would submit things like your charter or your policies and procedures, and we would take a look at that to make sure that the documentation is what we're looking for.

Once that process is completed ... That generally takes maybe around two

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months. Once that is completed, you move on to your onsite survey. That is where the reviewer comes to your facility. The purpose of that is we have seen on paper what your facility does, but we come to see it in person to make sure everything on paper is what's actually happening in the facility.

Let's move to the negative here. If the committee decides that you are not ready to move on to the desk survey, then the reviewer will give you some recommendations to help you with an action plan to put things into place to get yourself ready. You will not get your $9,000 back; however, you can apply again. You have one year from the date your Participating Hospital Agreement was signed to re-apply and submit your readiness assessment a second time or third time to get ready for CVCOE. At that time when the committee does feel you have those systems in place, we'll move on with the desk survey and the onsite survey.

I know that was really quick. I know there are other people that need to talk, but are there any questions that you have about CVCOE?

Katie B.: If anyone has a question, please hit *6, and you will come off mute and you can ask Joyce a question. If you think of something maybe more specific about your hospital that you want to do in private, you can always contact Cherie or I or Larissa with your question, and we will make sure we connect you with Joyce.

Joyce Wright: I would be happy to help you out. Feel free to contact us.

Katie B.: Joyce, thank you so much. That's really good information. Hopefully we'll have questions come in through email that we can connect you.

Joyce Wright: Okay. Thank you.

Katie B.: Thank you so much. Moving on, Cherie Boxbergerr is going to hop on and give us a little overview about using the CSV uploader for heart failure, which is very exciting. This means you don't have to hand enter everything, which I feel like is something we all want to hear. Cherie if you want to come off of mute and give us a little information about the CSV uploader.

Cherie Boxberger: Yes. Good morning everyone. Glad to be joining you. We did have around 25 of you pre-register for today. Just as a reminder, if you didn't pre-register, I'm gonna have some slides I'm going to go over. Please pop an email to Larissa DeLuna larissa.deluna@heart.org, and she'll get those sent out to you.

First let me say this opportunity to be a Cardiac Center of Excellence, I believe in all of our states there's opportunity for someone to be the first hospital to be able to promote themselves as a Cardiovascular Center of Excellence. You know what that would mean, along with the AHA/ACC icons, to be able to demonstrate to your community your overall commitment to heart care. If this is the first you've heard about Cardiovascular Center of Excellence, please reach out to your AHA director or pass the word along to your service line director or COO/CNO. It

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is a great opportunity. I know there are a number of communities who are working diligently to see if they can be the first.

Let's talk about the CSV uploader. Many of you, as I look at the preregistration list, have been a Get With the Guidelines Heart Failure participant for a long time. There are some of you who use an uploader because of your organization. For instance, [inaudible 00:15:54] uses Quantros, and Quantros uploads the data into Get With the Guidelines. But, even if you don't have one of those, all of you are eligible to have some of your data come directly out of your electronic medical record and populate into your Get With the Guidelines Heart Failure. I think sometimes we lose sight of this is available. Even if the uploader only brought in date of birth, all of the date and time fields, you would still have significant savings. I encourage you to reach out to your director if you're not sure who that is, just pop and email to swaquality@heart.org and let us know you're interested at looking at the CSV uploader. This is available for almost all of our tools, so I encourage you to see if you can save some time and effort by getting data directly imported into Get With the Guidelines Heart Failure and then you would just finish it out.

Any questions, or does anyone use a CSV uploader who would like to make a comment? Just *6. All right.

Speaker 5: I have a question.

Cherie Boxberger: Go ahead.

Speaker 5: Could you repeat the email address that you said to send ... We're looking to do this already, but we may need some help with some more of the specs to make sure that we're right on track.

Cherie Boxberger: Perfect. Just send it to swa ... like Southwest Airlines, but in this instance, it's Southwest Affiliates ... swaquality@heart.org.

Speaker 5: Thank you.

Cherie Boxberger: Let's us know, and we'll be glad to give you a hand and make sure you have the latest specifications. All right. I'm just going to give a few highlights about the Heart Failure Society of America. Hopefully, some of you attended, and you feel you can jump in and let us know what you learned as well. Katie and I were able to attend the conference in Grapevine, Texas, in September. I'll just share a few things I learned in some of the sessions, kind of just a foundational update.

With a million hospitalizations per year, which kind of struck me that with heart failure we have a million hospitalizations per year in this country, but the proportion of those that are [inaudible 00:18:23] is increasing. Right now it looks like across the country, a length of stay of four to five days. The in-hospital mortality across the country is three percent. However, as you get to 60 to 90 days, it increases to 90 percent, and right now, an average 30 percent re-

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admission rate. Of course, if you go out to six months, it's 50 percent. Certainly this continues to be a large and growing financial burden.

I was able to attend a meeting where Dr. [inaudible 01:20:16] presented. Dr. [inaudible 01:20:16] is out of California, and he is one of our physician leads on the clinical team that leads Get With the Guidelines Heart Failure. He gave a presentation kind of reminding what the goals are for treatment during a heart failure admission. Certainly, we all know alleviate symptoms, that's the reason they're coming in there initially; to reduce the extra cellular fluid volume or congestion, of course that's one of the symptoms often times; to improve their hemodynamics cause we really want the left and the right ventricles to have less pressure so they can fill more easily. Obviously, we need to maintain renal function so that all the organs can work well. Then, we want to optimize the initiation and dosing of GDMT. I don't know if you've heard these letters before, but Dr. [inaudible 01:20:16] is using these pretty extensively. It's Guideline Directed Medical Therapy. That is really what we're doing in Get With the Guidelines Heart Failure, guideline directed medical therapy. During the hospitalization, we want to optimize that kind of therapy that will improve the long-term outcome. Kind of interesting looking foundationally at what we're trying to do while they're in the hospital.

I also attended a session which was a study of a thousand couples where one spouse had heart failure. They actually studied the health of the caregiver to see if the non-heart failure spouse how healthy they are impacted the outcomes for the heart failure patients. In fact, they found that it did not impact the outcome for the heart failure patient but learning that they did determine was that the death of the heart failure patient greatly affected the health of the surviving spouse. That suggested really a need for enhanced bereavement care. When we talk about systems of care or Cardiovascular Centers of Excellence, we can't forget that other end of the spectrum where the patient does die and how does it impact their family.

One last study that I will tell you about was about ... Actually, there's two. Adherence with post discharge appointments. I would be interested in seeing how well your patients are showing up for the appointments you make for them. I think we all make a lot of assumptions about why patients don't show up. We visited some federally qualified health centers, and they have quite a few no shows, and they are trying to find out why that is. In this study, they determined what does not impact adherence. It's interesting, the following did not impact adherence: older age, female gender, a lower socioeconomic status, smoking history, and this is interesting, distance to the provider did not impact adherence as well as the number of heart failure medications. So those were not statistically significant for patients who did not follow up. Obviously, it's one of those deals where the research is indicating we need more research. Those are some of the things that I might have thought were related.

Finally, the last thing ... We went to many, many sessions. Something that was incredibly shocking was the disparity in the number of women who are evaluated

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and treated with LVAD and transplants. The data suggests that women are entering the system either so late that they can't have these things or that practitioners, primary practitioners, are not referring them early enough.

There was great discussion related to women and them ignoring symptoms or them being worried about more things with their family and therefore not taking care of getting into the physician. It is important to note that right now LVAD and transplant rates are far lower than our male counterparts. So, these are areas that we need to be focusing on and figuring out how these women whose cardiovascular systems are failing can get plugged into the system much earlier and take advantage of the treatment modalities that are there.

Is anyone on the line attended HFSA and would like to share something that they took away? *6.

In a future call, we'll talk a little more about the use of social media with heart failure. Katie attended a very interesting session, but we don't have time today, about how they are using Facebook Live and some other elements to communicate with their patients and families. We'll put that on the agenda for a future quality exchange.

You might want to just pop September 15 to 18 on your calendar. That is when the next Heart Failure Society of America will be held in 2018, and it will be in Nashville.

Recently, and some of you may be on the phone who participated in a pilot program we did in Austin, we had heart failure providers, a full contingency, everything from dietician to social work to physician to nurse come together last week in Austin to talk about the needs of heart failure coordinators in that community. Katie, can you give us an update?

Katie B.: Yes, thank you. Like Cherie said, some of you on the phone might have been at this breakfast. Please jump in at any time and give anything you felt was beneficial or things you would like to see in the future. I thought it was amazing. I'm not from Texas. I actually cover part of Texas but all of Oklahoma, and I live in Oklahoma. It was really great to get into another market and see what's happening. We just simply met for breakfast one morning, brought some food in. We had a great attendance. I think 22 people came from only two or three hospitals. We had a physician show up. We had representatives from social services, representatives from cardiac rehab, heart failure nurses, quality, a really great spectrum of people who were passionate about heart failure in Austin.

We just did a small presentation about the data that we saw in Get With the Guidelines as a market in Austin. That was a small portion of the discussion, but the main portion of discussion was best practice sharing and barriers that we were seeing with heart failures, which was really great to hear different perspectives from different hospitals. Like, in Austin, they have a program called the [inaudible 00:26:21] program for the uninsured low income. I know that's

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only specific to Austin, but I know other areas have other programs like that where they're helping with health insurance and helping with the underserved, but it's also a barrier in getting them treatment afterwards and giving followup to them.

We talked about barriers to technology for these patients that one hospital, actually the social services, they checked in every week for the first 180 days post discharge. Those patients were given a tablet ... We would love that hospital to do a presentation for us maybe on our next heart failure call ... Those patients were given a tablet to keep track of their weight, their diet, how they're feeling, and social services would check in with them every week and make sure that's happening.

Then we had a little break and we came back and discussed is there data reflective of what they think they're doing. Do we want to do something like this again. We feel like heart failure coordinators and people who are passionate about heart failure don't have quite the opportunity that people maybe work in stroke or maybe work in [inaudible 00:27:40] don't have the same opportunity to get together and have something like that just in their region. We are looking to have breakfasts in other regions of our affiliate. Obviously, if it's something that you all are interested in or think it would be a great idea for your area, we would love to host it.

Lastly, I will say at the very end, we kind of talked about some different guidelines and different resources that we also offer with our heart failure program. I'll go over that in just a little bit because that was kind of a big section that we discussed in this. We did it together as a group where we signed on to our new resources, went over them together how they can utilize them for their patients, how they can utilize them as a group for their physicians and other clinicians. That's something that was really useful to them. That's something I'll go over in a little bit on the resources section.

Cherie or Stephanie. I believe Stephanie might be on the line too. If there's anything that you guys can think of that we also did at that Austin breakfast you want me to elaborate on, please ... Or anyone that was at the Austin breakfast, please feel free to jump on and say what you liked, what you would like to see added or what you wish you could've had at that breakfast, I would love that. *6 to unmute.

Cherie Boxberger: Thanks Katie. We're going to be reaching out and have some other opportunities for us to meet in person, even though we're really going to focus on data on this call. I did email out to those of you who preregistered a slide presentation and that's what I'm gonna talk about now so if you want to pull that up. It was called Heart Failure Quality Exchange 1030 so it came out with your reminder email. If you didn't get this, we'll make sure it's in the resource kit that goes to all participants.

We wanted to talk a little bit about our performance as it relates to the affiliate.

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For those of you who have the slides, Slide 3 kind of shows the mortality rate for heart failure over the years. For those of you who don't, I'll describe it to you. From 2005 all the way to 2012 or 13, the mortality rate for heart failure has gone down. However, starting in 2012, we started to see that mortality rate ink up, so I included a slide that has that. Interestingly, we really believe this is happening because we're doing so well on our time critical cardiovascular diagnoses. So, our strokes and our STEMIs and our end STEMIs who are surviving those and as a result may have heart failure and might be more ill than in the past where they might have died from those things. It's kind of interesting, but we definitely need to keep our finger on the pulse of the fact that the mortality rate in heart failure is starting to ink back up. Certainly not what it was back in 2005, but it is heading in that direction.

You'll see on the slides, Slide 5 talks about the performance in the country as it relates to Get With the Guidelines and how by using Get With the Guidelines Heart Failure on Slides 5, 6 and 7, you definitely improve your performance on the guideline-based care.

What I did want to share today is our performance, and when I say our, our six state performance. For those who have the slides, it's Slide 8. The Southwest Affiliate includes Arkansas, Colorado, Oklahoma, New Mexico, Texas and then Wyoming ... Sometimes people are like Southwest, but yes, Wyoming. As we look at the four key achievement measures, the first one [inaudible 00:32:05], we're performing just slightly lower than the country in that measure. We are also, while still high near 90 percent, performing a tad bit lower on the evidence- based beta blockers, very high and very close to national on the LV function although slightly below national. In the area of the post-discharge appointment, we've made great strides. We're coming in just under 70 percent where in the nation, they're coming in just under 80. In the achievement measures, except for that post-discharge appointment, we're less than the nation.

Slide 9 takes up the next four quality measures of aldosterone antagonist at discharge, anticoagulation for certain patients, DVT prophylactics and of course, evaluating and placing CRT therapy. In all of these areas except for DVT ... Well that's not true, aldosterone antagonist we're about even with the country, and we're all low at about 40 percent. In the other areas, performing lower with anticoagulation and the CRT than in the nation.

The final four quality measures, ICB evaluation and/or replacement, influenza vaccine, pneumococcal vaccine and then the followup in seven days. We exceed the performance of the country on the influenza vaccine, slightly under on pneumonia and significantly under on the followup in seven days. What Katie alluded to is that when we showed the results to each of the hospitals in Austin, many of the people who were attending were not like yourselves. They worked with the data but they did not enter in the data, and they believed that their Get With the Guidelines data related to the followup appointment was not correct. So, I encourage those of you on the phone as you just got a report from your director about your performance that you take to that to the others who are

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working with the followup appointment and confirm they are having things documented as they should so that you can put them into Get With the Guidelines Heart Failure..

I encourage you don't just take those emails that are sent from your director, really open them up, look at them and then if you have questions on specific measures, we'll have time to talk about that here in a moment.

I want to jump ahead pretty quickly and get our best practices on to give us some things that they're working on. I'm excited that we'll start with Christie Weil. Christie is a nurse. She is the Quality Resources Manager for Shannon Medical Center, and they've been working on a process improvement for reduced readmissions. So, Christie, if you're on the line, *6 and tell us what you've been working on.

Christie: All right. Good morning everyone. My name is Christie. I am from Shannon Medical Center in San Angelo, Texas. One of the things that we've been working really hard on is our heart failure readmissions. That was something we identified a little over a year ago looking at our trends that we were kind of creeping up. We actually had hit about 27.5 percent on those CMS 65 and older heart failure readmissions, so we thought we really need to step in and do something about this.

Some of the things that we actually starting was we actually hired a transitional care nurse. She based her patients off of BOOST and LACE criteria. Those were the patients she went and saw while they were still in the hospital. We created a heart failure form that showed them the red, green, yellow. If they're in the red, obviously need to come to ER. If they're in the green, it listed out the symptoms, just need to call your primary care provider. Those type of things, and we felt that was really helpful. We had our marketing help us create a heart failure patient manual. It was for any literacy level, color pictures, it had a weight log in the back, blood pressure log, all those type things to start really reaching out to these patients. The transitional care nurse and myself, we started meeting with a couple of the nursing homes here in town. We did discover that on a lot of our heart failure readmissions, they were ones that we were sending to nursing homes that provided Snif care. We reached out to them and started actually working with a couple of those local facilities having regular meetings with them to see if they could help us treat and manage these patients there in the facilities instead of a lot of times their first reaction was send them to the ER.

We did implement a program in our emergency department using an iodine alert. The iodine alert would help the ER identify if that patient had just been in the facility as a heart failure admission. It would trigger on any patient that had been here within the previous 30 days with a heart failure admission just to give the ER a heads up, this patient was just here. That way they would know this was going to be a readmission. We would do our best on a lot of those patients, and even our low risk heart failure patients, treat them with maybe give them a dose of IV Lasix and let's just get them an appointment the next day in cardiology clinic.

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Lucky for Shannon, we are unique in that we own our clinic and our physicians belong to us. Even our clinic physicians that maybe don't even see patients in the hospital, they're ours and that really helps. We use a lot of incentives to drive the care and go the direction that we need to go with our patient care.

Now we've got the ER on board. They're helping us with these patients. Instead of again, their first initial reaction just putting them in the hospital and let the attendings deal with it. That really helped impact in the ER.

This summer we hired a gerontologist, which is the first time Shannon had ever had a physician that then could start working even with the nursing homes. That was a big thing for us as well.

We also started really pushing transitional care management codes on the clinic. Probably in the last year or two, we have made that a top priority in the clinic setting so they're seeing these patients within seven days. We actually had our cardiologist take it through our med exec committee, and we have it approved now that all heart failure patients are discharged with a heart failure appointment. We got a little bit of kick back obviously from some of the attendings that felt like I can manage my own patient, I can handle heart failure, those type things. But, we did get that approved through our senior leadership that they're not here to take over your patient, they're here to help manage the patient. We were able to make sure that every patient that works out of our door has an appointment within seven days, and usually that appointment within seven days is not only with the heart failure clinic but because of the TCM codes, with that primary care provider as well.

With a lot of these things going on, we do look at our readmissions on a monthly basis in our readmissions committee. Those readmissions kind of go up the chain. They go up to cardiac care committee, which is a bimonthly meeting, QMC, Quality Management Council, which is once a month and then it even goes up to our board of directors.

Some of the things that I look at when I look at the heart failure readmissions, what I break each heart failure re-admission down for is I look at their admission date, did they leave the hospital with that seven day appointment, which provider made the appointment, what was the appointment date. I look at where the location of the appointment was because if it's not within the Shannon organization if they have a primary care provider outside of our organization, I do call that doctor's office. I verify did that patient show up for this appointment. I document who their PCP is. I throw in that admission and that discharge Rothman Index from that initial admission. I note if they went home with any type of home health or if they went to a SNiF. I note the number of days after discharge that they were re-admitted and what the re-admission reason was.

We break down every single re-admission, and we look for patterns, that type of things. One of the trends that we have kind of discovered by looking at this on a

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monthly basis with these heart failure patients, is a lot of them are getting asked on discharge from that re-admission, they are going home at hospice. That's kind of our next step at how can we intervene. Do they need palliative care or hospice on that index admission. Of course that's always a hard topic. Nobody wants to have that conversation. We are really trying to push that into the culture here at Shannon that if they meet criteria and they're end stage, usually these patients have a lot of other comorbidities, let's at least start the conservation. Whether they go home on any type of palliative care or hospice, that's okay, but let's at least start the conversation.

Those are some of the big things that we've done. We have seen our readmissions drop. Second quarter we were down to 15 percent. For Shannon that's really good because when we started this project, we were up in that 27 percent area. We're pretty proud of the work that we've done, and we will obviously continue on with our projects and just always strategizing on different ways to effect this heart failure population.

Cherie Boxberger: Thank you so much Christie. We're going to have some time for questions, but I thought we'll go ahead and have our second presenter and then we can have both of them available for questions.

Irene ... I'm not positive of how to pronounce your name Irene. I apologize ... is a nurse, and she is the Director of Clinical Certification for Doctors Hospital at Renaissance. If you don't mind *6 and tell us about the work that you've been doing as you've improved your heart failure quality.

Irene: Thank you. We are as you had mentioned, a physician-owned hospital. We also are an academic facility so we work with the University of Texas Rio Grande Valley. We have some residents here. I think some of the initiative we've been working on is for the seven-day followup appointment and also some of the other quality measures that we look at for the program. We wanted to share just a few things that have helped us.

We see over six hundred heart failure patients annually. We are also certified as a chest pain center, stroke, heart failure, diabetes. We have multiple certifications so sometimes for the units, they're so many different measures we find that a challenge. We do have a tremendous administrative support. We have a dedicated heart failure coordinator. Something that really helps is, every morning they come in and they look at the census. What we were able to do is we have a [inaudible 00:44:27] electronic medical record, and we were able to build the, basically off of the ICD-10 codes, a census report that gets emailed every day to the heart failure coordinator. She comes in every morning, and she'll look to see if that patient is principally here for an admission related to heart failure and then goes from there as far as ... What we had is find like a discrete field so if the physician enters in a diagnosis of heart failure, we're able to capture that patient on our census. She'll go and she'll look through and make sure that they are meeting all of the measures concurrently.

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We also have worked with our data analyst. Definitely, we recommend finding somebody in the hospital, it might be your IT or quality department person who is very Excel savvy, because we found that we can build, I think he called it a form that based on visual basic. He's able to program if they're on our telemetry floor or if they're in our ICU, we have an email go out to those units once the heart failure coordinator looks at the measures and updates the spreadsheet. Anything that is falling out is highlighted in red, or if it's something that we need a followup on, it gets highlighted in yellow so we are able to track them more concurrently. Our heart failure coordinator rounds three times a week to follow up on all of the quality performance measures.

Also, one of the things that she does, is we work on setting up appointments early. Discharge planning is key. One of the first things is to see what is the discharge plan for that patient, especially once we start getting closer to Thursday, Friday where we're anticipating a weekend discharge. The units have multidisciplinary rounds every day so we anticipate what patients might be being discharged on the weekend, and we try to set up those appointments on Friday or even on Thursday and set them out on day six so that if that patient is still here early next week, we're able to still capture that appointment being set and it doesn't have to be canceled with the clinics.

Some of the challenges that we found were calling the primary care offices or the cardiology offices and they're full. Probably about two years ago, we were able to really sit down with all of the physicians and discuss importance of how the seven day appointment affects readmissions and get them engaged. We do have to talk to their office staff, and if we get any pushback from a physician's office, we will involve our medical director to engage them a little bit more as well.

Let's see what else have we worked on? Another thing is definitely providing education to all the stakeholders like residents. I think we have about two to three years now, we have residents so making sure that when they start that they're aware of what the heart measures are. We started seeing some of the fall outs with some of those physicians as well, then re-enforcing that education. We try to do lunch and learn with the residents. We also go to staff meetings. We created a badge, like a badge buddy. It has all the measures for heart failure on a badge so that way they could quickly reference it.

In our facility, we have our own hospitalist so they're employed by DHR as well as for our cardiology, we also have a cardiology group. We also have private cardiology offices. That was also once of the challenges of getting everybody engaged with these measures. We do present that data at least quarterly to our cardiology committee, and we talk about any barriers or any trends in the data that were seen. We also talk to the hospitalist committee about our data.

Also, we found that involving the pharmacist of the unit can also be helpful. Usually we have a pharmacist that rounds on our telemetry unit. One of the challenges that we had several years ago was the evidenced based beta blocker. We saw a lot of Metoprolol Tartrate being ordered so that was something that

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we had to really educate the nurses, the pharmacist, the hospitalists, residents, everybody to get on the same page with the evidence based beta blockers as well.

Creating reminders in our electronic medical records so if a patient has an ICD-10 of heart failure, if a physician or somebody puts in that discharge order, it's going to create a popup, and it'll just remind them again about all of the measures making sure that they are discharging the patient on appropriate medications and followup.

Another thing is also standardizing your order set. That's a challenge to make sure that the doctors are using the same order sets because a lot of those reminders are built into the order set. We have a task that goes out to the nurses to educate daily. We had to build a form to capture that documentation. A lot of different projects that we've worked on.

I don't know if anybody has any questions for us. *6 to come off mute to ask any questions.

Cherie Boxberger: You can ask questions of Christie or Irene. You can also send any questions that you think of, or maybe if you want to discuss with your team first to that swaquality@heart.org and we-

Caitlyn: I do have a question. This is Caitlyn from Memorial in Colorado Springs.

Irene: Great.

Caitlyn: You said your heart failure coordinator rounds three times per week. Who are they rounding with, just the team or with the patients?

Irene: They usually round by themselves. Usually they'll touch base with the nurses who have those patients, and they also touch base with the charge nurse. We found just to kind of go through each morning and look at the census and grasp what's going on because a lot of the multidisciplinary rounds take place in the morning really early so those rounds usually have the hospitalists or the attending, the nurse, case management, sometimes the pharmacists, could have the social worker sometimes. For us to really be able to see what was pending for that patient, take some time to go through the census list so usually, she does that in the afternoon, and then she'll touch base with the staff and see if any medications need to be adjusted or we need to add any medications, she'll recommend that to the nurse. She might even call the nurse if it's not one of the days that she's really rounding on. We really try to work with our charge nurse or the primary nurse.

Caitlyn: Do you guys do anything special for patient education as well.

Irene: What's interesting is that we did get a grant that's called a care link clinic. We do look at high risk heart failure re-admission patients and we do have those

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coordinators who come in and look at specific population so they do education on the heart failure zones and educate the patients about medications. Usually, it's the primary nurse who's responsible for providing that education and reinforcing the education. If the heart failure coordinator sees if we're not getting an hour of education or we haven't documented that we've given them the written heart failure instructions, she'll follow up with the nurse. Sometimes they do go in and talk to the patient as well, but we try to leave that with the primary nurses to make sure that if the heart failure coordinator isn't there or they're in meetings, it's still is part of their workflow that gets done.

Caitlyn: Okay.

Irene: What the transitional heart failure coordinators do from the care link clinic is they come in and they just also re-enforce that education. We do have in Sterner what's called a power form so it goes over diet, medications, everything that is recommended by Target Heart Failure and the Get With the Guidelines program.

Caitlyn: Okay.

Cherie Boxberger: Good question.

Irene: I think one of the questions that was on the list is PA projects that we didn't really feel worked very well was we had a paper checklist, and we had everything on the paper checklist. We found that they weren't really using it, so we are looking at other ways. I know one of the ideas was to laminate ring cards that can go on the computer on wheels to do this for all the programs just to list all the quality measures. It just helps as a reminder.

We also talked about having heart on the patient's door so that way it can remind everybody on the team. Also, we're a heart failure accredited program so we have to track our daily weights, the NYHA scale. Just having a visual reminder can really help to make sure everybody follows up on the measures.

Cherie Boxberger: I might jump in here that there is when you talk about the paper chart... We're not going to be able to go through them today, but on the slides, you have an introduction to an app, it's a professional app, and it actually has forms inside the app so you can answer those questions. It's like the checklist except then you can email it for instance to your extractor. Anyway, just a side note, that is one of the resources [inaudible 00:56:02] gives kind of a high level review of the remaining slides. It replaces the paper checklist so that might be something that might work.

We're down to about three minutes to go. Katie, you want to just give a quick remaining slides that all of us have.

Katie B.: Yes, and once again, if you didn't receive those slides, please contact Larissa or Cherie or I and we will send those to you.

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Near the end of the slides, you'll see some slides regarding Target Heart Failure and the Target Heart Failure app and some other really great resources. Those are just our new partnership with rebranding our Target Heart Failure. There's a Target Heart Failure app that Cherie just mentioned that diminishes the paper trail for heart failure discharge form, heart failure checklist. The LACE calculator is in that. It's a really great tool that you can carry around with you when you're talking to patients so it's not something you just have to put on paper and then go back to a computer and enter. You can actually do it as you're going. There's some great handouts, Spanish and English. I think they're at a fifth grade reading level for patients that you can actually print out from Target Heart Failure, but you do have to register as a Target Heart Failure hospital. It's free. It's easy. The way to get there, the link is in those slides. They way to get the app is in those slides. If anybody has any questions about any of that, please let us know, and we will walk you through that. You don't have to work with your IT. You can do it right now as we are talking. It will work on any tablet or phone.

The other resource that I just want to make sure you guys knew about, Scientific Sessions is being held in Anaheim, California. There's a nursing symposium Monday, November 13. That evening, award winning hospitals ... If you won a Get With the Guidelines award this last year, there will be a reception that night, a recognition banquet. If you guys are going to Scientific Sessions or have the money to go to Scientific Sessions, please let us know if you haven't registered, we will help you do that.

There is a webinar about diabetes and heart failure Tuesday, November 7, from 1:00 P.M. to 2:00 P.M. We will get you that information if you are interested in that. It's a great one by Dr. [inaudible 01:20:16].

Those are a quick overview of the resources.

I'm gonna kick it back to Cherie real quick to open it for any last minute questions.

Allison: Katie.

Katie B.: Yes.

Allison: This is Allison in the Houston area with AHA.

Katie B.: Hi Allison.

Allison: Hey. I just had a quick question for our two hospitals that shared best practice. I was just curious what they have put in place with their physicians and other care providers to encourage the prescribing of an aldosterone antagonistic at discharge. That seems to be a struggle I hear a lot of hospitals in my area talking about that they are just not getting physicians really on board with that and that it's kind of a controversial topic, I guess.

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Katie B.: I'll kick that to Christie or Irene if you want to jump on and address that, it would be great. Or, anybody on the line. Yeah, anybody. I'm sorry I was just referring to them, but anyone can.

Irene: I think it's just having a medical director whose also very engaged and willing to address some of the concerns with the physicians directly. If we find that a doctor is not prescribing the appropriate recommended guideline medications, we'll have our medical director review the case and then we send them with what we call a loop closure letter so we try to provide them with education in a letter. Or, we'll have our medical director also reach out to them, or we'll followup with them ourselves, depending on who the physician is.

We try to also discuss new measures so like when the [inaudible 01:00:28] measure came out, discuss it with the cardiology committee as well as the hospitalist committee so that way, they hear their peers' concerns or also that they support whatever the measures are. Pretty much, we've gotten good engagement from our cardiologists and hospitalists here.

Katie B.: Thanks Irene. That's great.

To respect everyone's time, we are at the top of the hour. That was a really great discussion. I know we probably have more, which we can actually carry over to our next heart failure quality exchange if we want to do some more best practices, or please let us know your director or at swaquality@heart.org with any questions. We would love to address them and get on the phone with you.

As a reminder, we do have more quality exchange discussions. It's the same exact phone number. There's a stroke one today at noon, a resuscitation one tomorrow at 8:00 A.M., atrial fibrillation tomorrow at noon and then Thursday morning, there's a coronary artery disease one at 8:00 A.M., which is probably [inaudible 01:01:37]over to more of what you all are doing.

Our next quality exchange for this group will be January 30 at 8:00 A.M. Once again, if there's topics that you want to hear about, things that we aren't addressing that are needs in your hospital, please let us know. This is for you, and we want to do what you guys are needing resources for.

That brings us to the end of this call. If you didn't pre-register, please just email that swaquality@heart.org, let us know you attended. We'll make sure you get the slides and resources we talked about. All attendees will receive a resource mailing and a short survey. That will help us know what you want to hear about next quarter.

Thank you so much to our speakers, Irene and Christie. That was great information, and we so appreciate all of you jumping on and sharing with us.

Until next time, have a great week. Thank you all.

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