# Presentation: 337906

## Quality Cardiovascular Care at Hamilton Medical Center

- Therese White, RN
- Clinical Resource Nurse Cardiovascular Services

**Meeting and Exceeding ****Best Practice**** ****Expectations**

## Hamilton Medical Center

**Hamilton Medical Center**
**Dalton, Georgia**

## About Hamilton Medical Center

- Centered in the heart of the Hamilton Health Care System is Hamilton Medical Center, a 282-bed hospital dedicated to providing quality care and service excellence. Twice named one of the Top 100 Hospitals in the United States by HCIA and Mercer Consulting, Hamilton Medical Center continually receives the maximum accreditation by the Joint Commission on Accreditation of Healthcare Organizations (JCAHO).

## The Level II trauma center, among the state’s busiest, provides outstanding immediate and ambulatory emergency care with an integrated chest pain center. 
Its centers for excellence include psychiatry and substance abuse, diabetes treatment, cancer care and maternal and infant care. 
Hamilton’s technologically advanced diagnostic facility includes a fully-accredited laboratory, a fully equipped imaging center and outpatient neurodiagnostic center.  The medical center is also home to an advanced computer radiology system, an ambulatory Surgery Center and outpatient women’s pavilion featuring mammography, ultrasound and bone densitometry capabilities.

- Its centers for excellence include psychiatry and substance abuse, diabetes treatment, cancer care and maternal and infant care.
- Hamilton’s technologically advanced diagnostic facility includes a fully-accredited laboratory, a fully equipped imaging center and outpatient neurodiagnostic center.  The medical center is also home to an advanced computer radiology system, an ambulatory Surgery Center and outpatient women’s pavilion featuring mammography, ultrasound and bone densitometry capabilities.

**About Hamilton Medical Center**

## Cardiovascular Services at Hamilton Medical Center include:
Chest Pain Center
Medical Intensive Care Unit
Cardiac Short Stay Unit
General Cardiac Care Unit
Diagnostic Cardiology Department
Cardiac Catheterization Laboratory\
New E.P. Lab Coming Soon

- Chest Pain Center
- Medical Intensive Care Unit
- Cardiac Short Stay Unit
- General Cardiac Care Unit
- Diagnostic Cardiology Department
- Cardiac Catheterization Laboratory\
- New E.P. Lab Coming Soon

**Cardiovascular Services**

## The Cardiovascular Service Line Team has been instrumental in the continual identification and implementation of measures to improve Cardiovascular care at Hamilton Medical Center.  The multidisciplinary team is represented by:

**Cardiovascular Services**

- 7 Cardiologists
- ECD Medical Director
- Hospitalist Director
- 2 Organizational Vice Presidents
- Chief Nursing Officer
- Cardiovascular Director

- Clinical Resource Nurse
- Cardiovascular Service Associates from each CV unit
- PI Director
- Laboratory
- Respiratory
- Radiology

## Identifying and Implementing Best Practice Compliance Tools

- Pathways in Cardiovascular Care
- Chest Pain Center Pathway
- Acute Myocardial Infarction Pathway
- Congestive Heart Failure Pathway
- Acute Coronary Syndrome/NSTEMI Pathway

## Universal Smoking Cessation Counseling
Every patient admitted to Hamilton Medical Center receives smoking cessation counseling. 
Counseling includes a written booklet taken from Clinical Practice Guideline on Smoking Cessation developed by a non-Federal panel of experts  sponsored by the Agency for Health Care Policy and Research. 
The booklet is included in all admission packets and counseling is completed at the time of admission or as soon as feasibly possible.

- Every patient admitted to Hamilton Medical Center receives smoking cessation counseling.
- Counseling includes a written booklet taken from *Clinical Practice Guideline on Smoking Cessation* developed by a non-Federal panel of experts  sponsored by the Agency for Health Care Policy and Research.
- The booklet is included in all admission packets and counseling is completed at the time of admission or as soon as feasibly possible.

- Identifying and Implementing Best Practice Compliance Tools

## Discharge Instructions 
Patient discharge instruction were revised and formatted to prompt nursing associates to document the required educational components to assure Best Practice Compliance, including diet, activity, weight monitoring, indicators for physician follow up and home medications.

- Patient discharge instruction were revised and formatted to prompt nursing associates to document the required educational components to assure Best Practice Compliance, including diet, activity, weight monitoring, indicators for physician follow up and home medications.

- Identifying and Implementing Best Practice Compliance Tools

## Best Practice Prompt Forms
AMI
CHF
ACS
In addition to CMS requirements, all Best Practice Prompt forms include indicators for early identification of Chronic Kidney Disease in the Cardiovascular Disease patient population.  (CKD/CVD Collaborative: Georgia Pilot Project of GMCF and The National Kidney Foundation)

**AMI**
**CHF**
**ACS**
**In addition to CMS requirements, all Best Practice Prompt forms include indicators for early identification of Chronic Kidney Disease in the Cardiovascular Disease patient population.  (CKD/CVD Collaborative: Georgia Pilot Project of GMCF and The National Kidney Foundation)**

- Identifying and Implementing Best Practice Compliance Tools

## Implementation of the Best Practice Prompt Tool

- Education in Best Practice Expectations and  Awareness of Best Practice Prompt Initiative
**Physicians**
**Nursing Associates**
**Clerical Staff**
**Supplying Best Practice Expectations and Reporting Practices**
**Introduction of form and appropriate utilization**
**Empowering Nursing Associates to identify and address areas of non-compliance**

## Best Practice Prompt Tools

**Attention All Health Care Providers, **
- This patient has been admitted on the ___ Clinical Pathway.  The following BEST PRACTICE GUIDELINES have been identified in the most appropriate course of treatment for ___ by one or more of the following organizations the ACC, AHA, NCEP, or NKF.  This form is a tool, intended to help our facility comply with best practice standards and evidenced based practice reviews by this institution as well as other agencies including CMS and JCAHO.  Compliance data from these reviews may be subject to publication.  HMC data is available upon request. ** This form will not be included in the permanent Medical Record.**

- This alert is included for health care providers on each prompt tool specified by diagnosis.

## Best Practice Prompt Tools

**Acute Care**
**Aspirin on Arrival (or documented contraindication)**
**Beta-blocker on Arrival (or documented contraindication)**
**Thrombolysis within 30 minutes of Arrival**
**Smoking Cessation Counseling**
**Documented Estimation of Left Ventricular (LV) Function**
**Discharge**
**Aspirin at Discharge (or documented contraindication)**
**Beta-blocker at Discharge (or documented contraindication)**
**ACE-Inhibitor prescribed at Discharge for patients with LVSD (or documented contraindication)**
_**Is LDL > 70?  (LDL Goal is <70 for CHD risk or CHD risk equivalents per NCEP)**_
**Statin Therapy (or documented contraindication)**
**Patient Education for Therapeutic Lifestyle Changes (TLC)**
_**Renal Assessment – Participation in CKD/CVD Collaborative**_
_**IS GFR LESS THAN 60?  **__**	**__**GFR < 60 NECESSITATES:**_
**Documented Assessment of Hypertension**
**ACE-I / ARB Therapy (or documented contraindication)**
**Dietary Consult**
**Dietary Discharge Teaching**
_**GFR < 60 with HGB < 12 indicates**_
**Evaluation for Anemia **
**Treatment of Anemia**

## Best Practice Prompt Tools

_**Congestive Heart Failure – CORE MEASURE STUDY**_
**Documented Estimation of Left Ventricular (LV) Function**
**ACE-I or ARB prescribed at Discharge for patients with LVSD (or documented contraindication)**
**Smoking Cessation Counseling**
**Complete Discharge Instructions**
_**Renal Assessment – Participation in CKD/CVD Collaborative**_
_**IS GFR LESS THAN 60?  **__**	**__**GFR < 60 NECESSITATES:**_
**Documented Assessment of Hypertension**
**ACE-I / ARB Therapy (or documented contraindication)**
**Dietary Consult**
**Dietary Discharge Teaching**
_**GFR < 60 with HGB < 12 indicates**_
**Evaluation for Anemia **
**Treatment of Anemia**

## Best Practice Prompt Tools

_**ACS/NSTEMI BEST PRACTICE INITIATIVE (CRUSADE)**_
**Acute Care (within 24 hours of presentation)**
**Aspirin on Arrival (or documented contraindication)**
**Low molecular weight or Unfractionated Heparin (or documented contraindication)**
**Beta Blocker (or documented contraindication)**
**GP IIB-IIIA Inhibitor (or documented contraindication)**
**Discharge**
**Smoking Cessation Counseling**
**Dietary Modification Counseling**
**ACE-Inhibitor prescribed for patients with LVSD <40%, HTN, CHF or DM. (or documented contraindication)**
**Aspirin at Discharge (or documented contraindication)**
**Combination ASA and Clopidogrel for 9 months after UA/NSTEMI.  Clopidogrel for 9 months after PCI (or documented contraindication)**
**Beta-blocker at Discharge (or documented contraindication)**
**Documentation for Cardiac Rehabilitation Plan**
_**Is LDL > 70?  (LDL Goal is <70 for CHD risk or CHD risk equivalents per NCEP)**_
**Statin Therapy (or documented contraindication)**
**Patient Education for Therapeutic Lifestyle Changes (TLC)**
_**Renal Assessment – Participation in CKD/CVD Collaborative**_
_**IS GFR LESS THAN 60?  **__**	**__**GFR < 60 NECESSITATES:**_
**Documented Assessment of Hypertension**
**ACE-I / ARB Therapy (or documented contraindication)**
**Dietary Consult**
**Dietary Discharge Teaching**
_**GFR < 60 with HGB < 12 indicates**_
**Evaluation for Anemia **
**Treatment of Anemia**

## Reporting Best Practice in Cardiovascular Services

- Performance Improvement Committee
- Quarterly reports indicating Best Practice Compliance reported by CMS are provided for Cardiovascular Services by the Service Line Facilitator.
- Ongoing communication between the PI Department and Service Line Facilitator to evaluate data on a more concurrent basis.
- Restructure of Case Management Department to further improve compliance by providing “real time” data.

## Disseminating data to physicians and associates in an effort to highlight areas of success and identify areas for improvement
Service Line Team Meetings
Monthly Staff Meetings
All Cardiovascular Units
Cardiovascular Services Newsletter, Heart Murmurs
Written notice in the event of non-compliance

- Service Line Team Meetings
- Monthly Staff Meetings
- All Cardiovascular Units
- Cardiovascular Services Newsletter, *Heart Murmurs*
- Written notice in the event of non-compliance

- Reporting Best Practice in Cardiovascular Services

## Plan for Further Improvement

- Pre-Printed Discharge Orders as an addition to each Cardiovascular Pathway prompting discharge compliance for Best Practice measures
- Restructuring of the Case Management Dept. to each nursing unit to further improve compliance by providing “real time” data and more efficiency in patient placement and length of stay.

## Ongoing Pathway Revisions
Prompted Shift Assessments to ensure consistency in documentation
Shift assessments will include an early warning score  and the discharge plan

- Prompted Shift Assessments to ensure consistency in documentation
- Shift assessments will include an early warning score  and the discharge plan

- Plan for Further Improvement

## Quality Cardiovascular Care at Hamilton Medical Center

- Therese White, RN
- Clinical Resource Nurse Cardiovascular Services

**Meeting and Exceeding ****Best Practice**** ****Expectations**

## Thank You