Primary Prevention ICD Therapy: Tools to Enhance Guideline Compliance
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Primary Prevention ICD Therapy: Tools to Enhance Guideline
Compliance
By: Margaret S. Thomas, RN,CVRN Michael J. Mirro, MD
Alicia S. Floor, AS,RN, Rob L.Plant, PharmD
Parkview Health Fort Wayne, Indiana
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Background
1) Data from NCDR- ICD Registry indicates ICD guideline non-compliance is a significant issue (JAMA 2010;305:91-92) a) Analysis of 111,707 primary prevention ICD implants at 1,227 centers(2006-2009) b) 25,145 (22.5%) implants performed did not meet evidenced-based implant criteria c) 9,257 (37%)implants occurred <40 days post-AMI d) 15,604 (62%)implants occurred in new CHF (<90 days) e) 3,022 (12%) implants occurred in CHF Class IV (NYHA) f ) 814 (3%) implants occurred <90 days post-CAB2) The Department of Justice (DOJ) has launched an investigation of 100 centers nationally to assess inappropriate use of ICD therapy in CMS patients (claims data 2003-2009)
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Objectives1) Review of ICD Registry data from PHI can enhance guideline compliance for primary prevention ICD therapy2) Critical source documentation in the outpatient record is subject to wide variation thus a standardized electronic pre-implant form will assist in documentation of key data fields3) Capture of potential new primary prevention ICD patients should occur through the use of EF alerts in the in-patient/out-patient imaging departments (Echo/Nuclear/Angio)4) Use of Wearable Cardiac Defibrillator (WCD) useful in protecting patient during waiting periods (<90 days new CHF or revascularization)5) Computerized Decision Support (CDS) can enhance guideline compliance at point of care6) Documentation of use or non-use of ICD therapy should occur electronically in the medical record.
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Methods
1) Educate Staff (Posters/Lectures)2) Review ICD Registry Data with CV-EP monthly3) Implementation of pre-implant ICD form that collects key clinical data elements electronically4) Deploy EF stickers on inpatient charts through imaging departments5) Deploy electronic CDS tools 6) Tract WCD use and patient outcomes
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SCD Prevention Program
• Patient Safety Issue : Hospital and Office• Educate All Staff : EF Documentation• Hospital : New CHF and AMI Patients• EF Stickers on Charts• HIT : EF Alerts and Drug Therapy (CDS)• LifeVest Policy : Prevent Patient Loss
• HIT= Health Information Technology• CDS= Computer Decision Support
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SCD:Primary Prevention
• Beta-Blockers• ACE-Inhibitors• Aldosterone Antagonists• Implantable Cardioverter-
Defibrillator(ICD)
• SCD= Sudden Cardiac Death
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Tools to Enhance SCA Prophylaxis
• Cardiac Imaging (Echo/Nuclear/Cath Lab)
• EF Stickers on All Charts (EF<36%)• Electronic EF Alerts for CHF• HIT : Clinical Decision Support (CDS)• HIT : Data Mining Capability for ICD use
• CDS= Computer Decision Support• HIT= Health Information Technology• SCA= Sudden Cardiac Arrest
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Low EF Sticker
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HIT Tools Embedded in EHR
• Clinical Decision Support EF Alerts
• PINNACLE Registry EF Data Entry
• HIT= Health Information Technology• EHR= Electronic Health Record
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SCA Prophylaxis Plan : Documentation
• ICD Implant Candidate• ICD not Indicated (Life expectancy <1
year)• ICD Indicated but needs 90 day wait• ICD Implant Refusal
• SCA= Sudden Cardiac Arrest
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Patient Treatment Algorithm
•Patient Identification EF<36%
• Office• Hospital
• Education
LifeVestOptimal Medical Therapy
Follow-up 90 days
Repeat EF<36%:
ICD Indicated
Repeat EF>35% Non-ICD indicated
EP referral & ICD
MTWA & Holter guided drug therapy & ILR
placement
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Conclusions• Implement Pre-Implant Form in ICD
implants (including generator changes)• Implement EF Sticker plan and follow-up• Implement HIT-CDS tools • Implement Primary Prevention CDS tool
with electronic documentation of ICD use/non-use