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

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)

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.

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

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

SCD:Primary Prevention

• Beta-Blockers• ACE-Inhibitors• Aldosterone Antagonists• Implantable Cardioverter-

Defibrillator(ICD)

• SCD= Sudden Cardiac Death

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

Low EF Sticker

HIT Tools Embedded in EHR

• Clinical Decision Support EF Alerts

• PINNACLE Registry EF Data Entry

• HIT= Health Information Technology• EHR= Electronic Health Record

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

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

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