Disease Management Acute Myocardial Infarction University Hospital Bern.
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Transcript of Disease Management Acute Myocardial Infarction University Hospital Bern.
Disease ManagementDisease Management Acute Myocardial InfarctionAcute Myocardial Infarction
University Hospital Bern University Hospital Bern
Background:Background:
1995/96 1997 1998 1999/2000
Department of Internal Medicine
Med.Klinik
Cardio- vascularDepartment
Emergency Department
Reperfusion Therapy 1995/96Reperfusion Therapy 1995/96
36
27
64
1511
53
0
10
20
30
40
50
60
70
1995 1996
PTCA
Lyse
No Reperf.
% p
at
Reperfusion Therapy 1995/96Reperfusion Therapy 1995/96%
pat
56
44 44
912
35
0
10
20
30
40
50
60
1995 1996
PTCALyseNo Reperf.
Prehospital delay < 6hPrehospital delay < 6h
Background:Background:
1995/96 1997 1998 1999/2000
Disease Management Acute Myocardial Infarction
Primary PTCA
Disease Management: Acute Myocardial Infarction (I).
• Objectives:
• Analysis and graphic visualization of patient flow from admission – discharge
• Development and implementation of updatable guidelines for the treatment of patients with AMI
• Quality control
Disease Management: Acute Myocardial Infarction (II).
• Objectives:
• Improvement of patient flow
• Reduction of time to reperfusion
• Shortening of hospital stay
• Improvement of clinical outcome
• Contain costs
Simplified Patient Flow of Patients With Acute Myocardial Infarction
ER
Cath.Lab.
Int.C
ICU
WARD Rehab.
Disease Management: Participants
Emergency Department
Cardiology
Intensive Care Unit
Rehabilitation
Administration, Cost accounting, Controlling
Health insurance
total 15 persons
4 days (half time)
1 fellow (cardiology) - 100% three months
1 attending (cardiology) - 50% three months
Behandlungsgrundsätze Akutes Koronarsyndrom
Diagnostik: Anamnese, klin. Status, EKG, (Troponinschnelltest)BE (Hämatologie, Elektroyte, Gerinnung, Kreatinin, Lipidstatus, CK + CK-MB, Troponin I, LDH, ASAT, Röhrchen für Testblut)
Therapie: - 2 l 02 nasal- Nitroglycerinkapsel s.l. 2x- ASS (Aspégic®) 500 mg iv- Morphin iv bei persist. Schmerzen- Heparin 5000 E im Bolus I.v., dann 1000 E/h i.v.- Betablocker i.v. (z. B. Lopresor® 5 mg i.v. max. 3x in 15 min, dann p.o. 3x25 mg/d). Vorsicht: Hypotonie vermeiden, insbes. unmittelbar vor Koronarografie - Bei persist. Symptomen Perlinganit i.v.
Bei A
ufnahme D
iagnose
Diagnose Akuter Myokardinfarkt
UAP/NQWMI Hochrisiko
UAP/NQWMI Hochrisiko
UAP/NQWMI Mittleres Risiko
UAP/NQWMI Niedriges Risiko
Symptome anhaltender Thoraxschmerz plus vegetative Symptome
Prolongierte AP (>20 min) AP + Links-herzinsuffizienz
Ruhe-AP Nächtliche AP
Ruhe-AP Nächtliche AP
Erstmalige AP Erhöhte AP- Frequenz
EKG Persistierende ST-Hebung Neuer LSB
Dynamische ST-Hebung Dynamische ST-Senkung
ST-Senkung (<1mm) T-inversion
ST-Senkung (<1mm) T-inversion
Normal Unverändert
Kardiale Marker
Troponin + CK +
Troponin + (CK (+))
Troponin + CK -
Troponin - (initial und nach 4 h) CK -
Troponin - (initial und nach 4 h) CK -
Mindestzahl pos. Kriterien
2 von 3 1 von 3 2 von 3 2 von 3 2 von 3
Akuter Myokardinfarkt
UAP/NQWMI hohes Risiko
UAP/NQWMI mittleres Risiko
UAP/NQWMI niedriges Risiko
- Direkt PTCAInselspital: alle Patienten falls keine KI Andere Spitäler: bei KI für Thrombolyse oder Hochrisikopatienten (ausgedehnte Ischämie, nach Kammerflimmern, hämodyn. Instabilität, etc.)Begleitherapie: Heparin, GP IIb/IIIa (laut Verordnung Kardiologie)
- Syst. Thrombolyse
Reteplase (Rapilysin®) 2x10 Ei.v. im Abstand von 30 min.,oder Alteplase (Actilyse) bei > 65kg: 15 mg Bolus iv. über 1 min, 50 mg iv über 30 min, 35 mg iv als Infusion über 60 minUFH 1000E/h iv (TZ II: 20-40 sec), oder LMWH s.c.
- Rescue PTCA Bei erfolgloser Thrombolyse (Persistierende ST-, Schmerz) nach 60-90 min., v.a. bei Vorderwandinfarkt oder hämodyn. Verschlechterung
- Schnelle Koronarografie und Revaskularisation (< 12 h)
- Fortfahren mit UFH/LMWH und antianginöser Therapie - GP IIb/IIIa: Andere Spitäler: Beginn mit Tirofiban (Aggrastat) oder Abciximab (Reopro ), Verlegung zur Revaskularisation.
Inselspital: Entscheid nach diagn. Koronarografie. Ausnahme: Wartezeit auf Koronarografie > 1 h
- LMWH (z.B. Enoxaparine (Clexane) 1 mg/kg 2x/d s.c. oder Nadroparin (Fraxiparine) 120 IU/kg s.c. 2x/d)
- Mobilisation
- Ischämienachweis
- Koronarografie bei
1) Auftreten eines Hochrisikokriterium2) Wiederauftreten von Ischämie 3) nach Ischämienachweis
Abkürzungen: LSB: LinksschenkelblockUFH= unfraktioniertes Heparin/LMWH=niedermolekulares HeparinAP=Angina pectoris/ TZ=Thrombinzeit /KI=Kontraindikationen
- Absetzen des Heparins
- Antianginöse Therapie (Betablocker per os)
- Mobilisation
- Ischämienachweis mittels Belastungstest
- Koronarografie bei Ischämienachweis, sonst Spitalentlassung
Anmeldung und Information:Von extern: 031/632 21 11Tagesarzt Kardiologie: 181 62 48Invasiver Oberarzt: 181 76 30Tages-Oberarzt: 181 71 84
Implementation of Disease Implementation of Disease ManagementManagement
1995/96 1997 1998 1999/2000
Disease Management Acute Myocardial Infarction
Primary PTCA
Patient Flow Sheet for Data Collection and Quality Control
First EvaluationFirst Evaluation Disease Management for the Treatment Disease Management for the Treatment
of Acute Myocardial Infarctionof Acute Myocardial Infarction
G.M. Kuster, F. Noti, D. Pfiffner, M. Fleisch, G.M. Kuster, F. Noti, D. Pfiffner, M. Fleisch, S. Windecker, E. Lipp, B. Meyer, B. Meier, F.R. EberliS. Windecker, E. Lipp, B. Meyer, B. Meier, F.R. Eberli
Patients and MethodsPatients and Methods
• Patients with ST-elevation myocardial infarction admitted within 12 hours after onset of chest pain (excl.: Rescue-PTCA).
• Analysis of patient flow: – Door to balloon time, Hospital stay
• Analysis of patient outcome:– In hospital cardiac adverse events– 6 month clinical follow-up
• Comparison of the years before (1998) with the years after (1999, 2000) introduction of DM
19981998 19991999 20002000(first half)
Number of pat. 67 91 58
Age (mean±SD) 64±12 61±13 63±13
Female (%) 22 16 24
Pre-hospital delay 206±194 199±157 235±173(min., mean±SD)
Patient CharacteristicsPatient Characteristics
Measure of Quality of Care for Successful Reperfusion Therapy
0.6
1.6
1.4
1.2
1.0
0.8
1.8
2.0
2.2
0-60 61-90 91-120 121-150 151-180 >180
Time, min
Mul
tiva
ria t
e ad
just
e d
Od d
s f o
r I n
- Hos
p ita
l Mo r
tali
ty
No. of Patients 2230 5734 6616 4461 2627 5412
*
* *
C. Cannon et al. JAMA 2000;283:2941-2947
D.M.: Improvement of Patient Flow in the Hospital
0 1 2 3 40
30
60
90
120
150
180
210
240
270
300
min
utes
1999 2000
82 74
100
1998
Door to Balloon Time = Time from Hospital Admission to Restoration of Normal Flow
Time from Hospital Admission to Cath. Lab.Time from Hospital Admission to Cath. Lab.
49(15-245)
43(5-165)
35(5-150)
0
20
40
1998 1999 2000
min
utes
median (range)
D. M.: Improved Pre-Cath. Lab. Steps
0
2
4
6
8
10
12
14
16
1998 1999 2000
Mortality
Re-MI
In-Hospital OutcomeIn-Hospital Outcome%
pat
ient
s
p<0.003 (Mortality)
In-Hospital Mortality and Re-Infarction
0
5
10
15
20
25
1998 1999 2000
All-Cause
Cardiovascular
Outcome: 6 Mt. Follow-upOutcome: 6 Mt. Follow-up%
pat
ient
s
p<0.003
Mortality (all-cause and cardiovascular)
0
2
4
6
8
10
12
14
1998 1999 2000
MI
UAP
Outcome: 6 Mt. Follow-upOutcome: 6 Mt. Follow-up%
pat
ient
s
Rehospitalisation for Acute Myocardial Infarction or Unstable Angina
Outcome: 6 Mt. Follow-upOutcome: 6 Mt. Follow-up
0
10
20
30
40
1998 1999 2000
% p
atie
nts
p<0.0003
Target Vessel Revascularisation (CABG and/or PTCA)
Comparison of Treatment for Acute Myocardial Infarction
Before and After Introduction of Disease Management
PatientsPatients
1995/96 19981998 1999 1999 2000 2000 (first half)
Number of pat. 56/55 67 91 58
Age (mean±SD) 65±13 64±12 61±13 63±13
Female 29% 22% 16% 24%
Known CAD 32% 27% 23% 13%
S/P CABG 5% 6% 10% 2%
Time from Onset of Symptoms to Hospital Time from Onset of Symptoms to Hospital Admission in Patients with AMIAdmission in Patients with AMI
1998 1999
2000
85 85.5 106
0 1 2 3 4 5 60
90
180
270
360
450
540
630
720
1995 1996 1998 1999 2000
120
220
160 180180
min
ute
s
Cardiogenic ShockCardiogenic Shock (% patients) (% patients)
1316
31
8
4
0
5
10
15
20
25
30
35
1995 1996 1998 1999 2000
% p
at
p<0.02
Length of Hospital StayLength of Hospital Stay (Insel;days)(Insel;days)
day
s
0
5
10
15
20
25
30
35
40
1995 1998 1996 1999 2000
14 13
7 5.5 5
0 1 2 3 4 5 6
day
s
0
5
10
15
20
25
30
35
40
1995 1998 1996 1999 2000
14 13
10
7 7
Length of Hospital StayLength of Hospital Stay (total;days)(total;days)
Patient Outcome: 6 Mt MortalityPatient Outcome: 6 Mt Mortality
79.3
11.5
20.4
3.53.5
18.5
0
5
10
15
20
25
1995 1996 1998 1999 2000
all cause
cardiovascular% p
at
p<0.003
SummarySummary
• The project Disease Management
– had no influence on prehospital delay
– improved patient flow within the hospital, as assessed by door to balloon time
– shortened length of hospital stay
– had a favorable effect on patient outcome, as assessed by a trend towards decreased MACE (death, MI, UAP) and decreased need for target vessel revascularization
ConclusionsConclusions (I) (I)
• The project Disease Management
– improved interdisciplinary patient management
– resulted in a uniform treatment according to evidence based medicine
• Surprisingly, Disease Management changed referral patterns. Patients were also referred for primary PTCA to the tertiary center, when they presented with uncomplicated myocardial infarction in an outside hospital
Conclusion (II)Conclusion (II)
• Disease Management is a helpful tool for improving treatment of patients with acute myocardial infarction.