“Door-to-Balloon Time Trends in STEMI Patients Transferred for PCI”
So much research is happening today in cardiology. Who is doing the research, and where are the patients coming from?
There are many hospitals nationwide participating in research as a part of the National Cardiovascular Data Registry (NCDR®). The NCDR is operated by the American College of Cardiology (ACC), in partnership with leading cardiovascular associations dedicated to compiling data and using it to create and implement protocols that improve care for patients nationwide. The CathPCI Registry®, a partnership between ACC and the Society for Coronary Angiography and Interventions (SCAI), was launched in 1997 as a rigorous method for collecting and analyzing clinical cardiovascular data. Inclusion criteria for the CathPCI Registry include consecutive patients who receive diagnostic cardiac catheterization and/or percutaneous coronary intervention (PCI). The program’s primary goals are to support local quality improvement and to create a place where healthcare providers can find support as they respond to increasing requirements for documentation of processes and outcomes. Today, the NCDR has expanded to include six registries: 5 hospital-based and one practice-based, as follows:
- ACTION Registry®-GWTG™ for high-risk ST-elevation myocardial infarction (STEMI)/non-STEMI (NSTEMI) patients
- CARE Registry® for carotid artery stenting and endarterectomy procedures
- CathPCI Registry® for cardiac catheterization and PCI procedures
- ICD Registry™ for tracking implantable cardioverter defibrillator procedures
- IMPACT Registry™ for adult and pediatric congenital heart conditions (coming soon)
- PINNACLE Registry®, a practice-based registry.
As the NCDR moves forward, there are plans for peripheral registries, to include the extremities, the aorta, the mesentery and the renal vasculature. All of these registries exist for one reason, as put forward in the NCDR Mission Statement:
“To improve the quality of cardiovascular patient care by providing information, knowledge and tools; implementing quality initiatives; and supporting research that improves patient care and outcomes.”
Each registry begins with data gathering to collect demographics, risk factors and registry-specific data points during and post-procedure until the patient is discharged. After the patient’s discharge, the form is completed by adding procedure results, any post-procedure complications, and the patient’s disposition. The data is then entered into either a third-party vendor or directly into the NCDR’s website (www.ncdr.com). Each quarter, the data is submitted to the NCDR for their analysis. The NCDR uses the data from the previous 4 quarters for their analysis, on a “rolling 4 quarters” (R4Q) basis. As a new quarter is added, the oldest quarter is dropped. The official NCDR report is released within approximately two weeks following the submission deadline.
The report is an in-depth document that consists of an executive summary and a detail section. Included in the executive summary are metrics that are either endorsed by NQF (National Quality Forum) or are felt to be notable to hospital executives. These metrics are listed by your hospital’s results, which are compared to all hospitals on the rolling 4 quarters. Following the executive summary is the detail section, expanding the metrics and providing information about each of the data elements collected. The detail section includes the denominator (how many patients are included in this element overall) and the numerator (how many patients met the qualifications in the element). For each element, it is possible to analyze the data and find where your hospital is falling short in comparison to national experience. By evaluating each metric and using the NCDR-assigned patient ID number, it is then possible to investigate each metric and find where problems exist, as well as to discover whether the issue lies in data collection, data entry or is actually reflective of the activities in the lab.
When a hospital is first beginning with a registry, the greatest challenge usually lies in the data collection and entry. Data gathering begins in the cath lab. Anyone who has worked in a cath lab knows how hectic it can be during a procedure, and especially during an emergency. Many data elements are skipped or omitted. It is important, however, that the lab staff correctly identify the data that can’t be found anywhere else: the in-room time, start and finish time, equipment, inflation times, and procedure medications. Having a software package that communicates with the hemodynamic software eliminates many of those problems by requiring the staff to enter the data only one time rather than on the monitor and then again on the paper form. The software also transmits the demographic data, eliminating translation errors in spelling and numbers.
Once the data are out of the lab, someone must complete each form with post-procedure data, audit it for completeness and correctness, and enter it into the software, if data are not automatically captured electronically. This person should have a clinical — preferably cath or electrophysiology lab — background, and be able to devote dedicated time to the task. In a low-volume lab, this can be accomplished as a project; in a high-volume lab, there should be someone dedicated to the registry full time.
There are a few things we have done to make the data gathering more efficient and less cumbersome. The first was to re-create the H&P form that physicians use for every patient brought to the lab. This form is designed to be simple to complete, and can be integrated into existing EMR software. Each section mirrors the data form for the registry, so that the information is in plain sight of the data abstractor. For hospitals with a large outpatient population or multiple physician groups, the form can be either faxed or scanned, and sent by secure email.
Secondly, we have created a special form for PCI. Again, it includes the data elements that are collected by the registry. We complete this form by hand from the cath report and use it for data entry. We find it much easier to read in this organizational format than in the report. This special form for PCI includes places to note a chronic total occlusion, bifurcation lesions, TIMI flow, pre/post stenosis percentage, etc., and, of course, the balloons, stents and other equipment.
Our third special help is a “default list.” We have found some clinicians may assume many facts. In the registry, we cannot assume that there is TIMI-3 flow, or whether a total occlusion is chronic or not. We have created these defaults so that we can make judgment calls from the physician’s dictation. Our physicians have signed off on them to keep us covered in case of an NCDR audit. The NCDR registries support the creation of hospital-generated default lists and requires them to be official policy for the facility.
The process that made the most difference in our results was running reports. We began to use our vendor software to create reports that mirror the metrics on the executive summary. This gives us the opportunity to examine the data and correct any outliers, if necessary, before we make our submission. We know what our report will look like. The most important benefit from this process is our ability to make changes in real time. While other facilities only know what changes to make after the quarterly report is issued, putting them at least 3 months behind, we are able to make adjustments based on monthly data. This keeps our data consistently aligned with the NCDR’s recommendations.
The CathPCI Registry’s newest use comes in the form of Appropriate Use Criteria (AUC), found in a published report.1 The metrics created from the CathPCI Registry, based on this AUC report, examine medical decision-making for appropriate PCI to evaluate best practices and result in safer, more cost-effective care. AUC is a nationwide movement that will affect every hospital and interventional cardiology facility in the United States. Every hospital will benefit greatly from participating in the CathPCI Registry and using the AUC guidelines to improve patient selection and efficient use of PCI for the maximum benefit of the hospital and patients.
The other NCDR registries, ICD, CARE, ACTION and PINNACLE, are newer registries and their metrics are reported in a similar fashion.
The ACTION Registry, a partnership between the ACC, American Heart Association, Society of Chest Pain Centers, and the Society of Hospital Medicine, is making great inroads into lowering door-to-balloon time. The registry uses the metrics associated with first medical contact, whether by an EMT in the field or a physician in his or her office, to discover the first time the cath ST-elevation myocardial infarction (STEMI) team can be called, and who should call them. Ambulance teams are beginning to send electronic messages containing patient information, including the electrocardiogram and vital signs. As the patient is on his or her way to the hospital, the cath team is also driving in. In large cities such as Dallas and Phoenix, this can make a difference in the team staying at home or being required to stay in-house. The bottom line is the ability to shorten the door-to-balloon time to less than 90 minutes, and hopefully save more lives and more cardiac tissue.
The research studies and reports supported and supplied by the NCDR are part of a greater purpose — to maximize patient care while lowering risk and cost. In today’s climate, where cost has become as important as patient care, we as medical professionals must be certain to keep our primary focus in mind — providing the best care possible to our patients. We cannot afford to sacrifice patient care for any reason.
Participants in any of the registries should do everything in their power to ensure that their data is complete and correct. I am available for anyone who would like some assistance in setting up or streamlining their program.
Good luck, have fun with the NCDR, and hopefully we can meet in person at the next annual meeting in Chicago!
Jane Haddox can be contacted at firstname.lastname@example.org.
- Patel MR, Dehmer GJ, Hirshfeld JW, Smith PK, Spertus JA. ACCF/SCAI/STS/AATS/ AHA/ASNC 2009 Appropriateness Criteria for Coronary Revascularization: A Report by the American College of Cardiology Foundation Appropriateness Criteria Task Force, Society for Cardiovascular Angiography and Interventions, Society of Thoracic Surgeons, American Association for Thoracic Surgery, American Heart Association, and the American Society of Nuclear Cardiology. Endorsed by the American Society of Echocardiography, the Heart Failure Society of America, and the Society of Cardiovascular Computed Tomography. J Am Coll Cardiol 2009;53:530–553; originally published online Jan 5, 2009; doi:10.1016/ j.jacc.2008.10.005.