CORE MEASURES

Are a standardized set of quality measures identified by the Joint Commission in association with the Centers for Disease Control, Centers for Medicare and Medicaid Services, American Hospital Association and the Institute for Healthcare Improvement, Joint Commission (2014).

Core Measures are designed to improve overall patient care by using Evidence-Based Practice to determine appropriate treatments to provide the best outcomes for patients. Hospitals are held accountable by measuring their performance in these core measure areas, Joint Commission (2014).

According to the CDC, 715,000 Americans have heart attacks every year and heart disease is the leading cause of death in the United States CDC (2014).

MI can cause irreversible damage to the heart or sudden death and the odds of surviving increase if clinician follow the time sensitive clinical guidelines outlines in the core measures AHA (2014).

DISEASE PROCESS MI is caused by the slow but insidious buildup of plaque in the arteries over time. This

plaque can rupture and cause ischemia and infarction of the heart muscle. This leads to cell death and necrosis of the affected tissue. The severity of the MI depends on which vessel was occluded and the size of the infarct. Hyperglycemia may be present for the first 72 hours after MI and must be well controlled. It is associated with a high risk of death Huether and McCance (2012).

Incidence: the prevalence of MI is much higher in males and increases with age CDC (2014).

Risk factors: Diabetes, obesity, poor diet, physical inactivity and excessive alcohol use CDC (2014).

Healthcare cost: 108.9 Billion dollars for healthcare services, medications and lost productivity CDC (2014).

Morbidity and mortality: 715,000 American have a MI each year. For 525,000 this will be their first heart attack. 190,000 will have already suffered a MI in the past. Heart disease accounts for one out of every four deaths that occur CDC (2014).

ASSESSMENT OF PATIENTS WITH MIPatients with acute MI generally present with the onset of sudden severe chest pain and may be accompanied by a sensation of pressure. Pain may also be noted in the jaw, neck, back, shoulder or radiating down the left arm. According to the American Heart Association, women may not experience chest pressure but report vague symptoms such as dizziness, shortness of breath, fatigue, upper abdominal pain or flu like symptoms. Some patients do not experience any pain AHA (2014). Heart rate and blood pressure reading may be elevated. The clinician may hear abnormal heart sounds, inspiratory crackles and they may be diaphoretic with cool clammy skin. Nausea and vomiting may also be present Huether and McCance (2012).Relevant medical history may include family history of heart disease, prior history of CAD, hypertension, diabetes, current medications, dietary habits, smoking, exercise habits, stress level and hyperlipidemia.

DIAGNOSTIC TESTS FOR MI Electrocardiogram to evaluate ST segment and presence of LBBB.

ST depression are signs of subendocardial ischemia and ST elevation is indicative of Transmural infarction. The test also identifies the coronary artery that is involved (Huether&McCance P.608)

Serial biomarkers (troponin and troponinT) if serologic test show high levels (troponin 1 >10 or T > 0.1) is indicative of acute myocardial infarction(Troponin test, 2012).

CK-MB and LDH are less specific and may indicate other conditions.

Asymptomatic individuals can go through stress testing, Radioisotope Thallium-201 or Stress echocardiography to detect any coronary obstruction.

Noninvasive coronary angiography using computed tomography, intravascular ultrasound and protein weighted magnetic resonance imaging to evaluate coronary atherosclerotic(Huether&McCance P.602)

Coronary angiography is invasive and used to determine the extent of CAD and whether percutaneous coronary intervention (Angioplasty or Stent placement) or coronary artery bypass is needed.

Another tool, the Physician TIMI Score can be used to determine mortality for patients with unstable angina and non-ST elevation MI, using a scoring system based on:

Historical Age of patient >3 CAD risk factors Known CAD Use of ASA in the past 7 days

Presentation Presence of severe angina in less than 24hrs Elevated bio markers/ST deviation>0.5mm

TREATMENT MODALITIES

ASA 162-325mg unless self administered EKG within 10 minutes of ER arrival Continuous Cardiac monitoring and vital signs IV access and use of MONA Repeat EKG every 10-30 minutes if symptoms continue

with non diagnostic ekg.

www.hcbi.hlm.nih.gov/pmc/articles

MEDICATION MANAGEMENT Vasodilators-Nitrogycerine, beta blockers Statins- Simvastatin, pravastin Anti-thrombolytics- unfractioned heparin,low molecular

heparin Anti-platelets- plavix, ASA, Iib/IIIa glycoprotein inhibitor i.e

ReoPro, Integrillin, Aggrastat Analgesics-Morphine Stool Softeners- Colace

PROGNOSIS

MI leading cause of sudden death Time is muscle(PCI <90 minutes) Irreversible heart muscle damage (CABG) Disturbance of cardiac rhythm Organic brain syndrome impaired blood flow Stroke secondary to detached clots Infection

(Huether&McCance p.609)

MYOCARDIAL INFARCTIONPrevention begins with Understanding risk factors

PATIENT TEACHING GUIDE POST MI

Patient teaching starts with understanding the learning style of each patient and family. Teaching starts with the CCU nurse but needs to maintain consistency as it is taught by the staff nurses, and home health nurses within the care-planning, setting goals and objectives that are realistic.

Preparing the patient and family for “what to expect” in the course of recovery and rehabilitation. This would also include cardiovascular anatomy and physiology, s/s of Angina and MI, and further tests i.e. EKGs, angiograms.

Parameters for activity including sexual activity , maximum heart rate, and to stop when pain or shortness of breath occur.

Patient should “listen to what the body is saying” to prevent overexertion to have an uncomplicated recovery.

Teach about cardiac diet i.e. low salt, and salt substitutes

Dirksen, Lewis Heitkemper

MI AS A CORE MEASURE Myocardial Infarction has evidence based practices (EBPs) that have been proven to

increase patient recovery time and survival rates. The Joint Commission (JC) has set these EBPs in the Core Measures for Quality Care as a “starting point“ for improving patient outcomes

Physician and Nursing staff will have an increased awareness of these EBPs when using the Core Measures for Quality Care guidelines and this will increase their ability to provide structured care that has demonstrated to improve patient outcomes.

Aspirin at Arrival Aspirin Prescribed at Discharge ACE Inhibitor or Angiotensin Receptor Blocker (ARB) for Left Ventricular Systolic Dysfunction Adult Smoking Cessation Advice/Counseling Beta-Blocker Prescribed at Discharge Beta-Blocker at Arrival Fibrinolytic Therapy Received within 30 Minutes of Hospital Arrival Primary Percutaneous Coronary Intervention (PCI) within 90 Minutes of Hospital

Arrival

AMI 30-day Mortality Stellaris Health

NURSING ROLE Initially it is the nurses role to quickly recognize the signs and symptoms of

an MI and call for emergency assistance (Code Blue) Provide the appropriate immediate interventions: IV access x 2, oxygen,

nitroglycerin, aspirin, and morphine if no relief provided. Obtain cardiac enzyme markers, electrolytes, and chest x-ray Obtain a 12 lead EKG to determine if it is a STEMI: complete occlusion of a

coronary vessel characterized by elevation of the ST segment- this establishes the “door to balloon time” need for Cardiac catheterization (PCI) the window is 90 minutes.

Delay in PCI related to rural settings with no Cath Lab available, patients may be treated with fibrinolytics within 30 minutes, such as tenecteplase,streptokinase,Activase or Retevase. Administration of these drugs, limits the progression of the MI by dissolving the thrombus in the coronary artery and restoring blood flow to the ischemic myocardium. Good medical history needed prior to using.

NSTEMI: incomplete occlusion of a coronary vessel and no ST-segment elevation- monitoring and pharmacological interventions.

https://www.nursece.com/courses/80

NURSING ROLESCONTINUED

Continuous cardiac monitoring, note any changes in cardiac function, pain, oxygenation, and respiratory distress

Monitor patients treated with heparin or lovenox , and thrombolytics for bleeding Monitor patients for coronary reocclusion, symptoms such as chest pain, nausea,

diaphoresis, and ST segment elevation usually are similar to those experienced with the original MI, and can occur within the first 24 hours following thrombolytic therapy.

Heart failure occurs when myocardial tissue is damaged and the ventricle no longer works as an efficient pump, heart failure can rapidly decline into cardiogenic shock and occurs when 40% or more of the myocardium has been affected by the infarction.

Reevaluate patients before during and after interventions to determine if symptoms have become worse, remained the same or improved partially or completely, this provides a guide on what treatments have worked and what ones have not and can help with identifying improvements or worsening of patient conditions and need for further interventions.

https://www.nursece.com/courses/80

Core measures benefit both the patient and the health care facility.

Since the MI core measure is standardized, hospitals are able to evaluate how well they are caring for patients based on Scientific and Evidenced Based Practice.

Patients also can benefit by reviewing how well a healthcare facility is practicing based on EBP.

The end goal is to provide best patient outcomes and reduce readmissions.

CONCLUSION

Georgia Regents medical center

About Heart Attacks (2013, January 13). Retrieved February 26, 2014, from The American Heart Association: http://www.heart.org/HEARTORG/Conditions/HeartAttack/AboutHeartAttacks/About-Heart-Attacks_UCM_002038_Article.jsp

America’s Heart Disease Burden Retrieved February 26, 2014 From Centers for Disease Control and Prevention: http://www.cdc.gov/heartdisease/facts.htm

Cheryl Duksta, RN, ADN, M.Ed , Jacquelyn Younker, RN, MSN (2012). STEMI Alert! Rapid Response to Myocardial Infarction. National Center of Continuing Education, Inc., Lakeway, Texas. Retrieved from https://www.nursece.com/courses/80

Hospital core quality measures. (n.d.). Retrieved March 02, 2014, from GRHealth: http://www.grhealth.org/how-we-compare/ContentPage.aspx?nd=2799

Huether, S. E., & McCance, K. L. (2012). Understanding Pathophysiology. St. Louis: Elsevier Mosby. Joint Commission Core Measures Sets (2014, March 5). Retrieved February 26, 2014, from The Joint

Commission:  http://www.jointcommission.org/core_measure_sets.aspx Lewis, S.M., Heitkemper, M.M., & Dirksen, S.R. (2000). Medical Surgical Nursing (5th ed.). St. Louis, Mo.:

Mosby , Inc. Montana cardiac initiative. (2013, August 15). Retrieved from Montana.Gov: http://cardiac.mt.gov/ Stellaris-Core-Measure-Education-Templete- August-2012. Retrieved 2/28/14 from:

https://www.wphospital.org/.../SHN-Core-Measure-Education.aspx Troponin test. (2012, January 11). Retrieved from Medline plus:

http://www.nlm.nih.gov/medlineplus/ency/article/007452.htm Understand your risk of heart attack. (2014, February 4). Retrieved February 27, 2014, from American

heart association: http://www.heart.org/HEARTORG/Conditions/HeartAttack/UnderstandYourRiskofHeartAttack/Understand-Your-Risk-of-Heart-Attack_UCM_002040_Article.jsp

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