MAVSG Mid-America Vascular Study Group (MAVSG) September 11th, 2019 Data Manager's Meeting: 9:00 - 9:50 am Central DuPage Hospital, 25 N Winfield Rd, Winfield, IL 60190 Data Managers Meeting Agenda Overview Welcome Attendance by hospital / clinic list Review of minutes from Data Managers call – 8.15.2019 Celebrate our regional LTFU improvement!!! Tracy Campin, BSN, RN – “Vascular Discharge Medication Project” Questions/ discussion Current hospitals and clinics in MAVSG! Barnes Jewish Hospital UnityPoint Health Des Moines Carle Foundation Hospital University of Chicago Medical Center Columbia Surgical Services, Inc. University of Kansas Hospital Authority Flint Hills Heart, Vascular, Vein Clinic, LLC University of Missouri Medical Center Gilvydis Vein Clinic Weiss Memorial Hospital Iowa Heart Center at Mercy Medical Center University of Iowa Hospitals and Clinics Mercy Hospital Springfield Memorial Hospital of Carbondale Mercy Hospital St. Louis St. Luke's Methodist Hospital Nebraska Medicine Alexian Brothers Medical Center NorthShore Hospital Loyola University Medical Center Central DuPage Hospital Advocate Good Samaritan Hospital Northwestern Memorial Hospital Saint Francis Medical Center OSF Saint Anthony Medical Center Kansas Heart Hospital OSF Saint Francis Medical Center Bryan Medical Center OSF St. Joseph Medical Center Nebraska Methodist Hospital Saint Luke's Hospital of Kansas City AMITA Health Adventist Medical Center La Grange Southern Illinois University School of Medicine Decatur Memorial Hospital SSM DePaul Health Center Loyola MacNeal Hospital SSM Saint Louis University Hospital Loyola Gottlieb Memorial Hospital SSM St. Clare Health Center The Methodist Medical Center of Illinois SSM St. Joseph Health Center Menorah Medical Center SSM St. Mary's Health Center Newest – MercyOne Siouxland Medical Center St. Anthony's Medical Center Saint Luke's Episcopal Presbyterian Hospital Minutes from August Data Manager Call Welcome MercyOne Siouxland Medical Center Welcome new AQC chair - Trissa Babrowski, MD Corrected Regional report – make sure you have the right one! As always – please keep your data managers section current, make Drs and or staff active/inactive in the registry. Spring Regional Reports - Reminder - cases thru 12.31.2019 and entered by 1.31.2020. Long Term Follow-up (LTFU)-LTFU Spring reports will cover 1.1.2017 thru 12.31.2017, entered by 1.31.2020. Cheryl gave highlights from the National meeting in June and encouraged everyone to come to next years meeting. HICN to MBI – a few rules to know-(slides) Discussion and clarification on coding discharge status-(slides) Lets Celebrate some success!!!! 8 centers over 85% !!!! 6 7 HICN to MBI – 2018 CMS Change O will not be used - only zero I will not be used - only 1 8 Question was raised - How to capture - Nursing home vs. Rehab Unit “Why is my percentage of nursing home patients so high?” “Am I abstracting differently?” Questions abstracting? First place to turn is the Data Variable Dictionary and Help Text in Resources. Discharge status from Variable Dictionary V.2.26 Feedback: Skilled Nursing vs. Rehab? 13 LET’S START AT THE VERY BEGINNING…. ▪ Nebraska Medicine joined VQI in 2016 ▪ NMC participates in 7 of 12 VQI modules: ▪ Carotid Artery Stent ▪ Carotid Endarterectomy ▪ Endovascular AAA ▪ Open AAA ▪ Infra-Inguinal Bypass ▪ Peripheral Vascular Intervention ▪ Thoracic and Complex EVAR BASELINE COMPLIANCE NEBRASKA MEDICINE 7/1/16 – 5/31/17 Compliance across each module fell below the national goal of 100% Total Compliance All Modules = 80% ANALYSIS • Outlined Current Process • Worked with vascular team to determine root causes leading to low compliance • Developed solutions • Created chart to summarize process, issues, solutions, timelines, and follow- ups • Categorized critical issues with appropriate solution START WITH A CHARTER KEY METRIC: INCREASE AWARENESS 1. Met with hospitalists to review initiative goal and plan 2. Communication to PCP via email or phone call if patient started on an antiplatelet and/or statin 3. Created a letter outlining the initiative and sent to all referring and primary providers (example below) KEY METRIC: MED ACKNOWLEDGEMENT WITHIN EMR 1. Smarttext created in progress note template within Epic 2. Added Antiplatelet and Statin medications to vascular post-op order sets KEY METRIC: GLOBAL RECOGNITION OF VASCULAR PATIENT ➢ Flag vascular patients in Epic who have a diagnosis of PAD, PVD, or AAA and trigger smarttext to address antiplatelet and statin medications. ANTIPLATELET AND STATIN THERAPY AT DISCHARGE *EXCLUDES PTS WITH A CONTRAINDICATION OR NON-COMPLIANCE 1/1/2016 – 6/30/2019 Discharge Medications 120% 97.5% 98.0% 100.0% 99.5% 96.0% 100% 82.0% 88.0% 80.0% 80% 60% 40% % OF PTS RECEIVING RECEIVING ANTIPLATELET+STATIN % PTS OF 20% 0% 2016 2017 Qtr 1 2018 Qtr 2 2018 Qtr 3 2018 Qtr 4 2018 Qtr 1 2019 Qtr 2 2019 Interventions • Added smarttext in progress note template – added on 5/1/17 • Communication of the initiative sent to primary care providers and hospitalist team - sent out 10/20/17 • Modify vascular order sets to include antiplatelet and statin use – Went into production 6/7/18 CONTROL PLAN Fallouts = Patients who were discharged by a service other than vascular. Problem = Other services are not aware to continue medications started in the hospital Solution = Implement vascular discharge summary smarttext Educate non-vascular providers SUSTAINING IMPROVEMENTS ❖ Continue to monitor discharge medication compliance Track on Spreadsheet, note fallouts, and report quarterly ❖ Documentation compliance Query added to EMR and sent to provider when an antiplatelet/statin is not prescribed SUSTAINING IMPROVEMENTS ❖ Continue to promote initiative awareness Quality article featured in hospital campus newsletter Discharge Medication Poster presented at the local State of the Art Nursing Conference For further details or questions, contact Tracy Campin at [email protected] End of Data Managers Meeting • Questions? • Comments?? • Discussions??? 26 Mid-America Vascular Study Group (MAVSG) September 11th, 2019 Data Manager's Meeting: 9:00 - 9:50 AM Main Meeting 10:00 AM - 3:00 PM Central DuPage Hospital, 25 N Winfield Rd, Winfield, IL 60190 Let us take a moment to remember ….. Thank you for Hosting!!!! Dr. Joe Schneider, MD et al and Barbara Johnson and Heidi Terry – our awesome event planners at Central DuPage! Thank you again! 30 MAVSG Meeting Agenda Welcome and Introduction David Chew, MD Old Business / Approve Spring 2019 Minutes David Chew MD National VQI Update Carrie Bosela, SVS PSO AQC Update Trissa Babrowski, MD VQC Update Ravi Hasanadka, MD RAC Update Nick Nolte, MD GC Committee Update David Chew, MD Regional Data Review David Chew, MD Lunch Break – 12:30 ish Afternoon Presentations: “BMI and Fluoroscopy Time in PVI” Nick Nolte, MD “Using the VQI to Improve Transfusion Practices in Lower Extremity Arterial Bypass” Dr Matt Chia MD “Visceral and Peripheral Interventions for Malperfusion after TEVAR for Type B Dissection” Dr Rhami Khorfan MD MS “Effect of Abdominal Aortic Aneurysm Size on Endoleak, Secondary Intervention and Survival Following EVAR Dr Benjamin Ferrel DO Discharge Statin and Antiplatelet Lorraine Zacarias, RTR, CI, VI New Business / Meeting Evaluation / Next meetings David Chew, MD Adjourn! Safe travels home and thank you for attending!! Welcome and Introductions Barnes Jewish Hospital UnityPoint Health Des Moines Carle Foundation Hospital University of Chicago Medical Center Columbia Surgical Services, Inc. University of Kansas Hospital Authority Flint Hills Heart, Vascular, Vein Clinic, LLC University of Missouri Medical Center Gilvydis Vein Clinic Weiss Memorial Hospital Iowa Heart Center at Mercy Medical Center University of Iowa Hospitals and Clinics Mercy Hospital Springfield Memorial Hospital of Carbondale Mercy Hospital St. Louis St. Luke's Methodist Hospital Nebraska Medicine Alexian Brothers Medical Center NorthShore Hospital Loyola University Medical Center Central DuPage Hospital Advocate Good Samaritan Hospital Northwestern Memorial Hospital Saint Francis Medical Center OSF Saint Anthony Medical Center Kansas Heart Hospital OSF Saint Francis Medical Center Bryan Medical Center OSF St. Joseph Medical Center Nebraska Methodist Hospital Saint Luke's Hospital of Kansas City AMITA Health Adventist Medical Center La Grange Southern Illinois University School of Medicine Decatur Memorial Hospital SSM DePaul Health Center Loyola MacNeal Hospital SSM Saint Louis University Hospital Loyola Gottlieb Memorial Hospital SSM St. Clare Health Center The Methodist Medical Center of Illinois SSM St. Joseph Health Center Menorah Medical Center SSM St. Mary's Health Center St. Anthony's Medical Center Saint Luke's Episcopal Presbyterian Hospital Old Business Changes to the By-laws discussed at our spring meeting and our spring meeting minutes were posted to our regional web site. No objections or corrections were received Any old business for discussion? Motion to approve the spring minutes ? Second ? 33 National VQI Update: Carrie Bosela, SVS PSO Welcome – Newest Center to MAVSG MercyOne Siouxland Medical Center Dr. Chad Laurich [email protected] 18 Regional Quality Groups Number of Participating Centers Location of VQI Participating Centers 600 Total VQI 500 Procedures: now 625,251 400 300 VQI 200 602 VQI Centers 100 601 centers in North America- 46 States and Canada 0 1 center in Singapore Jul-10 Jul-11 Jul-12 Jul-13 Jul-14 Jul-15 Jul-16 Jul-17 Jul-18 Jul-19 Jan-10 Jan-11 Jan-12 Jan-13 Jan-14 Jan-15