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-CAB
2) 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)
Objectives
1) Review of ICD Registry data from PHI can enhance guideline compliance
for primary prevention ICD therapy
2) 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 fields
3) 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 care
6) 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 monthly
3) Implementation of pre-implant ICD form that collects
key clinical data elements electronically
4) Deploy EF stickers on inpatient charts through imaging
departments
5) Deploy electronic CDS tools
6) Tract WCD use and patient outcomes
SCD Prevention Program
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•
•
•
•
•
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 CardioverterDefibrillator(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 LifeVest
Optimal
Medical
EF<36%
•
Office
• Hospital
• Education
Repeat
EF<36%:
ICD
Indicated
EP referral & ICD
Therapy
Follow-up 90
days
Repeat
EF>35%
Non-ICD
indicated
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