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Cardiac rehabilitation following transcatheter aortic valve replacement (TAVR) is associated with improved outcomes; however, it remains relatively underutilized in this patient population. As part of a quality improvement initiative, we sought to increase the rate of cardiac rehabilitation referral after TAVR at our institution. We designed and implemented a multidisciplinary program that included education of cardiothoracic surgery providers discharging post-TAVR patients on the benefits of cardiac rehabilitation with participation of cardiac rehabilitation personnel during discharge rounds with the surgical team. The study period was defined as 12 months prior to and 6 months following the implementation of the education program. Overall referral rates increased from 5% to 56% ( P < 0.0001), and referrals placed before hospital discharge increased from 0.8% to 53% ( P < 0.0001) over the study period. In conclusion, a combination of education regarding the benefits of cardiac rehabilitation and cardiac rehabilitation personnel participation in discharge rounds significantly increased referral to cardiac rehabilitation after TAVR., (Copyright © 2022 Wolters Kluwer Health, Inc. All rights reserved.)

Cardiac rehabilitation is a class 1 recommendation for acute coronary syndrome (ACS) patients according to the American College of Cardiology/American Heart Association. However, only 1 in 5 ACS patients are referred for cardiac rehabilitation nationally, and even fewer at our institution. We sought to improve the number of referrals to cardiac rehabilitation for post-ACS patients admitted to our inpatient cardiology service, and ultimately their participation in the program. We designed a quality improvement initiative that included education of patients and house staff, automated referral order, and participation of cardiac rehabilitation staff members on multidisciplinary rounds. We compared the number of patients who received a referral to cardiac rehabilitation, had the first appointment scheduled before hospital discharge, and attended the program before and after our intervention. Six months after initiation of the project, the proportion of ACS patients referred to cardiac rehabilitation before hospital discharge increased from 10% to 43% (P < 0.001). The mean number of patients with a cardiac rehabilitation appointment scheduled before discharge was 2 before and 5 after the intervention (P < 0.001), and the mean number of patients who attended their scheduled appointment was 1 before and 3 after the intervention (P = 0.001). Run charts demonstrated that the number of referrals and the number of scheduled appointments remained above the median following the intervention. In conclusion, an initiative that included education, automated referrals, and direct one-on-one contact with cardiac rehabilitation staff before discharge increased the number of cardiac rehabilitation referrals, and appointments scheduled and attended in post-ACS patients., (Copyright © 2021 Wolters Kluwer Health, Inc. All rights reserved.)

Medication nonadherence is a strong predictor of adverse events and unplanned 30-day readmissions in post-myocardial infarction (MI) patients. Nonadherence with dual antiplatelet therapy (DAPT) is of particular concern in post-MI patients, given the high rate of percutaneous coronary intervention in this population. Review of post-MI quality measures revealed that compared to national benchmarks, our safety net hospital had lower DAPT adherence rates and higher unplanned 30-day readmission rates. The aim was to improve these important quality measures by creating a transition of care pathway primarily focused on medication accessibility and affordability of DAPT and early follow-up. A multidisciplinary task force created a transition of care pathway that included bedside medication delivery, patient assistance program enrollment for medications, and follow-up within 10 days of discharge in a dedicated post-MI clinic. Resources for the pathway (personnel and hospital) were already available and repurposed. We compared quality measures of DAPT adherence, proportion of patients evaluated early after hospital discharge, and unplanned 30-day readmissions before and after the initiative. Following initiation of the transition of care pathway, DAPT adherence increased from 56% pre-intervention to 92% post-intervention (P < 0.0001). The proportion of patients scheduled for early clinic follow-up after discharge increased and unplanned 30-day readmissions decreased following initiation of the pathway. A transition of care pathway for post-MI patients using readily available resources was associated with increased DAPT adherence and decreased 30-day unplanned readmissions., (Copyright © 2020 Wolters Kluwer Health, Inc. All rights reserved.)

Background: Financial penalties rendered by the Centers for Medicare and Medicaid Services have brought about new challenges for safety net hospitals that serve a vulnerable patient population with risk factors associated with high readmission rates. Our goal was to determine the 1-year trajectory of unplanned readmissions in post-myocardial infarction (MI) patients, and to identify factors associated with readmission., Methods: A total of 261 acute MI patients admitted from April 2015 to April 2016 were evaluated in a multidisciplinary cardiology clinic within 10 days of hospital discharge and baseline characteristics and medical comorbidities were collected. Readmission and mortality data were obtained at 1 year through chart review and telephone follow-up., Results: At 1 year, there were 90 (34%) unplanned readmissions of which half were for noncardiac diagnoses. Of these, 69 patients (77%) were readmitted once, 16 (18%) were readmitted twice, 2 (2%) were readmitted 3 times, and 3 (3%) were readmitted 4 times over the subsequent year. Cardiac causes of 1-year readmission included recurrent MI in 23 (9%) and decompensated heart failure in 18 (7%) patients. Depressed left ventricular systolic function (hazard ratio, 2.23; 95% confidence interval, 2.00-2.44; P = 0.0003) and diabetes mellitus (hazard ratio, 1.60; 95% confidence interval, 1.38-1.82; P = 0.029) were associated with a significantly higher risk of readmission at 1 year., Conclusion: Following acute MI, patients are readmitted for cardiac and noncardiac diagnoses well beyond the 30-day mark. This is likely a function of the vulnerability of the patient population rather than a reflection of the medical care provided. More frequent surveillance may attenuate this problem.

Our goal was to assess adherence to American College of Cardiology/American Heart Association guideline-based medical therapy in patients admitted with type I non-ST elevation myocardial infarction (NSTEMI) and to determine factors associated with medication administration delay. We performed a retrospective analysis using data from the Acute Coronary Treatment and Intervention Outcomes Network (ACTION) Registry. Baseline patient demographics, 12-lead electrocardiogram (ECG) findings, laboratory values, medications administered and the time they were administered, and in-hospital clinical outcomes were collected. Global Registry of Acute Coronary Events risk scores were calculated for all patients. We included 1002 patients admitted from the emergency department with a type I NSTEMI. A total of 802 (80%) patients received appropriate initial therapy consisting of therapeutic anticoagulation with heparin and dual antiplatelet therapy. Of the 200 (20%) patients who did not receive therapy, documentation in the chart regarding possible contraindications for administration of the medications was missing in up to half. Female sex, older age, a normal initial ECG, and prolonged time spent in the emergency department were predictors of significant delay in receiving guideline-based medications, while an elevated initial troponin was a predictor of faster medication administration. Global Registry of Acute Coronary Events risk scores had no association with the timing of medication administration. In conclusion, 20% of NSTEMI patients did not receive American College of Cardiology/American Heart Association guideline-based medical therapy. Delay in medication administration was significant for women, older individuals, and patients who did not have ischemic findings on the initial ECG.

As part of a quality improvement project, we performed a process analysis to evaluate how patients presenting with type 1 non-ST elevation myocardial infarction (STEMI) are diagnosed and managed early after the diagnosis has been made. We performed a retrospective chart review and collected detailed information regarding the timing of the first 12-lead electrocardiogram, troponin order entry and first positive troponin result, administration of anticoagulation and antiplatelet medications, and referral for coronary angiography to identify areas of treatment variability and delay. A total of 242 patients with type 1 non-STEMI were included. The majority of patients received aspirin early after presentation to the emergency department; however, there was significant variability in the time from presentation to administration of other medications, including anticoagulation and P2Y12 therapy, even after an elevated troponin level was documented in the chart. Lack of a standardized non-STEMI admission order set, inconsistency regarding whether the emergency department physician or the cardiology admitting team order these medications after the diagnosis is made, and per current protocol, the initial call regarding the patient made to the cardiology fellow, not the admitting house staff, were identified as possible contributors to the delay. Patients who presented during "nighttime" hours had higher rates of atypical symptoms (P = 0.036) and longer delays to coronary angiography (46.5 versus 24 hours, P < 0.001) even in those deemed intermediate to high risk. A process analysis revealed considerable variation in non-STEMI treatment in our teaching hospital and identified specific areas for quality improvement measures.