A Quality Improvement project on the Importance of adherence to ESC guidelines for LV function assessment after STEMI

Qip

Scale of the problem:

• Severe Left Ventricular (LV) dysfunction is the strongest prognostic indicator and carries a high mortality risk.(1) (2)

• ESC Guidelines state "after acute myocardial infarction, both in stable patients and those on optimized heart failure medications, left ventricular ejection fraction should be measured again at 6 -12 weeks to evaluate need for implantation of primary preventive defibrillator ". (3)

• Patients with severe LV dysfunction following myocardial infarctions were being lost to followup.

Figures

Learning Points

Ideas tested/ discussed:

1. Incorporating LV reassessment in discharge summary – cumbersome and complicated.

2. Highlighting need on inpatient echo report – increased workload on echo department.

3. Junior doctor training and ward nurse input-junior doctor rotations pose a challenge.

4. Involvement of Heart Failure team.

Changes implemented:

• The first cycle of the QIP showed that there were no plans in place to reassess LV function in 57% of these vulnerable patients.

What did we aim to accomplish?

• Rectify deficiency and implement a robust, self-sustaining mechanism to identify these vulnerable patients.

• Appropriately screen patients for defibrillator implantation and thus improve patient safety.

How we planned to do this:

• Education and awareness: Junior doctor teaching sessions, CME discussions and posters to emphasize importance of LV function surveillance.

• Team-work: Seek the involvement of other teams such as specialist heart failure nurses and CCU.

What did we achieve?

• The second cycle found that 100% patients were appropriately referred to the HF teams and had OP echo requests for surveillance.

• Enhanced patient safety outcomes.

1. Posters: improved awareness among doctors and nurses.

2. HFN referral: Appropriate initiation of HF foundational therapy and an automatic referral for device therapy, if appropriate.

Reflections and ongoing vigilance:

1. This QIP showed us the importance of being aware of national and international standards of care.

2. The changes implemented were successful primarily due to excellent communication and teamwork.

3. We have planned ongoing surveillance with further cycles.

Take home messages:

1. LV function remains the strongest prognostic indicator after myocardial infarctions.

2. LVSD tends to improve with time and HF medications, but ongoing surveillance is mandatory.

3. Education, awareness, good communication and teamwork can improve patient safety outcomes.