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How to use
Acute Coronary Syndrome (ACS) Implementation Toolkit

Introduction and How to Use the Acute Coronary Syndrome (ACS) implementation toolkit

Welcome to the second edition of the Acute Coronary Syndrome (ACS) Implementation Toolkit, which is designed to enhance the efficiency and reliability of your quality improvement efforts in order to close the gap between best practices and what we currently do in caring for the inpatient with acute coronary syndrome (ACS). ACS is one of the top reasons for admissions in our hospitals and a major source of overutilization of resources—and therefore costs— for our institutions. The Implementation Toolkit is built on the foundation of the core principles of quality improvement, personal experiences and evidence-based medicine. A redesign in process, workflow and information is needed in order to implement effective regimens and protocols that optimize care for the hospitalized patient with ACS in your institution. The second edition encompasses the addition of additional antiplatelet medications available in the market as well as accommodates recent guidelines and nomenclature in the treatment of ACS. Thorough knowledge of the treatment of ACS is considered a Core Competency of Hospital Medicine and whether your practice treats these patients during the "upstream" portion of their treatment (from symptom onset to intervention) or "downstream" (from intervention until admission), understanding the tools used to stratify our ACS patients for treatment, complications and transitions of care is essential. In contrast to the first edition of the Implementation Toolkit, we begin with a thorough review of ACS, with further sections addressing evidence-based treatment strategies and methods to assure compliance and reduce readmissions. The second part of the second edition is an update of performance improvement methodologies to be used by your group to further show your organization value.

The Implementation Toolkit is not meant to be a "one-size-fits-all" program, but only a guide. Also, in contrast to the original edition, links to multiple sources have been added to further assist the end user.

Essential elements for reaching breakthrough levels of improvement in the care of the ACS inpatient include:
I. Part One: Acute Coronary Syndrome

  • Etiology of ACS and review of the new nomenclature established in 2014 that retitles unstable angina/NSTEMI as NSTE-ACS.
  • Initial Evaluation of Patients Suspected of ACS including assessment of symptoms and variations with presentation. This discussion will include identification of ECG changes and evidence-based recommendations for initial management.
  • Risk Stratification is critical to determine the modality of treatment whether it be via an invasive method and the timing of the intervention in addition to predetermine the risks involved with treatment, which is mostly bleeding.
  • Imaging and Diagnostics in Acute Coronary Syndrome is also important to understand and a major source of overutilization of resources. The timing of the studies compared to symptoms is the key to gaining the most from these studies. This section will discuss what the latest evidence reveals about non-invasive studies used in ACS to ascertain appropriate diagnosis and determine plan of treatment.
  • Therapeutic Management. The second edition addresses the different P2Y12 medications available in the market, including the most recent guidelines for the timing of their use. This section also addresses the use of anticoagulation and essential non-antithrombotic therapeutics as well.
  • Discharge and Transitions is recognized as a key component in assuring patient safety, compliance and avoidance of readmissions. This section will reveal best practices to assure appropriate transitions of care.
II. ACS Quality Improvement Program
  • Essential First Steps starting with obtaining institutional support for an ACS Performance Improvement (PI) program to identifying key stakeholders, forming a committee and establishing measures. This section will discuss best practice methods in building engagement in addition to quality improvement resources available for team members.
  • In-Depth Analysis of Current Processes and Failures introduces methods to identify areas in which gaps occur in addition to introducing critical QI tools like process flow mapping.
  • How Will You Know You Are Making a Difference? This section will show key principles of data collection in reporting data in addition to methods to structure, process outcomes and trend metrics. These metrics will allow the team to build a business case for your ACS improvement efforts.
  • Moving from Problems to Solutions using multidisciplinary team developmental intervention methods that link the team's efforts to the rest of the providers in the organization, including PI processes that aid in implementation in addition to recognizing opportunities in patient education and medication safety.


How to Use the Implementation Toolkit

Although it is designed to assist leaders who are starting from scratch, the Toolkit can also benefit teams that have already made considerable progress, as it is unlikely that any institution is performing optimally in all areas. We recommend that all users initially review Essential First Steps and In-Depth Analysis of Current Processes and Failures, which will help to assess your current status on all of the elements explained in these sections. Completing these sections first will put you in a position to proceed with good institutional support and to intelligently prioritize areas for intervention and allocation of resources.

Although the information is presented in an order that may facilitate the development of quality improvement efforts in many settings, you may find it difficult to follow our sequential order, as activities presented in different sections often occur in parallel in real-life settings. Your team should eventually assess and attempt to improve the full range of quality issues involving care of patients with ACS.

The Toolkit incorporates sections of all the essential elements described above to achieve breakthrough improvement. In addition, we highlight important topics and improvement tools such as run charts, process mapping and methods to hold the gains and spread your improvement methods. Methods for demonstrating financial return on investment are also presented.

The Toolkit provides links to guidelines, key references and examples of order sets, algorithms, protocols and educational materials that can be invaluable to your team. We strongly encourage using these materials to build an order set or protocol that you implement while following the general improvement framework presented in the rest of the Toolkit. This framework calls for a multidisciplinary team effort, specific goals, reliable and practical metrics, and monitoring and learning from variation from your protocol. Ignoring these principles can lead to mediocre results and disillusionment.

Following these methods can enable you to demonstrate the value of quality improvement work to your medical center and insurers, both because of the outcomes obtained and because of the cost savings often inherent in higher quality care. With ACS in particular, the pay for reporting/performance initiatives already exist that dramatically improve your ability to demonstrate value to your institution. Demonstrating value in quality improvement and cost savings can then be leveraged for protected time for hospitalists and others to improve the quality of care and safety of the hospitalized patient.

ACS Toolkit Project Team
The first edition of this toolkit was supported in part by an educational grant from the Bristol-Myers Squibb / Sanofi Pharmaceuticals Partnership in 2008.
The second edition of this Toolkit is supported in part by an educational grant from the AstraZeneca in 2015.

The Acute Coronary Syndrome (ACS) Toolkit is an online resource for visitors to the Society of Hospital Medicine's website. All content and links have been reviewed by Acute Coronary Syndrome Toolkit Project Team, however the Society of Hospital Medicine does not exercise any editorial control over content associated with the external links that have been made available via this website.