Background: Contrast induced nephropathy [CIN], because of its delay in onset, is often not clinically appreciated. While delayed assessment of renal function may show substantial recovery of renal function, episodes of CIN contribute to further deterioration of renal function. Angioplasty is currently predominately performed “ad hoc”, with the anatomy defined at the time of the procedure, increasing the contrast load. Concerns have also increased with the routine Emergency Room use of “triple rule out” contrast CTA (coronary obstruction, aorta dissection, pulmonary embolism) for chest pain, shortened stays and a reduction in “unnecessary” post procedure testing decreasing the detection and apparent incidence of CIN. Objectives: Procedural management of patients undergoing Catheterization [Cath] and Angioplasty was analyzed using Failure Modes and Effects Analysis [FMEA] and Mehran’s formula for predicting risk of CIN and weighting of risk factors to predict severity. The likelihood of occurrence and detection were derived from the cohort of patients undergoing Cath at Stony Brook University Hospital. For patients undergoing Cath preprocedural concerns included; preop hemodynamic assessment, unknown baselines (renal function, hematocrit), diabetes mellitus, inadequate hydration, estimation of maximum contrast load to avoid CIN, avoidance of nephrotoxic agents. Procedural concerns included: contrast type and volume, hydration/ end organ perfusion, use of IABP, unnecessary procedures/potential staging. Post procedural concerns included: adequacy of hydration, follow-up monitoring of renal function. Results: Procedural analysis reveals multiple opportunities for intervention to decrease the likelihood of CIN. The interventions most likely to improve the risk of CIN were identified as adequacy of hydration and limitation of contrast administration. Follow-up monitoring of renal function, with involvement of nephrology for management if indicated, was also deemed critical. Changes to the preprocedural order set in the EMR have been proposed to decrease the NPO interval, propose default hydration, suggest holding nephrotoxic drugs, provide an estimated maximal contrast volume. The ACIST injector will be reset to provide lower default contrast delivery. Education of physicians and staff to monitor and limit contrast use as possible is also underway. Conclusions: The risk of CIN can be lessened by appropriate recognition and treatment. FMEA in conjunction with the Mehran CIN prediction formula provides an effective means of identifying procedural concerns that can be appropriately targeted in the Cath Lab.

Objectives: Same day cardiac interventions are increasing; concerns that are not immediately apparent may be neglected. We sought to determine if pts at higher risk of contrast nephropathy are identified, appropriately treated and followed. Background: Contrast induced nephropathy [CIN] impacts on mortality risk; ranging from transient renal impairment with full recovery, to cumulative impairment, to renal failure and the need for permanent dialysis. Preprocedural modifiable [hydration status, contrast reexposure <72 hrs, nephrotoxic medications], partially modifiable [hypotension & heart failure], and non-modifiable [baseline renal function [eGFR<60], age >75 yrs] risk factors influence risk. Procedural factors [contrast volume, hypotension, IABP patients] increase risk. CIN risk is decreased by optimizing risk factors and hydration, minimizing contrast. Post procedure the Mehran CIN predictor is calculated and a 48 hr post IP or 7 day OP creatinine is obtained to identify CIN. Procedure: From 2016-17 pts undergoing interventional procedures exceeding the lab standard for radiation exposure were selected for review as representing a cohort likely to have increased contrast exposure. Results: There were 3,996 procedures [2,436 diagnostic, 1,560 interventions] performed in the reviewed period. Of 56 outlier pts, 11 were treated for structural heart disease and 45 underwent coronary angioplasty. Pre procedure risk factors included: age >75 [19/56], DM [19/56], HF [25/56], CKD 3 [12/55; 1 pt on HD]. Opportunities for decreasing contrast: LV gram 7/45, prior contrast exposure within 72 hrs 5/45, multivessel intervention 15/45. Few [7/45] of the pts received periprocedural hydration as recommended by the EHR power plan [cited reason heart failure 25/45]. Contrast use was as high as 475 cc; use of biplane imaging was infrequent. The Mehran CIN risk score was low in 13/55 [7.5% CIN/0.04% HD], intermediate in 36/55 [14.0% CIN/ 0.12 HD], high in 7/55 [26.1-57.3% CIN/ 1.09-12.6% HD]. Pre procedure creatinine was not available in 1 pt and volume of contrast administered undocumented in another pt. 48 hr creatinine was documented in 33/56 pts; 10 of the 33 pts developed post procedure CIN. Conclusions: Shortened hospitalizations decrease the awareness of and preventive treatment for CIN. A multidisciplinary team has identified multiple opportunities for practice improvement: provider education, review of the EHR power plan [for modification of pre and intraprocedural risk factors, implementation of correctly dosed fluid repletion with renal consultation for high risk patients, appropriate follow-up of creatinine], Preprocedural calculation and intraprocedural monitoring to achieve low risk contrast volume [(ml)/eGFR <3.7}, interventional report embedding CIN risk score, EHR tracking and audit to ensure implementation with appropriate feedback as necessary.

Background: With the development of appropriate use metrics for coronary angioplasty, application of these criteria to the NYS PCI data base resulted in 14.3% of PCIs in NYS being deemed “inappropriate”. While “inappropriate” has been changed to “rarely appropriate’’ in professional society guidelines, public interpretation of this designation, medicolegal issues, and reimbursement for procedures in this category remain concerns. Because the bulk of PCI procedures are ad hoc, appropriateness of treatment is largely determined by preprocedural documentation and treatment. Procedure: The 2010 SBUH “inappropriate” PCI rate from NYS was utilized as a baseline and compared with post intervention Qtr 4, 2012 - Qtr 3, 2013. Trained abstractors audited charts to identify patients that would potentially be classified “inappropriate” and determine which data elements were missing most frequently. A preprocedural screening tool was developed and implemented to establish PCI appropriateness as supported by adequate documentation and preprocedural medical therapy. Pretest outpatient NP screening identified and addressed concerns identified by using the preprocedural tool. A monthly meeting was organized where Physician Specific compliance reports that had been created were reviewed. Results: Baseline “inappropriate” interventions at SBUH comprised 24.8% of total PCI. Inappropriate classification was due to both inadequate documentation and less than optimal medical therapy. Implementation of the PCI AU tool resulted in a sustained decline in the “inappropriate” procedures to 1.6% (NCDR mean 2.5% for this time period). An additional unanticipated benefit of the process has been that the feedback provided to referring attendings continues to improve required documentation and medical therapy supporting PCI revascularization. The tool will be shared at presentation. Conclusions: The combination development of a PCI screening tool for potential ad hoc intervention patients and outpatient review of documentation and medical therapy allowed a substantial improvement in PCI appropriateness. Appropriate feedback to referring physicians augmented the effect of these process changes and improved appropriate utilization.

Background: Personalized benchmarking of practice is assuming increasing importance to assure patient safety and quality, cost-effective care. Comparing performance with national and local benchmarks has value for providing feedback and opportunity for continued practice improvement to the practitioner. From a hospital and practice perspective it can be used to identify outliers and potential concerns (either system or attributable to the individual) as well as its potential uses to reduce variance, validate care, and support “value purchasing” and managed care participation. Objectives: With the input of physicians, hospital administration, and CQI personnel, a tool was developed to allow assessment of individual and aggregate physician performance. The developed tool was developed to meet both personal and institutional objectives. It had to be timely, standardized, and accurate, with available national or institutional benchmarks. Both process and outcome indicators were felt to be appropriate for inclusion. Mandated, validated and relevant data collection was given preference for inclusion (ranked in order of preference: NYS DOH angioplasty data base, NCDR data, in-house non reported data) and objective hard outcomes were given preference over more subjectively collected information. A rolling 4 quarters of data was included for statistically infrequent events to minimize outliers due to sample inadequacy. In addition to tracking process and outcome metrics, utilization was also felt to be appropriate for inclusion. The developed tool incorporated data from multiple data sets with different validation turn around times, which resulted in different reporting time intervals. A total of 38 measures were collected including : mortality, major comorbidity, quality and utilization concerns. Measures deviating from benchmarks or demonstrating substantial variance were targeted for drill down and intervention to improve care. Results: A physician dashboard was developed and applied to 18 interventionalists, permitting benchmarking of individual and overall lab performance in meeting defined process, outcome and volume metrics. The dashboard facilitates individual and system benchmarking of performance, identifies areas of concerns, provides physician feedback, and promotes process improvement. Results are highlighted in green (goal met) or red (goal not met) for rapid assessment. The developed dashboard will be displayed. Conclusions: A dashboard was created to provide timely, rapid, visible assessment of comparative physician performance. The developed tool has proven useful to both hospital administration and physicians in monitoring and improving performance. The dashboard continues to evolve with continued periodic modifications addressing specific goals and concerns.

Introduction: Despite advances in angioplasty equipment and technique, reducing the incidence of CVA has remained an elusive target. Strokes increase mortality, cost and length of stay, residual disability. Hypothesis: 1. Monitor and benchmark CVAs, 2. Drill down for predictors, lapses in care, 3. Form a multidisciplinary group to identify failure modes, process controls. Methods: CVAs complicating coronary PCI from 2017 to present were reviewed. Results: There were 32 CVAs [5 hemorrhagic; 27 thrombotic] occurring in 6410 PCI by 18 operators [0.5%] & 9 deaths [0.28] CVA pts were high acuity: 2 [0.06] post Cardiac arrest, 11 [.34] STEMIs, 8 [.25] Non-STEMIs, 12 [.38] ACS. Age > 65 years in 22 [0.69]. Comorbidity: CVA/TIA/Carotid disease 8 [0.25], PAD 6 [0.19], CKD 4/5 in 3 [0.09], Atrial fib 4 [0.13], LVEF < 35% 12 [0.38]. Ventricular support for cardiogenic shock in 5 [0.16]. Access changed from femoral to radial with 7 CVA [0.22] associated with radial, 22 [0.69] with femoral, and 3 [0.09] with both. Anticoagulation: heparin alone 5 [0.16] and bivalirudin ± heparin in 27 [0.84]. Most interventions utilized bivalirudin. PCI with Heparin & Aspiration thrombectomy, in 5 [0.16] had a higher thrombotic CVA risk. Multidisciplinary review concerns included: 1. pt factors [bleeding/clotting history, current meds and side effects, risk factors for CVA/TIA {e.g. STEMI/non-STEMI, cardiogenic shock, atrial fibrillation, age, carotid disease}, 2. Equipment {e.g. access sheath size and length, catheter preshaped/shaped/multiple, wire [e.g. straight, curved tip, shapeable, hydrophilic, exchange], thrombectomy, angioplasty [balloon, rotoblator, stent], 3. Personnel [experience, volume, trainees], 4. Process [Anticoagulation {timing, heparin,/bivalirudin, dose, monitoring}, Cleaning hands/wires/bowl, Catheter exchanges, Case Duration. Patient monitoring, Brain attack protocol activation and response. Conclusions: The multidisciplinary group formulated a7 C’s Chain of prevention to lessen the risk of CVA: Continuous monitoring , Contributing factor identification, Consensus development of best practices, Cleanliness , Compulsive attention to detail / technique, Communication , Controversies in Care [notably DOACs].