Utilizing a registry for ST segment elevation myocardial infarction from a tertiary care hospital in Thailand: opportunities to improve the quality of care.

BACKGROUND: Treatment of acute coronary syndrome requires a reliable measurement of quality for ensuring evidence-based care. Clinical registries have been used to support quality improvement activities in some countries, but there are few data concerning their implementation in developing countries. In 2008, a multidisciplinary Siriraj ST segment elevation myocardial infarction (STEMI) registry team was formed with the intention to improve the process of care. This report summarizes observational data collected within the first year to characterize the clinical profile, management and in-hospital outcomes of STEMI patients at the author's institute. MATERIAL AND METHOD: The present study is a prospective, observational study. From June 2008 through June 2009, data from all consecutive patients presenting within 24 hours of STEMI at Siriraj Hospital were collected. The patient's data on demographics, procedures, medications and in-hospital outcomes were collected. RESULTS: During the 1-year period, 112 patients with STEMI were enrolled. The mean age was 59.3 years old and 81.3% were males. There was a high prevalence of diabetes, hypertension, dyslipidemia and current smoking. Median time from symptom onset to presentation was 120 minutes. 98 patients (84.8% of the patients) received reperfusion therapy in the form of thrombolytic therapy (21.4%) or primary percutaneous coronary intervention (PCI, 63.40%). For thrombolytic therapy, the median door to needle time was 68 minutes. Rescue PCI was performed in 20.8% of the thrombolytic treated patients. For primary PCI, the median door to balloon time was 118 minutes. In-hospital coronary artery bypass graft surgery was performed in 6% of the patients. In-hospital mortality rate was 9.8%. Re-infarction and stroke were rare events. CONCLUSION: Despite a high utilization rate of reperfusion therapy the time to reperfusion therapy exceeds the length of time recommended by current guidelines. The authors' findings provide important data for future benchmarking and represent a significant opportunity for quality improvement in STEMI-related care and outcomes.

Use of saline flush to prevent filter clotting in continuous renal replacement therapy without anticoagulant.

OBJECTIVE: This study aims to compare filter life between saline flushed and non-saline flushed strategies in critically ill patients at high risk of bleeding who are undergoing CRRT without anticoagulation. MATERIAL AND METHOD: A cohort of 121 critically ill patients with severe acute kidney injury (AKI) requiring CRRT in the medical intensive care unit (ICU) and cardiac care unit (CCU) of a tertiary care academic center were included. 78 of them used saline flushed through CRRT circuit. RESULTS: There was no significant difference between the two groups of treated patients in baseline characteristics, including the extent of coagulopathy and platelet count. Mean circuit survival was 21.2 h for circuits using saline flush and 20.4 h for those using non-saline flush (p = 0.8).The Kaplan-Meier curves revealed no difference in circuit survival time between saline flushed and non-saline flushed groups (p = 0.8). CONCLUSION: The use of saline flush into pre-filter site of CRRT circuit does not provide any benefit on circuit clotting prevention in high-risk of bleeding patients requiring CRRT without anticoagulant.

Benefit of post PCI medical checklist to improve adhering with best practice guidelines in the patients with coronary artery disease undergoing percutaneous coronary intervention (PCI).

OBJECTIVE: To evaluate the effectiveness of medical and health education checklist according to ACC/AHA guidelines for improving compliance in the patients with coronary heart disease who underwent percutanoeus coronary intervention (PCI). MATERIAL AND METHOD: This study was a prospective cohort study between control group (historical coronary artery disease (CAD) cases who underwent PCI between October 2008 and May 2009) and a case group (CAD cases who underwent PCI between May 2009 and January 2010) at Her Majesty Cardiac Center floor 8th and Cardiac Care Unit, Faculty of Medicine, Siriraj Hospital, Mahidol University. In the control group, basic care proceed. In the case group, usual cares plus medical and health educational checklists proceed at 24 hours Post PCI, before discharge and at 6 months follow-up at PCI clinic. RESULTS: The study consisted of 160 patients, 79 patients in the control group and 81 patients in the case group. In the case group, patient received more frequent use of in-hospital ACE-I (100% vs. 72%, p < 0.001), beta blockers (100% vs. 61.5%, p < 0.001). At 6 month follow-up, the use of ACE-I (100% vs. 84.6%, p < 0.001) and beta blockers (100% vs. 82.1%, p < 0.001), remain higher in the case group. Comparing case group and control group,using the applied post PCI medical checklist correlated with more frequent use of in hospital angiotensin-converting enzyme inhibitors (100% vs. 71.8%, p < 0.001), beta blockers (100% vs. 61.5%, p < 0.001). When looking at the quality of care indicators between two groups at 6 month followup, the patients with DM, CKD in the case group have better blood pressure control according to the guidelines (64.5% vs. 35.1%, p < 0.001). Six-month readmission rates were higher in control group as compared to case group (12.7% versus 5.2%, p < 0.005). CONCLUSION: We found that applied medical and health educational checklists improve both adhering to the best practice guideline and clinical outcome in the patients with CAD underwent PCI.