AMI documentation

Reviews of AMI records is performed monthly. This is a JCAHO core measure. Eight measures are monitored for compliance:

• ASA received within 24 hours of arrival

• ASA prescribed at D/C

• ACEI for LVSD at D/C

• Adult smoking cessation counseling

• Beta blocker received within 24 hours of arrival

• Beta blocker prescribed at D/C

• Thrombolytic agent received within 30 minutes of hospital arrival (Door to needle time)

• PTCA received within 90 min of hospital arrival (Door to balloon time)

• If ASA or BB are not administered within 24 hours of arrival, then the C/I must be documented in the medical record.

• If a patient comes through the ED and ASA and BB are not ordered, then you will be responsible for checking to see that the ASA and BB are ordered within 24 h.

• In some cases the Pt may present to the ED and not have an AMI until 48 h later.

• If a Pt was taking ASA and BB prior to hospital arrival, then the Pt should be D/C home on ASA and a BB.

• If a Pt received an ASA in the ambulance on the way to the hospital, then the ASA within 24h rule does not apply since there is supporting documentation that the Pt received this medication.

• Always use the standard order set for ACS (cardiac tracks I, II, and III)

• Always use the ACS specific Pt D/C record when D/C Pts.