Presentation on theme: "THE CODE STEMI PROJECT: Winning the Race"— Presentation transcript:
1THE CODE STEMI PROJECT: Winning the Race CODE STEMI: ThePinnacleHealthExperiencePinnacle has 2 hospitals with a total of 643 beds. We do about 900 stents/yrAvg 25 STEMI’s/quarterDo not have a cardiologist on site 24/7, Regular Cath lab hours 7a-7pDonald C. Durbeck, MD., FACC
2Baseline PerformanceIn 2005, our compliance rate for percentage of AMI patients receiving PCI within 120 minutes was at 59% with a median time of 110 minutes. The measure would also become more difficult to reach as it was scheduled to be revised in July of 2006, lowering the time to PCI goal to within 90 minutes.
3Evidence Based Approach Strategies which had statistically have been shown to improve outcomes were adopted from an article published in early 2006 entitled “Achieving Rapid Door-To-Balloon Times: How Top Hospitals Improve Complex Clinical Systems3”Bradley EH, Nallamothu BK, Curtis JP, et al. Summary of Evidence Regarding Hospital Strategies to Reduce Door-to-Balloon Times for Patients With ST-Segment Elevation Myocardial Infarction Undergoing Primary Percutaneous Coronary Intervention. Critical Pathways in Cardiology 2007; 6: Looked at 13 studies completed in the past 10 years.Bradley EH, Curry LA, Webster TR, et al. Achieving Rapid Door-to-Balloon Times: How Top Hospitals Improve Complex Clinical Systems. Circulation 2006;113:
4Racing ThemeWe adopted a NASCAR theme from a VHA symposium which suggested we liken ourselves to that of a pit crew who must orchestrate their every move to achieve a safe and fast pit stop. AMI care in the hospital setting must be a highly coordinated, safe, and time sensitive process.
5Create a Task Force Senior Administration Support Key Stakeholders Weekly MeetingsDashboardPhysician ChampionNurse ChampionQuarterly User’s MeetingDana Kellis, M.D. Senior Vice President Medical Affairs & Chief Medical OfficerDonald C. Durbeck, MD., FACC, Chairperson, Department of Cardiovascular ServicesLewis Shaw, MD Chairperson, Department of Emergency ServicesJean Wiest, RN Vice President, Cardiovascular ServicesAmy Helmuth, RN MSN ONC Director, Performance ImprovementEmergency Department Nurse ManagerDirector of Cath LabDirector of NursingPre-Hospital Care ProvidersFTE Dedication FTE for 6 months, .2 FTE maintenanceExcelClocks
8Data Drives Us Initiated by ED nurse Forms kept in bin in cardiac bay Clip-on digital clocks placed on clipboardForm, clipboard, and clocks travel with patient to the cath labCath Lab faxes completed formPerformance Improvement confirms time with scanned medical record and enters into data baseA task force of key stake holders which includes Senior Administration meets once a week for minutes to plan our strategy and review our progress. Other key personnel are invited on a week by week basis depending upon the agenda. An excel spreadsheet is maintained keeping track of each strategy, its progress and assignments made at each meeting. At 1-2 month intervals, a user’s meeting is held to obtain feedback from the front line staff.
9Excel SheetTime Interval CalculationsWeekday or Off hoursDay of WeekBoxed when times confirmed
10Immediate Feedback EARLY CASES Green line – Target goal 90 minutes Pink – Minutes to EKG Very few pre-hospital EKG’s early in projectDark Blue EKG to Activation – Variation in timesPrompt Data Feedback wtihin 1 week: D2B nationally- 57% D2B PA- 69%
11Immediate FeedbackRECENT CASESMuch less variation in process.
12Immediate Feedback Be transparent, list names Bar graphs and Calendar feedback updated within one working day of caseBoth are ed to all members of the projectAssign follow-up tasksPosted for front-line staffEnsure EMS providers also receive feedback
13Door to EKG Pre-Hospital EKG Triage Nurse in Waiting Room 11a – 11p Triage ProtocolDedicated bay for EKGHand Deliver EKG to ED PhysicianminutesBe willing to activate Code Stemi based upon Pre-hospital EKGPre-hospital EKG activates cath Lab: D2B nationally- 48% D2B PA- 34%
14EKG to Lab Activation ED Physician Activates Code Stemi Activate using Pre-hospital EKG when availableminutesContacting the Interventional CardiologistED physician Activates: D2B nationally- 49% D2B PA- 55%
15Activation to Arrival in Lab CODE STEMI TeamOne Call Activation using Central Page OperatorCell Phones vs. PagersScripted EducationPrep Patient – Gown, 2 IV sitesminutesEmergency Department BypassSingle call: D2B nationally- 27% D2B PA- 26%
16ER and Cath Lab Personnel Performance Improvement CODE STEMI TeamER and Cath Lab PersonnelSecurityNursing SupervisorPerformance Improvement
17Scripted Education PROCEDURE FOR EMERGENCY CARDIAC CATHETERIZATION Your physician believes you are having a heart attack. A heart attack occurs when an artery supplying the heart muscle becomes blocked with a blood clot. A heart attack can lead to permanent heart damage and represents a risk to your life. When treating a heart attack, time is of the essence. It is believed that if the clogged artery can be opened, the damage can be lessened and your risk of disability and death may be reduced.Your physician is proposing that you have a procedure called a cardiac catheterization. The goal of this procedure is to identify which artery of your heart is causing the attack. It is performed by a specially trained cardiologist. The procedure is done by placing a tube in an artery in your leg under local anesthesia. Dye is injected into to the arteries of your heart using x-rays. The discomfort from the procedure is generally minor. You will be given sedation as necessary. The cardiologist will attempt to identify the artery with a blood clot and re-establish blood flow by placing a small metal tube called a stent into the artery. You will receive medications to thin your blood…….INTERVENTIONALIST OBTAINS CONSENT
18Arrival to Device Time Room ready during off hours 2 of 3 on call must be within 20 minutesAll expected to be ready in 30 minutesSend patient as soon as 1 cath lab member in lab & interventionalist on siteIntervene on culprit artery firstminutes30 minutes - D2B nationally- 81% D2B PA- 76%
20Analysis of Missed Opportunities Follow up missed opportunities ASAPInterview staff involved in caseFollow all leadsTake results of investigation to weekly task force meetingKeep running list of reason for missesObtain necessary documentation for patient centered reason for delaysEach missed opportunity is immediately reviewed by the Performance Improvement Department and the Medical Director of Cardiovascular Services. All documentation is reviewed and interviews with staff conducted to gain insight into the cause of delays. The results of this investigation are taken to the weekly task force meeting for review and recommendations.
21Patient Related Delays, excluded Required ResuscitationPatient did not give consentNeeded CT Scan to rule out dissectionIn certain situations, clear justified reasons for a patient centered reason for delay are identified and adequate documentation of the delay by a physician is ensured.
22System Delays, not excluded 99 minutes (Door to EKG = 30 min) - Known COPD smoker arrived via EMS with back pain and SOB. Symptoms improved with breathing treatment in ambulance24 minutes -3rd STEMI in a row on a Sunday.112 minutes (EKG to Activation = 40 min) - 1st EKG ST wave abnormality, hesitation to activate as it may have looked like pericarditis103 minutes (Door to EKG = 40 min) – Female c/o bilateral arm numbness, mild SOB, dizzy95 minutes (Activation to Arrival = 50 min) – Cardiologist saw patient in ED before activating the interventionalist.
23Data AccuracyAbstractor’s send list of missed opportunities at end of month to compare with our on-going listUse QNET for resolutionPrior to quarterly submission to Joint Commission vendor, run final list of misses to ensure “mets”/”not mets” are coded correctly
29Program Expansion QUESTIONS? In-Patient CODE STEMI using Rapid Response TeamTransfer Patients from within the PinnacleHealth systemTransfer Patients from neighboring institutionsTransfer CenterHelicopter servicesQUESTIONS?