1. CARDIAC ALERT: A Change in Process
CARDIAC ALERT: A Change in Process. Results of a STEMI Treatment Protocol Over 5 Years.
Peter Kerwin, M.D.,
Colleen Kordish, R.N.,
June 10, 2008
Downers Grove Illinois
ADVOCATE GOOD SAMARITAN HOSPITAL
MIDWEST HEART SPECIALISTS

2. Optimal care in the time critical process of treating STEMI requires a coordinated protocol with EMS, ED and Cardiology functioning as one team

3. Maintaining optimal quality over time requires continual monitoring and evaluation of data related to the team’s effectiveness.

4. Reasons to Improve Door to Balloon Time
ACC/AHA Guidelines
Mission Lifeline
D2B Initiative
Get With The Guidelines
Core Measures
Marketing

5. Coroner says patient's death is a homicide Woman sought care in ER for 2 hours
By Andrew L. Wang Tribune staff reporter Published September 15, 2006
The death of a Waukegan woman in July after she spent nearly two hours in an emergency room waiting area was ruled a homicide Thursday during a Lake County coroner's inquest.

7. ACC/AHA guidelines Advocate Good Samaritan 2002: 99 min.
Door to intervention time 90 (120 min).
National Average minutes.
Advocate Good Samaritan 2002: 99 min.
Advocate Good Samaritan 2006: 63 min.

8. Decreasing D2B Time: Why Should We Care?
400,000 STEMI per year
1/3 STEMI patients receive no reperfusion therapy
Less than 40% patients receiving primary PCI have D2B < 90 minutes
Less than 10% EMS systems have 12 lead ECG capability
Circulation 2006;113;

9. Time is Muscle! And Mortality!
Each 30 minute delay in reperfusion with PCI increases 1 yr mortality 7.5%
Door to balloon <60 min, 1% 30 day mortality; Door to balloon >90 min, 6.4% mortality
DeLuca, Circulation 2004;109:
Berger, Circulation 1999;100:14-20.

10. Advocate Good Samaritan Hospital
300 bed community hospital
Level 1 Trauma Center
4 cardiology groups- separate call schedules
Primary PCI strategy since 1991

11. D2B- Our History Retrospective baseline 2001- 103 min
review- 55 min
Prospective baseline min
min

12. Cardiac Alert Brings Results:
Advocate Good Samaritan Hospital D2B cases <90 minutes
Cases
% < 90”
Mean
2002 1
17/42
40%
100 min.
2003 1
25/48
52%
94 min.
2004 2
35/46
76%
69 min.
2005 2
51/63
81%
68 min.
2006 2
62/68
91%
63 min.
1Tracked using AHA’s GWTG
2 GWTG/AMI Core Measures

13. CARDIAC ALERT: It’s Not All About Us!
M I D W E S T H E A R T
S P E C I A L I S T S
PETER KERWIN, M.D.

14. CARDIAC ALERT PROTOCOL
“Individual commitment to a group effort- that is what makes a team work, a company work, a society work, a civilization work.”
Vince Lombardi

15. The Cardiac Alert Team The Patient! Paramedics in the field
Triage Staff
ED MD’s
ED RN’s
Cardio diagnostics
Radiology
Cardiac Catheterization Lab
Cardiologists
Primary MD’s
ICU/Floor RN’s
Nurse Clinician/PA’s
CV Surgery

16. Cardiac Alert Goal Door to Balloon < 60 minutes Best Mortality
Achievable Goal

17. Goal for Acute MI Patients
Diagnostic ECG performed, interpreted and cardiologist/ cath lab notified – 5 to 10 minutes.
Cath Lab/Interventionalist notified, patient on table -30 minutes.
Prep- 5 minutes.
Angiogram, first inflation -15 minutes.

18. Goal for Acute MI Patients
60 Minutes
From ED admission to Cardiac Intervention
29 September 2003 “Go-Live” Date for Cardiac Alert

19. Cardiac Alert: Using Data to Implement Change
Map the process
Standardize time
Gather accurate baseline data
Evaluate the data
Make changes based on the data

20. Cardiac Alert: Improving Door to Balloon Time
Process driven approach to a time sensitive issue
Team approach
It’s Not All About Me!

21. Cardiac Alert: Guiding Principles
EMS/Triage RN empowered and educated to initiate call
Immediate ECG with immediate review
Any chest pain over age 30
Single call activates Alert – ECG, Cath Lab, Blood Lab, Radiology
Each individual role defined
Data with feedback

22. Ground Rules
Paramedics and triage nurses will be educated, never criticized for initiating Cardiac Alert.
Cardiologists will not fault ED for calling Cardiac Alert.
ED will decide cardiologist for unattached pts.
Cardiologists will not fault ED docs for occasional errors in cardiologist selection.
Physicians will lead by example.

23. Door to Balloon Time % < 90 Minutes

24. Cardiac Alert Brings Results:
Advocate Good Samaritan Hospital D2B cases <90 minutes
Cases
% < 90”
Mean
2002 1
17/42
40%
100 min.
2003 1
25/48
52%
94 min.
2004 2
35/46
76%
69 min.
2005 2
51/63
81%
68 min.
2006 2
62/68
91%
63 min.
1Tracked using AHA’s GWTG
2 GWTG/AMI Core Measures

25. D2B Data: Left Shift
Eliminate lag time
Decrease outliers

26. Baseline Data
Prospectively established case criteria
ST elevation on first ECG – 1cardiologist and 1 ED MD should agree
Patient admitted through the ED
Start with ~3 months of data (25% of a year)
Outliers were not omitted
Data was shared with the team, Emergency Department and Cardiology
Omitting outliers – 1-2 outliers every month or every other month is not an outlier. Patients will come in with atypical chest pain, the ED secretary will forget to call the cardiologist, the hospital operator will call in the GI Lab instead of the Cath Lab. There will be anomalous coronary arteries, difficulty wiring lesions and the patient will code and you’ll need to resuscitate them. This is what we call real world and your process should be able to accommodate them.
Limiting factor? You probably thnik it is the first ECG. I could agree with you but I won’t.
Admission time is minute zero. All times are in minutes.
Average STEMI patient
First ECG
ED MD evaluation
Cardiologist notified
Cath Lab notified
Cath Lab Table
First Inflation
Baseline Data (n=77) 20 21 32 40 73 99

27. STEMI Patients Door to Balloon Time (Baseline 2002-Sept 2003)
Admission time is minute zero. All times are in minutes and reflect total time elapsed since initial arrival.
Average STEMI patient
First ECG
ED MD evaluation
Cardiologist notified
Cardiac alert initiated
Cath Lab notified
Cath Lab Table
First Inflation
2002- Baseline Data 20 21 32
Did not apply 40 73 99
Omitting outliers – 1-2 outliers every month or every other month is not an outlier. Patients will come in with atypical chest pain, the ED secretary will forget to call the cardiologist, the hospital operator will call in the GI Lab instead of the Cath Lab. There will be anomalous coronary arteries, difficulty wiring lesions and the patient will code and you’ll need to resuscitate them. This is what we call real world and your process should be able to accommodate them.
Limiting factor? You probably thnik it is the first ECG. I could agree with you but I won’t.

28. Cardiac Alert Committee: Initial then quarterly meeting to review process and discuss outliers
Physician, Nursing and Administrative Representation from Cardiology, ED and EMS
Peter Kerwin, M.D., Medical Director, Cath Lab
Stephen Crouch, M.D., Medical Director, Emergency Dept.
Thomas Carmody, M.D., Vice Chairman, Emergency Dept.
John Grieco, M.D., Medical Director, Cardiac Surgery
Colleen Kordish, R.N., Cardiovascular Outcomes Coordinator
Sharon Mow, R.N., Director, Critical Care & Emergency Services
Cathy Smith, R.N., Manager, Cardiac Services
Lynn Polhemus, R.N., Manager, Emergency Dept.
Danielle Albinger, R.N., EMS Coordinator
William Iversen, Manager, EMSS & Trauma Services
Cardiologists, Nurses, ED Physicians, Paramedics

29. Cardiac Alert initiated Cardiologist notified
D2B Time Sequence
Average
STEMI
Patient
First ECG
ED MD evaluation
Cardiac Alert initiated
Cardiologist notified
Cath Lab notified
Patient placed on
Cath Lab Table
First Inflation
Baseline
Data (n=77) 20 21 x 32 40 73 99
2006 Data
(n=68) 5 7 10 63
2007 Data 4 45 67

30. Time from Cardiologist notification to patient on Cath Lab table
2007 = 38 minutes
2006 = 30 minutes
Baseline = 41 minutes
Why are we sliding back ?

31. Cardiac Alert Brings Results:
Advocate
Good Samaritan Hospital
(2005 STEMI data)
Cardiac Alerts occurring during Regular Hours
Cardiac Alerts occurring during
Off Hours
Total
Walk-in
Cardiac Alerts
54 minutes
93 minutes
81 minutes
Paramedic
41 minutes
67 minutes
60 minutes
46 minutes
78 minutes
National Averages
Magid DJ et al. JAMA 2005;294:
95 minutes
116 minutes
106 minutes

32. Good Samaritan D2B 2006 63 minutes n=68 2005 67.0 minutes
Regular Hours
Off Hours
Total
Walk-in
50 minutes
n=16
83 minutes
n=12
64 minutes
n=28
Paramedic
42 minutes
n=19
80 minutes
n=21
62 minutes
n=40
46 minutes
n=35
81 minutes
n=33
63 minutes
n=68
2005
54 minutes
92.6 minutes
80.9 minutes
41.4 minutes
68.6 minutes
59.3 minutes
45.7 minutes
77.5 minutes
67.0 minutes

33. 2007 D2B Improvements 2006 2007 Regular Hours Off Hours Total Walk-in
50 minutes
n=16
83 minutes
n=12
64 minutes
n=28
Paramedic
42 minutes
n=19
80 minutes
n=21
62 minutes
n=40
46 minutes
n=35
81 minutes
n=33
63 minutes
n=68
2007
n=11
84 minutes
n=25
72 minutes
n=36
37 minutes
73 minutes
61 minutes
n=32
41 minutes
n=22
79 minutes
n=46
67 minutes

34. Time from Cardiologist notification to patient on Cath Lab table (cont)
One reason for time increase:

35. Symptom Recognition : Symptom to Door often >2 1/2 Hours
Chest tightness/pressure
Radiation to arm/ neck/ jaw.
Dyspnea
Diaphoresis
Atypical symptoms often (diabetics, women)

36. Current Reperfusion Strategies ST- Elevation Myocardial Infarction
NRMI National Data – September 2001

38. Evidence Based Changes Create Immediate Benefits
Cath Lab is called earlier in the process
8 minute savings
Cardiologist will accept ED MD’s initial assessment
11 minute savings
We will listen to EMS
7 minute savings
For efficiency: one call will initiate new process
Hospital operator is the central communication point
Cardiac Catheterization Lab is notified by this call
We will use all errors as a learning opportunity
Physician Leaders role model appropriate behavior

39. “Outliers” Definition specific to institution/staff
Do not omit outliers
Identifies the cracks in your process
Analyze each case
Trend outliers
Example: “atypical symptoms”
Triage nurse was pre-diagnosing the patient
ED physicians provided education to nursing staff
“Cannot assume GI, pulmonary or musculoskeletal origin of pain without ECG”

40. D2B Alliance: Evidence Bases Strategies
ED physician activates the cath lab;
One call activates the cath lab;
Cath lab team ready in minutes;
Prompt data feedback;
Senior management commitment;
Team based approach.

41. Conclusions
Effective treatment of patients with STEMI is a time sensitive process requiring a well defined team approach.
Ongoing data collection and analysis with feedback allows for changes in process that improve care in patients with STEMI.
The role of the cardiologist in this process is not simply that of technician. We must now be team leaders as well.
D2B of 60 minutes or less is an achievable goal likely to improve mortality in STEMI.