THE CODE STEMI PROJECT: Winning the Race CODE STEMI: The PinnacleHealth Experience Pinnacle has 2 hospitals with a total of 643 beds.  We do about 900 stents/yr Avg 25 STEMI’s/quarter Do not have a cardiologist on site 24/7, Regular Cath lab hours 7a-7p Donald C. Durbeck, MD., FACC

Baseline Performance In 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.

Evidence 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: 91-97. 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;113:1079-85.

Racing Theme We 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.

Create a Task Force Senior Administration Support Key Stakeholders Weekly Meetings Dashboard Physician Champion Nurse Champion Quarterly User’s Meeting Dana Kellis, M.D. Senior Vice President Medical Affairs & Chief Medical Officer Donald C. Durbeck, MD., FACC, Chairperson, Department of Cardiovascular Services Lewis Shaw, MD Chairperson, Department of Emergency Services Jean Wiest, RN Vice President, Cardiovascular Services Amy Helmuth, RN MSN ONC Director, Performance Improvement Emergency Department Nurse Manager Director of Cath Lab Director of Nursing Pre-Hospital Care Providers FTE Dedication - .5 -.7 FTE for 6 months, .2 FTE maintenance Excel Clocks

Process Map

Data Drives Us Initiated by ED nurse Forms kept in bin in cardiac bay Clip-on digital clocks placed on clipboard Form, clipboard, and clocks travel with patient to the cath lab Cath Lab faxes completed form Performance Improvement confirms time with scanned medical record and enters into data base A task force of key stake holders which includes Senior Administration meets once a week for 30-60 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.

Excel Sheet Time Interval Calculations Weekday or Off hours Day of Week Boxed when times confirmed

Immediate Feedback EARLY CASES Green line – Target goal 90 minutes Pink – Minutes to EKG Very few pre-hospital EKG’s early in project Dark Blue EKG to Activation – Variation in times Prompt Data Feedback wtihin 1 week: D2B nationally- 57% D2B PA- 69%

Immediate Feedback RECENT CASES Much less variation in process.

Immediate Feedback Be transparent, list names Bar graphs and Calendar feedback updated within one working day of case Both are emailed to all members of the project Assign follow-up tasks Posted for front-line staff Ensure EMS providers also receive feedback

Door to EKG Pre-Hospital EKG Triage Nurse in Waiting Room 11a – 11p Triage Protocol Dedicated bay for EKG Hand Deliver EKG to ED Physician minutes Be willing to activate Code Stemi based upon Pre-hospital EKG Pre-hospital EKG activates cath Lab: D2B nationally- 48% D2B PA- 34%

EKG to Lab Activation ED Physician Activates Code Stemi Activate using Pre-hospital EKG when available minutes Contacting the Interventional Cardiologist ED physician Activates: D2B nationally- 49% D2B PA- 55%

Activation to Arrival in Lab CODE STEMI Team One Call Activation using Central Page Operator Cell Phones vs. Pagers Scripted Education Prep Patient – Gown, 2 IV sites minutes Emergency Department Bypass Single call: D2B nationally- 27% D2B PA- 26%

ER and Cath Lab Personnel Performance Improvement CODE STEMI Team ER and Cath Lab Personnel Security Nursing Supervisor Performance Improvement

Scripted 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

Arrival to Device Time Room ready during off hours 2 of 3 on call must be within 20 minutes All expected to be ready in 30 minutes Send patient as soon as 1 cath lab member in lab & interventionalist on site Intervene on culprit artery first minutes 30 minutes - D2B nationally- 81% D2B PA- 76%

Time to PCI

Analysis of Missed Opportunities Follow up missed opportunities ASAP Interview staff involved in case Follow all leads Take results of investigation to weekly task force meeting Keep running list of reason for misses Obtain necessary documentation for patient centered reason for delays Each 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.

Patient Related Delays, excluded Required Resuscitation Patient did not give consent Needed CT Scan to rule out dissection In 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.

System 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 ambulance 24 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 pericarditis 103 minutes (Door to EKG = 40 min) – Female c/o bilateral arm numbness, mild SOB, dizzy 95 minutes (Activation to Arrival = 50 min) – Cardiologist saw patient in ED before activating the interventionalist.

Data Accuracy Abstractor’s send list of missed opportunities at end of month to compare with our on-going list Use QNET for resolution Prior to quarterly submission to Joint Commission vendor, run final list of misses to ensure “mets”/”not mets” are coded correctly

Success

Control Chart

Patient Outcomes 2006 In 2006, when PCI was provided in less than 120 minutes, 89% of our patients were able to return home as compared to only 75% when PCI was over 120 minutes.

STEMI* In-Patient Mortality Rate * Of patients included in Primary PCI Joint Commission Measure.

ALL AMI In-Patient Mortality

Program Expansion QUESTIONS? In-Patient CODE STEMI using Rapid Response Team Transfer Patients from within the PinnacleHealth system Transfer Patients from neighboring institutions Transfer Center Helicopter services QUESTIONS?