AMI Door to Balloon Time

Overview Primary entry for ST-Segment Elevation Myocardial Infarction (STEMI) patients is through our emergency room. Improvement focus was in ED with collaboration with Cathertization Laboratory Services and Rapid Assessment Team personnel. Facility is a tertiary-care 672 bed county teaching hospital Over 108,000 annual ED visits, over 400 a day, projected to reach almost 200,000 for Changes needed to improve patient care and meet organizational defined quality measure performance standards. Alignment with organizational goals to produce leading patient outcomes through our patients obtaining the right care, in the right setting, by the right providers at the right time.

The Team CS&E Participants Team Lead: Ellen O’Connell, MD Assistant Professor, Emergency Services Robert Madris, RN, MSN, AMI Core Measure Analyst Project Manager: Margie Roche, MS Performance Improvement Project Manager Facilitator: Peter Hoffman, SVP & Chief Quality Officer Rusty Genzel, RN CCRN Emergency Department Service Manager Physician Champion: Ellen O’Connell, MD Assistant Professor, Emergency Services Tayo Addo, MD Assistant Professor, Internal Medicine Cardiology, Cardiac Catheterization Service Executive Sponsors: Bradley Simmons, SVP Surgical Services Josh Floren, SVP Medicine Services Jana Seale, RN III, Cardiac Catheterization Service Maury Belino, RN, PM Staff Nurse, Emergency Department Landon Sweeny, RN, AM Staff Nurse, Emergency Department

What We Are Trying to Accomplish? AIM STATEMENT Timely identification of STEMI and opening of blocked coronary arteries (Door to Balloon) improves patient outcomes. Quality measure guidelines define effective door to balloon time as less than 90 minutes from arrival at hospital until the balloon is up. Historically, from October 2008 through December 2009, an average of 54% STEMI patients achieved a door to balloon time of less than 90 minutes. The goal of this project is to achieve door to balloon time of less than 90 minutes in over 95% of patients with STEMI.

How Will We Know That a Change is an Improvement? Type of MeasuresTarget for Measures Door to Balloon Time ≤ 90 minutes for ≥ 95% of STEMI Patients Door to EKG Time ≤ 10 minutes Arrival to ED Departure Time ≤ 30 minutes Arrival to Balloon Up ≤ 90 minutes How will you Measure? All measurements will be collected through use of existing systems in ED, Cath Lab, and Cardiology (i.e., EPIC, Cardiology Systems, MUSE). Reported Core Measure data will also be used.

Baseline Data

Baseline Process Analysis Tools Plan ActivityWhoWhen Team Charter Developed – Board DirectedDr. Hoffman3/28/2010 Describe Current Process Process Flow Chart Team4/2010 Measure & Analyze Data Core Measure Knowledge Survey Core Measure Quarterly Data Chart Reviews Team5/2010 Ongoing Identify Improvement Opportunities Brainstorming Survey Results – Open Ended Analysis Chart Review Team4/2010 – 6/2010 Identify Root Causes of Problem Specific Root Cause Not Identifiable Several Small Areas of Possibility Team 4/2010 – 6/2010 Generate & Choose Solutions Process Flow Chart – Future State Critical Path Exercise Brainstorming & Consensus Team6/2010 – 7/2010

Baseline Process Analysis Tools

Selected Decision Making Tools 10 Chart Review Trending Information for Outliers

Selected Decision Making Tools 11

Selected Decision Making Tools

Team Focus DO Plan included 3-key areas: Earlier identification and treatment of STEMI patients Faster movement of patient from ED to Cath Lab Education of Staff on performance measures and changes

Implementing Change Earlier Identification of STEMI Nurse driven Walk Back Chest Pain Order Set – Triage Lead Revised ED Chest Pain directive procedure Faster movement from ED to Cath Lab Standardized Patient Prep Order Set After Hours RAT nurse straight to Cath Lab Cath Lab Notification of Patient Arrival Time »Arrival time added to Cath Lab activation page »Arrival time to be placed on colored arm band Clock Synchronization »Synchronize ED, Cath Lab and EKG machines to all be on EPIC (EMR) time Physician Education of STEMI Identification Review EKGs of Cath Lab Activation cases with ED Physicians Survey personnel involved in STEMI Case next business day Monthly case review – cross-functional team

Future State Process

Results/Impact Check ActivityDate Data Collection (Preliminary Data) August 16 – September 17, 2010 Data AnalysisSeptember 18 – September 24, rd QTR Data (Preliminary) October 30, 2010

Results/Impact Interventions in ED triage and Cath Lab activation processes have: Decreased overall mean time from minutes to 56.1 minutes. Increased overall performance from 57% to 90% of cases having door to balloon time of less than 90 minutes.

Interventions April 1, August 31, 2010

Interventions: Overall Performance

Expansion of Our Implementation Act ActivityDate HandoffOctober 2010 (TBD) Maintain Gain Follow Up Surveys Case Reviews CM Reports Ongoing Monthly Sessions Quarterly Monitoring Cases Physician Quality Conference Monthly

Lessons Learned There was not one single root cause for prolonged door to balloon time. Multiple factors such as atypical presentation, awareness of core measures by staff, delay in EKGs and other contributed to performance less than target. Importance of having representation from all disciplines was crucial to implementing changes. Physician understanding of reporting requirements for core measures and how important documentation is for reporting was crucial to change. Do not have meetings on Monday’s – multiple holidays caused some missed meeting days. At time of team start up identify alternate days for holidays.

Conclusions Current results are preliminary and data will not be finalized until December However, early results indicate that initial interventions have had a positive effect on door to balloon time. Short Term Steps: Refinement of Interventions Development of ongoing education for nurses and physicians Improving communication between ED physicians and Cath Lab physicians Updating Equipment (i.e., EKG machines and Fax/Scanners) Long Term Steps: Analysis of return on investment related to decreased length of stay and decreased morbidity in patients experiencing door to balloon time of <90 minutes. Research and possible use of field activation of Cath Lab by paramedics and EMS personnel Feasibility study of 24/7 Cath Lab Staffing

Acknowledgments Thank you for the guidance and information sharing throughout the process of our program. –Peter Hoffman, MD Senior Vice-President and Chief Quality Officer –Marisa Valdes, RN Interim Director of Performance Improvement

Thank you!