An Immediate Nursing Feedback Program for Primary PCI for ST-segment Elevation Myocardial Infarction Karen Mckenny RN, Theresa Fortner RN, Cheryl McNeil RN, Carol Woods RN, Shirley Gadbois RN, Heidi Igneri RN Joe Hastings RN, and Harold L. Dauerman,MD Joe Hastings RN, and Harold L. Dauerman,MD Fletcher Allen Health Care University of Vermont, Burlington, Vermont

Background  Based on DANAMI 2. Vermont adopts a primary PCI Regional Transfer Program 2007  4 Rural Hospitals  35 miles median travel distance  2008 (Nov) Immediate Nurse to Nurse Feedback program initiated.

The Vermont Rural STEMI Program: There is Only One Interventional Cardiology/PCI Center in the State of Vermont Vermont Population 600, 000 PCI Procedures at UVM/FAHC: 1400 PCI/year Vermont

Objectives  To determine a role for cardiovascular catheterization laboratory nursing in improving quality of care for regional primary PCI programs  To define the current level of nursing satisfaction with regional STEMI transfer programs  To implement a nurse to nurse immediate feedback program to improve education and program outcomes  To provide a semi-annual roundtable led by and for nursing to systematically address areas of need including potential sources of transfer delay and/or miscommunication.

Methods  All patients with STEMI referred for primary PCI to a single PCI center (Fletcher Allen/Univ. of Vermont) enrolled in a dedicated prospective registry  Study Period: November December 2009  The current study includes 1 PCI center and 4 regional STEMI referral centers

Methods  A pre-intervention survey of STEMI referral centers was completed in November 2008  A post intervention survey of STEMI referral centers was completed 9 months later  Differences between Survey endpoints were compared using chi square statistical techniques.  Changes in Door to Balloon Times and Triage Times were compared Quarter 1 vs Quarter 4 using student’s t test.

Pre-Intervention Survey Tool 8 questions:  Satisfaction regarding feedback  5 Point Lickert Scale  1= no feedback, 5 = excellent feedback  Interest in Round Table meetings  Educational Topics of interest

STEMI Feedback Form: Dedicated, Faxed Table of Times and Events To Both Nursing and Physicians Patient Name: Patient Name: Time Date of STEMI: 01/05/09 STEMI referral Hospital: STEMI referral Hospital: Copley Time of arrival to referring ED 3:29 Time of first FIELD/EMS/AMBULANCE ECG N/A Time of first ED ECG 3:29 Time FAHC cardiology paged with STEMI notification 3:47 Ambulance Service used VT EMS Time of departure by ambulance 3:47 Time of arrival in lab 4:30 Time of open artery (balloon inflation) 4:45 Door to Open Artery total time ( their door to our balloon) 1:15 OUR GOAL IS < 90 min

STEMI Feedback Form: Dedicated, Faxed Table of Times and Events To Both Nursing and Physicians Ambulance EKG to open artery n/a Medications given prior to transport: ASA 325______ X Clopidogrel 600_____ X Unfractionated Heparin Bolus____________ X Referring ED attending: Referring ED attending: Dr. STEMI Procedure details: Affected artery_______% stenosis_____ Hospital Adverse Events: Death___Emergent CABG____ Stroke____ Major Bleeding_____ Repeat PCI____ Transport Related eventsVT____VF____CPR____Defib__ Follow up phone call done/date Nurse x 1/5/09 1/5/09

Feedback Program  Feedback form filled out by Nurse Led Team at Primary PCI Site  Follow up phone call within hours to referring ED nurse for feedback and patient outcome report  Form Faxed within hours of STEMI to Referring STEMI Physician and Nurse Team

Semi-Annual Round Table meetings & Outreach Visits  Education of referring staff  Uniform algorithm for treatments and medications.  Networking, team building, and system improvement for the STEMI patient in Vermont

RESULTS STEMI Referral Center Volume & Feedback Transmission Name of Hospital Distance in miles/time from FAHC # of Beds STEMI transfer with follow up phone call Nov 08-Dec 09 STEMI transfer with follow up phone call Jan 10-Sept 10 Fletcher Allen Health Care Copley Medical Center 45miles 1 hour Northwestern Medical Center 25miles 30 min Porter Medical Center 37 miles 58 min Central Vermont Medical Center 41miles 45 min 45 min303431

Result of Intervention: Lickert Scale Satisfaction Scores

Triage Times 2009: Significant Improvement in Transfer Hospital Presentation to Cath Lab Activation after STEMI Nursing Feedback Program Initiated 29 min 19 min

Door to Balloon Times 2009: Significant Door to Balloon Time Improvement after STEMI Nursing Feedback Program 63min 58min 124min 86min

Door to Balloon Times: Significant Door to Balloon Time Improvement after STEMI Nursing Feedback Program

Conclusions  Nurse to Nurse feedback is a critical component of a successful rapid transfer STEMI program  Referring emergency department satisfaction can be dramatically improved with a feedback program  Roundtable and outreach lead to adoption of uniform state wide practices  The STEMI nursing feedback program leads to improved triage times and D2B times for transfer programs