Organizatin: ANNE ARUNDEL MEDICAL CENTER Slutin Title; REDUCTION OF STEMI DOOR TO BALLOON TIME: A COLLABORATIVE EFFORT! Prgram/Prject Descriptin, including Gals: In the treatment f acute ST elevatin mycardial infarctin (STEMI), ne f the mst imprtant factrs that determine patient utcme and mrtality is the time f reperfusin f the affected crnary artery. The natinal benchmark fr all prgrams dealing with acute crnary patients suffering frm STEMI s is 90 minutes frm the time frm patient arrives at the hspital t pening the effected vessel in the cardiac cath lab- the s called dr t balln time r D2B. In 2009, the STEMI D2B time f 90 minutes r less was just meeting the 75% required benchmark fr all STEMI patients wh presented t AAMC. This meant that ne quarter f all STEMI patients were nt meeting the natinal standard. Thrugh cllabrative meetings with the ED (Emergency Department) and CCL (Cardiac Cath Lab) leadership and staff, the data was analyzed and wrk was established t address certain pints in rder t expedite patient transprt t the cardiac cath lab. Specifically, Dr t Balln and Dr t EKG metrics served as primary indicatrs fr prcess imprvement. This infrmatin was shared at mnthly CPORT wrkgrup meetings, ED/CCL Quality and Medicine Quality meetings. Recgnized gaps were identified and discussed in the ED/CCL Quality cuncil and actin plans were devised t drive metrics. Identified factrs included, but were nt limited t, visualizatin f qualifying EKG by ED physician, nt perfrming EKGs n patients less than 35 years f age when presenting with atypical symptms, EKG techs exclusively perfrming EKGs in the ED, variability in perfrming EKGs n atypical presentatins within ten minutes f arrival, lack f a timely registratin prcess and lack f standard wrkflw amng cardiac interventinalists.the very cntinuance f the STEMI prgram at AAMC required that prcess imprvement changes be instituted in rder fr the institutin t meet the 90 minute D2B quality standard. Prcess: Specific data pints were added t the analysis after each STEMI case was cmpleted. Recgnized areas f imprvement were discussed in the ED/CCL Quality cuncil and CPORT wrkgrup meetings. Plans were then develped t imprve metrics. Analysis f data by the team revealed that just lking at the full time frame wuld nt imprve metrics and that nly targeted time lines culd drive imprvement fr the full prcess. The fllwing metrics were adpted t review fr every STEMI patient: Field activatin Arrival time Time EKG is cmpleted Time STEMI is recgnized- EKG qualifies Time STEMI team activated Qualifying EKG t activatin Time cardiac interventinalists respnds Time cath lab respnds Time f arrival f interventinalists and cath lab team Time cath lab ready Time patient leaves ED Time patient is n cath lab table Qualifying EKG t table time Table time t balln Qualifying EKG t balln Frm this infrmatin actin plans were develped t target the indicatrs that wuld drive specific results and imprve dr t balln times verall. Fcusing n prcess imprvement and nt individuals shwed steady increase in achieving these gals. It was als recgnized that revisins and mdificatins needed t be develped n prcesses that initially seemed t wrk. Review f all prcesses with an eye twards imprvement was necessary.
Slutin and Measurable Outcmes: The biggest impact was t establish a team cmmitted t the utcmes f imprving the dr t balln time. Breaking dwn the data and addressing the mst critical cmpnents prved t be the mst dynamic factr in ur success. Multiple slutins were implemented strategically as a team. Field activatin was recgnized as a factr that was underutilized. After many discussins with ED physicians, we realized that there was a great deal f reluctance t activate the cardiac cath lab team and physicians fr fear f false activatin. Cmmunicatin frm cardiac interventinalists and cath lab leadership reinfrced the desire f the cath lab team t be called and cnsulted immediately n any and all cases f pssible STEMI, even questinable nes. Educatin fr EMS was presented by the Cardiac Cath Lab Medical Directr and scripted language was develped fr pre-hspital prviders t enable them t share the severity f the patient presentatin. Arrival time f the interventinal cardilgist was nt always standard. A physician reprt card was created t share data surrunding arrival times t the ED. While all physicians were dedicated t the dr t balln times, they did nt recgnize the impact they had n the ED if there was any type f delay in respnse. Example f the physician reprt card with identifiers remved:
The gal t cmplete the EKG within ten minutes f the time the patient arrived was impacted by multiple factrs. Initially, EKG techs were utilized in the ED fr all EKGs including emergent nes. It was discvered that there culd be a delay in btaining emergent EKG s due t the wrklad f the EKG tech. It was recgnized that there was n standard wrk prcess fllwing the arrival f a STEMI patient t the ED. Additinally there existed arbitrary exclusin criteria based n age fr perfrming EKGs n atypical presentatins f chest pain. Despite transmissin f the EKGs t the ED via LifeNet starting in 2009, the practice f repeating the EKG n arrival t the ED cntinued until 2012. Prcess changes, including cmmitment f the ED physicians t activate STEMI prtcls n transmissin f EKG s frm EMS, resulted in a tremendus reductin in verall D2B times. When the EKG techs were therwise ccupied, patients presenting with acute chest pain symptms nw have their EKG s perfrmed by Patient Care Techs (PCTs) and RNs within the Emergency Department. The ED established standard perating prcedures (SOPs) fr the rapid respnse and prcedure fr handling the STEMI patient in the ED regardless f arrival mde. The develpment f the standard f practice fr the Emergency Department brught an easy visual prcess t the bedside. The ED develped a STEMI bx with all the required elements included in the bx. Once the bx was empty, the patient was ready fr transprt. This alleviated delays and bstacles experienced by the cath lab team nce the patient arrived in the lab. Staff frm bth departments began t take the pprtunity t assist in the ther department when the pprtunity was there. Additinally, a prcess t enable the ED staff t assist in transprt f the patient t the cath lab alleviated fears f the unknwn. It was thrugh imprved cmmunicatin and realizatin f each individual s respnsibilities that sils began t crumble and the patient became the true center f care. Example f STEMI bx:
Measurable Outcmes: Quarterly, the percent f patients whse artery has been pened in less than 90 minutes is cllected, analyzed and reprted. In 2012, the internal gal f meeting D2B <60 min was established. Data n every STEMI is cllected after each case. Belw is a run chart with strategic steps recgnized. The Median time fr every case is als reviewed, analyzed and reprted. This cntinues t shw the incredible wrk accmplished.
The Cardiac Prgram Crdinatr reprted the data cnsistently in real time cmmunicatin. While this practice has been in place fr many years, the breakdwn f the data int the afrementined data pints had significant impact t the respnse f varius departments. Sharing this infrmatin thrughut the hspital and t ur EMS partners has resulted in imprved care fr sme f ur sickest patients with acute crnary events. Example f In-hspital cmmunicatin: 10.10.2014 64 y.. male M.B Arrival Mde: EMS-Annaplis City Field Activatin: Yes ED MD: Dr.R. Nershad, Kara HPI Pt presents via EMS with STEMI, based n pre-hspital EKG. Pt cmplains f chest discmfrt since abut 9 p.m., last night, becming much wrse with mrning. N change with mvement r breathing. Sme assciated dyspnea, diaphresis, and nausea. N previus hx f cardiac disease. Pt received ASA and NTG en rute; pain is nw abut 5/10. Pt is frm Miami, here fr the bat shw. EKG: EKG 2mm ST segment elevatins leads 2, 3 and AVF- see attached CARDIOLOGY: Dr. M. Christine, Maryann, Clleen, Vicki Acute inferir MI STEMI The right crnary artery arse nrmally frm the arta, and is ttally ccluded in its mid prtin. After 1 balln inflatin we had TIMI 3 flw. We used a Prnt LP aspiratin thrmbectmy device, made 2 passes, remving 15 ml f bld. His EKG ST-segment elevatins had reslved. His chest pain had reslved, which initially had been 8/10, became 4/10, and is nw gne. Clinically he is nw imprved. We will take him t the ICU fr cntinued care. DOOR TO ED EKG ACTIVATION- CARD ARRIVAL DOOR- TABLE TIME TABLE TIME 2 BALLOON DOOR 2 BALLOON Q EKG 2 B 911-B FMC-B NA <30 12 56 68 NA 101 91 And an example f what is sent t EMS
The impact t cmmunicating with EMS has been nthing shrt f amazing in ur results. Sustainability: Reprting structures have been implemented t supprt and address utliers. Peer review ccurs in multiple venues such as CPORT M&M, Medicine Quality, and internal review f all STEMI patients by the Medical Directr f the CCL. Onging feedback t all staff members frm EMS t critical care is prvided in real time. Cntinuus invlvement and sharing f the data prvides rapid cycle review f the prcess and empwers staff t implement valuable revisins and new ideas. A strng example f cntinuus imprvement and spreading results was with the implementatin f the rapid registratin prcess develped frm nging analizatin f the data. Rle f Cllabratin and Leadership: Multidisciplinary teams were critical in the success f this prcess. Frm utside f the walls f the facility with EMS t the arrival f the patient int the critical care unit, cllabratin and teamwrk were essential t the success. Every type f practitiner, the EMT, ED nurse and physician, Cath Lab nurse, tech and Interventinal cardilgist, alng with ur in huse rad techs, escrt and peratrs play a crucial part in preparing fr the patient arrival and prvisin f quality care. Innvatin: This has been a challenging prcess that has cntinued ver many years withut lss f cmmitment r dedicatin. It has had many cntributrs thrughut the duratin f the prgram and at all times, the fcus f the prcess imprvement has been patient safety. Uniqueness cmes with the fact that this initiative extends beynd the walls f the hspital itself and encmpasses all invlved with the care f the acute heart attack patient. Related Tls and Resurces: AHA/ACC Guidelines fr management f STEMI and nn-stemi patients NCDR Natinal Registry Sciety f Cardivascular Patient Care
Cntact Persn: Julia Blackburn, MSN, RN, NE-BC Title: Clinical Directr CCL/IR/PRCU Email: jblackburn@aahs.rg Phne: 443-223-2750