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 2010.• 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 ServicesJosh 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 Measures Target 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 Data

Baseline Process Analysis Tools

PlanActivity Who When

Team Charter Developed – Board Directed Dr. Hoffman 3/28/2010

Describe Current Process•Process Flow Chart

Team 4/2010

Measure & Analyze Data• Core Measure Knowledge Survey• Core Measure Quarterly Data• Chart Reviews

Team 5/2010OngoingOngoing

Identify Improvement Opportunities•Brainstorming•Survey Results – Open Ended Analysis•Chart Review

Team 4/2010 – 6/2010

Identify Root Causes of Problem•Specific Root Cause Not Identifiable•Several Small Areas of Possibility

Team4/2010 – 6/2010

Generate & Choose Solutions•Process Flow Chart – Future State•Critical Path Exercise•Brainstorming & Consensus

Team 6/2010 – 7/2010

Baseline Process Analysis Tools

Walk-In Pt with Chest Pain

Registrar enters pt into EPIC & radio

for a tech

Tech walks pt back to EMS/Triage nurse

EMS/Triage nurse provides pod assignment

Pt goes through metal detector

Tech escorts pt to RN Pod lead

Pt arrives from Clinic or EMS (no

EKG done)*

Clinic staff or EMS transports pt to RN

Pod Lead

RN Pod Lead enters pt info into EPIC & assigns pt

to a room

Pt arrives from Clinic or EMS

(known STEMI)*

RN Pod Lead enters pt info into

EPIC assigns pt to critical care room

EKG repeated by ED Tech or nurse

Pt placed in bed & EKG performed by

pod RN or tech

ED Tech or RN takes EKG to

(resident or facility) physician

RN assesses the pt

Physician reviews EKG & interviews

EKG findings NOT consistent w/

STEMI but story concerning

EKG consistent with STEMI but

story not concerning

ED Physician calls CCU Fellow & fax

EKG for review

EKG finding c/w STEMI and pt

story concerning for MI***

Physician activates Cath Lab

(via STAT pgr operator 27890

ED Staff packages pt

CAT team goes to ED to assist with

transport

Patient to Cath Lab with CAT

team

Cath Lab Team performs

necessary procedure

Bedside Registration**

Bedside Registration**

CCU Fellow determines need for Cath Lab activation or discuss case with

attending

Pt admitted to CCU service if CCU Fellow determines Cath Lab

activation is not needed

ED phyisican and CCU fellow

determine who calls to activate

Cath Lab

Cath Lab needs to be

activated

Yes No

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

Future State Process

Future State Process

Results/Impact

CheckActivity Date

Data Collection (Preliminary Data)

August 16 – September 17, 2010

Data Analysis September 18 – September 24, 2010

3rd QTR Data (Preliminary)

October 30, 2010

Results/Impact

Interventions in ED triage and Cath Lab activation processes have:

•Decreased overall mean time from 123.4 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, 2010 - August 31, 2010

Interventions: Overall Performance

Expansion of Our Implementation

ActActivity Date

Handoff October 2010 (TBD)

Maintain Gain•Follow Up Surveys•Case Reviews•CM Reports

OngoingMonthly SessionsQuarterly

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 2010. 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!