CARDIAC ALERT:CARDIAC ALERT:A Change in Process.A Change in Process.

Results of a STEMI Treatment Results of a STEMI Treatment Protocol Over 5 Years.Protocol Over 5 Years.

Peter Kerwin, M.D.,

Colleen Kordish, R.N.,

June 10, 2008Downers Grove Illinois

ADVOCATE GOOD SAMARITAN HOSPITALMIDWEST HEART SPECIALISTS

Optimal care in the time critical Optimal care in the time critical process of treating STEMI requires a process of treating STEMI requires a coordinated protocol with EMS, ED coordinated protocol with EMS, ED and Cardiology functioning as one and Cardiology functioning as one

teamteam

Optimal care in the time critical Optimal care in the time critical process of treating STEMI requires a process of treating STEMI requires a coordinated protocol with EMS, ED coordinated protocol with EMS, ED and Cardiology functioning as one and Cardiology functioning as one

teamteam

Maintaining optimal quality over time Maintaining optimal quality over time requires continual monitoring and requires continual monitoring and evaluation of data related to the evaluation of data related to the

team’s effectiveness.team’s effectiveness.

Maintaining optimal quality over time Maintaining optimal quality over time requires continual monitoring and requires continual monitoring and evaluation of data related to the evaluation of data related to the

team’s effectiveness.team’s effectiveness.

Reasons to Improve Reasons to Improve Door to Balloon TimeDoor to Balloon TimeReasons to Improve Reasons to Improve Door to Balloon TimeDoor to Balloon Time

ACC/AHA Guidelines Mission Lifeline D2B Initiative Get With The Guidelines Core Measures Marketing

Coroner says patient's death is a Coroner says patient's death is a homicidehomicide

Woman sought care in ER for 2 Woman sought care in ER for 2 hourshours

Coroner says patient's death is a Coroner says patient's death is a homicidehomicide

Woman sought care in ER for 2 Woman sought care in ER for 2 hourshours

By Andrew L. WangTribune staff reporterPublished September 15, 2006

The death of a Waukegan woman in July after she spent nearly two hours in an emergency room waiting area was ruled a homicide Thursday during a Lake County coroner's inquest.

ACC/AHA guidelinesACC/AHA guidelinesACC/AHA guidelinesACC/AHA guidelines

Door to intervention time 90 (120 min). National Average 100-110 minutes. Advocate Good Samaritan 2002: 99 min. Advocate Good Samaritan 2006: 63 min.

Decreasing D2B Time: Decreasing D2B Time: Why Should We Care?Why Should We Care?Decreasing D2B Time: Decreasing D2B Time: Why Should We Care?Why Should We Care?

400,000 STEMI per year 1/3 STEMI patients receive no reperfusion therapy Less than 40% patients receiving primary PCI have

D2B < 90 minutes Less than 10% EMS systems have 12 lead ECG

capability

• Circulation 2006;113;2152-2163

Time is Muscle!Time is Muscle! And Mortality! And Mortality!

Time is Muscle!Time is Muscle! And Mortality! And Mortality!

Each 30 minute delay in reperfusion with PCI increases 1 yr mortality 7.5%

Door to balloon <60 min, 1% 30 day mortality; Door to balloon >90 min, 6.4% mortality

DeLuca, Circulation 2004;109:1223-1225.Berger, Circulation 1999;100:14-20.

Advocate Good Samaritan HospitalAdvocate Good Samaritan HospitalAdvocate Good Samaritan HospitalAdvocate Good Samaritan Hospital

300 bed community hospital Level 1 Trauma Center 4 cardiology groups- separate call schedules Primary PCI strategy since 1991

D2B- Our HistoryD2B- Our HistoryD2B- Our HistoryD2B- Our History

Retrospective baseline 2001- 103 min 1991-1995 review- 55 min Prospective baseline 2002-2003- 99 min 2006- 63 min

Cardiac Alert Brings Results:

Cases % < 90” Mean

2002 1 17/42 40% 100 min.

2003 1 25/48 52% 94 min.

2004 2 35/46 76% 69 min.

2005 2 51/63 81% 68 min.

2006 2 62/68 91% 63 min.

1Tracked using AHA’s GWTG2 GWTG/AMI Core Measures

• AdvocateAdvocate Good Samaritan Hospital D2B cases <90 minutesGood Samaritan Hospital D2B cases <90 minutes

CARDIAC ALERT:CARDIAC ALERT: It’s Not All About Us! It’s Not All About Us!CARDIAC ALERT:CARDIAC ALERT:

It’s Not All About Us! It’s Not All About Us!

PETER KERWIN, M.D.M I D W E S T H E A R T S P E C I A L I S T S

M I D W E S T H E A R T S P E C I A L I S T S

CARDIAC ALERT PROTOCOLCARDIAC ALERT PROTOCOLCARDIAC ALERT PROTOCOLCARDIAC ALERT PROTOCOL

“Individual commitment to a group effort- that is what makes a team work, a company work, a society work, a civilization work.”

Vince Lombardi

The Cardiac Alert TeamThe Cardiac Alert TeamThe Cardiac Alert TeamThe Cardiac Alert Team The Patient! Paramedics in the field Triage Staff ED MD’s ED RN’s Cardio diagnostics Radiology Cardiac Catheterization Lab Cardiologists Primary MD’s ICU/Floor RN’s Nurse Clinician/PA’s CV Surgery

Cardiac Alert GoalCardiac Alert GoalCardiac Alert GoalCardiac Alert Goal

Door to Balloon < 60 minutes

Best Mortality

Achievable Goal

Goal for Acute MI PatientsGoal for Acute MI PatientsGoal for Acute MI PatientsGoal for Acute MI Patients

Diagnostic ECG performed, interpreted and cardiologist/ cath lab notified – 5 to 10 minutes.

Cath Lab/Interventionalist notified, patient on table -30 minutes.

Prep- 5 minutes. Angiogram, first inflation -15 minutes.

Goal for Acute MI PatientsGoal for Acute MI PatientsGoal for Acute MI PatientsGoal for Acute MI Patients

60 Minutes From ED admission to Cardiac Intervention 29 September 2003 “Go-Live” Date for Cardiac Alert

Cardiac Alert: Cardiac Alert: Using Data to Implement ChangeUsing Data to Implement Change

Cardiac Alert: Cardiac Alert: Using Data to Implement ChangeUsing Data to Implement Change

Map the process

Standardize time

Gather accurate baseline data

Evaluate the data

Make changes based on the data

Cardiac Alert:Cardiac Alert:Improving Door to Balloon TimeImproving Door to Balloon Time

Cardiac Alert:Cardiac Alert:Improving Door to Balloon TimeImproving Door to Balloon Time

Process driven approach to a time sensitive issue Team approach It’s Not All About Me!

Cardiac Alert: Guiding PrinciplesCardiac Alert: Guiding PrinciplesCardiac Alert: Guiding PrinciplesCardiac Alert: Guiding Principles

EMS/Triage RN empowered and educated to initiate call

Immediate ECG with immediate review Any chest pain over age 30

Single call activates Alert – ECG, Cath Lab, Blood Lab, Radiology

Each individual role defined Data with feedback

Ground RulesGround RulesGround RulesGround Rules Paramedics and triage nurses will be educated,

never criticized for initiating Cardiac Alert. Cardiologists will not fault ED for calling Cardiac

Alert. ED will decide cardiologist for unattached pts. Cardiologists will not fault ED docs for

occasional errors in cardiologist selection. Physicians will lead by example.

Door to Balloon Time % < 90 MinutesDoor to Balloon Time % < 90 MinutesDoor to Balloon Time % < 90 MinutesDoor to Balloon Time % < 90 Minutes

40

52

7681

9185

0102030405060708090

100

2002 2003 2004 2005 2006 2007

Year

% <

90

min

ute

s

Cardiac Alert Brings Results:

Cases % < 90” Mean

2002 1 17/42 40% 100 min.

2003 1 25/48 52% 94 min.

2004 2 35/46 76% 69 min.

2005 2 51/63 81% 68 min.

2006 2 62/68 91% 63 min.

1Tracked using AHA’s GWTG2 GWTG/AMI Core Measures

• AdvocateAdvocate Good Samaritan Hospital D2B cases <90 minutesGood Samaritan Hospital D2B cases <90 minutes

D2B Data: D2B Data: Left ShiftLeft Shift

D2B Data: D2B Data: Left ShiftLeft Shift

Eliminate lag time

Decrease outliers

Advocate Good Samaritan HospitalSTEMI D2B Cases by Time Intervals: 2002-2003

0

4

1315

20

14

6

32

0

5

10

15

20

25

≤30 31-50 51-70 71-90 91-110 111-130 131-150 151-170 ≥171

Minutes

ST

EM

I D2

B C

as

es

Advocate Good Samaritan HospitalSTEMI D2B Cases by Time Intervals: 2006

5

17

25

15

2 1 1 20

0

5

10

15

20

25

30

≤30 31-50 51-70 71-90 91-110 111-130 131-150 151-170 ≥171

Mintues

ST

EM

I D2

B C

as

es

Baseline DataBaseline DataBaseline DataBaseline Data

Admission time is minute zero. All times are in minutes.

Average STEMI patient

First ECG

ED MD evaluation

Cardiologist notified

Cath Lab notified

Cath Lab Table First Inflation

Baseline Data (n=77) 20 21 32 40 73 99

Prospectively established case criteria ST elevation on first ECG – 1cardiologist and 1 ED MD should agree Patient admitted through the ED

Start with ~3 months of data (25% of a year) Outliers were not omitted Data was shared with the team, Emergency Department and Cardiology

STEMI Patients Door to Balloon TimeSTEMI Patients Door to Balloon Time(Baseline 2002-Sept 2003)(Baseline 2002-Sept 2003)

STEMI Patients Door to Balloon TimeSTEMI Patients Door to Balloon Time(Baseline 2002-Sept 2003)(Baseline 2002-Sept 2003)

Average STEMI patient First ECG

ED MD evaluation

Cardiologist notified

Cardiac alert

initiated

Cath Lab notified

Cath Lab Table

First Inflation

2002- Baseline Data

20 21 32 Did not apply

40 73 99

Admission time is minute zero. All times are in minutes and reflect total time elapsed since initial arrival.

Cardiac Alert Committee: Cardiac Alert Committee: Initial then quarterly meeting to review Initial then quarterly meeting to review

process and discuss outliersprocess and discuss outliers

Cardiac Alert Committee: Cardiac Alert Committee: Initial then quarterly meeting to review Initial then quarterly meeting to review

process and discuss outliersprocess and discuss outliers Physician, Nursing and Administrative Representation

from Cardiology, ED and EMS

Peter Kerwin, M.D., Medical Director, Cath Lab

Stephen Crouch, M.D., Medical Director, Emergency Dept.

Thomas Carmody, M.D., Vice Chairman, Emergency Dept.

John Grieco, M.D., Medical Director, Cardiac Surgery

Colleen Kordish, R.N., Cardiovascular Outcomes Coordinator

Sharon Mow, R.N., Director, Critical Care & Emergency Services

Cathy Smith, R.N., Manager, Cardiac Services

Lynn Polhemus, R.N., Manager, Emergency Dept.

Danielle Albinger, R.N., EMS Coordinator

William Iversen, Manager, EMSS & Trauma Services

Cardiologists, Nurses, ED Physicians, Paramedics

D2B Time SequenceD2B Time SequenceD2B Time SequenceD2B Time Sequence

Average STEMI Patient First ECG

ED MD evaluation

Cardiac Alert initiated

Cardiologist notified

Cath Lab notified

Patient placed on

Cath Lab Table First Inflation

Baseline Data 02-03 (n=77)

20 21 x 32 40 73 99

2006 Data (n=68)

5 7 7 10 x 40 63

2007 Data (n=68) 4 5 5 7 x 45 67

Time from Cardiologist notification to Time from Cardiologist notification to patient on Cath Lab tablepatient on Cath Lab table

Time from Cardiologist notification to Time from Cardiologist notification to patient on Cath Lab tablepatient on Cath Lab table

2007 = 38 minutes 2006 = 30 minutes Baseline = 41 minutes Why are we sliding back ?

Cardiac Alert Brings Results:Cardiac Alert Brings Results:Cardiac Alert Brings Results:Cardiac Alert Brings Results:Advocate

Good Samaritan Hospital

(2005 STEMI data)

Cardiac Alerts occurring during Regular Hours

Cardiac Alerts occurring during

Off HoursTotal

Walk-in

Cardiac Alerts54 minutes 93 minutes 81 minutes

Paramedic

Cardiac Alerts

41 minutes 67 minutes 60 minutes

Total 46 minutes 78 minutes 67 minutes

National Averages

Magid DJ et al. JAMA 2005;294:

803-812.

95 minutes 116 minutes 106 minutes

2006 Regular Hours Off Hours Total

Walk-in 50 minutesn=16

83 minutesn=12

64 minutesn=28

Paramedic 42 minutesn=19

80 minutesn=21

62 minutesn=40

Total 46 minutesn=35

81 minutesn=33 63 minutes

n=68

2005 Regular Hours Off Hours Total

Walk-in 54 minutes 92.6 minutes 80.9 minutes

Paramedic 41.4 minutes 68.6 minutes 59.3 minutes

Total 45.7 minutes 77.5 minutes 67.0 minutes

Good Samaritan D2B

2007 D2B Improvements2007 D2B Improvements2007 D2B Improvements2007 D2B Improvements

2006 Regular Hours Off Hours Total

Walk-in 50 minutesn=16

83 minutesn=12

64 minutesn=28

Paramedic 42 minutesn=19

80 minutesn=21

62 minutesn=40

Total 46 minutesn=35

81 minutesn=33

63 minutesn=68

2007 Regular Hours Off Hours Total

Walk-in 46 minutesn=11

84 minutesn=25

72 minutesn=36

Paramedic 37 minutesn=11

73 minutesn=21

61 minutesn=32

Total 41 minutesn=22

79 minutesn=46

67 minutesn=68

Time from Cardiologist notification to Time from Cardiologist notification to patient on Cath Lab table (cont)patient on Cath Lab table (cont)

Time from Cardiologist notification to Time from Cardiologist notification to patient on Cath Lab table (cont)patient on Cath Lab table (cont)

One reason for time increase:

Symptom Recognition : Symptom to Symptom Recognition : Symptom to Door often >2 1/2 HoursDoor often >2 1/2 Hours

Symptom Recognition : Symptom to Symptom Recognition : Symptom to Door often >2 1/2 HoursDoor often >2 1/2 Hours

Chest tightness/pressure Radiation to arm/ neck/ jaw. Dyspnea Diaphoresis Atypical symptoms often (diabetics, women)

Current Reperfusion StrategiesCurrent Reperfusion StrategiesST- Elevation Myocardial InfarctionST- Elevation Myocardial Infarction

Current Reperfusion StrategiesCurrent Reperfusion StrategiesST- Elevation Myocardial InfarctionST- Elevation Myocardial Infarction

46

20

32

0

10

20

30

40

50

Pe

rce

nt

of

Pa

tie

nts

None Lytic PCI

NRMI National Data – September 2001

Evidence Based Changes Evidence Based Changes Create Immediate BenefitsCreate Immediate Benefits Evidence Based Changes Evidence Based Changes Create Immediate BenefitsCreate Immediate Benefits

Cath Lab is called earlier in the process 8 minute savings

Cardiologist will accept ED MD’s initial assessment 11 minute savings

We will listen to EMS 7 minute savings

For efficiency: one call will initiate new process Hospital operator is the central communication point Cardiac Catheterization Lab is notified by this call

We will use all errors as a learning opportunity Physician Leaders role model appropriate behavior

““Outliers”Outliers”““Outliers”Outliers”

Definition specific to institution/staff Do not omit outliers Identifies the cracks in your process Analyze each case Trend outliers Example: “atypical symptoms”

Triage nurse was pre-diagnosing the patient ED physicians provided education to nursing staff “Cannot assume GI, pulmonary or musculoskeletal origin of

pain without ECG”

D2B Alliance:D2B Alliance:Evidence Bases Strategies Evidence Bases Strategies

D2B Alliance:D2B Alliance:Evidence Bases Strategies Evidence Bases Strategies

ED physician activates the cath lab; One call activates the cath lab; Cath lab team ready in 20-30 minutes; Prompt data feedback; Senior management commitment; Team based approach.

ConclusionsConclusionsConclusionsConclusions Effective treatment of patients with STEMI is a time

sensitive process requiring a well defined team approach.

Ongoing data collection and analysis with feedback allows for changes in process that improve care in patients with STEMI.

The role of the cardiologist in this process is not simply

that of technician. We must now be team leaders as well.

D2B of 60 minutes or less is an achievable goal likely to improve mortality in STEMI.