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Carolinas Medical Center
OPTIMIZING DOOR-TO-BALLOON TIME:OPTIMIZING DOOR-TO-BALLOON TIME: STRATEGIES FOR SUCCESSSTRATEGIES FOR SUCCESS
B. Hadley Wilson, MD.B. Hadley Wilson, MD.J. Lee Garvey, MD.J. Lee Garvey, MD.
Patricia M. Pye, RN, MSPatricia M. Pye, RN, MSKevin M. Collier, RCISKevin M. Collier, RCIS
Carolinas Medical CenterCarolinas Medical Center
Carolinas Medical Center
Time is Muscle: Every 10 minute delay to Percutaneous Coronary Intervention (PCI) results in a 1% change in mortality*
In 2004, National Registry for Myocardial Infarctions (NRMI) data for STEMI reported median time for door to reperfusion was 97 minutes, only 43% were reperfused in less than or equal to 90 minutes.
Background
Source: Nallamothu BK et al, AM Journal Cardiology 2003
Carolinas Medical Center
Process Improvement Case Study:Carolinas Medical Center (CMC)
2004 evaluation demonstrated CMC had opportunities for improvement
• 72 minutes EMS patients
• 116 minutes non-EMS patients
• 87 minutes overall
Multi-disciplinary team was challenged to improve Door-to-Balloon process
• EMS, ED Physicians, Cardiologists, ED Staff, Cath Lab, CCU, Bed Management, Lab, Radiology, Respiratory Care, House Supervisor
CMC’s process improvement plan was based on practices paralleling Code Trauma => Code STEMI
Carolinas Medical Center
Process Improvement Case Study:Carolinas Medical Center (CMC)
Team developed enhanced goals for Code STEMI that exceed the ACC/AHA Standard:
• Goal #1: 90% of patients reperfused within 60 minutes of ED arrival (compared to national guidelines of < 90 minutes)
• Goal #2: 90% of patients reperfused within 90 minutes of first medical contact (compared to national guideline of < 90)
Source: ACC/AHA Guidelines 7/04
Carolinas Medical Center
Identification: Medic paramedics are trained to acquire and read 12-lead electrocardiograms (ECG) on patients suspected of a heart attack. The ECG result is quickly transmitted from the field to an ED physician at CMC.
Activation: If the ECG shows specific changes in certain electrical impulses (ST segments) within the heart, the Emergency physician activates “Code STEMI” initiating an immediate response from the Code STEMI Team.
Treatment: Patient is received by Code STEMI Team upon arrival to CMC ED with a rapid triage process to confirm STEMI and then immediately transported to the cardiac catheterization lab where the coronary artery is opened
Program objective: develop a coordinated system of care - modeled after Code Trauma - that streamlines the identification, activation,
and provision of treatment for STEMI that surpasses national targets.
New CMC ProcessCode STEMI – Protocol Driven Program
Carolinas Medical Center
Critical Success Factors
EMS and ED Physician initiate Code STEMI
Single page activates entire team => parallel actions commence
ED and Cath Lab begin preparations
On-Call Cardiologist and CCU Nurse go to ED
Respiratory Care and Laboratory are available in ED
Joint assessment occurs in the ED
Cardiologist and CCU Nurse assist EMS in transporting patient to Cath Lab
Patient is prepared for PCI
Bed Management finds accommodations
Trust in revised roles and responsibilities
Carolinas Medical Center
Patient presents with symptoms of
ACS
Cardiologist on Call
CCU
12 Lead ECG
Proceed to ED without activation
of Code STEMI
Radio report to ED
Dx for
STEMI?
Yes
No
RespiratoryCCL Call
Team
Hospital Lab
Bed Management
Radiology
CMC Code STEMI Protocol
Standing Ready 24/7
ED activates Code STEMI
Simultaneous Page to:
Carolinas Medical Center
Lessons Learned fromCarolinas Medical Center
It takes real commitment from the Multi-disciplinary Team
• EMS, ED Physicians, Cardiologists, ED Staff, Cath Lab, CCU, Bed Management, Lab, Radiology, Respiratory Care, House Supervisor
Establish a specific goal to Meet or Exceed ACC Standard
Adopt a continuous process improvement philosophy => on-going monitoring and modification of the process
Intensive education for EMS on acquiring and interpreting ECGs
Recognize that a cultural change is necessary
Be flexible – forward thinking => all play in same sandbox
Trust in revised roles and responsibilities
Be patient-focused: Time is Muscle
Carolinas Medical Center
Bottom Line Results Overall Door-to-Balloon Time Improvements
October 2004 – June of 2006
Number of cases
Range Mean
(minutes)
Median
(minutes)
% < 90
minutes
% < 60
minutes
Before Code STEMI
59 27-289 88.9 76.0 33/59 =
56%
18/59 =
31%
After Code STEMI
153 10 - 172 58.4 54.0 134/153 =
88%
92/153 =
60%
Carolinas Medical Center
Bottom Line Results EMS & Non EMS Arrivals
October 2004 – June of 2006
0%10%20%30%40%50%60%70%80%90%
100%
Field to Balloon Door to Balloon
Pre STEMI <90 mins Post STEMI <90 minsPre STEMI <60 mins Post STEMI <60 mins
58.4
91
0
10
20
30
40
50
60
70
80
90
100
CMC NationalAverage
American College of Cardiology Benchmark <90 minutes
Minimizing Time to Treatmentfrom Arrival in the ED to treatment in the Cath Lab
Saving LivesMortality Rate
4%
7%
0%
2%
4%
6%
8%
10%
CMC NationalAverage
Source: NRMI; Solucient
Bottom Line ResultsCarolinas Medical Center