Beverly J. Miller, RN, MSN, CNS, NP

Clinical Educator/Supervisor RN

WakeMed North Healthplex Emergency Services

bemiller@wakemed.org

2009.07.25

Raising the Bar for Health Raising the Bar for Health Care PerformanceCare PerformanceStrategyStrategy to Pursue Perfection: to Pursue Perfection:

““EKG Door-to-Doc EKG Door-to-Doc << 10 min” 10 min”

Standard:

• WakeMed is a recognized Chest Pain Center.

• All Emergency Departments are to achieve Door-to-Doc EKG times of < 10 minutes for all patients aged >18 with complaint of chest pain.

Problems:Problems:

• Current EKG times averaged 11-16 minutes (up to 30+)

• Independent activities by staff (PAR, RN, RT, Techs)

• Paradigm of Triage (RN presumes the patient’s

chest hurts because they have been coughing for 3 weeks, etc, effectively pre-screening the patient)

Strategy:Strategy:

• Create STAT Interprofessional Departmental Task Force to review and propose solutions

• Test proposed solutions• Adjust until standards are

consistently met• Provide education and feedback• Timeframe: 1 shift

Door-to-Doc EKG Time Line:Door-to-Doc EKG Time Line:

• Adult patient enters ED Adult patient enters ED and statesand states

“ “I am having Chest Pain”…I am having Chest Pain”…

THE CLOCK STARTS HERETHE CLOCK STARTS HERE

– What happens next?What happens next?

Elapsed time 0:00:00

Audits (prior to new process):Audits (prior to new process):

• Overall, less than 40% of patients Overall, less than 40% of patients were getting EKGs within 10 minute were getting EKGs within 10 minute timeframe (64% of perceived timeframe (64% of perceived possibly cardiac by staff)possibly cardiac by staff)

• Perceived ‘non-cardiac’ patients Perceived ‘non-cardiac’ patients were often not having EKGs were often not having EKGs completed for up to 45 minutes.completed for up to 45 minutes.

Previous Process:Previous Process:

• PAR pages RT PAR pages RT (time: 3-4+ minutes)(time: 3-4+ minutes)

• RT calls to determine need: neb/EKGRT calls to determine need: neb/EKG(time: 1-3 minutes)(time: 1-3 minutes)

• RT brings EKG machine to triage to run RT brings EKG machine to triage to run diagnostic exam as soon as possiblediagnostic exam as soon as possible

(time: 2-5 minutes)(time: 2-5 minutes)

• EKG setup and run; result to MDEKG setup and run; result to MD(time: 5-7 minutes)(time: 5-7 minutes)

(Potential time = 19+ minutes)(Potential time = 19+ minutes)

Paradigm Shift:Paradigm Shift:

• Prior to initiation of new process, Prior to initiation of new process, staff were ‘pre-screening’ patients staff were ‘pre-screening’ patients based on clinical presentationbased on clinical presentation

• New paradigm was neededNew paradigm was needed

NewNew Paradigm: Paradigm:

• ““The EKG The EKG ISIS the screen!” the screen!”

• If EKG abnormal, patient If EKG abnormal, patient goes directly to back for goes directly to back for initiation of treatmentinitiation of treatment

• If the EKG is normal, the If the EKG is normal, the patient can wait in the patient can wait in the lobby in queue barring lobby in queue barring other clinical red flagsother clinical red flags

What is Different?What is Different?

• No more paging: use radio No more paging: use radio for instant communicationfor instant communication

• Assign EKG tech so RT is Assign EKG tech so RT is not interrupted in dutiesnot interrupted in duties

• Mini registration concurrent Mini registration concurrent with EKG setupwith EKG setup

• Multiple simultaneous Multiple simultaneous processes shave time from processes shave time from all sidesall sides

PAR:PAR:

• Patient Account Rep radios EKG Patient Account Rep radios EKG tech (each shift, an ED tech is tech (each shift, an ED tech is assigned a radio for this top-priority assigned a radio for this top-priority purpose)...provides accountabilitypurpose)...provides accountability

• Patient is immediately taken to Patient is immediately taken to Triage #2 (EKG room) by wheelchairTriage #2 (EKG room) by wheelchair

• Mini-registration is doneMini-registration is done

Elapsed time

0:00:45

Triage #2:Triage #2:

• Designated Chest Pain Room with Designated Chest Pain Room with dedicated EKG machinededicated EKG machine

• EKG tech enters data, connects EKG tech enters data, connects patient to EKG machine and performs patient to EKG machine and performs EKG while triage RN takes additional EKG while triage RN takes additional historyhistory

• EKG is immediately taken to the MDEKG is immediately taken to the MD

• Time documented Time documented isis the time on EKG the time on EKG

Elapsed time 0:00:45+0:04:30

Education:Education:

• Email to all staff (interdisciplinary) Email to all staff (interdisciplinary) regarding importance of goalsregarding importance of goals

• New process explained for each New process explained for each team memberteam member

• Flowchart emailed to all staffFlowchart emailed to all staff• Flowcharts laminated and placed Flowcharts laminated and placed

throughout departmentthroughout department• IMs to staff real-time following Chest IMs to staff real-time following Chest

Pain patients in departmentPain patients in department• Auditing of ALL charts where chest Auditing of ALL charts where chest

pain is the presenting complaintpain is the presenting complaint

2009.06.25 BJM

Designated EKG tech each shift

Results:

• The first day, some charts were still not meeting The first day, some charts were still not meeting time goals of time goals of << 10 minutes door-to-doc 10 minutes door-to-doc

• Some staff expressed a concern about perceived Some staff expressed a concern about perceived “back-timing” of EKGs“back-timing” of EKGs

• One problem was that staff was not charting EKGs One problem was that staff was not charting EKGs until several minutes later while documentinguntil several minutes later while documenting

• Over the course of several days of consistent Over the course of several days of consistent

real-time auditing and feedback (Kudos for real-time auditing and feedback (Kudos for getting it right and reminders when not) the % getting it right and reminders when not) the % compliance reached almost 100% -- the few compliance reached almost 100% -- the few exceptions were explainable and correctableexceptions were explainable and correctable

• Scanned EKGs were reviewed to be certain that Scanned EKGs were reviewed to be certain that the EKG time documented was the actual time the EKG time documented was the actual time recorded on the EKGrecorded on the EKG

• Daily monitoring (real-time and audits) continuesDaily monitoring (real-time and audits) continues

First Month Failures in EKG DOOR-TO-DOC TimesFirst Month Failures in EKG DOOR-TO-DOC Times

Date EKG Time Reason for Delay

6/25/2009 28 report of "burning sensation in chest" (old paradigm)

6/25/2009 11 attempted to do more complete registration

6/27/2009 12 PAR used pager instead of Nextel direct connect radio

6/28/2009 11 delay in order entry

7/17/2009 11 delay in order entry

Data Analysis

The EKGIS

the screen