CARDIAC ALERT: A Change in Process' Results of a STEMI Treatment Protocol Over 5 Years'

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CARDIAC ALERTA Change in Process.Results of
a STEMI Treatment Protocol Over 5 Years.

• Peter Kerwin, M.D.,
• Colleen Kordish, R.N.,
• June 10, 2008
• Downers Grove Illinois
• ADVOCATE GOOD SAMARITAN HOSPITAL
• MIDWEST HEART SPECIALISTS

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Optimal care in the time critical process of
treating STEMI requires a coordinated protocol
with EMS, ED and Cardiology functioning as one
team
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Maintaining optimal quality over time requires
continual monitoring and evaluation of data
related to the teams effectiveness.
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Reasons to Improve Door to Balloon Time

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

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Coroner says patient's death is a homicideWoman
sought care in ER for 2 hours

• 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.

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ACC/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.

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Decreasing D2B Time 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 lt 90 minutes
• Less than 10 EMS systems have 12 lead ECG
  capability
• Circulation 20061132152-2163

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Time is Muscle! And Mortality!

• Each 30 minute delay in reperfusion with PCI
  increases 1 yr mortality 7.5
• Door to balloon lt60 min, 1 30 day mortality
  Door to balloon gt90 min, 6.4 mortality

• DeLuca, Circulation 20041091223-1225.
• Berger, Circulation 199910014-20.

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Advocate Good Samaritan Hospital

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

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D2B- Our History

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

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• Cardiac Alert Brings Results

• Advocate Good Samaritan Hospital D2B cases lt90
  minutes

• 1Tracked using AHAs GWTG
• 2 GWTG/AMI Core Measures

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CARDIAC ALERT Its 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
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CARDIAC 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

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The Cardiac Alert Team

• The Patient!
• Paramedics in the field
• Triage Staff
• ED MDs
• ED RNs
• Cardio diagnostics
• Radiology
• Cardiac Catheterization Lab
• Cardiologists
• Primary MDs
• ICU/Floor RNs
• Nurse Clinician/PAs
• CV Surgery

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Cardiac Alert Goal

• Door to Balloon lt 60 minutes
• Best Mortality
• Achievable Goal

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Goal 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.

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Goal for Acute MI Patients

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

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Cardiac Alert Using Data to Implement Change

• Map the process
• Standardize time
• Gather accurate baseline data
• Evaluate the data
• Make changes based on the data

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Cardiac AlertImproving Door to Balloon Time

• Process driven approach to a time sensitive issue
• Team approach
• Its Not All About Me!

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Cardiac 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

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Ground 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.

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Door to Balloon Time lt 90 Minutes
lt 90 minutes
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• Cardiac Alert Brings Results

• Advocate Good Samaritan Hospital D2B cases lt90
  minutes

• 1Tracked using AHAs GWTG
• 2 GWTG/AMI Core Measures

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D2B Data Left Shift

• Eliminate lag time
• Decrease outliers

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Baseline Data

• 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

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

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STEMI Patients Door to Balloon Time(Baseline
2002-Sept 2003)
Admission time is minute zero. All times are in
minutes and reflect total time elapsed since
initial arrival.
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Cardiac Alert Committee Initial then quarterly
meeting to review process 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

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D2B Time Sequence
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Time from Cardiologist notification to patient on
Cath Lab table

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

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Cardiac Alert Brings Results
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Good Samaritan D2B
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2007 D2B Improvements
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Time from Cardiologist notification to patient on
Cath Lab table (cont)

• One reason for time increase

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Symptom Recognition Symptom to Door often gt2
1/2 Hours

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

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Current Reperfusion StrategiesST- Elevation
Myocardial Infarction
NRMI National Data September 2001
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Evidence Based Changes Create Immediate Benefits

• Cath Lab is called earlier in the process
• 8 minute savings
• Cardiologist will accept ED MDs 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

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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

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D2B AllianceEvidence 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.

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Conclusions

• 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.