Cardiac Alert at Advocate Good Samaritan Hospital: Improving Care of the CAD Patient by Decreasing D2B

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Cardiac Alert at Advocate Good Samaritan
HospitalImproving Care of the CAD Patient by
Decreasing D2B

• Peter Kerwin, M.D., Medical Director Cardiac
  Catheterization Lab, Chairman of Interventional
  Cardiology for Midwest Heart Specialists,
  Co-chair of Cardiac Alert Team
• Colleen Kordish, R.N., Cardiovascular Outcomes
  Coordinator, Co-chair of Cardiac Alert Team
• 5 December 2006
• Downers Grove Illinois

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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
• 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.
• Circulation 20061132152-2163
• DeLuca, Circulation 20041091223-1225.
• Berger, Circulation 199910014-20.

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• Cardiac Alert Brings Results

• Advocate Good Samaritan Hospital D2B cases lt90
  minutes

Cases lt 90
2002 1 17/42 40
2003 1 25/48 52
2004 2 35/46 76
2005 2 51/63 81
2006 2,3 42/46 91

• 1Tracked using GWTG
• 2 GWTG/AMI Core Measures
• 3 January September, 2006

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Cardiac Alert Brings Results
Advocate Good Samaritan Hospital (2005 STEMI data) Cardiac Alerts occurring during Regular Hours Cardiac Alerts occurring during Off Hours Total
Walk-in Cardiac Alerts 54 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 2005294 803-812. 95 minutes 116 minutes 106 minutes
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Impact of Cardiac Alert2002/03 vs. 2006
Admission is minute zero. All times are in
minutes.
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 (n77) 19.5 21 x 32 40 73 99
2006 Data Jan - Sept (n46) 5 6 7 8 x 41 64
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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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The Cardiac Alert Team

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

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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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Cardiac Alert Goal

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

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Cardiac Alert Using Data to Implement Change

• Map the process
• Standardize time
• Gather baseline data
• Evaluate the data
• Make changes based on evidence and reason

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Map the Baseline D2B Process
Ambulance Arrival
Walk-in Arrival
Hospital ECG
ED MD Evaluation
PCI performed
Cardiologist notified
Cardiac Cath Lab team notified
Cath Lab transfers Patient onto Cath Lab Table
Cath Lab team and Cardiologist meet in ED
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Time Standardization

• Identify Real Time
• Set Clocks
• Be reasonable the two minute rule
• Associate specific times with your process so the
  data collector can go back to the patients
  record at their leisure and still obtain accurate
  times
• The clinical staff should be able to treat the
  patient not their paperwork

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Time and Process Coordinated
Ambulance Arrival Time documented In EMS record
Walk-in Arrival Time documented in ED record
Hospital ECG Time documented on ECG print-out
ED MD Evaluation Time documented in ED record
PCI performed Time documented in Cath Lab record
Cardiac Cath Lab team Notified Time documented
by Hospital Operator
Cardiologist Notified Time documented in ED
record
Cath Lab transfers Patient onto Cath Lab
Table Time documented in Cath Lab record
Cath Lab team and Cardiologist meet in ED
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Gather Baseline Data

• Establish case criteria
• ST elevation on first ECG 1cardiologist and 1ED
  MD should agree
• Patient admitted through the ED
• Start with 3 months of data (25of a year)
• Do not omit outliers
• Measure process intervals so you can create a
  time line (shown below)
• This is not Poker! Do not hide 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 (n77) 19.5 21 32 40 73 99
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Evaluate the Baseline Data
Cath Lab

• Who is the limiting factor?
• Call them earlier
• Make it easy one phone call
• Remember You are only as fast as your slowest
  team member

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

Average STEMI patient First ECG ED MD evaluation Cardiologist notified Cath Lab notified
Baseline Data (n77) 19.5 21 32 40
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Evaluate the Baseline Data
Cardiologist

• Who is the limiting factor?
• ST elevation on first ECG 68
• Invasive cardiac procedures 89
• Cardiac cath, PCI, IABP, CABG, ICD, pacemaker
• 2005 data
• If your cardiologist is willing to accept some
  false positives in order to be called a little
  earlier then you too can implement the Cardiac
  Alert

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

Average STEMI patient First ECG ED MD evaluation Cardiologist notified
Baseline Data (n77) 19.5 21 32
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Evaluate the Baseline Data

• What is the limiting factor now?
• ED MD?
• First 12-lead ECG?
• It is definitely not your ED MD!
• ED MD is the key to this process
• diagnostician
• calls the cardiologist
• coordinates the ED staff medications, testing,
  patient assessment

?
Admission time is minute zero. All times are in
minutes
Average STEMI patient First ECG ED MD evaluation
Baseline Data (n77) 19.5 21
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Evaluate the Baseline Data
ECG

• Method of patient arrival
• Walk-in (n38)
• Door to ECG 25 minute average
• 25 min x 50 12.5 minutes
• Ambulance (n39)
• Door to ECG 14 minute average
• 14 min. x 50 7 minutes

Admission time is minute zero. All times are in
minutes
Average STEMI patient First ECG ED MD evaluation
Baseline Data (n77) 19.5 21
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Evaluate the Baseline Data
ECG

• ECG for walk-in patient arrival
• Door to ECG 25 minutes
• Adheres to the 80/20 rule
• You will spend 80 effort for 20 gain
• If this issue is a challenge at your facility
  then improve everywhere else first then come back
  to this issue
• In many cases the triage nurse knew the patient
  was an AMI
• What if we listen to the RN? Empower them?
• Improvement efforts increase technology,
  streamline process, make it routine, quicker
  access to ECG machines

Admission time is minute zero. All times are in
minutes
Average STEMI patient First ECG ED MD evaluation
Baseline Data (n77) 19.5 21
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Evaluate the Baseline Data
ECG

• ECG for ambulance arrival
• Door to ECG 14 minutes
• Paramedics notify ED pre-arrival
• 90 accuracy with AMI symptoms
• What if we listen to them? Empower them?
• What if we ask the paramedic Do you think this
  is an AMI?
• Listen to actual paramedic calls these
  paramedics are professionals!

Admission time is minute zero. All times are in
minutes
Average STEMI patient First ECG ED MD evaluation
Baseline Data (n77) 19.5 21
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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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Cardiac Alert Process(2006 Data)
Ambulance Arrival
Walk-in Arrival
ECRN asks Do you think this is an AMI?
Minute 0
Minute 0
ED RN Initiates Cardiac Alert
ECRN Initiates Cardiac Alert
Hospital ECG
5 min
ED MD Evaluation
Initiate Cardiac Alert
6 min
Cardiac Alert notifies Cath Lab
MD Initiates Cardiac Alert
7 min
Cardiologist notified
Patient on Cath Lab Table
PCI performed
41 min
8 min
64 min
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Cardiac Alert Cardiac Catheterization Lab

• Cardiac Cath Lab (3 person team)
• 1st person to arrive
• opens lab
• prepares room then changes into scrubs
• goes to the ED to assist in transport if
  necessary
• 2nd person to arrive
• changes in scrubs
• goes to ED to package patient for transport to
  the Cath Lab
• it is the responsibility of this person to
  eliminate all delays by supporting and assisting
  the ED staff wherever necessary
• 3rd person to arrive
• assists wherever needed
• This routine improves efficiency by eliminating
  overlapping actions 24 minute improvement (see
  following graph)

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Cath Labs 2001 Performance Improvement Project
Baseline 71 min.
Mean 47.2 min.
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Cardiac Alert at Advocate Good Samaritan
HospitalImproving Care of the CAD Patient by
Decreasing D2B

• Peter Kerwin, M.D., Medical Director Cardiac
  Catheterization Lab, Chairman of Interventional
  Cardiology for Midwest Heart Specialists,
  Co-chair of Cardiac Alert Team
• 630-719-4799
• Colleen Kordish, R.N., Cardiovascular Outcomes
  Coordinator, Co-chair of Cardiac Alert Team
• 630-275-1592
• Advocate Good Samaritan Hospital
• 3815 Highland Avenue
• Downers Grove, Illinois 60515