St. Rose Dominican Hospital

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St. Rose Dominican Hospital

• Cardiac Care Team
• UPDATE
• September 2003

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Prepared by

• Pamela Rowse, RN
• Cardiac Care Team Leader
• Assistant Nurse Manager ED

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The Henderson Roses
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Living by our Mission and ValuesSt. Catherine
of SienaandSt. Rose of DeLima
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Striving For Excellence
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Background

• Early Team activities were missing important
  resources.
• Meetings were not well attended by team members.
• Interdisciplinary collaboration was fragmented.

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Reorganization

• The Emergency Department actively joined the Team
  in December of 2002.
• In March of 2003 Expansion began in the Team
  Configuration.
• Benchmarks were reviewed in detail and
  discussions ensued to meet the standards.

• The name changed from AMI Team, to Cardiac
  Care Team.
• Resources influencing outcomes were outlined.
• Strategic Team expansion resulted.
• Focus expanded to ALL services impacting the
  desired end product, that being excellence in
  Cardiac Care.

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Team Members Now
Emergency Department Critical Care ED Physicians Cardiology
Cardiologists Pharmacy Medical Surgical Nursing Education
Case Management Nutrition Services EMS/HFD QM/RM
Cardiac Rehab Cardiac Cath Lab Radiology Laboratory
Communications Respiratory Therapy Administration Corporate
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Diagramed Full Process

• What are the important components to success and
  good patient outcomes.?

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Chest Pain Cardiac Emergency

• Onset of pain is the triggering factor in
  recognizing and acting on a true cardiac
  emergency
• The Team realized that this was one area where we
  must have impact to be successful in our
  outcomes.
• Denial and lack of public awareness was one of
  the focuses.

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Activating 911

• How could we achieve early activation of the 911
  system?
• HFD Assisted us with statistics regarding the
  current stats in our Community.
• Average time from CP to 911 activation was 53
  minutes
• We felt it was imperative to impact in earlier
  notification of emergency services.

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Community Education
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Time Is Muscle

• The Communications Department at St. Rose
  Dominican was contacted regarding public
  education
• Response was very supportive and projects
  discussed in conjunction with Henderson Fire
  Department/EMS
• Once More a Team Effort and quality in our
  delivery of care.

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EMS Response
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Pre-Hospital Statistics for Cardiac Care

• Once 911 is activated, our community has a
  maximum dispatch response time of 2 min
• EMS Response to the Scene is approximately 7
  min
• Early Cardiac Alert Systems were already being
  put into place by HFD to enable them to react
  with expediency when arriving at the scene for
  particularly patients presenting with ST
  Elevation.

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STEMI Patients

• The Team discovered that the HFD was working
  diligently on a program for ST elevation MI
  Protocols
• A presentation was made to the Cardiac Care Team
  outlining their plans.
• This dove-tailed perfectly into our Team
  Activities including standing physician orders.
• Early Recognition and Resource activation took a
  step forward.
• Presentations were scheduled for the Emergency
  Department Physicians and Cardiology.

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Emergency Department Early Activation

• Part of the Early Activation of ED Resources came
  from the statistics that we were given regarding
  benchmarks of care delivery.
• Timing of response from EKG, Laboratory, and
  Radiology didnt meet our desired goal.
• It was essential to have emergent notification of
  all needed resources for an acute MI patient
  delivery.
• A system for group paging was discussed and
  implemented.

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Door To Data

• Arrival of the EKG Technician for accurate data
  for diagnosis was imperative. This was addressed
  with the AMI Group Pager system.
• HFD however, helped us to move even further in
  this arena.
• Technology with their rescue units enables them
  to transmit via fax accurate and clear 12 lead
  EKG data directly to the hospital ED Physician
  for review.
• This would enable activation of resources prior
  to the arrival of the patient.

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Time to Lytics

• Time to administration of thrombolytics was an
  essential benchmark.
• This component was impacted by Nursing, Pharmacy,
  and Education.
• Tracking was established to monitor times.
• We also included the administration of lytics in
  the critical care units and provided an
  educational program through pharmacy to
  facilitate this.

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Door to PTCA

• A new cath lab was installed at the DeLima Campus
  allowing PTCA to be completed there.
• Tracking of response times by the Cardiologists
  was initiated.
• 100 review was established.

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Morbidity Mortality

• Reports were outside of Benchmarks
• Reviewed stats from Midas and NIRMI
• Investigated the co-utilization of NIRMI numbers
  with significant co-morbidities pull out.
• Needed to pull NIRMI numbers into current review.
• Contacted another CHW Facility regarding their
  process.
• Pursuing Alternatives such as dedicated FTEs.

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Corroboration

• All Resources Must Be Included
• To
• Achieve Best Practice

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Public and Patient Education

• It is OUR responsibility to identify and
  provide education for our patients and our
  customers.
• Cardiac Disease in one of the number one causes
  of death and disability in our country and we
  must help provide the necessary interventions.
• It is an issue that is broad in scope and vitally
  important.
• And one that the St. Rose Cardiac Care Team
  didnt take lightly.

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Nursing Education

• The education of our nursing staff is
  multi-faceted and imperative.
• Disease Process Understanding.
• Recognition of needs.
• Intervention in a timely and appropriate manner.
• Patient Education and Advocacy.

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Physician Education

• Communication of the National Guidelines and
  Community Standards
• Providing Tools for accurate admission orders
  that are streamlined.
• Introduction of Clinical Pathways to facilitate
  compliance to LOS standards that assists not
  only medical but nursing treatment of patients
  with cardiac conditions.
• Provide information regarding resources that will
  facilitate their patients recovery such as
  outpatient services, Rehab, PT, Nutrition etc.

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Smoking Cessation

• Identify all opportunities for education.
• Provide the resources and support for patients to
  achieve this essential goal.
• Be able to document the efforts made.
• Achieve desired benchmarks

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Aspirin, Beta Blockers, Ace Inhibitors

• Provide opportunity for appropriate
  documentation.
• Provide triggers for ordering and follow-through
• Provide patient and provider education regarding
  need.

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Nutrition

• Provide notification and access to essential
  clients by the Nutrition Team.
• Take home information regarding daily activities
  and impact of diet on disease process.
• Follow-up Resources regarding education and
  questions.
• Disease specific tips for adhering to a healthy
  life-style

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Medications

• Patient understanding of prescribed medications.
• Assisting patients with financial resources to
  adhere to medication regimes outlined for them.
• Providing resources for education and food and
  drug interactions that will allow nursing to
  assist in the education process at discharge.

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Rehab Exercise

• Active participation in the inpatient visit and
  mechanism for notification and orders.
• Coordination with other educational processes.
• Notification of follow-up resources provided.

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Discharge Instructions

• Standardize the documents utilized for Discharge
  Instructions and documentation by Nursing.
• Provide the tools for adequate education of
  patients by the nursing staff that is going to be
  held accountable for its completion.
• Establishment of a resource library and packets
  for disease specific education by nursing.
• Education regarding how to provide Discharge
  Instruction

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Our Team Challenges

• Systems for implementation of action plan such
  as
• Dedicated fax machines for EKG Transmissions,
• Immediate registration of AMI patients for early
  intervention,
• Education of all staff regarding cardiac care
  education and discharge planning,
• Process for reporting to the nursing departments
  regarding ejection fractions,
• Standardized forms for discharge documentation,
• Materials available for after hour discharges,
• Notification of essential services needed to
  deliver appropriate assessment and intervention.

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Our Team Successes

• Implementation of the STEMI Standing Orders.
• AMI Group Page System
• Near Completion of the CHF Standing Orders
• Collaborative effort with Community EMS for Early
  Activation and Public Education.
• Successful achievement of benchmarks for door to
  data and door to lytics
• Expansion of Active Team to include all
  necessary resources.
• Active involvement of physicians in outcomes
  and program implementation.

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Proposals

• Utilization of the St. Rose Website for
• Patient and Staff Education
• Resources and Referrals
• Internet links for information
• Schedules for outpatient education programs
• Contacts and Educational Downloads

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St. RoseServing Our CommunityFor Better Cardiac
Care