An Immediate Nursing Feedback Program for Primary PCI for ST-segment Elevation Myocardial Infarction...
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An Immediate Nursing Feedback An Immediate Nursing Feedback Program for Program for
Primary PCI for ST-segment Primary PCI for ST-segment Elevation Myocardial InfarctionElevation Myocardial Infarction
Karen Mckenny RN, Theresa Fortner RN, Cheryl McNeil RN, Karen Mckenny RN, Theresa Fortner RN, Cheryl McNeil RN, Carol Woods RN, Shirley Gadbois RN, Heidi Igneri RN Carol Woods RN, Shirley Gadbois RN, Heidi Igneri RN
Joe Hastings RN, and Harold L. Dauerman,MDJoe Hastings RN, and Harold L. Dauerman,MD
Fletcher Allen Health CareFletcher Allen Health Care
University of Vermont, Burlington, VermontUniversity of Vermont, Burlington, Vermont
BackgroundBackground
Based on DANAMI 2. Vermont adopts a Based on DANAMI 2. Vermont adopts a primary PCI Regional Transfer Program 2007primary PCI Regional Transfer Program 2007 4 Rural Hospitals4 Rural Hospitals 35 miles median travel distance35 miles median travel distance
2008 (Nov) Immediate Nurse to Nurse 2008 (Nov) Immediate Nurse to Nurse Feedback program initiated.Feedback program initiated.
The Vermont Rural STEMI Program:The Vermont Rural STEMI Program:There is Only One Interventional There is Only One Interventional
Cardiology/PCI Center in the State of Cardiology/PCI Center in the State of VermontVermont
Vermont Population 600, 000
PCI Procedures at UVM/FAHC: 1400
PCI/year
Vermont
Objectives
To determine a role for cardiovascular catheterization laboratory nursing in improving quality of care for regional primary PCI programs
To define the current level of nursing satisfaction with regional STEMI transfer programs
To implement a nurse to nurse immediate feedback program to improve education and program outcomes
To provide a semi-annual roundtable led by and for nursing to systematically address areas of need including potential sources of transfer delay and/or miscommunication.
MethodsMethods
All patients with STEMI referred for primary All patients with STEMI referred for primary PCI to a single PCI center (Fletcher PCI to a single PCI center (Fletcher Allen/Univ. of Vermont) enrolled in a Allen/Univ. of Vermont) enrolled in a dedicated prospective registrydedicated prospective registry
Study Period: November 2008 - December Study Period: November 2008 - December 20092009
The current study includes 1 PCI center and The current study includes 1 PCI center and 4 regional STEMI referral centers4 regional STEMI referral centers
MethodsMethods A pre-intervention survey of STEMI referral centers A pre-intervention survey of STEMI referral centers
was completed in November 2008was completed in November 2008
A post intervention survey of STEMI referral centers A post intervention survey of STEMI referral centers was completed 9 months laterwas completed 9 months later
Differences between Survey endpoints were Differences between Survey endpoints were compared using chi square statistical techniques. compared using chi square statistical techniques.
Changes in Door to Balloon Times and Triage Times Changes in Door to Balloon Times and Triage Times were compared Quarter 1 vs Quarter 4 using were compared Quarter 1 vs Quarter 4 using student’s t test.student’s t test.
Pre-Intervention Survey ToolPre-Intervention Survey Tool
8 questions:8 questions: Satisfaction regarding feedbackSatisfaction regarding feedback 5 Point Lickert Scale5 Point Lickert Scale
1= no feedback, 5 = excellent 1= no feedback, 5 = excellent feedbackfeedback
Interest in Round Table meetingsInterest in Round Table meetings Educational Topics of interestEducational Topics of interest
STEMI Feedback Form: Dedicated, Faxed STEMI Feedback Form: Dedicated, Faxed Table of Times and Events To Both Table of Times and Events To Both
NursingNursing and Physicians and PhysiciansPatient Name: Patient Name: TimeTime
Date of STEMI: 01/05/09Date of STEMI: 01/05/09
STEMI referral Hospital: STEMI referral Hospital: CopleyCopley
Time of arrival to referring EDTime of arrival to referring ED 3:293:29
Time of first FIELD/EMS/AMBULANCE ECGTime of first FIELD/EMS/AMBULANCE ECG N/AN/A
Time of first ED ECGTime of first ED ECG 3:293:29
Time FAHC cardiology paged with STEMI Time FAHC cardiology paged with STEMI notificationnotification 3:473:47
Ambulance Service usedAmbulance Service used VT EMSVT EMS
Time of departure by ambulanceTime of departure by ambulance 3:473:47
Time of arrival in labTime of arrival in lab 4:304:30
Time of open artery (balloon inflation)Time of open artery (balloon inflation) 4:454:45
Door to Open Artery total time ( their door to Door to Open Artery total time ( their door to our balloon)our balloon) 1:151:15
OUR GOAL IS OUR GOAL IS < 90 min< 90 min
STEMI Feedback Form: Dedicated, Faxed STEMI Feedback Form: Dedicated, Faxed Table of Times and Events To Both Table of Times and Events To Both
Nursing Nursing and Physiciansand Physicians
Ambulance EKG to open arteryAmbulance EKG to open artery n/an/a
Medications given prior to transport: ASA 325______Medications given prior to transport: ASA 325______ XX
Clopidogrel 600_____ Clopidogrel 600_____ XX
Unfractionated Heparin Bolus____________Unfractionated Heparin Bolus____________ XX
Referring ED attending: Referring ED attending: Dr. STEMIDr. STEMI
Procedure details: Affected artery_______% Procedure details: Affected artery_______% stenosisstenosis__________
Hospital Adverse Events: Death___Emergent Hospital Adverse Events: Death___Emergent CABG____ Stroke____ Major Bleeding_____ Repeat CABG____ Stroke____ Major Bleeding_____ Repeat PCI____PCI____
Transport Related Transport Related eventsVT____VF____CPR____Defib__eventsVT____VF____CPR____Defib__
Follow up phone call done/date Follow up phone call done/date Nurse xNurse x
1/5/091/5/09
Feedback ProgramFeedback Program
Feedback form filled out by Nurse Led Team Feedback form filled out by Nurse Led Team at Primary PCI Siteat Primary PCI Site
Follow up phone call within 24-48 hours to Follow up phone call within 24-48 hours to referring ED nurse for feedback and patient referring ED nurse for feedback and patient outcome reportoutcome report
Form Faxed within 24-48 hours of STEMI to Form Faxed within 24-48 hours of STEMI to Referring STEMI Physician and Nurse TeamReferring STEMI Physician and Nurse Team
Semi-Annual Semi-Annual Round Table meetings & Outreach VisitsRound Table meetings & Outreach Visits
Education of referring staff Education of referring staff Uniform algorithm for treatments and Uniform algorithm for treatments and
medications.medications. Networking, team building, and system Networking, team building, and system
improvement for the STEMI patient in improvement for the STEMI patient in VermontVermont
RESULTS RESULTS STEMI Referral Center Volume STEMI Referral Center Volume
& Feedback Transmission& Feedback Transmission
Name of HospitalName of Hospital Distance in Distance in miles/time from miles/time from
FAHCFAHC
## of of
Beds Beds
STEMI transfer STEMI transfer with follow up with follow up
phone call phone call
Nov 08-Dec 09Nov 08-Dec 09
STEMI transfer STEMI transfer with follow up with follow up
phone call phone call
Jan 10-Sept 10Jan 10-Sept 10
Fletcher Allen Fletcher Allen Health CareHealth Care
500500 7979 6565
Copley Medical Copley Medical CenterCenter
45miles45miles
1 hour1 hour
2525 1616 1313
Northwestern Northwestern Medical CenterMedical Center
25miles25miles
30 min30 min
7070 3131 1616
Porter Medical Porter Medical CenterCenter
37 miles37 miles
58 min58 min
3030 2323 1919
Central Vermont Central Vermont Medical CenterMedical Center
41miles41miles
45 min45 min
3030 3434 3131
Result of Intervention:Result of Intervention:Lickert Scale Satisfaction ScoresLickert Scale Satisfaction Scores
0
1
2
3
4
5
Lic
kert
Sco
re, 1
to
5
Pre Intervention Post Intervention
Triage Times 2009:Triage Times 2009:Significant Improvement in Transfer Hospital Significant Improvement in Transfer Hospital
Presentation to Cath Lab Activation after STEMI Presentation to Cath Lab Activation after STEMI Nursing Feedback Program InitiatedNursing Feedback Program Initiated
0
5
10
15
20
25
30
35
All Referral Hospitals
Ave
rage
Tri
age
Tim
es;
min
utes Quarter 1
Quarter 429 min
19 min
Door to Balloon Times 2009:Door to Balloon Times 2009:Significant Door to Balloon TimeSignificant Door to Balloon Time
Improvement after STEMI Nursing Improvement after STEMI Nursing Feedback ProgramFeedback Program
0
20
40
60
80
100
120
140
FAHC PCI Center All Referral Hospitals
Ave
rage
DT
B ti
me,
min
utes
Quarter 1
Quarter 4
63min58min
124min
86min
Door to Balloon Times:Door to Balloon Times:Significant Door to Balloon TimeSignificant Door to Balloon Time
Improvement after STEMI Nursing Feedback Improvement after STEMI Nursing Feedback ProgramProgram
0
20
40
60
80
100
120
140
FAHC PCI Center All Referral Hospitals
Ave
rage
DT
B t
ime,
min
utes
Start of program Dec 08 Quarter 4 Dec 09 Jan 10-Sept 10
63min
58 min
57 min
124 min
86 min
93 min
ConclusionsConclusions Nurse to NurseNurse to Nurse feedback is a critical component of a feedback is a critical component of a
successful rapid transfer STEMI programsuccessful rapid transfer STEMI program
Referring emergency department satisfaction can be Referring emergency department satisfaction can be dramatically improved with a feedback programdramatically improved with a feedback program
Roundtable and outreach lead to adoption of Roundtable and outreach lead to adoption of uniform state wide practicesuniform state wide practices
The STEMI nursing feedback program leads to The STEMI nursing feedback program leads to improved triage times and D2B times for transfer improved triage times and D2B times for transfer programsprograms