THE CODE STEMI PROJECT: Winning the Race

CODE STEMI: The

PinnacleHealth

Experience

Donald C. Durbeck, MD., FACC

Baseline Performance

Evidence Based Approach

Bradley EH, Curry LA, Webster TR, et al. Achieving Rapid Door-to-Balloon Times: How Top Hospitals Improve Complex Clinical Systems. Circulation 2006;113:1079-85.

Racing Theme

Create a Task Force

• Senior Administration Support

• Key Stakeholders

• Weekly Meetings

• Dashboard

• Physician Champion

• Nurse Champion

• Quarterly User’s Meeting

Process Map

Data Drives Us Initiated by ED nurse

Forms kept in bin in cardiac bay

Clip-on digital clocks placed on clipboard

Form, clipboard, and clocks travel with patient to the cath lab

Cath Lab faxes completed form

Performance Improvement confirms time with scanned medical record and enters into data base

Immediate Feedback

EARLY CASES

Immediate Feedback

RECENT CASES

Immediate Feedback

Be transparent, list names

Bar graphs and Calendar feedback updated within one working day of case

Both are emailed to all members of the project

Assign follow-up tasks

Posted for front-line staff

Ensure EMS providers also receive feedback

Door to EKG

Pre-Hospital EKG

Triage Nurse in Waiting Room 11a – 11p

Triage Protocol

Dedicated bay for EKG

Hand Deliver EKG to ED Physician

minutes

EKG to Lab Activation

ED Physician Activates Code Stemi

Activate using Pre-hospital EKG when available

minutes

Activation to Arrival in Lab

CODE STEMI Team

One Call Activation using Central Page Operator

Cell Phones vs. Pagers

Scripted Education

Prep Patient – Gown, 2 IV sites

minutes

CODE STEMI Team

SecuritySecurity

Nursing Nursing SupervisorSupervisor

Performance Performance ImprovementImprovement

ER and Cath Lab Personnel

Scripted Education

PROCEDURE FOR EMERGENCY CARDIAC CATHETERIZATION

• Your physician believes you are having a heart attack. A heart attack occurs when an artery supplying the heart muscle becomes blocked with a blood clot. A heart attack can lead to permanent heart damage and represents a risk to your life. When treating a heart attack, time is of the essence. It is believed that if the clogged artery can be opened, the damage can be lessened and your risk of disability and death may be reduced.

• Your physician is proposing that you have a procedure called a cardiac catheterization. The goal of this procedure is to identify which artery of your heart is causing the attack. It is performed by a specially trained cardiologist. The procedure is done by placing a tube in an artery in your leg under local anesthesia. Dye is injected into to the arteries of your heart using x-rays. The discomfort from the procedure is generally minor. You will be given sedation as necessary. The cardiologist will attempt to identify the artery with a blood clot and re-establish blood flow by placing a small metal tube called a stent into the artery. You will receive medications to thin your blood…….

INTERVENTIONALIST OBTAINS CONSENT

Arrival to Device Time

Room ready during off hours

2 of 3 on call must be within 20 minutes

All expected to be ready in 30 minutes

Send patient as soon as 1 cath lab member in lab & interventionalist on site

Intervene on culprit artery first

minutes

Time to PCI

-20

0

20

40

60

80

100

120

140

Q1

20

06

Q2

20

06

Q3

20

06

Q4

20

06

Q1

20

07

Q2

20

07

Q3

20

07

Door to EKG EKG to Lab Activation Activation to Lab Lab to Balloon

-20

0

20

40

60

80

100

120

140

Q1

20

06

Q2

20

06

Q3

20

06

Q4

20

06

Q1

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07

Q2

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Q3

20

07

Door to EKG EKG to Lab Activation Activation to Lab Lab to Balloon

Analysis of Missed Opportunities

Follow up missed opportunities ASAP

Interview staff involved in case

Follow all leads

Take results of investigation to weekly task force meeting

Keep running list of reason for misses

Obtain necessary documentation for patient centered reason for delays

Patient Related Delays, excluded

Required Resuscitation

Patient did not give consent

Needed CT Scan to rule out dissection

System Delays, not excluded

• 99 minutes (Door to EKG = 30 min) - Known COPD smoker arrived via EMS with back pain and SOB. Symptoms improved with breathing treatment in ambulance

• 24 minutes -3rd STEMI in a row on a Sunday.

• 112 minutes (EKG to Activation = 40 min) - 1st EKG ST wave abnormality, hesitation to activate as it may have looked like pericarditis

• 103 minutes (Door to EKG = 40 min) – Female c/o bilateral arm numbness, mild SOB, dizzy

• 95 minutes (Activation to Arrival = 50 min) – Cardiologist saw patient in ED before activating the interventionalist.

Data Accuracy

• Abstractor’s send list of missed opportunities at end of month to compare with our on-going list

• Use QNET for resolution

• Prior to quarterly submission to Joint Commission vendor, run final list of misses to ensure “mets”/”not mets” are coded correctly

Success

HH ED STEMI & ACUTE MI CASE REVIEW, NON TRANSFERS

0

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Min

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Control Chart

TIME TO PCI XMR Chart

0

50

100

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Q12006

Q22006

Q32006

Q42006

Q12007

Q22007

UCL MEAN LCL

Patient Outcomes 2006

PCI is less than 120 minutes

7%4%

89%

D/C Alive, Not toHome

In-House Mortality

D/C Alive, to Home

PCI is greater than 120 minutes

17%

8%

75%

D/C Alive, Not toHome

In-House Mortality

D/C Alive, to Home

STEMI* In-Patient Mortality Rate

IN HOUSE MORTALITYHARRISBURG HOSPITAL ED STEMI WITH PCI, NON TRANSFERS

0%

2%

4%

6%

8%

10%

12%

Q1 2006 Q2 2006 Q3 2006 Q4 2006 Q1 2007 Q2 2007 Q3 2007

* Of patients included in Primary PCI Joint Commission Measure.

ALL AMI In-Patient Mortality

IN HOUSE MORTALITYHARRISBURG HOSPITAL ALL AMI IN-PATIENT MORTALITY RATE

0.0%

2.0%

4.0%

6.0%

8.0%

10.0%

12.0%

Q1

2004

Q2

2004

Q3

2004

Q4

2004

Q1

2005

Q2

2005

Q3

2005

Q4

2005

Q1

2006

Q2

2006

Q3

2006

Q4

2006

Q1

2007

Q2

2007

Program Expansion

• In-Patient CODE STEMI using Rapid Response Team

• Transfer Patients from within the PinnacleHealth system

• Transfer Patients from neighboring institutions

• Transfer Center

• Helicopter services

QUESTIONS?