The Code Stemi Project_ Winning the Race by malj

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									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          minutes

   Triage Nurse in Waiting
    Room 11a – 11p
   Triage Protocol
   Dedicated bay for EKG
   Hand Deliver EKG to
    ED Physician
                             EKG to Lab Activation

   ED Physician Activates           minutes
    Code Stemi
   Activate using Pre-
    hospital EKG when
    available
                         Activation to Arrival in Lab

   CODE STEMI Team
                                       minutes

   One Call Activation
    using Central Page
    Operator
   Cell Phones vs. Pagers
   Scripted Education
   Prep Patient – Gown, 2
    IV sites
                  CODE STEMI Team
ER and Cath Lab
   Personnel                 Security



                             Nursing
                            Supervisor




                           Performance
                           Improvement
                                                 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                              minutes


   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
                                                                                Time to PCI
140


120


100


 80


 60


 40


 20


  0
        Q1 2006




                    Q2 2006




                                      Q3 2006




                                                      Q4 2006




                                                                      Q1 2007




                                                                                    Q2 2007




                                                                                                       Q3 2007
-20

      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
                                  Minutes




              20
                   40
                        60
                             80
                                  100
                                        120
                                              140
                                                    160
                                                          180
                                                                200
                                                                      220




          0
21-Dec

 2-Jan

 9-Jan

25-Jan

23-Feb

20-Mar

12-Apr

19-Apr

 1-May

20-May

28-May

 9-Jun

29-Jun

 13-Jul

 7-Aug

12-Aug

29-Aug

15-Sep

 6-Oct

19-Oct

 3-Nov

19-Nov

13-Dec

25-Dec

 3-Jan

17-Jan

12-Feb

 1-Mar
                                                                            HH ED STEMI & ACUTE MI CASE REVIEW, NON TRANSFERS




 7-Mar

11-Mar

19-Mar

12-Apr

29-Apr

 7-May

22-May

 5-Jun

28-Jun

  7-Jul

 2-Aug

 3-Sep
                                                                                                                                Success
                                       Control Chart

TIME TO PCI XMR Chart                    UCL   MEAN          LCL

 350

 300

 250

 200

 150

 100

 50

  0
    Q1             Q2     Q3     Q4      Q1            Q2
   2006           2006   2006   2006    2007          2007
                                 Patient Outcomes 2006

PCI is less than 120 minutes                  PCI is greater than 120 minutes


      7%
           4%                                          17%
                       D/C Alive, Not to                               D/C Alive, Not to
                       Home                                            Home
                                                             8%
                       In-House Mortality                              In-House Mortality

                       D/C Alive, to Home                              D/C Alive, to Home
                                            75%
89%
            STEMI* In-Patient Mortality Rate
                               IN HOUSE MORTALITY
                HARRISBURG HOSPITAL ED STEMI WITH PCI, NON TRANSFERS



      12%

      10%

       8%

       6%

       4%

       2%

       0%
             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 MORTALITY
                            HARRISBURG HOSPITAL ALL AMI IN-PATIENT MORTALITY RATE

12.0%

10.0%

8.0%

6.0%

4.0%

2.0%

0.0%
        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?

								
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