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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