OPTIMIZING DOOR-TO-BALLOON TIME: STRATEGIES FOR SUCCESS B. Hadley Wilson, MD. J. Lee Garvey, MD. Patricia M. Pye, RN,

1. OPTIMIZING DOOR-TO-BALLOON TIME: STRATEGIES FOR SUCCESS B. Hadley Wilson, MD. J. Lee Garvey, MD. Patricia M. Pye, RN, MS Kevin M. Collier, RCIS Carolinas Medical Center

2. Time is Muscle: Every 10 minute delay to Percutaneous Coronary Intervention (PCI) results in a 1% change in mortality* In 2004, National Registry for Myocardial Infarctions (NRMI) data for STEMI reported median time for door to reperfusion was 97 minutes, only 43% were reperfused in less than or equal to 90 minutes. Background Just we talked about I would show comparison between 2004 and 2005 for NRMI D2B time.Just we talked about I would show comparison between 2004 and 2005 for NRMI D2B time.

3. Process Improvement Case Study:Carolinas Medical Center (CMC) 2004 evaluation demonstrated CMC had opportunities for improvement 72 minutes EMS patients 116 minutes non-EMS patients 87 minutes overall Multi-disciplinary team was challenged to improve Door-to-Balloon process EMS, ED Physicians, Cardiologists, ED Staff, Cath Lab, CCU, Bed Management, Lab, Radiology, Respiratory Care, House Supervisor CMC�s process improvement plan was based on practices paralleling Code Trauma => Code STEMI Would you like to explain what you mean by overall remember the audience mix? Would you like to explain what you mean by overall remember the audience mix?

4. Process Improvement Case Study:Carolinas Medical Center (CMC) Team developed enhanced goals for Code STEMI that exceed the ACC/AHA Standard: Goal #1: 90% of patients reperfused within 60 minutes of ED arrival (compared to national guidelines of < 90 minutes) Goal #2: 90% of patients reperfused within 90 minutes of first medical contact (compared to national guideline of < 90)

5. Identification: Medic paramedics are trained to acquire and read 12-lead electrocardiograms (ECG) on patients suspected of a heart attack. The ECG result is quickly transmitted from the field to an ED physician at CMC. Activation: If the ECG shows specific changes in certain electrical impulses (ST segments) within the heart, the Emergency physician activates �Code STEMI� initiating an immediate response from the Code STEMI Team. Treatment: Patient is received by Code STEMI Team upon arrival to CMC ED with a rapid triage process to confirm STEMI and then immediately transported to the cardiac catheterization lab where the coronary artery is opened New CMC ProcessCode STEMI � Protocol Driven Program

6. Critical Success Factors EMS and ED Physician initiate Code STEMI Single page activates entire team => parallel actions commence ED and Cath Lab begin preparations On-Call Cardiologist and CCU Nurse go to ED Respiratory Care and Laboratory are available in ED Joint assessment occurs in the ED Cardiologist and CCU Nurse assist EMS in transporting patient to Cath Lab Patient is prepared for PCI Bed Management finds accommodations Trust in revised roles and responsibilities This slide has different font then the rest. This slide has different font then the rest.

8. Lessons Learned fromCarolinas Medical Center It takes real commitment from the Multi-disciplinary Team EMS, ED Physicians, Cardiologists, ED Staff, Cath Lab, CCU, Bed Management, Lab, Radiology, Respiratory Care, House Supervisor Establish a specific goal to Meet or Exceed ACC Standard Adopt a continuous process improvement philosophy => on-going monitoring and modification of the process Intensive education for EMS on acquiring and interpreting ECGs Recognize that a cultural change is necessary Be flexible � forward thinking => all play in same sandbox Trust in revised roles and responsibilities Be patient-focused: Time is Muscle

9. Bottom Line Results Overall Door-to-Balloon Time ImprovementsOctober 2004 � June of 2006

10. Bottom Line Results EMS & Non EMS ArrivalsOctober 2004 � June of 2006

11. Bottom Line ResultsCarolinas Medical Center