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CARDIAC ALERT: A Change in Process. Results of a STEMI Treatment Protocol Over 5 Years. Peter Kerwin, M.D. , Colleen Kordish, R.N. , June 10, 2008 Downers Grove Illinois ADVOCATE GOOD SAMARITAN HOSPITAL MIDWEST HEART SPECIALISTS.

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Cardiac alert a change in process results of a stemi treatment protocol over 5 years

CARDIAC ALERT:A Change in Process.Results of a STEMI Treatment Protocol Over 5 Years.

Peter Kerwin, M.D.,

Colleen Kordish, R.N.,

June 10, 2008

Downers Grove Illinois

ADVOCATE GOOD SAMARITAN HOSPITAL

MIDWEST HEART SPECIALISTS


Cardiac alert a change in process results of a stemi treatment protocol over 5 years

Optimal care in the time critical process of treating STEMI requires a coordinated protocol with EMS, ED and Cardiology functioning as one team


Cardiac alert a change in process results of a stemi treatment protocol over 5 years
Maintaining optimal quality over time requires continual monitoring and evaluation of data related to the team’s effectiveness.


Reasons to improve door to balloon time
Reasons to Improve monitoring and evaluation of data related to the team’s effectiveness.Door to Balloon Time

  • ACC/AHA Guidelines

  • Mission Lifeline

  • D2B Initiative

  • Get With The Guidelines

  • Core Measures

  • Marketing


Coroner says patient s death is a homicide woman sought care in er for 2 hours
Coroner says patient's death is a homicide monitoring and evaluation of data related to the team’s effectiveness.Woman sought care in ER for 2 hours

By Andrew L. WangTribune staff reporterPublished September 15, 2006

The death of a Waukegan woman in July after she spent nearly two hours in an emergency room waiting area was ruled a homicide Thursday during a Lake County coroner's inquest.


Acc aha guidelines
ACC/AHA guidelines monitoring and evaluation of data related to the team’s effectiveness.

  • Door to intervention time 90 (120 min).

  • National Average 100-110 minutes.

  • Advocate Good Samaritan 2002: 99 min.

  • Advocate Good Samaritan 2006: 63 min.


Decreasing d2b time why should we care
Decreasing D2B Time: monitoring and evaluation of data related to the team’s effectiveness.Why Should We Care?

  • 400,000 STEMI per year

  • 1/3 STEMI patients receive no reperfusion therapy

  • Less than 40% patients receiving primary PCI have D2B < 90 minutes

  • Less than 10% EMS systems have 12 lead ECG capability

    • Circulation 2006;113;2152-2163


Time is muscle and mortality
Time is Muscle! monitoring and evaluation of data related to the team’s effectiveness. And Mortality!

  • Each 30 minute delay in reperfusion with PCI increases 1 yr mortality 7.5%

  • Door to balloon <60 min, 1% 30 day mortality; Door to balloon >90 min, 6.4% mortality

  • DeLuca, Circulation 2004;109:1223-1225.

  • Berger, Circulation 1999;100:14-20.


Advocate good samaritan hospital
Advocate Good Samaritan Hospital monitoring and evaluation of data related to the team’s effectiveness.

  • 300 bed community hospital

  • Level 1 Trauma Center

  • 4 cardiology groups- separate call schedules

  • Primary PCI strategy since 1991


D2b our history
D2B- Our History monitoring and evaluation of data related to the team’s effectiveness.

  • Retrospective baseline 2001- 103 min

  • 1991-1995 review- 55 min

  • Prospective baseline 2002-2003- 99 min

  • 2006- 63 min


Cardiac alert a change in process results of a stemi treatment protocol over 5 years

  • Advocate monitoring and evaluation of data related to the team’s effectiveness.Good Samaritan Hospital D2B cases <90 minutes

Cardiac Alert Brings Results:

  • 1Tracked using AHA’s GWTG

  • 2 GWTG/AMI Core Measures


Cardiac alert it s not all about us
CARDIAC ALERT: monitoring and evaluation of data related to the team’s effectiveness. It’s Not All About Us!

PETER KERWIN, M.D.

MI D W E S T HE A R T

S P E C I A L I S T S


Cardiac alert protocol
CARDIAC ALERT PROTOCOL monitoring and evaluation of data related to the team’s effectiveness.

  • “Individual commitment to a group effort- that is what makes a team work, a company work, a society work, a civilization work.”

    Vince Lombardi


The cardiac alert team
The Cardiac Alert Team monitoring and evaluation of data related to the team’s effectiveness.

  • The Patient!

  • Paramedics in the field

  • Triage Staff

  • ED MD’s

  • ED RN’s

  • Cardio diagnostics

  • Radiology

  • Cardiac Catheterization Lab

  • Cardiologists

  • Primary MD’s

  • ICU/Floor RN’s

  • Nurse Clinician/PA’s

  • CV Surgery


Cardiac alert goal
Cardiac Alert Goal monitoring and evaluation of data related to the team’s effectiveness.

  • Door to Balloon < 60 minutes

  • Best Mortality

  • Achievable Goal


Goal for acute mi patients
Goal for Acute MI Patients monitoring and evaluation of data related to the team’s effectiveness.

  • Diagnostic ECG performed, interpreted and cardiologist/ cath lab notified – 5 to 10 minutes.

  • Cath Lab/Interventionalist notified, patient on table -30 minutes.

  • Prep- 5 minutes.

  • Angiogram, first inflation -15 minutes.


Goal for acute mi patients1
Goal for Acute MI Patients monitoring and evaluation of data related to the team’s effectiveness.

  • 60 Minutes

    • From ED admission to Cardiac Intervention

    • 29 September 2003 “Go-Live” Date for Cardiac Alert


Cardiac alert using data to implement change
Cardiac Alert: monitoring and evaluation of data related to the team’s effectiveness.Using Data to Implement Change

  • Map the process

  • Standardize time

  • Gather accurate baseline data

  • Evaluate the data

  • Make changes based on the data


Cardiac alert improving door to balloon time
Cardiac Alert: monitoring and evaluation of data related to the team’s effectiveness.Improving Door to Balloon Time

  • Process driven approach to a time sensitive issue

  • Team approach

  • It’s Not All About Me!


Cardiac alert guiding principles
Cardiac Alert: Guiding Principles monitoring and evaluation of data related to the team’s effectiveness.

  • EMS/Triage RN empowered and educated to initiate call

  • Immediate ECG with immediate review

    • Any chest pain over age 30

  • Single call activates Alert – ECG, Cath Lab, Blood Lab, Radiology

  • Each individual role defined

  • Data with feedback


Ground rules
Ground Rules monitoring and evaluation of data related to the team’s effectiveness.

  • Paramedics and triage nurses will be educated, never criticized for initiating Cardiac Alert.

  • Cardiologists will not fault ED for calling Cardiac Alert.

  • ED will decide cardiologist for unattached pts.

  • Cardiologists will not fault ED docs for occasional errors in cardiologist selection.

  • Physicians will lead by example.


Door to balloon time 90 minutes
Door to Balloon Time % < 90 Minutes monitoring and evaluation of data related to the team’s effectiveness.

% < 90 minutes


Cardiac alert a change in process results of a stemi treatment protocol over 5 years

  • Advocate monitoring and evaluation of data related to the team’s effectiveness.Good Samaritan Hospital D2B cases <90 minutes

Cardiac Alert Brings Results:

  • 1Tracked using AHA’s GWTG

  • 2 GWTG/AMI Core Measures


D2b data left shift
D2B Data: Left Shift monitoring and evaluation of data related to the team’s effectiveness.

  • Eliminate lag time

  • Decrease outliers


Baseline data
Baseline Data monitoring and evaluation of data related to the team’s effectiveness.

  • Prospectively established case criteria

    • ST elevation on first ECG – 1cardiologist and 1 ED MD should agree

    • Patient admitted through the ED

  • Start with ~3 months of data (25% of a year)

  • Outliers were not omitted

  • Data was shared with the team, Emergency Department and Cardiology

Admission time is minute zero. All times are in minutes.


Stemi patients door to balloon time baseline 2002 sept 2003
STEMI Patients Door to Balloon Time monitoring and evaluation of data related to the team’s effectiveness.(Baseline 2002-Sept 2003)

Admission time is minute zero. All times are in minutes and reflect total time elapsed since initial arrival.


Cardiac alert committee initial then quarterly meeting to review process and discuss outliers
Cardiac Alert Committee: monitoring and evaluation of data related to the team’s effectiveness.Initial then quarterly meeting to review process and discuss outliers

  • Physician, Nursing and Administrative Representation from Cardiology, ED and EMS

  • Peter Kerwin, M.D., Medical Director, Cath Lab

  • Stephen Crouch, M.D., Medical Director, Emergency Dept.

  • Thomas Carmody, M.D., Vice Chairman, Emergency Dept.

  • John Grieco, M.D., Medical Director, Cardiac Surgery

  • Colleen Kordish, R.N., Cardiovascular Outcomes Coordinator

  • Sharon Mow, R.N., Director, Critical Care & Emergency Services

  • Cathy Smith, R.N., Manager, Cardiac Services

  • Lynn Polhemus, R.N., Manager, Emergency Dept.

  • Danielle Albinger, R.N., EMS Coordinator

  • William Iversen, Manager, EMSS & Trauma Services

  • Cardiologists, Nurses, ED Physicians, Paramedics


D2b time sequence
D2B Time Sequence monitoring and evaluation of data related to the team’s effectiveness.


Time from cardiologist notification to patient on cath lab table
Time from Cardiologist notification to patient on Cath Lab table

2007 = 38 minutes

2006 = 30 minutes

Baseline = 41 minutes

Why are we sliding back ?





Time from cardiologist notification to patient on cath lab table cont
Time from Cardiologist notification to patient on Cath Lab table (cont)

One reason for time increase:


Symptom recognition symptom to door often 2 1 2 hours
Symptom Recognition : Symptom to Door often >2 1/2 Hours table (cont)

  • Chest tightness/pressure

  • Radiation to arm/ neck/ jaw.

  • Dyspnea

  • Diaphoresis

  • Atypical symptoms often (diabetics, women)


Current reperfusion strategies st elevation myocardial infarction
Current Reperfusion Strategies table (cont)ST- Elevation Myocardial Infarction

NRMI National Data – September 2001


Evidence based changes create immediate benefits
Evidence Based Changes table (cont)Create Immediate Benefits

  • Cath Lab is called earlier in the process

    • 8 minute savings

  • Cardiologist will accept ED MD’s initial assessment

    • 11 minute savings

  • We will listen to EMS

    • 7 minute savings

  • For efficiency: one call will initiate new process

    • Hospital operator is the central communication point

    • Cardiac Catheterization Lab is notified by this call

  • We will use all errors as a learning opportunity

    • Physician Leaders role model appropriate behavior


Outliers
“Outliers” table (cont)

  • Definition specific to institution/staff

  • Do not omit outliers

  • Identifies the cracks in your process

  • Analyze each case

  • Trend outliers

  • Example: “atypical symptoms”

    • Triage nurse was pre-diagnosing the patient

    • ED physicians provided education to nursing staff

    • “Cannot assume GI, pulmonary or musculoskeletal origin of pain without ECG”


D2b alliance evidence bases strategies
D2B Alliance: table (cont)Evidence Bases Strategies

  • ED physician activates the cath lab;

  • One call activates the cath lab;

  • Cath lab team ready in 20-30 minutes;

  • Prompt data feedback;

  • Senior management commitment;

  • Team based approach.


Conclusions
Conclusions table (cont)

  • Effective treatment of patients with STEMI is a time sensitive process requiring a well defined team approach.

  • Ongoing data collection and analysis with feedback allows for changes in process that improve care in patients with STEMI.

  • The role of the cardiologist in this process is not simply that of technician. We must now be team leaders as well.

  • D2B of 60 minutes or less is an achievable goal likely to improve mortality in STEMI.