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

1. 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

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

3. Maintaining optimal quality over time requires continual monitoring and evaluation of data related to the team’s effectiveness.

4. Reasons to Improve Door to Balloon Time • ACC/AHA Guidelines • Mission Lifeline • D2B Initiative • Get With The Guidelines • Core Measures • Marketing

5. Coroner says patient's death is a homicideWoman 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.

7. ACC/AHA guidelines • Door to intervention time 90 (120 min). • National Average 100-110 minutes. • Advocate Good Samaritan 2002: 99 min. • Advocate Good Samaritan 2006: 63 min.

8. Decreasing D2B Time: 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

9. Time is Muscle! 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.

10. Advocate Good Samaritan Hospital • 300 bed community hospital • Level 1 Trauma Center • 4 cardiology groups- separate call schedules • Primary PCI strategy since 1991

11. D2B- Our History • Retrospective baseline 2001- 103 min • 1991-1995 review- 55 min • Prospective baseline 2002-2003- 99 min • 2006- 63 min

12. AdvocateGood Samaritan Hospital D2B cases <90 minutes Cardiac Alert Brings Results: • 1Tracked using AHA’s GWTG • 2 GWTG/AMI Core Measures

13. CARDIAC ALERT: 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

14. CARDIAC ALERT PROTOCOL • “Individual commitment to a group effort- that is what makes a team work, a company work, a society work, a civilization work.” Vince Lombardi

15. The Cardiac Alert Team • 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

16. Cardiac Alert Goal • Door to Balloon < 60 minutes • Best Mortality • Achievable Goal

17. Goal for Acute MI Patients • 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.

18. Goal for Acute MI Patients • 60 Minutes • From ED admission to Cardiac Intervention • 29 September 2003 “Go-Live” Date for Cardiac Alert

19. Cardiac Alert: Using Data to Implement Change • Map the process • Standardize time • Gather accurate baseline data • Evaluate the data • Make changes based on the data

20. Cardiac Alert:Improving Door to Balloon Time • Process driven approach to a time sensitive issue • Team approach • It’s Not All About Me!

21. Cardiac Alert: Guiding Principles • 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

22. Ground Rules • 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.

23. Door to Balloon Time % < 90 Minutes % < 90 minutes

24. AdvocateGood Samaritan Hospital D2B cases <90 minutes Cardiac Alert Brings Results: • 1Tracked using AHA’s GWTG • 2 GWTG/AMI Core Measures

25. D2B Data: Left Shift • Eliminate lag time • Decrease outliers

26. Baseline Data • 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.

27. STEMI Patients Door to Balloon Time(Baseline 2002-Sept 2003) Admission time is minute zero. All times are in minutes and reflect total time elapsed since initial arrival.

28. Cardiac Alert Committee: 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

29. D2B Time Sequence

30. Time from Cardiologist notification to patient on Cath Lab table 2007 = 38 minutes 2006 = 30 minutes Baseline = 41 minutes Why are we sliding back ?

31. Cardiac Alert Brings Results:

32. Good Samaritan D2B

33. 2007 D2B Improvements

34. Time from Cardiologist notification to patient on Cath Lab table (cont) One reason for time increase:

35. Symptom Recognition : Symptom to Door often >2 1/2 Hours • Chest tightness/pressure • Radiation to arm/ neck/ jaw. • Dyspnea • Diaphoresis • Atypical symptoms often (diabetics, women)

36. Current Reperfusion StrategiesST- Elevation Myocardial Infarction NRMI National Data – September 2001

38. Evidence Based Changes 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

39. “Outliers” • 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”

40. D2B Alliance: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.

41. Conclusions • 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.