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AMI Door to Balloon Time

AMI Door to Balloon Time. Overview. Primary entry for ST-Segment Elevation Myocardial Infarction (STEMI) patients is through our emergency room. Improvement focus was in ED with collaboration with Cathertization Laboratory Services and Rapid Assessment Team personnel.

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AMI Door to Balloon Time

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  1. AMI Door to Balloon Time

  2. Overview • Primary entry for ST-Segment Elevation Myocardial Infarction (STEMI) patients is through our emergency room. • Improvement focus was in ED with collaboration with Cathertization Laboratory Services and Rapid Assessment Team personnel. • Facility is a tertiary-care 672 bed county teaching hospital • Over 108,000 annual ED visits, over 400 a day, projected to reach almost 200,000 for 2010. • Changes needed to improve patient care and meet organizational defined quality measure performance standards. Alignment with organizational goals to produce leading patient outcomes through our patients obtaining the right care, in the right setting, by the right providers at the right time.

  3. The Team CS&E Participants

  4. What We Are Trying to Accomplish? AIM STATEMENT Timely identification of STEMI and opening of blocked coronary arteries (Door to Balloon) improves patient outcomes. Quality measure guidelines define effective door to balloon time as less than 90 minutes from arrival at hospital until the balloon is up. Historically, from October 2008 through December 2009, an average of 54% STEMI patients achieved a door to balloon time of less than 90 minutes. The goal of this project is to achieve door to balloon time of less than 90 minutes in over 95% of patients with STEMI.

  5. How Will We Know That a Change is an Improvement?

  6. Baseline Data

  7. Baseline Data

  8. Baseline Process Analysis Tools Plan

  9. Baseline Process Analysis Tools

  10. Selected Decision Making Tools Chart Review Trending Information for Outliers

  11. Selected Decision Making Tools

  12. Selected Decision Making Tools

  13. Team Focus DO Plan included 3-key areas: • Earlier identification and treatment of STEMI patients • Faster movement of patient from ED to Cath Lab • Education of Staff on performance measures and changes

  14. Implementing Change • Earlier Identification of STEMI • Nurse driven Walk Back Chest Pain Order Set – Triage Lead • Revised ED Chest Pain directive procedure • Faster movement from ED to Cath Lab • Standardized Patient Prep Order Set • After Hours RAT nurse straight to Cath Lab • Cath Lab Notification of Patient Arrival Time • Arrival time added to Cath Lab activation page • Arrival time to be placed on colored arm band • Clock Synchronization • Synchronize ED, Cath Lab and EKG machines to all be on EPIC (EMR) time • Physician Education of STEMI Identification • Review EKGs of Cath Lab Activation cases with ED Physicians • Survey personnel involved in STEMI Case next business day • Monthly case review – cross-functional team

  15. Future State Process

  16. Future State Process

  17. Future State Process

  18. Results/Impact Check

  19. Results/Impact Interventions in ED triage and Cath Lab activation processes have: • Decreased overall mean time from 123.4 minutes to 56.1 minutes. • Increased overall performance from 57% to 90% of cases having door to balloon time of less than 90 minutes.

  20. Interventions April 1, 2010 - August 31, 2010

  21. Interventions: Overall Performance

  22. Expansion of Our Implementation Act

  23. Lessons Learned • There was not one single root cause for prolonged door to balloon time. • Multiple factors such as atypical presentation, awareness of core measures by staff, delay in EKGs and other contributed to performance less than target. • Importance of having representation from all disciplines was crucial to implementing changes. • Physician understanding of reporting requirements for core measures and how important documentation is for reporting was crucial to change. • Do not have meetings on Monday’s – multiple holidays caused some missed meeting days. At time of team start up identify alternate days for holidays.

  24. Conclusions Current results are preliminary and data will not be finalized until December 2010. However, early results indicate that initial interventions have had a positive effect on door to balloon time. • Short Term Steps: • Refinement of Interventions • Development of ongoing education for nurses and physicians • Improving communication between ED physicians and Cath Lab physicians • Updating Equipment (i.e., EKG machines and Fax/Scanners) • Long Term Steps: • Analysis of return on investment related to decreased length of stay and decreased morbidity in patients experiencing door to balloon time of <90 minutes. • Research and possible use of field activation of Cath Lab by paramedics and EMS personnel • Feasibility study of 24/7 Cath Lab Staffing

  25. Acknowledgments Thank you for the guidance and information sharing throughout the process of our program. • Peter Hoffman, MD • Senior Vice-President and Chief Quality Officer • Marisa Valdes, RN • Interim Director of Performance Improvement

  26. Thank you!

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