Door-to-Balloon Time – Every Minute Counts

1. Door-to-Balloon Time – Every Minute Counts Conemaugh Memorial Medical Center, Johnstown, PA Robert G. Stenberg, MD, Medical Director, Cardiac Catheterization Lab Daniel R. Wehner, MD, Chairman, Dept. of Emergency Medicine Sandy Horner, RN, Director, Cardiac Services Karen Allshouse, RN, BS, Coordinator, Cardiac Services Oct. 17, 2007

2. Background • Conemaugh Memorial Medical Center - 711 bed hospital in Johnstown, PA- Community hospital with some tertiary hospital characteristics- Level I trauma center- Residency programs in general surgery, internal medicine, family medicine, pathology, transitional, and Pharmacy (post-PhD pharmacy training)

3. Background • Conemaugh Memorial Medical Center - 70,234 Emergency Department patient visits in 2006- Approximately the 10th busiest Emergency Department in the state of Pennsylvania- Busiest Emergency Department in the western half of Pennsylvania- Two dedicated medical helicopters

4. Cardiac Services Statistics – Conemaugh Memorial Medical Center • Cath lab and cardiac surgery programs initiated in 1990 • 3 full time core Interventional Cardiologists, one locum tenens (approximately half time) • 2 Cardiac Surgeons

5. Cath Lab Versus Surgical Volume

6. Where we came from (2002) • 2002 mean door-to-balloon time of 133 minutes for ST-elevation myocardial infarction (STEMI) • No concerted focus on institutional speed of response to acute myocardial infarction patients • Highly variable response times with the mean representing a mixture of occasional excellent and timely responses and some very long and delayed responses • Sometimes chaotic and multi-layered physician call system

7. Process Improvements(initiated in 2003) • Initiated a Level I and II acuity system • Developed a unified global Interventional Cardiologist call schedule that transcended group affiliations (one call, no confusion) • Emergency Department direct activation of a Cath Lab call-out

8. Level I & II Acuity System • Prior to 2003, all Cath Lab emergencies were treated equal • This lack of delineation of true “emergencies” from “urgencies” can desensitize a Cath Lab or even an entire institution as to when you really need to respond quickly

9. Level I & II Acuity System • Level I - top priority emergencies- ST-elevation myocardial infarction- Cardiogenic shock • Level II - lower priority emergencies - Acute coronary syndrome (with ST depression or positive biomarkers) - Ongoing chest pain of uncertain etiology (cardiac versus non-cardiac etiology)- Numerous other situations could also apply

10. Process Improvement (2003Our D2B Team Is Formed • Monthly meetings for about 1 hour • All emergency Cath Lab cases for the prior month reviewed in detail • Multidisciplinary team:Physicians: Medical Director, Cardiac Cath Lab Chairman, Dept. of Emergency MedicineNurses: Director of Cardiac Services Coordinator, Cardiac Services Manager, Dept. of Emergency Medicine Cath Lab NurseTechnician: Manager, Cardiac Cath Lab

11. D2B Time – Every Minute Counts • It’s not just a slogan • Every minute REALLY does count • Our Performance Improvement team found numerous issues that impacted upon our door-to-balloon times by a meticulous case-by-case analysis of each and every Level I emergency case

12. Sources of Time Delay • Atypical clinical presentations, especially with walk-in patients (triage issues) • Ambulance-delivered patients were less likely to experience delays • Physician specific (mostly locums docs)- Emergency Department Physician - delayed or distracted- Cath Lab Interventionalist – too protracted history/exam/consent process

13. Sources of time delay Pager and staff call-in inconsistencies- We did not (and do not) have Cath Lab staff in-house on a 24/7 coverage basis- Pagers sometimes failed to go off (geographic and topographic issues, mountainous, rural)- Call-back system in place (to verify the staff has been notified), but a significant time penalty is incurred when call-back is delayed and further phone calls become required

14. Sources of Time Savings- Hospital quality pre-hospital EKG’s

15. Sources of Time Savings- Hospital quality pre-hospital EKG’s

16. Sources of Time Savings- Hospital quality pre-hospital EKG’s • Cell phone transmission • Approximately $400 for adapter to the LifePak 12 • About half of our ambulance services have this capability • Pre-Hospital Manager recently added to our Performance Improvement Team

17. Annual Number of Level I Emergency Cardiac CatheterizationsConemaugh Memorial Medical Center

18. Results(mean and median door-to-balloon times, 2002 – 2007)

19. Results(mean and median door-to-balloon times, 2002 – 2007)(minutes – y axis) (year – x axis)

20. Results(proportion of Level I emergencies where D2B times of< 90 and < 60 minutes were actually achieved)(% of cases – y axis) (year – x axis)

21. Door-to-EKG Times in the Emergency Department (2002 – 2007) Associated with Level I Emergencies

22. Conclusions (What were the most important variables to improve D2B times at Conemaugh Memorial Medical Center from 2002 to 2007) • Level I and II Acuity System • Unified global Interventional Cardiology call schedule • Direct Emergency Department activation of the Cardiac Cath Lab • Frequent (monthly to quarterly) multidisciplinary Performance Improvement team meetings to assess on a case by case basis the multitude of factors that can result in time delays • Achieving <60 minute D2B times will depend substantially on increased pre-hospital diagnosis so the Emergency Department can be bypassed (direct to the Cath Lab) whenever possible