care and service delivery to patients...

CARE AND SERVICE DELIVERY TO PATIENTS PRESENTING

WITH ACUTE CORONARY SYNDORME AT

BALLARAT HEALTH SERVICES BALLARAT HEALTH SERVICES

- an Emergency Department Snapshot

Cardiac Clinical Facilitator ProjectNovember 2011 to June 2012

CARE AND SERVICE DELIVERY TO PATIENTS PRESENTING

WITH ACUTE CORONARY SYNDORME AT

BALLARAT HEALTH SERVICES – JULY 2010 TO JUNE 2011BALLARAT HEALTH SERVICES – JULY 2010 TO JUNE 2011

an Emergency Department Snapshot

Cardiac Clinical Facilitator ProjectNovember 2011 to June 2012

Project Overview

♥ Department of Health funded project

♥ Specifically focusing on Acute Coronary Syndrome

and Heart Failure

♥ Review of care and service delivery across the

continuumcontinuum

♥ Review period was 12 months

♥ Rural project

♥ Coordinated and supported through the

Cardiac Clinical Care Network of Victoria

Department of Health funded project – 12 months

Specifically focusing on Acute Coronary Syndrome

Review of care and service delivery across the

Review period was 12 months

Coordinated and supported through the

Cardiac Clinical Care Network of Victoria

Project Overview Continued....

♥ No project aims or objectives

♥ Gap Analysis – 32 recommendations

♥ Recommendations were of 2 categories: patient care

related and health service related

♥ Organisational Survey – BHS Cardiac Services profile♥ Organisational Survey – BHS Cardiac Services profile

♥ Steering Committee to support, direct and advise on

projects stemming from the gap analysis

♥ Supported through regular contact with the facilitator

group and Department of Health

No project aims or objectives

32 recommendations

Recommendations were of 2 categories: patient care

related and health service related

BHS Cardiac Services profileBHS Cardiac Services profile

Steering Committee to support, direct and advise on

projects stemming from the gap analysis

Supported through regular contact with the facilitator

group and Department of Health

Data Collection and Methodology

♥ IBA cyber queries provided raw data

♥ Created extra fields of data by using excel formulas

♥ Merging of a number of other data bases into raw

cyber query data

♥ Review of Bossnet histories: 10% of raw data sample♥ Review of Bossnet histories: 10% of raw data sample

♥ Discussions with relevant key stakeholders

related recommendations

♥ Very data intensive

Data Collection and Methodology

IBA cyber queries provided raw data

Created extra fields of data by using excel formulas

Merging of a number of other data bases into raw

Review of Bossnet histories: 10% of raw data sampleReview of Bossnet histories: 10% of raw data sample

Discussions with relevant key stakeholders – health

related recommendations

TIME = HEART MUSCLE

•Poor patient outcomes

•Increased risk of readmission to hospital

“The ECG is the sole test required to select patients

for emergency reperfusion (fibrinolytic therapy or

direct percutaneous coronary intervention)”Guidelines for the Management of Acute Coronary Syndrome 2006

National Heart Foundation of Australia and The Cardiac Society of Australia and New Zealand

TIME = HEART MUSCLE

Poor patient outcomes

Increased risk of readmission to hospital



direct percutaneous coronary intervention)”Guidelines for the Management of Acute Coronary Syndrome 2006 – The Medical Journal of Australia


ACS Acute Activity at BHS

100

150

200

250

300

350

NU

MB

ER

OF

AD

MIS

SIO

NS

Total ACS Admissions by DRG at BHS

♥ 701 admissions to BHS with ♥ 12% (83) STEMI ♥ 44% (307 &312) each UA and NSTEMI♥ 570 of these through an ED admission pathway

0

50

100

UA STEMINU

MB

ER

OF

AD

MIS

SIO

NS

ACUTE CORONARY SYNDROME DRG

ACS Acute Activity at BHS – 2010/2011

Total ACS Admissions by DRG at BHS - 2010/11

STEMI NSTEMI


ACS Acute Activity at BHS continued….

40

60

80

100

120

140

No

OF

AD

MIS

SIO

NS

Total ACS Emergency Department Admissions by Triage

Category by DRG at BHS

0

20

40

UA STEMI

No

OF

AD

MIS

SIO

NS


♥ 75% of STEMI admissions through ED received a triage category of 1 or 2

♥ 54% of Unstable Angina admissions received a triage category of 1 or 2

♥ 46% of NSTEMI admissions received a triage category of 1 or 2

Total ACS Emergency Department Admissions by Triage

Category by DRG at BHS - 2010/11

1

2

3

STEMI NSTEMI


3

4

75% of STEMI admissions through ED received a triage category of 1 or 2

54% of Unstable Angina admissions received a triage category of 1 or 2

46% of NSTEMI admissions received a triage category of 1 or 2

ACS Acute Activity Continued….

1:002:003:004:005:006:007:008:009:00

LEN

GT

H O

F S

TAY

IN

HO

UR

S

ACS Emergency Department Average Length of Stay by

DRG at BHS - 2010/11

♥ STEMI admissions had an average LOS in ED of less than 4 hours

♥ Both Unstable Angina and NSTEMI admissions had an average LOS in

ED of just over 8 hours

0:001:002:00

UA STEMI

LEN

GT

H O

F S

TAY

IN

HO

UR

S


ACS Emergency Department Average Length of Stay by

2010/11

STEMI admissions had an average LOS in ED of less than 4 hours

Both Unstable Angina and NSTEMI admissions had an average LOS in

STEMI NSTEMI



30

40

50

60

70

80

90

NU

MB

ER

OF

AD

MIS

SIO

NS

Total ACS Emergency Department Admissons by ED Length of

Stay at BHS -

0

10

20

00 01 02 03 04 05 06 07 08 09 10 11

NU

MB

ER

OF

AD

MIS

SIO

NS

EMERGENCY DEPARTMENT LENGTH OF STAY BY HOUR

♥ 32% of ACS ED admissions had an ED LOS of 4 hours or less

♥ An additional 39% (225) of admissions had an ED LOS of 8 hours or less

Total ACS Emergency Department Admissons by ED Length of

2010/11

12 13 14 15 16 17 18 19 20 21 22 23 24

EMERGENCY DEPARTMENT LENGTH OF STAY BY HOUR

32% of ACS ED admissions had an ED LOS of 4 hours or less

An additional 39% (225) of admissions had an ED LOS of 8 hours or less


Recommendation 1All patients presenting with chest pain for investigation should have the earliest possible access to 12 Lead ECG * pre hospital in ambulance* within 10 minutes of arrival to ED

6

8

10

12

14

16

No

OF

AD

MIS

SIO

NS

Triage Time to First ECG by DRG at BHS

0

2

4

6

0-10 mins 11-20 mins

No

OF

AD

MIS

SIO

NS

TIME INTERVAL

♥ Snapshot looking at 70 ACS admissions

♥ 40% (28) received an ECG within 10 minutes of arrival

♥ 30% (21) received an ECG between 11-20 minutes of arrival

♥ 30% (21) received an ECG 20 minutes after arrival in ED

All patients presenting with chest pain for investigation should have the earliest possible access to 12 Lead ECG

Triage Time to First ECG by DRG at BHS - 2010/11

UA

20 mins 20+ mins

TIME INTERVAL

STEMI

NSTEMI

40% (28) received an ECG within 10 minutes of arrival

20 minutes of arrival

30% (21) received an ECG 20 minutes after arrival in ED


Recommendation 2:

All health services should have timely access to pathology services in particular troponin levels

50

100

150

No

OF

AD

MIS

SIO

NS

Triage Time to Troponin Availability Time by DRG at BHS

2010/11

0


No

OF

AD

MIS

SIO

NS

TIME INTERVAL

♥ Snapshot of 439 admissions

♥ 25% had a troponin turn around time of within 60 minutes

♥ 15% had a troponin turn around time of 61-

♥ 59% had a troponin turn around time of greater than 90 minutes

All health services should have timely access to pathology services in particular troponin levels

Triage Time to Troponin Availability Time by DRG at BHS -

2010/11

UA

STEMI

90 mins 90+ mins

TIME INTERVAL

STEMI

NSTEMI

25% had a troponin turn around time of within 60 minutes

-90 minutes

59% had a troponin turn around time of greater than 90 minutes


50

100

150

200

250

No

OF

AD

MIS

SIO

NS

Time of Troponin Specimen Collection in ED to Time of Result

Availability by DRG at BHS

0

50


No

OF

AD

MIS

SIO

NS

TIME INTERVAL

♥ Snapshot of 490 admissions

♥ 85% (419) had a troponin turn around time of within 60 minutes

♥ 9% (42) had a troponin turn around time of 61

♥ 6% (29) admissions had a turn around time of greater than 90 minutes

Time of Troponin Specimen Collection in ED to Time of Result

Availability by DRG at BHS - 2010/11

UA

STEMI

NSTEMI

90 mins 90+ mins

TIME INTERVAL

NSTEMI

85% (419) had a troponin turn around time of within 60 minutes

9% (42) had a troponin turn around time of 61-90 minutes

6% (29) admissions had a turn around time of greater than 90 minutes


Recommendation 4All patients with ST segment myocardial infarction (STEMI) who are eligible for thrombolysis or primary PCI receive a reperfuaccordance with evidence-based clinical practice guidelines* Patients eligible for primary PCI receive a door to balloon time in 90 minutes in 75% of cases

10

15

20

25

No

OF

AD

MIS

SO

NS

Door To PCI Time for STEMI Admissons at BHS

0

5

0 to 90 min

No

OF

AD

MIS

SO

NS

TIME INTERVAL

♥ 33 STEMI admissions underwent PCI

♥ 39% (13) received a door to PCI time of within 90 minutes

♥ 61% (20) received a door to PCI time of greater than 90 minutes

All patients with ST segment myocardial infarction (STEMI) who are eligible for thrombolysis or primary PCI receive a reperfusion therapy in

* Patients eligible for primary PCI receive a door to balloon time in 90 minutes in 75% of cases

Door To PCI Time for STEMI Admissons at BHS - 2010/11

STEMI

greater 90 min

INTERVAL

STEMI

39% (13) received a door to PCI time of within 90 minutes

61% (20) received a door to PCI time of greater than 90 minutes

ACS Acute Activity Continued…..

Recommendation 4 cont…..* Patients eligible for thrombolysis receive thrombolysis within 30 minutes or less from presentation to the ED

3

4

5

6

7

No

OF

AD

MIS

SIO

NS

STEMI Admissions & ED Presentation to

Thrombolysis Time Intervals at BHS

♥ 10 patients were eligible for thrombolysis

♥ 40% (4) received thrombolysis within 30 minutes of arrival to ED

♥ 60% (6) received thrombolysis greater than 30 minutes of arrival to ED

0

1

2

3

0-30 mins

No

OF

AD

MIS

SIO

NS

TIME INTERVAL

* Patients eligible for thrombolysis receive thrombolysis within 30 minutes or less from presentation to the ED

STEMI Admissions & ED Presentation to

Thrombolysis Time Intervals at BHS - 2010/11

40% (4) received thrombolysis within 30 minutes of arrival to ED

60% (6) received thrombolysis greater than 30 minutes of arrival to ED

30+ mins

TIME INTERVAL

ACS Acute Activity Continued…

150

200

250

300

350

NU

MB

ER

OF

AD

MIS

SIO

NS

Acute Coronary Syndrome Admissions & Average Length

of Stay Vs State Average Length of Stay at BHS

0

50

100

150

Unstable Angina STEMI

NU

MB

ER

OF

AD

MIS

SIO

NS

DIAGNOSTIC RELATED GROUP

♥ 701 ACS admissions♥ ALOS in hospital for Unstable Angina admissions matched the state average LOS♥ ALOS in hospital for STEMI admissions was less than the SALOS♥ ALOS in hospital for NSTEMI admissions was 2 days longer than the SALOS

4

5

6

7

8

NU

MB

ER

OF

DA

YS

Acute Coronary Syndrome Admissions & Average Length

of Stay Vs State Average Length of Stay at BHS - 2010/11

Admissions

0

1

2

3

4

NSTEMI

NU

MB

ER

OF

DA

YS

DIAGNOSTIC RELATED GROUP

Admissions

ALOS

SALOS

ALOS in hospital for Unstable Angina admissions matched the state average LOSALOS in hospital for STEMI admissions was less than the SALOSALOS in hospital for NSTEMI admissions was 2 days longer than the SALOS

TIME = HEART MUSCLE

•Poor patient outcomes

•Increased risk of readmission to hospital



direct percutaneous coronary intervention)”Guidelines for the Management of Acute Coronary Syndrome 2006


TIME = HEART MUSCLE

Poor patient outcomes

Increased risk of readmission to hospital



direct percutaneous coronary intervention)”Guidelines for the Management of Acute Coronary Syndrome 2006 – The Medical Journal of Australia


DEIVA Pathway

D Doctor notified within 10 minutes of arrival

E 12 Lead ECG within 10 minutes of arrival

I IV Cannula inserted, bedI IV Cannula inserted, bed

V Vital signs and cardiac monitoring

A Aspirin 300 mg

Not necessarily in this order Consider: oxygen if saturations < 93% & ongoing pain management

notified within 10 minutes of arrival

within 10 minutes of arrival

edside troponin & other bloodsedside troponin & other bloods

and cardiac monitoring

Not necessarily in this order Consider: oxygen if saturations < 93% & ongoing pain management

STEMI Pathway & Worksheet (PCI)

♥ 3 tools in 1

♥ Pathway, worksheet and audit tool

♥ Simple 1 page document

♥ Document follows the patient through the pathway

♥ MR form to be retained within the patient’s history

♥ Provides the ability to track progress through the pathway/process♥ Provides the ability to track progress through the pathway/process

♥ Ability to identify areas of service delivery we do well, and areas

that require improvement

♥ Aligning pathway for thrombolysis

♥ Education/communication plan to support implementation

♥ KPI with completion of form and door to balloon times

♥ Significance♥ Proposed commencement of pathway is

STEMI Pathway & Worksheet (PCI) – ED to CVS

Pathway, worksheet and audit tool

Document follows the patient through the pathway

MR form to be retained within the patient’s history

Provides the ability to track progress through the pathway/processProvides the ability to track progress through the pathway/process

Ability to identify areas of service delivery we do well, and areas

Aligning pathway for thrombolysis

Education/communication plan to support implementation

KPI with completion of form and door to balloon times

Proposed commencement of pathway is September

Person 1

00:00

Pt G arrived at

BHS ED

00:16Pt G transferred

from stretcher to bed

00:24ECG 1

Showing ST ↑

00:44ECG 2

R sided

00:59ECG 3

01:33ECG 4

STEMI PATHWAY – EMERGENCY DEPARTMENT TO SJOG CATHETER LABORATORY

The Case Study of Mrs G

00:10

Time to first

ECG & Doctor

Notified KPI

01:30

Door to balloon

Inflation time KPI

Personnel

00:00

BHS ED

00:06

Triage

00:07

Patient Registraion

00:46ST ↑ documented

in pt notes by ED nurse

01:01Documented in notes Pt G

seen by Dr C and plan was to

discuss with Med Reg

02:16ECG 5

02:28ECG 6

03:35Pt arrived

at SJOG lab

03:38Procedure

commenced

03:41Arterial

Access 03:50

Balloon

Inflation

EMERGENCY DEPARTMENT TO SJOG CATHETER LABORATORY

The Case Study of Mrs G

03:50

02:30Interventional cardiologist

contacted by Med Reg

02:40Interventional cardiologist

received faxed ECG from

ED & activated SJOG lab

02:56Pt consent

obtained

at SJOG lab

June 2012

Time is Muscle

Any delay in time of reperfusion = death of myocardium.

This increases the chance of re admission with cardiac failure.cardiac failure.

Reduces the benefit of performing PCI.

Plan for door to needle time of 30 to 60min is what metro aim for and achieve (most of the time)

Time is Muscle

Any delay in time of reperfusion = death of

This increases the chance of re admission with

Reduces the benefit of performing PCI.

Plan for door to needle time of 30 to 60min is what metro aim for and achieve (most of the time)

Coronary Arteries General

View

Coronary Arteries General

View

Brachiocephalic

Coronary Arteries

Aortic Valve Cusps

Right Coronary Ostium

Left Common Carotid

Left Subclavian

Coronary Arteries

Left Coronary Ostium

Aortic Valve Cusps

St Elevation on ECGSt Elevation on ECG

Normal VersuNormal Versu

Progression of AtherosclerosisProgression of Atherosclerosis

Progression of Atherosclerosis con’tProgression of Atherosclerosis con’t

Normal LV function on EchoNormal LV function on Echo

Apical Akinesis on EchoApical Akinesis on Echo

Prioritising time is always difficult

• Vomiting will settle.

• X Ray can wait.

• Chest pain could be causing death of heart muscle which will never recover. An ECG seen by muscle which will never recover. An ECG seen by the right eyes ASAP COULD STOP THIS.

Prioritising time is always difficult

Chest pain could be causing death of heart muscle which will never recover. An ECG seen by muscle which will never recover. An ECG seen by the right eyes ASAP COULD STOP THIS.

Be a D E I V A

They will survive…

Be a D E I V A

They will survive…

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