optimizing door-to-balloon time:

Carolinas Medical Center

OPTIMIZING DOOR-TO-BALLOON TIME:OPTIMIZING DOOR-TO-BALLOON TIME: STRATEGIES FOR SUCCESSSTRATEGIES FOR SUCCESS

B. Hadley Wilson, MD.B. Hadley Wilson, MD.J. Lee Garvey, MD.J. Lee Garvey, MD.

Patricia M. Pye, RN, MSPatricia M. Pye, RN, MSKevin M. Collier, RCISKevin M. Collier, RCIS

Carolinas Medical CenterCarolinas Medical Center


Time is Muscle: Every 10 minute delay to Percutaneous Coronary Intervention (PCI) results in a 1% change in mortality*

In 2004, National Registry for Myocardial Infarctions (NRMI) data for STEMI reported median time for door to reperfusion was 97 minutes, only 43% were reperfused in less than or equal to 90 minutes.

Background

Source: Nallamothu BK et al, AM Journal Cardiology 2003


Process Improvement Case Study:Carolinas Medical Center (CMC)

2004 evaluation demonstrated CMC had opportunities for improvement

• 72 minutes EMS patients

• 116 minutes non-EMS patients

• 87 minutes overall

Multi-disciplinary team was challenged to improve Door-to-Balloon process

• EMS, ED Physicians, Cardiologists, ED Staff, Cath Lab, CCU, Bed Management, Lab, Radiology, Respiratory Care, House Supervisor

CMC’s process improvement plan was based on practices paralleling Code Trauma => Code STEMI


Process Improvement Case Study:Carolinas Medical Center (CMC)

Team developed enhanced goals for Code STEMI that exceed the ACC/AHA Standard:

• Goal #1: 90% of patients reperfused within 60 minutes of ED arrival (compared to national guidelines of < 90 minutes)

• Goal #2: 90% of patients reperfused within 90 minutes of first medical contact (compared to national guideline of < 90)

Source: ACC/AHA Guidelines 7/04


Identification: Medic paramedics are trained to acquire and read 12-lead electrocardiograms (ECG) on patients suspected of a heart attack. The ECG result is quickly transmitted from the field to an ED physician at CMC.

Activation: If the ECG shows specific changes in certain electrical impulses (ST segments) within the heart, the Emergency physician activates “Code STEMI” initiating an immediate response from the Code STEMI Team.

Treatment: Patient is received by Code STEMI Team upon arrival to CMC ED with a rapid triage process to confirm STEMI and then immediately transported to the cardiac catheterization lab where the coronary artery is opened

Program objective: develop a coordinated system of care - modeled after Code Trauma - that streamlines the identification, activation,

and provision of treatment for STEMI that surpasses national targets.

New CMC ProcessCode STEMI – Protocol Driven Program


Critical Success Factors

EMS and ED Physician initiate Code STEMI

Single page activates entire team => parallel actions commence

ED and Cath Lab begin preparations

On-Call Cardiologist and CCU Nurse go to ED

Respiratory Care and Laboratory are available in ED

Joint assessment occurs in the ED

Cardiologist and CCU Nurse assist EMS in transporting patient to Cath Lab

Patient is prepared for PCI

Bed Management finds accommodations

Trust in revised roles and responsibilities


Patient presents with symptoms of

ACS

Cardiologist on Call

CCU

12 Lead ECG

Proceed to ED without activation

of Code STEMI

Radio report to ED

Dx for

STEMI?

Yes

No

RespiratoryCCL Call

Team

Hospital Lab

Bed Management

Radiology

CMC Code STEMI Protocol

Standing Ready 24/7

ED activates Code STEMI

Simultaneous Page to:


Lessons Learned fromCarolinas Medical Center

It takes real commitment from the Multi-disciplinary Team

• EMS, ED Physicians, Cardiologists, ED Staff, Cath Lab, CCU, Bed Management, Lab, Radiology, Respiratory Care, House Supervisor

Establish a specific goal to Meet or Exceed ACC Standard

Adopt a continuous process improvement philosophy => on-going monitoring and modification of the process

Intensive education for EMS on acquiring and interpreting ECGs

Recognize that a cultural change is necessary

Be flexible – forward thinking => all play in same sandbox

Trust in revised roles and responsibilities

Be patient-focused: Time is Muscle


Bottom Line Results Overall Door-to-Balloon Time Improvements

October 2004 – June of 2006

Number of cases

Range Mean

(minutes)

Median

(minutes)

% < 90

minutes

% < 60

minutes

Before Code STEMI

59 27-289 88.9 76.0 33/59 =

56%

18/59 =

31%

After Code STEMI

153 10 - 172 58.4 54.0 134/153 =

88%

92/153 =

60%


Bottom Line Results EMS & Non EMS Arrivals

October 2004 – June of 2006

0%10%20%30%40%50%60%70%80%90%

100%

Field to Balloon Door to Balloon

Pre STEMI <90 mins Post STEMI <90 minsPre STEMI <60 mins Post STEMI <60 mins

58.4

91

0

10

20

30

40

50

60

70

80

90

100

CMC NationalAverage

American College of Cardiology Benchmark <90 minutes

Minimizing Time to Treatmentfrom Arrival in the ED to treatment in the Cath Lab

Saving LivesMortality Rate

4%

7%

0%

2%

4%

6%

8%

10%

CMC NationalAverage

Source: NRMI; Solucient

Bottom Line ResultsCarolinas Medical Center

optimizing door-to-balloon time:

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