the code stemi project: winning the race code stemi: the pinnaclehealth experience donald c....
TRANSCRIPT
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THE CODE STEMI PROJECT: Winning the Race
CODE STEMI: The
PinnacleHealth
Experience
Donald C. Durbeck, MD., FACC
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Baseline Performance
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Evidence Based Approach
Bradley EH, Curry LA, Webster TR, et al. Achieving Rapid Door-to-Balloon Times: How Top Hospitals Improve Complex Clinical Systems. Circulation 2006;113:1079-85.
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Racing Theme
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Create a Task Force
• Senior Administration Support
• Key Stakeholders
• Weekly Meetings
• Dashboard
• Physician Champion
• Nurse Champion
• Quarterly User’s Meeting
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Process Map
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Data Drives Us Initiated by ED nurse
Forms kept in bin in cardiac bay
Clip-on digital clocks placed on clipboard
Form, clipboard, and clocks travel with patient to the cath lab
Cath Lab faxes completed form
Performance Improvement confirms time with scanned medical record and enters into data base
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Immediate Feedback
EARLY CASES
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Immediate Feedback
RECENT CASES
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Immediate Feedback
Be transparent, list names
Bar graphs and Calendar feedback updated within one working day of case
Both are emailed to all members of the project
Assign follow-up tasks
Posted for front-line staff
Ensure EMS providers also receive feedback
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Door to EKG
Pre-Hospital EKG
Triage Nurse in Waiting Room 11a – 11p
Triage Protocol
Dedicated bay for EKG
Hand Deliver EKG to ED Physician
minutes
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EKG to Lab Activation
ED Physician Activates Code Stemi
Activate using Pre-hospital EKG when available
minutes
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Activation to Arrival in Lab
CODE STEMI Team
One Call Activation using Central Page Operator
Cell Phones vs. Pagers
Scripted Education
Prep Patient – Gown, 2 IV sites
minutes
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CODE STEMI Team
SecuritySecurity
Nursing Nursing SupervisorSupervisor
Performance Performance ImprovementImprovement
ER and Cath Lab Personnel
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Scripted Education
PROCEDURE FOR EMERGENCY CARDIAC CATHETERIZATION
• Your physician believes you are having a heart attack. A heart attack occurs when an artery supplying the heart muscle becomes blocked with a blood clot. A heart attack can lead to permanent heart damage and represents a risk to your life. When treating a heart attack, time is of the essence. It is believed that if the clogged artery can be opened, the damage can be lessened and your risk of disability and death may be reduced.
• Your physician is proposing that you have a procedure called a cardiac catheterization. The goal of this procedure is to identify which artery of your heart is causing the attack. It is performed by a specially trained cardiologist. The procedure is done by placing a tube in an artery in your leg under local anesthesia. Dye is injected into to the arteries of your heart using x-rays. The discomfort from the procedure is generally minor. You will be given sedation as necessary. The cardiologist will attempt to identify the artery with a blood clot and re-establish blood flow by placing a small metal tube called a stent into the artery. You will receive medications to thin your blood…….
INTERVENTIONALIST OBTAINS CONSENT
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Arrival to Device Time
Room ready during off hours
2 of 3 on call must be within 20 minutes
All expected to be ready in 30 minutes
Send patient as soon as 1 cath lab member in lab & interventionalist on site
Intervene on culprit artery first
minutes
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Time to PCI
-20
0
20
40
60
80
100
120
140
Q1
20
06
Q2
20
06
Q3
20
06
Q4
20
06
Q1
20
07
Q2
20
07
Q3
20
07
Door to EKG EKG to Lab Activation Activation to Lab Lab to Balloon
-20
0
20
40
60
80
100
120
140
Q1
20
06
Q2
20
06
Q3
20
06
Q4
20
06
Q1
20
07
Q2
20
07
Q3
20
07
Door to EKG EKG to Lab Activation Activation to Lab Lab to Balloon
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Analysis of Missed Opportunities
Follow up missed opportunities ASAP
Interview staff involved in case
Follow all leads
Take results of investigation to weekly task force meeting
Keep running list of reason for misses
Obtain necessary documentation for patient centered reason for delays
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Patient Related Delays, excluded
Required Resuscitation
Patient did not give consent
Needed CT Scan to rule out dissection
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System Delays, not excluded
• 99 minutes (Door to EKG = 30 min) - Known COPD smoker arrived via EMS with back pain and SOB. Symptoms improved with breathing treatment in ambulance
• 24 minutes -3rd STEMI in a row on a Sunday.
• 112 minutes (EKG to Activation = 40 min) - 1st EKG ST wave abnormality, hesitation to activate as it may have looked like pericarditis
• 103 minutes (Door to EKG = 40 min) – Female c/o bilateral arm numbness, mild SOB, dizzy
• 95 minutes (Activation to Arrival = 50 min) – Cardiologist saw patient in ED before activating the interventionalist.
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Data Accuracy
• Abstractor’s send list of missed opportunities at end of month to compare with our on-going list
• Use QNET for resolution
• Prior to quarterly submission to Joint Commission vendor, run final list of misses to ensure “mets”/”not mets” are coded correctly
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Success
HH ED STEMI & ACUTE MI CASE REVIEW, NON TRANSFERS
0
20
40
60
80
100
120
140
160
180
200
220
21-D
ec
2-Ja
n
9-Ja
n
25-J
an
23-F
eb
20-M
ar
12-A
pr
19-A
pr
1-M
ay
20-M
ay
28-M
ay
9-Ju
n
29-J
un
13-J
ul
7-A
ug
12-A
ug
29-A
ug
15-S
ep
6-O
ct
19-O
ct
3-N
ov
19-N
ov
13-D
ec
25-D
ec
3-Ja
n
17-J
an
12-F
eb
1-M
ar
7-M
ar
11-M
ar
19-M
ar
12-A
pr
29-A
pr
7-M
ay
22-M
ay
5-Ju
n
28-J
un
7-Ju
l
2-A
ug
3-S
ep
Min
utes
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Control Chart
TIME TO PCI XMR Chart
0
50
100
150
200
250
300
350
Q12006
Q22006
Q32006
Q42006
Q12007
Q22007
UCL MEAN LCL
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Patient Outcomes 2006
PCI is less than 120 minutes
7%4%
89%
D/C Alive, Not toHome
In-House Mortality
D/C Alive, to Home
PCI is greater than 120 minutes
17%
8%
75%
D/C Alive, Not toHome
In-House Mortality
D/C Alive, to Home
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STEMI* In-Patient Mortality Rate
IN HOUSE MORTALITYHARRISBURG HOSPITAL ED STEMI WITH PCI, NON TRANSFERS
0%
2%
4%
6%
8%
10%
12%
Q1 2006 Q2 2006 Q3 2006 Q4 2006 Q1 2007 Q2 2007 Q3 2007
* Of patients included in Primary PCI Joint Commission Measure.
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ALL AMI In-Patient Mortality
IN HOUSE MORTALITYHARRISBURG HOSPITAL ALL AMI IN-PATIENT MORTALITY RATE
0.0%
2.0%
4.0%
6.0%
8.0%
10.0%
12.0%
Q1
2004
Q2
2004
Q3
2004
Q4
2004
Q1
2005
Q2
2005
Q3
2005
Q4
2005
Q1
2006
Q2
2006
Q3
2006
Q4
2006
Q1
2007
Q2
2007
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Program Expansion
• In-Patient CODE STEMI using Rapid Response Team
• Transfer Patients from within the PinnacleHealth system
• Transfer Patients from neighboring institutions
• Transfer Center
• Helicopter services
QUESTIONS?