OPTIMIZING DOOR-TO-BALLOON TIME: STRATEGIES FOR SUCCESS B. Hadley Wilson, MD. J. Lee Garvey, MD. Patricia M. Pye, RN, MS K...
<ul><li>Time is Muscle:  Every 10 minute delay to Percutaneous Coronary Intervention (PCI) results in a 1% change in morta...
Process Improvement Case Study: Carolinas Medical Center (CMC) <ul><li>2004 evaluation demonstrated CMC had opportunities ...
Process Improvement Case Study: Carolinas Medical Center (CMC) <ul><li>Team developed enhanced goals for Code STEMI that e...
<ul><li>Identification :   Medic paramedics are trained to acquire and read 12-lead electrocardiograms (ECG) on patients s...
Critical Success Factors <ul><li>EMS and ED Physician initiate Code STEMI  </li></ul><ul><li>Single page activates entire ...
Patient presents with symptoms of ACS Cardiologist on Call CCU 12 Lead ECG   Proceed to ED without activation of Code STEM...
Lessons Learned from Carolinas Medical Center <ul><li>It takes  real  commitment from the Multi-disciplinary Team </li></u...
Bottom Line Results  Overall Door-to-Balloon Time Improvements October 2004 – June of 2006 18/59 =  31% 33/59 =  56% 76.0 ...
Bottom Line Results  EMS & Non EMS Arrivals October 2004 – June of 2006
Bottom Line Results Carolinas Medical Center American College of Cardiology Benchmark  <90 minutes Minimizing Time to Trea...
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Optimizing Door-to-Balloon Time:

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  • Just we talked about I would show comparison between 2004 and 2005 for NRMI D2B time.
  • Would you like to explain what you mean by overall remember the audience mix?
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  • Optimizing Door-to-Balloon Time:

    1. 1. OPTIMIZING DOOR-TO-BALLOON TIME: STRATEGIES FOR SUCCESS B. Hadley Wilson, MD. J. Lee Garvey, MD. Patricia M. Pye, RN, MS Kevin M. Collier, RCIS Carolinas Medical Center
    2. 2. <ul><li>Time is Muscle: Every 10 minute delay to Percutaneous Coronary Intervention (PCI) results in a 1% change in mortality* </li></ul><ul><li>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. </li></ul>Background Source: Nallamothu BK et al, AM Journal Cardiology 2003
    3. 3. Process Improvement Case Study: Carolinas Medical Center (CMC) <ul><li>2004 evaluation demonstrated CMC had opportunities for improvement </li></ul><ul><ul><li>72 minutes EMS patients </li></ul></ul><ul><ul><li>116 minutes non-EMS patients </li></ul></ul><ul><ul><li>87 minutes overall </li></ul></ul><ul><li>Multi-disciplinary team was challenged to improve Door-to-Balloon process </li></ul><ul><ul><li>EMS, ED Physicians, Cardiologists, ED Staff, Cath Lab, CCU, Bed Management, Lab, Radiology, Respiratory Care, House Supervisor </li></ul></ul><ul><li>CMC’s process improvement plan was based on practices paralleling Code Trauma => Code STEMI </li></ul>
    4. 4. Process Improvement Case Study: Carolinas Medical Center (CMC) <ul><li>Team developed enhanced goals for Code STEMI that exceed the ACC/AHA Standard: </li></ul><ul><ul><li>Goal #1 : 90% of patients reperfused within 60 minutes of ED arrival ( compared to national guidelines of < 90 minutes ) </li></ul></ul><ul><ul><li>Goal #2 : 90% of patients reperfused within 90 minutes of first medical contact ( compared to national guideline of < 90 ) </li></ul></ul>Source: ACC/AHA Guidelines 7/04
    5. 5. <ul><li>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. </li></ul><ul><li>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. </li></ul><ul><li>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 </li></ul>New CMC Process Code STEMI – Protocol Driven Program 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.
    6. 6. Critical Success Factors <ul><li>EMS and ED Physician initiate Code STEMI </li></ul><ul><li>Single page activates entire team => parallel actions commence </li></ul><ul><ul><li>ED and Cath Lab begin preparations </li></ul></ul><ul><ul><li>On-Call Cardiologist and CCU Nurse go to ED </li></ul></ul><ul><ul><li>Respiratory Care and Laboratory are available in ED </li></ul></ul><ul><ul><li>Joint assessment occurs in the ED </li></ul></ul><ul><ul><li>Cardiologist and CCU Nurse assist EMS in transporting patient to Cath Lab </li></ul></ul><ul><ul><li>Patient is prepared for PCI </li></ul></ul><ul><ul><li>Bed Management finds accommodations </li></ul></ul><ul><li>Trust in revised roles and responsibilities </li></ul>
    7. 7. 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 Respiratory CCL Call Team Hospital Lab Bed Management Radiology CMC Code STEMI Protocol Standing Ready 24/7 ED activates Code STEMI Simultaneous Page to:
    8. 8. Lessons Learned from Carolinas Medical Center <ul><li>It takes real commitment from the Multi-disciplinary Team </li></ul><ul><ul><li>EMS, ED Physicians, Cardiologists, ED Staff, Cath Lab, CCU, Bed Management, Lab, Radiology, Respiratory Care, House Supervisor </li></ul></ul><ul><li>Establish a specific goal to Meet or Exceed ACC Standard </li></ul><ul><li>Adopt a continuous process improvement philosophy => on-going monitoring and modification of the process </li></ul><ul><li>Intensive education for EMS on acquiring and interpreting ECGs </li></ul><ul><li>Recognize that a cultural change is necessary </li></ul><ul><li>Be flexible – forward thinking => all play in same sandbox </li></ul><ul><li>Trust in revised roles and responsibilities </li></ul><ul><li>Be patient-focused: Time is Muscle </li></ul>
    9. 9. Bottom Line Results Overall Door-to-Balloon Time Improvements October 2004 – June of 2006 18/59 = 31% 33/59 = 56% 76.0 88.9 27-289 59 Before Code STEMI 92/153 = 60% 134/153 = 88% 54.0 58.4 10 - 172 153 After Code STEMI % < 60 minutes % < 90 minutes Median (minutes) Mean (minutes) Range Number of cases
    10. 10. Bottom Line Results EMS & Non EMS Arrivals October 2004 – June of 2006
    11. 11. Bottom Line Results Carolinas Medical Center American College of Cardiology Benchmark <90 minutes Minimizing Time to Treatment from Arrival in the ED to treatment in the Cath Lab Saving Lives Mortality Rate Source:  NRMI; Solucient

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