Cardiac Alert  at  Advocate  Good Samaritan Hospital: Improving Care of the CAD Patient by Decreasing D2B Peter Kerwin, M....
Decreasing D2B Time:  Why Should We Care? <ul><li>400,000 STEMI per year </li></ul><ul><li>1/3 STEMI patients receive no r...
<ul><li>Cardiac Alert Brings Results: </li></ul><ul><li>1 Tracked using GWTG </li></ul><ul><li>2 GWTG/AMI Core Measures </...
Cardiac Alert Brings Results: 67 minutes 78 minutes 46 minutes Total 106 minutes 116 minutes 95 minutes National Averages ...
Impact of Cardiac Alert 2002/03 vs. 2006 Admission is minute zero.  All times are in minutes. 7 x Cardiac Alert initiated ...
Cardiac Alert: Improving Door to Balloon Time <ul><li>Process driven approach to a time sensitive issue </li></ul><ul><li>...
The Cardiac Alert Team <ul><li>The Patient! </li></ul><ul><li>Paramedics in the field </li></ul><ul><li>Triage Staff </li>...
Cardiac Alert: Guiding Principles <ul><li>EMS/Triage RN empowered and educated to initiate call </li></ul><ul><li>Immediat...
Cardiac Alert Goal <ul><li>Door to Balloon < 60 minutes </li></ul><ul><li>Best Mortality </li></ul><ul><li>Achievable Goal...
Cardiac Alert:  Using Data to Implement Change <ul><li>Map the process </li></ul><ul><li>Standardize time </li></ul><ul><l...
Ambulance   Arrival Walk-in  Arrival Hospital ECG Cardiologist  notified Cardiac  Cath Lab team  notified Cath Lab transfe...
Time Standardization <ul><li>Identify “Real Time” </li></ul><ul><li>Set Clocks </li></ul><ul><ul><li>Be reasonable – the  ...
Ambulance Arrival: Time documented  In EMS record Walk-in Arrival: Time documented  in ED record Hospital ECG: Time docume...
Gather Baseline Data <ul><li>Admission time is minute zero.  All times are in minutes. </li></ul><ul><li>Establish case cr...
Evaluate the Baseline Data <ul><li>Admission time is minute zero.  All times are in minutes </li></ul><ul><li>Who is the l...
Evaluate the Baseline Data <ul><li>Admission time is minute zero.  All times are in minutes </li></ul><ul><li>Who is the l...
Evaluate the Baseline Data <ul><li>What is the limiting factor now? </li></ul><ul><ul><li>ED MD? </li></ul></ul><ul><ul><l...
Evaluate the Baseline Data <ul><li>Method of patient arrival </li></ul><ul><ul><li>Walk-in: (n=38) </li></ul></ul><ul><ul>...
Evaluate the Baseline Data <ul><li>ECG for walk-in patient arrival:  </li></ul><ul><ul><ul><li>Door to ECG: 25 minutes </l...
Evaluate the Baseline Data <ul><li>ECG for ambulance arrival:  </li></ul><ul><ul><ul><li>Door to ECG: 14 minutes </li></ul...
Evidence Based Changes  Create Immediate Benefits   <ul><li>Cath Lab is called earlier in the process  </li></ul><ul><ul><...
Ambulance   Arrival Walk-in  Arrival Hospital ECG Cardiologist  notified Patient on  Cath Lab Table ED MD  Evaluation PCI ...
 
 
Cardiac Alert:  Cardiac Catheterization Lab  <ul><li>Cardiac Cath Lab (3 person team)  </li></ul><ul><ul><li>1st person to...
Cath Lab’s 2001  Performance Improvement Project Baseline = 71 min. Mean = 47.2 min.
Cardiac Alert  at  Advocate  Good Samaritan Hospital: Improving Care of the CAD Patient by Decreasing D2B <ul><li>Peter Ke...
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Cardiac Alert webinar for GWTG 06.ppt

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  • Omitting outliers – 1-2 outliers every month or every other month is not an outlier. Patients will come in with atypical chest pain, the ED secretary will forget to call the cardiologist, the hospital operator will call in the GI Lab instead of the Cath Lab. There will be anomalous coronary arteries, difficulty wiring lesions and the patient will code and you’ll need to resuscitate them. This is what we call real world and your process should be able to accommodate them. Limiting factor? You probably thnik it is the first ECG. I could agree with you but I won’t.
  • The Real limiting factor is the cath lab. Remember that D2B is a process and should respond to process theories. One theory states that you are only as fast as your slowest team member.
  • Cardiac Alert webinar for GWTG 06.ppt

    1. 1. Cardiac Alert at Advocate Good Samaritan Hospital: Improving Care of the CAD Patient by Decreasing D2B Peter Kerwin, M.D. , Medical Director Cardiac Catheterization Lab, Chairman of Interventional Cardiology for Midwest Heart Specialists, Co-chair of Cardiac Alert Team Colleen Kordish, R.N. , Cardiovascular Outcomes Coordinator, Co-chair of Cardiac Alert Team 5 December 2006 Downers Grove Illinois
    2. 2. Decreasing D2B Time: Why Should We Care? <ul><li>400,000 STEMI per year </li></ul><ul><li>1/3 STEMI patients receive no reperfusion therapy </li></ul><ul><li>Less than 40% patients receiving primary PCI have D2B < 90 minutes </li></ul><ul><li>Less than 10% EMS systems have 12 lead ECG capability </li></ul><ul><li>Each 30 minute delay in reperfusion with PCI increases 1 yr mortality 7.5%. </li></ul><ul><li>Door to balloon <60 min, 1% 30 day mortality; Door to balloon >90 min, 6.4% mortality. </li></ul><ul><ul><ul><ul><ul><li>Circulation 2006;113;2152-2163 </li></ul></ul></ul></ul></ul><ul><ul><ul><ul><ul><li>DeLuca, Circulation 2004;109:1223-1225. </li></ul></ul></ul></ul></ul><ul><ul><ul><ul><ul><li>Berger, Circulation 1999;100:14-20. </li></ul></ul></ul></ul></ul>
    3. 3. <ul><li>Cardiac Alert Brings Results: </li></ul><ul><li>1 Tracked using GWTG </li></ul><ul><li>2 GWTG/AMI Core Measures </li></ul><ul><li>3 January – September, 2006 </li></ul><ul><li>Advocate Good Samaritan Hospital D2B cases <90 minutes </li></ul>91% 42/46 2006 2,3 81% 51/63 2005 2 76% 35/46 2004 2 52% 25/48 2003 1 40% 17/42 2002 1 Cases % < 90”
    4. 4. Cardiac Alert Brings Results: 67 minutes 78 minutes 46 minutes Total 106 minutes 116 minutes 95 minutes National Averages Magid DJ et al. JAMA 2005;294: 803-812 . 60 minutes 67 minutes 41 minutes Paramedic Cardiac Alerts 81 minutes 93 minutes 54 minutes Walk-in Cardiac Alerts Total Cardiac Alerts occurring during Off Hours Cardiac Alerts occurring during Regular Hours Advocate Good Samaritan Hospital (2005 STEMI data)
    5. 5. Impact of Cardiac Alert 2002/03 vs. 2006 Admission is minute zero. All times are in minutes. 7 x Cardiac Alert initiated 99 73 40 32 21 19.5 Baseline Data (n=77) 64 41 x 8 6 5 2006 Data Jan - Sept (n=46) First Inflation Patient placed on Cath Lab Table Cath Lab notified Cardiologist notified ED MD evaluation First ECG Average STEMI Patient
    6. 6. Cardiac Alert: Improving Door to Balloon Time <ul><li>Process driven approach to a time sensitive issue </li></ul><ul><li>Team approach </li></ul><ul><li>It’s Not All About Me! </li></ul>
    7. 7. The Cardiac Alert Team <ul><li>The Patient! </li></ul><ul><li>Paramedics in the field </li></ul><ul><li>Triage Staff </li></ul><ul><li>ED MD’s </li></ul><ul><li>ED RN’s </li></ul><ul><li>Cardiodiagnostics </li></ul><ul><li>Radiology </li></ul><ul><li>Cardiac Catheterization Lab </li></ul><ul><li>Cardiologists </li></ul><ul><li>Primary MD’s </li></ul><ul><li>ICU/Floor RN’s </li></ul><ul><li>Nurse Clinician/PA’s </li></ul><ul><li>CV Surgery </li></ul>
    8. 8. Cardiac Alert: Guiding Principles <ul><li>EMS/Triage RN empowered and educated to initiate call </li></ul><ul><li>Immediate ECG with immediate review </li></ul><ul><ul><li>Any chest pain over age 30 </li></ul></ul><ul><li>Single call activates Alert – ECG, Cath Lab, Blood Lab, Radiology </li></ul><ul><li>Each individual role defined </li></ul><ul><li>Data with feedback </li></ul>
    9. 9. Cardiac Alert Goal <ul><li>Door to Balloon < 60 minutes </li></ul><ul><li>Best Mortality </li></ul><ul><li>Achievable Goal </li></ul>
    10. 10. Cardiac Alert: Using Data to Implement Change <ul><li>Map the process </li></ul><ul><li>Standardize time </li></ul><ul><li>Gather baseline data </li></ul><ul><li>Evaluate the data </li></ul><ul><li>Make changes based on evidence and reason </li></ul>
    11. 11. Ambulance Arrival Walk-in Arrival Hospital ECG Cardiologist notified Cardiac Cath Lab team notified Cath Lab transfers Patient onto Cath Lab Table ED MD Evaluation PCI performed Map the Baseline D2B Process Cath Lab team and Cardiologist meet in ED
    12. 12. Time Standardization <ul><li>Identify “Real Time” </li></ul><ul><li>Set Clocks </li></ul><ul><ul><li>Be reasonable – the two minute rule </li></ul></ul><ul><li>Associate specific times with your process so the data collector can go back to the patient’s record at their leisure and still obtain accurate times </li></ul><ul><li>The clinical staff should be able to “treat the patient not their paperwork” </li></ul>
    13. 13. Ambulance Arrival: Time documented In EMS record Walk-in Arrival: Time documented in ED record Hospital ECG: Time documented on ECG print-out Cardiologist Notified: Time documented in ED record Cardiac Cath Lab team Notified: Time documented by Hospital Operator Cath Lab transfers Patient onto Cath Lab Table: Time documented in Cath Lab record ED MD Evaluation: Time documented in ED record PCI performed: Time documented in Cath Lab record Time and Process Coordinated Cath Lab team and Cardiologist meet in ED
    14. 14. Gather Baseline Data <ul><li>Admission time is minute zero. All times are in minutes. </li></ul><ul><li>Establish case criteria </li></ul><ul><ul><li>ST elevation on first ECG – 1cardiologist and 1ED MD should agree </li></ul></ul><ul><ul><li>Patient admitted through the ED </li></ul></ul><ul><li>Start with ~3 months of data (25%of a year) </li></ul><ul><li>Do not omit outliers </li></ul><ul><li>Measure process intervals so you can create a time line (shown below) </li></ul><ul><li>This is not Poker! – Do not hide data </li></ul>99 73 40 32 21 19.5 Baseline Data (n=77) First Inflation Cath Lab Table Cath Lab notified Cardiologist notified ED MD evaluation First ECG Average STEMI patient
    15. 15. Evaluate the Baseline Data <ul><li>Admission time is minute zero. All times are in minutes </li></ul><ul><li>Who is the limiting factor? </li></ul><ul><ul><li>Call them earlier </li></ul></ul><ul><ul><li>Make it easy – one phone call </li></ul></ul><ul><ul><li>Remember: You are only as fast as your slowest team member </li></ul></ul>Cath Lab 40 32 21 19.5 Baseline Data (n=77) Cath Lab notified Cardiologist notified ED MD evaluation First ECG Average STEMI patient
    16. 16. Evaluate the Baseline Data <ul><li>Admission time is minute zero. All times are in minutes </li></ul><ul><li>Who is the limiting factor? </li></ul><ul><ul><li>ST elevation on first ECG: 68% </li></ul></ul><ul><ul><li>Invasive cardiac procedures: 89% </li></ul></ul><ul><ul><ul><li>Cardiac cath, PCI, IABP, CABG, ICD, pacemaker </li></ul></ul></ul><ul><ul><ul><li>2005 data </li></ul></ul></ul><ul><ul><li>If your cardiologist is willing to accept some false positives in order to be called a little earlier then you too can implement the Cardiac Alert </li></ul></ul>Cardiologist 32 21 19.5 Baseline Data (n=77) Cardiologist notified ED MD evaluation First ECG Average STEMI patient
    17. 17. Evaluate the Baseline Data <ul><li>What is the limiting factor now? </li></ul><ul><ul><li>ED MD? </li></ul></ul><ul><ul><li>First 12-lead ECG? </li></ul></ul><ul><li>It is definitely not your ED MD! </li></ul><ul><ul><li>ED MD is the key to this process </li></ul></ul><ul><ul><ul><li>diagnostician </li></ul></ul></ul><ul><ul><ul><li>calls the cardiologist </li></ul></ul></ul><ul><ul><ul><li>coordinates the ED staff – medications, testing, patient assessment </li></ul></ul></ul>Admission time is minute zero. All times are in minutes ? 21 19.5 Baseline Data (n=77) ED MD evaluation First ECG Average STEMI patient
    18. 18. Evaluate the Baseline Data <ul><li>Method of patient arrival </li></ul><ul><ul><li>Walk-in: (n=38) </li></ul></ul><ul><ul><ul><li>Door to ECG: 25 minute average </li></ul></ul></ul><ul><ul><ul><li>25 min x 50% = 12.5 minutes </li></ul></ul></ul><ul><ul><li>Ambulance: (n=39) </li></ul></ul><ul><ul><ul><li>Door to ECG: 14 minute average </li></ul></ul></ul><ul><ul><ul><li>14 min. x 50% = 7 minutes </li></ul></ul></ul>Admission time is minute zero. All times are in minutes ECG 21 19.5 Baseline Data (n=77) ED MD evaluation First ECG Average STEMI patient
    19. 19. Evaluate the Baseline Data <ul><li>ECG for walk-in patient arrival: </li></ul><ul><ul><ul><li>Door to ECG: 25 minutes </li></ul></ul></ul><ul><ul><ul><li>Adheres to the 80/20 rule </li></ul></ul></ul><ul><ul><ul><ul><li>You will spend 80% effort for 20% gain </li></ul></ul></ul></ul><ul><ul><ul><ul><li>If this issue is a challenge at your facility then improve everywhere else first then come back to this issue </li></ul></ul></ul></ul><ul><ul><ul><li>In many cases the triage nurse knew the patient was an AMI </li></ul></ul></ul><ul><ul><ul><li>What if we listen to the RN? Empower them? </li></ul></ul></ul><ul><ul><ul><li>Improvement efforts – increase technology, streamline process, make it routine, quicker access to ECG machines </li></ul></ul></ul>Admission time is minute zero. All times are in minutes ECG 21 19.5 Baseline Data (n=77) ED MD evaluation First ECG Average STEMI patient
    20. 20. Evaluate the Baseline Data <ul><li>ECG for ambulance arrival: </li></ul><ul><ul><ul><li>Door to ECG: 14 minutes </li></ul></ul></ul><ul><ul><ul><li>Paramedics notify ED pre-arrival </li></ul></ul></ul><ul><ul><ul><li>90% accuracy with AMI symptoms </li></ul></ul></ul><ul><ul><ul><li>What if we listen to them? Empower them? </li></ul></ul></ul><ul><ul><ul><li>What if we ask the paramedic “Do you think this is an AMI? </li></ul></ul></ul><ul><ul><ul><li>Listen to actual paramedic calls – these paramedics are professionals! </li></ul></ul></ul>Admission time is minute zero. All times are in minutes ECG 21 19.5 Baseline Data (n=77) ED MD evaluation First ECG Average STEMI patient
    21. 21. Evidence Based Changes Create Immediate Benefits <ul><li>Cath Lab is called earlier in the process </li></ul><ul><ul><li>8 minute savings </li></ul></ul><ul><li>Cardiologist will accept ED MD’s initial assessment </li></ul><ul><ul><li>11 minute savings </li></ul></ul><ul><li>We will listen to EMS </li></ul><ul><ul><li>7 minute savings </li></ul></ul><ul><li>For efficiency: one call will initiate new process </li></ul><ul><ul><li>Hospital operator is the central communication point </li></ul></ul><ul><ul><li>Cardiac Catheterization Lab is notified by this call </li></ul></ul><ul><li>We will use all errors as a learning opportunity </li></ul><ul><ul><li>Physician Leaders role model appropriate behavior </li></ul></ul>
    22. 22. Ambulance Arrival Walk-in Arrival Hospital ECG Cardiologist notified Patient on Cath Lab Table ED MD Evaluation PCI performed Cardiac Alert Process (2006 Data) MD Initiates Cardiac Alert ED RN Initiates Cardiac Alert Initiate Cardiac Alert ECRN asks “ Do you think this is an AMI?” ECRN Initiates Cardiac Alert Cardiac Alert notifies Cath Lab Minute 0 Minute 0 5 min 41 min 7 min 8 min 6 min 64 min
    23. 25. Cardiac Alert: Cardiac Catheterization Lab <ul><li>Cardiac Cath Lab (3 person team) </li></ul><ul><ul><li>1st person to arrive </li></ul></ul><ul><ul><ul><li>opens lab </li></ul></ul></ul><ul><ul><ul><li>prepares room then changes into scrubs </li></ul></ul></ul><ul><ul><ul><li>goes to the ED to assist in transport if necessary </li></ul></ul></ul><ul><ul><li>2nd person to arrive </li></ul></ul><ul><ul><ul><li>changes in scrubs </li></ul></ul></ul><ul><ul><ul><li>goes to ED to package patient for transport to the Cath Lab </li></ul></ul></ul><ul><ul><ul><li>it is the responsibility of this person to eliminate all delays by supporting and assisting the ED staff wherever necessary </li></ul></ul></ul><ul><ul><li>3rd person to arrive </li></ul></ul><ul><ul><ul><li>assists wherever needed </li></ul></ul></ul><ul><ul><li>This routine improves efficiency by eliminating overlapping actions – 24 minute improvement (see following graph) </li></ul></ul>
    24. 26. Cath Lab’s 2001 Performance Improvement Project Baseline = 71 min. Mean = 47.2 min.
    25. 27. Cardiac Alert at Advocate Good Samaritan Hospital: Improving Care of the CAD Patient by Decreasing D2B <ul><li>Peter Kerwin, M.D. , Medical Director Cardiac Catheterization Lab, Chairman of Interventional Cardiology for Midwest Heart Specialists, Co-chair of Cardiac Alert Team </li></ul><ul><ul><li>630-719-4799 </li></ul></ul><ul><li>Colleen Kordish, R.N. , Cardiovascular Outcomes Coordinator, Co-chair of Cardiac Alert Team </li></ul><ul><ul><li>630-275-1592 </li></ul></ul><ul><ul><ul><li>Advocate Good Samaritan Hospital </li></ul></ul></ul><ul><ul><ul><li>3815 Highland Avenue </li></ul></ul></ul><ul><ul><ul><li>Downers Grove, Illinois 60515 </li></ul></ul></ul>

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