Cardiac AlertCardiac Alert at at AdvocateAdvocate Good Samaritan Hospital: Good Samaritan Hospital:

Improving Care of the CAD Patient by Improving Care of the CAD Patient by Decreasing D2BDecreasing D2B

Peter Kerwin, M.D.Peter Kerwin, M.D., Medical Director Cardiac , Medical Director Cardiac Catheterization Lab, Chairman of Interventional Catheterization Lab, Chairman of Interventional

Cardiology for Midwest Heart Specialists, Co-chair of Cardiology for Midwest Heart Specialists, Co-chair of Cardiac Alert TeamCardiac Alert Team

Colleen Kordish, R.N.Colleen Kordish, R.N., Cardiovascular Outcomes , Cardiovascular Outcomes Coordinator, Co-chair of Cardiac Alert TeamCoordinator, Co-chair of Cardiac Alert Team

5 December 20065 December 2006Downers Grove IllinoisDowners Grove Illinois

Decreasing D2B Time: Decreasing D2B Time: Why Should We Care?Why Should We Care?

400,000 STEMI per year400,000 STEMI per year1/3 STEMI patients receive no reperfusion therapy1/3 STEMI patients receive no reperfusion therapyLess than 40% patients receiving primary PCI have D2B Less than 40% patients receiving primary PCI have D2B < 90 minutes< 90 minutesLess than 10% EMS systems have 12 lead ECG Less than 10% EMS systems have 12 lead ECG capabilitycapabilityEach 30 minute delay in reperfusion with PCI increases Each 30 minute delay in reperfusion with PCI increases 1 yr mortality 7.5%. 1 yr mortality 7.5%. Door to balloon <60 min, 1% 30 day mortality; Door to Door to balloon <60 min, 1% 30 day mortality; Door to balloon >90 min, 6.4% mortality.balloon >90 min, 6.4% mortality.

Circulation 2006;113;2152-2163Circulation 2006;113;2152-2163DeLuca, Circulation 2004;109:1223-1225.DeLuca, Circulation 2004;109:1223-1225.Berger, Circulation 1999;100:14-20.Berger, Circulation 1999;100:14-20.

Cardiac Alert Brings Results:Cardiac Alert Brings Results:

CasesCases % < 90”% < 90”

2002 2002 11 17/4217/42 40%40%

2003 2003 11 25/4825/48 52%52%

2004 2004 22 35/4635/46 76%76%

2005 2005 22 51/6351/63 81%81%

2006 2006 2,32,3 42/4642/46 91%91%11Tracked using GWTGTracked using GWTG22 GWTG/AMI Core MeasuresGWTG/AMI Core Measures33 January – September, 2006January – September, 2006

• AdvocateAdvocate Good Samaritan Hospital D2B cases <90 minutesGood Samaritan Hospital D2B cases <90 minutes

Cardiac Alert Brings Results:Cardiac Alert Brings Results:

AdvocateAdvocate Good Samaritan Good Samaritan

Hospital Hospital

(2005 STEMI data)(2005 STEMI data)

Cardiac Alerts Cardiac Alerts occurring during occurring during Regular HoursRegular Hours

Cardiac Alerts Cardiac Alerts occurring duringoccurring during

Off HoursOff HoursTotalTotal

Walk-in Walk-in

Cardiac AlertsCardiac Alerts54 minutes54 minutes 93 minutes93 minutes 81 minutes81 minutes

ParamedicParamedic

Cardiac AlertsCardiac Alerts

41 minutes41 minutes 67 minutes67 minutes 60 minutes60 minutes

TotalTotal 46 minutes46 minutes 78 minutes78 minutes 67 minutes67 minutes

National AveragesNational Averages

Magid DJ et al. Magid DJ et al. JAMAJAMA 2005;294: 2005;294:

803-812803-812..

95 minutes95 minutes 116 minutes116 minutes 106 minutes106 minutes

Average Average STEMI STEMI PatientPatient

First First ECGECG

ED MD ED MD evaluation evaluation

Cardiac Cardiac Alert Alert initiatedinitiated

Cardiologist Cardiologist notifiednotified

Cath Lab Cath Lab notifiednotified

Patient Patient placed on placed on Cath Lab Cath Lab TableTable

First First InflationInflation

Baseline Baseline Data Data (n=77)(n=77) 19.519.5 2121 xx 3232 4040 7373 99992006 Data2006 DataJan - SeptJan - Sept(n=46)(n=46) 55 66 77 88 xx 4141 6464

Admission is minute zero. All times are in minutes.

Impact of Cardiac AlertImpact of Cardiac Alert2002/03 vs. 20062002/03 vs. 2006

Cardiac Alert:Cardiac Alert:Improving Door to Balloon TimeImproving Door to Balloon Time

Process driven approach to a time Process driven approach to a time sensitive issuesensitive issue

Team approachTeam approach

It’s Not All About Me!It’s Not All About Me!

The Cardiac Alert TeamThe Cardiac Alert TeamThe Patient!The Patient!Paramedics in the fieldParamedics in the fieldTriage StaffTriage StaffED MD’sED MD’sED RN’sED RN’sCardiodiagnosticsCardiodiagnosticsRadiologyRadiologyCardiac Catheterization LabCardiac Catheterization LabCardiologistsCardiologistsPrimary MD’sPrimary MD’sICU/Floor RN’sICU/Floor RN’sNurse Clinician/PA’sNurse Clinician/PA’sCV SurgeryCV Surgery

Cardiac Alert: Guiding PrinciplesCardiac Alert: Guiding Principles

EMS/Triage RN empowered and educated EMS/Triage RN empowered and educated to initiate callto initiate call

Immediate ECG with immediate reviewImmediate ECG with immediate review– Any chest pain over age 30Any chest pain over age 30

Single call activates Alert – ECG, Cath Single call activates Alert – ECG, Cath Lab, Blood Lab, RadiologyLab, Blood Lab, Radiology

Each individual role definedEach individual role defined

Data with feedbackData with feedback

Cardiac Alert GoalCardiac Alert Goal

Door to Balloon < 60 minutesDoor to Balloon < 60 minutes

Best MortalityBest Mortality

Achievable GoalAchievable Goal

Cardiac Alert: Cardiac Alert: Using Data to Implement ChangeUsing Data to Implement Change

Map the processMap the process

Standardize timeStandardize time

Gather baseline dataGather baseline data

Evaluate the dataEvaluate the data

Make changes Make changes based on evidence and based on evidence and reasonreason

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 ProcessMap the Baseline D2B Process

Cath Lab team

and Cardiologist

meet in ED

Time StandardizationTime Standardization

Identify “Real Time”Identify “Real Time”

Set ClocksSet Clocks– Be reasonable – the Be reasonable – the two minute ruletwo minute rule

Associate specific times with your process so the data Associate specific times with your process so the data collector can go back to the patient’s record collector can go back to the patient’s record at their at their leisure leisure and still obtain accurate timesand still obtain accurate times

The clinical staff should be able to “treat the patient not The clinical staff should be able to “treat the patient not their paperwork” their paperwork”

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 CoordinatedTime and Process Coordinated

Cath Lab team

and Cardiologist

meet in ED

Gather Baseline DataGather Baseline Data

Admission time is minute zero. All times are in minutes.Admission time is minute zero. All times are in minutes.

Average STEMI Average STEMI patientpatient

First First ECGECG

ED MD ED MD evaluation evaluation

Cardiologist Cardiologist notifiednotified

Cath Lab Cath Lab notifiednotified

Cath Lab Cath Lab TableTable

First First InflationInflation

Baseline Data Baseline Data (n=77)(n=77) 19.519.5 2121 3232 4040 7373 9999

Establish case criteriaEstablish case criteria– ST elevation on first ECG – 1cardiologist and 1ED MD should agreeST elevation on first ECG – 1cardiologist and 1ED MD should agree– Patient admitted through the EDPatient admitted through the ED

Start with ~3 months of data (25%of a year)Start with ~3 months of data (25%of a year)

Do not omit outliers Do not omit outliers

Measure process intervals so you can create a time line (shown below)Measure process intervals so you can create a time line (shown below)

This is not Poker! – Do not hide dataThis is not Poker! – Do not hide data

Evaluate the Baseline DataEvaluate the Baseline Data

Admission time is minute zero. All times are in minutesAdmission time is minute zero. All times are in minutes

Average STEMI Average STEMI patientpatient

First First ECGECG

ED MD ED MD evaluation evaluation

Cardiologist Cardiologist notifiednotified

Cath Lab Cath Lab notifiednotified

Baseline Data Baseline Data (n=77)(n=77) 19.5 19.5 2121 3232 4040

Who is the limiting factor?Who is the limiting factor?– Call them earlierCall them earlier– Make it easy – one phone callMake it easy – one phone call– Remember:Remember: You are only as fast as your slowest You are only as fast as your slowest

team memberteam member

Cath Lab

Evaluate the Baseline DataEvaluate the Baseline Data

Admission time is minute zero. All times are in minutesAdmission time is minute zero. All times are in minutes

Average STEMI Average STEMI patientpatient

First First ECGECG

ED MD ED MD evaluationevaluation

Cardiologist Cardiologist notifiednotified

Baseline Data Baseline Data (n=77)(n=77) 19.5 19.5 2121 3232

Who is the limiting factor?Who is the limiting factor?– ST elevation on first ECG: 68%ST elevation on first ECG: 68%– Invasive cardiac procedures: 89%Invasive cardiac procedures: 89%

Cardiac cath, PCI, IABP, CABG, ICD, pacemakerCardiac cath, PCI, IABP, CABG, ICD, pacemaker

2005 data2005 data

– If your cardiologist is willing to accept some false positives in order to 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 Alertbe called a little earlier then you too can implement the Cardiac Alert

Cardiologist

Evaluate the Baseline DataEvaluate the Baseline Data

What is the limiting factor now?What is the limiting factor now?– ED MD?ED MD?– First 12-lead ECG?First 12-lead ECG?

It is definitely It is definitely not not your ED MD!your ED MD!– ED MD is the key to this processED MD is the key to this process

diagnosticiandiagnostician

calls the cardiologistcalls the cardiologist

coordinates the ED staff – medications, testing, patient assessmentcoordinates the ED staff – medications, testing, patient assessment

Average STEMI Average STEMI patientpatient

First First ECGECG

ED MD ED MD evaluationevaluation

Baseline Data Baseline Data (n=77)(n=77) 19.5 19.5 2121

Admission time is minute zero. All times are in minutesAdmission time is minute zero. All times are in minutes

?

Evaluate the Baseline DataEvaluate the Baseline Data

Method of patient arrivalMethod of patient arrival– Walk-in: (n=38)Walk-in: (n=38)

Door to ECG: 25 minute averageDoor to ECG: 25 minute average

25 min x 50% = 12.5 minutes25 min x 50% = 12.5 minutes

– Ambulance: (n=39)Ambulance: (n=39)Door to ECG: 14 minute averageDoor to ECG: 14 minute average

14 min. x 50% = 7 minutes14 min. x 50% = 7 minutes

Average STEMI Average STEMI patientpatient

First First ECGECG

ED MD ED MD evaluationevaluation

Baseline Data Baseline Data (n=77)(n=77) 19.5 19.5 2121

Admission time is minute zero. All times are in minutesAdmission time is minute zero. All times are in minutes

ECG

Evaluate the Baseline DataEvaluate the Baseline Data

ECG for walk-in patient arrival: ECG for walk-in patient arrival: Door to ECG: 25 minutesDoor to ECG: 25 minutesAdheres to the 80/20 ruleAdheres to the 80/20 rule

– You will spend 80% effort for 20% gain You will spend 80% effort for 20% gain – If this issue is a challenge at your facility then improve everywhere If this issue is a challenge at your facility then improve everywhere

else first then come back to this issueelse first then come back to this issue

In many cases the triage nurse knew the patient was an AMIIn many cases the triage nurse knew the patient was an AMIWhat if we listen to the RN? Empower them?What if we listen to the RN? Empower them?Improvement efforts – increase technology, streamline process, Improvement efforts – increase technology, streamline process, make it routine, quicker access to ECG machinesmake it routine, quicker access to ECG machines

Average STEMI Average STEMI patientpatient

First First ECGECG

ED MD ED MD evaluationevaluation

Baseline Data Baseline Data (n=77)(n=77) 19.5 19.5 2121

Admission time is minute zero. All times are in minutesAdmission time is minute zero. All times are in minutes

ECG

Evaluate the Baseline DataEvaluate the Baseline Data

ECG for ambulance arrival: ECG for ambulance arrival: Door to ECG: 14 minutesDoor to ECG: 14 minutes

Paramedics notify ED pre-arrivalParamedics notify ED pre-arrival

90% accuracy with AMI symptoms90% accuracy with AMI symptoms

What if we listen to them? Empower them?What if we listen to them? Empower them?

What if we ask the paramedic “Do you think this is an AMI?What if we ask the paramedic “Do you think this is an AMI?

Listen to actual paramedic callsListen to actual paramedic calls – these paramedics are – these paramedics are professionals!professionals!

Average STEMI Average STEMI patientpatient

First First ECGECG

ED MD ED MD evaluationevaluation

Baseline Data Baseline Data (n=77)(n=77) 19.5 19.5 2121

Admission time is minute zero. All times are in minutesAdmission time is minute zero. All times are in minutes

ECG

Evidence Based Changes Evidence Based Changes Create Immediate BenefitsCreate Immediate Benefits

Cath Lab is called earlier in the process Cath Lab is called earlier in the process – 8 minute savings8 minute savings

Cardiologist will accept ED MD’s initial assessment Cardiologist will accept ED MD’s initial assessment – 11 minute savings11 minute savings

We will listen to EMS We will listen to EMS – 7 minute savings7 minute savings

For efficiency: one call will initiate new process For efficiency: one call will initiate new process – Hospital operator is the central communication pointHospital operator is the central communication point– Cardiac Catheterization Lab is notified by this callCardiac Catheterization Lab is notified by this call

We will use all errors as a learning opportunity We will use all errors as a learning opportunity – Physician Leaders role model appropriate behaviorPhysician Leaders role model appropriate behavior

Ambulance

Arrival

Walk-in

Arrival

Hospital ECG

Cardiologist

notified

Patient on

Cath Lab Table

ED MD

Evaluation

PCI performed

Cardiac Alert ProcessCardiac Alert Process(2006 Data)(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

Cardiac Alert: Cardiac Alert: Cardiac Catheterization Lab Cardiac Catheterization Lab

Cardiac Cath Lab (3 person team) Cardiac Cath Lab (3 person team) – 1st person to arrive1st person to arrive

opens lab opens lab prepares room then changes into scrubsprepares room then changes into scrubsgoes to the ED to assist in transport if necessary goes to the ED to assist in transport if necessary

– 2nd person to arrive2nd person to arrivechanges in scrubschanges in scrubsgoes to ED to package patient for transport to the Cath Lab goes to ED to package patient for transport to the Cath Lab it is the responsibility of this person to it is the responsibility of this person to eliminate all delayseliminate all delays by by supporting and assisting the ED staff wherever necessary supporting and assisting the ED staff wherever necessary

– 3rd person to arrive3rd person to arriveassists wherever neededassists wherever needed

– This routine improves efficiency by eliminating overlapping This routine improves efficiency by eliminating overlapping actions – 24 minute improvement (see following graph)actions – 24 minute improvement (see following graph)

Cath Lab’s 2001 Cath Lab’s 2001 Performance Improvement ProjectPerformance Improvement Project

Cath Lab Notified until Patient Is on the Cath Lab Table: (Off Hours Cases Only) April 2001 - September 2001

0

10

20

30

40

50

60

70

80

1 4 7 10 13 16 19 22 25 28 31 34 37 40 43 46 49

Patients

Min

ute

s

Baseline = 71 min.

Mean = 47.2 min.

Cardiac AlertCardiac Alert at at AdvocateAdvocate Good Samaritan Hospital: Good Samaritan Hospital:

Improving Care of the CAD Patient by Improving Care of the CAD Patient by Decreasing D2BDecreasing D2B

Peter Kerwin, M.D.Peter Kerwin, M.D., Medical Director Cardiac Catheterization Lab, Chairman of , Medical Director Cardiac Catheterization Lab, Chairman of Interventional Cardiology for Midwest Heart Specialists, Co-chair of Cardiac Alert Interventional Cardiology for Midwest Heart Specialists, Co-chair of Cardiac Alert TeamTeam

– 630-719-4799630-719-4799

Colleen Kordish, R.N.Colleen Kordish, R.N., Cardiovascular Outcomes Coordinator, Co-chair of Cardiac , Cardiovascular Outcomes Coordinator, Co-chair of Cardiac Alert TeamAlert Team

– 630-275-1592630-275-1592

Advocate Good Samaritan Hospital Advocate Good Samaritan Hospital

3815 Highland Avenue3815 Highland Avenue

Downers Grove, Illinois 60515Downers Grove, Illinois 60515