GAP-D2B An Alliance for Quality

GAP-D2B Goal n To achieve a door-to-balloon time of </= 90 minutes for at least 75% of non- transfer primary PCI patients with ST- segment elevation myocardial infarction in all participating hospitals performing primary PCI.

What is ACC doing to address this issue? n Assembled the ACC D2B Work Group and (5) subgroups comprised of physician and nurse volunteers and ACC staff n Summarized the evidence and identified the evidence-based strategies n Currently developing the tools and educational materials to support the strategies. n Collaboration with strategically-related organizations is being pursued.

Disseminating the “How”: Evidence-based Strategies 1.Pre-hospital ECG to activate the cath lab 2.ED physician activates the cath lab 3.One call activates the cath lab 4.Cath lab team ready in minutes 5.Prompt data feedback 6.Senior management commitment 7.Team-based approach

Themes n Clear, explicit goal n Administrative support n Clinical champions n Data feedback n Systems approach n Collaborative teams n Culture Circulation 2006;113:

Lowering door-to-balloon…a how-to guide n Patients presenting to the ED with CP are rapidly triaged; an ECG is obtained and immediately shown to an ED physician. Goal: Door to ECG<5 minutes. n ED physician empowered to activate cath lab Interventionalist-does not have to wait until a cardiologist sees the patient.

n 24/7 staff and Interventional Cardiologist coverage. Staff expected to arrive no later than 30 minutes after being called. n ED staff trained in the expeditious preparation of the patient. Adequate but limited assessment and preparation performed. Orders standardized wherever possible (IV access, groin shave, Reopro etc.)

n Transport to cath lab can occur even before entire cath lab staff or cardiologist is present. When 2 out of 3 are there, “ready call” is made. Cardiologist will briefly assess patient at the door if missed in ED. n Limited injections of non-infarct related arteries are taken with diagnostic catheters, before proceeding directly to the culprit vessel a with an interventional guide. LV gram and other imaging done at the end of case.

n Entire process is continually reviewed by a collaborative committee consisting of : ED physician, Cardiologist, Cath lab staff, Administrators, pre-hospital providers, nursing, etc. n A subcommittee reviews charts on all cases with door to device times of greater than 90 minutes, and feedback is provided to those involved. n Transfers from outside hospitals are taken directly to the cath lab, bypassing the ED and CCU.

Path Forward n Disseminate the ‘How’ and recruit other hospitals to develop similar programs n Focus on total door-to-balloon time n Focus on associated outcomes n Foster cooperation between PCI and non-PCI hospitals to develop regional MI systems and improve access n Public education to decrease symptom- to-door time and use of 911

Challenges/Limitations n Delays are common n Relationship with outcome strong n Disparity is hospital-based n Time of day/day of week important n Specialization important n Pre-hospital ECG rare

Relationship between door to balloon time and mortality in NRMI registry Door to balloon time (min)Mortality (%) < – – > McNamara RL et al. J Am Coll Cardiol 2006; 47:2180–2186.

Goals National Time Goals n Door to ECG 5 minutes n Door to Cath Lab 30 minutes n Door to Cath Lab device 55 minutes Total =90 minutes Centra Health Goals n Door to ECG 5 minutes n Door to Cath Lab 30 minutes n Door to Cath Lab device 25 minutes Total =60 minutes

Total Door-to-Balloon Time Circulation 2005;111:761-7

LYNCHBURG GENERAL HOSPITAL (ID # )

Why pursue D2B at this point? n ACC physicians, staff and our strategic partners are working together on GAP-D2B. n ACC Governor survey indicates that D2B is one of the top areas of interest. n GAP-D2B is consistent with ACC-AHA and SCAI Guidelines. n Opportunity for the ACC BOG to exert its leadership by beginning the launch of a national quality improvement initiative. n Achieving the D2B goal will have a significant positive impact on patient outcomes and mortality.

How will ACC execute a solution? n Recruitment begins NOW WITH YOU! n The formal “launch” will occur in November 2006 at AHA. n Over 130 hospitals have already expressed interest in this national collaborative. n GAP-D2B website will enable participants to post data, communicate and evaluate best practices. n ACC Work Group developing tools and materials necessary to successfully reduce door-to-balloon time.

What is asked of hospital participants? n Commit to implementing the evidence-based strategies. n Commit to submission of your data. n Allow ACC to use hospital name in D2B promotional materials. n Help contribute to community by sharing stories, successes and obstacles. n Learn from others. n No cost to join.

Role of Chapter Executives n Establish a Chapter Quality Council. n Work with Governor to convene D2B team. n Coordinate Chapter level activities and communications. n Assist Governor in recruitment and follow up.

Role of Governors n Identify physician champions in your state n Work with physician champions to recruit your primary PCI hospitals to GAP-D2B n Contact your local QIO for collaboration potential n Contact your local MCOs for collaboration potential n information to n WE CHALLENGE EACH GOVERNOR TO RECRUIT AT LEAST 4 HOSPITALS BY NOV. 1