Cardiac Reperfusion Team Protocol Reduces Door-to-Balloon Time at Hamot Medical Center Antonios D. Katsetos, DO, Thomas Williams, MS, Theresa Kisiel, CRNP, Robert J. Ferraro, MD, Ronald S. Strony, MD

Background Hamot Medical Center (HMC) established a Chest Pain Center in 1998 Evaluation of chest pain with rapid rule out process HMC’s “Cardiac ER” introduced in January 2004: Cardiac Alert process Focus on emergent chest pain patients Decision made to undertake the rigorous Society of Chest Pain Centers accreditation process

Background Chest Pain/AMI process team formed in April 2004 Multidisciplinary group dedicated to evaluating & improving emergency cardiac care on presentation, throughout hospital stay to discharge, and across the continuum of after-care Cardiac “Reperfusion Team” implemented in February 2005 Goal to improve care of presenting STEMI patients Rapid identification and treatment of patients presenting to the ED with STEMI

Process Reperfusion Team protocol: EKG is performed as soon as possible after patient presentation to triage (goal time <10 minutes) The EKG is presented immediately to the attending ED physician for interpretation Reperfusion team is mobilized if STEMI is identified (“cardiac alert” is called)

Process The reperfusion team responds to ED immediately upon the Cardiac Alert call: ED physician ED nurse Attending cardiologist Nursing supervisor Pharmacist Cardiac cath lab (CCL) staff IV team Lab tech Radiology tech

Process Patients appropriate for PCI are transferred from the ED to the CCL as soon as possible after reperfusion team activation

Methods Retrospective review of reperfusion team activations occurring between February, 2005 and September, 2007 was performed with attention to four key operational components: Door to EKG completion time EKG to CCL arrival time CCL arrival to balloon time Total D2B time

Results Door to EKG time: Review of data demonstrated that when door to EKG time is < 10 minutes, D2B is < 90 minutes Initial ED focus: Reduce door to EKG time: Second EKG cart added Additional triage room added Focused education of triage nurses Yellow wrist bands for all chest pain patients (indicates the clock is ticking)

Door to EKG Time

EKG to In CCL Time

Results

Results

Results

Discussion The greatest opportunity for improvement in D2B exists in reducing the time from EKG completion to CCL arrival Transmission of pre-hospital EKG’s has been shown to decrease EKG-to-CCL time We are currently working with pre-hospital providers in our area to achieve EKG transmission on all chest pain patients

Discussion EMS personnel must be taught to acquire and transmit EKG’s on all chest pain patients EMS agencies must be provided with the equipment necessary to acquire and transmit EKG’s from the field

Discussion Improved off-hours CCL readiness: Evaluating cost effectiveness of having 24 hour in-house cath lab personnel Utilize non-CCL staff (e.g. nursing supervisor) to unlock lab and power up equipment, etc., while awaiting CCL staff arrival

Next Steps Assessing the feasibility of direct-to-CCL admissions for STEMI patients identified by EMS An in-house reperfusion team protocol was instituted in August, 2006 Evaluation is currently underway Assessing regional STEMI transfers for opportunities for improvement