CARDIAC ALERT: A Change in Process CARDIAC ALERT: A Change in Process. Results of a STEMI Treatment Protocol Over 5 Years. Peter Kerwin, M.D., Colleen Kordish, R.N., June 10, 2008 Downers Grove Illinois ADVOCATE GOOD SAMARITAN HOSPITAL MIDWEST HEART SPECIALISTS

Optimal care in the time critical process of treating STEMI requires a coordinated protocol with EMS, ED and Cardiology functioning as one team

Maintaining optimal quality over time requires continual monitoring and evaluation of data related to the team’s effectiveness.

Reasons to Improve Door to Balloon Time ACC/AHA Guidelines Mission Lifeline D2B Initiative Get With The Guidelines Core Measures Marketing

Coroner says patient's death is a homicide Woman sought care in ER for 2 hours By Andrew L. Wang Tribune staff reporter Published September 15, 2006 The death of a Waukegan woman in July after she spent nearly two hours in an emergency room waiting area was ruled a homicide Thursday during a Lake County coroner's inquest.

ACC/AHA guidelines Advocate Good Samaritan 2002: 99 min. Door to intervention time 90 (120 min). National Average 100-110 minutes. Advocate Good Samaritan 2002: 99 min. Advocate Good Samaritan 2006: 63 min.

Decreasing D2B Time: Why Should We Care? 400,000 STEMI per year 1/3 STEMI patients receive no reperfusion therapy Less than 40% patients receiving primary PCI have D2B < 90 minutes Less than 10% EMS systems have 12 lead ECG capability Circulation 2006;113;2152-2163

Time is Muscle! And Mortality! Each 30 minute delay in reperfusion with PCI increases 1 yr mortality 7.5% Door to balloon <60 min, 1% 30 day mortality; Door to balloon >90 min, 6.4% mortality DeLuca, Circulation 2004;109:1223-1225. Berger, Circulation 1999;100:14-20.

Advocate Good Samaritan Hospital 300 bed community hospital Level 1 Trauma Center 4 cardiology groups- separate call schedules Primary PCI strategy since 1991

D2B- Our History Retrospective baseline 2001- 103 min 1991-1995 review- 55 min Prospective baseline 2002-2003- 99 min 2006- 63 min

Cardiac Alert Brings Results: Advocate Good Samaritan Hospital D2B cases <90 minutes Cases % < 90” Mean 2002 1 17/42 40% 100 min. 2003 1 25/48 52% 94 min. 2004 2 35/46 76% 69 min. 2005 2 51/63 81% 68 min. 2006 2 62/68 91% 63 min. 1Tracked using AHA’s GWTG 2 GWTG/AMI Core Measures

CARDIAC ALERT: It’s Not All About Us! M I D W E S T H E A R T S P E C I A L I S T S PETER KERWIN, M.D.

CARDIAC ALERT PROTOCOL “Individual commitment to a group effort- that is what makes a team work, a company work, a society work, a civilization work.” Vince Lombardi

The Cardiac Alert Team The Patient! Paramedics in the field Triage Staff ED MD’s ED RN’s Cardio diagnostics Radiology Cardiac Catheterization Lab Cardiologists Primary MD’s ICU/Floor RN’s Nurse Clinician/PA’s CV Surgery

Cardiac Alert Goal Door to Balloon < 60 minutes Best Mortality Achievable Goal

Goal for Acute MI Patients Diagnostic ECG performed, interpreted and cardiologist/ cath lab notified – 5 to 10 minutes. Cath Lab/Interventionalist notified, patient on table -30 minutes. Prep- 5 minutes. Angiogram, first inflation -15 minutes.

Goal for Acute MI Patients 60 Minutes From ED admission to Cardiac Intervention 29 September 2003 “Go-Live” Date for Cardiac Alert

Cardiac Alert: Using Data to Implement Change Map the process Standardize time Gather accurate baseline data Evaluate the data Make changes based on the data

Cardiac Alert: Improving Door to Balloon Time Process driven approach to a time sensitive issue Team approach It’s Not All About Me!

Cardiac Alert: Guiding Principles EMS/Triage RN empowered and educated to initiate call Immediate ECG with immediate review Any chest pain over age 30 Single call activates Alert – ECG, Cath Lab, Blood Lab, Radiology Each individual role defined Data with feedback

Ground Rules Paramedics and triage nurses will be educated, never criticized for initiating Cardiac Alert. Cardiologists will not fault ED for calling Cardiac Alert. ED will decide cardiologist for unattached pts. Cardiologists will not fault ED docs for occasional errors in cardiologist selection. Physicians will lead by example.

Door to Balloon Time % < 90 Minutes

Cardiac Alert Brings Results: Advocate Good Samaritan Hospital D2B cases <90 minutes Cases % < 90” Mean 2002 1 17/42 40% 100 min. 2003 1 25/48 52% 94 min. 2004 2 35/46 76% 69 min. 2005 2 51/63 81% 68 min. 2006 2 62/68 91% 63 min. 1Tracked using AHA’s GWTG 2 GWTG/AMI Core Measures

D2B Data: Left Shift Eliminate lag time Decrease outliers

Baseline Data Prospectively established case criteria ST elevation on first ECG – 1cardiologist and 1 ED MD should agree Patient admitted through the ED Start with ~3 months of data (25% of a year) Outliers were not omitted Data was shared with the team, Emergency Department and Cardiology 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. Admission time is minute zero. All times are in minutes. Average STEMI patient First ECG ED MD evaluation Cardiologist notified Cath Lab notified Cath Lab Table First Inflation Baseline Data (n=77) 20 21 32 40 73 99

STEMI Patients Door to Balloon Time (Baseline 2002-Sept 2003) Admission time is minute zero. All times are in minutes and reflect total time elapsed since initial arrival. Average STEMI patient First ECG ED MD evaluation Cardiologist notified Cardiac alert initiated Cath Lab notified Cath Lab Table First Inflation 2002- Baseline Data 20 21 32 Did not apply 40 73 99 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.

Cardiac Alert Committee: Initial then quarterly meeting to review process and discuss outliers Physician, Nursing and Administrative Representation from Cardiology, ED and EMS Peter Kerwin, M.D., Medical Director, Cath Lab Stephen Crouch, M.D., Medical Director, Emergency Dept. Thomas Carmody, M.D., Vice Chairman, Emergency Dept. John Grieco, M.D., Medical Director, Cardiac Surgery Colleen Kordish, R.N., Cardiovascular Outcomes Coordinator Sharon Mow, R.N., Director, Critical Care & Emergency Services Cathy Smith, R.N., Manager, Cardiac Services Lynn Polhemus, R.N., Manager, Emergency Dept. Danielle Albinger, R.N., EMS Coordinator William Iversen, Manager, EMSS & Trauma Services Cardiologists, Nurses, ED Physicians, Paramedics

Cardiac Alert initiated Cardiologist notified D2B Time Sequence Average STEMI Patient First ECG ED MD evaluation Cardiac Alert initiated Cardiologist notified Cath Lab notified Patient placed on Cath Lab Table First Inflation Baseline Data 02-03 (n=77) 20 21 x 32 40 73 99 2006 Data (n=68) 5 7 10 63 2007 Data 4 45 67

Time from Cardiologist notification to patient on Cath Lab table 2007 = 38 minutes 2006 = 30 minutes Baseline = 41 minutes Why are we sliding back ?

Cardiac Alert Brings Results: Advocate Good Samaritan Hospital (2005 STEMI data) Cardiac Alerts occurring during Regular Hours Cardiac Alerts occurring during Off Hours Total Walk-in Cardiac Alerts 54 minutes 93 minutes 81 minutes Paramedic 41 minutes 67 minutes 60 minutes 46 minutes 78 minutes National Averages Magid DJ et al. JAMA 2005;294: 803-812. 95 minutes 116 minutes 106 minutes

Good Samaritan D2B 2006 63 minutes n=68 2005 67.0 minutes Regular Hours Off Hours Total Walk-in 50 minutes n=16 83 minutes n=12 64 minutes n=28 Paramedic 42 minutes n=19 80 minutes n=21 62 minutes n=40 46 minutes n=35 81 minutes n=33 63 minutes n=68 2005 54 minutes 92.6 minutes 80.9 minutes 41.4 minutes 68.6 minutes 59.3 minutes 45.7 minutes 77.5 minutes 67.0 minutes

2007 D2B Improvements 2006 2007 Regular Hours Off Hours Total Walk-in 50 minutes n=16 83 minutes n=12 64 minutes n=28 Paramedic 42 minutes n=19 80 minutes n=21 62 minutes n=40 46 minutes n=35 81 minutes n=33 63 minutes n=68 2007 n=11 84 minutes n=25 72 minutes n=36 37 minutes 73 minutes 61 minutes n=32 41 minutes n=22 79 minutes n=46 67 minutes

Time from Cardiologist notification to patient on Cath Lab table (cont) One reason for time increase:

Symptom Recognition : Symptom to Door often >2 1/2 Hours Chest tightness/pressure Radiation to arm/ neck/ jaw. Dyspnea Diaphoresis Atypical symptoms often (diabetics, women)

Current Reperfusion Strategies ST- Elevation Myocardial Infarction NRMI National Data – September 2001

Evidence Based Changes Create Immediate Benefits Cath Lab is called earlier in the process 8 minute savings Cardiologist will accept ED MD’s initial assessment 11 minute savings We will listen to EMS 7 minute savings For efficiency: one call will initiate new process Hospital operator is the central communication point Cardiac Catheterization Lab is notified by this call We will use all errors as a learning opportunity Physician Leaders role model appropriate behavior

“Outliers” Definition specific to institution/staff Do not omit outliers Identifies the cracks in your process Analyze each case Trend outliers Example: “atypical symptoms” Triage nurse was pre-diagnosing the patient ED physicians provided education to nursing staff “Cannot assume GI, pulmonary or musculoskeletal origin of pain without ECG”

D2B Alliance: Evidence Bases Strategies ED physician activates the cath lab; One call activates the cath lab; Cath lab team ready in 20-30 minutes; Prompt data feedback; Senior management commitment; Team based approach.

Conclusions Effective treatment of patients with STEMI is a time sensitive process requiring a well defined team approach. Ongoing data collection and analysis with feedback allows for changes in process that improve care in patients with STEMI. The role of the cardiologist in this process is not simply that of technician. We must now be team leaders as well. D2B of 60 minutes or less is an achievable goal likely to improve mortality in STEMI.