1. Kelowna General Hospital
AMI
IMPROVEMENT
TEAM
Coming Full Circle: AMI & Med Rec Across the Continuum Western Node Collaborative

2. Background
KGH – very busy 333 bed Tertiary Care facility, averaging 104% capacity
191 random AMI charts from Oct to Oct were audited by student nurses, and showed weaknesses in:
Door to Thrombolytic time
Smoking cessation counseling/ interventions
AMI Team evolved in response to recommendations from this study
Coming Full Circle: AMI & Med Rec Across the Continuum Western Node Collaborative

3. Background
Multidisciplinary Team from a number of areas: Emerg, Critical Care, Cardiology, Cath Lab, Cardiac Rehab/Community, QI, Pharmacy, BCAS, Health Records, etc.
Recommendations acted upon:
Triage standing order for administering ASA and ordering diagnostics
EHS administers ASA in the field
ALS EHS perform 12 lead ECG in the field
Coming Full Circle: AMI & Med Rec Across the Continuum Western Node Collaborative

4. Background
Despite above modifications in practice, Avg. Time to Thrombolytic has not improved
Original Team experienced dissolution when Emerg Manager champion left job in early 2006.
New AMI Team formed in Jan and charter written.
Coming Full Circle: AMI & Med Rec Across the Continuum Western Node Collaborative

5. Aim Statements
Document goal of “Best Process of Care” by increasing percentage of patients receiving Perfect Care Measure by 10% by December 2007.
Increase percentage of patients receiving timely initiation of thrombolytics to 85% by Apr. 1, 2008.
Coming Full Circle: AMI & Med Rec Across the Continuum Western Node Collaborative

6. Aim Statements
Increase percentage of smokers receiving smoking cessation intervention to 95% by Apr. 1, 2008.
Provide Quality Improvement AMI Initiative feedback to appropriate front line staff on a monthly basis.
Coming Full Circle: AMI & Med Rec Across the Continuum Western Node Collaborative

7. Team Members Physicians Cardiologist Nurse Managers
Clinical Nurse Educators/ Patient Care Coordinators
Bedside Nurses
Clinical Pharmacist
Respiratory Therapist
Cardiac Revascularization / Cardiac Rehab Coordinators
BCAS Rep
Quality Improvement (SHN) Rep
Coming Full Circle: AMI & Med Rec Across the Continuum Western Node Collaborative

8. Changes Tested
Concurrent audit tool (initiated by Triage RN, traveling with patient chart) developed and trialed
With incentive rewards
Without incentive rewards
Development/ implementation of STEMI/ NSTEMI order sets, following Best Practice guidelines (in progress)
Coming Full Circle: AMI & Med Rec Across the Continuum Western Node Collaborative

9. Changes Tested
Retrospective chart audits of patients receiving thrombolytics:
looked for variance from Best Practice
examined times of elements contributing to delay to thrombolytic i.e. times of:
Arrival
Triage
Bed
ECG
Physician exam
Thrombolytic administered
Coming Full Circle: AMI & Med Rec Across the Continuum Western Node Collaborative

10. Results
Compliance with Triage Nurse initiating concurrent audit form was about 10%, with incentive rewards. Unfortunately staff compliance for completing the audit tool disappeared with the funding for rewards.
Concurrent audit forms were not always accurately completed. Sometimes information was entered that would reflect more favorably on department performance.
Coming Full Circle: AMI & Med Rec Across the Continuum Western Node Collaborative

11. Results
Bundle elements that were a problem two years ago remain a problem, i.e.
Door to Thrombolytic time
graph shows it is actually getting worse
Smoking cessation counseling/ interventions
Limited data follows…
Coming Full Circle: AMI & Med Rec Across the Continuum Western Node Collaborative

12. Results
Coming Full Circle: AMI & Med Rec Across the Continuum Western Node Collaborative

13. Results
Coming Full Circle: AMI & Med Rec Across the Continuum Western Node Collaborative

14. Keys to Success and Lessons Learned
Good communications at all phases are imperative. Processes that take place without adequate input from all stakeholders fail to get buy-in.
Incentive rewards and compensation improve participation and compliance!
Chart audits are time consuming. It is a non-sustainable way of obtaining data.
Coming Full Circle: AMI & Med Rec Across the Continuum Western Node Collaborative

15. Keys to Success and Lessons Learned
PDSA’s are most likely to succeed when there is a champion on the floor to engage staff, drive the process, and promote effective communications.
Difficult to do PDSA’s in understaffed/ grossly overcapacity ward or department. We have backed off working in ED until a project improving patient flow is completed.
Coming Full Circle: AMI & Med Rec Across the Continuum Western Node Collaborative

16. Next Steps Add more front-line nurse champions to team
Focus on ways to improve smoking cessation counseling and interventions
proposal has been submitted to Health Canada’s Tobacco Control Program
Re-focus on improving Time to Thrombolytic once flow of patients through ED has improved.
Coming Full Circle: AMI & Med Rec Across the Continuum Western Node Collaborative

17. Contact Information
Sherri Ellis (Registered Nurse, Cardiology)
(250)
Karla Waller (Registered Nurse, Cardiology)
Holly Morgan (Clinical QI Coordinator)
(250) Ext 7210
Coming Full Circle: AMI & Med Rec Across the Continuum Western Node Collaborative