1. 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

2. 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

3. 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

4. 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)

5. 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

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

7. 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

8. 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)

9. Door to EKG Time

10. EKG to In CCL Time

11. Results

12. Results

13. Results

14. 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

15. 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

16. 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

17. 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