1. St. Rose Dominican Hospital “Cardiac Care Team” UPDATE September 2003

2. Prepared by: Pamela Rowse, RN Cardiac Care Team Leader Assistant Nurse Manager ED

3. “The Henderson Roses”

4. “Living by our Mission and Values” St. Catherine of Siena and St. Rose of DeLima

5. Striving For Excellence

6. “Background”  Early Team activities were missing important resources.  Meetings were not well attended by team members.  Interdisciplinary collaboration was fragmented.

7. “Reorganization”  The Emergency Department actively joined the Team in December of 2002.  In March of 2003 – Expansion began in the Team Configuration.  Benchmarks were reviewed in detail and discussions ensued to meet the standards.  The name changed from “AMI” Team, to “Cardiac Care Team”.  Resources influencing outcomes were outlined.  Strategic Team expansion resulted.  Focus expanded to ALL services impacting the desired end product, that being “excellence in Cardiac Care”.

8. Team Members Now Emergency Department Critical CareED Physicians Cardiology CardiologistsPharmacyMedical Surgical Nursing Education Case Management Nutrition Services EMS/HFDQM/RM Cardiac Rehab Cardiac Cath Lab RadiologyLaboratory Communications Respiratory Therapy Administration Corporate

9. “Diagramed Full Process” “What are the important components to success and good patient outcomes….?”

10. Chest Pain – Cardiac Emergency  Onset of pain is the triggering factor in recognizing and acting on a true cardiac emergency  The Team realized that this was one area where we must have impact to be successful in our outcomes.  Denial and lack of public awareness was one of the focuses.

11. “Activating 911”  How could we achieve early activation of the 911 system?  HFD – Assisted us with statistics regarding the current stats in our Community.  Average time from CP to “911” activation was “53 minutes”  We felt it was imperative to impact in earlier notification of emergency services.

12. “Community Education”

13. “Time Is Muscle”  The Communications Department at St. Rose Dominican was contacted regarding “public education”  Response was very supportive and projects discussed in conjunction with Henderson Fire Department/EMS  Once More a “Team Effort” and quality in our delivery of care.

14. EMS Response

15. “Pre-Hospital Statistics for Cardiac Care”  Once “911” is activated, our community has a maximum dispatch response time of “2 min”  EMS Response to the Scene is approximately “7 min”  Early “Cardiac Alert” Systems were already being put into place by HFD to enable them to react with expediency when arriving at the scene for particularly patients presenting with ST Elevation.

16. “STEMI Patients”  The Team discovered that the HFD was working diligently on a program for “ST elevation MI Protocols”  A presentation was made to the Cardiac Care Team outlining their plans.  This “dove-tailed” perfectly into our Team Activities including standing physician orders.  Early Recognition and Resource activation took a step forward.  Presentations were scheduled for the Emergency Department Physicians and Cardiology.

17. “Emergency Department Early Activation”  Part of the Early Activation of ED Resources came from the statistics that we were given regarding benchmarks of care delivery.  Timing of response from EKG, Laboratory, and Radiology didn’t meet our desired goal.  It was essential to have emergent notification of all needed resources for an acute MI patient delivery.  A system for “group paging” was discussed and implemented.

18. “Door To Data”  Arrival of the EKG Technician for accurate data for diagnosis was imperative. This was addressed with the “AMI Group Pager” system.  HFD however, helped us to move even further in this arena.  Technology with their rescue units enables them to transmit via fax accurate and clear 12 lead EKG data directly to the hospital ED Physician for review.  This would enable activation of resources prior to the arrival of the patient.

19. “Time to Lytics”  Time to administration of thrombolytics was an essential benchmark.  This component was impacted by Nursing, Pharmacy, and Education.  Tracking was established to monitor times.  We also included the administration of lytics in the critical care units and provided an educational program through pharmacy to facilitate this.

20. “Door to PTCA”  A new cath lab was installed at the DeLima Campus allowing PTCA to be completed there.  Tracking of response times by the Cardiologists was initiated.  100% review was established.

21. “Morbidity & Mortality”  Reports were outside of Benchmarks  Reviewed stats from Midas and NIRMI  Investigated the co-utilization of NIRMI numbers with significant co-morbidities pull out.  Needed to pull NIRMI numbers into current review.  Contacted another CHW Facility regarding their process.  Pursuing Alternatives such as dedicated FTEs.

22. “ Corroboration ” All Resources Must Be Included To Achieve “Best Practice”

23. “Public and Patient Education”  It is “OUR” responsibility to identify and provide education for our patients and our customers.  Cardiac Disease in one of the number one causes of death and disability in our country and we must help provide the necessary interventions.  It is an issue that is broad in scope and vitally important.  And one that the St. Rose Cardiac Care Team didn’t take lightly.

24. Nursing Education  The education of our nursing staff is multi- faceted and imperative.  Disease Process Understanding.  Recognition of needs.  Intervention in a timely and appropriate manner.  Patient Education and Advocacy.

25. “Physician Education”  Communication of the “National Guidelines” and “Community Standards”  Providing “Tools” for accurate admission orders that are streamlined.  Introduction of “Clinical Pathways” to facilitate compliance to “LOS” standards that assists not only medical but nursing treatment of patients with cardiac conditions.  Provide information regarding resources that will facilitate their patient’s recovery such as outpatient services, Rehab, PT, Nutrition etc.

26. “Smoking Cessation”  Identify all opportunities for education.  Provide the resources and support for patients to achieve this essential goal.  Be able to document the efforts made.  Achieve desired benchmarks

27. Aspirin, Beta Blockers, Ace Inhibitors  Provide opportunity for appropriate documentation.  Provide triggers for ordering and follow- through  Provide patient and provider education regarding need.

28. “Nutrition”  Provide notification and access to essential clients by the Nutrition Team.  Take home information regarding daily activities and impact of diet on disease process.  Follow-up Resources regarding education and questions.  Disease specific “tips” for adhering to a healthy life- style

29. “Medications”  Patient understanding of prescribed medications.  Assisting patients with financial resources to adhere to medication regimes outlined for them.  Providing resources for education and food and drug interactions that will allow nursing to assist in the education process at discharge.

30. “Rehab – Exercise”  Active participation in the inpatient visit and mechanism for notification and orders.  Coordination with “other” educational processes.  Notification of follow- up resources provided.

31. “Discharge Instructions”  Standardize the documents utilized for Discharge Instructions and documentation by Nursing.  Provide the tools for adequate education of patients by the nursing staff that is going to be held accountable for it’s completion.  Establishment of a resource library and packets for “disease specific” education by nursing.  Education regarding “how to provide Discharge Instruction”

32. “Our Team Challenges”  Systems for implementation of “action plan” such as  Dedicated fax machines for EKG Transmissions,  Immediate registration of AMI patients for early intervention,  Education of all staff regarding cardiac care education and discharge planning,  Process for reporting to the nursing departments regarding ejection fractions,  Standardized forms for discharge documentation,  Materials available for after hour discharges,  Notification of “essential” services needed to deliver appropriate assessment and intervention.

33. “Our Team Successes”  Implementation of the STEMI Standing Orders.  “AMI Group Page System  Near Completion of the CHF Standing Orders  Collaborative effort with Community EMS for Early Activation and Public Education.  Successful achievement of benchmarks for “door to data and door to lytics”  Expansion of “Active” Team to include all necessary resources.  Active involvement of “physicians” in outcomes and program implementation.

34. “Proposals”  Utilization of the St. Rose Website for:  Patient and Staff Education  Resources and Referrals  Internet links for information  Schedules for “outpatient education programs”  Contacts and Educational Downloads

35. St. Rose Serving Our Community For Better Cardiac Care