1. Door to Balloon Times: How we got to where we are Brittany Cunningham, RN, MSN VHVI Quality Consultant July 27 th, 2011

2. Disclosures

3. Background Annually close to 400,000 people suffer from a ST-elevation myocardial infarcation In 2004, the median time to percutaneous coronary intervention (PCI) was 293 minutes, according to The Joint Commission.

4. Historical Timeline

5. Terminology Door-to-balloon time (D2B) is a measurement in emergency cardiac care, specifically in the treatment of STEMI. The interval starts with the patient's arrival in the emergency department, and ends when, in the cath lab, a catheter crosses and opens the blockage utilizing a balloon.

7. Signs/ Symptoms Chest Pain Shortness of Breath Nausea Vomiting Palpitations Sweating Anxiety (impending doom) Indigestion Weakness Fatigue “silent”

10. D2B Alliance Joined a D2B Alliance in 2006 with over 1000 institutions which developed 6 key measures + 1 additional optional measure for success: – ED Physician activates the cath lab – Single-call activation system activates the cath lab – Cath lab team is available within 20-30 minutes – Prompt data feedback – Senior Mgmt commitment – Team-based approach – Prehospital 12-lead ECG activates the cath lab (optional)

11. Multidisciplinary team ED management Educators from all areas Quality Staff CVICU management VHVI administration NFD administration VHVI physician leadership Interventionalists Cathlab administration Cathlab management ED cardiologist Pharmacist ED Medical Director ED administration Cathlab Medical Director Heat station manager Life Flight Representative VHVI Quality Consultant General Cardiologist Staff from all areas

12. Chest Pain=Immediate ECG (10 minutes or less) for: Any patient who presents to the ED with: Non-traumatic chest discomfort > 30 years old (all patients with a history of recent cocaine use) – Pressure/aching/tightness/heaviness – Burning – Sharp/stabbing/pleuritic Any patient with a recent history of having a coronary stent placed Chest discomfort prior to arrival Shortness of breath Non-traumatic arm or shoulder pain Beware atypical symptoms: – Diaphoresis – Dizziness, syncope/near syncope – Palpitations – Nausea > 50 Years Old – Epigastric pain >50 years old – Weakness > 50Years Old – Altered mental status or any symptom you think might be cardiac in origin Must have an immediate EKG performed and reviewed by an ED attending!!!!!

13. Streamlined Process

14. Clear definitions/ time stamps

15. Individual Case Review within 24-48hrs

16. Continuous Monthly Review

17. SPC charts to identify interval delays

18. Mean= 3.85 Mean=7.58

19. SWAT Team Implementation CVICU Charge Nurse On-Call Cardiology Fellow ED Nurse Cathlab RN Cathlab Procedure Tech Interventional Fellow Interventionalist

22. Questions?