AMI Door to Balloon Time
Overview
• Primary entry for ST-Segment Elevation Myocardial Infarction
(STEMI) patients is through our emergency room.
• Improvement focus was in ED with collaboration with
Cathertization Laboratory Services and Rapid Assessment Team
personnel.
• Facility is a tertiary-care 672 bed county teaching hospital
• Over 108,000 annual ED visits, over 400 a day, projected to reach
almost 200,000 for 2010.
• Changes needed to improve patient care and meet organizational
defined quality measure performance standards.
Alignment with organizational goals to produce leading
patient outcomes through our patients obtaining the right
care, in the right setting, by the right providers at the right
time.
The Team
Team Lead: Ellen O’Connell, MD
Robert Madris, RN, MSN,
Assistant Professor, Emergency Services
AMI Core Measure Analyst
Project Manager: Margie Roche, MS
Performance Improvement Project Manager
Facilitator: Peter Hoffman, SVP & Chief
Quality Officer
Rusty Genzel, RN CCRN
Physician Champion: Ellen O’Connell, MD
Emergency Department Service Manager
Assistant Professor, Emergency Services
Tayo Addo, MD
Executive Sponsors:
Assistant Professor, Internal Medicine Cardiology,
Cardiac Catheterization Service
Bradley Simmons, SVP Surgical Services
Josh Floren, SVP Medicine Services
Jana Seale, RN III,
Cardiac Catheterization Service
Maury Belino, RN,
PM Staff Nurse, Emergency Department
Landon Sweeny, RN,
AM Staff Nurse, Emergency Department
CS&E Participants
What We Are Trying to Accomplish?
AIM STATEMENT
Timely identification of STEMI and opening of blocked coronary
arteries (Door to Balloon) improves patient outcomes.
Quality
measure guidelines define effective door to balloon time as less than
90 minutes from arrival at hospital until the balloon is up. Historically,
from October 2008 through December 2009, an average of 54% STEMI
patients achieved a door to balloon time of less than 90 minutes. The
goal of this project is to achieve door to balloon time of less than 90
minutes in over 95% of patients with STEMI.
How Will We Know
That a Change is an Improvement?
Type of Measures
Target for Measures
Door to Balloon Time
≤ 90 minutes for ≥ 95% of STEMI Patients
Door to EKG Time
≤ 10 minutes
Arrival to ED Departure Time
≤ 30 minutes
Arrival to Balloon Up
≤ 90 minutes
How will you Measure?
• All measurements will be collected through use of existing systems in ED, Cath
Lab, and Cardiology (i.e., EPIC, Cardiology Systems, MUSE).
• Reported Core Measure data will also be used.
Baseline Data
Mean Door to Balloon in Minutes
x
x-bar = 66 Min
LCL
UCL
Target= <90 Min
200
180
160
140
Minutes
120
100
80
60
40
20
PODS Live
ASAP Live
Staffing to Volume
New Residents
0
1
3
Q4 '08
5
7
9
11 13 15 17 19 21 23 25 27 29 31 33 35 37 39 41 43 45 47 49 51 53 55 57 59 61 63 65
Q1 '09
Q2 '09
Q3 '09
Q4 '09
Q1 '10
Baseline Data
AMI 8a - Door to Balloon Percent of Cases ≤ 90 Minutes
Target is ≥ 95%
P
UCL
Average
LCL
Target
100%
95%
90%
Percent of Cases ≤ 90 Minutes
80%
70%
60%
50%
40%
30%
20%
10%
0%
Data as reported to UHC Core Measures and from Cases that Met Criteria
Baseline Process Analysis Tools
Plan
Activity
Who
When
Team Charter Developed – Board Directed
Dr. Hoffman
3/28/2010
Describe Current Process
•Process Flow Chart
Team
4/2010
Team
5/2010
Ongoing
Ongoing
Team
4/2010 – 6/2010
Measure & Analyze Data
• Core Measure Knowledge Survey
• Core Measure Quarterly Data
• Chart Reviews
Identify Improvement Opportunities
•Brainstorming
•Survey Results – Open Ended Analysis
•Chart Review
Identify Root Causes of Problem
•Specific Root Cause Not Identifiable
•Several Small Areas of Possibility
Generate & Choose Solutions
•Process Flow Chart – Future State
•Critical Path Exercise
•Brainstorming & Consensus
4/2010 – 6/2010
Team
Team
6/2010 – 7/2010
Baseline Process Analysis Tools
Selected Decision Making Tools
Chart Review Trending Information for Outliers
10
Selected Decision Making Tools
11
Selected Decision Making Tools
Team Focus
DO
Plan included 3-key areas:
• Earlier identification and treatment of STEMI
patients
• Faster movement of patient from ED to Cath
Lab
• Education of Staff on performance measures
and changes
Implementing Change
• Earlier Identification of STEMI
• Nurse driven Walk Back Chest Pain Order Set – Triage Lead
• Revised ED Chest Pain directive procedure
• Faster movement from ED to Cath Lab
• Standardized Patient Prep Order Set
• After Hours RAT nurse straight to Cath Lab
• Cath Lab Notification of Patient Arrival Time
» Arrival time added to Cath Lab activation page
» Arrival time to be placed on colored arm band
• Clock Synchronization
» Synchronize ED, Cath Lab and EKG machines to all be on EPIC
(EMR) time
• Physician Education of STEMI Identification
• Review EKGs of Cath Lab Activation cases with ED Physicians
• Survey personnel involved in STEMI Case next business day
• Monthly case review – cross-functional team
Future State Process
Future State Process
Future State Process
Results/Impact
Check
Activity
Date
Data Collection
(Preliminary Data)
August 16 – September 17, 2010
Data Analysis
September 18 – September 24, 2010
3rd QTR Data
(Preliminary)
October 30, 2010
Results/Impact
Interventions in ED triage and Cath Lab
activation processes have:
• Decreased overall mean time from 123.4
minutes to 56.1 minutes.
• Increased overall performance from 57%
to 90% of cases having door to balloon
time of less than 90 minutes.
Interventions April 1, 2010 August 31, 2010
STEMI Patient Door to Balloon Time
Total Time in minutes
UCL
Average
LCL
Target ≤ 90
600
500
Total Time in minutes
UCL
400
300
Triage Process Change:
Triage Lead Order EKG
RAT/CATH Nurse call ready
for patient to ED Charge
Nurse instead of coming to ED
200
FEB
Patient EPIC arrival time
added to Cath Lab
Activation STAT Page
123.4
MAR
100
JAN
MAY
JUN
JUL
56.1
77.2
Baseline Data
90
AUG
0
1
2
3
4
5
6
7
8
9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38
January 1, 2010 through August 31, 2010
April through August data is not final.
Interventions: Overall Performance
AMI 8a - Door to Balloon Percent of Cases ≤ 90 Minutes
Target is ≥ 95%
P
100%
UCL
Average
UCL
2(2)
1(1)
Target ≥ 95
LCL
2(2)
4(4)
5(5)
9(10)
Percent of Cases ≤ 90 Minutes
90%
5(6)
80%
70%
60%
50%
2(3)
3(5)
CL
2(4)
57%
1(2)
40%
5(6)
4(5)
2(3)
90%
1(2)
2(5)
1(2)
1(2)
3(7)
2(6)
30%
1(4)
1(4)
20%
Inter ventions
10%
0%
0(2)
Data as reported to UHC Core Measures and from Cases that Met Criteria
April-10 through Aug-10 preliminary - not final
x(x)₌ successful case (total cases meeting core measure criteria)
Expansion of Our
Implementation
Act
Activity
Date
Handoff
October 2010 (TBD)
Maintain Gain
•Follow Up Surveys
•Case Reviews
•CM Reports
Ongoing
Monthly Sessions
Quarterly
Monitoring Cases
•Physician Quality
Conference
Monthly
Lessons Learned
• There was not one single root cause for prolonged door to
balloon time.
• Multiple factors such as atypical presentation, awareness of
core measures by staff, delay in EKGs and other contributed
to performance less than target.
• Importance of having representation from all disciplines was
crucial to implementing changes.
• Physician understanding of reporting requirements for core
measures and how important documentation is for reporting
was crucial to change.
• Do not have meetings on Monday’s – multiple holidays
caused some missed meeting days. At time of team start up
identify alternate days for holidays.
Conclusions
Current results are preliminary and data will not be finalized until
December 2010. However, early results indicate that initial
interventions have had a positive effect on door to balloon time.
Short Term Steps:
• Refinement of Interventions
• Development of ongoing education for nurses and physicians
• Improving communication between ED physicians and Cath Lab physicians
• Updating Equipment (i.e., EKG machines and Fax/Scanners)
Long Term Steps:
• Analysis of return on investment related to decreased length of stay and
decreased morbidity in patients experiencing door to balloon time of <90 minutes.
• Research and possible use of field activation of Cath Lab by paramedics and EMS
personnel
• Feasibility study of 24/7 Cath Lab Staffing
Acknowledgments
Thank you for the guidance and information sharing
throughout the process of our program.
– Peter Hoffman, MD
• Senior Vice-President and Chief Quality Officer
– Marisa Valdes, RN
• Interim Director of Performance Improvement
Thank you!