An Immediate Nursing Feedback An Immediate Nursing Feedback Program for Program for

Primary PCI for ST-segment Primary PCI for ST-segment Elevation Myocardial InfarctionElevation Myocardial Infarction

Karen Mckenny RN, Theresa Fortner RN, Cheryl McNeil RN, Karen Mckenny RN, Theresa Fortner RN, Cheryl McNeil RN, Carol Woods RN, Shirley Gadbois RN, Heidi Igneri RN Carol Woods RN, Shirley Gadbois RN, Heidi Igneri RN

Joe Hastings RN, and Harold L. Dauerman,MDJoe Hastings RN, and Harold L. Dauerman,MD

Fletcher Allen Health CareFletcher Allen Health Care

University of Vermont, Burlington, VermontUniversity of Vermont, Burlington, Vermont

BackgroundBackground

Based on DANAMI 2. Vermont adopts a Based on DANAMI 2. Vermont adopts a primary PCI Regional Transfer Program 2007primary PCI Regional Transfer Program 2007 4 Rural Hospitals4 Rural Hospitals 35 miles median travel distance35 miles median travel distance

2008 (Nov) Immediate Nurse to Nurse 2008 (Nov) Immediate Nurse to Nurse Feedback program initiated.Feedback program initiated.

The Vermont Rural STEMI Program:The Vermont Rural STEMI Program:There is Only One Interventional There is Only One Interventional

Cardiology/PCI Center in the State of Cardiology/PCI Center in the State of VermontVermont

Vermont Population 600, 000

PCI Procedures at UVM/FAHC: 1400

PCI/year

Vermont

Objectives

To determine a role for cardiovascular catheterization laboratory nursing in improving quality of care for regional primary PCI programs

To define the current level of nursing satisfaction with regional STEMI transfer programs

To implement a nurse to nurse immediate feedback program to improve education and program outcomes

To provide a semi-annual roundtable led by and for nursing to systematically address areas of need including potential sources of transfer delay and/or miscommunication.

MethodsMethods

All patients with STEMI referred for primary All patients with STEMI referred for primary PCI to a single PCI center (Fletcher PCI to a single PCI center (Fletcher Allen/Univ. of Vermont) enrolled in a Allen/Univ. of Vermont) enrolled in a dedicated prospective registrydedicated prospective registry

Study Period: November 2008 - December Study Period: November 2008 - December 20092009

The current study includes 1 PCI center and The current study includes 1 PCI center and 4 regional STEMI referral centers4 regional STEMI referral centers

MethodsMethods A pre-intervention survey of STEMI referral centers A pre-intervention survey of STEMI referral centers

was completed in November 2008was completed in November 2008

A post intervention survey of STEMI referral centers A post intervention survey of STEMI referral centers was completed 9 months laterwas completed 9 months later

Differences between Survey endpoints were Differences between Survey endpoints were compared using chi square statistical techniques. compared using chi square statistical techniques.

Changes in Door to Balloon Times and Triage Times Changes in Door to Balloon Times and Triage Times were compared Quarter 1 vs Quarter 4 using were compared Quarter 1 vs Quarter 4 using student’s t test.student’s t test.

Pre-Intervention Survey ToolPre-Intervention Survey Tool

8 questions:8 questions: Satisfaction regarding feedbackSatisfaction regarding feedback 5 Point Lickert Scale5 Point Lickert Scale

1= no feedback, 5 = excellent 1= no feedback, 5 = excellent feedbackfeedback

Interest in Round Table meetingsInterest in Round Table meetings Educational Topics of interestEducational Topics of interest

STEMI Feedback Form: Dedicated, Faxed STEMI Feedback Form: Dedicated, Faxed Table of Times and Events To Both Table of Times and Events To Both

NursingNursing and Physicians and PhysiciansPatient Name:  Patient Name:  TimeTime

Date of STEMI: 01/05/09Date of STEMI: 01/05/09

STEMI referral Hospital:         STEMI referral Hospital:          CopleyCopley

Time of arrival to referring EDTime of arrival to referring ED 3:293:29

Time of first FIELD/EMS/AMBULANCE ECGTime of first FIELD/EMS/AMBULANCE ECG N/AN/A

Time of first ED ECGTime of first ED ECG 3:293:29

Time FAHC cardiology paged with STEMI Time FAHC cardiology paged with STEMI notificationnotification 3:473:47

Ambulance Service usedAmbulance Service used VT EMSVT EMS

Time of departure by ambulanceTime of departure by ambulance 3:473:47   

Time of arrival in labTime of arrival in lab 4:304:30

Time of open artery (balloon inflation)Time of open artery (balloon inflation) 4:454:45

Door to Open Artery total time ( their door to Door to Open Artery total time ( their door to our balloon)our balloon) 1:151:15

OUR GOAL IS OUR GOAL IS < 90 min< 90 min

STEMI Feedback Form: Dedicated, Faxed STEMI Feedback Form: Dedicated, Faxed Table of Times and Events To Both Table of Times and Events To Both

Nursing Nursing and Physiciansand Physicians

Ambulance EKG to open arteryAmbulance EKG to open artery n/an/a

Medications given prior to transport: ASA 325______Medications given prior to transport: ASA 325______ XX

Clopidogrel 600_____ Clopidogrel 600_____ XX

Unfractionated Heparin Bolus____________Unfractionated Heparin Bolus____________ XX

Referring ED attending:               Referring ED attending:                Dr. STEMIDr. STEMI

Procedure details: Affected artery_______% Procedure details: Affected artery_______% stenosisstenosis__________

Hospital Adverse Events: Death___Emergent Hospital Adverse Events: Death___Emergent CABG____ Stroke____ Major Bleeding_____ Repeat CABG____ Stroke____ Major Bleeding_____ Repeat PCI____PCI____

Transport Related Transport Related eventsVT____VF____CPR____Defib__eventsVT____VF____CPR____Defib__

Follow up phone call done/date Follow up phone call done/date Nurse xNurse x

1/5/091/5/09

Feedback ProgramFeedback Program

Feedback form filled out by Nurse Led Team Feedback form filled out by Nurse Led Team at Primary PCI Siteat Primary PCI Site

Follow up phone call within 24-48 hours to Follow up phone call within 24-48 hours to referring ED nurse for feedback and patient referring ED nurse for feedback and patient outcome reportoutcome report

Form Faxed within 24-48 hours of STEMI to Form Faxed within 24-48 hours of STEMI to Referring STEMI Physician and Nurse TeamReferring STEMI Physician and Nurse Team

Semi-Annual Semi-Annual Round Table meetings & Outreach VisitsRound Table meetings & Outreach Visits

Education of referring staff Education of referring staff Uniform algorithm for treatments and Uniform algorithm for treatments and

medications.medications. Networking, team building, and system Networking, team building, and system

improvement for the STEMI patient in improvement for the STEMI patient in VermontVermont

RESULTS RESULTS STEMI Referral Center Volume STEMI Referral Center Volume

& Feedback Transmission& Feedback Transmission

Name of HospitalName of Hospital Distance in Distance in miles/time from miles/time from

FAHCFAHC

## of of

Beds Beds

STEMI transfer STEMI transfer with follow up with follow up

phone call phone call

Nov 08-Dec 09Nov 08-Dec 09

STEMI transfer STEMI transfer with follow up with follow up

phone call phone call

Jan 10-Sept 10Jan 10-Sept 10

Fletcher Allen Fletcher Allen Health CareHealth Care

500500 7979 6565

Copley Medical Copley Medical CenterCenter

45miles45miles

1 hour1 hour

2525 1616 1313

Northwestern Northwestern Medical CenterMedical Center

25miles25miles

30 min30 min

7070 3131 1616

Porter Medical Porter Medical CenterCenter

37 miles37 miles

58 min58 min

3030 2323 1919

Central Vermont Central Vermont Medical CenterMedical Center

41miles41miles

45 min45 min

3030 3434 3131

Result of Intervention:Result of Intervention:Lickert Scale Satisfaction ScoresLickert Scale Satisfaction Scores

0

1

2

3

4

5

Lic

kert

Sco

re, 1

to

5

Pre Intervention Post Intervention

Triage Times 2009:Triage Times 2009:Significant Improvement in Transfer Hospital Significant Improvement in Transfer Hospital

Presentation to Cath Lab Activation after STEMI Presentation to Cath Lab Activation after STEMI Nursing Feedback Program InitiatedNursing Feedback Program Initiated

0

5

10

15

20

25

30

35

All Referral Hospitals

Ave

rage

Tri

age

Tim

es;

min

utes Quarter 1

Quarter 429 min

19 min

Door to Balloon Times 2009:Door to Balloon Times 2009:Significant Door to Balloon TimeSignificant Door to Balloon Time

Improvement after STEMI Nursing Improvement after STEMI Nursing Feedback ProgramFeedback Program

0

20

40

60

80

100

120

140

FAHC PCI Center All Referral Hospitals

Ave

rage

DT

B ti

me,

min

utes

Quarter 1

Quarter 4

63min58min

124min

86min

Door to Balloon Times:Door to Balloon Times:Significant Door to Balloon TimeSignificant Door to Balloon Time

Improvement after STEMI Nursing Feedback Improvement after STEMI Nursing Feedback ProgramProgram

0

20

40

60

80

100

120

140

FAHC PCI Center All Referral Hospitals

Ave

rage

DT

B t

ime,

min

utes

Start of program Dec 08 Quarter 4 Dec 09 Jan 10-Sept 10

63min

58 min

57 min

124 min

86 min

93 min

ConclusionsConclusions Nurse to NurseNurse to Nurse feedback is a critical component of a feedback is a critical component of a

successful rapid transfer STEMI programsuccessful rapid transfer STEMI program

Referring emergency department satisfaction can be Referring emergency department satisfaction can be dramatically improved with a feedback programdramatically improved with a feedback program

Roundtable and outreach lead to adoption of Roundtable and outreach lead to adoption of uniform state wide practicesuniform state wide practices

The STEMI nursing feedback program leads to The STEMI nursing feedback program leads to improved triage times and D2B times for transfer improved triage times and D2B times for transfer programsprograms