stemi-our system of care: a big town perspective with a small town compassion door-to-balloon (d2b)...
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STEMI-OUR System of Care: A Big Town Perspective with a Small Town Compassion
Door-to-Balloon (D2B)
Intensive Analysis
Wm. Todd Gray, D.O., F.A.C.C.
June 3, 2011
Our Vision
Door 2 Balloon-GOAL Identification of STEMI’s earlier which
included partnerships with our local EMS. D2B < 90 minutes for 100% of patients (non-
transfers) Facility internal goal of <69 minutes for 100%
of patients (non-transfers) Improve documentation of delay when time >
90 minutes, especially if delay occurred within our Cardiac Catherization Lab
Changing “Time”
At DRMC our 1st priority was to offer the best to our growing community. This included looking at our current process for cardiac patients.
“Best Practices” were involved in every aspect of implementing our current Door 2 Balloon(D2B) Dashboard.
GOAL
Door 2 Balloon “SWEET” S-STEMI W-Within E-Emergent E-Event T-Time
S-STEMIInitial identification-EMS
Partnership with local EMS providers: 19/19 local EMS have ability to transmit 12 lead EKG’s directly to ED physician/staff
Transmission of 12 lead EKG directly to physician's phones
Ability to call STEMI directly from field and allow bypassing of ED and go directly to Cath Lab.
Since implementation 1st Q 2011 Median Time--- 59 minutes
W-Within Response Time Initiatives = Saving MuscleIn the beginning…….
• In 2007 our Cardiologists Median Arrival Time=34 minutes
• In 2007 our Interventionists Arrival Time=64 minutes– 2008-Implementation of Interventional Call (Eliminated
call to Cardiologist)– 2010-“I-Card Only” parking spaces and badge only
access direct to Cath Lab• Cath Lab (30 min goal)
– Reduce calls required to activate Cath Lab Team—5555(pager system)
GOAL= 30 mins
W-Within
Response Time InitiativesCath Lab (30 min goal)
Reduce calls required to activate Cath Lab Team—5555
GOAL= 30 mins
E-Emergent
2008-Developed and Implemented “STEMI BOX” Consent Code STEMI D2B checklist Atomic Clock Clippers Acute STEMI medications(i.e. ASA) IV’s and Lab Tubes 2010-Code STEMI Order Set 2010-Currently all lab results print to Cath Lab
E-Emergent
Skinny “STEMI BOX” - October 2008(Triage Nurse initiates for walk-in patients to ED)
Consent Code STEMI D2B checklist Atomic Clock Aspirin In 2010 DRMC implemented an algorithm for our In-
House STEMI process.
E-Event-D2 EKG TimeDoor 2 EKG-2007- 4 minsDoor 2 EKG-2010-3 mins
E-Event-D2 Cath Lab(2007&2010)Door 2 Cath Lab-2007-54.5 minsDoor 2 Cath Lab-2010-36 mins
T-Time-D2B(2007 & 2010)D2B 2007-88 minsD2B 2010-66 mins
Code STEMI Process
ED
Code STEMIInterventional Cardiologist Called
Directly by ED DoctorHUC--5555
• Team members calls HUC to say Cath team on way.
• Off-hours night Supervisors turns on cath lab
Event & Time- Data
Door to EKG Response time physician
Cardiologist in Cath Lab
I-Card in Cath Lab Cath Lab Team arrival
Pt. Door to Cath Lab Door to Balloon0
10
20
30
40
50
60
70
80
90
100
4
10
32.5
70.5
22
54.5
88
30 0
33
14.5
34
66
3 2.50
34
30
40
59
5
10
30 30 30
200720101st Q 2011Goal
Denton Regional Medical Center2007,2010,&1st Q 2011
D2B SWEET—Process Improvement
Process for Transfer STEMIs identified Collection of Transfer Data -2nd Q 2010 Request Transfer facility to arrival DRMC-2010
~Median 52 minutes DRMC door to intervention-2010
~ Median 41 minutes Process for In-Patient Chest Pain identified-2010
~ Median >90 minutes-STEMI occurred after CABG earlier in day
Why “DRMCs” Process WORKS
• Prompt data feedback – 100% review of all Code STEMI on a
daily basis
• Immediate notification of team members to review process for
any outliers
• Team-based approach—Weekly D2B meetings to review
STEMI’s by the D2B sub-committee
• Administrative support
• Concurrent review
• Physician review of cases at CV Meetings
EMS PhysicianInterventional Cardiologist
Nursing Staff
Ancillary Staff
Administration
ED Staff
EMS
Cath Lab Staff