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 Initiatives

Cath 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 ProcessED

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