The D2B Quality Alliance

1. The D2B Quality Alliance Matthew E. Fitzgerald, DrPH Sr. Director, Science & Quality American College of Cardiology

2. Evidence-base Review Subgroup Betsy Bradley, PhD � Chair Yale School of Public Health Connecticut Jeptha Curtis, MD Yale University Connecticut Chris Granger, MD Duke Clinical Research Institute North Carolina Mauro Moscucci, MD University of Michigan Michigan Brahmajee Nallamothu, MD University of Michigan Michigan Harlan Krumholz, MD Yale University Connecticut

3. Evaluation and Research Subgroup Brahmajee Nallamothu, MD � Chair University of Michigan - Michigan Wayne Batchelor, MD Southern Medical Group - Florida Betsy Bradley, PhD Yale School of Public Health -Connecticut Jeptha Curtis, MD Yale University - Connecticut Chris Granger, MD Duke Clinical Research Institute North Carolina Harlan Krumholz, MD Yale University - Connecticut Mauro Moscucci, MD University of Michigan - Michigan April Simon, RN, MSN Cardiac Data Solutions - Indiana Kalon Ho, MD Beth Israel Deaconess Medical Center - Massachusetts David Janicke, MD SUNY at Buffalo - New York Fred Masoudi, MD, MPH Denver Health Medical Center - Colorado

4. Toolkit Subgroup Wayne Batchelor, MD - Chair Southern Medical Group Florida Ralph Brindis, MD, MPH Oakland Kaiser Medical Center California Jeptha Curtis, MD Yale University Connecticut Eva Kline-Rogers, RN, MS University of Michigan Michigan Harlan Krumholz, MD Yale University Connecticut Peter O�Brien, MD Lynchburg General Hospital Virginia Art Riba, MD Oakwood Hospital and Medical Ctr - Michigan April Simon, RN, MSN Cardiac Data Solutions Indiana Charles Chambers, MD Penn State Milton Hershey Med Ctr Pennsylvania David Magid, MD, MPH Kaiser Permanente Colorado

5. Change Package Subgroup Eva Kline-Rogers, RN, MS - Chair University of Michigan � Michigan Wayne Batchelor, MD Southern Medical Group Florida Chris Granger, MD Duke Clinical Research Institute North Carolina Harlan Krumholz, MD Yale University Connecticut Mauro Moscucci, MD University of Michigan Michigan Ivan Rokos, MD UCLA � Olive View California Aaron Kugelmass, MD Henry Ford Health System Michigan Barry Uretsky, MD University of Texas � Galveston Texas

6. Partnership and Communications Subgroup John Brush, MD � Chair Sentara Hospital Virginia Ralph Brindis, MD, MPH Oakland Kaiser Medical Center California Harlan Krumholz, MD Yale University Connecticut Peter O�Brien, MD Lynchburg General Hospital Virginia Art Riba, MD Oakwood Hospital and Medical Ctr Michigan April Simon, RN, MSN Cardiac Data Solutions Indiana Ivan Rokos, MD UCLA � Olive View California Barry Uretsky, MD University of Texas � Galveston Texas Henry Ting, MD Mayo Clinic Minnesota

7. PIM Subgroup Eric S Holmboe, MD American Board of Internal Medicine Pennsylvania Henry Ting, MD Mayo Clinic Minnesota Ivan Rokos, MD UCLA � Olive View California Janet Parkesovich Yale New Haven Hospital Connecticut Patrick O�Gara, MD Brigham & Women�s Hospital Massachusetts John Spertus, MD, MPH Mid America Heart Institute Missouri Martha Radford, MD New York University Hospitals Ctr New York

8. Relationship Between Delay in PTCA and 30-day Mortality Primary PTCA in the Era of Balloon Angioplasty GUSTO IIb Substudy

10. As can be seen by the green bars, in 1999, only 46% of the patients in the fibrinolytic cohort were treated within the recommended 30 minute door-to-drug time, and only 35% of the patients in the PCI cohort were treated within the recommended 90 minute door-to-balloon time. These numbers are humbling. Even more humbling is the fact that these proportions did not change significantly over the next three years. As can be seen by the green bars, in 1999, only 46% of the patients in the fibrinolytic cohort were treated within the recommended 30 minute door-to-drug time, and only 35% of the patients in the PCI cohort were treated within the recommended 90 minute door-to-balloon time. These numbers are humbling. Even more humbling is the fact that these proportions did not change significantly over the next three years.

11. Hospital-Level Variation in Median Door-to-Balloon Times

12. D2B Quality Alliance Goal Goal: To improve door-to-balloon (D2B) times at participating hospitals in non-transfer patients with ST-segment elevation myocardial infarction (STEMI) undergoing primary percutaneous coronary intervention (PCI). Outcome Measure: The proportion of hospitals with at least 75 percent of all their non-transfer patients undergoing primary PCI with D2B times of 90 minutes or less.

13. Evidence Base Synthesis of existing literature (13 studies) - Pre/post interventional studies - Qualitative studies of top performers - National cross-sectional studies Together, these data provide insights about specific interventions that work

14. Time Intervals in Fastest and Slowest Quintiles of Hospitals Door-to-ECG 8 9 ECG-to-lab 47 68 Lab-to-balloon 29 41 TOTAL 94 128 Door-to-ECG 8 9 ECG-to-lab 47 68 Lab-to-balloon 29 41 TOTAL 94 128

15. Strategies that Work (10-15 minutes saving in some cases) 1. ED activation of cath lab 2. Single-call system 3. Cath team target 20-30 minute assembly time 4. Prompt data feedback to ED and cath lab staff 5. Senior management commitment 6. Team-based approach 7. Pre-hospital ECGs activate cath lab team

16. Room for Improvement Emergency medicine activation 22% of hospitals on days 27% of hospital on nights and weekends Single-call system 14% of hospitals Expectation for cath lab team arrival after page 11% of hospitals within 20 minutes 77% of hospitals within 21-30 minutes

17. Interaction Among EMS, ED, and Cath Lab EMS routinely calls in or transmits ECGs 40% of hospitals Hospital activates while patient is still en route 9% of hospitals

18. Reported False Alarm Rates Hospitals where cardiology activates cath lab ? 1 (range: 0-3) in 6 months Hospitals where emergency medicine activates ? 2 (range: 1-4) in 6 months Hospitals that activate while patient en route ? 2 (range: 1-4) in 6 months

19. Organizational Context Explicit goal of improving door-to-balloon time Senior management support Uncompromising clinical champions (and teams) Organizational culture that fostered resilience to challenges and setbacks (non-blame) Data feedback to trend, motivate, and reward

20. Summary The literature supports a set of specific strategies associated with faster door-to-balloon time These are underutilized currently Changes require organizational commitment and cooperation among disciplines and departments National GAP-D2B campaign can help foster needed organizational visibility and commitment

21. D2B Tool Kit Subgroup Developed by experts in the field and in D2B research Included representatives of D2B Team across disciplines and specialties: Nurses Emergency physicians Interventional cardiologists Quality improvement professionals

22. Development Process

23. Development Process Submissions identified point in process when tool is used Submissions identified function of person responsible for completing the tool QI stories provided lessons learned from implementation associated with the tool Submissions identified point in process when tool is used Submissions identified function of person responsible for completing the tool QI stories provided lessons learned from implementation associated with the tool

24. Development Process Hospital Site Reviewers 19 total hospitals D2B times ranging from 55 � 152 min Peer Reviewers 13 total peer reviewers Representatives from: ACC Quality Strategic Directions Committee ACC Board of Governors ACC Cardiac Care Associate Membership American College of Emergency Physicians American Heart Association Institute for Healthcare Improvement Society for Cardiovascular Angiography and Interventions Hospital Site Reviewers 19 total hospitals D2B times ranging from 55 � 152 min Peer Reviewers 13 total peer reviewers Representatives from: ACC Quality Strategic Directions Committee ACC Board of Governors ACC Cardiac Care Associate Membership American College of Emergency Physicians American Heart Association Institute for Healthcare Improvement Society for Cardiovascular Angiography and Interventions

25. D2B Tool Kit How to use D2B toolkit Strategies Checklist Process Flow Chart �STEMI Alert� Checklist Cath Lab Activation Protocol Team Roles and Responsibilities Time Entry Form with Target Times Data Collection Form Standard Order Set Pre-hospital ECG Checklist

26. Take Home Messages

27. D2B: An Alliance for Quality International quality improvement campaign to reduce door-to-balloon times in STEMI patients 200+ hospitals, 27 strategic partners (and growing!) Participating hospitals asked to commit to following: � Implement as many of 6 evidence-based strategies as possible � Allow ACC to publicize their good efforts � Complete three surveys to let ACC know what the hospital is doing to improve D2B times � Participate in the D2B online community to share experiences and learn from others

28. D2B: An Alliance for Quality Reasons for joining D2B: Improve on CMS/JCAHO core measure results ABIM and CME credit for participation Publicity for your efforts No cost to hospitals to join It�s the right thing to do! March 1, 2007 � deadline for hospitals to join D2B and be included in initial public release of participating hospitals at ACC �07 (hospitals are permitted to join after March 1) More information: www.d2balliance.org

30. D2B Manual and Tool Kit

31. D2B Tool Kit

32. How to Participate and What is Expected of Hospitals Complete a Participation Agreement and Join the D2B Alliance! Commit to implementing the evidence-based strategies. Allow D2B Alliance to use hospital name in D2B promotional materials. Help contribute to the learning community by sharing stories, successes and obstacles. And it�s FREE - No cost to join.

33. Where can I get more information? www.d2balliance.com * website for information on D2B, download tools and resources, sign up your hospital and participate in the online D2B community D2B Staff Email � d2bstaff@acc.org