American College Of Cardiology Door to Balloon Time D2B Initiative For Better Care OF Acute Myocardial Infarction

1. American College Of CardiologyDoor to Balloon Time (D2B) Initiative For Better Care OF Acute Myocardial Infarction Bruce Bagley, M.D. Matthew Fitzgerald Colleen Kordish, RN

2. Significance of D2B Time 400,000 STEMI per year Less than 40% patients receiving primary PCI have D2B < 90 minutes Each 30 minute delay in reperfusion with PCI increases 1 yr mortality 7.5% Door to balloon <60 min, 1% 30 day mortality Door to balloon >90 min, 6.4% 30 day mortality Circulation 2006;113;2152-2163 DeLuca, Circulation 2004;109:1223-1225. Berger, Circulation 1999;100:14-20.

3. Cardiac Alert Brings Results:

4. Cardiac Alert: Using Data to Implement Change Map the process Standardize time Gather baseline data Evaluate the data Make changes based on the evidence

6. Time Standardization Identify �Real Time� Set computers and clocks Associate specific times with your process so the data collector can go back to the patient�s record at their leisure and still obtain accurate times The clinical staff should be able to �treat their patient not your paperwork�

8. Gather Baseline Data Admission time is minute zero. All times are in minutes. Omitting outliers � 1-2 outliers every month or every other month is not an outlier. Patients will come in with atypical chest pain, the ED secretary will forget to call the cardiologist, the hospital operator will call in the GI Lab instead of the Cath Lab. There will be anomalous coronary arteries, difficulty wiring lesions and the patient will code and you�ll need to resuscitate them. This is what we call real world and your process should be able to accommodate them. Limiting factor? You probably thnik it is the first ECG. I could agree with you but I won�t. Omitting outliers � 1-2 outliers every month or every other month is not an outlier. Patients will come in with atypical chest pain, the ED secretary will forget to call the cardiologist, the hospital operator will call in the GI Lab instead of the Cath Lab. There will be anomalous coronary arteries, difficulty wiring lesions and the patient will code and you�ll need to resuscitate them. This is what we call real world and your process should be able to accommodate them. Limiting factor? You probably thnik it is the first ECG. I could agree with you but I won�t.

9. Evaluate the Baseline Data Admission time is minute zero. All times are in minutes The Real limiting factor is the cath lab. Remember that D2B is a process and should respond to process theories. One theory states that you are only as fast as your slowest team member.The Real limiting factor is the cath lab. Remember that D2B is a process and should respond to process theories. One theory states that you are only as fast as your slowest team member.

10. Evaluate the Baseline Data Admission time is minute zero. All times are in minutes

11. Evaluate the Baseline Data What is the limiting factor now? It is definitely not your ED MD! ED MD is the key to this process diagnostician calls the cardiologist coordinates the ED staff � medications, testing, patient assessment and diagnosis

12. Evaluate the Baseline Data Method of patient arrival Walk-in: (n=38) Door to ECG: 25 minute average 25 min x 50% = 12.5 minutes Ambulance: (n=39) Door to ECG: 14 minute average 14 min. x 50% = 7 minutes

13. Evaluate the Baseline Data ECG for ambulance arrival: Door to ECG: 14 minutes Paramedics notify ED pre-arrival 90% accuracy with AMI symptoms What if we listen to them? Empower them? What if we ask the paramedic �Do you think this is an AMI? Listen to actual paramedic calls � these paramedics are professionals!

14. Evaluate the Baseline Data ECG for walk-in patient arrival: Door to ECG: 25 minutes Adheres to the 80/20 rule You will spend 80% effort for 20% gain If this issue is a challenge at your facility then improve everywhere else first then come back to this issue In many cases the triage nurse knew the patient was an AMI What if we listen to the RN? Empower them? Common improvement efforts � increase technology, streamline process, make it routine, quicker access to ECG machines

15. Evidence Based Changes Create Immediate Benefits Cath Lab is called earlier in the process 8 minute savings Cardiologist will accept ED MD�s initial assessment 11 minute savings We will listen to EMS 7 minute savings For efficiency: one call will initiate new process Hospital operator is the central communication point Cardiac Catheterization Lab is notified by this call We will use all errors as a learning opportunity Physician Leaders role model appropriate behavior

17. Cardiac Alert: Guiding Principles EMS/Triage RN empowered and educated to initiate call Immediate ECG with immediate review Single call activates Alert � ECG, Cath Lab, Blood Lab, Radiology, etc� Each individual role defined Eliminate Arrogance Data with feedback

20. Are You Ready?