Improving D2B Time in ST-Elevation Myocardial Infarction

UPMC Cardiovascular Institute

Improving D2B Time in ST-Elevation Myocardial Infarction

Sun Scolieri, MDAssistant Professor of Medicine



History at UPMC Presbyterian

Data collection began in Jan 2004 and analysis revealed:• Average time to intervention first 6 months: 447 minutes• No standardization of process• Multiple layers involved in facilitating a patient from the

Emergency Department door to the Cardiac Catheterization Laboratory with successful intervention.

• Commitment to minimize D2B time at UPMC Presbyterian• Original goal <120 minutes, later reduced to <90 minutes• Variety of measures implemented July through September

2006 at UPMC Presbyterian ED/Cardiology


Process Flow Pre Initiative

Patient arrives in ED with Chest Pain

Triage via ED RN

EKG Completed

Assessment by ED Physician

Chest Pain Team Called

Assessment by Cardiology Attending/Fellow

Cardiology Assessment Team contacts

Interventional Cardiologist

Decision for Cardiac Catheterization

Cath Lab Call Team notified – 30 minute window to

arrive at hospital

Transported to Cath Lab

Procedure and Intervention


Improvement Plan

Task force initiated including:• ED and Cardiology Physicians• ED and Cardiology Management and Staff

• Emergency Medical Services Personnel and Management Team

• MedCall Referral Management


Tracking System Initiated

Tracking form developed and implemented.

2. Emergency Department initiates form as soon as patient arrives.

3. ED staff completes form and sends with patient upon transport.

4. Cath Lab Staff completes remaining portion of the form and Manager collects and tallies information.


Acute Myocardial Infarct Tracking Log

Pt Name__________________________

Medical Record #___________________

Date______________________________

Procedure Time Comments 1. Prearrival Activation- Chest Pain

Team

2. Arrival to ED

3. First EKG

4. Chest Pain Team activated by ED

5. Arrival of Cardiology fellow in ED

6. Decision for cath/on-call staff

paged

7. CCU attending called by fellow

8. Cath attending called by fellow

9. Time ED ready

10. Time Cath ready.

(Call Cath Lab to clear transport 30

min after page/allow 20 rings)

2-4745

Ready? Y or N

11. If no, second attempt to call Cath

Lab (5min later) 2-4745

Ready? Y or N

12. If no, page Kitty Zell #3446

13. Transported to Cath Lab

14. Time into lab

15. Time case began

16. Time of access

17. Time of Angiojet

18. Time wire across lesion

19. Time first balloon inflation


Before and After D2B Initiative Emergency Department

BEFORE

• Patient (pt) arrives with c/o CP EKG was done by ED staff and presented to either the resident, ED attending or left in room awaiting MD evaluation

• Upon PCI decision; pt waited in ED for cath lab team arrival before further preparation

• RN would go to McKesson to retrieve cardiac medications many times during ED treatment phase

AFTER

• After initial EKG is completed, EKG is taken immediately to ED attending physician for review

• Upon PCI decision; pt is changed to gown, procedural translucent EKG leads are placed, and groin prepped by ED staff

• All Cardiac meds for AMI are available in one box in the McKesson called “AMI Kit” to increase efficiency


Before and After Decision-Making Process

BEFORE

• Assessment by the ED Physician• Chest Pain Team called• Assessment by Cardiology

Fellow• Cardiology Fellow pages

Cardiology attending on-call• Cardiology Attending on-call

makes decision to contact Interventional Cardiologist

• Interventional Cardiologist pages Cath Lab on-call Team

AFTER

• Assessment by ED Physician• Chest Pain Team,

Interventional Cardiologist, Cardiology Fellow and Cath Lab on-call team paged simultaneously.


Before and After Cath Lab ProtocolsBEFORE

• Cath Lab paged only after full ED and Cardiology assessment

• Travel time 30 minutes• Search for Parking in PUH

Garage• Prepare procedure room• Call for patient when all three

staff members as well as Cardiologist and Fellow have arrived

AFTER

• Cath Lab called in based on ED physician assessment.

• Travel time 30 minutes• Park in Emergency Department

spaces• No room preparation needed –

room left “ready” for emergency patient

• First staff member present calls for patient – ED staff will stay and assist if patient transported before rest of call team arrives.


Assessment Post Event

Acute MI Logs collected and analyzed within 24-48 hours of procedure

Immediate feedback to all Physicians, Staff members, EMS staff and MedCall Staff providing a “report card” of

Outcome.


From: Sent: Monday, November 06, 2006 1:13 PM To: All Involved Cath Lab, Emergency Department, Administration, EMS, and

MedCall Parties Subject: Acute MI Patient

UPMC Cardiology and ED services are striving to improve our door-to-balloon times for acute MI patients that present to our hospital. Our overall goal is to reduce that time to <90 mins in as many instances as possible. Below is a summary of our most recent episode with excellent results:

Patient: E. W, service date 11/03/06, Friday ED Arrival EKG CP Team CPTeam Arr CCL Page To CCL Across Lesion Total Time Comments

1:40p 1:41p 1:45p 1:47p 1:50p 2:00p 2:27p 47 mins. Excellent!

Sample Feedback Email


Guideline Applied Practice~Door-To-Balloon GAP-D2B Goal

• To achieve a door-to-balloon time of

< 90 minutes for at least 75% of non-transfer primary PCI patients with ST-segment elevation myocardial infarction in all participating hospitals performing primary PCI.


Difference?• We analyzed non-transfer patients with STEMI

presenting between July 2005 and May 2007 at UPMC Presbyterian Hospital.

• The baseline group consisted of 63 consecutive STEMI patients between July 2005 and August 2006, and we compared these to 31 consecutive STEMI patients enrolled after protocol implementation, between September 2006 and May 2007.


UPMC Presbyterian Time to PCIJuly 2005 -May 2007

020406080

100120140160180200

Ju

l-0

5

Au

g-0

5

Se

p-0

5

Oct-

05

De

c-0

5

Ja

n-0

6

Fe

b-0

6

Ma

r-0

6

Ma

r-0

6

Ap

r-0

6

Ju

n-0

6

Ju

l-0

6

Au

g-0

6

Se

p-0

6

Oct-

06

No

v-0

6

Ja

n-0

7

Fe

b-0

7

Ap

r-0

7

Min

ute

s

Time to PCI Target 90 Minutes Trend

Full implementation of D2B initiative

Data based on admission date available as of June 15, 2007


UNDER 90 MINUTES

87.1%

28.6%

0

20

40

60

80

100

Pre Post

Initiation

Pe

rce

nt

7/05-8/06 9/06-5/07

N=63 N=31

p<0.00001


MEAN D2B TIME

108.3

72.2

0

20

40

60

80

100

120

Pre Post

Initiation

Tim

e (m

inu

tes)

N=63 N=31

p<0.00001

7/05-8/06 9/06-5/07


MEAN D2B TIME

108.3

72.270.7

0

20

40

60

80

100

120

Pre Post Updated

INITIATION

TIM

E (

Min

ute

s)

7/05-8/06 9/06-5/07 9/06-8/07

N=63 N=31 N=37

p<0.00001

Data based on admission date available as of September 15, 2007


ACC: Evidence-based Strategies

1.Pre-hospital ECG to activate the cath lab

2.ED physician activates the cath lab3.One call activates the cath lab4.Cath lab team ready in 20-30 minutes5.Prompt data feedback6.Senior management commitment7.Team-based approach


How to make it work

1) Commitment from leadership of involved departments to make improvement of D2B highest priority.

2) Empowerment of emergency physician to directly activate cardiac cath team

3) Single call activation system for in-house cardiology, cath lab staff, interventional fellow and attending.

4) Defined time expectations for triage to ECG time, decision to activate cath lab, transfer time.

5) Detailed real time feedback of each component of D2B to all caregivers involved within 1 day of patient encounter.


Thank You

• Joon Sup Lee, MD• Suresh Mulukutla, MD• Vincent Mosesso, MD• Donald Yealy, MD• Charissa Pacella, MD

• Kitty Zell, BSN• Peg Richards, BSN

• MedCall/ Referral center

• Emergency Services • ER staff and personnel• Cath lab staff and

personnel• Administrative support

Improving D2B Time in ST-Elevation Myocardial Infarction

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