Speed can save lives in health care, especially in the treatment of heart attack victims. Rapid response means blocked arteries are opened faster, blood flow is restored to the heart and more muscle tissue is saved. Delay can mean lives lost.
Experts at Cox involved in all aspects of care for acute heart attack patients have collaborated to drastically reduce the time it takes to get a patient through the hospital doors to the preferred treatment of angioplasty in the cardiac catheterization lab. Their effort to improve the so-called door-to-balloon core quality measurement has resulted in dramatically lower response times and more lives being saved.
The national standard for door-to-balloon is 90 minutes or less. The latest data from the second quarter of 2008 and validated by the Centers for Medicare and Medicaid Services (CMS) and The Joint Commission, show CoxHealth with an average door-to-balloon time of 57 minutes. In that quarter, the fastest time for an individual case was 28 minutes. Numbers like these put Cox in the top 10 percent of the state and among the best hospitals in the nation for the treatment of emergency cardiac patients.
“I’ve been amazed at the lower door-to-balloon times,” says cardiologist Dr. James Ceaser. “I thought we would have to wait until we had the new emergency room, more space and more staff to make improvements to our times. But everyone has done an absolutely wonderful job. We all should be proud.”
The system of care responsible for the falling door-to-balloon rates at Cox today began to take shape more than two years ago. The American Heart Association and the American College of Cardiology had recommended changing the 120-minute national standard, which Cox was meeting, to the current 90 minutes or less. Since door-to-balloon is evidence-based medicine, research showed better patient outcomes with faster treatment. At Cox, the race was on.
Employees in the Pre-Hospital, Emergency and Cardiology departments formed a committee to analyze the complex process involved in identifying, transporting and treating patients with acute myocardial infarction (MI), a sudden and intense heart attack that occurs when blood flow to an artery of the heart is blocked.
The MI throughput committee identified several ways to create a more coordinated system, such as increasing interdepartmental communication, improving technology, and expanding ongoing education and feedback. The team focused on every step in the chain of care that could be sapping precious time and developed strategies that shaved seconds and minutes from the process.
Some of the changes that produced a more coordinated response to acute MI patients include: earlier activation of the Cath Lab; an overhaul of the education of paramedics in the use and interpretation of 12-lead EKG to detect acute MI and training for all Emergency department staff to perform EKGs instead of only hospital EKG technicians.
“Communication has helped with little things that can eat up precious time,” says LaDonna Smith, RN, a 20-year veteran of the Cath Lab. “Each department was doing its work in isolation and not thinking about what was happening before or after the patient got to them and left. When we started communicating our needs, the process really began to speed up.”
And the clock begins ticking as soon as the call for help comes into Central Dispatch at Cox North.
Emergency Medical Services dispatchers like Ron Litle usually work in a state of alertness but when a caller is complaining of symptoms like chest pain and shortness of breath, the situation is heightened even further.
“Pre-Hospital has made this a priority. Hair stands up on their neck if they think somebody is having an MI in the field,” says John Archer, Cox South Emergency department director. “They know they’re part of a group trying to get our times down to compete nationally.”
EMS operations manager Mike Dawson says the ability of Central Dispatch to “auto launch” or activate Cox Air Care based on caller information cuts response times. But the most significant factor is better education for paramedics in the detection with electrocardiogram (EKG) of an acute MI.
Using 12-lead EKGs, paramedics determine if a specific area of the EKG is elevated, which indicates the severity of damage to the heart. This is known as ST-elevation.
EMS medical director and ER physician Dr. Matthew Brandt developed an aggressive educational program that requires Cox paramedics to spend four non-consecutive 8-hour days each quarter training on 12-lead EKG use and interpretation, and the detection of ST-elevation-MI or STEMI.
“Last year, I took ten EKGs at random and asked our paramedics to determine if they showed the presence of a STEMI or not,” says Dr. Brandt. “Then, I showed the same EKGs to our ER physicians. The results were nearly identical.”
Dr. Brandt says the proven competency of paramedics in the recognition of STEMI has improved trust with emergency room physicians. Trust has also improved between ER physicians and cardiologists. At one time, after the ER physician confirmed a STEMI with the EKG, the cardiologist reviewed the EKG before the Cath Lab was activated.
“When the paramedics call us now and say we’re ten minutes out with an ST-elevated MI, we activate the Cath Lab team and the cardiologists right then. Think of the time that saves,” says Dr. Brandt.
The ED has taken that step even further by allowing the communications nurse who receives the call from EMS to activate the Cath Lab. That activation sets off a series of events that now happen simultaneously and with the same urgency as trauma and stroke.
The Cath Lab team responds from home or in house to set up the lab which can take up to 30 minutes. ER staff begins preparations. Once the patient comes through the door, three nurses, one technician, the ER doctor and a registration staff member surround the patient. Basic medications and an IV are started, blood is drawn, another EKG and chest X-ray are performed, and the patient is registered. In about 10-15 minutes, the patient is ready to head to the fourth floor Cath Lab.
“The ER team, the nurses, medics, the techs, everybody takes it as a challenge on how fast we can have that patient ready,” says Archer. “The Cath Lab team calls us as soon as they hit the building instead of waiting until they finish setting up the lab. Ten minutes later, we’re rolling with the patient.”
All ER staff were trained to perform the additional EKG required in the emergency room. Previously, only EKG technicians from Cardiology could perform the test after traveling to the ER from wherever they happened to be in the hospital. Changes throughout the process began to add up to time savings.
Cath Lab director Alan Kettelkamp says adding a night team Monday-Thursday improves times and provides a better continuum of care, since the Cath Lab is now staffed 24-hours from Monday morning through Friday evening.
“The patient comes in terrified that something horrible is happening to them,” says Kettelkamp. “Because of the hard work of everyone in the entire process, we’re able to get a balloon in the artery, and open it up. Blood is restored to the heart, the patient improves instantly, and we know that we pulled this patient out of a very bad situation.”
The process doesn’t end there. Details of the patient’s outcome loop back to all of the people involved in the care of STEMI patients with the help of real time feedback by the Quality Resource department.
“Communication is the biggest thing I do,” says Chris Schulze, Cardiovascular Services performance indicator facilitator. “We share data about standards and provide feedback on how we’re doing case by case and month by month. The boots on the ground figure out how to get it done more efficiently.”
And the MI Throughput committee continues to review protocols to find more ways to deliver even faster, more effective treatment for STEMI patients in the future.
“We are constantly looking for barriers and knocking them down,” says Archer.
“I believe that we removed our biggest obstacles to success through face-to-face and heart-to-heart communication,” says Becky Watts, administrative director of Cardiovascular Services.
“Until our experts had the opportunity to understand the demands and processes of each other’s departments, we were not successful in truly working together as a team.”
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