In the world of stroke care, there’s nothing more important than these three syllables: time is brain. A blocked artery ravages brain tissue at the rate of some 2 million neurons per minute. What applies to the head also holds for the heart. The longer the heart muscle is deprived of blood, the greater the damage.
The Cath Lab at UCH (the control area for the procedural rooms is pictured here) now activates to treat a STEMI patient with a pre-hospital call from EMS providers.
Ideally, the elapsed time from the moment emergency providers bring a patient suffering a type of heart attack known as a STEMI into the hospital to the start of a catheterization to clear an arterial blockage should be 90 minutes or less for at least 75 percent of patients, excluding those transferred from another facility.
Meeting this so-called door-to-balloon (D2B) time standard requires practiced coordination between many providers. The system now in place at University of Colorado Hospital has stood the test. As of mid-May, the hospital had gone 388 days without a single D2B time exceeding 90 minutes. The median time is now 66.5 minutes, according to Kim Marshall, RN, CPHQ, quality improvement specialist with the hospital’s Cardiac and Vascular Center.
That’s a potentially lifesaving improvement for patients. A 2015 American College of Cardiology report noted that while D2B time is not the sole measure of improved outcomes in STEMI patients, it “directly correlates with an amount of time the myocardium undergoes ischemic damage.” The report adds that observational studies associate shorter D2B times with lower 30-day and one-year mortality rates.
Heart of the matter
The success at UCH isn’t an accident, said Chris McStay, MD, chief of clinical operations for the University of Colorado School of Medicine’s Department of Emergency Medicine. The hospital’s Door-to-Balloon committee has collaborated to build a solution that includes emergency medical services workers transporting patients, ancillary health techs administering EKGs, and Emergency Department and Cardiac Cath Lab staff and providers assessing and treating patients.
The work was supported by a team from the Institute for Healthcare Quality, Safety and Efficiency (IHQSE) that assisted with data analysis and implementation, McStay added. John Messenger, MD, medical director for the Cardiac Cath Lab, also provided strong support, he said.
One key procedural change was to start the response clock earlier, McStay said. For example, standard practice for years had been for paramedics to call ahead to the ED with a cardiac alert when patients met criteria for a STEMI. However, the cardiologist on-call was notified only after the patient arrived and had an EKG performed by ED staff. The cardiologist then made the call on whether or not to activate the Cath Lab.
Today, the “pre-hospital” notification from the field activates the Cath Lab, saving precious time. The practice accepts that on-call staff may be summoned to set up a procedural room for a patient who may not be a true heart attack victim, but that hasn’t been a frequent occurrence, said Tim Nelson, RT(R), manager of the Cath Lab. He said the field alerts have resulted in only five “false positives” in the past six months. Nonetheless, Nelson said he reworked timekeeping policy for on-call staff to help protect them from taking a financial hit for responding to a false alarm.
Front and center
The project also smoothed front-end operations in the ED. Standard procedure had called for a provider to order a patient’s EKG. In a busy environment, that practice made it difficult to perform a 12-lead EKG in the recommended 10 minutes or less recommended by the American Heart Association.
One part of the solution: train emergency medicine techs at the front of the ED – an area called “pivot” – to evaluate patients for symptoms that indicate the need for an EKG, such as chest pain, shortness of breath, dizziness, and altered mental status, and allow them to initiate the EKG for patients who meet the criteria. The criteria and instructions for placing an EKG order are posted at pivot.
To further streamline the process, the hospital placed a dedicated ancillary health tech (AHT) – the position responsible for performing EKGs – at pivot, said AHT Supervisor Joseph Jazinski. With the changes, the hospital met the 10-minute-or-less door-to-EKG goal about 90 percent of the time in the first quarter of 2016, up from 50 percent in the second quarter of 2015. That improvement is a crucial part of minimizing the overall D2B time, Jazinski said.
“If we miss the 10-minute goal, everything else cascades,” Jazinski said. To keep skills sharp, all AHTs, both new and experienced, received a one-hour course on the fundamentals of 12-lead EKGs, including basic anatomy of the heart, he added.
Moving parts for beating hearts
Indeed, the entire response to a STEMI alert relies on disparate parts, separately set in motion to meet a common goal. Nelson said the on-call Cath Lab team can generally get to the hospital within 30 minutes of a page, then set up a procedural room and get a patient on the table in about 10 minutes. It’s critical to avoid wasted time because there is great variation in the amount of damage a blockage causes, Nelson said.
“It might be only a 10 percent blockage, or it could be that multiple vessels are blocked,” he said. The location of the lesion can also have an impact, he said. For example, a STEMI that occurs at a vessel branch can be especially difficult – and time consuming – to treat.
The clinical benefits of improving D2B times aside, the operational changes have helped to strengthen the hospital’s relationship with Falck, its main ambulance provider, and the Aurora Fire Department, McStay said. The Door-to-Balloon Committee worked closely with EMS providers on reviewing cases and making sure to communicate their feedback to physicians and hospital staff. Kevin Waters, EMS bureau chief for Aurora Fire, “has a seat at the committee table,” McStay said.
In addition, the hospital has invited EMS providers in to follow their patients to the Cath Lab to observe the care they receive.
“It’s one way we can ensure that EMS feels valued,” McStay said. “It’s important that EMS wants to bring patients here because the more that we do, and the higher our volume of cases, the better the team gets at providing safe care.” He added that UCH provides feedback to all ambulance systems, including Denver Health.
Jazinski said he’s made a similar effort to keep AHTs involved in the process. Performing a few dozen EKGs a day can become hum-drum, so Jazinski arranged for AHTs to receive information about each Cath Lab case that involved an EKG. The emails lay out details of the case, including the door-to-EKG time and images of the vessel before and after the Cath Lab procedure. An AHT involved in an especially quick door-to-EKG time gets kudos for his or her work.
“It’s a way to celebrate our successes and keep staff motivated,” Jazinski said. “This is a team effort, and we have more buy-in when our staff is interested and excited about the care we provide.”