QI process pin-points delays at point of entry

Health system finds opportunities for improvement

Faster throughput can clear waiting rooms and boost patient satisfaction, but there are also instances where time-to-treatment can make a critical difference in outcomes. For example, for patients suffering from ST-segment-elevation myocardial infarctions (STEMI), the most severe form of heart attacks, every 15-minute delay in providing balloon angioplasty to clear blocked arteries results in a 1% increase in mortality, according to Ehtisham Mahmud, MD, co-director of the Sulpizio Cardiovascular Center at the University of California, San Diego, and chair of the UC San Diego Health System's door-to-balloon time committee. Treatment delays for STEMI patients can also lead to severe complications, including arrhythmia, heart failure, and chronic debilitation, adds Mahmud.

This is why the UC San Diego Health System has made door-to-balloon time for STEMI patients a constant target for improvement. And these efforts have paid off handsomely: In the past year, the health system, which includes three EDs, has brought average door-to-balloon times down to less than 60 minutes, beating national recommendations by more than a third, say hospital administrators. While such an improvement requires institutional leadership and commitment, sources from UC San Diego say there is no reason why other EDs cannot follow a similar roadmap to success.

Analyze the process

For one thing, it's not hard to get clinicians to rally around a goal with such clear benefits, explains David Guss, MD, chair of the Department of Emergency Medicine at UC San Diego. "Improving time from door to balloon [for STEMI patients] has real impact on patients and saves lives, so it is one of those goals that is associated with something meaningful," he says.

To tackle the issue, UC San Diego established a multidisciplinary team consisting of all the key players, including ED leadership, general cardiologists, interventional cardiologists, pharmacists, and catheterization laboratory staff. "You can't just delegate this to junior people to take care of," says Guss. "They can play very important roles in monitoring and tweaking, but you need leadership so that it is very clear that this is an important endeavor for the institution, and then you've got to stick with it."

The way the team addressed the issue was by breaking the entire process, from the time a patient arrives at the ED until the final act of opening an artery occurs, into all of its individual parts to see where delays were occurring and where there were opportunities for improvement, explains Guss. "Then, rather than pointing fingers or executing blame, we decided we would all work together to make the process as effective as it could be," he says.

The health system's electronic medical record (EMR) system facilitates this type of analysis because it time stamps every action, says Guss. "All of the clocks in the ED and all of the apparatus that we use are synchronized so that even if there is something that is not entered into the EMR, you can still look at the time stamp on an EKG and see exactly when it was performed," he says. "You can look at the interpretation of the EKG and know exactly when it was performed, and you can look at the paging system and see exactly when a page went out."

Look at the point of entry

By carrying out this type of analysis, team members quickly became aware of a major opportunity for improvement as soon as the patient walks in the door of the ED. Traditionally, patients entering an ED at UC San Diego would first encounter a registration person who had relatively little medical training, so this person's ability to recognize someone who could potentially be having a heart attack was limited, says Guss. To solve this problem, the health system created a "greeter" position to be the first point of contact for all patients.

The "greeter" is an emergency medical technician who has received added training from the health system's educator on how to recognize potentially life-threatening conditions, such as heart attacks, explains Beverly Kress, RN, BSN, the director of nursing, emergency/critical care, at UC San Diego. "Sometimes there are subtle symptoms, especially in females, that would alert [a clinician] that a patient is having a heart attack," says Kress, noting that upper-abdominal, gastric discomfort can be a tip-off for heart attack.

"The first person a patient will see behind a window is the greeter, and instead of [collecting demographic] and registration information, the greeter will find out why the patient is presenting to the ED, and chest pain is always going to warrant getting the patient straight to the back immediately," she says. The patient can then receive an EKG at the same time he or she is providing registration information.

"We realized that often these patients were not getting EKGs for 10, 15, or 20 minutes after arrival, so we put an EKG machine in the triage area and made it the very first action that gets taken, even while the patient's history and basic vital signs are being obtained," says Guss.

"Then we made sure that the EKG is brought to the attention of someone who can accurately read it immediately, and right there, we were able to shave 10 to 15 minutes off of our average door-to-balloon times."

Standardize procedures

The multidisciplinary team also created a "code STEMI" that ED staff will activate whenever they identify a STEMI patient. This action, which involves notifying the telecom operator, alerts several key people to take action: a rapid response nurse will come to the ED to provide an extra set of hands; a pharmacist will prepare the appropriate medications for a heart catheterization procedure; the cath lab team will prepare for a STEMI procedure; and a member of the security team will secure a trauma elevator that can go straight to the cath lab, so that there are no interruptions and no time lost, explains Kress.

By creating "STEMI packets," ED personnel have been able to further trim steps out of the patient preparation process, notes Susan Watson, RN, BSN, a nurse manager in the ED who is also part of the multidisciplinary STEMI team. "In the cath lab, they use different tubing than we use in the ED [to facilitate the administration of several drugs at once], so instead of them having to change the tubing once the patient is transported upstairs, we go ahead and initiate the cath lab's specific tubing, and we immediately put the patient on a transport monitor," says Watson. "The cath lab also uses disposable leads, which the ED does not use, so we go ahead and use the type of leads that the cath lab uses so that no time is wasted once the patient gets to the cath lab."

Implement a CQI process

The multidisciplinary STEMI team meets monthly to analyze every STEMI case and to evaluate why certain cases went well and why others went less optimally, says Guss. "We set standards for how long each step should take, and then we can go back and dissect why [a particular step] took two or three minutes longer than the standard," he says. "Sometimes, it is just an outlier or a breakdown in the system, and other times, it represents a problem with the system that we need to tweak."

Establishing targets is no problem because there are plenty of established benchmarks for STEMI patients, but you need to stay on top of it, says Guss. "It has got to be a CQI [continuous quality improvement] process," he adds.

One way the health system intends to further improve door-to-balloon times is by working on better field determination of STEMI patients because a significant number of these patients enter the ED via ambulance, explains Guss. "There is enough general education out there in the community so that when people have chest pain, they don't just jump in their cars and drive in, they dial 911 and get picked up," he says. "So we are working with the medics to make sure they get EKGs rapidly, and we are just now instituting a system where we can get access to those EKGs while the patient is still in the field, so that we can activate a STEMI response before the patient even gets to the hospital."

With this kind of CQI process in place, individual changes are not difficult to achieve, explains Guss. The new greeter position and the purchase of an additional EKG machine took some time because they required institutional expenditures, but he notes that most of the improvements were not complicated. "It was just a matter of creating a culture in which this was going to be a top priority for us," he says. "Failure was not going to be acceptable, and once that point was made clear, everything else fell into place.