ED slashes treatment time for heart attack drugs

Shorter times for other treatments satisfy patients

For years, Overlook Hospital in Summit, NJ, has been on the cutting edge in cardiac treatment. The hospital was one of the first in the nation to have a cardiac care unit and was also one of the first to do pre-hospital EKGs. So it wasn’t much of a surprise when the emergency department (ED) decided to pursue another new idea: a chest pain observation unit.

It was something of a surprise, however, when the multidisciplinary team charged with setting up the unit found that one key indicator of treatment for heart attack patients was way above the national standard. In fact, the median time to thrombolytic treatment for heart attack patients in Overlook’s ED was 61 minutes, twice the standard set by the Bethesda, MD-based National Institute of Health’s National Heart Attack Alert Program of 30 minutes or less. For every hour earlier that medical professionals can give thrombolytics, or clot-busters, to open the arteries, 32 lives per 1,000 patients are saved. So the team decided to take action.

The primary result, says Linda Kosnik, RN, MSN, unit manager of the ED, was a collaborative effort that slashed the time to thrombolytic treatment to a range of 16 to 24 minutes. The secondary result was a domino effect of improving other processes including time to treatment of pain and time to administration of antibiotics for pneumonia plus a huge leap in patient satisfaction. In fact, when Overlook began its improvement efforts four years ago, ED patient satisfaction scores ranked the hospital in the South Bend, IN-based Press, Ganey Associate’s 20th percentile. Now the hospital rests atop the 99th percentile. Overlook has been designated a best practice hospital by the Baltimore-based Health Care Financing Administration, and Kosnik and colleague James Espinosa, MD, chairman of Overlook’s ED, have been named co-chairs of the 1998 Institute for Healthcare Improvement’s collaborative on reducing delays and improving patient satisfaction in the ED.

How did they do it? First, Kosnik says, was getting buy-in from physicians and nurses. Instead of saying to the staff that they needed to cut waiting times, they focused on improving heart attack patient care. "Health care professionals are all very comfortable with the idea of improving patient outcomes. If you start talking about processes like reducing delays, they think of that as administrative," Kosnik says.

"It’s not as quick of a buy-in. We encourage people to select a clinical process and an operational process because you’ll get automatic buy-in." Improving a clinical process almost always leads to cutting waiting times, she says.

Finding the sources of delays

The team broke the process down into manageable pieces and identified the potential causes for delay. A cardiac consult was required on every patient before thrombolytic delivery, and sometimes there was difficulty contacting the patient’s private physician. There were delays in ordering and delivering EKGs. There was variation in patient assessment and in decision making. Overcrowding in the ED, an insufficient nurse/patient ratio, and the lack of a team approach also contributed to the problem.

Interventions that cut treatment time include:

- Creating a time-to-treatment assessment tool that starts with the paramedic in the field.

- Increase physician use of pre-hospital EKG. Paramedics had stopped doing the tests in the field because physicians were ordering duplicate tests upon the patient’s arrival.

- Develop a five-minute protocol for walk-ins: An EKG is done within five minutes on any patient with pain from the nose to the navel.

- Standardize protocols, including taking the EKG to the physician immediately no matter what he or she is doing at the time.

- Empower ED physicians to initiate treatment by protocol without a cardiac consult.

- Change staff mix to provide more technician support.

Once the dramatic improvement in thrombolytic treatment occurred, the ED staff pushed on for more improvements. A similar process led the ED to cut time to antibiotic treatment for pneumonia patients from a standard four hours down to 130 minutes. More efforts are under way to get the time under two hours, Kosnik says. Interventions in this area included developing a pneumonia pathway, empowering the triage staff to order X-rays, and having X-rays done within 20 minutes, as well as stocking pre-selected antibiotics in the ED.

In pain management, the team discovered the average time to pain medications was 78 minutes. After six months using some fairly simple interventions, the team has cut that to 54 minutes. "Most people come to the ER for pain," she says. "We deal with the medical problem as opposed to the pain, even though pain impacts all outcomes: medical, patient satisfaction, cost, and quality of life." People with a wrist injury, for example, are more satisfied and less impatient if they’ve been given a pain medication. And they’re a lot happier if you splint the wrist before you do the X-ray, she says. So staff were taught how to splint and to administer a pain scale that acknowledges the patient is in pain and determine what action to take: Tylenol or Advil, splinting, ice, elevation, etc.

If you decide to analyze your ED, start by going to the staff, she says. "They know what’s wrong. Brainstorm, and let them decide what they would like to focus on first. Once you do one process, it will spill over to other things." Kosnik also encourages benchmarking with other hospitals. But she cautions that you need to make sure you’re talking about the exact same thing when you discuss waiting times. One hospital might focus on the time it takes to see the physician, for example, while another might look at the total time spent in the ED.

For possible benchmarking partners, keep an eye out for the Institute for Health Improvement (IHI) emergency department collaborative. Last March, thirty hospitals began looking at such areas as clinical cycle time reduction (such as time to thrombolytic treatment), administrative cycle time reduction (such as reducing total length of stay), improving patient satisfaction, and cost outcomes.

For more information on Overlook Hospital or the IHI collaborative, contact Linda Kosnik at 99 Beauvoir Ave., Summit, NJ 07902. Telephone: (908) 522-2148. Or connect to the IHI Web site at www.ihi.org.