The cardiac alert system at Memorial Hospital activates several in-house groups, the cath lab team, and a cardiologist to respond to the emergency department.

As the ambulance transported the patient to the hospital, the cardiologist and cath lab teams were also responding. By the time Mr. Jones arrived in the emergency department, the cath lab crew had readied the procedure room and the cardiologist was with the ED physician, ready to receive the patient. Minutes later, Mr. Jones was taken to the cath lab, where his blocked artery was opened with primary angioplasty by the interventional cardiologist. Time from door to open artery: less than 60 minutes. Reality or fantasy?

Memorial Hospital of Colorado Springs is a 477-bed non-teaching, community-owned, not-for-profit institution that serves all of Colorado Springs and southern Colorado. The Medical Director for the Emergency Medical Services is also the Medical Director of the largest and busiest emergency department in the state, seeing over 90,000 patient visits per year. Invasive cardiology serves about 3,000 cath lab patients annually and performs over 7,000 procedures. The two-room cath lab area is a full-service program for adult and pediatric patients, performing diagnostic and interventional procedures.

Memorial Hospital of Colorado Springs has become one leader in a growing number of hospitals committed to finding new methods to decrease door-to-balloon time. Our program, initiated in May of 2004, has treated more than 165 acute myocardial infarction (AMI) patients, with 91% of our patients having average times under the 120 minutes recommended by the Joint Commission on the Accreditation of Healthcare Organizations (JCAHO). Our average door-to-balloon time for all AMI patients in 2005 was 67.1 minutes.

The first cardiac alert system began some 10 years ago at the Derbyshire Royal Infirmary, England, where paramedics were trained to obtain and evaluate the AMI patient™s ECG and initiate the hospital-based cardiology alert team.1 There are multiple versions of the cardiac alert system in hospitals across the nation. Some hospitals utilize thrombolytic agents as their primary focus of treatment, others focus on a select population of the AMI patients (male ST-elevation) and others target ambulance AMI patients only. Other hospitals focus on primary PCI, which requires 24/7 in-house staffing of cardiologist and cath lab teams. What makes Memorial Hospital™s program so unique is a lean process methodology, applied to the entire patient experience from home to open vessel. The cardiac alert system uses primary angioplasty 24/7 as best practice for all AMI patients, whether arriving by ambulance or walk-ins, without requiring in-house cardiology team staffing.

The literature in cardiology abounds with the discussion about best practices in the care of the AMI patient.2-4 The conclusion of these authors are that early and aggressive treatment of the AMI patient with primary PCI creates better outcomes for those patients versus the use of thrombolytics. These guidelines have been adopted by JCAHO, with door-to-balloon recommended times of under 120 minutes, and the American College of Cardiology (ACC), which recommends less than 90 minutes.7

The Problem
The problem that faces hospitals across the country is how to meet JCAHO guidelines and deliver rapid treatment to the AMI patient in less than 120 minutes. Expeditious treatment of AMI patients had become increasingly difficult at Memorial Hospital over the past few years. An increasing community size, the different practice patterns of cardiologists and growing volumes in the emergency room all created less than desirable times, with a high range of 300 minutes.

The System: The old process
Our first attempt was to streamline and be efficient with our current in-hospital process was as follows: patient arrives in ED, ECG performed, cardiologist called, then evaluates patient, cath lab called in, and interventional cardiologist called in. We altered the simple things like the registration process, calling the intervention physician earlier, creating a single page number, setting up a dry cath lab table, etc. However, no matter how hard we all pushed and prodded the system, we still could not get below 120 minutes (Figure 1).

The Ideal Design
Applying lean thinking to the door-to-balloon time processes allowed the team to understand non-value-added steps and value-added steps in the patient process. Lean thinking caused the team to recognize that value related to the care of the patient might not equal value to the door-to-balloon time. Looking through this lens and moving from a sequential process to a simultaneous process allowed the team to propose a redesign of the door-to-balloon time that eliminated duplicate steps and deleted non-value-added steps. Making this change involved a marked shift in thought process for the entire team (Figure 2).

Two major changes needed to occur. First, all cardiology physicians had to decide and agree that primary PCI (intervention) was the treatment of choice for the AMI patient. Secondly, all team members had to agree that simultaneous care of the patient was optimal and would be the new norm. This involved an increased level of trust and integration between previously siloed department staff and physicians.
Several other barriers existed that threaten to derail the program. Getting a timely ECG, developing patient criteria and creating collaborative relationships were challenges. Relationship development between cardiologist and the emergency room physicians, as well as between EMS system and the hospital also posed several problems. However, the major challenge was the culture shift involved in moving all cardiologists to use primary PCI as the treatment protocol for all AMI patients.

The team decided on a four-phased approach to bring the program to fruition. Each of us addressed the major barriers in our respective areas, with the team lead taking on the physician component as well. Two basic premises were created: 1) Doing what was best for the patient; and 2) Allowing the redesign to be created by staff and having it be department-specific. Each barrier was approached with these thoughts in mind. For example, designing roles and responsibilities for the emergency department nurse was accomplished by the involved ED staff members and refined over time.

In phase one, we focused on getting stakeholder buy-in to the new process and then initiated education about the process. This was accomplished with several meetings between a small group of interventional cardiologists and the emergency department physicians. In these meetings, the physician group was responsible for creating treatment protocols, patient criteria, and physician accountabilities. As our champions, these physician then rolled out the new design at every cardiology-associated meeting possible.

In addition, the EMS coordinator created new educational material for the paramedics on ECG criteria, built new protocols for the first responders, created algorithms and set up ECG educational programs. A quality assurance program was created which obtained ECGs in order to monitor their quality and appropriateness. The ED team lead developed educational programs for the staff to explain the purpose and importance of the redesign, worked with the staff on defining roles and job duties, and helped implement the change of the AMI pathway. Since the lean methodology process was occurring simultaneously in the cath lab,8 the staff were already altering their processes and eliminating wasteful steps. Due to all these efforts, this large AMI redesign spawned several further process improvement projects in other departments.

Phase two involved putting in place all the educational programs and developing the quality assurance tools. The EMS system started faxing all ECGs to the emergency department on all patients complaining of chest pain for more than 20 minutes. These ECGs were then used as an educational tool with the paramedics to determine which patient, based on ECG and physical assessment, would have been a candidate for the cardiac alert system. During this phase, several derailers became evident broken fax machines and an inability to fax ECGs from the scene. A major concern was the perceived increased scene time to accomplish and fax an ECG. In phase two, however, the QA process demonstrated that scene time did not increase significantly.

Phase three was implementation of the pilot program with very narrow patient criteria. Only ambulance patients with marked elevated ST-segment AMIs would be considered. Our first patient had a door-to-balloon time of 55 minutes and we knew we were on the right track. The pilot program progressed, with the first 5 patients all having times well under 90 minutes. However, like many community hospitals, the team discovered that over 45% of our AMI patients did not come to the hospital by ambulance and that led to expanded criteria that included all AMI patients, regardless of mode of transportation.

At present, we are in the process of implementing phase four. In this phase, quality indicators for mortality, morbidity, cost, length of stay and satisfaction metrics will be investigated and benchmarked nationally. It is anticipated that we will continue to refine our processes to gain even more efficiency. In addition, phase four allows for expansion of the program via helicopter outreach areas. We have already begun offering aspects of this program to our neighboring military hospitals close to Colorado Springs.

Results
After one full year of the cardiac alert program, our data shows our door-to-balloon time was reduced from 135 minutes to 67.1 minutes and continues to drop, making the program a dramatic success story. In addition, Memorial Hospital has continued to sustain the initial gains (Figure 3).

Other major metrics were analyzed and all showed dramatic improvement. The AMI redesign begins with the ECG. Door-to-ECG time was improved when the entire team became aware of the imperative values of the ECG to initiation the cardiac alert process.

Door-to-cath lab time encompasses a range of activities: patient registration, physician responsiveness, cath lab availability (either room, staff or both), patient preparation, cath lab preparation, transport to procedure room, etc. Addressing these metrics required an appreciation of the issues that surrounded the movement of the patient through the hospital system.

Memorial Hospital has two designated cath labs that are full most of the time. A new process for bumping the schedule and making room for the cardiac alert patient was created. The cath lab schedule was also redesigned in a stair-step pattern that allowed a room to be available about every 15“20 minutes. We will continue to drill down in these areas and address issues as they arrive.

Cath lab-to-diagnostic time was dependent on the patient condition, physician availability and arterial access. In the redesign, diagnostic-to-PCI time was dramatically decreased by having the interventional cardiologist called at the same time as the cath lab crew. Where previously a non-interventional cardiologist would accomplish the diagnostic portion of the catheterization, now the interventional physician does both the diagnostic and intervention. Table 2 demonstrates the progress towards our internal cardiac alert metrics and targets.

A focus on continuous process improvement is paramount in all new redesigns and programs. All AMI charts are currently evaluated and analyzed for time lapses, either positive or negative. The team felt it was important to learn from all cases, both the good and the bad. Our system uses the ECG technician as the main starting point. Each ECG demonstrating an AMI is attached to a tracking data collection tool sheet.

Using this system allows a two-fold process to occur. The physician team member can be assured that all AMI patients are actually called cardiac alerts and that all cardiac alert patients actually have ECG markers. It is important not to over-call the cardiac alert and likewise, to not miss calling appropriate patient alerts. In addition, this system also quickly allows for identification of speed bumps within the system.

As we met each of our objectives on specific metrics or overall times, the alert team leader sent out memos making the rest of the team aware of our success. The immediate reinforcement of successful times created tremendous energy for the project. Also, calls were made to the fire departments and paramedics to keep them in the loop. Likewise, issues were analyzed and addressed immediately to keep the program on track.

Initially, the team met monthly to analyze the data and make recommendations for change to the process and metrics. Brainstorming about challenges in each of the areas led to creative solutions from the team. The team has just begun tracking the length of stay, costs, mortality and morbidity of these patients to determine further metrics of this program.

Expansion has begun into the outlying areas of Colorado Springs via our helicopter program. We created stickers for ECG machines with phone contact numbers to call if a patient has the AMI markers. These stickers have been placed in physician offices and urgent care centers across the city. In addition to collaboration with the initial five fire departments, the program has expanded to meet the needs of our surrounding military bases and included other outlying fire departments.

Discussion
The cardiac alert process required the coordination and commitment of all cardiology staff, physicians, paramedics and many other hospital departments. Without their efforts, the program would not have been successful. Further refinement of the process will continue with additional research into the areas of morbidity, mortality, length of stay and costs.

As the use of cell phones increases, the team has discovered a decrease in landlines in our area homes. This has created a difficulty for faxing the ECG. Technology is emerging to fax ECGs via cell phones or create Internet capabilities whereby ECGs can be deposited into hospital storage systems directly from the ambulances. These technologies are on the brink of being able to enhance the efficiencies of the system.

Another major concern is the AMI patient population that does not utilize the EMS system and arrives at the emergency department directly. Finding a way to quickly triage, assess and determine their immediate needs will be another area for process improvement. The emergency department has already begun to place an emergency physician and an ECG in the triage area to catch the critical patient quickly.

Any discussion on lean process and redesign would not be complete without addressing the response of the patients, staff and physicians. Initially, many physicians and staff were concerned that they would be called in inappropriately. We have had only 3 inappropriate calls out of 165 patients. As time has passed, the staff and physicians are very happy with the system and committed to continue the process. Another areas of concern was that the patient would be pushed through the system without appropriate assessment and time to address emotional as well as the physical issues. We have discovered that the majority of our patients are impressed and pleased with the cardiac alert system. Our call-back system revealed that the majority of the patients expressed appreciation for the rapid response to their heart attack and would overwhelmingly recommend Memorial Hospital to others.

Conclusion
This program has shown that the interval between door and balloon time can be reduced dramatically by engaging the pre-hospital system. As cardiovascular disease claims hundreds of thousands of lives per year, it is incumbent on all hospital systems to develop a method to care effectively and efficiently for these patients.

Fast-tracking and streamlining the care of the cardiac patient is important to the patient™s heart health after their AMI. The AMI patient™s outcome is determined by the quality of care they receive in the first 60 minutes. With the cardiac alert system, Memorial Hospital is certain that we can influence this outcome.