Lehigh Valley Hospital ranked first in 2008 and second in 2010 in lowest mortality for heart attack care in the U.S., according to U.S. Centers for Medicare and Medicaid Services “Hospital Compare” data (www.hospitalcompare.hhs.gov). The hospital, with an already successful STEMI program, decided to try and lower its door-to-balloon times still further. Lehigh Valley Health Network is composed of three hospital facilities — two in Allentown and one in Bethlehem, Pennsylvania. Seeking to improve an already well-established ST-elevation myocardial infarction (STEMI) system of care, Lehigh Valley Health Network initiated a real-time feedback process. Our goal was to improve clinical outcomes by reducing door-to-balloon times. We also believed real-time feedback would strengthen our relationship with emergency medical services, and improve the way we support our local STEMI staff and that of our transferring hospitals.
Using proven methods for D2B time reductionOur Acute Coronary Syndrome (ACS) Committee reviewed a study by Bradley et al outlining six strategies for improving door-to-balloon (D2B) time in the STEMI patient.1 We were already using four of the six strategies: 1) Emergency physician activation of the cardiac catheterization laboratory; 2) Single call to a central page operator to activate the cardiac catheterization laboratory; 3) Emergency department (ED) activation of the cardiac catheterization laboratory while the patient is en route; and 4) Staff arrival in the cardiac catheterization laboratory within 20 minutes after being paged. The fifth strategy, real-time feedback, seemed simple. However, it required the creation of a standardized method of data collection and communication, with a “report card” that contained important information about each patient’s care. We believed timely feedback about time to treatment would enhance our relationship with emergency medical services (EMS), improve communication with our local STEMI staff and transferring hospitals, as well as improve patient outcomes.
The process of adding real-time data feedbackWe sought to add a process for real-time (within 24 hours) data feedback. Feedback needed to be given to our EMS partners, ED nurses and physicians at our local and transferring hospitals, as well as the catheterization lab nurses and technologists. Their performance during a local or regional STEMI emergency was documented, emphasizing time to diagnosis, treatment and patient outcome. The first step was creating an IRB-approved, semi-automated database, enabling a high degree of automation for the real-time data feedback. All STEMI data was maintained in a format allowing for the security of the patient’s confidential information, while at the same time providing ease of access to the people involved with the analysis of the data. The database was created using Microsoft Access (Figure 1). We tracked various metrics, including events that occurred before, during and after a STEMI. We evaluated every STEMI case, analyzing metrics agreed upon by our ACS Committee and established by the American Heart Association/American College of Cardiology guidelines.2 The elements of the report include: patient outcome, time elements, D2B time, validation of the pre-hospital ECG interpretation, medical treatment, and images of the coronary vessels before and after percutaneous coronary intervention (PCI). This report was emailed to all members involved with the STEMI case within 24 hours of patient arrival. The second step was to identify the person responsible for monitoring the flow of STEMI patients. Our ACS program coordinator was given the responsibility for generating a report on every STEMI patient within 24 hours of treatment. All cases that presented to our hospital as part of our STEMI system of care received one of three versions of the STEMI report.
• The local case report is for STEMI patients who present to our EDs (Figure 2). • The transferring hospital report targets the hospital sending the STEMI patient by air or ground transport to our facility for PCI (Figure 3). • The EMS report contains metrics that allows EMS to look at their performance during the case and view pictures of the coronary vessels. This further enhances their education and re-enforces correct interpretation of ECGs (Figure 4).The third step was to distribute the case report to all departments involved with the care of the patient. We decided to send the local case reports via email to the directors in the ED, cardiac cath cab, transfer center and cardiac intensive care unit. The directors prepared a bulletin board within their respective departments where they display the case reports for their staff to view. Case reports generated for EMS were distributed via email through our network’s EMS liaisons; the reports were then posted on bulletin boards in their respective EMS stations. Much of the feedback sent to EMS was used as an educational opportunity, with follow-up case review events occurring regularly with squads throughout our region. Reports were generated for our transferring hospitals to see their own performance and help them identify areas for improvement. All reports are sent within 24 hours of the patients’ presentation to a hospital. All case reports are de-identified before distribution.
Nine-month resultsWe examined 9 months of data pre- and post-implementation of the feedback process. Pre-implementation, our median D2B time was 52 minutes. Post-implementation, our median D2B time was reduced by 13%, to 45 minutes. In addition to our reduced D2B time, we experienced an increase of 7% in the number of pre-hospital STEMI alert activations. Other benefits of our feedback process included improved and more frequent communication among all team members, resulting in strengthening of relationships. The EMS and transferring hospital reports enhanced cooperation between these members of the STEMI care team. Real-time feedback became such an appreciated response that ‘thank you’ phone calls were commonly received.
ConclusionReal time feedback provided within 24 hours of patient arrival with STEMI was successful in reducing D2B time. It also enhanced our relationship with EMS and referring hospitals. The most important outcome from this process was improved communication with all members of the team, including administrators, physicians, nurses, technologists, EMS, Information Services, and members of our ACS Committee. A successful feedback process requires a dedicated person responsible for data collection. Providing an accurate, consistent, and timely report will maximize the opportunity for reducing time to treatment and improving patient outcome. The feedback process ultimately benefits the patient, as everyone strives for excellence in every case. Our process flow chart (Figure 5) can be replicated.
1. Bradley EH, Herrin J, Wang Y, et al. Strategies for reducing the door-to-balloon time in acute myocardial infarction. N Engl J Med 2006;355:2308-2320. 2. Kushner F, et al. 2009 focused updates: ACC/AHA guidelines for the management of patients with ST-elevation myocardial infarction (updating the 2004 guideline and 2007 focused update) and ACC/AHA/SCAI guidelines on percutaneous coronary intervention (updating the 2005 guideline and 2007 focused update): A report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines. Circulation 2009;DOI:10.1161/CIRCULATIONAHA.109.192663.The authors can be contacted at firstname.lastname@example.org