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Abstract
Co-authors: Terri Baudoin, BSN, RN, RCIS – Director, Cardiovascular Services, Conway Medical Center; Dody Martin, BSN, RN – Director/Chest Pain Center Coordinator, Telemetry, Clinical Observation, Conway Medical Center
Terri Baudoin, BSN, RN, RCIS – Director, Cardiovascular Services, Conway Medical Center; Dody Martin, BSN, RN – Director/Chest Pain Center Coordinator, Telemetry, Clinical Observation, Conway Medical Center Problem Statement or Scientific Question: Despite the assumption that sound processes were in place, Door to Electrocardiogram (D2ECG) times for ST Elevation Myocardial Infarction (STEMI) patients entering through triage were well below the expected National Cardiovascular Data Registry (NCDR®) 50th percentile.
Background/Project Intent: Conway Medical Center (CMC) evaluates approximately 47,000 patients annually in the Emergency Department (ED) with a large portion presenting with Acute Coronary Syndrome. Recognizing this demand, CMC established a Percutaneous Coronary Intervention (PCI) with STEMI program in August 2020. Our data trends published in the NCDR Chest Pain – MI RegistryTM demonstrated steady improvement in Door to Balloon (D2B) time until fourth quarter 2022, at which time the median D2B time increased to 105 minutes, well above the national benchmark of 90 minutes. Analysis identified an opportunity to improve our performance. Specifically, outliers in second quarter 2023 increased the average D2ECG time for STEMI patients presenting through triage over the preceding six months to 92 minutes, well above the expected NCDR metric of <= 10 minutes.
Methodology: A multidisciplinary team was created to improve the time for obtaining D2ECG. Providers, nursing leaders, and staff champions collaborated biweekly to implement the following: Nurse first designation: 1. Designated a registered nurse (RN) as the first point of contact for patients entering the ED. Having an RN as this contact allowed more efficient and accurate assessment, bypassing registration as the initial priority. 2. Educated all clinical staff to recognize signs and symptoms indicative of an MI. Prioritized any patient with complaint of chest pain to receive an ECG immediately: 1. Once the nurse first recognizes the patient with a possible MI, the tech is immediately instructed to obtain an ECG. 2. Staff trained to prioritize ECGs over other tasks. 3. The ECG equipment was relocated to a designated room close to ED triage to minimize delayed activation. 4. ECGs are immediately given to the ED physician to review and determine if a STEMI alert needs to be activated. Implemented a Provider In Triage (PIT): 1. With physician collaboration, we assigned a trained Advanced Practice Provider (APP) to ED triage, along with the triage nurse, to evaluate patients at risk for a cardiac event and in need of an immediate ECG. 2. This change allowed quicker prioritization and sorting of potential ACS patients.
Results: In June 2023 we began to observe that the new triage process began to impact our NCDR metrics with improved results and evidence of average D2ECG times of 2 minutes in 16 patients. We also saw 100% of triaged patients with a D2B <= 90 minutes. Over the next three quarters CMC realized a 99% improvement in D2ECG and no missed D2B opportunities. These efficiencies also contributed to lowering left without being seen (LWBS) rates to less than one percent and improved throughput of arrival to departure from 161 minutes to 142 minutes.
Value Proposition: Efforts to reduce D2ECG involve improving coordination and communication between healthcare teams leading to a more patient-centered care approach. Lower D2ECG contributes to smoother patient flow and increases patient satisfaction. By introducing the role of a PIT, patient flow improves even further and contributes to lower LWBS rates, ensuring fewer patients leave without the proper diagnoses while reducing wait times and freeing up resources. Quicker recognition through Nurse First designation has shortened D2ECG times ensuring a STEMI is diagnosed promptly, leading to faster initiation of treatment or D2B, which is crucial for reducing the amount of heart muscle damage and improving outcomes. D2B times <= 90 minutes have been consistently shown to be associated with reduced mortality.² Optimizing D2ECG and D2B times efficiencies in STEMI patients improves outcomes, enhances patient satisfaction, and aligns with quality metrics and accreditation standards.
Conclusions: In conclusion, lower D2ECG times in STEMI patients led to faster diagnosis and D2B times. This enhanced coordination and communication, optimized resource utilization, improved patient throughput and patient outcomes. Our innovative collaborative efforts focused on education, communication, and ED process changes resulting in the program receiving not only American College of Cardiology (ACC) Chest Pain reaccreditation, but also its first PCI accreditation in October 2023.
References: 1. Lee CK, Meng SW, Lee MH, et al. The impact of door-to-electrocardiogram time on door-to-balloon time after achieving the guideline-recommended target rate. PLoS One. 2019;14(9):e0222019. Published 2019 Sep 9. doi:10.1371/journal.pone.0222019 2. McNamara, R, Wang, Y, Herrin, J. et al. Effect of Door-to-Balloon Time on Mortality in Patients With ST-Segment Elevation Myocardial Infarction. J Am Coll Cardiol. 2006 Jun, 47 (11) 2180–2186. https://doi.org/10.1016/j.jacc.2005.12.072
Terri Baudoin, BSN, RN, RCIS – Director, Cardiovascular Services, Conway Medical Center; Dody Martin, BSN, RN – Director/Chest Pain Center Coordinator, Telemetry, Clinical Observation, Conway Medical Center Problem Statement or Scientific Question: Despite the assumption that sound processes were in place, Door to Electrocardiogram (D2ECG) times for ST Elevation Myocardial Infarction (STEMI) patients entering through triage were well below the expected National Cardiovascular Data Registry (NCDR®) 50th percentile.
Background/Project Intent: Conway Medical Center (CMC) evaluates approximately 47,000 patients annually in the Emergency Department (ED) with a large portion presenting with Acute Coronary Syndrome. Recognizing this demand, CMC established a Percutaneous Coronary Intervention (PCI) with STEMI program in August 2020. Our data trends published in the NCDR Chest Pain – MI RegistryTM demonstrated steady improvement in Door to Balloon (D2B) time until fourth quarter 2022, at which time the median D2B time increased to 105 minutes, well above the national benchmark of 90 minutes. Analysis identified an opportunity to improve our performance. Specifically, outliers in second quarter 2023 increased the average D2ECG time for STEMI patients presenting through triage over the preceding six months to 92 minutes, well above the expected NCDR metric of <= 10 minutes.
Methodology: A multidisciplinary team was created to improve the time for obtaining D2ECG. Providers, nursing leaders, and staff champions collaborated biweekly to implement the following: Nurse first designation: 1. Designated a registered nurse (RN) as the first point of contact for patients entering the ED. Having an RN as this contact allowed more efficient and accurate assessment, bypassing registration as the initial priority. 2. Educated all clinical staff to recognize signs and symptoms indicative of an MI. Prioritized any patient with complaint of chest pain to receive an ECG immediately: 1. Once the nurse first recognizes the patient with a possible MI, the tech is immediately instructed to obtain an ECG. 2. Staff trained to prioritize ECGs over other tasks. 3. The ECG equipment was relocated to a designated room close to ED triage to minimize delayed activation. 4. ECGs are immediately given to the ED physician to review and determine if a STEMI alert needs to be activated. Implemented a Provider In Triage (PIT): 1. With physician collaboration, we assigned a trained Advanced Practice Provider (APP) to ED triage, along with the triage nurse, to evaluate patients at risk for a cardiac event and in need of an immediate ECG. 2. This change allowed quicker prioritization and sorting of potential ACS patients.
Results: In June 2023 we began to observe that the new triage process began to impact our NCDR metrics with improved results and evidence of average D2ECG times of 2 minutes in 16 patients. We also saw 100% of triaged patients with a D2B <= 90 minutes. Over the next three quarters CMC realized a 99% improvement in D2ECG and no missed D2B opportunities. These efficiencies also contributed to lowering left without being seen (LWBS) rates to less than one percent and improved throughput of arrival to departure from 161 minutes to 142 minutes.
Value Proposition: Efforts to reduce D2ECG involve improving coordination and communication between healthcare teams leading to a more patient-centered care approach. Lower D2ECG contributes to smoother patient flow and increases patient satisfaction. By introducing the role of a PIT, patient flow improves even further and contributes to lower LWBS rates, ensuring fewer patients leave without the proper diagnoses while reducing wait times and freeing up resources. Quicker recognition through Nurse First designation has shortened D2ECG times ensuring a STEMI is diagnosed promptly, leading to faster initiation of treatment or D2B, which is crucial for reducing the amount of heart muscle damage and improving outcomes. D2B times <= 90 minutes have been consistently shown to be associated with reduced mortality.² Optimizing D2ECG and D2B times efficiencies in STEMI patients improves outcomes, enhances patient satisfaction, and aligns with quality metrics and accreditation standards.
Conclusions: In conclusion, lower D2ECG times in STEMI patients led to faster diagnosis and D2B times. This enhanced coordination and communication, optimized resource utilization, improved patient throughput and patient outcomes. Our innovative collaborative efforts focused on education, communication, and ED process changes resulting in the program receiving not only American College of Cardiology (ACC) Chest Pain reaccreditation, but also its first PCI accreditation in October 2023.
References: 1. Lee CK, Meng SW, Lee MH, et al. The impact of door-to-electrocardiogram time on door-to-balloon time after achieving the guideline-recommended target rate. PLoS One. 2019;14(9):e0222019. Published 2019 Sep 9. doi:10.1371/journal.pone.0222019 2. McNamara, R, Wang, Y, Herrin, J. et al. Effect of Door-to-Balloon Time on Mortality in Patients With ST-Segment Elevation Myocardial Infarction. J Am Coll Cardiol. 2006 Jun, 47 (11) 2180–2186. https://doi.org/10.1016/j.jacc.2005.12.072
Co-authors: Terri Baudoin, BSN, RN, RCIS – Director, Cardiovascular Services, Conway Medical Center; Dody Martin, BSN, RN – Director/Chest Pain Center Coordinator, Telemetry, Clinical Observation, Conway Medical Center
Terri Baudoin, BSN, RN, RCIS – Director, Cardiovascular Services, Conway Medical Center; Dody Martin, BSN, RN – Director/Chest Pain Center Coordinator, Telemetry, Clinical Observation, Conway Medical Center Problem Statement or Scientific Question: Despite the assumption that sound processes were in place, Door to Electrocardiogram (D2ECG) times for ST Elevation Myocardial Infarction (STEMI) patients entering through triage were well below the expected National Cardiovascular Data Registry (NCDR®) 50th percentile.
Background/Project Intent: Conway Medical Center (CMC) evaluates approximately 47,000 patients annually in the Emergency Department (ED) with a large portion presenting with Acute Coronary Syndrome. Recognizing this demand, CMC established a Percutaneous Coronary Intervention (PCI) with STEMI program in August 2020. Our data trends published in the NCDR Chest Pain – MI RegistryTM demonstrated steady improvement in Door to Balloon (D2B) time until fourth quarter 2022, at which time the median D2B time increased to 105 minutes, well above the national benchmark of 90 minutes. Analysis identified an opportunity to improve our performance. Specifically, outliers in second quarter 2023 increased the average D2ECG time for STEMI patients presenting through triage over the preceding six months to 92 minutes, well above the expected NCDR metric of <= 10 minutes.
Methodology: A multidisciplinary team was created to improve the time for obtaining D2ECG. Providers, nursing leaders, and staff champions collaborated biweekly to implement the following: Nurse first designation: 1. Designated a registered nurse (RN) as the first point of contact for patients entering the ED. Having an RN as this contact allowed more efficient and accurate assessment, bypassing registration as the initial priority. 2. Educated all clinical staff to recognize signs and symptoms indicative of an MI. Prioritized any patient with complaint of chest pain to receive an ECG immediately: 1. Once the nurse first recognizes the patient with a possible MI, the tech is immediately instructed to obtain an ECG. 2. Staff trained to prioritize ECGs over other tasks. 3. The ECG equipment was relocated to a designated room close to ED triage to minimize delayed activation. 4. ECGs are immediately given to the ED physician to review and determine if a STEMI alert needs to be activated. Implemented a Provider In Triage (PIT): 1. With physician collaboration, we assigned a trained Advanced Practice Provider (APP) to ED triage, along with the triage nurse, to evaluate patients at risk for a cardiac event and in need of an immediate ECG. 2. This change allowed quicker prioritization and sorting of potential ACS patients.
Results: In June 2023 we began to observe that the new triage process began to impact our NCDR metrics with improved results and evidence of average D2ECG times of 2 minutes in 16 patients. We also saw 100% of triaged patients with a D2B <= 90 minutes. Over the next three quarters CMC realized a 99% improvement in D2ECG and no missed D2B opportunities. These efficiencies also contributed to lowering left without being seen (LWBS) rates to less than one percent and improved throughput of arrival to departure from 161 minutes to 142 minutes.
Value Proposition: Efforts to reduce D2ECG involve improving coordination and communication between healthcare teams leading to a more patient-centered care approach. Lower D2ECG contributes to smoother patient flow and increases patient satisfaction. By introducing the role of a PIT, patient flow improves even further and contributes to lower LWBS rates, ensuring fewer patients leave without the proper diagnoses while reducing wait times and freeing up resources. Quicker recognition through Nurse First designation has shortened D2ECG times ensuring a STEMI is diagnosed promptly, leading to faster initiation of treatment or D2B, which is crucial for reducing the amount of heart muscle damage and improving outcomes. D2B times <= 90 minutes have been consistently shown to be associated with reduced mortality.² Optimizing D2ECG and D2B times efficiencies in STEMI patients improves outcomes, enhances patient satisfaction, and aligns with quality metrics and accreditation standards.
Conclusions: In conclusion, lower D2ECG times in STEMI patients led to faster diagnosis and D2B times. This enhanced coordination and communication, optimized resource utilization, improved patient throughput and patient outcomes. Our innovative collaborative efforts focused on education, communication, and ED process changes resulting in the program receiving not only American College of Cardiology (ACC) Chest Pain reaccreditation, but also its first PCI accreditation in October 2023.
References: 1. Lee CK, Meng SW, Lee MH, et al. The impact of door-to-electrocardiogram time on door-to-balloon time after achieving the guideline-recommended target rate. PLoS One. 2019;14(9):e0222019. Published 2019 Sep 9. doi:10.1371/journal.pone.0222019 2. McNamara, R, Wang, Y, Herrin, J. et al. Effect of Door-to-Balloon Time on Mortality in Patients With ST-Segment Elevation Myocardial Infarction. J Am Coll Cardiol. 2006 Jun, 47 (11) 2180–2186. https://doi.org/10.1016/j.jacc.2005.12.072
Terri Baudoin, BSN, RN, RCIS – Director, Cardiovascular Services, Conway Medical Center; Dody Martin, BSN, RN – Director/Chest Pain Center Coordinator, Telemetry, Clinical Observation, Conway Medical Center Problem Statement or Scientific Question: Despite the assumption that sound processes were in place, Door to Electrocardiogram (D2ECG) times for ST Elevation Myocardial Infarction (STEMI) patients entering through triage were well below the expected National Cardiovascular Data Registry (NCDR®) 50th percentile.
Background/Project Intent: Conway Medical Center (CMC) evaluates approximately 47,000 patients annually in the Emergency Department (ED) with a large portion presenting with Acute Coronary Syndrome. Recognizing this demand, CMC established a Percutaneous Coronary Intervention (PCI) with STEMI program in August 2020. Our data trends published in the NCDR Chest Pain – MI RegistryTM demonstrated steady improvement in Door to Balloon (D2B) time until fourth quarter 2022, at which time the median D2B time increased to 105 minutes, well above the national benchmark of 90 minutes. Analysis identified an opportunity to improve our performance. Specifically, outliers in second quarter 2023 increased the average D2ECG time for STEMI patients presenting through triage over the preceding six months to 92 minutes, well above the expected NCDR metric of <= 10 minutes.
Methodology: A multidisciplinary team was created to improve the time for obtaining D2ECG. Providers, nursing leaders, and staff champions collaborated biweekly to implement the following: Nurse first designation: 1. Designated a registered nurse (RN) as the first point of contact for patients entering the ED. Having an RN as this contact allowed more efficient and accurate assessment, bypassing registration as the initial priority. 2. Educated all clinical staff to recognize signs and symptoms indicative of an MI. Prioritized any patient with complaint of chest pain to receive an ECG immediately: 1. Once the nurse first recognizes the patient with a possible MI, the tech is immediately instructed to obtain an ECG. 2. Staff trained to prioritize ECGs over other tasks. 3. The ECG equipment was relocated to a designated room close to ED triage to minimize delayed activation. 4. ECGs are immediately given to the ED physician to review and determine if a STEMI alert needs to be activated. Implemented a Provider In Triage (PIT): 1. With physician collaboration, we assigned a trained Advanced Practice Provider (APP) to ED triage, along with the triage nurse, to evaluate patients at risk for a cardiac event and in need of an immediate ECG. 2. This change allowed quicker prioritization and sorting of potential ACS patients.
Results: In June 2023 we began to observe that the new triage process began to impact our NCDR metrics with improved results and evidence of average D2ECG times of 2 minutes in 16 patients. We also saw 100% of triaged patients with a D2B <= 90 minutes. Over the next three quarters CMC realized a 99% improvement in D2ECG and no missed D2B opportunities. These efficiencies also contributed to lowering left without being seen (LWBS) rates to less than one percent and improved throughput of arrival to departure from 161 minutes to 142 minutes.
Value Proposition: Efforts to reduce D2ECG involve improving coordination and communication between healthcare teams leading to a more patient-centered care approach. Lower D2ECG contributes to smoother patient flow and increases patient satisfaction. By introducing the role of a PIT, patient flow improves even further and contributes to lower LWBS rates, ensuring fewer patients leave without the proper diagnoses while reducing wait times and freeing up resources. Quicker recognition through Nurse First designation has shortened D2ECG times ensuring a STEMI is diagnosed promptly, leading to faster initiation of treatment or D2B, which is crucial for reducing the amount of heart muscle damage and improving outcomes. D2B times <= 90 minutes have been consistently shown to be associated with reduced mortality.² Optimizing D2ECG and D2B times efficiencies in STEMI patients improves outcomes, enhances patient satisfaction, and aligns with quality metrics and accreditation standards.
Conclusions: In conclusion, lower D2ECG times in STEMI patients led to faster diagnosis and D2B times. This enhanced coordination and communication, optimized resource utilization, improved patient throughput and patient outcomes. Our innovative collaborative efforts focused on education, communication, and ED process changes resulting in the program receiving not only American College of Cardiology (ACC) Chest Pain reaccreditation, but also its first PCI accreditation in October 2023.
References: 1. Lee CK, Meng SW, Lee MH, et al. The impact of door-to-electrocardiogram time on door-to-balloon time after achieving the guideline-recommended target rate. PLoS One. 2019;14(9):e0222019. Published 2019 Sep 9. doi:10.1371/journal.pone.0222019 2. McNamara, R, Wang, Y, Herrin, J. et al. Effect of Door-to-Balloon Time on Mortality in Patients With ST-Segment Elevation Myocardial Infarction. J Am Coll Cardiol. 2006 Jun, 47 (11) 2180–2186. https://doi.org/10.1016/j.jacc.2005.12.072
When Time Counts, Preparation Matters: Improving Electrocardiogram (ECG) Times
Mrs. Lynn Taggart
Affiliations:
null
null
Abstract
Co-authors: Terri Baudoin, BSN, RN, RCIS – Director, Cardiovascular Services, Conway Medical Center; Dody Martin, BSN, RN – Director/Chest Pain Center Coordinator, Telemetry, Clinical Observation, Conway Medical Center
Terri Baudoin, BSN, RN, RCIS – Director, Cardiovascular Services, Conway Medical Center; Dody Martin, BSN, RN – Director/Chest Pain Center Coordinator, Telemetry, Clinical Observation, Conway Medical Center Problem Statement or Scientific Question: Despite the assumption that sound processes were in place, Door to Electrocardiogram (D2ECG) times for ST Elevation Myocardial Infarction (STEMI) patients entering through triage were well below the expected National Cardiovascular Data Registry (NCDR®) 50th percentile.
Background/Project Intent: Conway Medical Center (CMC) evaluates approximately 47,000 patients annually in the Emergency Department (ED) with a large portion presenting with Acute Coronary Syndrome. Recognizing this demand, CMC established a Percutaneous Coronary Intervention (PCI) with STEMI program in August 2020. Our data trends published in the NCDR Chest Pain – MI RegistryTM demonstrated steady improvement in Door to Balloon (D2B) time until fourth quarter 2022, at which time the median D2B time increased to 105 minutes, well above the national benchmark of 90 minutes. Analysis identified an opportunity to improve our performance. Specifically, outliers in second quarter 2023 increased the average D2ECG time for STEMI patients presenting through triage over the preceding six months to 92 minutes, well above the expected NCDR metric of <= 10 minutes.
Methodology: A multidisciplinary team was created to improve the time for obtaining D2ECG. Providers, nursing leaders, and staff champions collaborated biweekly to implement the following: Nurse first designation: 1. Designated a registered nurse (RN) as the first point of contact for patients entering the ED. Having an RN as this contact allowed more efficient and accurate assessment, bypassing registration as the initial priority. 2. Educated all clinical staff to recognize signs and symptoms indicative of an MI. Prioritized any patient with complaint of chest pain to receive an ECG immediately: 1. Once the nurse first recognizes the patient with a possible MI, the tech is immediately instructed to obtain an ECG. 2. Staff trained to prioritize ECGs over other tasks. 3. The ECG equipment was relocated to a designated room close to ED triage to minimize delayed activation. 4. ECGs are immediately given to the ED physician to review and determine if a STEMI alert needs to be activated. Implemented a Provider In Triage (PIT): 1. With physician collaboration, we assigned a trained Advanced Practice Provider (APP) to ED triage, along with the triage nurse, to evaluate patients at risk for a cardiac event and in need of an immediate ECG. 2. This change allowed quicker prioritization and sorting of potential ACS patients.
Results: In June 2023 we began to observe that the new triage process began to impact our NCDR metrics with improved results and evidence of average D2ECG times of 2 minutes in 16 patients. We also saw 100% of triaged patients with a D2B <= 90 minutes. Over the next three quarters CMC realized a 99% improvement in D2ECG and no missed D2B opportunities. These efficiencies also contributed to lowering left without being seen (LWBS) rates to less than one percent and improved throughput of arrival to departure from 161 minutes to 142 minutes.
Value Proposition: Efforts to reduce D2ECG involve improving coordination and communication between healthcare teams leading to a more patient-centered care approach. Lower D2ECG contributes to smoother patient flow and increases patient satisfaction. By introducing the role of a PIT, patient flow improves even further and contributes to lower LWBS rates, ensuring fewer patients leave without the proper diagnoses while reducing wait times and freeing up resources. Quicker recognition through Nurse First designation has shortened D2ECG times ensuring a STEMI is diagnosed promptly, leading to faster initiation of treatment or D2B, which is crucial for reducing the amount of heart muscle damage and improving outcomes. D2B times <= 90 minutes have been consistently shown to be associated with reduced mortality.² Optimizing D2ECG and D2B times efficiencies in STEMI patients improves outcomes, enhances patient satisfaction, and aligns with quality metrics and accreditation standards.
Conclusions: In conclusion, lower D2ECG times in STEMI patients led to faster diagnosis and D2B times. This enhanced coordination and communication, optimized resource utilization, improved patient throughput and patient outcomes. Our innovative collaborative efforts focused on education, communication, and ED process changes resulting in the program receiving not only American College of Cardiology (ACC) Chest Pain reaccreditation, but also its first PCI accreditation in October 2023.
References: 1. Lee CK, Meng SW, Lee MH, et al. The impact of door-to-electrocardiogram time on door-to-balloon time after achieving the guideline-recommended target rate. PLoS One. 2019;14(9):e0222019. Published 2019 Sep 9. doi:10.1371/journal.pone.0222019 2. McNamara, R, Wang, Y, Herrin, J. et al. Effect of Door-to-Balloon Time on Mortality in Patients With ST-Segment Elevation Myocardial Infarction. J Am Coll Cardiol. 2006 Jun, 47 (11) 2180–2186. https://doi.org/10.1016/j.jacc.2005.12.072
Terri Baudoin, BSN, RN, RCIS – Director, Cardiovascular Services, Conway Medical Center; Dody Martin, BSN, RN – Director/Chest Pain Center Coordinator, Telemetry, Clinical Observation, Conway Medical Center Problem Statement or Scientific Question: Despite the assumption that sound processes were in place, Door to Electrocardiogram (D2ECG) times for ST Elevation Myocardial Infarction (STEMI) patients entering through triage were well below the expected National Cardiovascular Data Registry (NCDR®) 50th percentile.
Background/Project Intent: Conway Medical Center (CMC) evaluates approximately 47,000 patients annually in the Emergency Department (ED) with a large portion presenting with Acute Coronary Syndrome. Recognizing this demand, CMC established a Percutaneous Coronary Intervention (PCI) with STEMI program in August 2020. Our data trends published in the NCDR Chest Pain – MI RegistryTM demonstrated steady improvement in Door to Balloon (D2B) time until fourth quarter 2022, at which time the median D2B time increased to 105 minutes, well above the national benchmark of 90 minutes. Analysis identified an opportunity to improve our performance. Specifically, outliers in second quarter 2023 increased the average D2ECG time for STEMI patients presenting through triage over the preceding six months to 92 minutes, well above the expected NCDR metric of <= 10 minutes.
Methodology: A multidisciplinary team was created to improve the time for obtaining D2ECG. Providers, nursing leaders, and staff champions collaborated biweekly to implement the following: Nurse first designation: 1. Designated a registered nurse (RN) as the first point of contact for patients entering the ED. Having an RN as this contact allowed more efficient and accurate assessment, bypassing registration as the initial priority. 2. Educated all clinical staff to recognize signs and symptoms indicative of an MI. Prioritized any patient with complaint of chest pain to receive an ECG immediately: 1. Once the nurse first recognizes the patient with a possible MI, the tech is immediately instructed to obtain an ECG. 2. Staff trained to prioritize ECGs over other tasks. 3. The ECG equipment was relocated to a designated room close to ED triage to minimize delayed activation. 4. ECGs are immediately given to the ED physician to review and determine if a STEMI alert needs to be activated. Implemented a Provider In Triage (PIT): 1. With physician collaboration, we assigned a trained Advanced Practice Provider (APP) to ED triage, along with the triage nurse, to evaluate patients at risk for a cardiac event and in need of an immediate ECG. 2. This change allowed quicker prioritization and sorting of potential ACS patients.
Results: In June 2023 we began to observe that the new triage process began to impact our NCDR metrics with improved results and evidence of average D2ECG times of 2 minutes in 16 patients. We also saw 100% of triaged patients with a D2B <= 90 minutes. Over the next three quarters CMC realized a 99% improvement in D2ECG and no missed D2B opportunities. These efficiencies also contributed to lowering left without being seen (LWBS) rates to less than one percent and improved throughput of arrival to departure from 161 minutes to 142 minutes.
Value Proposition: Efforts to reduce D2ECG involve improving coordination and communication between healthcare teams leading to a more patient-centered care approach. Lower D2ECG contributes to smoother patient flow and increases patient satisfaction. By introducing the role of a PIT, patient flow improves even further and contributes to lower LWBS rates, ensuring fewer patients leave without the proper diagnoses while reducing wait times and freeing up resources. Quicker recognition through Nurse First designation has shortened D2ECG times ensuring a STEMI is diagnosed promptly, leading to faster initiation of treatment or D2B, which is crucial for reducing the amount of heart muscle damage and improving outcomes. D2B times <= 90 minutes have been consistently shown to be associated with reduced mortality.² Optimizing D2ECG and D2B times efficiencies in STEMI patients improves outcomes, enhances patient satisfaction, and aligns with quality metrics and accreditation standards.
Conclusions: In conclusion, lower D2ECG times in STEMI patients led to faster diagnosis and D2B times. This enhanced coordination and communication, optimized resource utilization, improved patient throughput and patient outcomes. Our innovative collaborative efforts focused on education, communication, and ED process changes resulting in the program receiving not only American College of Cardiology (ACC) Chest Pain reaccreditation, but also its first PCI accreditation in October 2023.
References: 1. Lee CK, Meng SW, Lee MH, et al. The impact of door-to-electrocardiogram time on door-to-balloon time after achieving the guideline-recommended target rate. PLoS One. 2019;14(9):e0222019. Published 2019 Sep 9. doi:10.1371/journal.pone.0222019 2. McNamara, R, Wang, Y, Herrin, J. et al. Effect of Door-to-Balloon Time on Mortality in Patients With ST-Segment Elevation Myocardial Infarction. J Am Coll Cardiol. 2006 Jun, 47 (11) 2180–2186. https://doi.org/10.1016/j.jacc.2005.12.072
Co-authors: Terri Baudoin, BSN, RN, RCIS – Director, Cardiovascular Services, Conway Medical Center; Dody Martin, BSN, RN – Director/Chest Pain Center Coordinator, Telemetry, Clinical Observation, Conway Medical Center
Terri Baudoin, BSN, RN, RCIS – Director, Cardiovascular Services, Conway Medical Center; Dody Martin, BSN, RN – Director/Chest Pain Center Coordinator, Telemetry, Clinical Observation, Conway Medical Center Problem Statement or Scientific Question: Despite the assumption that sound processes were in place, Door to Electrocardiogram (D2ECG) times for ST Elevation Myocardial Infarction (STEMI) patients entering through triage were well below the expected National Cardiovascular Data Registry (NCDR®) 50th percentile.
Background/Project Intent: Conway Medical Center (CMC) evaluates approximately 47,000 patients annually in the Emergency Department (ED) with a large portion presenting with Acute Coronary Syndrome. Recognizing this demand, CMC established a Percutaneous Coronary Intervention (PCI) with STEMI program in August 2020. Our data trends published in the NCDR Chest Pain – MI RegistryTM demonstrated steady improvement in Door to Balloon (D2B) time until fourth quarter 2022, at which time the median D2B time increased to 105 minutes, well above the national benchmark of 90 minutes. Analysis identified an opportunity to improve our performance. Specifically, outliers in second quarter 2023 increased the average D2ECG time for STEMI patients presenting through triage over the preceding six months to 92 minutes, well above the expected NCDR metric of <= 10 minutes.
Methodology: A multidisciplinary team was created to improve the time for obtaining D2ECG. Providers, nursing leaders, and staff champions collaborated biweekly to implement the following: Nurse first designation: 1. Designated a registered nurse (RN) as the first point of contact for patients entering the ED. Having an RN as this contact allowed more efficient and accurate assessment, bypassing registration as the initial priority. 2. Educated all clinical staff to recognize signs and symptoms indicative of an MI. Prioritized any patient with complaint of chest pain to receive an ECG immediately: 1. Once the nurse first recognizes the patient with a possible MI, the tech is immediately instructed to obtain an ECG. 2. Staff trained to prioritize ECGs over other tasks. 3. The ECG equipment was relocated to a designated room close to ED triage to minimize delayed activation. 4. ECGs are immediately given to the ED physician to review and determine if a STEMI alert needs to be activated. Implemented a Provider In Triage (PIT): 1. With physician collaboration, we assigned a trained Advanced Practice Provider (APP) to ED triage, along with the triage nurse, to evaluate patients at risk for a cardiac event and in need of an immediate ECG. 2. This change allowed quicker prioritization and sorting of potential ACS patients.
Results: In June 2023 we began to observe that the new triage process began to impact our NCDR metrics with improved results and evidence of average D2ECG times of 2 minutes in 16 patients. We also saw 100% of triaged patients with a D2B <= 90 minutes. Over the next three quarters CMC realized a 99% improvement in D2ECG and no missed D2B opportunities. These efficiencies also contributed to lowering left without being seen (LWBS) rates to less than one percent and improved throughput of arrival to departure from 161 minutes to 142 minutes.
Value Proposition: Efforts to reduce D2ECG involve improving coordination and communication between healthcare teams leading to a more patient-centered care approach. Lower D2ECG contributes to smoother patient flow and increases patient satisfaction. By introducing the role of a PIT, patient flow improves even further and contributes to lower LWBS rates, ensuring fewer patients leave without the proper diagnoses while reducing wait times and freeing up resources. Quicker recognition through Nurse First designation has shortened D2ECG times ensuring a STEMI is diagnosed promptly, leading to faster initiation of treatment or D2B, which is crucial for reducing the amount of heart muscle damage and improving outcomes. D2B times <= 90 minutes have been consistently shown to be associated with reduced mortality.² Optimizing D2ECG and D2B times efficiencies in STEMI patients improves outcomes, enhances patient satisfaction, and aligns with quality metrics and accreditation standards.
Conclusions: In conclusion, lower D2ECG times in STEMI patients led to faster diagnosis and D2B times. This enhanced coordination and communication, optimized resource utilization, improved patient throughput and patient outcomes. Our innovative collaborative efforts focused on education, communication, and ED process changes resulting in the program receiving not only American College of Cardiology (ACC) Chest Pain reaccreditation, but also its first PCI accreditation in October 2023.
References: 1. Lee CK, Meng SW, Lee MH, et al. The impact of door-to-electrocardiogram time on door-to-balloon time after achieving the guideline-recommended target rate. PLoS One. 2019;14(9):e0222019. Published 2019 Sep 9. doi:10.1371/journal.pone.0222019 2. McNamara, R, Wang, Y, Herrin, J. et al. Effect of Door-to-Balloon Time on Mortality in Patients With ST-Segment Elevation Myocardial Infarction. J Am Coll Cardiol. 2006 Jun, 47 (11) 2180–2186. https://doi.org/10.1016/j.jacc.2005.12.072
Terri Baudoin, BSN, RN, RCIS – Director, Cardiovascular Services, Conway Medical Center; Dody Martin, BSN, RN – Director/Chest Pain Center Coordinator, Telemetry, Clinical Observation, Conway Medical Center Problem Statement or Scientific Question: Despite the assumption that sound processes were in place, Door to Electrocardiogram (D2ECG) times for ST Elevation Myocardial Infarction (STEMI) patients entering through triage were well below the expected National Cardiovascular Data Registry (NCDR®) 50th percentile.
Background/Project Intent: Conway Medical Center (CMC) evaluates approximately 47,000 patients annually in the Emergency Department (ED) with a large portion presenting with Acute Coronary Syndrome. Recognizing this demand, CMC established a Percutaneous Coronary Intervention (PCI) with STEMI program in August 2020. Our data trends published in the NCDR Chest Pain – MI RegistryTM demonstrated steady improvement in Door to Balloon (D2B) time until fourth quarter 2022, at which time the median D2B time increased to 105 minutes, well above the national benchmark of 90 minutes. Analysis identified an opportunity to improve our performance. Specifically, outliers in second quarter 2023 increased the average D2ECG time for STEMI patients presenting through triage over the preceding six months to 92 minutes, well above the expected NCDR metric of <= 10 minutes.
Methodology: A multidisciplinary team was created to improve the time for obtaining D2ECG. Providers, nursing leaders, and staff champions collaborated biweekly to implement the following: Nurse first designation: 1. Designated a registered nurse (RN) as the first point of contact for patients entering the ED. Having an RN as this contact allowed more efficient and accurate assessment, bypassing registration as the initial priority. 2. Educated all clinical staff to recognize signs and symptoms indicative of an MI. Prioritized any patient with complaint of chest pain to receive an ECG immediately: 1. Once the nurse first recognizes the patient with a possible MI, the tech is immediately instructed to obtain an ECG. 2. Staff trained to prioritize ECGs over other tasks. 3. The ECG equipment was relocated to a designated room close to ED triage to minimize delayed activation. 4. ECGs are immediately given to the ED physician to review and determine if a STEMI alert needs to be activated. Implemented a Provider In Triage (PIT): 1. With physician collaboration, we assigned a trained Advanced Practice Provider (APP) to ED triage, along with the triage nurse, to evaluate patients at risk for a cardiac event and in need of an immediate ECG. 2. This change allowed quicker prioritization and sorting of potential ACS patients.
Results: In June 2023 we began to observe that the new triage process began to impact our NCDR metrics with improved results and evidence of average D2ECG times of 2 minutes in 16 patients. We also saw 100% of triaged patients with a D2B <= 90 minutes. Over the next three quarters CMC realized a 99% improvement in D2ECG and no missed D2B opportunities. These efficiencies also contributed to lowering left without being seen (LWBS) rates to less than one percent and improved throughput of arrival to departure from 161 minutes to 142 minutes.
Value Proposition: Efforts to reduce D2ECG involve improving coordination and communication between healthcare teams leading to a more patient-centered care approach. Lower D2ECG contributes to smoother patient flow and increases patient satisfaction. By introducing the role of a PIT, patient flow improves even further and contributes to lower LWBS rates, ensuring fewer patients leave without the proper diagnoses while reducing wait times and freeing up resources. Quicker recognition through Nurse First designation has shortened D2ECG times ensuring a STEMI is diagnosed promptly, leading to faster initiation of treatment or D2B, which is crucial for reducing the amount of heart muscle damage and improving outcomes. D2B times <= 90 minutes have been consistently shown to be associated with reduced mortality.² Optimizing D2ECG and D2B times efficiencies in STEMI patients improves outcomes, enhances patient satisfaction, and aligns with quality metrics and accreditation standards.
Conclusions: In conclusion, lower D2ECG times in STEMI patients led to faster diagnosis and D2B times. This enhanced coordination and communication, optimized resource utilization, improved patient throughput and patient outcomes. Our innovative collaborative efforts focused on education, communication, and ED process changes resulting in the program receiving not only American College of Cardiology (ACC) Chest Pain reaccreditation, but also its first PCI accreditation in October 2023.
References: 1. Lee CK, Meng SW, Lee MH, et al. The impact of door-to-electrocardiogram time on door-to-balloon time after achieving the guideline-recommended target rate. PLoS One. 2019;14(9):e0222019. Published 2019 Sep 9. doi:10.1371/journal.pone.0222019 2. McNamara, R, Wang, Y, Herrin, J. et al. Effect of Door-to-Balloon Time on Mortality in Patients With ST-Segment Elevation Myocardial Infarction. J Am Coll Cardiol. 2006 Jun, 47 (11) 2180–2186. https://doi.org/10.1016/j.jacc.2005.12.072
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