Two Hospitals-One Heart: World Class Heart Care through Multi-Disciplinary Collaboration American Nurses Association Susie Schnitker RN, BSN, CEN 7 th Annual Nursing Quality Conference Director of Critical Care Services February 18, 2013 Schneck Medical Center Session 206 8:30 am-9:30 am Seymour, Indiana 1
Seymour, Indiana SEYMOUR 2
Schneck Medical Center • 97 beds • Not-for-profit • Facilities – Main Campus – State-of-the-Art Cancer Center – Outpatient Rehabilitation Center – Home Services – Convenient Care Centers 3
Objectives • Describe the benefits of a collaborative approach to heart care • Define measures to focus priorities for cycles of improvement 4
Best in Class Door to Balloon (D2B) for ST-Elevation Myocardial Infarction (STEMI) Patients 5
What is a STEMI STEMI is an acronym meaning "ST segment elevation myocardial infarction," which is a type of heart attack. This is determined by an electrocardiogram (ECG) test. In a STEMI, the coronary artery is completely blocked off by the blood clot, and as a result virtually all the heart muscle being supplied by the affected artery starts to die. During an acute STEMI seconds count! There is a direct relationship between the amount of time a heart artery is blocked and the severity of the heart attack and odds of survival • 1.5 million Heart attacks occur in the US each year with 500,000 deaths • A heart attach occurs about every 20 seconds with a heart attack death about every minute. • Heart attack is a leading killer of both men and women in the United States 6
Estimated In-hospital Mortality D2B Time STEMI 10 Gold standard <120 minutes for hospitals In Hospital Adjusted Risk 8 without a Cath Lab of Mortality (%) 6 4 2 0 15 30 69 90 120 150 180 Time (minutes) 7
4. Project Implementation 1. & Results Project Selection M A N A T G E E A M M E N T Current 2. 3. Situation PROJECT Solution Development Analysis 8
Development of “Code STEMI “ Four Main Drivers Behind D2B Purpose: Time Improvement Patient Outcomes CMS Guidelines JC Guidelines Risk Management Goal: Achieve best in class door to balloon times for patients suffering from ST-segment elevation myocardial Infarctions (STEMI) by working with our competitor hospital and local EMS to implement an ideal system of care to provide seamless transitions from each stage of care to the next. The American Heart Association and the American College of Cardiology recommend that the door-to-balloon time interval be no more than 90 minutes and under 120 minutes when the patient has to be transferred to another hospital. 9
DMAIC Identify scope of project & key stakeholders DEFINE Identify stakeholder requirements Create data collection tool MEASURE Identify key measurements Gather and analyze data ANALYZE Median D2B time = 167 Min Collaborate with CRH & Jackson County EMS IMPROVE Identify & eliminate barriers to implementation Implement monitoring method CONTROL Deploy results to all key stakeholders 10
Project Charter STEMI I MPROVEMENT PROJECT Project Charter Organizations: Champions: Process Owners: Schneck Medical Center , Jackson Tammy Dye & Vicki Matt Chandler, Susie County EMS, Columbus Regional Johnson Schnitker Staci Glick, Julie Health, Bailey & Dennis Brasher Project: ED STEMI: Rapid Identification and Intervention Problem Statement: In quarter one 2010 our median door to balloon time was 167 minutes. The American Heart Association and the American College of Cardiology recommend that the door-to-balloon time interval be no more than 90 minutes and under 120 minutes when the patient has to be transferred to another hospital. Project Objective: The objective of this project was to create a process that allowed 100% of STEMI patients to be reperfused with a door to balloon time under 90 minutes. 11
SIPOC EMS Patient Transportation 1.Onset of symptoms Positive patient outcomes Registration Families 12 Lead EKG 2.EMS Dispatch Pt & Family Triage Nurse Staff Doctor 3.12-lead ECGs satisfaction assessment Emergency Physicians 4.Early Diagnosis Accurate, timely Physician History & SMC, CRH, & 5.Transport to SMC information. Physical Dispatch JCEMS 6.ED MD confirms Accurate, timely Diagnosis Dispatch diagnosis, pt stays treatment Handoff in ambulance Door to Balloon Communication 7.Notify CRH/Activate time under 90 Cath Lab minutes 8.Transport to CRH 9.Cath Team receives patient from EMS 10.Patient treated 12
Excellence Every Person, Every Time • Project Impact on Key Stakeholders Patient • Improved outcomes • Increase patient satisfaction SMC,CRH, & • Increase in clinical quality JCEMS • Increase possibility for further collaborations Physicians & Staff • Streamlined processes • Increased staff engagement • Door to balloon times under 90 minutes (best in class) • Address to balloon times under 120 minutes (best in class) • Improved patient outcomes 13
4. Project Implementation 1. Project Selection & Results M T A E N A A M G E M E 2. Current Situation N Analysis T 2. 3. PROJECT Solution Development 14
STEMI Kaizen Event ED STEMI Kaizen Event Agenda 2 Day 1 (September 27th, 2010) Day 2 (September 28th, 2010) D Training and review of 0830-0900 current data (SZ) 0830-1015 Future state process map a 0900-0930 SIPOC 1015-1030 Break 0930-0945 Break 1030-1200 Action Plan y Review/validate current 0945-1030 state map 1200-1230 LUNCH Affinity diagram and creation Implement Improvements K of Customer Requirement through 5S and system re- 1030-1100 Tree 1230-1500 design A Brainstorming of potential failure modes using I Man/Machines/Materials 1100-1200 soft tool 1500-1630 Control Plan 1200-1245 LUNCH Z 1245-1400 FMEA 1400-1415 Break E 1415-1500 FMEA N 1500-1630 Brainstorm of improvments 15
SWOT Chest Pain Center Accreditation Engaged Stakeholders No Cath Lab (Schneck Medical Center) Variances in standard of care Develop partnerships with EMS & CRH Standardize care every patient, every time Quality of care due to locums ED physicians Loss of market share 16
Goal: Door to Balloon Time <90 Minutes Schneck Stats Employees 800 Beds 113 CRH Stats Employees 1,625 Beds 225 17
Current State Process Map Patient calls 911 ED Physician assess & Patient is transported to diagnose. EKG is receiving facility repeated EMS Responds ED Physician contacts Indianapolis facility to Facility receives patient Patient intervention transfer patient EKG obtained Facility activates catheterization lab Patient is transferred to Transports to SMC Cath lab EMS or helicopter is contacted to transport Patient is triaged and patient placed in treatment room 18
Desired State Process Map Patient calls 911 Transports to SMC Patient is transported patient to CRH Patient is triaged in Patient intervention ambulance bay EMS Responds Facility receives patient and transports to Cath Lab Paramedic obtains ED Physician contacts EKG & activates Code CRH cardiologist with STEMI. Medical additional information control activates Cath Lab 19
Narrowing the List of Opportunities F ailure M ode E ffect A nalysis 20
4. Project Implementation 1. Project Selection & Results M A T N E A A G M E M E 3. N Solution T Current 2. Development 3. Situation PROJECT Analysis 21
Solution Development Society for American Evidence Chest Pain Guidelines/ Heart Based Best Accreditation Standards Association Practice American Society of Cardiology Evidenced Based AMI Simulation System Design 22
Solution Development Grant Application and Recipient: Simulation for Improved Teamwork in Myocardial Infarction SIM-FIT MI An in situ Educational Initiative Tailored to Individual Hospital Needs April 13, 2011 Taped and analyzed by The American College of Cardiology 23
Solution Development • EMS performs 12 lead EKG and field activates one call process to cath lab for positive STEMI EKG’s • SMC ED physician and nursing team assesses and stabilizes patient in ambulance for transport to CRH • Developed similar process for walk in STEMI patients • Standardized equipment between all providers • Data collection and rapid feedback to everyone involved in the process • Collaboration & coordination of resources • Mock code event to identify waste in process • Training & education to Dispatch, EMS, SMC ED Staff, CRH ED Staff, Cath Lab Staff 24
Intended Benefits • Intended Benefits – Intangible – Tangible • Increase stakeholder • Improve door to satisfaction with transition balloon times of care processes • Improve patient • Increase engagement of outcomes staff in the success of the initiative • Look for opportunities to collaborate on other initiatives 25
Data Pre-Implementation EMS Arrival to STEMI Indoor to EKG Outdoor Time 13 Min 80 Min Goal < 5 Min Goal < 30 Min Door to Balloon Time 167 minutes Goal < 90 Min Transfer time STEMI Door to btw Non PCI & Door Time PCI Facilities 159 Min 56 Min Goal < 26 Min Goal < 56 Min 26
4. 1. 4. Project Selection Project Implementation & Results M A T N E A A G M E M E N T Current 2. 3. Situation PROJECT Solution Development Analysis 27
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