Cath Lab Digest - December 2007 - (Page 9) DECEMBER 2007 STEMI INTERVENTIONS 9 continued from page 1 Making STEMI a Priority ovale [ASD/PFO] closure, valvuloplasty, Rotoblater, laser, etc.). St. Luke’s also has two hybrid suites located within the cardiovascular operating rooms that perform combination percutaneous and surgical procedures. The lab is open for scheduled procedures 16 hours per day, Monday through Friday, and 12 hours on Saturday and Sunday. The remaining hours (Monday-Friday 11pm-7am, and Saturday-Sunday 7pm-7am), the lab is available for emergencies, covered by a four-person call crew consisting of 2 RNs and 2 technologists. All members of the clinical staff take call duty and must be cross-trained to function effectively in all types of emergency cases, including PCI for STEMI patients. As we all know, the public is still very much in denial about heart disease. Patients frequently ignore signs and symptoms of a heart attack, instead of calling 911 for immediate assistance. Patients or family members will drive to a hospital instead of calling for an ambulance when all signs indicate they are experiencing a myocardial infarction. While our efforts do not address these issues, we have worked to assure that once a patient arrives at our hospital, each minute will be used effectively and efficiently to provide the patient with the best chance for recovery and a healthy life. It is pretty straightforward for any hospital to get a STEMI patient to the cath lab when the emergency medical team (EMS) gives you a 30minute warning prior to delivering the patient to the ED. It also presents less of a challenge in the middle of the day with all resources readily available in-house. Making the doorto-balloon time in < 90 minutes when the patient drives himself to the hospital at 2 am and then walks into the ED is an entirely different ballgame. Upon arrival to the emergency room, patients can present with a wide range of symptoms and complaints when they are having a STEMI. Even when the signs are immediately recognized, both large metropolitan medical centers and smaller suburban hospitals, generally do not have cath lab staff or staff cardiologist in the building. To achieve this target, it was obvious to the STEMI Committee that we needed to make some changes and develop a standardized plan. It is interesting to note that usually the resources available to a large metropolitan hospital collaborate in favor of delivering efficient and quality service to patients. In working to achieve the < 90-minute admit to time of treatment in our hospital, however, we discovered that an abundance of resources and being located in one of the largest medical centers in the world did not always work to our advantage! One of the first challenges the team faced was assuring well-trained CCL staff could be available within a few minutes of a STEMI patient entering our emergency room. Most of the employees in our hospital do not live within a few minutes of the hospital. Busy parking garages were another obstacle to our prompt response. In fact, many of our cardiac cath lab nurses and technologists live 20 to 30 miles from the hospital and have to deal with freeway traffic and constant freeway construction 24 hours a day in their commute. Additionally, the number of cardiologists and emergency room physicians on staff at our hospital created another level of complexity in creating a standard treatment practice for STEMI patients. Everyone’s actions needed to be coordinated to assure patient care progressed without waiting for a phone call or page to be returned. Even the decision about which supplies and equipment needed to be pulled had to be discussed and communicated via a standard treatment plan. Suburban hospitals may find some of these issues are not relevant to them, as they are frequently located in residential areas (hospital staff may live nearby). Also, smaller hospitals have fewer emergency department (ED) physicians and cardiologists who are involved in responding to STEMI emergencies on a more frequent and regular basis. Despite these challenges, St. Luke’s made a commitment to not only meet but to try and exceed the AHA/ACC guidelines for STEMI patient care. In making this commitment, we knew some significant changes would have to be made, not only in how the ED handled STEMI patients, but in the way the cardiac catheterization laboratory participated in the process. Without administrative support and a positive team effort, the success of our program would not have happened so quickly. Prior to forming a multi-disciplinary team of physicians, nurses, non-medical staff (admitting services, page operators, medical records) and hospital administration, we were reporting an average of less than 25% compliance during the first five months of 2007. Since June of 2007, we can proudly boast a 100% record with a mean door-to-balloon time of less than 75 minutes. How did it happen? In a word, standardization. It also took a great deal of determination and plain old common sense. We quickly learned that the standardization of all aspects of care, from treatment protocols to administrative processes, translates into a more efficient patient care delivery system. Time is muscle, which is what the < 90-minute door-to-balloon time is all about — an effort to provide better patient outcomes. Experienced administrators and managers have long known that if you want an issue to be resolved
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