J. Ambrose, MD, FACC, Cardiologist
S. Reese, MD, FACC, Cardiologist
J. Ahn, MD, FACC, Cardiologist
R. Cameron, MD, Director of Emergency Medicine
D. Ahearn, MD, FACP, Vice President of Medical Affairs
J. Kurtz, RN, BSN, CEN, Manager, Emergency Department
P. Crawford, RN, Catheterization Lab Manager
Emergency Department, catheterization lab, and ancillary support staff

• AMI mortality
• AMI core measure composite score*
• Percent of ST elevated myocardial infarction (STEMI) patients with a door to balloon time of less than 120 minutes

*We calculate our composite score as follows: 

• Our denominator is the total number of patients in the category that are eligible for at least one of the measures. 
• The numerator is the total number of patients who received all of the care for AMI that they were eligible to receive.
  

Example:
10 patients are admitted with AMI

9 patients receive all of the care for AMI they were eligible to receive

Composite Score: 9/10 = 90 percent

We improved the acute myocardial infarction (AMI) composite score from 89.4 to 91.7, and 100 percent of patients with an ST elevated myocardial infarction (STEMI) had a door to balloon inflation time within 120 minutes (an increase from 62 percent in FY04).

• Provided staff education outlining the evidenced-based components of care of AMI patients with emphasis on door to balloon inflation times of less than 120 minutes (“Time is Muscle”).
• Developed standard AMI admission and discharge order sets, listing essential medications and check boxes to indicate reason if medications were not administered/ordered.
• In Emergency Department (ED), carefully balanced nitrate use to preserve BP, while more consistently increasing use of beta-blockers.
• Redefined notification system for “on call” catheterization (cath) lab team (i.e., beeped "911" for ED to signal need for PCI as soon as ED physician detects STEMI).
• Improved door to EKG time.
• Developed an accompanying ED/cath lab tracking sheet, listing essential steps and times. All sheets are reviewed and help pinpoint system delays in need of correction.
• Improved access to medications stored in the cath lab by installing a keyless, secure entry system to prevent lost minutes while retrieving keys.
• Provided staff and physicians with feedback in the form of regular reports featuring door to EKG times, door to balloon inflation times, and AMI core measure component and composite data. (Aggregate and physician-specific AMI core measure reports provided quarterly.)
• Developed a Cardiovascular Morbidity/Mortality Committee to provide in-depth review of any complications/deaths and input on improving care delivery processes.

• Frequent measurement and feedback, including practitioner-specific data (timely, objective, useful, and relevant) drives change.
• Aggregate component and composite metrics presented at medical staff, senior management, and board of director meetings.
• Expert physician champions are key in leading and living the change.
• Star player will rise to the challenge of changing the processes of care when they believe it will improve outcomes.
• Success stories, using actual cases, create a powerful and motivating learning experience (a PowerPoint presentation, incorporating video cath lab images brought this success story to life for staff, leaders, board members, and colleagues statewide).
• Investing time during the planning phase of the PDSA cycle assures the changes are well thought out and communicated, reducing rework later.
• The body of evidence-based medicine is ever growing, requiring frequent adjustments to established care processes (i.e., Angiotensin Receptor Blocker use.)
• Clinical review of each AMI core measure deficiency is helpful in understanding underlying causes and applying corrective actions.

Carole Berger, RN, BSN, Performance Improvement Manager
DuBois Regional Medical Center
Email: cvberger@drmc.org