Kathleen J. Griffith, RN, Pathway and Outcomes Manager
Helen Macfie, PharmD, Vice President of Performance Improvement
Mitzi Caulfield, RN, BA, Clinical Coordinator, Cardiac Cath Lab
Trish Cruz, RN, BSN, Clinical Coordinator, Cardiac Cath Lab
Claudia Gold, MD, Emergency Department Performance Improvement
Donald Mahon, MD, Director of Cardiology
Renee Mazzerol, RN, MSN, Director of Cardiac Services
James Pierog, MD, Director of Emergency Department
John Senteno, RN, BSN, Director Emergency Department
Katie Skelton, RN, MSN, Vice President of Patient Care Services
Amy Waunch, RN, MSN, FNP, Clinical Nurse Specialist, Emergency Department

To increase our compliance to key evidence-based therapies and patient counseling for treatment of acute myocardial infarction (AMI) to composite and all-or-none scores of 95 percent or greater by April 2005 (vs. CMS benchmarks).

• Aspirin at arrival
• Aspirin at discharge
• ACEI for LVSD
• Beta-blocker at arrival
• Beta-blocker at discharge
• Door to lytic
• Door to PCI
• Smoking cessation advice
• Composite and all-or-none scores
• Survival rate/index

Tier 1 Tactics (10^-1) – Intent and Standardization

• Created buy-in to measures by reviewing the inclusion and exclusion criteria for each indicator for CMS/ORYX, thereby accelerated the learning curve on the varying definitions compared to prior/other benchmarks.
• Expanded the Chest Pain Center hours to 24/7 with observation area for 23-hour evaluation.
• Revised criteria for EKG screening in the ED to include atypical presentations (e.g., non-STEMI, female, gastric).
• Overhauled ED and Cath Lab process flow including transmission of EKG results by the EMS, setting time threshold cutoffs, implementing a master clock system, centralizing the Cath Lab call-back system, fast-tracking Cath Lab set-up with ED transport and pre-set equipment/supplies, and availability of non-interventional or interventional cardiologist to start the case.
• Revised elective Cath Lab schedule to expand blocks, hours of service.
• Added smoking history to admission assessment for all patients.
• Trained acute MI care champions in each care area.

Tier 2 Tactics (10^-2) – Independent Redundancy

• Activated Chest Pain Center default orders tailored to AMI type, incorporated on ED record, with RN follows up with ER physician if variation.
• Inserted opportunity for ED MD to give the lytic if door-to-Cath Lab time predicted to exceed 90 minutes.
• Initiated concurrent redundant review in the Cath Lab to identify and mitigate fallouts (e.g., ASA or beta-blocker within 24 hours of arrival).
• Created brochure for first- and second-hand smoking cessation, made default care for all patients regardless of diagnosis.
• Implemented Quality Management review of all admitted patients for evidence-based indicators, with concurrent review with ED, cardiologist if fallout.
• Reviewed final fallouts routinely with ED, hospitalist and cardiology physicians and nursing staff, with drill-down data for PCI process as well as non-STEMIs, to create enhanced understanding of overall scoring and further PI opportunities.
• Next changes: Adding to manager/director/VP and hospitalist incentive goals.

We improved our overall composite score from 91 percent (1Qtr.04) to 98 percent (2Qtr.05), and our all-or-none reliability from 83 percent (Jan 2005) to 96 percent (May-Jun 2005) respectively, by implementing AMI pathways in the Emergency Department, enhancing triage for atypical presentations, expediting Cath Lab call-back process flow, using redundancy checks for evidence-based therapies, and creating default counseling for first- or second-hand smoking cessation.

Using reliability concepts to segment the ST elevation MI (STEMI) patient population and design processes to prevent initial failure and to identify and mitigate fallouts has made a significant impact on our reliability. Our multidisciplinary team included cardiologists, ED physicians, chest pain nurses, ED nurses, Cardiac Cath Lab nurses, executive leadership, and Quality Management/Pathway and Outcomes Manager.

Our efforts focused on early detection of the AMI patient through “casting a wider net” (initial ECG), streamlining calls to the cardiologist and Cardiac Cath Lab, creating an order set (pathway) with prompts/reminders for key interventions (e.g., ASA, beta-blocker, lytic, and PCI preparation), and initiating “Tier 2” tactics to get us to 10^-2 or better reliability.

Lessons Learned:

• Core Training: Train and reinforce definitions for CMS/ORYX indicators with all team members to create buy-in to results and performance improvement opportunities.
• Small Tests of Change: Using small tests to try out ideas, refine, re-test, refine, and then spread once works well.
• Use of Reliability Theory: Learned from the IHI IMPACT innovation community how to effectively implement Tier 1 and Tier 2 design and strategies. Key success factors include consideration of redundancy and default opportunities.
• Concurrent Review and Data: Use of trained and centralized Quality Management staff to review care processes concurrently, intervene if able, review fallouts with staff and physicians, and share real-time trended data.

Kathleen Griffith, RN, Pathway and Outcome Manager
St. Joseph Hospital, Orange
Kathleen.Griffith@stjoe.org

[Storyboard presentation at IHI's National Forum, December 2005]