The Challenge: McLeod Regional Medical Center in Florence, South Carolina, is known for excellence in many areas, particularly emergency care. As one of only two Level II designated trauma centers in the state, McLeod treats about 50,000 critically injured or ill patients every year; approximately 600 of these patients are experiencing an acute myocardial infarction (AMI), or heart attack. McLeod staff use state-of-the-art methods to treat patients having heart attacks, but doing the right thing is only half the battle — everything must be done quickly to be effective. This is where McLeod staff knew they could improve.
The Background: McLeod Regional Medical Center, part of McLeod Health, is a large acute-care hospital serving 12 rural counties with a population of close to one million. Located in Florence, a city of about 30,000 in northeast South Carolina, McLeod is in the heart of South Carolina’s Pee Dee region, named for the Indian tribe that originally inhabited the area. As a Pursuing Perfection hospital, one of 278 hospitals participating in a quality demonstration project sponsored by the Centers for Medicare & Medicaid Services (CMS) and Premier, Inc., and now a part of IHI’s 100,000 Lives Campaign, McLeod has distinguished itself as a leader at improving care processes and patient outcomes.
The Situation: Every year, an estimated 1.1 million people in the United States are diagnosed with an AMI, and approximately 350,000 of these patients die during the acute phase. Speed is essential in the initial care of AMI patients because, in the parlance of those who work with AMI patients, “time is muscle.” The clot that causes an AMI deprives the heart of oxygen and other nutrients, causing muscle cells to die. The sooner the artery is cleared and proper blood flow to the heart is restored, the better the patient’s chance of recovery.
Treatment for heart attack patients today almost always involves the use of a catheter balloon and stent to break the clot, open the artery, and keep it open. Called percutaneous transluminal coronary angioplasty, or PTCA, the procedure is more commonly known as balloon dilation or balloon angioplasty. National guidelines from the American College of Cardiology and the Joint Commission on Accreditation of Healthcare Organizations recommend a “door-to-balloon” time of 120 minutes or less for maximum benefit. This is one of seven components of good AMI care, including administration of aspirin and beta-blockers on admission and discharge, ACE inhibitors when appropriate, and counseling smokers to quit. (For more information on improved care for AMI, see the 100,000 Lives Campaign.)
With lessons from Pursuing Perfection to guide their work, McLeod leaders chose to set a 90-minute goal for reperfusion (when blood flow is re-established in the blocked artery). “When we first measured it in 2001, we were only reperfusing about 17 percent of our AMI patients within 90 minutes,” recalls Care Manager Joan Coleman, RN, MN. “Everyone was shocked when they saw that number, and a lot of people thought 90 minutes was just unrealistic. But the literature said it could be done, and other hospitals were doing it, so we knew we had to try.”
The Solution: “We began by looking at how AMI patients enter the system,” says Daphne Heffler, RN, BSN, CCRN, Vice President of Cardiac Services. “We evaluated each step, what happens and what needs to happen.” The idea was to identify places in the care process where precious minutes could be saved.
Patients transported by ambulance are often brought to the ED in McLeod’s HeartReach ambulance, staffed by cardiac emergency nurses and paramedics, and equipped with sophisticated mobile cardiology equipment such as an EKG machine. This enables staff to make critical evaluations en route to the hospital and alert the hospital’s emergency providers, who in turn set the wheels in motion to receive and treat a heart attack patient.
Patients who arrive at the emergency department on their own, Heffler says, are quickly evaluated by a triage nurse who is trained in the symptoms of AMI. This in itself is an important detail. “Triage functions are often filled by paramedics or emergency medical technicians, people who are certainly skilled but not as highly trained as nurses. We realized we needed someone in that role who is trained to recognize an acute MI and can get those patients into the system right away,” says Heffler.
If the patient exhibits signs or symptoms of an AMI, he or she is taken immediately to the hospital’s Chest Pain Center, a six-bed unit within the ED, where an EKG is quickly administered and reviewed by a physician. “This process averages about four minutes,” says Coleman, “well within our goal of 10 minutes.” All ED staff are trained to administer EKGs, another important detail when time is of the essence. “You can’t wait for someone to come from the EKG department,” says Heffler.
The Chest Pain Center, which opened in September 2003, was the direct result of McLeod’s effort to improve AMI care. The Center includes all the equipment and personnel necessary to quickly diagnose a heart attack, such as EKG machines, stress test equipment, and telemetry monitoring, as well as emergency medications and equipment for stabilizing or resuscitating patients.
When an ED physician determines that the patient is experiencing an AMI, the catheterization (or cath) lab is immediately notified, to get the process that will open up blocked arteries underway as soon as possible. In the “old days,” says Heffler, only a cardiologist could “activate” the cath lab, particularly after hours when it is not routinely staffed. “The ED physician would call the cardiologist, who would come see the patient, confirm the diagnosis, and alert the cath lab.” Now, the ED uses a newly created “999 code” to alert the cardiologist. “This code means ‘This is not a consult, this is an acute MI,’” explains Heffler. “The ED physician and cardiologist talk immediately by phone, and the cardiologist gives the ED physician permission to activate the cath lab.”
“The cardiologist always has the final say,” emphasizes Alan Blaker, MD, an interventional cardiologist. Often, says Blaker, the cardiologist is nearby and can get to the ED immediately or meet the patient at the cath lab. But for those times when the cardiologist might be otherwise unavailable, says Blaker, “we had to get past the point where the cardiologist needed to see the patient in the ED before calling the cath lab.”
Meanwhile, ED nurses in the Chest Pain Center hustle to get the patient prepared, starting IVs and oxygen, gathering medical history, getting lab tests, and informing family members. Over in the cath lab, plans are in motion to receive the emergency patient, which can sometimes mean bumping a scheduled procedure. If it is after hours, cath lab staff are called in from home, and they alert the ED as soon as two or more staff are there and ready. “In a larger, more congested city it may be necessary for staff to stay in the facility,” says Blaker. “But we all live 10 to 15 minutes away. It hasn’t affected our ability to meet our goal.”
This fact has come as something of a surprise to some. “At the beginning, some people thought the only way we could meet our goal was by keeping the cath lab open ‘round the clock,’” says Daphne Heffler. Faulty assumptions such as this are common at the outset of quality improvement journeys, say experts. “We found that was a solution we didn’t need to jump to,” says Heffler.
Clear goals and good communication have been crucial elements in the hospital’s ability to improve handoffs of AMI patients, shaving important minutes off their treatment time. “We had never established clear goals,” says Daphne Heffler, recalling the way things used to be. Joan Coleman concurs. “Telling someone to do something ‘quickly’ is not specific enough,” she says. Now, each step in the process has a time goal associated with it.
Coleman and Heffler both note that the work has created teams out of staff members who used to work independently. “This work did a lot to build a single team out of the ED staff and cath lab staff,” says Heffler. “They became one team with one goal. We all succeed or we all fail if we fail the patient.”
To celebrate the impressive progress the staff has made in meeting their goals, a breakdown of every “999 event” is posted on bulletin boards in the ED and cath lab. “The name of every single person involved is listed. From secretarial staff to housekeeping to cath staff, everyone on that team gets acknowledged for accomplishing the goal,” says Coleman. “Our ‘door-to-balloon’ times have been as low as 41 and 43 minutes, and that is hugely motivating.” And for “999” episodes where the 90-minute window is not met, the times associated with each part of the process are posted, though not with names. “Often there is a reason we didn’t meet the goal,” says Heffler, such as when a patient has a cardiac arrest in the ED and needs to be resuscitated. “But we scrutinize all the cases carefully and learn from each one.”
Results: McLeod defines “perfect care” for AMI patients as provision of all seven key components of care, or documentation of clear contraindication. Patients are only counted as having received “perfect care” if all seven care components are given in appropriate time frames and so documented, or that clear contraindications are documented.
In January 2001, 80 percent of AMI patients received perfect care. Through the introduction of new processes in the ED and cath lab, along with systematic reminders about aspirin and beta-blockers on admission and discharge, this figure increased to 100 percent by November 2003 and has essentially stayed there. Inpatient mortality for the same time period decreased and for the most part has held steady around 4 percent, nearly half of the average reported by hospitals to the Joint Commission on Accreditation of Healthcare Organizations and Centers for Medicare & Medicaid Services.
What Team Members Say: “We used to think setting a goal of 90 percent was great. Pursuing Perfection has taught us to ask ourselves which 10 percent of our patients would we not like to give perfect care to? Now we set our goals at 100 percent.” —Joan Coleman, RN, MN, Care Manager
“I feel confident that we provide state-of-the-art care to AMI patients. It gives me a feeling of satisfaction to know that when a patient comes here with an AMI, they are going to get treated as well as or better than anywhere else in the country.” —Alan Blaker, MD, Interventional Cardiologist
Learn More about Pursuing Perfection at McLeod Regional Medical Center:
Visit McLeod's website
Read about Improving Medication Safety at McLeod Regional Medical Center
Read about Recruiting and Retaining Nurses at McLeod Regional Medical Center
Read about Leadership Rounds at McLeod Regional Medical Center
Listen to a conversation with Donna Isgett, RN, MSN, Vice President for Clinical Effectiveness at McLeod Health
