To improve the care of acute myocardial infarction (AMI) patients at Baptist Memorial Hospital-Memphis by implementing evidence-based care practices.

Specific goals (achieve within six months using principles of deliberate design for reliability):

• Increase smoking cessation advice/counseling in patients with a history of smoking cigarettes to 95 percent or greater
• Increase PCI received within 120 minutes of hospital arrival to 95 percent or greater
• Decrease door-to-PCI median time to less than or equal to 90 minutes

• Adult smoking cessation advice/counseling rate
• Median door-to-PCI (percutaneous coronary intervention) time
• PCI received within 120 minutes of hospital arrival rate

During the past year, we participated in the IHI Innovation Community for Improving Reliability in Key Clinical Areas. Our core measure teams applied the principles of reliability to clinical processes using a three-tier design strategy: standardization (prevent initial failure), redundancy (identify and mitigate failure), and redesign (based on failure modes). The AMI team initially focused on two clinical processes for improvement: door-to-PCI (a timed measure) and smoking cessation advice/counseling  (a process measure). 

Smoking Cessation Advice/Counseling

• Added smoking assessment/cessation education to the Nursing Admission Assessment form.
• Pre-printed smoking cessation education on the Interdisciplinary Patient Education form as a prompter to assess/educate. All patient education is documented on this form. 
• Added smoking cessation advice statement to the Patient Discharge Instructions form.
• Initiated process for respiratory therapists to assess smoking history of all patients on the Respiratory Care Protocol and provide smoking cessation education.
• Instituted “RC Smoke” process — a computer entry order for respiratory care services to provide smoking cessation education. 
• Collaborated with Admissions and Respiratory Care Service to identify smokers in Admissions for smoking cessation education. Admissions added a checkbox to the daily admissions form to assess for smoking and provided a daily list to Respiratory Care for smoking cessation education.
• Incorporated check for smoking cessation education during multidisciplinary rounds on Cardiac Medicine units. 
• Initiated Quality Indicator checklist for case manager verification of core measure compliance.
• Initiated smoking cessation education and avoidance of secondhand smoke advice for all patients receiving Cardiac Rehab Services. This made providing smoking cessation education a routine part of the staff’s work. Revised Cardiac Rehab documentation sticker to include smoking cessation education. 
• Testing AMI HF Discharge Checklist for physician to verify/document that smoking advice provided.
• Developed Nursing Discharge Checklist to verify core measure compliance.

Door-to-PCI Time Process for ST Segment Elevated Myocardial Infarction (STEMI)

• Developed standardized Emergency Department (ED) Chest Pain Track order sets.
• Created a timeline and set goals for specific door-to-PCI processes (e.g., time to EKG: less than or equal to 10 minutes, etc). In order to meet the less than or equal to 90 minute goal for door-to-PCI, the ED and Cath Lab were each allotted 45 minutes for their processes. 
• Conducted drill-down on cases with door-to-PCI times greater than 90 minutes and provided feedback to physicians and staff. 
• Implemented a process for ED to verify by 9:00 AM the preferred cardiac interventionalist for the cardiologist on-call after 5:00 PM. 
• Revised guidelines for the ED staff to identify atypical chest pain presentations. This prompts the staff to recognize chest pain equivalent symptoms and to initiate chest pain care processes. 
• Expedited door to EKG time by sending walk-in patients presenting with typical or atypical chest pain directly for EKG before Triage process. Triage assessment process continued after the EKG. 
• Purchased digital clocks for ED, synchronized all clock times, including clocks on EKG machines. 
• Implemented “Code STEMI” overhead page in ED to immediately alert all ED staff of STEMI patient and initiate a parallel team response. Defined each team member’s role. 
• Initiated the setting of a timer by the Triage nurse to track the timed process and to increase staff awareness of time. 
• Revised transfer process so that Cath Lab nurse goes to the ED to transfer the patient to the Cath Lab. This process promotes communication between ED and Cath Lab nurses and prevents unnecessary delays in transferring patients to the Cath Lab. 
• Implemented 9-1-1 page for all STEMI to notify the Cardiac Interventionalist and Cath Lab simultaneously. 
• Implemented ED/Lab process to expedite reporting of results directly to Cath Lab. ED labels lab request slip with “STEMI” to alert lab to run point of service and call results to Cath Lab.

By applying reliability strategies to the design of care processes, we improved performance in smoking cessation education and door-to-PCI timeliness. Implementing the “Code STEMI” and defining each team member’s role clearly sparked the commitment to improving the door-to-PCI time. The staff and physicians are excited over the improvements. Redesign of smoking cessation education processes resulted in improvement in all three core measure diagnoses: AMI, heart failure, and pneumonia. 

Lessons Learned:

• Target a specific measure for improvement.
• Focus on a segmented population.
• Test small, spread, implement.
• Conduct multidisciplinary spot checks to determine effectiveness of processes and redundancies.
• Involve physicians and front-line staff to increase buy-in.
• Drill down on all data — look for trends/reasons for failure.
• Provide data feedback to staff and physicians.
• Celebrate success!

Mary Ann Northern, RN, BA, Performance Improvement Specialist
Baptist Memorial Hospital-Memphis
maryann.northern@bmhcc.org

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