Abstract 80: STEMI System collaboration within the Steward Health Care System substantially reduces Door-to-Door-to-Balloon times: A system of care based model

Abstract

Introduction: The 2008 release of the American College of Cardiology/American Heart Association (ACC/AHA) Clinical Performance Measures for AMI prompted more thorough investigations of STEMI systems modeled after the AHA's Mission: Lifeline. Large retrospective studies have shown that response times vary substantially based on the structure of the individual system. Quality improvement studies should focus on a clearly defined system to accurately identify and apply beneficial measures. Hypothesis: We hypothesize that by analyzing process intervals between arrival at a non PCI hospital and PCI at a receiving hospital a focused Project Intervention (PI) strategy can improve overall Door-to-Door-to-Balloon (D2D2B) times within the ACC/AHA goal of 90 minutes. Methods: A Retrospective review of 31 patients with STEMI transferred from Carney Hospital to St. Elizabeth's Medical Center for PCI between January 2010 and December 2011. Records were collected from Carney Hospital Emergency Department, EMS transport providers, and St. Elizabeth's Medical Center Cardiac Catheterization Laboratory. Data was compiled for each and broken down into the following time intervals: Door to ECG, ECG to STEMI activation, ECG to EMS call, EMS call to arrival, EMS arrival to depart, EMS depart to PCI hospital arrival, Cath lab arrival to device deployment. In addition, door-in-door-out (DIDO) time segments were also analyzed. PI initiatives included: 1) ECG upon arrival 2) Immediate read 3) Remote activation of STEMI page 4) Preferred EMS provider 5) STEMI order sets 6) Adoption of EMS load and go procedure 7) Mapping of ideal transportation routes 8) PCI hospital efficiencies. Results: When comparing STEMI patient transfers before and after PI in July 2010 geometric mean D2D2B time decreased from 152 to 79 minutes ( t -Test, P =0.006), representing an 80% improvement in times under ACC/AHA 90 minute goal. In addition, cardiac catheterization lab arrival to device deployment times decreased from 51 to 22 minutes ( t -Test, P =0.037). Conclusions: This study focuses on a STEMI system of care model where key intervals are identified along with focused QI efforts designed to optimize efficiencies, limit practice variation, and reduce D2D2B times. Although long-term mortality was not assessed, ACC/AHA Mission: Lifeline goals have shown that reduction in door to PCI times correlate with improved survival and overall morbidity. Urgent demand exists for expansion of STEMI systems with implementation of the identified process interventions within both the Steward Health Care System and similar systems throughout the country.