Changing ED Culture to Improve Care for Patients with STEMI: The Primary PCI Project

Abstract

The American College of Cardiology and the American Heart Association (ACC/AHA) recommend treating ST-segment elevation myocardial infarction (STEMI) with primary percutaneous coronary intervention (PCI) within 90 (± 30) minutes of ED arrival. To reduce treatment delays created by inefficient hospital systems, a performance improvement team was convened. The purpose of this study was to examine the effect that ED professional practice and system changes had on reducing time to primary PCI. A descriptive study was conducted to determine adherence to the ACC/AHA standard and hospital performance measures (≤50 minutes ED door-to-laboratory time and ≤40 minutes laboratory-to-balloon time). All patients with STEMI admitted from December 1998 to December 2003 to this emergency department, a level I trauma center located in the Northeast, were included. Approval for conducting this study was obtained from this institution's Human Subjects Research Review Committee. Five key success factors for accelerating improvement were applied, including committed nurse-physician champions, shared goals, system solutions to eliminate barriers, credible and timely data feedback, and substantial administrative support. The ED nursing director and cardiac clinical nurse specialist, having expert knowledge and skill in practice and performance improvement, served as clinical champions. Collaborating with physician champions, the ED culture transformed from one of inertia to urgency. Project interventions included implementing the STEMI protocol with explicit goals from ED arrival (EKG ≤10 minutes, ED attending diagnosis ≤20 minutes, and patient transfer to laboratory ≤45 minutes), staff education, establishing a system to assure credibility of data, prospective data collection with real-time performance feedback, root-cause analysis of delayed cases, implementation and evaluation of improvement interventions, and ED nursing administrative support by holding staff accountable for performance. Intervals that measured ED performance were: ED arrival to first EKG, EKG to diagnosis, and diagnosis to laboratory. Total time to PCI (minutes) was measured from time of ED arrival to first balloon inflation. Approximately 125 primary PCIs were performed annually. By the second year, ED performance improved from a mean of 103 to 47 minutes. Total time to PCI improved from a mean of 162 to 79 minutes. ED performance contributed significantly to the overall reduction in time to PCI, because laboratory performance was consistently within 40 minutes. Improvements were sustained over time. Clinically significant improvement in performance was accomplished using a model that emphasized the role of nurse champions. Nurses selected for this role must have proven ability to navigate the health care system, build trust across disciplines and departments, be innovative, maintain momentum for change, remain focused on the shared goal, and foster a blameless culture that is patient-centered with zero tolerance for missed opportunities to provide excellence in nursing care. This model may be replicated to other practice environments and disease conditions.