Code 42: A Quality Initiative Program for Improving Door-to-Balloon Times in ST-Elevation Myocardial Infarction

ABSTRACT: Resurrection Medical Center implemented an initiative to address patients presenting with an ST-elevation myocardial infarction (STEMI). This facility followed their performance improvement process using evidence-based strategies in order to comply with standards set by accrediting bodies. Quality improvement staff nurses take an active role in this practice. Because of this quality initiative, there has been a positive effect on the quality of care on this specific patient population. Quality Today Quality initiatives are a hot topic in today’s healthcare arena. Healthcare consumers now can pick and choose where they receive healthcare services. Consumers want and expect the best treatment and care when they walk into a healthcare facility. Yet patients do not always receive the best in quality.1 Because of consumers’ interest in excellence and compliance with quality indicators, healthcare facilities are looking to improve their quality scores. Healthcare consumers can look up information and retrieve report card-type data on healthcare facilities. The Centers for Medicare and Medicaid Services (CMS) and the Hospital Quality Alliance (HQA) have developed a website where consumers can compare hospital quality data. After logging on to the website https://www. hospitalcompare.hhs.gov/, consumers are greeted with “Hospital Compare, a quality tool for adults.”2 Accrediting Bodies The CMS and The Joint Commission are two governing bodies that determine quality indicators. Quality indicators, or how well a healthcare facility complies with quality measures, can also be linked with financial reimbursement and insurance recognition. With the current economic uncertainty, most healthcare facilities are interested in increasing their compliance rates with quality indicators in order to secure financial compensation. The American College of Cardiology (ACC) and the American Heart Association (AHA) set standards of care comprehensive of the entire cardiac patient population. These standards range from the care of patients with congestive heart failure to those with unstable angina, to those presenting with myocardial infarction. Door-To-Balloon Time The ACC/AHA has provided a measure for the door-to-balloon time of patients presenting with ST-elevation myocardial infarction (STEMI). Initially, 120 minutes was the standard door-to-balloon time. In 2004, this standard was changed by the AHA/ACC to 90 minutes.4 Clinically, the clock starts when a patient presents to the healthcare facility and stops when the patient is treated with a primary percutaneous coronary intervention (PCI) and reperfusion flow is established. The goal is to open the artery causing the STEMI as quickly and safely as possible in order to promote reperfusion of the vessel.5 A delay in reperfusion has been linked with morbidity and mortality.4,6,7 Exceeding the Current Quality Measure Even though the time frame of 90 minutes is recommended by the ACC/AHA, CMS and The Joint Commission as a quality indicator, healthcare facilities continue to exceed the 90-minute goal.8,9 This is a major concern for healthcare facilities and patients. If public and private parties are setting evidence-based guidelines to be applied in practice, then why is this not happening? Looking into this concern led to a major performance improvement measure at Resurrection Medical Center (RMC). Performance Distinction/Quality Improvement at Resurrection Medical Center Code 42 Committee In 2006, the director of performance distinction brought the specific quality measure of door-to-balloon time into the limelight at RMC. At the time, 4.8% of patients presenting to RMC underwent PCI within the 90-minute time frame. This was below the goal of 97.1%, as set by the CMS. As a large, urban hospital in Chicago, improving our door-to-balloon time was an immediate focus of quality improvement. In order to expedite this quality improvement initiative, we followed the FOCUS-PDCA methodology as a process to improve delivery of care (Table 1). Several studies have suggested strategies for reducing door-to-balloon times.8,10–13 An interdisciplinary committee, called Code 42, was formed. The initial Code 42 committee team members included the director of performance distinction, the director of critical care, the medical directors of the emergency department (ED), cardiology and the cardiac catheterization laboratory (CCL), the ED nurse manager, CCL manager, CCL radiology technologist, quality improvement RNs, and the ED nurse educator. At the first meeting in July 2006, the Code 42 committee discussed strategies that could improve our facility’s door-to-balloon times. Strategy One The first strategy discussed recommended that the ED physician activate the CCL. Having the ED physician activate the CCL has been shown to reduce myocardial infarction size, patient length of stay, and total hospital costs.14 Activation of the CCL by the ED physician was not the practice at RMC. Prior to the implementation to Code 42, when a patient presented with chest pain or a suspected myocardial infarction, the cardiologist on call would physically go to see the patient in the ED. Then, after a STEMI was determined, the CCL was activated by the nursing supervisor. If a STEMI was identified during weekday working hours, the cardiologist called the CCL directly to alert the team. Activation of the CCL by the ED physician is now the current practice at RMC. Strategy Two Having a single call to a central paging system activate the CCL team was the second strategy for improving door-to-balloon times. As with the aforementioned strategy, RMC did not observe this in practice. Instead, when a STEMI was diagnosed and the cardiologist wanted to go to the CCL emergently, the nurse supervisor would page each of the four CCL team members individually. Each team member was then required to call back. This meant the nursing supervisor had to page four different numbers, wait for the callbacks and explain the details of the case four times. This practice was using up precious time for the patient. The Code 42 committee decided to implement a central page system at RMC. The call center was contacted and all of the CCL staff was informed of the change. Pagers were synchronized for a central page. This change in practice was relatively smooth and presented no extraneous challenges or issues. Strategy Three The third strategy was to have the ED physician alert the CCL staff while the patient is en route to the hospital. Yet this is one strategy the Code 42 committee has not applied in practice. Currently, the EMS system does not have the capability to transmit electrocardiograms (ECGs). On occasion, RMC does receive prehospital ECGs. A patient may present to an immediate care center, or his or her physician’s office, from which the ECG is then faxed to the ED. RMC will consider putting this strategy into practice in the future. Strategy Four The fourth strategy relates to the time frame in which the CCL team is expected to arrive at the cath lab after being paged. Bradley et al8 found 20 minutes to be a manageable time frame. The Code 42 committee decided on a 30-minute time frame, with the clock starting when the staff member receives the initial page. All CCL staff members must be in the hospital within 30 minutes of being paged. This is true of the interventional cardiologist as well. All the CCL staff has accepted this requirement, even those who may live farther than 30 minutes from the hospital. Strategy Five Having an attending cardiologist on site at all times is the fifth strategy. However, RMC does not require that an attending cardiologist be on site at any given time. Instead, there is an interventional cardiologist on call every day of the week. Like the CCL staff, they are expected to be within 30 minutes from the facility when they are on call. “The interventional cardiologists are expected to be no more than 30 minutes from the hospital during their call time. They know there are consequences if they (the cardiologist) are the cause of the delay and we exceed the 90-minute door-to-balloon time.” — Medical Director of Cardiology at RMC Strategy Six Using real-time data feedback for ED and CCL staff is the final strategy to try and positively affect door-to-balloon times. The Code 42 committee meets on a monthly basis and there is open communication between the ED, CCL and quality department when a patient presents with a STEMI. If a case exceeds the 90-minute door-to-balloon time, the chart is reviewed and the appropriate parties are re-educated regarding the urgency and importance of delivering high-quality care. Additional Changes In addition to the above strategies, the Code 42 committee suggested and implemented other improvements that have made an impact on door-to-balloon times. ECGs are now expected to be performed within 10 minutes of arrival for any patient presenting with chest pain or cardiac symptoms (Table 2). Originally, the ED department was staffed during daytime working hours with one ECG technician. Now, all the ED staff has been trained on performing ECGs so they can execute this task without delay. Since four CCL staff comprise an on-call team, the RN on call is able to go directly to the ED to receive a report and prepare the patient for the procedure, while the other team members prepare the CCL suite and pick up the medication keys. Continuous Staff Feedback and Review Every month, the Code 42 committee meets to review all the recent STEMI cases. The quality improvement nurses are responsible for chart review and abstraction on each patient. A paper tool is started by the ED staff to keep track of the critical time spots (Table 3). Included on the Code 42 tool is arrival time, ECG time, Code 42 page time, time the physician was paged, time the physician returned the page, time the CCL staff arrived in the ED, time the patient was on the table and time of reperfusion of the culprit artery. This paper tool is then validated by the quality distinction nurses. Any discrepancies are tracked and discussed. If a patient’s case exceeds the 90-minute door-to-balloon time, the chart is brought to the meeting. A thorough review of the chart is performed by the quality improvement nurses. In order to enforce a door-to-balloon time of ≤ 90 minutes, the Code 42 committee, backed by the medical directors and administration, can remove the interventional cardiologists from the call team if they exceed the 90-minute time frame on more than two occasions, which has not yet occurred. Accolades for the Code-42 Initiative The Code 42 committee has been actively participating in improving the quality of care and adhering to standards as set by the ACC/AHA and CMS. RMC reports to both CMS and the ACC Cath PCI Registry. Improving the door-to-balloon times of our STEMI patients is a major accomplishment (Table 4). Emphasizing the importance of treating these patients in a timely manner has been well received at RMC and is taken quite seriously. All who are involved in the prompt response to these patients are making a statement about the quality of care at RMC. Moving Forward The Code 42 committee is now looking at ways to streamline the care of patients who are already in-house and experience a STEMI. Take, for example, the patient who presents to the ED with a fractured hip, is sent to surgery and in the postoperative period, experiences a STEMI. The plan is to devise a protocol to address these patients who are already admitted to the hospital. Highlighting RMC’s success in achieving 90-minute door-to-balloon times for STEMI patients at a near-90% compliance rate positively affects staff morale, improves compliance rates with quality indicators, and allows the community to see RMC as a healthcare center that strives for excellence when it comes to taking care of cardiac patients. The Code 42 committee has been a catalyst for participation in other cardiac programs such as Get With the Guidelines (Coronary Artery Disease), a quality initiative through the AHA for cardiac patients, and D2B: An Alliance for Quality™, a Guidelines Applied in Practice Program introduced by the ACC. RMC is continuing to work on improvement activities in cardiac care, and a nurse practitioner has been hired to oversee the management of patients with coronary artery disease. An interdisciplinary team proved to be the most effective approach in improving our center’s door-to-balloon times. Reviewing the evidence-based research and allowing for open communication are two elements that have added to the success of the Code 42 committee and its work. Following the quality protocol of FOCUS-PDCA has proven to positively affect RMC’s door-to-balloon times in STEMI patients. Moscussi and Eagle15 state: “Achieving the 90-minute gold standard is possible, but it will require sustained investment on the part of institutions and caregivers alike.” RMC can proudly state that we have achieved and will continue to adhere to the 90-minute gold standard. The author can be contacted at: Katherine.Kelly@reshealthcare.org

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