Communication: The Key to Optimal Care Processes for Heart and Brain Attacks

When it comes to a hospital’s image in the marketplace, differentiating characteristics can do much to solidify a positive reputation. Leaders at all levels of the organization, especially those within the cardiovascular service line, must consider this important question: What makes our facility better than another? This question is often harder to answer than you might think! And knowing the answer is even more critical in a competitive market where multiple hospitals are vying for the ‘top spot.’ For instance, do you have state-of-the-art equipment, renowned physicians, a new facility? There are many other elements to consider, all of which undoubtedly contribute to making your hospital stand out. But tangible elements aren’t the only ones to consider. What about the intangibles — the essence of what makes your service line unique? Communication is one of these intangibles, and one we believe is the “glue” that brings all of the tangible aspects together. Communication in EVERY form and forum is essential to cardiac program success, particularly for the emergent population, including those experiencing heart attacks and brain attacks (i.e. stroke). When diagnosing and treating these patients, quick and efficient communication needs to occur, because it leads to quality outcomes. If communication is lacking, the patient is put at risk for further complications or even death...time is heart muscle AND time is brain tissue. The more time that passes before treatment for either of these conditions, the more likely the patient’s condition will deteriorate, which could lead to less than optimal outcomes. To help establish communication standards for the triage of emergent patients, The American College of Cardiology (ACC) and the Brain Attack Coalition (BAC) set national benchmarks for time-to-treatment. The ACC recommends a door-to-balloon time of less than 90 minutes from arrival for STEMI patients; while the BAC recommends a door-to-CT interpretation time of less than 45 minutes. How do you make sure that your facility is communicating effectively in order to mobilize resources to meet these benchmarks and quickly improve the condition of the patient? In order to achieve successful communication and therefore quality outcomes, we recommend a solid operational care process that includes optimal patient flow, solid pre-hospital (EMS) linkages, and, perhaps most critical, engaged physicians to drive clinical decision-making. Optimal Patient Flow Key steps must be taken to evaluate the patient from start to finish, which requires mapping out patient flow across the entire continuum of care. This process is grueling because it needs to be detailed and meticulous, but is absolutely necessary for successful communication and resultant quality outcomes. When outlining patient flow, the areas of focus should be: defining processes based on the location of the acute attack (field vs. inpatient unit); timing and transmission of EKG for STEMI or CT for stroke; necessary laboratory studies (EKG for STEMI or CT for stroke); care team alert notification; response times; communication with other departments for associated care processes; post-procedure care protocols through discharge and follow-up care. Efforts to establish optimal patient flow should encompass an evaluation of the full continuum of care. In a sense, mapping out the patient flow provides the rules of communication. Indeed, it should clearly identify the roles and responsibilities of each individual involved with the patient across the full continuum of care. For instance: • Who is responsible for activation of the “on call” STEMI or stroke team? • Which physician or specialist is on-call when? • Who is documenting the time of each relevant measure (e.g., time patient arrived, time of EKG, time of balloon inflation)? If one person does not follow their communication responsibility, a delay in treatment could potentially occur, which may ultimately affect outcomes. Once patient flow and responsibilities are initially agreed upon, we advocate multiple unannounced mock runs several weeks before going ‘live’ and/or on an ongoing basis to test any newly established patient flow for ensuring compliance with existing standards. These processes take commitment, time, and effort, but the hard work will undoubtedly be worth it as streamlined care and excellent quality outcomes follow. Pre-Hospital Linkages Unless a patient walks into the emergency room on their own, EMS is typically the first responder to a patient emergency in the community. If your facility does not have solid communication with your EMS providers, you must start to develop this relationship now! Engage EMS from the beginning of the patient flow discussions since they are the front line of the pre-hospital process. In our experience, EMS is typically left out of the loop until right before a program goes ‘live,’ which can cause problems immediately prior to start-up. Most, if not all, EMS providers have existing cardiac and/or stroke protocols in place. Some EMS providers may even have digital capability, allowing 12-lead transmission from the field so as to verify an active STEMI. Several studies related to this technology have shown it made a significant impact on reducing door-to-balloon times. For stroke patients, the initial CT to establish whether the stroke is hemorrhagic or ischemic is paramount to directing these subsequent course of care. As community providers look to expand existing cardiovascular services to treat the STEMI and/or stroke patient population, EMS will begin to see your facility as one striving for quality and excellence. A strong link will also ensure that EMS knows first-hand that your hospital staff is able to take care of heart attack and stroke patients effectively and efficiently. With this knowledge, EMS providers will be less likely to bypass your facility in the future. In conjunction with patient flow participation, additional ways to involve EMS providers are to: • Allow free meals in your cafeteria for the EMS team; • Build an EMS lounge off of the emergency department, or create a dedicated space for EMTs; • Offer computer access or wireless capabilities; • Host EMS and ED luncheons that provide educational credits; • Extend invitations to on-going cath conference sessions; • Extend invitations to case reviews of patients brought to your facility in order to integrate them in the performance improvement process. Involving EMS may be easier for some facilities than others for various reasons, but, either way, this strategy is an essential piece of the hospital’s operational success related to heart attack and stroke — one that is too often overlooked. Strong Physician Relationships We know no facility is a stranger to physician conflict. Physician involvement in emergent care and collaboration from every department affected by heart attack or stroke patients is the quintessential element of communication, though also the most difficult to achieve. Since these patients touch multiple areas of the hospital, multiple specialties and physician groups need to be involved. How do you bring different specialists and/or practice groups to sit at the same table? We advocate that our clients appoint a physician champion — one who possesses a multi-disciplinary vision and approach to quality patient care. This individual must also possess a clear understanding of the vision and mission of the hospital, as well as the cardiac and/or stroke program. The champion must serve as an advocate for both the physicians and the hospital — balancing the interests of both to find solutions that best serve the patient. Cardiologists, radiologists, neurologists, neurosurgeons, ED physicians, hospitalists, and intensivists must all know their role, and also understand how their communication relates to successfully treating heart attacks and strokes. From a physician perspective, there are several other communication issues that must be addressed, such as up-to-date on-call schedules, activation, and call-back and arrival times, that are critical to a multi-disciplinary approach to patient care and quality outcomes. There are implications for all of the above on the day-to-day operations and care delivery. Any breaks in this communication chain can wreak havoc on efforts to achieve efficiency and quality. Furthermore, effective physician leaders clearly communicate care priorities with each other and the cooperation that is necessary across disciplines. Hospitals must find ways to work with physicians to find out what drives them to practice at the facility, how the organization measures up to other hospitals where they practice, why they refer cases to one another, and also why they may refer cases out of your facility. This information must then be filtered back through administrative and operational channels to assure that positive program features are reinforced, issues are addressed, and solutions implemented. Doing so can ensure that the needs of the physician customer are considered a priority and that attention is given to satisfying them. So, what makes your facility better than another when treating heart attack and stroke patients? The answer should be “communication”! The results: • Developing efficient, timely, and tested patient flows across the continuum of care will lessen confusion and strengthen accountability. • Engaging EMS from the start will have a downstream effect of new patients, and also raise perception within the community. • Implementing a multi-disciplinary approach with a physician champion will help solidify physician support and cooperation. Each of these objectives requires clear and consistent communication. No doubt, organizations that fail to achieve effective communication within their teams may compromise patient care. Such a scenario can also lead to shortfalls in program achievement. A structured approach to communication should be embedded into internal meetings and collaboration with external stakeholders, such as EMS providers. Ongoing efforts to evaluate and improve communication within the program infrastructures that support stroke and STEMI care can translate to improved outcomes and support for program growth, progress, and momentum. Amy is a Manager of Consulting Services and Kristin is a Consultant at Corazon, Inc., offering consulting, recruitment, and interim management for the heart, vascular, and stroke specialties. To learn more about Corazon, visit www.corazoninc.com or call (412) 364-8200. To reach the authors, email anewell@ corazoninc.com or kturkovich@ corazoninc.com.

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