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How to Reduce the Door to Balloon Time for AMI Patients
Windy Tanner
South University
NSG4029 Leadership in a Diverse Society
Dr. Evalyn Gossett
February 15, 2022
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How to Reduce the Door to Balloon Time for AMI Patients
Acute myocardial infarction is a medical emergency requiring advanced treatment with thrombolytics or percutaneous coronary intervention (PCI). The ideal reperfusion approach for ST-segment elevation myocardial infarction (STEMI) is PCI (Lawton et al., 2022). In 2013 the American College of Cardiology and the American Heart Association (AHA) established standards that facilities that can perform primary PCI should activate treatment by PCI within 90 minutes of first engagement. Nurse leaders must evaluate the factors and monitor if measures are
attainable, reviewing each critical point to assess the benchmarks and determine what barriers are
presently impeding the goal of the door to balloon time (D2B) in less than 90 minutes. Each component is vital in gathering, processing, and interpreting the information, and any delay can affect patient outcomes negatively. Decreasing the door to balloon time for STEMI patients can significantly reduce one-year mortality. Hospitals that continuously monitor and improve D2B times by minimizing internal and prehospital delays may enhance the outcomes of patients with ST-elevation and experiencing an AMI (Park et al., 2019).
Quality Initiative
Door to Balloon time at our facility for the last three months averages 75 minutes which is better than the 90-minute standard. Park, Choi, Lee, Kim, Hwang, and Rhee (2019) inform us that improving that measure closer to 60 minutes improves survival rates for STEMI patients. In completing chart reviews evaluating each process evaluating time, calculating the data points of how long it takes to complete a task. Data collection starts from the entry point of arrival at registration in ER, to triage, to EKG, and further reviewed for times of door to MD evaluation and review of 12 lead EKG. A flowsheet for documentation includes the times of each step, recording the paging out of the cardiac catheterization team, the team's response to the page,
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arrival to the lab by staff and the patient, access time, and then reperfusion time with a balloon or
export catheter device. Hospitals obtain benchmarks from databases like the National Cardiovascular Data Registry or the AHA website for best practices in hospitals that provide primary PCI. Quality indicator According to the AHA, the standard door to EKG time goal is less than 10 minutes from arrival with chest pain or shortness of breath to the emergency room physician reviewing the EKG (Maliszawski et al., 2020). Retrospective reviews reveal a delay in meeting this benchmark, which results in a delay in identifying a STEMI in progress. Delays in one step of the process result in a longer D2B time than desired. The average time of the door to EKG is 13.5 minutes over the review period of three months for patients exhibiting cardiac in origin complaints, averaging 25 EKGs performed daily in the emergency room. The EKG to physician notification and evaluation was less than the benchmark of 5 minutes. The goal is to review the ECG and paging of the STEMI to the cardiovascular team in less than 15 minutes of EKG. Our average was 8 minutes for 9 STEMI reviews. We observed our page response time less than 2 minutes, exceeding the national benchmark. The goal is for the catheterization team to arrive less
than 30 minutes from the page. Data reveals an average of 22 minutes for after-hour pages. The door to peripheral access time goal was 45 minutes, and the average over the three months was 44 minutes. The data reveals that the door to EKG requires further evaluation for delay causes. Fox and Diercks (2016) state that early diagnostic delays impact AMI patients' morbidity and mortality. Understanding the impact of timing and the quality of care by emergency room staff and protocols driven to help the team prioritize the EKG order and task completion (Maliszawski
et al., 2020).
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Best Practices
According to the American Heart Association and World Health Organization, coronary artery disease is a prominent foundation of death (Lawton et al., 2022). Acute myocardial infarction is a medical emergency where time is of the utmost essence to prevent heart damage or
death. A percutaneous coronary intervention involves a catheter-guided wire crossing the culprit lesion and using a balloon to open the artery or an export catheter to remove the clot preventing blood flow to the heart. For patients experiencing STEMI, the D2B time of fewer than 90 minutes is a well-established cardiovascular goal by AHA and the Society of Cardiovascular Angiography and Interventions (SCAI). High priority reperfusion strategies for STEMI patients improves the mortality rate. The recommendation is to utilize fibrinolytic treatment in situations where primary PCI is not feasible within 120 minutes of first medical contact. The American College of Cardiology (ACC) and AHA establish clinical guidelines for chest pain and STEMI care. The guidelines use systematic methods to evaluate, interpret and provide quality cardiovascular care (Lawton et al., 2022). Prompt identification of patients presenting with cardiac-specific complaints gets an electrocardiograph within 10 minutes of arrival. The patient is assessed and evaluated by a physician within 15 minutes of arrival, including the review of the
EKG. When ST elevation is present on the EKG tracing, hospital staff prepares to transfer the patient to a primary PCI-capable facility or the cardiac catheterization lab. If the facility is a PCI center that offers twenty-four-hour seven days a week care, the goal is to have a D2B time of fewer than 90 minutes (Levine et al., 2019). Patients are prepped for the procedure and taken to the cardiac catheterization lab within 30 minutes of the STEMI recognition. SCAI further states that benchmark data supports a STEMI page to peripheral access of forty-five minutes. Chhabra, Eagles, Kwok, and Perry (2019) recommend that facilities implement improvements in triage
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disposition, continuing education for triage personnel, and the availability of staff dedicated to immediate care to achieve best practices in cardiac care. Collaboration with all key stakeholders is vital while obtaining support to achieve best practices for STEMI patients. Implementing best practice guidelines, monitoring the quality of care, and reporting the data back to the team members organizations can improve door to balloon times and significantly impact STEMI outcomes (Butt et al., 2020). Financial Impact Coronary artery disease has many effects on the body. It decreases myocardial perfusion, resulting in angina due to the reduced blood flow resulting in myocardial infarction. It is also associated with peripheral artery disease (PAD), cerebrovascular disease, and aortic stenosis. CAD can result in physical disabilities, and other complications resulting in more extended hospital stays. The financial impact of STEMI patients related to difficulties can be astronomical.
If reperfusion of the blood flow to the heart does not occur timely, other organs are affected. Poor cardiac and organ perfusion can result in kidney damage, lifelong heart damage, lethal arrhythmias that can progress into cardiac arrest. Each complication increases the financial burden on the healthcare system to provide care. STEMI care generally requires 24 hours in the intensive care unit. They rapidly transfer to a progressive cardiac team and can ideally be discharged home within thirty-six to forty-eight hours post PCI. The effects of poor reperfusion result in longer intensive care days, increased medical tests, and advanced monitoring for complications, all impacting the hospitals' cost to provide care. The impact of the patient's cability to return to work and the toll on their physical, psychological, and economic quality of life is significant. The patient may experience lost wages, higher medical bills, permanent disability, or death due to poor quality of care and not adhering to best practices. Readmission
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rates for STEMI patients cause a substantial financial burden on the healthcare system. Prolonged hospitalization stays occur in patients that experience more complications post-
procedure or have other comorbidities (Kim et al., 2018). Value-based purchasing through the Centers for Medicare and Medicaid (CMS) can reduce reimbursement rates to hospitals that do not meet quality standards (Roberts et al., 2018). The quality of care that hospital staff provides directly impacts the organization's cost of care. The reimbursement rate can have devastating effects on patients and their loved ones. Therefore, the implementation of protocols to follow best practices improves the quality of care and drastically affects the financial stability of an organization (Burns and Pauly, 2018).
Plan, Do, Study, Act Model
The establishment of quality enhancement initiatives is best when leaders question the results, inquire about the problem, evaluate the accomplishment of goals, identify how a change affects a task or outcome, understands what observations result as an improvement, and what changes need to be made to improve (Murray, 2017). The Plan, Do, Study, Act (PDSA) is a continuous cycle that includes developing a plan to introduce a minor change, putting the plan into action, collecting data concerning the process, then analyzing the results to summarize for information regarding the change. The final step is to consider one of three actions, "adopt the change, adapt the change, or abandon the change" (Murray, 2017, p.161). Then the process starts
over in planning, doing, studying, then acting again. PDSA Project
The first results of chart reviews show that 13.5 minutes is the average for door to EKG time and will be the focus of this study for lowering the D2B time. The PDSA aims to reduce the
entrance to EKG time. The plan targets the patients entering the health system through the
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emergency room via private vehicle. Staff involvement is critical to understand the system delays, plan what changes need to occur, and provide education on the importance of meeting this benchmark. Interviews with registration and triage nurse will help identify the current challenges and possible changes that need considering. Baseline data has been present for the past three months. After the interviews, report the results to the emergency department chair for input on the barriers and possible solutions. The rollout for the change must include education and communication with clear protocols to implement the change. Data collection records patient
arrival with a chief complaint and the EKG completion time. After two weeks of the process adaptations, an analysis of the study will evaluate to see if the results show improvements in the door to EKG time. Interviews with staff will occur again to see if the changes were efficient and positively impacted the quality of care. Completion of a more profound evaluation will need to transpire to see if the reduction of the ingress to EKG interval improves the door to balloon time for STEMI patients. An assessment of the system occurs again, and implementation of the change officially ensues, modified, or retired. And the cycle repeats until the quality of care is meeting the expectations. The Plan-Do-Study-Act (PDSA) framework is an implementation model to execute changes to advance the quality of care (Donnelly and Kirk, 2015). The PDSA tool provides an improved structure process to derive trustworthy conclusions about their efficiency in obtaining the goals (Taylor et al., 2014).
Quality Improvement Measures
Quality improvement projects have several steps that nurse leaders must utilize. The first measure in reducing the D2B time is determining the deficiencies, establishing priorities, and selecting the appropriate method for assessing the performance, either structure, process, or outcome. Murray (2017) reports that implementing a combination of approaches provides a more
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detailed measurement of the quality of care and can help drive the improvement process. A combination approach will provide more data and insight into the structure and function, analyzing for causative factors for delays in obtaining timely EKGs. Some structure measures will include staffing with relation to the volume of the emergency department and the availability
of equipment. The arrival time to sign in, triage disposition, and EKG time related to D2B time will be the process measures, and each can be part of a process cause for delay. The outcome measurement will include patient satisfaction, length of stay, emergency room disposition, and readmission rates. Measuring each structure process and outcome approach can provide reliable data to understand where changes may need to occur. Retrospective chart reviews and concurrent
reviews during live rounding are ways that the data collection will take place for the measurement. Establishing which patients will be in the study is imperative to accurate data collection. We will only review patients that present to the emergency department via private vehicle and present with complaints of chest pain, shortness of breath, or another cardiac-related symptom. EMS always completes prehospital EKGs on this patient population, excluding them. The final measure will be how the process change implementation befalls. Hospitals widely use the Donabedian model to advance the quality criteria and enrich patient safety and quality of care
for patients (Binder et al., 2021).
Quality Tools
Murray (2017) instructs us that quality tools enhance data collection by identifying trends
potential problems and act as a storyboard to present data. Selecting the right tools is essential in any quality project to communicate the information and complete analysis of possible issues and aid in planning changes. A run chart is an excellent way to present data over time and reveal how
a process operates. In evaluating the EKG time, a run chart would be an efficient way to show
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the data with time to arrival to EKG completion in minutes on the vertical axis and hours in a day on the horizontal axis or days in a week. The median line would be the goal, and any data points above the line would indicate a fallout, and any issues below the line would be favorable for achieving the goal. A run chart is an excellent way to evaluate whether changes in the triage process and order of events had any change on EKG times. Evaluating a run chart by the hour can reveal if staffing and volume affect EKG times and prompt a modification in the staffing model. The fishbone diagram can analyze outliers to determine and identify causes for delays. The cause-and-effect chart is completed retrospectively and helps conduct a root cause of the problem and relate the outcome to structure issues (Murray, 2017). Another helpful tool to analyze the data would be the Pareto chart. It breaks down all the causes and can evaluate if minor issues play a more prominent contributing factor in the variance. Using the Pareto chart, decisions can follow, first focusing on applying specific changes to obtain the most considerable impact on the change model (Murray, 2017). Control charts help understand the variations in processes by dividing causes into specific categories that require different management reactions (Finison et al., 1993). The concept of the Pareto chart is appraising the contributing factors and the causes that have an immense burden on the system—identifying and addressing these causes first to improve the outcome faster, saving time and money (Alkiayat, 2021). Quality improvement projects can use a variety of tools. The run chart, fishbone diagram, and Pareto chart can help communicate the results and identify causes for the delay in the door to EKG time and further improve the measure and ultimately improve the D2B time. Leadership Model
Healthcare organizations need leadership active in quality improvement initiatives and can motivate others to meet the organization's goals. Transformational leadership represents a
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greater understanding of what is happening throughout the organization and encompasses moral character and guiding principles with a strong ethical responsibility to achieve success (Siangchokyoo et al., 2020). Leaders that guide others with a caring heart create a rich environment where all team members contribute to the mission statement and goals of the organization. They value the input of others and understand that people are what make an organization great. They tend to encourage others to reach their full potential while fostering an open-door policy for others to help in the decision-making (Murray, 2017). Boamah, Laschinger,
Wong, and Clarke (2018) state that transformational leadership affects job satisfaction and decreases adverse patient outcomes by empowering the nursing workforce. They support healthy
work environments by promoting autonomy in the nursing practice, which results in improved quality patient care and higher patient satisfaction scores (Boamah et al., 2018). Nursing leadership is fundamental to bestowing high-quality care and satisfactory consequences from patient outcomes. Conclusion
Consumers expect that healthcare organizations provide high-quality care. There are national benchmarks concerning quality, outcome, and process measures to compare data and guide ranking facilities. Clinical guidelines and best practices inform healthcare providers of the standard of care set by a group of medical peers. Nursing leaders must evaluate performance to ensure meeting patient safety measures and the quality of care exceeds the organization's expectations. Data tools such as run charts, fishbone diagrams, and Pareto charts assist managers in reporting, evaluating, and interpreting the data to make informed decisions about changes needed to improve processes. Poor quality of care and inadequate patient safety can lead to devastating financial impacts on the institution. CMS guides reimbursement rates to facilities
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through quality indicators. Transformational leadership can impact organizations by leading and implementing change. Nurses that develop their abilities to foster the motivation of others and inspire staff to soar are considered transformational leaders. Quality initiatives need involvement
from all staff to recognize barriers and implement positive changes to improve patient care. Reducing the door to EKG times can enhance the entrance to balloon time for STEMI patients having subsequent positive effects on patient survival, hospital quality indicator results, patient satisfaction, and financial impacts.
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