St. Luke's Episcopal Hospital, home of the Texas Heart Institute, figures prominently in the campus of the Texas Medical Center in Houston, Texas. It boasts one of the largest cardiac catheterization laboratories in the world, devoting three labs to electrophysiology studies (cardiac mapping, bi-ventricular automatic implantable cardioverter defibrillators [AICD], pulmonary vein ablations, permanent pacemakers [PPM]), three labs to peripheral vascular procedures (abdominal aortic aneurysm repair, limb salvage, carotid and peripheral stenting), and the remaining five labs to coronary procedures (diagnostic, percutaneous coronary interventions [PCI], atrial septal defect/patent foramen ovale [ASD/PFO] closure, valvuloplasty, Rotoblater, laser, etc.). St. Luke’s also has two hybrid suites located within the cardiovascular operating rooms that perform combination percutaneous and surgical procedures. The lab is open for scheduled procedures 16 hours per day, Monday through Friday, and 12 hours on Saturday and Sunday. The remaining hours (Monday-Friday 11pm-7am, and Saturday-Sunday 7pm-7am), the lab is available for emergencies, covered by a four-person call crew consisting of 2 RNs and 2 technologists. All members of the clinical staff take call duty and must be cross-trained to function effectively in all types of emergency cases, including PCI for STEMI patients.

As we all know, the public is still very much in denial about heart disease. Patients frequently ignore signs and symptoms of a heart attack, instead of calling 911 for immediate assistance. Patients or family members will drive to a hospital instead of calling for an ambulance when all signs indicate they are experiencing a myocardial infarction. While our efforts do not address these issues, we have worked to assure that once a patient arrives at our hospital, each minute will be used effectively and efficiently to provide the patient with the best chance for recovery and a healthy life.

It is pretty straightforward for any hospital to get a STEMI patient to the cath lab when the emergency medical team (EMS) gives you a 30-minute warning prior to delivering the patient to the ED. It also presents less of a challenge in the middle of the day with all resources readily available in-house. Making the door-to-balloon time in < 90 minutes when the patient drives himself to the hospital at 2 am and then walks into the ED is an entirely different ballgame. Upon arrival to the emergency room, patients can present with a wide range of symptoms and complaints when they are having a STEMI. Even when the signs are immediately recognized, both large metropolitan medical centers and smaller suburban hospitals, generally do not have cath lab staff or staff cardiologist in the building. To achieve this target, it was obvious to the STEMI Committee that we needed to make some changes and develop a standardized plan.

It is interesting to note that usually the resources available to a large metropolitan hospital collaborate in favor of delivering efficient and quality service to patients. In working to achieve the < 90-minute admit to time of treatment in our hospital, however, we discovered that an abundance of resources and being located in one of the largest medical centers in the world did not always work to our advantage! One of the first challenges the team faced was assuring well-trained CCL staff could be available within a few minutes of a STEMI patient entering our emergency room. Most of the employees in our hospital do not live within a few minutes of the hospital. Busy parking garages were another obstacle to our prompt response. In fact, many of our cardiac cath lab nurses and technologists live 20 to 30 miles from the hospital and have to deal with freeway traffic and constant freeway construction 24 hours a day in their commute. Additionally, the number of cardiologists and emergency room physicians on staff at our hospital created another level of complexity in creating a standard treatment practice for STEMI patients.

Everyone’s actions needed to be coordinated to assure patient care progressed without waiting for a phone call or page to be returned. Even the decision about which supplies and equipment needed to be pulled had to be discussed and communicated via a standard treatment plan.

Suburban hospitals may find some of these issues are not relevant to them, as they are frequently located in residential areas (hospital staff may live nearby).

Also, smaller hospitals have fewer emergency department (ED) physicians and cardiologists who are involved in responding to STEMI emergencies on a more frequent and regular basis.

Despite these challenges, St. Luke’s made a commitment to not only meet but to try and exceed the AHA/ACC guidelines for STEMI patient care. In making this commitment, we knew some significant changes would have to be made, not only in how the ED handled STEMI patients, but in the way the cardiac catheterization laboratory participated in the process.

Without administrative support and a positive team effort, the success of our program would not have happened so quickly. Prior to forming a multi-disciplinary team of physicians, nurses, non-medical staff (admitting services, page operators, medical records) and hospital administration, we were reporting an average of less than 25% compliance during the first five months of 2007. Since June of 2007, we can proudly boast a 100% record with a mean door-to-balloon time of less than 75 minutes. How did it happen? In a word, standardization. It also took a great deal of determination and plain old common sense. We quickly learned that the standardization of all aspects of care, from treatment protocols to administrative processes, translates into a more efficient patient care delivery system. Time is muscle, which is what the < 90-minute door-to-balloon time is all about an effort to provide better patient outcomes.

Experienced administrators and managers have long known that if you want an issue to be resolved (and remain resolved), you enlist the help of the people that actually perform the task. This is Management 101. Empower the clinicians to find and implement solutions. We began with a few staff nurses from the cardiac cath lab and ED, and a small focus committee that quickly grew to an interdepartmental and multi-disciplinary team made up of physicians, nurses, and non-medical participants. Our Health System Board recognized the importance of this issue and wanted the group to succeed. The STEMI committee, as it came to be called, soon became a stand-alone committee reporting to the hospital core measure group and the hospital CEO. Cardiologists and ED physicians were asked to join the committee and provide physician peer review and medical direction to the initiative.

One of the first tasks of the team evaluating STEMI performance was to make a list of challenges to success. Communication issues were a common theme. Committee members prioritized the list and then got to work. It is important to remember that not everything is going to work the first time around. Following is a partial list of issues we compiled that impacted the delivery of efficient care for STEMI patients:

1. Many cardiac cath lab staff live greater than 30 minutes from the hospital.

2. On any given STEMI case, there are approximately 10-12 medical and non-medical staff that may be involved with direct patient care. This small handful of people are drawn from the following large group of staff at St. Luke’s. Consistency (standardization) means that all need to agree and follow protocols and processes.

44 cardiologists on staff with interventional privileges.

40 ED physicians

22 cardiology fellows

60 cardiac cath lab staff assigned to take call

80 ED nursing staff

17 page operators

4 rapid response team members and nursing supervisors.

3. Less than optimal communication between cardiac cath lab staff members when responding to on-call procedures.

4. Lack of a written standard treatment protocol for STEMI patients in the ED (only acute MI). Yes, STEMI patients are different from other AMI patients.

5. Lack of standard catheterization protocols and equipment.

6. Lack of guidelines for initiating a STEMI page. A less-than- efficient paging system (physician answering services, ED vs. hospital operator paging).

7. Turf issues between ED and cardiac cath lab staff.

8. Turf issues between cardiologists.

9. Less-than-optimal communication between all members of the patient care team.

10. Need for staff education (ED and cardiac cath lab) on STEMI patient care priorities of treatment.

11. No system for procedure/ process review.

12. Lack of time performance guidelines for the different segments of patient care.

13. An absence of EKG telemetry transmission between ED and EMS for advanced hospital notification.

14. Parking for cardiac cath lab staff responding to emergency was less than optimal.

This one article does not permit a full accounting of how St. Luke’s addressed each of these challenges and concerns, but essentially, we found solutions in the standardization of protocols and processes.

One significant change was to empower the ED triage nurses to initiate the STEMI page without an ED physician’s or cardiologist’s direction. Before instituting this change, only a cardiologist could activate the cardiac cath lab team. We went one step further and empowered the triage nurse to activate the STEMI protocol. If a patient presented with a complaint of chest pain (or associated symptoms) then a 12-lead EKG was immediately performed. Since the triage nurse was the first clinician to look at the EKG, it made sense to empower the triage nurse to initiate the STEMI page. This change in practice easily took 20-30 minutes off the total treatment time. There was some concern expressed that nurses cannot and should not diagnose, but having the triage nurse accept this responsibility was a procedural/process issue, not a medical diagnostic issue. The page merely put all the players in motion and got them to the patient more efficiently. Before any patient went to the cardiac cath lab, he or she was seen by one of the cardiology fellows (CCU fellow or Cardiology House Officer) or a staff cardiologist to confirm that the ST-elevation was due to MI. Yes, we initially had a lot of false alarms. Did we care? No. We felt strongly that 100 false positives were better than just one false negative. We also decided that if the cardiac cath lab call crew got paged and then cancelled, then they were still paid. It is hoped that as a result of experience and time, these false alarms will decrease.

Another significant change in process was to the notification system. Prior to instituting the paging protocol, the ED secretary notified the cardiologist via an answering service. Even during the day, the cardiologist’s office had to be called to contact the cardiologist (either a private or AMI cardiologist on ED call). Since instituting the protocol, the AMI cardiologist on call to the ED is contacted first and is included in the standardized paging protocol. If the patient had a private cardiologist, he was contacted by the ED unit secretary and if he responded before the patient went to the cardiac cath lab, then he assumed the role of primary medical direction upon arrival. Sometimes, however, the private cardiologist would arrive after the procedure had started in the cath lab. Hospital administration and all the medical staff cardiologists agreed that the most important thing was to get the patient to the lab and the artery open. The cardiologists at St. Luke’s understand the importance of this decision and work together. If at some point in the treatment process the private cardiologist arrives, then they mutually agree upon who will finish the procedure. Billing issues for the on-call AMI cardiologist were handled by the hospital administration.

Ultimately, the key is empowering the clinicians. Keeping the lines of communication open for new ideas and encouraging feedback from all who participate in the process is essential to continued success. This includes the ED physicians, cardiologists, cardiology fellows, rapid response nurses, ED nurses, and cath lab nurses and technologists. The importance of getting all the clinicians and staff to buy into the process to improve the quality of patient care cannot be underestimated. All the hands-on patient caregivers need to know that what they are doing makes a difference. During the last few months at St. Luke’s, each and every case has been reviewed for time parameter performance criteria and medical outcome. We are fortunate to have an internal email system that that can be accessed by every employee and physician. Utilizing hospital email provides a quick, efficient way to not only let the staff know that we made the less than 90-minute goal, but also provides an opportunity for education. Whenever possible, follow-up emails are sent within 24-48 hours after the PCI procedure. These e-mail reports are of a generic nature and review procedural performance without disclosing any pertinent patient medical record information that might violate HIPPA standards. In composing these e-mails, I can review the EKG, the ED record, angiograms, talk to the rapid response nurse who assisted with transport to the CCL, talk with the cardiology fellow and staff cardiologist and then draw all this information into a concise report that lets everyone know not only what happened to the patient, but why it happened. For example, the last email sent out reviewed the case of a patient with a totally occluded right coronary artery (RCA). The email discussed the case in detail. Angiograms confirmed a totally occluded RCA, consistent with the EKG that showed ST-elevation in the inferior leads, supporting the need for a physician order to complete a right-sided EKG when the EKG suggests inferior involvement. It would also explain the bradycardia and why the cardiologist chose to put a temporary pacer wire in during the procedure, because an occluded RCA can have a significant effect on the A-V node, etc.

As each of the staff has a chance to participate in these procedures, it extends and reinforces our clinical knowledge. The benefits of providing this kind of follow-up have had a very positive impact on the staff.

Another significant challenge was to develop a standardized equipment list and outline a suggested procedure protocol for the cardiac cath lab, an idea suggested by one of the staff cardiologists at St. Luke’s. Cardiologists at St. Luke’s Episcopal Hospital are used to doing complicated, high-risk PCI procedures, one of the reasons for our very existence. Our inventory of supplies is probably double or triple what you might find in a smaller hospital. For instance, our cardiologists may study films for some time before deciding what particular guiding catheter should be used in a complex case. STEMI patients meant a change in mindset for the cardiologist. We have over 40 cardiologists on staff that have interventional privileges. Sixteen of these cardiologists take regular AMI call for the ED. Any one of these physicians might be called upon to perform a PCI for a STEMI patient. St. Luke’s is also a teaching hospital with a four-year cardiology fellowship program. STEMI patients need to get their artery open and they need it opened immediately. While STEMI patients are certainly an opportunity to learn, it is not the best time to teach a new fellow how to seat a guiding catheter or pass a wire across a lesion. Getting so many cardiologists to agree on a small standard inventory of guiding catheters, wires, and a couple of balloons that could fit on one moveable cart was not an easy task. Once the list was decided upon and the cart stocked, I placed a small sign on the cart that said, Just get a guide, get a wire, and get a balloon and GET’ER DONE! (my attempt at a little levity in an otherwise serious and stressful situation.)

In conclusion, helping to set up a standardized STEMI program at St. Luke’s has been a rewarding experience. We have reduced our mean door-to-balloon time from 111 minutes for the first five months of 2007 to 57 minutes for the following five months. Compliance in meeting the < 90 minutes goal has gone from < 25% to 100%. Through administrative support, physician cooperation, and the active and positive participation of the hospital staff, we have put procedures and processes in place that will ensure that the standard of a less than 90-minute door-to-balloon time will be consistently met, whether St. Luke’s sees one or two STEMI patients per month or fifty.

Larry H. Brown can be contacted at lbrown@sleh.com