Transcript B)McKenney - Feedback Post MI

An Immediate Nursing Feedback
Program for
Primary PCI for ST-segment
Elevation Myocardial Infarction
Karen Mckenny RN, Theresa Fortner RN, Cheryl McNeil RN,
Carol Woods RN, Shirley Gadbois RN, Heidi Igneri RN
Joe Hastings RN, and Harold L. Dauerman,MD
Fletcher Allen Health Care
University of Vermont, Burlington, Vermont
Background
 Based on DANAMI 2. Vermont adopts a
primary PCI Regional Transfer Program 2007
 4 Rural Hospitals
 35 miles median travel distance
 2008 (Nov) Immediate Nurse to Nurse
Feedback program initiated.
The Vermont Rural STEMI Program:
There is Only One Interventional
Cardiology/PCI Center in the State of
Vermont
Vermont
Vermont Population
600, 000
PCI Procedures at
UVM/FAHC: 1400
PCI/year
Objectives
To determine a role for cardiovascular catheterization
laboratory nursing in improving quality of care for
regional primary PCI programs
To define the current level of nursing satisfaction with
regional STEMI transfer programs
To implement a nurse to nurse immediate feedback
program to improve education and program outcomes
To provide a semi-annual roundtable led by and for
nursing to systematically address areas of need including
potential sources of transfer delay and/or
miscommunication.
Methods
 All patients with STEMI referred for primary
PCI to a single PCI center (Fletcher
Allen/Univ. of Vermont) enrolled in a
dedicated prospective registry
 Study Period: November 2008 - December
2009
 The current study includes 1 PCI center and
4 regional STEMI referral centers
Methods
 A pre-intervention survey of STEMI referral centers
was completed in November 2008
 A post intervention survey of STEMI referral centers
was completed 9 months later
 Differences between Survey endpoints were
compared using chi square statistical techniques.
 Changes in Door to Balloon Times and Triage Times
were compared Quarter 1 vs Quarter 4 using
student’s t test.
Pre-Intervention Survey Tool
8 questions:
 Satisfaction regarding feedback
 5 Point Lickert Scale
 1= no feedback, 5 = excellent
feedback
 Interest in Round Table meetings
 Educational Topics of interest
STEMI Feedback Form: Dedicated, Faxed
Table of Times and Events To Both
Nursing and Physicians
Patient Name:
Time
Date of STEMI: 01/05/09
STEMI referral Hospital:
Time of arrival to referring ED
Time of first FIELD/EMS/AMBULANCE ECG
Copley
3:29
N/A
Time of first ED ECG
3:29
Time FAHC cardiology paged with STEMI
notification
3:47
Ambulance Service used
VT EMS
Time of departure by ambulance
3:47
Time of arrival in lab
4:30
Time of open artery (balloon inflation)
4:45
Door to Open Artery total time ( their door to
our balloon)
OUR GOAL IS
1:15 < 90 min
STEMI Feedback Form: Dedicated, Faxed
Table of Times and Events To Both
Nursing and Physicians
Ambulance EKG to open artery
n/a
Medications given prior to transport: ASA 325______
X
Clopidogrel 600_____
X
Unfractionated Heparin Bolus____________
X
Referring ED attending:
Dr. STEMI
Procedure details: Affected artery_______%
stenosis_____
Hospital Adverse Events: Death___Emergent
CABG____ Stroke____ Major Bleeding_____ Repeat
PCI____
Transport Related
eventsVT____VF____CPR____Defib__
Follow up phone call done/date
Nurse x
1/5/09
Feedback Program
 Feedback form filled out by Nurse Led Team
at Primary PCI Site
 Follow up phone call within 24-48 hours to
referring ED nurse for feedback and patient
outcome report
 Form Faxed within 24-48 hours of STEMI to
Referring STEMI Physician and Nurse Team
Semi-Annual
Round Table meetings & Outreach Visits
 Education of referring staff
 Uniform algorithm for treatments and
medications.
 Networking, team building, and system
improvement for the STEMI patient in
Vermont
RESULTS
STEMI Referral Center Volume
& Feedback Transmission
Name of Hospital
Distance in
miles/time from
FAHC
Fletcher Allen
Health Care
#
of
Beds
STEMI transfer
with follow up
phone call
Nov 08-Dec 09
STEMI transfer
with follow up
phone call
Jan 10-Sept 10
500
79
65
Copley Medical
Center
45miles
1 hour
25
16
13
Northwestern
Medical Center
25miles
30 min
70
31
16
Porter Medical
Center
37 miles
58 min
30
23
19
Central Vermont
Medical Center
41miles
45 min
30
34
31
Result of Intervention:
Lickert Scale Satisfaction Scores
Pre Intervention
Post Intervention
4
3
2
1
N
ll
A
H
C
FA
C
VM
C
or
th
we
st
er
Po
rt
op
le
y
0
C
Lickert Score, 1 to 5
5
Triage Times 2009:
Significant Improvement in Transfer Hospital
Presentation to Cath Lab Activation after STEMI
Nursing Feedback Program Initiated
Average Triage Times; minutes
35
30
Quarter 1
Quarter 4
29 min
25
20
19 min
15
10
5
0
All Referral Hospitals
Door to Balloon Times 2009:
Significant Door to Balloon Time
Improvement after STEMI Nursing
Feedback Program
Average DTB time, minutes
140
Quarter 1
Quarter 4
120
100
124min
86min
80
63min
60
58min
40
20
0
FAHC PCI Center
All Referral Hospitals
Door to Balloon Times:
Significant Door to Balloon Time
Improvement after STEMI Nursing Feedback
Program
Average DTB time, minutes
140
124 min
120
86
min
100
80
63
min
58
min
57
min
93
min
60
40
20
0
FAHC PCI Center
Start of program Dec 08
All Referral Hospitals
Quarter 4 Dec 09
Jan 10-Sept 10
Conclusions
 Nurse to Nurse feedback is a critical component of a
successful rapid transfer STEMI program
 Referring emergency department satisfaction can be
dramatically improved with a feedback program
 Roundtable and outreach lead to adoption of uniform
state wide practices
 The STEMI nursing feedback program leads to
improved triage times and D2B times for transfer
programs