2.50
Hdl Handle:
http://hdl.handle.net/10755/198294
Title:
Developing an Internationally-recognized STEMI Protocol in a Rural Hospital
Abstract:
[ENA Annual Conference 2011 - Evidence-based Practice Presentation]Developing an Internationally-recognized STEMI Protocol in a Rural Hospital

Purpose: American Heart Association guidelines recommend patients with ST-segment elevation myocardial infarctions (STEMI) or new onset left bundle branch block (LBBB) receive reperfusion therapy within 90 minutes of diagnosis. A rural hospital’s Emergency Department (ED) identified need to decrease STEMI patient turn-around time to achieve goal of 100% of cases meeting door-to-balloon time of 90 minutes or less.

Design: A STEMI protocol based on best-practice evidence was developed as a quality improvement project. Project involved communication, collaboration, and problem-solving among multi-organizations: rural hospital’s ED, tertiary care hospital, and district’s Emergency Medical Services (EMS), and involved multi-disciplines, including: nursing, ED physicians, Lab, Pharmacy, cardiologists, nursing support services, and local EMS personnel.

Setting: Protocol was developed at a private, 70-bed, accredited Level II community hospital located in rural northwestern Vermont. Distance to nearest tertiary care Level I trauma center with PCI availability is 28 miles, requiring 25-35 minutes travel time.

Participants/Subjects: All patients presenting to the hospital’s Emergency Department diagnosed with STEMI or new onset of LBBB on EKG during protocol development time period.

Methods: Rapid cycle methodology and continuous review were utilized. Improvement was defined as decrease in time from door-to-transfer. Time in ED goal was 30 minutes or less; this was divided into increments: door-to-EKG, door-to-diagnosis, door-to-initiation-of-care, and door-to-transfer. Nursing identified barriers and opportunities for improvement within each increment and recommended multiple tests of change, including changes in nursing procedure such as staff double-teaming care, and leaving patient on EMS stretcher until initial EKG obtained and STEMI or new-onset LBBB ruled out. EMS agreed transporting squads would remain in ED to transfer STEMI patients whenever possible; the local EMS service committed to 10-minute availability for all STEMI transfers. Administration of heparin drip and eptifibatide prior to transfer was eliminated based on cardiology recommendations. Pharmacy created “STEMI kit” to expedite medication administration. Laboratory transmitted test results directly to receiving hospital. Tertiary hospital agreed to accept all STEMI patients from receiving hospital. Overall time was continuously reviewed. Tests of change demonstrating improvement were immediately adopted. ED nurses and physicians developed documentation tool that includes physician and transfer orders and ED nursing and transfer notes; receiving hospital given copy upon transfer. Percentage of cases achieving goal of 90 minutes or less from door-to-balloon was calculated.

Results/Outcomes: Data collected on 6 patients from May 1 to September 30, 2010. Five cases met recommended door-to-balloon time (83%). STEMI data is reviewed quarterly; process improvement is ongoing. This rural hospital achieved best STEMI times in Vermont. Protocol is currently being shared with other rural Vermont hospitals and has been presented at national and international cardiology conferences as a model for best-practice.

Implications: Rural hospitals face unique challenges in successfully meeting best-practice guidelines. This ED improved cardiac care for rural patients through development and implementation of a STEMI protocol involving collaboration among multiple stakeholders. Other patient care improvements may be achieved through protocol development using this multi-disciplinary, collaborative model that extends beyond the walls of an organization.

Repository Posting Date:
21-Dec-2011
Date of Publication:
21-Dec-2011

Full metadata record

DC FieldValue Language
dc.titleDeveloping an Internationally-recognized STEMI Protocol in a Rural Hospitalen_GB
dc.identifier.urihttp://hdl.handle.net/10755/198294-
dc.description.abstract[ENA Annual Conference 2011 - Evidence-based Practice Presentation]Developing an Internationally-recognized STEMI Protocol in a Rural Hospital<br/><br/>Purpose: American Heart Association guidelines recommend patients with ST-segment elevation myocardial infarctions (STEMI) or new onset left bundle branch block (LBBB) receive reperfusion therapy within 90 minutes of diagnosis. A rural hospital’s Emergency Department (ED) identified need to decrease STEMI patient turn-around time to achieve goal of 100% of cases meeting door-to-balloon time of 90 minutes or less.<br/><br/>Design: A STEMI protocol based on best-practice evidence was developed as a quality improvement project. Project involved communication, collaboration, and problem-solving among multi-organizations: rural hospital’s ED, tertiary care hospital, and district’s Emergency Medical Services (EMS), and involved multi-disciplines, including: nursing, ED physicians, Lab, Pharmacy, cardiologists, nursing support services, and local EMS personnel. <br/><br/>Setting: Protocol was developed at a private, 70-bed, accredited Level II community hospital located in rural northwestern Vermont. Distance to nearest tertiary care Level I trauma center with PCI availability is 28 miles, requiring 25-35 minutes travel time.<br/><br/>Participants/Subjects: All patients presenting to the hospital’s Emergency Department diagnosed with STEMI or new onset of LBBB on EKG during protocol development time period.<br/><br/>Methods: Rapid cycle methodology and continuous review were utilized. Improvement was defined as decrease in time from door-to-transfer. Time in ED goal was 30 minutes or less; this was divided into increments: door-to-EKG, door-to-diagnosis, door-to-initiation-of-care, and door-to-transfer. Nursing identified barriers and opportunities for improvement within each increment and recommended multiple tests of change, including changes in nursing procedure such as staff double-teaming care, and leaving patient on EMS stretcher until initial EKG obtained and STEMI or new-onset LBBB ruled out. EMS agreed transporting squads would remain in ED to transfer STEMI patients whenever possible; the local EMS service committed to 10-minute availability for all STEMI transfers. Administration of heparin drip and eptifibatide prior to transfer was eliminated based on cardiology recommendations. Pharmacy created “STEMI kit” to expedite medication administration. Laboratory transmitted test results directly to receiving hospital. Tertiary hospital agreed to accept all STEMI patients from receiving hospital. Overall time was continuously reviewed. Tests of change demonstrating improvement were immediately adopted. ED nurses and physicians developed documentation tool that includes physician and transfer orders and ED nursing and transfer notes; receiving hospital given copy upon transfer. Percentage of cases achieving goal of 90 minutes or less from door-to-balloon was calculated. <br/><br/>Results/Outcomes: Data collected on 6 patients from May 1 to September 30, 2010. Five cases met recommended door-to-balloon time (83%). STEMI data is reviewed quarterly; process improvement is ongoing. This rural hospital achieved best STEMI times in Vermont. Protocol is currently being shared with other rural Vermont hospitals and has been presented at national and international cardiology conferences as a model for best-practice.<br/><br/>Implications: Rural hospitals face unique challenges in successfully meeting best-practice guidelines. This ED improved cardiac care for rural patients through development and implementation of a STEMI protocol involving collaboration among multiple stakeholders. Other patient care improvements may be achieved through protocol development using this multi-disciplinary, collaborative model that extends beyond the walls of an organization.<br/><br/>en_GB
dc.date.available2011-12-21T12:44:57Z-
dc.date.issued2011-12-21T12:44:57Z-
dc.date.accessioned2011-12-21T12:44:57Z-
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