Organizational Change Project Reducing D2B Time for STEMI Patients

Introduction

The paramount goal of the Change Project is to maintain and reduce the D2B intervals in the STEMI patients less than 60 minutes, namely, to 45 minutes applying evidence-based practice strategies to obtain better patient outcomes.

Justification for Change

There is a need for the enhancement of primary Percutaneous Coronary Intervention (PCI) and D2B reduction:

  • Regional Medical Center (RMC) hospital leadership is the first area to be improved as it plays a paramount role in the change management.
  • Organizational and political issues such as the personnel training and action plan require the improvement as well (Adams, Wong, & Wijeysundera, 2015).
  • Individualistic behaviors of the staff members should be eliminated in order to create the integrated team that would collaborate effectively.

There should be the overall change strategy concerning all the vital issues connected to the topic.

Communication is one of the most significant aspects of the change plan, the appropriate implementation of which would promote the cooperation.

Accreditation Standards

According to the American Heart Association (AHA) that have attained the required standards of STEMI patients’ treatment, D2B times should be less than 90 minutes (Wilson et al., 2013).

The catheterization laboratory (cath lab) must be operational at all times and should have the necessary equipment to be activated during emergencies:

  • the Cath lab team must always be prepared to respond to emergencies and should respond within 30 minutes;
  • the team-based approach is strongly recommended;
  • the data feedback systems should be as effective as possible;
  • all STEMI accredited hospitals’ senior management must be fully committed to efficiency in reducing D2B times and augmented outcomes of STEMI patients (Langabeer et al., 2015)

AHA and education issues

  • public education on the need for healthy lifestyle standards, which studies have linked to reduced STEMI cases (Stoner, Stoner, Young, & Fryer, 2012). For example, CPR education training;
  • policymakers and lawmakers education on the need to allocate sufficient resources to STEMI hospitals.
  • AHA is among the leading organizations (outside the federal government) in funding cardiovascular diseases research, spending more than $3.8 billion (Laslett et al., 2012).

Thus, AHA is inspiring, inspecting, and collaborates with other bodies to provide evidence-based strategies to reduce D2B times to less than 90 minutes.

Evidence Based Practice Strategies

Despite American College of Cardiology/American Heart Association (ACC/AHA) guidelines, it seems necessary to implement 45 to 60 minutes D2B. The following practices contribute to the achievement of the goal:

  • the concept of Lean as a Quality Improvement Tool;
  • the implementation of Six Sigma strategy;
  • special programs and procedures that would involve medical personnel stakeholders to collaborate and improve the reperfusion period;
  • according to Joost, Blumrath, and Radke (2012), “respective training of staff members leads to a significant reduction in Door to Balloon (DTB) intervals” (p. 140);
  • the STEMI patients receiving centers should work 24/7 and should be equipped with professional cardiologists (Savage et al., 2010);
  • Stowens, Sonnad, and Rosenbaum (2015) state that using Emergency Medical Services (EMS) dispatch to note STEMI patients’ D2B intervals;
  • before starting the change project, it is of great importance to evaluate the change context. Precisely speaking, organizational, environmental, and readiness to change components should be assessed;
  • potential gaps and feedbacks should be considered.

Internal and External Challenges

External Factors (outside the PCI-capable center)

  • delays concerning ignoring symptoms, reluctance to bother others, and lack of knowledge some factors related to STEMI;
  • most STEMI patients do not use 911. In fact, only about 60% of STEMI patients use ambulance (Mathews et al., 2011);
  • most STEMI patients transported by personal vehicles suffer cardiac arrest in route to STEMI PCI-capable centers.

Therefore, Common STEMI protocols should be accepted to enhance timely access to reperfusion. All STEMI referring hospitals should have an STEMI protocol connected to the PCI center to avoid longer processes in communication and notifying a PCI hospital (American College of Cardiology Foundation & American Heart Association, 2013).

Internal Factors (at the PCI-capable center):

  • a single call for the EM physician to activate the CCL;
  • delays in emergency team arrival (it is also expected that STEMI team should only take 20 to 30 minutes to arrive at the center);
  • patients may not be in a condition to granting an informed consent immediately once they arrive at the hospital (Victor, et al., 2012);
  • the administrative support and team-based approach are vital driving forces;
  • appropriate communication between multidisciplinary team members.

Thus, human factors, processes, procedures, and organizational factors could either support or derail the project.

Evaluating for Trends and Gaps

According to Rathore et al., there are several factors that might impact D2B: gender, race, age, medical history, peculiarities of the PCI, and others.

In 2005-2006, the register included 43 801 STEMI patients admitted in the first 12 hours of the disease patients in the four categories where D2B was <60, 60-89, 90-119, and ≥120 minutes (Rathore et al., 2010).

Trends and gaps analysis ensures the comprehensiveness and relevance of the topic.

Chieffo et al. (2012) discussed D2B intervals in females.

The first line consisting of A, B, and C represents a 58-year-old woman with 14 hours pain in the chest while the second panel of D, E, and F demonstrates a 37-year-old female with two days pain. Both of them were treated with a good result. However, the second one was treated with two metal stents. Delay in diagnosis and treatment in women with the STEMI symptoms.

Feedback Monitoring

Kunadian et al. (2010) examine the issue of the data-monitoring system that allows receiving rapid feedback. They use Statistical Process Control (SPC) methodology.

Data feedback and analysis allow planned changes in service delivery to be quantified” (Kunadian et al., 2010, p. 1562).

Same Page Strategy

Kontos et al. (2011) state that the activation of the catheterization laboratory (CCL) via the same page strategy reduce the D2B time.

As a result, the best outcome was achieved in the primary PCI (Percutaneous Intervention) with early activation of the staff working on the CCL (Cardiac Catheterization Laboratory).

Conclusion

The smaller the D2B intervals, the greater the likelihood of success of the reperfusion intervention, and the better the prognosis for the patient. It is necessary to reduce the D2B intervals less than 60 minutes focused on evidence based practices.

Potential challenges as well as trends and gaps were identified in order to provide the comprehensive study and develop the considered challenge project. Only the timely interaction and communication of all the staff members involved in the PCI intervention might reduce the D2B times.

The awareness of the STEMI patients and timely call to 911 will also promote the reduction of D2B intervals.

References

Adams, J., Wong, B., & Wijeysundera, H. C. (2015). Root causes for delayed hospital discharge in patients with ST-segment Myocardial Infarction (STEMI): a qualitative analysis. BMC Cardiovascular Disorders, 15(2), 107.

American College of Cardiology Foundation & American Heart Association. (2013). 2013 ACCF/AHA Guideline for the Management of ST-Elevation Myocardial Infarction. Circulation, 127(1), e362-e425.

Chieffo, A., Buchanan, G., Mauri, F., Mehilli, J., Vaquerizo, B., Moynagh, A.,… Morice, M. (2012). ACS and STEMI treatment: Gender-related issues. EuroIntervention, 8(1), 27-35.

Joost, A., Blumrath, C., & Radke, P. (2012). TCT-485 A simple strategy to significantly reduce the “door-to-balloon” time in patients with acute ST-elevation myocardial infarction. Journal of the AmericanCollege of Cardiology, 60(17), 140-142.

Kontos, M. C., Kurz, M. C., Roberts, C. S., Joyner, S. E., Kreisa, L., Ornato, J. P., & Vetrovec, G. W. (2011). Emergency physician–initiated Cath lab activation reduces door to balloon times in ST-segment elevation myocardial infarction patients. The American Journal of Emergency Medicine, 29(8), 868-874.

Kunadian, B., Morley, R., Roberts, A. P., Adam, Z., Twomey, D., Hall, J. A.,… Belder, M. A. (2010). Impact of implementation of evidence-based strategies to reduce door-to-balloon time in patients presenting with STEMI: Continuous data analysis and feedback using a statistical process control plot. Heart, 96(19), 1557-1563.

Langabeer, J., Alqusairi, D., DelliFraine, J. L., Fowler, R., King, R., Segrest, W., & Henry, T. (2015). Reassessing After-Hour Arrival Patterns and Outcomes in ST-Elevation Myocardial Infarction. West Journal Emergency Medicine, 16(3), 388–394.

Laslett, L. J., Alagona, P., Clark, B. A., Drozda, J. P., Saldivar, F., Wilson, S. R.,… Hart, M. (2012). The Worldwide Environment of Cardiovascular Disease: Prevalence, Diagnosis, Therapy, and Policy Issues. Journal American College of Cardiology, 60(25), 1-49.

Mathews, R., Peterson, E. D., Li, S., Roe, M. T., Glickman, S. W., Wiviott, S. D., Wang, T. Y. (2011). Use of Emergency Medical Service Transport Among Patients with ST- Segment–Elevation Myocardial Infarction. Circulation, 124(2), 154-163.

Rathore, S. S., Curtis, J. P., Chen, J., Wang, Y., Nallamothu, B. K., Epstein, A. J., & Krumholz, H. M. (2010). Association of door-to-balloon time and mortality in patients admitted to hospital with ST elevation myocardial infarction: National cohort study. BMJ, 338(2), 1-7.

Savage, M., Raffel, C., Walters, D., & Gough, C. (2010). Pre-hospital Ambulance Notification of ST-Elevation Myocardial Infarction (STEMI) Significantly Improves Door to Balloon Time (DTB) for Primary Percutaneous Coronary Intervention (PPCI)—Australian Setting. Heart, Lung and Circulation, 19(2), 244-245.

Stoner, L., Stoner, K. R., Young, J. M., & Fryer, S. (2012). Preventing a Cardiovascular Disease Epidemic among Indigenous Populations through Lifestyle Changes. International Journal of Preventive Medicine, 3(4), 230–240.

Stowens, J., Sonnad, S., & Rosenbaum, R. (2015). Using EMS Dispatch to Trigger STEMI Alerts Decreases Door-to-Balloon Times. Western Journal of Emergency Medicine, 16(3), 472-480.

Swanson, N., Nunn, C., Holmes, S., & Devlin, G. (2010). Door to balloon times: streamlining admission for primary percutaneous coronary intervention. The New Zealand Medical Journal,123(1309), 18-25.

Victor, S. M., Gnanaraj, A., Vijayakumar, S., Pattabiram, S., & Mullasari, A. S. (2012). Door-to-Balloon: Where do we lose time? Single center experience in India. Indian Heart Journal, 64(6), 582–587.

Wilson, B. H., Humphrey, A. D., Cedarholm, J. C., Downey, W. E., Haber, R. H., Kowalchuk, G. J.,… Garvey, L. (2013). Achieving Sustainable First Door-to-Balloon Times of 90 Minutes for Regional Transfer ST-Segment Elevation Myocardial Infarction. Journal of American Cardiovascular Interventions, 6(10), 1064-1071.

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