Where: Schneck Medical Center, a 113-bed community hospital in Seymour, Ind.
The issue: Getting door-to-balloon times for cardiac catheterization below 90 minutes.
Two years ago, Schneck Medical Center was struggling to meet the American College of Cardiology's goal of having all patients who suffer an ST-elevation myocardial infarction (MI) get from the hospital door to the catheterization lab in 90 minutes. Schneck doesn't have its own cath lab, and the time required to transfer patients meant that the hospital's average was around 120 minutes in 2010.
“When patients came in with acute ST-elevation MI, they would be transferred to one of the Indianapolis hospitals, which are about an hour drive or a 20-minute helicopter ride,” said Douglas Towriss, MD, director of Schneck's hospitalist program.
There was a closer hospital with a cath lab: Columbus Regional Hospital, just 26 miles away. Historically, the two hospitals had not collaborated closely, but they were brought together by a natural disaster in 2008.
“The White River runs right next to Columbus Regional and it flooded the town. It closed the hospital for six months. Our town was flooded too, but our hospital wasn't. That night, I personally took 17 transfers,” said Dr. Towriss. “We employed as many of their employees as we could temporarily and really partnered with them.”
With this newly collaborative relationship, and financial support from an American College of Cardiology grant, the hospitals set to work on a project to reduce door-to-balloon time.
How it works
A task force with members from both hospitals and the Jackson County Emergency Medical Service developed a protocol for speeding up and better coordinating diagnosis and treatment of MI.
“We benchmarked how much time EMS should spend on the scene,” said Dr. Towriss. “[EMS] performs the EKG, and [the patient is] evaluated at our hospital. [If a patient requires catheterization] we notify Columbus Regional, and so by the time the patient shows up there, which is about a 27-minute ambulance ride, the cardiology team's been notified and assembled and they're waiting for the patient.”
Speeding the transfers required mostly small process changes. “We looked at every detail you can think of that would slow down somebody arriving onsite,” Dr. Towriss said. “We made sure our paperwork was the same as [Columbus Regional's] paperwork. We have somebody from our hospital register the patient, so that they're actually registered before they get there.”
A flow sheet travels along with each patient through the transfer process. “Columbus can look at that and know we've given aspirin and we've done this and we've done that. We're not repeating EKGs unnecessarily,” he said.
The hospitals tested their project with a simulation, conducted by the American College of Cardiology in April 2011. The door-to-balloon time for the mock patient was 86 minutes.
Since then, Schneck's times for treatment of real patients have gone even lower. The average door-to-balloon time in August 2011 was 65 minutes, and since then the hospital has had four patients who were treated in less than 60 minutes. Their fastest time so far is 53 minutes. The project's success was recognized with the 2011 Malcolm Baldrige National Quality Award.
Dr. Towriss noted that in some cases, the process is so smooth that door-to-balloon time may actually be shorter for Schneck's transferred patients than for those who arrive to a hospital equipped with catheterization.
Despite their attempts to create a smooth process from the start of collaboration, project leaders have continued to find issues to work on. “Recently, we were meeting with them and we found out that the number we were faxing papers to was registration. So there was a delay, because the EKG went to registration and not to the cath lab,” said Dr. Towriss.
Another of the program's quarterly meetings revealed that although Columbus and Schneck use the same type of defibrillators, the EMS service uses another type with different pads. “That requires somebody to take all their defibrillator pads off and put new ones on at the time when they're most likely to need defibrillation,” said Dr. Towriss. Using funds from another grant, Schneck is evaluating a process that will allow the defibrillators to be integrated among all three organizations.