Racing Hearts: ED Process and Design Changes Can Continue to Reduce the Time It Takes to Move STEMI Patients From Door-to-Balloon

The American College of Cardiology (ACC) launched its D2B (door to balloon) Alliance for Quality campaign in 2006. The continuing campaign aims to reduce the D2B time for ST-elevated myocardial infarction (STEMI) patients to 90 minutes or less.

The campaign came about in response to a 2004 ACC study indicating that STEMI mortalities declined to 3 percent from much higher levels when primary percutaneous coronary intervention (PPCI) or coronary angioplasty began within 90 minutes of the patient’s arrival at the emergency department (ED).

The ACC developed a six-step strategy to speed the patient’s progress through the ED to the catheterization lab:

1. An ED physician asks for the catheterization lab team to be activated.
2. The hospital implements a system that can notify the entire cath lab staff with a single call.
3. The cath lab team assembles in 30 minutes or less.
4. The team provides prompt data feedback. 
5. Senior management makes a commitment. 
6. Team-based approach is used. 

The ACC included a seventh strategic measure but called it optional: Train emergency medical technicians (EMTs) to complete 12-lead electrocardiograms (ECGs) prior to their arrival at the hospital, identify possible STEMI patients in the field and notify the ED staff of the ECG results.

In the years since the ACC introduced its strategic plan, the pre-hospital ECG has proven so effective that it has begun to lose its optional status. However, it is not yet mandated, since not all ambulance or medic units have been trained to perform and interpret 12-lead ECGs, nor are all ambulances equipped for them. Pre-hospital ECGs are nevertheless strongly recommended if they can be done. The strategy, according to the ACC, would ensure that STEMI patients were identified and transferred to the cath lab within 90 minutes of arriving at the ED, if not faster.

Since the launch of the D2B campaign, more than 1,000 hospitals in the U.S. and around the world have adopted the ACC’s six-step strategy, and experience now proves beyond a shadow of doubt that speed at the hospital saves the lives of STEMI patients. But this is really just the beginning of the story. More recent studies have raised a host of additional issues. For instance, studies now show that reducing time below the 90-minute standard saves even more lives. Other studies have looked at mortality rates of patients who drive themselves to the hospital, patients transferred from EDs at hospitals with no cath lab, patients who lie down and rest for a couple hours before deciding to go to the hospital and non-STEMI patients who eventually develop an elevated ST-segment ECG.

In each study, the shorter the time from the door of the ED to the inflation of the angioplasty balloon, the better the chances of survival.

But once the seven strategic steps have been implemented, how is it possible to go faster?
Healthcare architects and process improvement consultants are moving forward on the theory that ED design and process changes can add speed and add to the lifesaving gains made possible by the ACC’s strategic D2B program.

Reworking ED designs and processes

Experience suggests a host of design and process changes that will improve the quality of care delivered by an ED generally, while further reducing D2B time for STEMI patients. Here are some ideas that have proven useful:

Walk-ins: Sometimes possible MI patients decide not to call the ambulance and go the ED on their own. Older ED designs and traditional processes cannot accommodate the need for a 10-minute door-to-ECG or the proper sorting of emergent versus non-urgent patient presentation. Effective, newer designs allow patients in need of acute care to see an RN first. The RN will assess the patient and, if necessary, move him or her immediately into the acute care area where necessary treatment interventions can begin. In cases of both emergent and non-urgent patients, triage nurses can assess the patient first and ensure that acute patients receive appropriate care as quickly as possible. Registration takes place later.

Universal treatment beds: New ED designs are incorporating the concept of universal treatment beds (UTBs) in which all patients — with complaints from acute to mild symptoms — can be treated. Inside these rooms, the bed parallels the corridor, and a clinical zone with monitors and diagnostic equipment surrounds the bed. UTBs bring care to the patient instead of taking the patient to the care, while ensuring that ED patients with acute needs can be treated comprehensively and that STEMI patients reach the cath lab in 90 minutes or faster.

Another important feature of the UTB is creation of a patient zone and a family zone within a private treatment room of at least 140 square feet, which is larger than required by code. Critical design features include space for the family. The layout also allows room for the clinical staff to treat the patient. In addition, the placement of the bed enables the clinical team to more easily view the patient from the corridor or the nurse’s station. The larger space and new design also provide space for additional medical equipment at the bedside should that become necessary. 

Sub-waiting areas for patients and families: EDs occasionally reach capacity and cannot accommodate more patients. For such occasions, sub-waiting areas with chairs can help ED staff manage high volumes of patients or a surge in patient volume. Such spaces ensure that critically ill patients have access to private treatment rooms, while less acute patients occupy sub-waiting areas.

Separate sub-waiting areas with chairs can also accommodate the needs of family members while procedures are being conducted. Research and common sense indicate that the presence of family members benefits patients, especially those battling acute symptoms.

Floor planning: When laying out floor plans for new hospitals, designers should consider the physical path from the ED to the cath lab and, if possible, place these departments close together. In existing hospitals, it may be possible to relocate the cath lab closer to the ED. When that is impossible, designers can consider ways to speed the trip from the ED to the cath lab. In some cases, this might involve the addition of ramps allowing swift floor changes, and back or side doors into the cath lab.

Bedside services: Changing to a system of bedside or treatment room registration can add physical space to an ED by eliminating traditional registration bays from the walk-in entry. It is also possible to collect copays at bedside and eliminate the need for a separate administrative discharge area. Further, a concierge prescription program can electronically transfer prescriptions to a retail pharmacy or even make the medicines available through an InstyMeds machine prior to discharge. 

Protocol rooms and quality care: Extra space near triage can be used to back up triage rooms with vertical/protocol rooms equipped to perform ECGs. Protocol rooms’ purpose is to provide a location for limited care or quick processes. Among the benefits of protocol rooms is improved quality of care for all patients.

When the ED is operating at capacity and a possible STEMI or NSTEMI patient arrives, protocol rooms support the door-to-ECG time of 10 minutes by providing a space where the ECG can be immediately performed, and IV lines and cardiac monitoring can be initiated while a treatment bed is being readied for the patient. Protocol rooms can also be used to deliver non-urgent care and treatment, keeping acute care beds open and available for acute patients who arrive in the ED.

Prompt data feedback: Prompt data feedback includes the ability of ED clinical staff to perform 12-lead ECGs using the bedside cardiac monitor. The procedure offers several benefits. For one thing, it eliminates the need to obtain the department or hospital ECG machine, and it makes unnecessary calling the hospital ECG tech to the ED to perform the ECG.

Finally, incorporating point-of-care testing (POCT) results in the teams’ quickly learning the troponin level, making the identification of low- and high-risk patients faster and easier. While a hospital lab turnaround time requires about 45 to 60 minutes to obtain the results of a troponin level test, POCT done at the bedside in the ED can deliver the results in 15 minutes.

Monitoring non-STEMI patients: A patient arrives with mild and vague symptoms and the ED follows the recommended procedure of a 10-minute door to ECG, but finds no acute changes on the ECG. Initial blood work sometimes also shows no problem. Yet the patient had felt strange enough to come to the ED in the first place. With the development of the chest pain protocol in EDs, the NSTEMI patient or unstable angina patient is no longer released without serial testing — repeat ECGs and enzyme testing, followed by a stress test of some type. Of importance when dealing with mild or vague symptoms is the quick identification that the patient is low risk, but that the potential or risk for cardiac injury does exist. The patient needs to be kept for monitoring and treatment of symptoms and possible later testing, but the situation is not an emergency. Quickly identifying a low-risk patient and moving him or her to an appropriate unit frees up the ED treatment bed for the next emergency patient.

Senior management commitment: The commitment of senior management to deploying initiatives that will improve ED performance is essential to reducing door-to-balloon time for STEMI patients and for improved monitoring of NSTEMI patients. As noted above, key process initiatives include immediate bedding, consistent implementation of patient care protocols, a standard approach to obtaining ECGs performed by ED staffs using bedside cardiac monitors, and a physical design that supports the work.

Team-based approach: EDs across the country have been working to match nurse-to-patient ratio to patient volume, acuity and length of stay. Ratios proven appropriate today are one RN to four patients for normal volumes and one RN to three patients during high-volume periods.

ED technicians support the clinical team. Working under the direction of the RN, the technicians help to engage the patients upon arrival and to implement stabilizing care immediately. Their assistance in these non-RN duties is very valuable in meeting door-to-ECG and D2B times.

Anecdotal evidence suggests that assigning ED physicians to ED clinical teams responsible for all patients in particular treatment zones improves door-to-physician times and physician productivity.

These changes can all help to drive the time from D2B for STEMI patients below 90 minutes, achieve the required 10-minute door-to-ECG time for walk-in patients reporting STEMI symptoms, accommodate non-STEMI patients, make room for families to be with loved ones, address bed shortages at peak hours, and generally improve the quality of care offered in the ED.

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Kristyna Culp, MBA, Managing Principal, FreemanWhite Catalyst, www.freemanwhite.com/catalyst, can be reached at kculp@freemanwhite.com or 704.517.1949.

Kristyna Culp is a Managing Principal of FreemanWhite and works in Catalyst. She serves as the Leader for Operations and Director of Process Improvement. Catalyst is the firm’s consulting division specializing in strategic, operational, and master planning. A graduate of UNC Charlotte and the University of Tennessee, she has been an integral part of FreemanWhite’s leadership for 15 years. Early in her tenure, she created and adapted a simulation model framework to validate, test, and quantify various scenarios to help clients fully understand the existing structure and workflow of their departmental operations and company organization and to quantify future operational and physical design scenarios.

During an engagement, Ms. Culp implements a data collection framework and builds workflow diagrams and graphic representations of the current processes using the collected data. Utilizing computer simulation, data mining techniques, and client interviews, she determines organizational and physical bottlenecks to optimize workflow. She then uses the derived data and models to recommend opportunities for operational and physical design improvement.

Kathy Clarke, RN, BSN, CEN®, FreemanWhite, can be reached at KClarke@freemanwhite.com.