What's Working

Code Heart: Reducing Time to PCI at Memorial Regional Hospital

Changes in the national hospital quality measures taking effect this summer will challenge hospitals to reduce the time from a heart attack patient's arrival to receiving an angioplasty to just 90 minutes. Many hospitals struggle to consistently meet the current goal of two hours–realizing the new measure will require laser-like focus.

Memorial Regional Hospital in Broward County, Florida, is nevertheless optimistic. In the past year, the hospital improved its time to PCI (percutaneous coronary intervention) by 60 percent. Now eight out of 10 heart attack patients at Memorial receive PCI in less than 120 minutes and this improves each quarter (see results).

The Code Heart Process

Until the last several months, treating a heart attack patient at Memorial was a sequential process, with actions taking place one after another–first in the emergency department (ED), then in the cardiac catheterization lab (CCL).

After being named an Expecting Success grantee last fall, however, the hospital reinvigorated its Code Heart process, a combined effort of the hospital's ED, CCL and quality improvement (QI) physicians and staff, toward reducing the time to PCI. Now when a patient arrives in the ED with symptoms suggesting a heart attack, the staff immediately administers an electrocardiogram. If the results show myocardial infarction, 'code heart' is immediately paged throughout the ED and the CCL.

"That's the signal for everyone to get everything moving without wasting a minute," says Rochelle Ayala, M.D., a primary care physician at Memorial who facilitates the coordination of the Code Heart process with ED, QI and CCL staff. "From the moment 'code heart' is called, the cath team has 30 minutes to get the lab ready, and that includes travel time for physicians and staff if it's the middle of the night. The ED staff also pushes to get its job done quickly–aspirin and beta blockers administered, lab tests done, paperwork finished–and get the patient to the lab."

To track outcomes, identify delays and focus the team, Memorial developed a Code Heart Tracking Tool, which allows ED and CCL staff to simultaneously record their role in the Code Heart process. The form is intentionally simple, allowing for interventions to be listed and the time recorded. Within 24 hours, a manager of quality reviews the Tracking Tool data and identifies the fallouts.

Monday Morning Quarterbacking

Every other Monday, leaders from the ED and CCL meet to review a Code Heart Analysis Tool, which summarizes each patient's experience. Delays are flagged. After discussion, department leaders must, in writing, identify why the goal was not met and identify the action needed and person responsible to ensure success in the future. Both ED and CCL staff think the analyses are crucial to the success of Code Heart.

"As a group we dissect the process into small pieces and learn from our mistakes. We really don't dwell on what went wrong, we ask each other what we can do to fix it," says Michele Slane, administrative director of Memorial's Cardiac and Vascular Institute. "The human tendency is to point fingers and assign blame, but we have worked hard to build relationships that get past that and focus on fixing the problems."

Advice for Other Hospitals

While Memorial staff members don't claim to have overcome all the barriers, the Code Heart process has yielded tips for other hospitals.

• Create an environment of trust
The Memorial team says they do not get personal or defensive–and they mean it. "Everyone must check egos and boxing gloves at the door if this is going to work," says Dr. Ayala.
• Engage quality improvement staff
Code Heart leaders say the QI staff's involvement and the clarity of the data keep the goal front and center.
• Track and check each case
The tracking and analysis tools are instrumental for improvement and help each person working in the ED or CCL form goals to achieve success.
• Hardwire the process
The Code Heart team says old habits are hard to break, but all systems and technology needs to be checked and communicated to become hardwired. "We even had to synchronize the clocks between departments and on our equipment," Slane says. 
• Over-communicating creates champions
Memorial staff leaders discuss Code Heart at every opportunity. They say it creates physician champions and reinforces buy-in toward meeting the goal.

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Spotlight On...

Memorial Healthcare System is a five-hospital system in Southeast Florida serving a population of about 700,000 people. Memorial Regional Hospital, the System's flagship hospital, is home to the Cardiac and Vascular Institute, which offers clinical cardiology, invasive and interventional cardiology, electrophysiology, cardiac surgery, interventional radiology, vascular surgery, interventional vascular medicine and a 12-week Cardiac Rehabilitation Program. 

• Staffed beds: 690
• Hospital type: Public, not-for-profit
• Community location: Suburban
• Annual heart patients: 864 myocardial infarction, 855 heart failure
• Annual cardiac catheterizations: 3,746 (1,929 PCI)

 

 

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