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Safer Healthcare Now!. Cape Breton Regional AMI Collaborative. Dawn Hollohan & Sharon MacLeod. Cape Breton Regional Hospital. The Beginnings. GOAL: Door to Thrombolytic within 30mins for 90% of patients presenting with AMI by March 30 th 2010. Change Ideas. - PowerPoint PPT Presentation

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  • Safer Healthcare Now!Cape Breton Regional AMI CollaborativeDawn Hollohan & Sharon MacLeod

  • Cape Breton Regional Hospital

  • The BeginningsGOAL:

    Door to Thrombolytic within 30mins for 90% of patients presenting with AMI by March 30th 2010

  • Change IdeasEducation re AMI collaborative (posters, email, in-service)

    Syncing of Clocks to EKG machine

    Data collection FORM (staff engagement FUN initiative)

    Recommendations from industrial engineer re process improvement

    We mapped the process.

  • Change Ideas

    Changed phone in triage room to a Speed dial & educated the nursing staff to use same

    White board outside triage room Improving EKG Pt room identification.

    Place and an EKG machine within the dept.

  • Change Ideas

    Sharing the 10minsER owns 4 mins EKG dept owns 6mins

    Change to Delegated Medical Function (DMF)Now EKG is 1st priority

  • Data collection sheet

  • Bonusthere was help with data collection!

  • Analysis tab of the tally sheet

  • Why change it?Why does 10 minutes pass so quickly?Who was using up all the time? (Triage or ECG?)How close are we to the goal?Is the mean time to ECG helpful?Would the median be better?Does the time of day matter?Was sampling the best method for the team?

  • The data informs the team

  • Changes are made based on the data

  • In ConclusionWe cannot forget EHS !!! RESTORE Program

    Our Stats

    We may do hundreds of Normal EKGs but it is the ONE abnormal that we need to catch... This is our message...

  • Thank you.

    Any questions?

    Contact information:Dawn Hollohan902 567-8021hollohand@cbdha.nshealth.ca

    Sharon MacLeod902 577-0360macleodshar@cbdha.nshealth.ca

    *Hello, Today, I am going to talk briefly about how using the AMI tally sheet for tracking ECGs helped us improve the percentage of patients who received an ECG within 10 minutes of their 1st medical contact. *The Cape Breton Regional Hospital is the largest acute care facility in our region with 326 beds. The ED department at the Regional Hospital averages 85 patients a month who require an ECG and one AMI a week. We developed our goal...Door to Lytic 90%We recognized the obstacle to achieving this goal. One being door to EKG within 10 mins. We work in a unionized building where EKG techs do all EKGs 24/7. After much discussion regarding this we realized we needed to be inventive in our collaboration to get the EKG done within the required time frame. Therefore we needed to collect the data...the times form arrival to EKG..& we needed to do this manually we do not have EDIS. So we started wtih some changes using PDSA cycles.*To start the process we began with education regarding the AMI collaborative and we continue to keep the message out there by Posters , Staff meetings, emails etc. Syncing the clocks within the dept to computer. We placed a white board outside the triage room so that the EKG tech upon arrival into the dept would go directly to the board.

    1st PDSA ..We developed the data form which is a specific color in the dept... This form collects data on time of arrival into triage...The time EKG called...Time 1st EKG obtained.... & Time lytic administered. We had to get by in from staff to fill in the form... We used a weekly draw and gave out gift cards to the nurse or ward clerk who filled in the most forms for that week.

    As recommended by the industrial engineer we mapped the process that was in place at the time looking at areas where we could cut down time.

    We changed the phone in the triage room to incorporate a speed dial function... Staff are to call immediately . We placed a white board outside the triage room so that the EKG tech upon arrival into the dept would go directly to the board.We placed an EKG machine within the deptso the tech just had to come to the dept without getting and pushing a machine. Then we Homed it giving it its actual place in the deptthis prevented waste of time looking for the machine.

    *

    We came to an agreement that we would share the 10 mins ...ED owns 4 mins... EKG owns 6 mins that means ED staff have 4 mins from pt arrival to make the call to the EK dept.... The EKG tech has 6 mins to get to the dept and do the EKG.... We are stuck at 70 % the last couple of mths. We have identified that the majority of time it is the ED not making the call quick enough.

    We officially changed the district wide Delegated Medical Function for Nursing Staff Care of the Patient with Chest Pain.... EKG is now 1st priority**This slide shows the data collection form that Sharon mentioned that is used to capture the data. It is completed by nursing and is placed on the clipboard for all patients for whom an ECG is requested. *One of the stumbling blocks to involvement with improvement projects is data collection and reportingreporting not only to the collaborative team members, but also to frontline staff who are the actual change agents.

    The data from the form shown in the last slide was entered into the AMI tally sheet provided by SHN by the ward clerk.

    Before initiating the bundle item, the team collected baseline data by retrospective chart audits and that data is shown on the slide.

    On this slide you can see the original AMI tally sheet where each row represents a patient.*This slide shows the analysis worksheet in the original AMI tally sheet and the calculations based on the data entered in the other worksheet (individual times).

    Thirteen charts of patients who received a thrombolytic were chosen at random and it was found that approximately 62% of these patients, 8 out of 13, got an ECG within 10 minutes and 8 were administered the thrombolytic within 30 minutes. We seemed to be doing quite well already.

    At the end of October, our data showed that only 34% of our patients presenting with chest pain got an ECG within 10 minutes. The patients in our baseline sample all required a thrombolytic and while I am not clinical myself, the team indicated that those patients were perhaps more obvious then other patients would be and so an experienced nurse would be more likely to order an ECG quite quickly in those cases

    Our baseline data wasnt really representative of reality. Now we understood that we had a long way to go to reach the goal.

    In the next couple of months, we did make some improvement, 45% in November and 49% in December had an ECG within 10 minutes of 1st medical contact. *By the end of December it was clear to the team that we were not making progress fast enough, but we really didnt know what was wrong. Of course, we all had theories, but that wasnt data.

    So we wanted to collect another time that we thought was important to our progressthe time ECG was called by triageand some corresponding analysis. The spreadsheet was changed to include this time as well as changes made to calculate on each record whether the patient got an ECG within 10 minutes and the time ECG called to ECG completed.

    As Sharon stated earlier, triage was given 4 minutes to make the call and ECG was given 6 minutes to get the ECG completed. What we found was that the problem was with no one groupthere was room for improvement all around. I think it was a surprise that triage was taking so long to make the call to ECG.

    We also wanted to know and show how close we were to the goal, so we calculated how many ECGs were completed in 13 minutesin other words, we needed the staff to know that it was do-able.

    Another theory we wanted to explore was whether the time of day mattered, so we included a time period column. On nights, there was only one ECG tech for the entire hospital (about 326 beds) and we thought that might be a potential problem. During the day there were staff breaks and lunches that we thought might be affect our success in those time slots. After a few months we discovered that the time period with the lowest percentage of ECGs completed in 10 minutes was between 19:00 and midnight. This helped to focus our efforts.

    We also wanted to look at the median value (the midpoint where 50% of the responses were above and 50% were below) because a single bad response time affected the mean more then the median value.

    Finally, we wanted to keep the data on 100% of patients who needed an ECG rather than the 40 patients that the SHN tally sheet was designed to have.

    *The slide is showing the revised tally sheet we are currently using. You cant see it very well, but there are a few new columns for collecting the time ECG was called and the calculation to determine if it was within the allotted time. Each row represents a patient as before and this data is entered by the ward clerk from the data collection sheets, which I will show you later.

    After making changes that were driven by the data, such as, adding a speed dial to the triage phone to call ECG fast and getting another cell phone for the ECG tech that was specifically for the ED (tech didnt need to answerjust head directly to ED), we began to improve. April we had 76% of ECGs within 10 minutes and subsequent months have been between 65% and 75%. *This slide shows what is on the analysis tab of our revised tally sheet, which automatically populates as the data on the individual patients is entered by the ward clerk.

    The spreadsheet automatically calculates the number and percentage of ECGs within 10 minutes and lytics within 30 minutes and graphs it. It has both the mean and the median for 1st medical contact to ECG and Time ECG called to ECG. It also calculates the number and percentage of ECGs within 10 minutes by time period.

    As soon as the ward clerk has completed entering the individual data, this s

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