improving clinical outcomes – the case for electronic ed

Improving Clinical Outcomes –

The Case for Electronic ED Door to

EKG Time Monitoring

2014 Distinguished Achievement Award for Clinical ExcellenceTM Competition

October 22, 2014

St. Dominic-Jackson Memorial is a leading 535 bed tertiary medical center owned

by the Dominican Sisters of Springfield Illinois and serving central Mississippi

since 1946.

MISSION – Christian Healing

VALUES – I CARE

Integrity

Collaboration

Accountability

Respect

Excellence

3000+ Employees

Over 20000 Inpatients Annually

Additional 10000+ OPIB/OBV Encounters Annually

Over 51000 Emergency Room Visits Annually

Accredited by the Joint Commission continually since 1955

Accredited Chest Pain Center

Certified Stroke Center

Certified Inpatient Diabetes Center

Certified Wound Care Center

Stacey Ferguson RHIT, Data Registry Coordinator

Ernie Fortenberry CAHIMS, Senior Data Architect

Nikki Nissen RN, MSN, Emergency Services Director

Sherry Jones RN, MSN, Clinical Decision Support Coordinator

ED Door to EKG Time – A Critical Measure of Patient Safety and Clinical Outcomes

Issues Identified:

Manual data abstraction to monitor time and only on Acute Myocardial Infarction (MI) patients

Data was on National Cardiovascular Data Registry (NCDR) ACTION Registry®-GWTGTM with significant delay in reviewing and reporting

Noted decreased performance on metric

Need Identified:

Electronic method for monitoring all chest pain (CP) and Acute Coronary Syndrome (ACS) patients Door to EKG times

Result:

Performance Improvement Project

Issues with data integrity

Impossible to do 100%

No real time/actionable data

Hard to locate in electronic health record (EHR)

Registrar owns the data

Purpose/Goal

Increase the percentage of patients receiving EKG within 10 minutes

for patients presenting with CP to 70%.

Problem Statement:

Although the median time from door to EKG is 7 minutes, the

previous six months of data in the ACTION Registry and the

American Heart Association (AHA) Mission Lifeline revealed a

decrease in the percentage of patients with EKG within 10 minutes

of arrival. The time from Door to EKG had not been tracked for

patients who presented to the ED with CP.

Project Start Date: July 20, 2013

77.3

71.8

66.7

56.5

62.8

80

73

50

58

0

10

20

30

40

50

60

70

80

90

1Q '12 2Q '12 3Q '12 4Q '12 1Q '13

ACTION Registry Mission Lifeline

6 Month Decline Observed

ACTION Responsibility Due Date Status Create a report in Business

Intelligence (BI) to track all

chest pain patients and the

average door to initial EKG

time.

Sherry Jones

Ernie Fortenberry July 30, 2013 Completed

Validate & analyze times on

new BI Highlight to identify

any trends in Door to EKG

events greater than 10

minutes.

Stacey Ferguson July 30, 2013 Completed

Add a dedicated EKG

machine to Triage. Chad Neely July 30, 2013 Completed

Get input from Triage RNs and

RT EKG techs for ideas to

make the process more

streamlined.

Nikki Nissen July 30, 2013 Completed

Provide staff education. Nikki Nissen for ED

and Chad Neely for RT August 15, 2013 Completed

Manual Process of Extracting Data

McK Horizon Emergency Care

Data Elements Feed to Performance Manager 1st ED Pract Contact Date/Time Acuity Acuity Date-Time

Admitted to Hospital Date-Time Arrival Date-Time AS400 Admit Date-Time

Assigned Bed Date-Time in ER Assigned RN Attending MD

Chart Final Signature Date-Time Chest Pain Obs Bed Date-Time Chest Pain Obs Patient

Chief Complaint Chief Complaint 2 Count

Discharge Date-Time Disposition Disposition Date-Time

Disposition Decision Date/Time Disposition from ED by Pt Type Disposition to Signature Days

Disposition to Signature Hrs Disposition to Signature Mins ED Arrival Date/Time

ED Bed Assign ED Bed Request ED Departure Date/Time

ED Departure Date-Time ED Practitioner (McK) ER Disposition

ER Event Count ER Event Description ER Event Field

ER Event Performed Date ER Event Performed Date-Time ER Event Seq

ER Event UniqueID ER Observation ER Room

Exam Started Date-Time Location MD Disposition Date-Time

MD Disposition MD Name MD Disposition to MD Refer ED Pt to Obs

MD Start Date-Time MD Starting Exam Mode of Arrival

Omnipaque Completed Date-Time Omnipaque Entered Date-Time Primary Complaint

Primary Dx Code Primary Dx Description Primary Dx Dx Seq

Refer ED Pt to Obs Date-Time Registration Date Removed from TB by

Removed from TB Date-Time RN Disposition Date-Time RN Disposition RN Name

RN Disposition to Secondary Complaint Signing MD

Signing RN Staff Name Treating Provider

Treatment Space placed Date/Time Triage Acuity Code Triage Date/Time

Triage Date-Time Triage Nurse Name Visit Complete Flag

Visit ID

GE MUSE

Cardiology Information System

Data Elements Feed to Performance Manager Acquisition Cart Number

Acquisition Date-Time

Acquisition Tech ID

Acquisition Tech Name

Confirm Date-Time

Edit Date-Time

Order No

Ordering MD

Overreader MD

Perform Location Abbr

Perform Location Code

Perform Location Name

Perform Room

Referring MD

Test Name

Test Reason

TestId

Units

Daily Feeds

Performance

Manager

Data Warehouse

Automated Process of Extracting Data

Series Patient

Account Interface

External

Databases

Standard Feeds

Extended Objects

Custom Objects

Da

ta In

teg

rato

r

Person / Encounter Data

Clinical Data

Benchmarking Data

Financial Data

Wo

rksh

ee

t

Business Insight

Highlights

Scorecards

Performance

Manager

Data Warehouse

Analyses

3M HDM

AHRQ QI

Cerner Lab

GE Centicity

RIS-IC

GE Centicity

Cardiology DMS

GE Centicity

Perinatal

GE MUSE

CIS

Cerner Apache

HealthStream

Patient

Satisfaction

McK Horizion

Clinical

Infrastructure

McK Horizon

Emergency

Care

McK Horizon

Surgical

Manager

McK Pathways

Healthcare

Scheduling

McK Patient

Folder

McK

Performance

Visibility

McK Series

Patient

Accounting

Midas+ SolutionsProject RED

Re-Engineered

Discharge

St Dominic

SQL

Databases

Zip Code Distance

Performance

Manager

Data Warehouse 20 Systems that are not

Standard Feeds into the

Data Warehouse

> 1000 Extended Data Elements

External Data Elements Integrated into

Performance Manager’s Extended Data

Integrated EKG data from source system to

Performance Manager (PM)

Worksheet and subset created with associated BI

highlights

Daily integration of EKG data allows for key clinical

leaders to monitor for success or identify process issues

promptly and employ LEAN techniques for correction

New process took a labor intensive manual process on

small sample of MI patients to an electronic process

encompassing 100% of the identified at-risk patient

population

Utilized similar methodology and techniques to improve

ED patient turn around times on key radiology and

laboratory procedures and tests

Replicated model for use in Diabetes Center program

and achieved associated certification from accrediting

body

Provided assistance to other organizations through

webinars and conference calls to assist with data

integration methods – example: integrating Clinical Core

Measure data sets from other vendor into Performance

Manager

55

62

63

57

59

61

50

52

54

56

58

60

62

64

Jan '13 Feb '13 Mar '13 Apr '13 May '13 Jun '13

Percentage of ED Chest Pain Patients with EKG within 10 Minutes

Jan – Jun 2013

58

62 63

69 71

67 64 65

68

73

66

73

0

10

20

30

40

50

60

70

80

Apr '13 May '13 Jun '13 Jul '13 Aug '13 Sep '13 Oct '13 Nov '13 Dec '13 Jan '14 Feb '14 Mar '14

Percentage of ED Chest Pain Patients with EKG within 10 Minutes of Arrival

Data includes ALL CP/ACS patients arriving to the ED

Ability to analyze trends by day of week, hour of day,

Triage personnel

Deep dive to the encounter/account level and evaluate

extended time based on presenting complaint and final

diagnosis

Moved from data-driven to a more data-enabled model

for process improvement which leads to consistency in

patient care

Multi-Disciplinary Team:

ED and EKG Staff

Chief Medical Information Officer

Cardiology Service Line Administrator

Physician Champions from ED and Cardiology Services

ED Director and ED Manager

Respiratory/EKG Director and Manager

Senior Data Architect

Clinical Decision Support Coordinator

Data Registry Coordinator

Level 1 Heart Attack Program Coordinator

Project Governance Structure:

Bi-directional support from Cardiology Service Line Administrator and Executive Team:

Funding of dedicated EKG carts for ED Triage

Funding for additional Triage Technician

Bi-directional support between ED Director and Respiratory/EKG Director:

Training for all ED Triage Nursing Staff and Respiratory/EKG Technician(s)

100% Adoption by Triage Staff in rapid implementation of the EKG evaluation for qualifying patient populations

Data Governance Structure:

Actively engaged in implementing a more formal Data Governance Model for the Organization

Road to Success:

Immediate education/training of Triage Technician on EKG patient

setup

Addition of dedicated EKG carts permanently assigned to ED Triage

Additional Triage Technician on high volume days/times for CP

patients (based on BI Highlight analysis of data)

Additional stretcher/curtain for ED Ambulatory area to be used when

EKG Triage areas are saturated due to high ED patient volumes

Result:

Positive trend toward consistently meeting national benchmark – at

end of PI Project 70% of CP patients were receiving an EKG within

the 10 minute benchmark

Accurate and timely clinical information

Information available to all levels of staff and key clinical

stakeholders

Consistent results leading to improved execution of

diagnostic plans

Rapid treatment decisions for the CP population

Project success integral part of attaining Chest Pain

Center Accreditation

By using the 70% evidenced based industry standard

and integrated clinical decision support, St. Dominic’s

leveraged the full components of multiple data systems

and integration to provide effective, process-driven care

for a specific patient population.

A focus of identified opportunity for process improvement

led to strategies to measure, monitor and improve

outcomes for a specific population with time-sensitive

needs. Process applicable to other populations.

By moving to an electronic method of monitoring,

manual evaluation and associated reporting lag time

have been eliminated with improved efficiency and

utilization of staff and workflow processes.

To provide prompt, process-driven care, the Door to

EKG performance improvement plan employed multiple

disciplines and strategies to result in improved

timeliness in managing the ED CP/ACS population.

The methods employed in improvement of Door to EKG

times have been sustainable and have been repeated in

additional patient populations.

Michael L. Sanders, MD

Chief Medical Information Officer/Assistant VP of Medical Affairs

St Dominic – Jackson Memorial Hospital

969 Lakeland Drive

Jackson, MS

Questions?

Contact Information:

Stacey Ferguson – sferguson@stdom.com

Ernie Fortenberry – efortenberry@stdom.com

Nikki Nissen – nnissen@stdom.com

Sherry Jones – shejones@stdom.com