improving clinical outcomes – the case for electronic ed
TRANSCRIPT
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
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
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
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
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.
St Dominic – Jackson Memorial Hospital
969 Lakeland Drive
Jackson, MS
Questions?
Contact Information:
Stacey Ferguson – [email protected]
Ernie Fortenberry – [email protected]
Nikki Nissen – [email protected]
Sherry Jones – [email protected]