Part II: A

At Ephraim McDowell Regional Medical Center (EMRMC), organizational leadership guides and leads professionals, Associates, clinicians and the community we serve to participate in defining, promoting and achieving quality health. The visionary leadership at EMRMC has guided pursuit of patient-focused excellence by embedding high-performing beliefs and behaviors throughout the organization. EMRMC’s leaders apply a working definition of quality as: “The continuous and public evaluation of performance.”

At EMRMC, people accept individual responsibility for the quality of their work and routinely obtain genuine commitment and active involvement from their leaders. Working as a unit, both together and with their Associates, they strive for excellence, integrate fundamental management techniques, support existing improvement efforts and use technical tools in a disciplined approach to reach for measured, evidence-based, best practice processes and results.

To consistently achieve best results, EMRMC Leadership dedicates resources and training to build and use tools that implement the mission and vision of Ephraim McDowell Health (EMH). The EMH mission statement, as well as the F.I.R.S.T. values, is embedded in the quality structure and performance goals. The mission statement states “Ephraim McDowell Health is committed to providing a healing environment in the communities we serve, built on best people, practices and performance” and is brought to life through the actions of our Associates and professional staff.

Associates are held accountable to our FIRST values, which are:Friendliness: An environment that is filled with compassion, care and concernInnovation: The freedom and challenge to seek and apply new knowledgeRespect: Recognition of each person as a valued and unique individualService: Commitment to excellenceTrust: Adhering to principles that foster honesty, integrity, confidence and safety

EMH’s quality efforts are based on four pillars of excellence. Our mission, vision and values are guided by these principles:

Operational EffectivenessClinical EffectivenessRelationshipsSafety

Part II: B

Ephraim McDowell Health (EMH) has adopted a team approach to continuously improving the way in which it does business with its customers. Customers include patients, families, visitors, physicians, Auxiliary members and health system departments. EMH made the decision to redefine employees as “Associates” in order to formalize their role as partners and colleagues. Together with our Associates, EMH strives to keep customers a top priority. EMH Associates who are the most familiar with customer needs are encouraged to be involved in developing solutions that successfully fulfill those needs. EMH leaders actively coach Associates to

participate in solutions and actively try new approaches and changes that improve our processes and services. The teams cross departments and work collaboratively to improve our performance results both for outcomes and the patient experience.

Performance improvement training is required for all Associates annually. In addition, as new teams and councils are formed, “just-in-time” training occurs with support from the EMH Education Department. The training includes background information, data analysis and reporting. In addition to the requirement supporting the development of performance improvement skills, all Associates are required to report errors and incidents. Their performance on this requirement is included in their annual performance appraisal. Linked to the corporate value of “Innovation”, Associates are expected to use their training, skills and experience to identify challenges and apply their new knowledge to correct them. Combined with the pillar of “Service”, this commitment to excellence underpins collaborative efforts throughout EMH.

Collaboration, and an emphasis on interdisciplinary initiatives, offers Associates, medical staff, midlevel’s and leaders the opportunity to work together to achieve best outcomes. EMH’s routine (weekly) display and discussion of measured results strengthens everyone’s commitment and efforts. Keeping current results “top of mind” provides continuous feedback on these efforts. As a result, current priorities are not only communicated through the organization but efforts are maintained to achieve continuously improving results. This ongoing peer review has impacted the culture of EMH and enabled peers to interact with peers. More and more Associates and medical practitioners are holding each other accountable for maintaining the standards of care. Through this relentless level of review, another pillar “Safety” has been strengthened, and safety results are improving. However, these efforts are becoming “part of the work” and not an add-on. As a result, Associate and medical staff satisfaction is improving as demonstrated through “pulse” survey results that are collected throughout the year.

Most importantly, EMH continuously assesses patient and family experiences. Another strategic pillar, “Relationships”, is measured, in part, through paper and phone surveys that are used to collect information about their individual and collective experience. While reviewed weekly, these critical outcome measures are used to guide responsive action plans. In addition, department-based, performance trends of these results are evaluated through the EMH Structure of Accountability. That structure has built a clear and visible understanding among the leaders within EMH that guides and supports best, measured performance.

Part II. C. Process Improvement

Ten years ago, in 2005, Ephraim McDowell Regional Medical Center (EMRMC) was one of only two hospitals in Kentucky that was granted a certificate of need by the Cabinet for Family and Health Services to perform primary Percutaneous Coronary Intervention (PCI) without on-site surgical back-up. The goal of this pilot project was to improve patient outcomes through increased access of care for patients experiencing an ST Elevated Myocardial Infarction (STEMI) and to determine the safety of primary PCI without on-site surgical back-up. The University of Louisville published a statistical report on the pilot project, showing improved outcomes for patients and concluding the safety of PCI without on-site surgical back-up.

Comparisons of EMRMC 2005 Outcome MeasuresOutcome EMRMC

(n = 77)Reference Values p-value

Mortality - In-hospital, n (%, 95% CI) - W/ onsite CABG - W/O onsite CABG

2 (2.6, 0.3-9.1)2.2% 2.2%

1.0 (NS) 1.0 (NS)

Door-to-Balloon Time - W/ onsite CABG - W/O onsite CABG

100.1 mins100.4 mins 94.0 mins

0.952 (NS) 0.217 (NS)

Door-to-Balloon Time < 90 minutes - n (%, 95% CI) - W/ onsite CABG - W/O onsite CABG

28 (50.0, 36.9-63.1)44.8% 44.8%

0.516 (NS) 0.516 (NS)

Cardiac Arrests - PCI Related, n (%, 95% CI) - W/ onsite CABG - W/O onsite CABG

0 (0.0, 0.0-4.7)0.4% NA

1.0 (NS) NA

Emergency OH Surgeries Performed, - PCI Related, n (%, 95% CI) - W/ onsite CABG - W/O onsite CABG

0 (0.0, 0.0-4.7)0.4% 0.3%

1.0 (NS) 1.0 (NS)

NA – Not Available, NS – Not Significant, * – Significant at the 5% level.

Thus, in August 2010, EMRMC was granted full privileges by the state of Kentucky to perform elective and primary PCIs. With the opportunity to perform both elective and primary PCIs, EMRMC began a journey to expand its cardiology services with the ultimate goal of earning accreditation as a certified Chest Pain Center. In 2004, the hospital medical staff included one interventional cardiologist and one diagnostic cardiologist who had access to one cardiac catheterization lab and were supported by four registered nurses and two radiological technologists. Ten years later, in 2014, EMRMC’s cardiology services have expanded to include two state-of-the-art catheterization suites with a five-bed area for providing pre- and post-catheterization care. The provider mix has also expanded to include four interventional cardiologists, one diagnostic cardiologist, one vascular surgeon and seven registered nurses and three radiological technologists.

In January 2014, a Chest Pain Center Committee was formed at EMRMC with a purpose of improving cardiac care for the Acute Coronary Syndrome (ACS) patient through evidence-based practices, education, optimizing resources for patients and ongoing performance improvement. The committee’s mission is to guide patients through a cardiac pathway to improve quality of care and outcomes for ACS patients (See Attachments A-F).

The multi-disciplinary committee is comprised of the chief nursing officer; physicians from the specialties of cardiology, hospitalists and Emergency Department; Cath Lab staff; nursing representing the Critical Care Unit, Cardiovascular Unit and E.D.; Emergency Medical Services;the Chest Pain coordinator (Kim Reynolds, APRN, CCRN, FNP-C, CCCC); the Chest Pain medical director (Sharat Koul, D.O.); and staff from education, diagnostics, lab, community

services, performance improvement/clinical effectiveness, case management, regulatory compliance and information services.

The committee identified two goals that would be tracked through performance improvement measures. Those goals were:

1. To reduce mortality and morbidity for people experiencing an ST Elevation Myocardial Infarction through a systematic approach to reducing the time to reperfusion.

2. To reduce mortality and morbidity for people experiencing a Non ST Elevation Myocardial Infarction or Unstable Angina through standardized processes.

Non-STEMI STEMI# of Cases Mortality # of Cases Mortality

CY2013 CY2014 CY2013 CY2014 2013 2014 2013 2014175 237 3.4% 0.8% 348 434 7.2% 6.5%

To determine that the first goal was being met, the committee chose to track the following:First medical contact to EKG time <10 minutesFirst medical contact to reperfusion time <90 minutesDoor to door to balloon time <120 minutesNumber of EKGs transmitted to facilityDoor to EKG provider interpreted time <10 minutesPatient with ACS with 72-hour return to facilityOrder to time of troponin result>90% of Chest Pain/ACS will receive TIMI risk stratificationDoor to balloon <90 minutesCore measure elements for AMI

35.40%

2.60%

24.70%

0.70%

Non STEMI CasesIncreased

Non-Stemi MortalityDecreased

STEMI Cases Increased STEMI MortalityDecreased

Mortality Reduction During a 24 Month Period

CY2013 - CY2014

40.0

50.0

60.0

70.0

80.0

90.0

100.0

110.0

120.0

130.0

Oct

-13

Nov

-13

Dec-

13

Jan-

14

Feb-

14

Mar

-14

Apr-

14

May

-14

Jun-

14

Jul-1

4

Aug-

14

Sep-

14

Oct

-14

Nov

-14

Dec-

14

Ephraim McDowell Regional Medical Center Door to Door to Balloon

All Facilities

Haggin Memorial

Ephraim McDowell Fort LoganHospital

Goal <120 Minutes

-

10.0

20.0

30.0

40.0

50.0

60.0

70.0

80.0

90.0

100.0

Oct-13 Dec-13 Feb-14 Apr-14 Jun-14 Aug-14 Oct-14 Dec-14

Min

utes

Ephraim McDowell Regional Medical Center Average Door to Balloon

Avg Door To Balloon

0

5

10

15

20

25

Ephraim McDowell Regional Medical Center First Medical Contact to EKG

Goal <10 Min First Medical Contact to EKG

6

7

8

9

10

11

12

13

14

Oct

-13

Nov

-13

Dec-

13

Jan-

14

Feb-

14

Mar

-14

Apr-

14

May

-14

Jun-

14

Jul-1

4

Aug-

14

Sep-

14

Oct

-14

Nov

-14

Dec-

14

Min

utes

Ephraim McDowell Regional Medical Center EKG Provider Interpreted Time

Goal <10 Min

EKG Provider Interpreted Time

As it began its work, the committee faced many challenges, including that coding queries for low-risk chest pain patients were being utilized and there was an overall need for physician engagement. Perhaps the greatest challenge was that there was no standardized risk stratification used for Chest Pain/ACS patients and that patients moved from observation to inpatient status were not properly stratified for risk.

The committee established a goal to develop a standardized risk stratification tool for patients presenting with chest pain to the Emergency Department and to decrease the number of patients who were admitted to observation status and then changed to inpatient status. The cardiology and E.D. physicians collaborated and selected the TIMI (Thrombolysis in Myocardial Infarction) score as a standardized risk stratification tool. TIMI was a validated risk stratification tool that was simple and effective for an initial risk assessment. The goal for compliance was for more than 90% of chest pain patients presenting to the E.D. receive the TIMI risk stratification tool. As of May 2014, that compliance goal had been met.

Historical Points 1

) 1 1

1

93.00%93.50%94.00%94.50%95.00%95.50%96.00%96.50%97.00%97.50%98.00%98.50%99.00%99.50%

100.00%

OverallComposite

Aspirin AtArrival

AspirinPrescribed

at Discharge

Primary PCIwithin 90

Minutes ofHospitalArrival

StatinPrescribed

at Discharge

Ephraim McDowell Regional Medical Center

FY 2013

FY 2014

The Joint Commission Nat. Avg.

The Joint Commission Top 10%

TIMI Risk Stratification Tool

Presentation 1

1 1

-7)

Additional process improvements that developed from the committee’s work included the following:

A collaboration with EMS providers increased EKG transmissions from the field in two of the counties in our service area

0.0%10.0%20.0%30.0%40.0%50.0%60.0%70.0%80.0%90.0%

100.0%

Oct-13 Dec-13 Feb-14 Apr-14 Jun-14 Aug-14 Oct-14 Dec-14

Ephraim McDowell Regional Medical Center

Goal Patients with risk stratification Linear (Patients with risk stratification)

0.0%

20.0%

40.0%

60.0%

80.0%

100.0%

Oct

-13

Nov

-13

Dec-

13

Jan-

14

Feb-

14

Mar

-14

Apr-

14

May

-14

Jun-

14

Jul-1

4

Aug-

14

Sep-

14

Oct

-14

Nov

-14

Dec-

14

Ephraim McDowell Regional Medical Center % of First Medical Contact EKG Transmitted To

Hospital

% of First Medical Contact EKGTransmitted on ACS Patients

Linear (% of First MedicalContact EKG Transmitted onACS Patients)

Education and awareness to decrease door to EKG provider interpretedSharing data between Lab and the E.D. to decrease TAT troponin

A decline in the prevalence of Coronary Arterial Disease despite an aging population, as shown in the 2014 Community Assessment performed through our Community Service DepartmentPrevalence of Heart Disease

Sources: PRC Community Health Surveys, Professional Research Consultants, Inc. [Item 130] 2013 PRC National Health Survey, Professional Research Consultants, Inc.Notes: Asked of all respondents.

7.4%

15.5%

2.5%

8.6% 8.8% 7.3% 8.2%

6.1%

BoyleCounty

CaseyCounty

GarrardCounty

LincolnCounty

MercerCounty

Wash-ingtonCounty

TotalService

Area

US 6.00%

7.00%

8.00%

9.00%

10.00%

11.00%

12.00%

TSA2011

TSA2014

A “One Call Does It All” process to decrease door to door to balloon times

Because of the efforts of the Chest Pain Center Committee, improvements in the quality of care and outcomes for the ACS patient have been achieved through standardized processes and the work of interdisciplinary teams. Following an on-site survey in December 2014, Ephraim McDowell Regional Medical Center was granted accreditation as a Chest Pain Center with PCI through the Society of Cardiovascular Patient Care.

Attachment A EMDS for 9-1-1 Chest Pain Patients

Pa ent develops Chest Pain and calls 9-1-1.

9-1-1 center obtains loca on of pa ent and enters data

into system – EMS is dispatched.

Dispatch stays on phone with pa ent un l EMS arrives.

9-1-1 center asks pa ent: Describe pain.

Does pain radiate? Do you have allergy to ASA? If no, chew 160-235 mg prior

to EMS arrival.

Keep EMS updated on pa ent’s condi on.

9-1-1 center stays on phone with pa ent un l EMS arrives.

Developed by 9-1-1 dispatch center for Boyle County: Robin Vest-Parks 10/29/14

Attachment B EMS to Emergency Department Flow Chart

Developed by EMS Committee 10/15/2013 Updated 11/2014 Trina Clarkson & EMS Committee Updated 12/2014 Kim Reynolds

Goals for EMS: First Medical Contact to

EKG <10minutes

Activate Code STEMIs from the field and transmit EKG’s if has capabilities

Patient calls 911 with c/o CP

911 dispatches EMS to location

EMS arrives at patient -ASA 325mg -Obtain IV access -Oxygen -Morphine & NTG per protocol -Obtain 12lead EKG within 10 min -Transmit to closest PCI facility if have capabilities

Does EKG indicate STEMI

Yes

If EMRMC transmit to

859-239-6700

No Transport via

ground to appropriate

facility

PCI facility

<30 min

Activate CODE STEMI For EMRMC call 859-239-1100

No Activate closest

Air Transport Air EVAC

1-800-247-3822

Handoff to air transport

Yes

Transport via ground to PCI

facility

Handoff to ED RN

Reference: Than et al,. Rapid Assessment of Possible Cardiac Chest Pain, JACC VOL 598, NO 23, 2012 (Developed by Vicky Skimmerhorn, Kim Reynolds & Dr Koul 10/2013) Edited: 5/2014 Dr Guerrant &Trina Clarkson Edited: 11/2014 Kim Reynolds

□

Patient presents to ED typical/atypical

s/s ACS

-Triage with EKG to provider interpreted <10min -Baseline Troponin collected <10min -Continuous Cardiac Monitoring

Refer to STEMI/NSTEMI/UA

pathway EKG Negative

Troponin Negative

Alternative Dx

Remove from Cardiac Pathway

ED LIP to Risk Stratify Using TIMI

TIMI <2

-Discharge from ED with F/U with Cardiology within 72hrs -Place on precautionary medications

-Repeat Troponin & EKG in 2 hrs

-Medical Mgt per ED LIP

2hr Trop & EKG

Negative

-Admit to CVU per PCP or Hospitalist -Serial EKG & Cardiac Markers at 6 & 12 hrs - Exercise or Nuclear Stress test before discharge

TIMI Score Calculation Each positive variable equals score of 1

-Age >65yrs -Three or more risk factors for CAD (family hx CAD, HTN, DM, current smoker -Use of Aspirin past 7 days -Previous coronary stenosis >50% -Severe angina (>2events in past 24 hrs or persisting discomfort) -ST segment deviation >0.05 mV on first EKG

Low Risk ACS No Other Assignable Causes

**If ST elevation occurs at any time page Code STEMI

Alternative Dx

Remove from Cardiac Pathway

*Deviation from pathway requires appropriate supporting physician documentation*

Yes

No

No

Yes

Yes

No

No

Yes Yes

No

Attachment C

Patient arrives by EMS or private car with symptoms suggestive of ischemia or infarction.

Emergency Department places in cardiac room immediately and begins cardiac workup.

MD assesses patient within 10 minutes & performs risk stratification using TIMI.

Initiate ED Chest pain order set

Oxygen, ASA, IV access EKG, pain control, labs (CBC, Cardiac biomarkers to include troponin, potassium, magnesium) within 10 minutes.

Physician Interprets EKG

High Risk Unstable Angina/ NSTEMI Invasive Management

High Risk Unstable Angina/NSTEMI

Conservative Management

If s/s persist, perform con nuous ST segment monitoring or serial EKG’s per LIP discre on.

Admit to cardiovascular unit to hospitalists/LIP.

Consult cardiology.

Ini ate an coagulant/an platelet therapy.

Ac vate CHESTPN/ACS order set.

Consider Cardiac Cath.

Evaluate EF func on.

Admission to cardiovascular unit to Hospitalists/LIP

Serial enzymes & EKG at 0-6-12

Ini ate an coagulant/an platelet therapy

Consult cardiology

Ac vate CHESTPN/ACS order set

If third troponin nega ve, MD to determine course of follow-up treatment

Consider non-invasive stress test

Evaluate EF func on

Algorithm for Management of Probable or Definite UA/NSTEMI Patients Presenting to Emergency Room

If at any me the EKG becomes consistent with STEMI then

ACTIVATE CODE STEMI.

Developed by Sharon Dailey, Dr Koul, Sabrina Mullins, Leslie McQueen, Leanne Edwards, Ashley Murphy 03/2014

A achment D

Attachment E Developed by Amy Coleman & Trina Clarkson 12/2013 Updated: Trina Clarkson 11/2014 Updated: Kim Reynolds 11/2014

STEMI EKG

from another facility “One

Call Does It All”

Walk In STEMI

STEMI EKG Transmission

from field

ED RN Team

Place in bed immediately Triage into system Initiate Chest Pain protocol order set Collect Trop within 10 min

ED Tech Obtain EKG & show to provider (door to

provider interpreted <10min) Place on continuous cardiac monitor/ST

segment monitoring

ED Physician Assess patient

EKG Interpreted as STEMI by ED Physician Date, Time & Initial

ED physician Call PBX @ 1011 initiates CODE

STEMI

PBX places mass group page Cardiology/Cath team to

return page <5 min

By-pass ED patient straight to Cath Lab

Hand off ED RN to ED RN to Cath Lab RN

ED RN to register pt while en route and place order

for cath into system

Is patient coming from

another facility?

Yes Cath

Team in-house?

Yes

No

ED RN Team & ED Tech open STEMI Box/Prepare pt for Cath

Lab refer to STEMI Checklist Assessment by ED physician &

Consider repeat EKG if from field/another facility

STEMI Checklist

ED RN Team 2 large bore IV’s Administer Meds Obtain Consent Initiate PI form Place Cath Order ED Tech Place Radiolucent Defib pads & leads Shave groin

ED RN Hand off to Cath Lab RN & assist in transport to cath lab Hand off EKG

No