Cardiovascular disease, including acute myocardial infarction (AMI), is the leading cause of death in the United States. Each year 900,000 people in the United States are diagnosed with AMI; of these, approximately 225,000 cases result in death. It is estimated that an additional 125,000 patients die before obtaining medical. Due to this, the Joint Commission stakeholders identified cardiovascular disease as one of the initial priority focus areas for hospital core measure development.
Effective Management of AMI Patients
Evidence indicates that effective management of AMI patients is the timing of reperfusion therapy. The earlier therapy is initiated, the better the outcome. Patients presenting with AMI and ST segment elevation or left bundle branch block (LBBB) are at a relatively high risk of death. This risk may be reduced by thrombolytic therapy or PTCA, but only if administered and performed in a timely manner. Thrombolytic therapy has its greatest benefit if administered within the first 3 hours after the onset of symptoms. Therefore, it is critical for facilities to keep track of when a patient arrives in their facility to the point they get therapy or are transferred to a facility that is capable of providing the therapy. Current guidelines recommend 30 minutes to thrombolytic therapy and 90 minutes to PTCA.
Joint Commission Study
The Joint Commission performed a pilot study in 1999 to collect input from a variety of stakeholders including clinical professionals, hospitals, consumers, state hospital associations and medical societies about potential focus areas for an initial set of hospital core measures. The study included information on “door to balloon time” and “door to thrombolytic therapy”.
The study found that the two elements, thrombolytic therapy or PTCA, were challenging to collect. This was primarily due to imprecise medical record documentation. Patient arrival time was only found present in the medical record in 75% of the cases during the pilot test. PTCA time was found present in the medical record in 70% of the cases. The data element assessing ST segment elevation was also problematic because ST segment elevation was often not explicitly stated in the ECG documentation. The importance of these measures for monitoring AMI patient care transcends concerns raised by the data element related issues.
Preliminary data from the pilot test show an average median rate of 67.75 minutes for time to thrombolysis and an average median rate of 310.85 minutes (5.2 hours) for time to PTCA. Therefore both of these measure rates would indicate an opportunity for improvement.
Hospitals can elicit assistance from their vendors in order to help with the accuracy of these times. If your facility has or is thinking about getting a real time locating solution (RTLS) for asset management and patient or staff tracking, these hardware systems along with the software solution can timestamp these elements in real time. This eliminates the need for second guessing or filling in the blanks after the fact. The RTLS system, by placing a locating tag on the patient, can record the patient’s movement throughout the facility and timestamp when the patient arrives in a designated area. The sophistication of these systems varies. Some are far advanced and can drive workflow and throughput by sending alerts or messages to providers that a “Code STEMI” is in progress, therefore alerting the operating room (OR) crew to get prepared for the cardiac patient. They can also record interactions between patients and assets such as an EKG machine, time stamping the time the ECG was complete.
How accurate is your “door to therapy time?”
~Jamie Karns, R.N. MSN/MPH CNS