David Bonner, Team Leader, Clinical Operations at NCDR Hello. I'm David Bonner, the Team Leader of Clinical Operations at NCDR. I'd like to thank you for joining us today and welcome you back to our pre-conference for the ACC's 2021 Virtual Quality Summit. I hope you're all having a nice afternoon. This year, again, we're pleased to offer a four-part series of conversations with our Clinical Quality Advisor team. They will highlight important information aimed to help lead you to a successful journey in transforming cardiovascular care and improving heart health. This third session is focused on quality improvement in action. We're lucky to have tapped into a very unique quality team at Iris Medical Center in Iville, Idaho. The Iris Medical Center team are googly-eyed over their team efforts, and they're very generous to let us peek into their processes. Keep a close eye out for how they incorporate the use of NCDR data and products as they navigate quality improvement like good pupils. In Iville, they're keeping an eye on quality. Let's begin this conversation with a quick introduction of our expert panel of staff at Iville Medical Center. From Iris Medical Center in Iville, Idaho, I'd like to introduce the very skilled quality staff, our Quality Department Supervisor, Mrs. Kristen Eyedrops. NCDR is like eye candy to me. The Cardiology Steering Committee Chair, Dr. Nando Conjunctivitis. When you're not up to date on your data, you will feel very isolated. Our Cardiology Service Line Director, Mrs. Retina Pond. I always want to see eye to eye with NCDR. Our ED Medical Director, Dr. Alyssa Eilash. How ironic, they actually included the Emergency Department in this team. The ED Medical Fellow, Dr. Anita Glasses. I have my eyes on cardiology research. And the Chest Pain MI Registry Quality Coordinator, Ms. Shelly Kelly-Eyelid. If my team does not get the data right, I make them sit in the cornea. The Cath Lab Supervisor, John Icebee-Floaters. My mantra is, don't make an eyesore of yourself. Work with your physicians and clinicians to provide accurate documentation all of the time. The EMS Liaison, Kat Arax. Even my phone has glasses now that I've lost all my contacts. And finally, our Chest Pain MI Registry Quality Coordinator, Yen-Aiz Dai. I have looked at so many data results. I have double vision. We were able to follow the Iris Medical Center around to see their process for success using NCDR data registries. We first captured the team identifying a problem. The Quality Department Supervisor, Kristen Eidrops, just finished a meeting with the Cardiology Service Line Director, Retna Pond, and of course their VP. They're not so pleased with their public reporting star rating for heart attack care. Kristen Eidrops is holding a team meeting with her Chest Pain MI Registry Quality Coordinators, Callie Shelley-Eyelid, and Yen-Aiz Dai to identify the problems. You know what they say, when in Idaho... Good morning, team. I just met with Retna and our Vice President, and they're not super happy with our star ratings that are reflected on CardioSmart. They're really wondering why we're not at four stars in regards to our heart attack care. Can you guys remind me, what is used to generate a star rating in the first place? I am so happy to discuss this with you. I have concerns, and I was literally in the process of setting up a meeting with you. Our NCDRE reports dashboard demonstrates our performance for cardiac rehabilitation referral and first medical contact to device times are below the U.S. 50th percentile benchmark. Both NCDR performance measures of cardiac rehabilitation referral and first medical contact to device times are two of the 14 measures that contribute to NCDR's overall defect-free care composite, which is named all heart attack care in the ACC's CardioSmart public reporting. That's really good to know, but I could have sworn that our performance in all of those process measures were pretty stellar, no? No. On the eReports dashboard, we are below the 50th percentile and parallels my concerns, which are, first, cardiac rehabilitation among medically treated patients continues to be a challenge. Secondly, our executive summary metric first medical contact to device time is not consistent from one patient to another. And lastly, aspirin on arrival, the cardiologists have taken steps towards ensuring patients are getting aspirin regardless if the patient took their aspirin at home, and we are actually starting to see some improvement. Well that's good news to hear, and cardiac rehab, now that you mention it, has always been a thorn in my side, but I'm still so surprised about door-to-balloon. I still can't believe our door-to-balloon numbers are poor. Are you sure we're capturing the data correctly? Yes. Yan and I are meticulous about evaluating data when evaluating the NCDR executive summary metric and measures companion guide, and we access for key stroke errors, and every Friday we submit our data, and then on Monday morning, we review the NCDR reports dashboard results using NCDR executive summary metrics and measures companion guide, ensuring that the results are accurate. Once we confirm the data is correct, we prepare our report using the NCDR published data on the e-reports dashboard for Tuesday morning cardiologist meeting. Yeah, wait, it's not door-to-balloon, it's the FMC-to-balloon. It's the first medical contact. When the EMS contacts the patient, the clock starts that time. That's correct. When a STEMI patient arrives by EMS, the expectation based on the ACC AHA guidelines and the NCDR's metric 37 reperfusion is expected to be within 90 minutes regardless of the mode of arrival and includes the time the patient is being cared for by EMS, and the time does not start at our door unless the patient arrives by self or family arrival. Yan and I decided to dig a little further. In addition to evaluating the NCDR e-reports dashboard benchmarking results, we exported the patient-level drill-down reports to Excel. This way we could filter them. When we filter by mode of arrival and time to device, we found patients who arrived by EMS during off hours are more likely than not to meet the 90-minute window. The time in the cath lab is taking more than an hour and reperfusion is severely delayed because of it. Yeah, right. When we look at these cases and we see ED repeats EKGs, even the patient was brought in by EMS, and that takes time. I don't know why. Those are all very valid points, but first and foremost, I guess I really didn't realize that we were looking at first-level contact being EMS now, so I was kind of blown away by this conversation. So thank you for updating me and explaining the dashboard results. So you said cardiac rehab and first medical contact to balloon. Where do we really look at, in your opinion? I think first medical contact. Yes, first medical contact to balloon or to device, yes. All right. So I'm going to try and focus our efforts there, but before I do that, do you have any kind of ammunition that I could take to a meeting in regards to whenever you really drill down into the patient-level detail on the dashboard of why, is there any system issues, is there any trends or any common concerns that you're seeing whenever you look at the records? Yes. When the patients arrive by EMS on off hours, we're finding that the ED dwell time is extended, and it's taking a long time to get the patient actually to the cath lab for reperfusion. So I'm not sure what's going on during the off hours, but it appears that that is the problematic area. Okay. So I'm hearing the ED dwell time is a little bit too long. So these are all great points, and you provide many areas for opportunity, but I think in order to improve our first medical contact to balloon performance, we're probably going to have to do a collaborative approach and get those patients out of ED quicker. So I'm thinking I'm going to get in touch with some stakeholders in our EMS, our ED, and our cath lab, and some leadership to get on board and have a follow-up meeting to discuss this and kind of brainstorm through our problems. Shelly, Kelly, can you please print out the quality improvement toolkit available under clinical toolkits under quality improvement for institutions for me? Absolutely. And I'll also, I'll provide you the reports that Jen and I have created. This will also help you in your investigation and your collaboration with the other teams. Fabulous. I need all the help I can get. Thank you, ladies. Thank you. Well, that was great work identifying the problem. Kristen Eyedrops is now going to hold a multidisciplinary team meeting to clarify the problem, brainstorm, and produce an intervention. So to do that, she's going to call in the ED medical director, Dr. Lissa Eilash, the cardiology steering committee chair, Dr. Nando Conjunctivitis, the cath lab supervisor, John I.C. Floaters, the EMS liaison, Kat Arax, and the ED medical fellow, Dr. Anita Glasses. Let's watch this like we have pink eye. Thank you all for being here on such short notice. After a discussion with my heart attack champions, Kelly, Shelley, and Stye, I find out, I have found out that we're not giving our heart attack patients timely reperfusion for really a multitude of reasons. But out of the things we discussed, we find the common denominator to be that our patients, specifically our STEMI patients, are sitting in the ED for far too long. Well, if we had enough beds, or I miraculously grew an extra pair of hands, or the cath lab wasn't very busy during business hours, or if they got here on time, off hours, you know, all this could help. True, and those are good points. I didn't, I hope I didn't come off as being too pointedly and placing blame, because that's not what we're here to do. Because we certainly understand the difficulties that you experience in the ED for sure. But what we're here today to do is to bring ideas to the table in a more collaborative approach. So we have some fresh eyes here from across different departments, but the purpose is to break down our internal silos instead of working in a departmental fashion and work in a collaborative fashion so that we're all moving at the same time. So I'm actually going to open up the floor to you first, Dr. Lisa Eilash. In a perfect world where money was no option, how would you get your STEMI patients out of your ED faster? Well, thank you, Kristen, and for providing me the drill down from the eReports dashboard as to the times where it's the longest dwell time for patients. We strive to make the patient get to the cath lab in a timely fashion. So in a perfect world, I wish we could have a STEMI activation where multiple entities are involved, where we're meeting the patient at the bedside, they know their responsibilities, and EMS gives us timely activation notice so that we're all prepared to meet and greet the patient when they arrive. So that's really good feedback, and actually underneath clinical toolkits, there is a team role responsibilities available to help us kind of assign those type of roles to everybody involved with the care of those patients. I'll share that with the group, but you know what? I think you might even benefit from being given access to our eReports dashboard. I'll have to talk with Shelly, who's our RSM, to see if they can give you some dashboard access for yourself so you could take a look at these patients. Thank you. Sure. I'm going to move on while I jot down these notes to Dr. Nando Conjunctivitis. What are your thoughts? Well, in the perfect world where money was no object, and of course, if money is no object, it's a perfect world, but it would be helpful to have more resources when we receive patients with MIs. Maybe in a perfect world, we can have an in-house cardiologist who is stationed at the ER and could receive MI patients coming from the field, confirming the diagnosis right when the patient enters and right away move to the cath lab, but the cath lab staff needs to be there. So maybe in a perfect world, we'll have the cath lab in-house, or maybe we'll have them stay closer to the hospital so they don't have to worry about the drive here or parking, but of course, perfect world. Yeah, you make some good points. It would be really nice to have people in-house. However, I don't think that the cath lab staff would want to stay overnight for that once in a while off-hour STEMI. So I haven't jotted it down, but John, I see floaters. What do you see from your cath lab staff? Any suggestions? Yeah, thanks for inviting me to the meeting, Kristen. We're always looking at how we can move patients, STEMI patients specifically, to the lab quicker, whether they're in-house or from the emergency room or transfers in from facilities in the field. One idea we've floated is having the first cath lab staff member who's on call as soon as they arrive in the hospital and as they go into the cath lab to start preparing the room. They can call for that patient to come down from the emergency room because it's going to take a little bit of time. And then as the other staff members trickle in, then they might even be able to help go and assist bringing that patient down to the cath lab from the emergency room, especially if they need extra help, like if the patient is tubed and has a lot of different drips or something like that. The other issue that we come up against and that we hear complaints about is the parking situation is just really, really difficult. In this urban, congested environment that we work in, it is really difficult for the staff to find parking close to the hospital. Sometimes they circle around several times, and that really does cause a delay of minutes that are very valuable. So dedicated parking close to the lab would really be helpful. So those are actually some good suggestions, but I think, honestly, you could probably do that at the departmental level. So I'm going to let you take those back to your staff to implement those kind of changes. I'm really trying to figure something out that we can measure. So Cataracts, since you're new to the group, as we'd ever had EMS kind of join us in this meeting before, what are you hearing from our EMS providers? Well, from the EMS providers group, we would have no problem with completely bypassing the ED when there's an identified STEMI. But in order to do that, the ED would have to activate the cath lab prior to our actually arriving at your facility more consistently. So I hear feedback from our EMS that, and this happens all the time, that we get to the ED, a provider wants to repeat the ECG, which takes time, and then they activate the cath lab staff. All of this, from our point of view, is delay upon delay. And you can only imagine how frustrating it is for us when we've already identified the STEMI. Yeah, I hear you. But you've repeated something that my colleague said about repeating that ECG. So again, another process issue. But I think that something that you mentioned that is measurable by using our chest pain and NCDR registry data is capturing our pre-arrival activation times whenever they arrive by EMS. So I think that is where I'm going to take this back to my team to kind of come up with solutions on how we can implement a good pre-arrival activation system. And in regards to that, there are some really useful door-to-balloon clinical toolkits available on the Quality Improvement for Institutions homepage that I will be sending everybody to see if there's anything that we can implement into our hospital system. So thank you again for your time. I appreciate all this feedback. Is there anything else anybody would like to add to the conversation? Silence is golden. No, I'll touch base later. So that was a lot of really good information. We watched the team capture the process of identifying a problem initially. Now we just watch them clarifying the problem, brainstorming, and producing an intervention. Let's next watch the team plan and execute. So after holding a follow-up meeting with the chest pain and my registry quality coordinators, Houston Eyedrops now holds a follow-up meeting with the cardiology service line director, Retina Pond. In that, they share the processes implemented to improve pre-arrival activation. Well, Mrs. Retina Pond, I'm very excited to bring to you some information. We had a really productive collaborative meeting from our stakeholders and leaders from our EMS community to our ED all the way to our cath lab. I think our discussion really opened some eyes to all the folks who were present. In fact, there's going to be minor process changes taken back to the departmental level for internal discussion to promote continued change outside of what I'm going to share with you now. But the focus is going to be on getting our STEMI patients out of the ED because they're just sitting there for far too long. So it sounds like you had some great collaborative meetings. What I'd like to know is how you're going to accomplish this. Yep. So what we find that our patients that are sitting in the ED for too long are not getting pre-arrival activation. And there is actually a clinical toolkit that's available to us on our Quality Improvement for Institutions webpage that kind of gives us a standard process on how to really implement pre-arrival activation at our facility. So this will get the cath lab staff and our on-call cardiologists during off hours and whenever our ED is super busy, moving at the same time the patient is coming to the hospital. And this is, of course, at no extra charge to the organization. So you're going to use the NCDR toolkits to develop a process to get those patients to the cath lab sooner. Yep. And there's actually going to be a multitude of ways if you really want to listen through them all. I'll tell you more about it. Well, the one thing I had a concern about was EMS. So this is an outside entity. So how are we going to track that data? That's a great question. So just by participating in the NCDR registry, specifically chest pain MI in this instance, we're able to do a data extract to measure our performance of pre-arrival activation because they actually have a data element in the data set that captures that. So with that data element, we can do a data extract of our raw data. And my colleagues are going to do that and produce a report 24 hours after the patient, the STEMI patient specifically, has been reperfused. And with our collaboration with EMS, we have a contact and that is going to be sent to their email. Of course, if I removed, it's just going to be the metrics and going to be sent to anybody that touched that patient, like I said, within 24 hours. Well, I like the collaborative method that you've used, and I will be interested to see how these process changes that you're going to implement will affect our public reporting score in three months. So, and the other thing is that I think is really wonderful about this is that we can do all these things with NCDR reports and you're sure there's no additional cost. There is none. I checked under clinical toolkits, under quality improvement for institutions homepage. And in addition to just door to balloon, which has like 10 really cool resources that we could share with our entire organization, there's also ones on heart failure and how to download clinical practice guideline apps. And I think it'll just take us more if we use these robust tools and we're more aware of our performance. That's wonderful. I can't wait to see the results your team is going to bring to me in three months. Thanks so much. Yeah, no problem. Wow, that was some great information you guys shared. I look forward to seeing some of that displayed in an abstract at one of our future ACC quality summits. We'd like to thank our special guests from iVille, Idaho today and Wink or Blink to wish them great continued success with ACC, NCDR and all of their vision for the future. Thank you so much team. So the moral of the story is keep your eyes wide open when it comes to quality and always remember there's no I in team.

NCDR

ACC

Clinical Quality Advisor

Iville, Idaho

quality improvement

STEMI patients