Improving Clinical Outcomes The Case for Electronic ED Door to EKG Time Monitoring

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1 Improving Clinical Outcomes The Case for Electronic ED Door to EKG Time Monitoring 2014 Distinguished Achievement Award for Clinical Excellence TM Competition October 22, 2014

2 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.

3 MISSION Christian Healing VALUES I CARE Integrity Collaboration Accountability Respect Excellence

4 Employees Over Inpatients Annually Additional OPIB/OBV Encounters Annually Over 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

5 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

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7 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 -GWTG TM 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

8 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

9 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

10 Month Decline Observed Q '12 2Q '12 3Q '12 4Q '12 1Q '13 ACTION Registry Mission Lifeline

11 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. Validate & analyze times on new BI Highlight to identify any trends in Door to EKG events greater than 10 minutes. Sherry Jones Ernie Fortenberry July 30, 2013 Completed Stacey Ferguson July 30, 2013 Completed Add a dedicated EKG machine to Triage. Get input from Triage RNs and RT EKG techs for ideas to make the process more streamlined. Chad Neely July 30, 2013 Completed Nikki Nissen July 30, 2013 Completed Provide staff education. Nikki Nissen for ED and Chad Neely for RT August 15, 2013 Completed

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13 Manual Process of Extracting Data

14 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 McK Horizon Emergency Care Data Elements Feed to Performance Manager 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 Daily Feeds 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 Performance Manager Data Warehouse

15 Automated Process of Extracting Data

16 Data Integrator Worksheet Series Patient Account Interface Performance Manager Data Warehouse Business Insight Financial Data Benchmarking Data Highlights Scorecards External Databases Clinical Data Analyses Standard Feeds Extended Objects Custom Objects Person / Encounter Data

17 3M HDM GE Centicity RIS-IC GE Centicity Cardiology DMS GE Centicity Perinatal GE MUSE CIS HealthStream Patient Satisfaction St Dominic SQL Databases Project RED Re-Engineered Discharge Cerner Apache Performance Manager Data Warehouse 20 Systems that are not Standard Feeds into the Data Warehouse > 1000 Extended Data Elements Midas+ Solutions AHRQ QI Cerner Lab Zip Code Distance McK Performance Visibility McK Patient Folder McK Horizon Emergency Care McK Horizon Surgical Manager McK Pathways Healthcare Scheduling McK Horizion Clinical Infrastructure McK Series Patient Accounting

18 External Data Elements Integrated into Performance Manager s Extended Data

19 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

20 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

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22 Percentage of ED Chest Pain Patients with EKG within 10 Minutes Jan '13 Feb '13 Mar '13 Apr '13 May '13 Jun '13

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24 Percentage of ED Chest Pain Patients with EKG within 10 Minutes of Arrival Apr '13 May '13 Jun '13 Jul '13 Aug '13 Sep '13 Oct '13 Nov '13 Dec '13 Jan '14 Feb '14 Mar '14

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26 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

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28 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

29 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

30 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

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32 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

33 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.

34 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. 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.

35 The methods employed in improvement of Door to EKG times have been sustainable and have been repeated in additional patient populations.

36 Michael L. Sanders, MD Chief Medical Information Officer/Assistant VP of Medical Affairs

37 Questions? Contact Information: Stacey Ferguson Ernie Fortenberry Nikki Nissen Sherry Jones St Dominic Jackson Memorial Hospital 969 Lakeland Drive Jackson, MS