When Minutes Count: Equitable Access to Acute Coronary Syndrome Care
Sydney West Area Health Service
Abstract
In 2003, Greater Metropolitan Clinical Taskforce (GMCT) provided $45,000 per annum to provide high quality care to patients regardless the point of entry. The funding was used to enhance Acute Coronary Syndrome (ACS) care across the cardiovascular network, in particular to address access from patients of the outer metropolitan and rural hospitals.
A number of strategies were put in place to streamline the Emergency Primary Percutaneous Intervention (PCI) at Nepean Hospital to ensure the provision of Emergency 24-hour Primary PCI.
Furthermore, Pathways to streamline ACS Pathways for patients coming from Lithgow Hospital were put in place. This established clinical priorities for early transfer and enhanced access to interventional cardiology services.
ACS has demonstrated process efficiency, reduction in reported problems and the reduction of mean Balloon Time from 97.9 minutes to 70.44 minutes.
In addition, patients from Lithgow are now able to gain greater access to Level 5 Cardiology Services and the hours to Angiography for these patients is less than 48 hours.
Aim
To improve access to Emergency Primary Percutaneous Intervention (PCI).
Nature of the Problem
Nepean Hospital is a 420-bed major referral hospital situated at Penrith and is located at the base of the Blue Mountains.
Nepean Hospital Interventional Cardiology Service is relatively young. It started providing Angiography services in September 1995 and elective PCI in May 2006, and evolved to offer a 24 hour Primary PCI Service from May 2007.
There was a need to rapidly develop systems to provide high quality, safe and timely care to all patients, regardless of point of entry and referral source.
There was also an identified need to strengthen clinical relationship across the Cardiovascular Western Cluster Network to ensure equity of access to interventional cardiology services.
Extent of the Problem
Research shows that if treatment for myocardial infarct commences within 90 minutes of arrival, in-hospital mortality is 3.0%, but increases to 4.2%, 5.7% and 7.4% when delay ranges between 91-120 minutes, 121-150 minutes, and more than 150 minutes respectively. (Nallamothu, et.al. 2007; 1632).
In July 2006, the Cardiology Service at Nepean Hospital commenced a 24hour Primary PCI service.
Balloon time (interval between a patient's arrival at a hospital and the insertion of an angioplasty balloon into their artery) and skin time (inserting a scope with a light on it to go underneath the skin) were collected on 25 patients.
The Balloon-Time was 97.90 (range 42 – 185) minute and Skin-Time was 76.9 minutes (range 26 – 137 minutes). Both exceeded the best practice goals of 60 minutes skin-time and 90 minutes balloon-time.
The use of Six-Sigma quality methodology was conducted to reduce skin-time to less than 60 minutes and subsequently reduce balloon time which is 25 minutes post skin-time (Lignocaine injection to groin).
In May 2007, the provision of Cardiology Services and Interventional Primary PCI Service was extended to Lithgow Health Service.
In January 2006, the project to implement ACS Pathways was approved and commenced. ACS Pathways has been shown to guide staff in the recognition, management, and appropriate transfer of patients suffering ACS (Ferry,et.al 2004).
Graph 1: Xbar-R Chart of Time to Skin in Minutes
Tests performed with unequal sample sizes. |
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This graph shows the skin time for the first 25 cases since the After Hours Primary PCI Service began on the 1st July 2006. There is wide variability in the skin times for each case and the mean skin time was 76.9 minutes (median 67 minutes). |
Strategic Importance
This project has addressed many of the strategies identified by the NSW Health Strategic Direction 2, to create better experiences for people using health services, through utilisation of clinical redesign principles to implement a model of care that has been demonstrated to provide good access to care, good experience, safe care and efficient service.
Planning and Implementing Solutions
A Primary PCI Project team, drawn from Emergency, Cardiology, Reception and Patient Flow units, was formed utilising the Six Sigma methodology. A process map exercise to assess the current inefficiencies of the system was conducted. As a result the following were implemented:
- Provision of education to staff on the pathways and evidence based outcomes.
- Audit of all admissions and provision of feedback to staff.
- Flyers on each Primary PCI performance displayed to provide feedback and motivation to staff.
- Poster developed and displayed in prominent locations.
Graph 2: Xbar-R Chart of Time to Skin in Minutes by Change
Tests performed with unequal sample sizes. |
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Graph 2 shows the changes to the Primary PCI system and the impact on the mean skin time.
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Extending ACS care to Lithgow Health Service
- Establish a Working Group involving representation from Lithgow Health Service, Nepean Cardiology and Patient Flow Unit.
- By end February 2007
- developed 1st Draft ACS Pathways for Lithgow and patient flow system to facilitate one phone call system (see Figure 3).
- defined Performance Indicators and ensure performance meets State-wide benchmarks.
- defined reporting mechanism of Performance Indicators for ACS pathways.
- By end March 2007
- Consultation conducted with Cardiology VMOs.
- By end April 2007
- Consultation with GP/VMOs in Lithgow Health Service.
- By 1st May 2007
- ACS Pathways implemented across Western Cluster and system in place to monitor clinical performance.
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Figure 3 shows the ideal patient journey for a patient from Lithgow Hospital |
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Outcomes and Evaluation
The Primary PCI project has demonstrated process efficiency, reduction in reported problems and the reduction of mean Balloon Time from 97.9 minutes to 70.44 minutes. This has the potential to save six more lives per thousand people treated with Primary PCI.
Audits were conducted on 86 patients, there is evidence of increased Cardiology consultations and transfers to Nepean for Angiography and improvement in adherence to the evidence based practice guidelines within the Pathways.
Patients from Lithgow are gaining greater access to Level 5 Cardiology Services and the hours to Angiography for these patients was less than 48hrs (expected KPI <48hrsfor NSTEMI patients) (mean time 33.7 hours).
Graph 3: I Chart of Time to Skin in Minutes by Change
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This graph shows four stages of the project and the resultant impact on the mean skin time.
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Graph 4: Collection of 2nd TnT - Compliance Rate
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| At the end of May 2007 the ACS Pathways had been in place for 4 weeks and the audit report for this period showed that 7 (2 High Risk UAP & 5 Rapid Discharge) patients had been discharged prior to the 2nd TnT test. Since May 31st to end December 2007 the audits show a 100% improvement with all patients on UAP/Pathways NSTEMI & Rapid Discharge receiving a 2nd TnT blood test. |
Graph 5: Hours to Angiogram (KPI <48hrs)
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Graph 6: Rapid Discharge EST Arrangements Documented
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| Chest Pain Management - Rapid Discharge. There is evidence that Exercise Stress Testing arrangements are being documented, whether as an inpatient or outpatient. |
Sustaining Change
Standardising Systems of Care across the Sydney West Area Health Service Western Cluster Cardiovascular Network. There is a need to strengthen clinical relationships across the Western Cluster Cardiovascular Network to ensure good clinical governance and sustainability.
A team of multidisciplinary staff from the three hospitals within the Western Cluster, (Nepean, Blue Mountains and Lithgow Hospitals) was formed in November 2007. The ACS Pathways were rewritten to ensure clinical prioritisation based on evidence-based risk stratification, agreed admission strategies, equity of access to appropriate level of service, use of common language and understanding for management and treatment of patients with ACS.
These revised pathways and systems are now in place across the Western Cluster. A system of case review and auditing has been implemented across the Network in order to ensure best practice goals are met.
Future Scope
The system developed for networking and management of ACS through the use of ACS Pathways is applicable to all Public Hospitals.
The one phone call conference call system to arrange urgent transfers utilises existing telecommunication processes and technology - no need to invest in new technology.
References
- Bradley E.H, J. Wang, Y.W, Barton, et al. (2006) Strategies for Reducing the Door-to-Balloon Time in Acute Myocardial Infarction. The New England Journal of Medicine. November 30, No.22, V.355:2308-2320.
- Clinical Excellence Commission and Greater Metropolitan Clinical taskforce (GMCT) Management of the Deteriorating Workshop (29/11/2006). Minutes.
- Ferry, Catherine T., Fitzpatrick, M. Andrew, Long Paul W., et al. (2004) Towards a Safer Culture: clinical pathways in acute coronary syndromes and stroke. Medical Journal of Australia. 180 (10suppl) S92-S96.
- Nallamothu, B.K., Bradley, E.H., Harlan, M. Krumholz, M.D. (2007) Time to Treatment in Primary Percutaneous Coronary Intervention. The New England Journal of Medicine. October 18 N.16 V. 357: 1631- 1638.
- National Heart Foundation of Australia and New Zealand Guidelines for the management of acute coronary syndrome 2006. Medical Journal of Australia. 17th April 2006 V184:No.8.
- Quality in Australia Study 2006 - Minutes of the Clinical Excellence Commission and Greater Metropolitan Clinical taskforce (GMCT) Management of the Deteriorating Patient Workshop 29/11/2006.
Contact
Associate Director - Clinical Governance, Clinical Governance Unit
Sydney West Area Health Service
This project was entered in the 2008 NSW Health Awards, Create Better Experiences for People Using Health Services category.
