Time Is Muscle Initiative

1
Time Is Muscle Initiative

• University Hospitals of Cleveland
• University Hospitals Health System

2
University Hospitals of Cleveland

• 947-bed tertiary medical center
• Pediatric Level I Trauma Center
• Full service hospital
• Primary teaching hospital of Case Western Reserve
  University (Case) School of Medicine

3
University Hospitals of Cleveland

• The Alfred and Norma Lerner Tower
• Samuel Mather Pavilion
• Lakeside Hospital for adult med/surg care
• Rainbow Babies Childrens Hospital
• University MacDonald Womens Hospital
• University Hospitals Ireland Cancer Center
• University Psychiatric Center-Hanna Pavilion

4
University Hospitals Health System (UHHS)

• Regions premier healthcare delivery system,
• Serving patients at more than 150 locations
• Network of
• specialty care physicians,
• skilled nursing,
• elder health,
• behavioral health,
• rehab and home care services,
• managed care and insurance programs
• occupational health and wellness programs.

5
University Hospitals Health System (UHHS)

• UHHS is comprised of
• UHC Tertiary Care Referral Center
• 11 affiliated or owned regional hospitals
• 25 outpatient medical centers
• Nearly 25,000 physicians and employees
• Northern Ohios second largest employer

6
University Hospitals Health System
7
Acute Myocardial Infarction

• Important cause of mortality in patients with
  atherosclerosis
• ½ Of all pts expire before reaching a medical
  facility
• Definitive therapy reduces morbidity (saves heart
  muscle) and mortality
• Hence time is muscle

8
TIM Time is Muscle Initiative-Outline

• Development of TIM at UHC
• Development of TIM System-wide
• Development of Pre-TIM process

9
Benefits of Time Is Muscle Team Initiative

• Improve patient outcomes
• Improve process
• Meet regulatory and third party care standards
• JCAHO,
• insurance companies

10
TIM Protocol

• Developed at UHC in 2001
• Goal improve time to coronary intervention
• Based on UH consortium benchmarking study on AMI

11
TIM Protocol Committee

• Cardiologists,
• ED physicians and nursing,
• Cath lab,
• Coronary intensive care unit staff
• Telemetry floor staff
• Quality management center staff

12
Time Is Muscle
13
Time Is Muscle(Continued)
14
TIM Lessons Learned

• Dedicated pager to activate team
• Streamline communication
• Delegation for who does diagnosing
• Influence standard of care
• Reduce time it took for transfer in
• Reduce delay in pre-hospital setting

15
UHHS System-wide TIM

• 70-80 of AMI patients are transfers for
  percutaneous coronary intervention
• Committee formed with representation from all
  system hospitals
• Representatives included ED, cardiology, nursing,
  administration
• System committee chaired by Ravi Nair, TIM
  champion here at UHC

16
Keys to Success

• Medical staff consensus building
• Local presentations to staff by dr. Nair
• UHC transfer center key role
• Facilitating consultation with UHC cardiology
• Facilitating transfers from system hospitals
• Quality center tracks performance
• Database created to monitor outcomes

17
System Tim-nursing

• System-wide committee formed with nursing
  representatives
• Standardized
• documentation for nursing care path
• patient education information
• staff education video tapes

18
Prehospital -TIM Rationale

• To further reduce time to PCI
• Pre-arrival MI identification
• Earlier treatment
• Earlier notification of ED staff,
  interventionalist, and
• Pre-arrival activation of cath lab

19
Pre-Hospital TIM

• UHC provides local EMS medical direction
• Cleveland Heights
• Shaker Heights
• University Heights
• EMS telemetered 12-lead EKGs
• LifeNet ECG receiving station in the ED
• EKG reviewed and consult with ED doctor
• Auto fax forwarding of EKG to cardiology

20
Development of Pre-Hosp. TIM

• ED and Cardiology leadership agreed on medical
  protocol
• Acquisition of equipment
• LifePack 12 cables and cell phone connection
• LifeNet ECG receiving station in ED
• EMS Training
• Testing

21
Pre-Hospital TIM Carepath
22
Pre-Hospital TIM Carepath(Continued)
23
(No Transcript)
24
UHC ED TRANSFER CENTER
Heights EMS
25
Sample LifeNet EKG
26
Pre-TIM Timeline

• 926 pt calls 911 complaining of chest pain
• 927 EMS dispatched
• 932 EMS arrives in patients home
• 950 pt assessed, RX started, 12-lead EKG
  obtained
• 953 EKG received in UHC ED/CICU from EMS
• 954 EKG demonstrates acute MI, cardiologist
  notified

27
Pre-TIM Timeline, ctd

• 955 Cath lab activated
• 1005 EMS arrives in UHC ED
• 1030 pt departs for cath lab
• 1041 pt arrives in cath lab
• 1055 right coronary angiogram infused
• Time from 911 call to angiogram 89 minutes

28
Results to Date

• Median Time to PCI reduced from 142 minutes to 94
  minutes
• PCI within 120 minutes increased from 17 to 80

29
Pre-TIM Results

• Process is new, being developed
• Numbers are small
• Time to PCI for patients utilizing Pre-TIM
  process shortened to average of 70 minutes

30
Keys to our success

• Clinical Staff owned the project
• Clinical Staff identified the process issues that
  were barriers to success
• Learned from outliers

31
Keys to our success

• Great collaboration between Cardiology and ED
  Physicians
• Involvement of Quality Center instrumental in
  moving group forward
• Ongoing monitoring and feedback

32
Questions