Hospitals are struggling to meet revised national quality measures that call for heart attack patients to move from arrival in the emergency department (ED) to receipt of an angioplasty in just 90 minutes. In even the biggest, most state-of-the-art facilities, getting from door-to-balloon in such a brief period requires the ED and cardiac catheterization lab (CCL) to work like coordinated parts of a well-oiled machine.

Meeting the new door-to-balloon measure is not easy for hospitals. Crowded emergency rooms, competing priorities for staff and chronic delays in preparing the catheterization lab is commonplace in many hospitals in the nation.

Despite these conditions, Memorial Regional Hospital in Broward County, Florida, is making serious headway. In the past 18 months, the hospital has dramatically improved its procedures for PCI (percutaneous coronary intervention). For the past eight months, Memorial has met 90-minute door-to-balloon goals an average of 85 percent of the time. In January, nine out of ten patients received PCI in 90 minutes or less. Early figures for February suggest they hit 100 percent.

The Code Heart Process

To meet the new goals, the hospital is perfecting its 'Code Heart' process, a combined effort of the physicians, administrators, nurses and staff of the hospital's ED, CCL, and Quality and Patient Safety (QI) Departments. Before Code Heart, treating a heart attack patient at Memorial was a sequential process, with actions taking place one after another - first in the emergency department, then in the cardiac catheterization lab.

"Previous to Code Heart, we didn't activate our heart team until we had done everything else in the emergency room, which wasted time and heart muscle," says Melinda Stibal, administrative director of emergency and trauma services at Memorial. "Now instead of doing serial processing of heart attack patients, we do simultaneous processing. It has made all the difference."

Today, if a patient arrives in the emergency room with symptoms suggesting a heart attack, the staff immediately administers an electrocardiogram. If the results show myocardial infarction, 'Code Heart' is immediately paged throughout the ED and the CCL.

"That's the signal for everyone to get everything moving," says Rochelle Ayala, M.D., a primary care physician at Memorial who facilitates the coordination of the Code Heart process with ED, QI and CCL staff. "From the moment Code Heart is called, the cath team has to get the lab ready and the ED staff pushes to get its job done quickly. That means heparin, aspirin, beta blockers and nitroglycerin administered, lab tests drawn, paperwork expedited - and get the patient to the lab."

Changes in the ED

Because it is a Level-I trauma center, Memorial already had systems in place to quickly activate hospital staff to respond to especially acute situations. They used lessons from this system to design the Code Heart process.

"We looked at every step in the process to see where we could do things faster and eliminate redundancy," Stibal says. "In the past, every patient used to have a chest x-ray in the ED and we'd do all the lab work and then give them an EKG. Now the focus is on the EKG before anything else, so that we can determine if we need to activate the cath lab. Now when Code Heart is called, everybody moves and not a minute is wasted."

Changes in ED procedure include:

• ED staff activates Code Heart before speaking with the interventional cardiologist. "An interventionalist is still part of the process, of course, but we don't wait to get his or her opinion before alerting the cath lab," Stibal says. "Doing it the old way was delaying us 10 to 15 minutes."
• Once Code Heart is called, ED charge nurses and staff immediately go to the patient to facilitate transfer to the cath lab - thus establishing clear priorities for the most urgently needed patient care.
• A 'Code Heart Medication Kit' was created to include all needed medications, packaged together and stored in a central place. Now one kit contains all items, instead of opening four different drawers to get different medicines.
• The ED team now takes ownership for transferring the patient to the CCL, rather than having cath lab staff call the ED when they are ready to receive the patient. "That one change helped the ED team take ownership for the pace of the process," Stibal says.

Involving Emergency Medical Services

Although the hospital works with multiple providers of emergency medical services (EMS), Memorial's ED staff met with each to discuss how EMS is critical to meeting the 90-minute-to-PCI goal.

Staff developed a presentation on the new Code Heart process and outlined specific ways that EMS fit into the process. Now most EMS providers fax EKGs to the hospital before a patient's arrival so that Code Heart can be called before a patient arrives.

"EMS providers rarely know the destiny of their patients after they drop them off at the ED, but we have worked hard to show them our results so they can see how crucial they are to saving lives," says Stibal. "We've given them a lot of information and they have offered good feedback, which helps with buy-in and improves the program."

Memorial staff members have developed an EMS Feedback Tool to help EMS staff track their own progress in providing timely treatment for cardiac patients.

Monday Morning Quarterbacking

To track outcomes, identify delays and focus the team, Memorial developed a Code Heart Tracking Tool, which allows ED and CCL staff to simultaneously record their role in the Code Heart process. The form is intentionally simple, allowing for all interventions to be listed and the time recorded. Within 24 hours, ED and CCL leaders, and QI managers review the Tracking Tool data and identify opportunities for improvement. Feedback is immediately shared among the team.

Every month, leaders from the ED, CCL and QI Departments meet to review a Reperfusion Log, which summarizes each patient's experience and helps the team track how it is meeting its goal and where delays occur. After discussion, department leaders identify why the goal was not met and list specific actions needed for future success- and assign the person(s) responsible for implementing the necessary changes. Both ED and CCL staff think these analyses are crucial to the success of Code Heart.

"We provide constant feedback to the staff - what we did really well, what opportunities we missed, how we can do better the next time - so that each experience makes us better," says Stibal. "We also have worked very hard to build teamwork among the ED and the CCL staff. There's friendly competition, but after seeing overall success, we know we are in this together."

Dr. Ayala agrees that creating mutual accountability and teamwork are vital for success. "We have 90 minutes, not 45 minutes for each department, so they share a single goal," she says. "Staff members from both departments work much more collaboratively with each other. The importance of getting immediate performance data and sharing feedback across the teams helps us constantly improve. Reviewing every case as one team and talking about how we could all improve helps us avoid the blame game. It's a natural temptation, but everyone has learned to resist."

Advice for Other Hospitals

While Memorial staff members don't claim to have overcome all the barriers, the Code Heart process has yielded tips for other hospitals.

• Engage a broad team: Pulling together a broad team at the outset helps create staff champions. At Memorial, the medical director of the ED was involved from the first discussion, which helped secure physician support throughout the process.
• Identify a neutral facilitator: As facilitator of the Code Heart process, Dr. Ayala is neither working for the ED nor the cath lab. "Neutrality helps keep the focus where it belongs, on the care of the patient, not on the ED or the CCL," she says.
• Believe the goal can be met: Dr. Ayala believes it is crucial that the whole team believes the 90-minute goal can be consistently met. "This is not about numbers, it is about patients," she says. "We fully expect that 100 percent of the patients who come through these doors having a heart attack will have their life-saving procedure in 90 minutes or less. Not believing that we can achieve our goal every time just creates another barrier."
• Create an environment of trust: The Memorial team says they do not get personal or defensive - and they mean it. "Everyone must check egos and boxing gloves at the door if this is going to work," says Dr. Ayala.
• Engage quality improvement staff: Code Heart leaders say the QI staff's involvement and the clarity of the data keep the goal front and center.
• Track and review each case: The tracking and analysis tools are instrumental for improvement and helping each person in the ED or CCL form goals to achieve success.
• Hardwire the process: The Code Heart team says old habits are hard to break, but all systems and technology needs to be checked and communicated to become hardwired. "We even had to synchronize the clocks between departments and on our equipment," Stibal says.
• Over-communicating creates champions: Memorial staff leaders discuss Code Heart at every opportunity. They say it creates physician champions and reinforces buy-in toward meeting the goal.

Memorial Regional Hospital

Memorial Healthcare System is a six-hospital system in Southeast Florida serving a population of about 700,000 people. Memorial Regional Hospital, a level-I trauma center, is the system's flagship hospital.

• Staffed beds: 690
• Hospital type: Public, not-for-profit
• ED Volume: 7,000 patients a month

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Rochelle Ayala, M.D.
Administrator and CMO Primary Care Services
Memorial Regional Hospital
Broward County, Florida

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Melinda Stibal, R.N., B.S., C.E.N.
Administrative Director of Emergency and Trauma Services
Memorial Regional Hospital
Broward County, Florida