Sanford USD Medical Center, Sioux Falls, S.D.

Cardiologists and cardiovascular staff at Sanford USD Medical Center in Sioux Falls, S.D., pride themselves for providing the best care in the area. But it took the process associated with gaining Chest Pain Center accreditation for them to realize just how good they are.

“The paperwork is enormous and took about a year to put together,” says Christine Clayton, a certified nurse practitioner at Sanford. “But we realized that we had about 98 percent of the pieces in place and we just needed to package it in the right way.”

In October 2009, the Society of Chest Pain Centers conferred its blessing on Sanford. “It’s just another step in our quest to provide quality care,” says Tom Stys, medical director of cardiology at Sanford. “While we’ve made some changes to our clinical practice routines through the process, we’ve also formalized many practices that we already had in place.”

Teamwork

Sanford‘s Chest Pain Center had to demonstrate its commitment to quality patient care by meeting or exceeding a set of eight criteria and core measure quality indices:

• Integrating the emergency department with the local emergency medical system (EMS);
• Assessing, diagnosing and treating patients quickly;
• Effectively treating low-risk patients with acute coronary syndrome and no assignable cause for their symptoms;
• Continually seeking to improve processes and procedures;
• Ensuring Chest Pain Center personnel competency and training;
• Maintaining organizational structure and commitment;
• Having a functional design that promotes optimal patient care; and
• Supporting community outreach programs that educate the public to promptly seek medical care if they display symptoms of a possible heart attack.

“The first thing we did was a gap analysis. We looked at each key element and assessed where we were and where we needed to go,” says Clayton.

The accreditation lasts for three years, but Sanford will not be resting on its laurels. “Reaccreditation is not intended to reward the status quo,” says Monica Huber, vice president of ER/trauma at Sanford. “We will need to show continued progress, improvement and enhancement, particularly in areas of community outreach, research and evidence-based practices.”

Door-to-balloon times

National guidelines for door-to-balloon (D2B) times call for less than 90 minutes. In 2009, Sanford’s highest D2B average was 70 minutes (June), while its lowest was 12 minutes (July). “Our time is the best in the state,” Stys says. The success of the D2B program is due to several features, including standardizing protocols for their chest pain network, which encompasses all of Sanford’s emergency rooms, as well as those of outlying facilities (about 35 smaller hospitals).

Standardized protocols help physicians, especially those in rural areas, quickly triage patients into low, intermediate and high risk. “My intention for creating our chest pain network was to have an integrated systems approach where we close the feedback loop from the patient arriving at the referring facility, the process of initial therapy, stabilization, transportation to Sanford Heart, discharge and feedback,” Stys says.

One of the key elements for Chest Pain Center accreditation is how Sanford interacts with EMS and emergency room physicians, as well as inpatient services and patient follow up. The chest pain team reviews all important temporal benchmarks: time to activate the transportation team, time to ER and time to therapy. If any benchmark is below the threshold, Sanford works with its rural partners to help make improvements.

Fine-tuning processes

Early in the accreditation process, Sanford discovered that the emergency department had a much better relationship with EMS than did the cardiologists and the cath lab. As a result, the accreditation team conducted a mock STEMI drill with EMS personnel. The team discovered it could essentially bypass the emergency room except to put a name band on the patient, thereby shortening D2B times. “It was helpful to do the drill to see everybody’s role in the process,” Clayton says.

Huber calls that their “aha!” moment. “We had made assumptions that everybody knew what everybody else was doing. And they didn’t,” she says.

Each month, a multi-disciplinary team meets to review statistics. The team includes EMS personnel, directors from nursing, ED and cardiology, and Q/A representatives. All the data are displayed on an IT dashboard. “With month-to-month tracking, we can ensure our variation is either going in the right direction or that it can be explained by statistical control measures,” Clayton says.

One of the challenges for Sanford is that many of its patients are from small rural facilities that can be a significant distance from the main campus. These rural facilities do not have the same resources as Sanford. “We’ve had to reach out to them, share our learning and help them to give their patients the best care,” Huber says.

The dashboard chronicles everything in the cardiovascular program, Stys says, providing a quick overview of how the cardiovascular teams are doing. There are many parameters collected and analyzed. They pertain to quality, outcomes, volumes, physician performance, radiation exposure, contrast usage and the types and numbers of stents. “Utilization is a huge part of the quality dashboard,” he says.

Standardization & order sets

The Sanford team standardized order sets so that hospitals in the network follow the same approach for all chest pain patients. Embedded in the standardized assessment are the TIMI guidelines, which help to quickly risk-stratify patients. There is also an order set for STEMI for thrombolytics and an order set for non-STEMI patients. In addition, Sanford set up a thrombolytics lending program to help smaller facilities keep the valuable drugs in stock.

To accomplish the standardization, an outreach coordinator facilitated monthly meetings between Sanford staff and directors from the rural hospitals. To reach consensus regarding the order sets, other multidisciplinary teams consisting of pharmacy directors, cardiologists and emergency department physicians met. Guidelines often offer multiple choices of actions to take. The teams spent hours reviewing all this information and determined which choices were best in terms of cost and efficacy for their patients and their regions.

The Society of Chest Pain Centers promotes protocol-based medicine, often delivered through a Chest Pain Center model to address the diagnosis and treatment of acute coronary syndromes and heart failure. “We believe that protocol-based medicine is the foundation for providing the best evidence-based standardized care to our patients,” Huber says. “Having that foundation makes it easier to reproduce quality care at other facilities. And that is what it’s all about: sharing know-ledge to benefit patient care.”