ACCA: In situ simulation can reduce D2B times, reveal systemic breakdowns

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ATLANTA—In situ simulation as a means to improving door-to-balloon (D2B) times during STEMI significantly reduces times, and is a well-suited method to “address organizational challenges that compromise patient and quality of care,” according to research presented at the American College of Cardiology Administrators (ACCA) annual cardiovascular administrators leadership conference this week.

According to lead investigator William R. Hamman, MD, PhD, from Western Michigan University in Battle Creek, Mich., the research conducted by him and his colleagues had three primary goals:

  • To identify cultural, procedural and training-related barriers that prevent hospitals from achieving average D2B times of less than 90 minutes.
  • To assess the usefulness of the in situ simulation approach, which had previously been validated in obstetrics, for improving teamwork behaviors and patient safety outcomes in cardiology.
  • To identify best practices for reducing D2B times, and to share these findings with others.

Hamman said that 1.2 million STEMI procedures are performed each year in the U.S., costing more than $150 billion annually. STEMIs also account for nearly one in five deaths annually.

While D2B times under 90 minutes save lives, the U.S. average is much higher, according to Hamman. “Because STEMI care requires multi-disciplinary coordination, in situ simulation is ideally suited to studying this domain,” he said.

Out of the American College of Cardiology’s D2B registry, 16 hosptials were selected for inclusion, with locations in 12 states: California, Florida, Illinois, Indiana, Maine, Michigan, Montana, New Jersey, Ohio, Oregon, Pennsylvania and Virginia. They included a mix of teaching (40 percent) and non-teaching (60 percent) facilities, which had a mean of 371 beds and a mean D2B compliance of 74 percent.

The simulations were completed between May and October 2009, and the same simulation scenario was enacted at each hospital and videotaped:

  • EMS crews transported a simulated patient who was complaining of chest pain.
  • The patient was then transferred to either the ED or the cardiac cath lab, where simulated angioplasty was performed.
  • Three trained raters scored the videotapes at seven “events” during the simulation.
  • Post-simulation surveys were collected.

After statistically controlling for historical data concerning D2B performance across the 16 hospitals, Hamman and colleagues found that the teamwork ratings accounted for 10-15 percent of the criterion variance in the D2B measures, depending on the specific simulation event.

The researchers observed several “systemic problems” across the hospitals, including “inconsistent rules which resulted in the ED team needlessly repeating time-critical behaviors that were already performed by the EMS crews; how failing to register the patients while en route led to needless delays upon arrival at the cardiac cath lab; and the lack of well-defined hand-off procedures between EMS crews and their counterparts in both the ED and cardiac cath lab.”

The post-simulation, completed by 109 simulation participants (52 percent response rate), “overwhelmingly reported that the simulation was well designed, met their expectations and was practically relevant,” Hamman reported. An analysis of the surveys showed a “slightly higher” reaction to the simulation scenario itself, compared to that of the post-simulation debriefing.

In situ simulations can result in “improved teamwork behaviors” and both practically and statistically significant reductions in D2B times, according to Hamman. “Because the simulations were conducted in the actual care environment, rather than in an artificial simulation lab,” he said, “we were able to identify systemic factors that inflated D2B times.”

The research was funded through grants from the American College of Cardiology, Battle Creek Unlimited, the Forest Park Foundation and the Michigan Economic Development Corporation, as well as an educational grant from Pfizer and St. Jude Medical.