3/8/2014. Kevin Daniel RN, CEN Quality Improvement Northside Hospital System
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1 Kevin Daniel RN, CEN Quality Improvement Northside Hospital System 1
2 Mission: Lifeline Goals Promote the ideal STEMI and Cardiac Resuscitation systems of care Help STEMI and Cardiac Arrest patients get the life-saving care they need in time Bring together healthcare resources into an efficient, synergistic system Improve overall quality of care 2013, American Heart Association Mission: Lifeline Regional Hospital Report System ID: Quarter 2, 2013 *Confidential Information* Participant ID: Hospital Code: This document contains confidentialmaterial, if User desires to publish, present externally or otherwise distribute or use, in whole or in part, any aggregate data or reports provided by Mission: Lifeline, or produced in connection with or derived from Mission: Lifeline reports, with the exception of strictly internal use within User's organization, User must first obtain the prior express written consent of American Heart Association. To the extent User is permitted to publish aggregate data, such aggregate data and any related information published or presented in connection with it must be reviewed and approved by American Heart Association prior to publication. To request such permission, please contact the Mission: Lifeline ProgramCoordinator at or Data provided by: Prepared by: 2
3 All Hospitals in your system Time in the ED FMC to Door Door to Arr at CathLab Arrat CathLab to Device Act Longest PCI TIme Box and Whisker Plots First Medical Contact to Device Activation Distribution of Times (minutes) Direct Presentaion, Arriving via EMS Median PCI Time 75 th Percentile Average PCI Time Goal < 90 min 25 th Percentile Shortest PCITime First Medical Contact to Device Activation Distribution of Times (minutes) Direct Presentaion, Arriving via EMS Goal < 90 min 1 Site labels and the corresponding number of patients eligible for at least one time interval are displayed on the x-axis 2 Boxes are not displayed when there are no eligible patients in the time frame. 1 Site labels and the corresponding number of patients eligible for at least one time interval are displayed on the x-axis 2 Boxes are not displayed when there are no eligible patients in the time frame
4 heart.org/missionlifeline Mission: Lifeline Regional Report Companion Guides Mission: Lifeline Regional Hospital Report Glossary Mission: Lifeline Regional Hospital Report Interpretation Manual 3110 Critical Process Timelines: First Medical Contact to Device for Non-Transfers Arriving via Ambulance (pages 5-6) Variable Definition Inclusion/Exclusion 4030 Criteria 7100 & 7109 & First Medical Contact to Device Transferred from Outside Facility = No 3110 All STEMI patients indicated for immediate primary PCI, excluding transfers in, patients Activation with STEMI diagnosed on4041 subsequent ECG, patients administered thrombolytics, 8020 Means of Transport to First Facility = Ambulance (Direct Presentation EMS Only) documented non-system reasonfor delay 7110 in PCI, and FMC to PCI >12 hours. Median Time in Minutes (current quarter) Patients may have missing or negative values for specific time intervals, which excludes them from ONLY the affected intervals. All other intervals with valid date/time data are o First Medical Contact to Door included in the graph (Arrival date/time) (Pre-arrival 1st Medical Contact date/time) & 3106 Includes all direct presenters arriving via Ambulance only; Mobile ICU and Air transport are Graph on o Door to Arrival at Cath Lab not included. (Cath Lab 7101 Arrival & 7102 date/time) (Arrival3201 date/time) Page 5 o Arrival at Cath Lab to Device Activation (First Device Activation date/time) (Cath Lab Arrival date/time) 7103 & & 7102 o First Medical Contact to Device Activation (National Median) (First Device Activation date/time) (Pre-arrival 1st Medical Contact date/time) 7103 & & 7109 & First Medical Contact to Device Transferred from Outside Facility = No All STEMI patients indicated for 4041 immediate primary PCI, and had a reported first device Activation activation date/time after first medical contact, 7110 excluding transfers-in, 8020patients with STEMI Means of Transport to First Facility = Ambulance diagnosed on subsequent ECG, patients administered thrombolytics, documented nonsystem reason for delay in PCI, and FMC to PCI time > 12 hours. Graph on Distribution of Times in Minutes (current quarter) Includes all direct presenters arriving via Ambulance only; Mobile ICU and Air transport are First Medical Contact to Device Activation Page & & 3106 not included. (First Device Activation date/time) (Pre-arrival 1st Medical Contact date/time) 3106 EMS = Ambulance only, does not include Mobile ICU or Air transport POV = Personally Operated Vehicle (i.e., self/family transport) FMC = First Medical Contact Confidential Information (ver 09/24/2013) 4
5 ArrivalDate DCDate FirstFacMeansTrans Combine Date & Time FirstMedConDate FirstMedConTime TranOutsideFac StemiNoted StemiFirstNoted PCI FMC to to Device Combine Hours/Minutes Date & Time Minutes FirstDevActiDate FirstDevActiTime PCIDelayReason ReperCand ThromTherapy ThromDate PCI DelayReason ICD9PrinDiag 1/28/20131/31/2013 Ambulance 1/28/2013 3:37:00 1/28/13 3:37 No Yes First ECG Yes 1/28/2013 4:54:00 1/28/13 4:54 1:1777 None Yes No Rural M 2/1/2013 2/4/2013 Ambulance 2/1/201314:35:00 2/1/13 14:35 No Yes First ECG Yes 2/1/201316:03:00 2/1/13 16:03 1:2888 None Yes No Forsyth 2/22/20132/23/2013 Ambulance 2/22/201316:01:002/22/13 16:01 No Yes First ECG Yes 2/22/201317:12:002/22/13 17:12 1:3797 Patient delays in providing Patient delays in providing consent for the procedure Yes No consent 97 for the procedure 3/16/20133/19/2013 Ambulance 3/16/201310:25:003/16/13 10:25 No Yes First ECG Yes 3/16/201311:26:003/16/13 11:26 1:0161 None Yes No Gwinnett Forsyth Arrival at First Facilityto Device Median Time (minutes) TransferIn forprimarypci Door in/ Door Out < 30 mins Arrto Door Out at 1 st Fac Door Out 1 st Fac to PCI Door In PCI Door in to Device Arrival to Device Activation Distribution of Times (minutes) Direct Presentaion, All Arrival Modes 75% of the pts Arrival to Device < 75 mins Goal < 90 min 1 Site labels and the corresponding number of patients eligible for at least one time interval are displayed on the x-axis 2 Boxes are not displayed when there are no eligible patients in the time frame
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