Root Cause Analysis

Understanding the diagnostic process is the first step towards improving diagnosis in health care

By ThinkReliability Staff

On September 22, 2015, the Institute of Medicine (IOM) released a report entitled “Improving Diagnosis in Health Care“. To achieve that goal, the committee, “developed a conceptual model to articulate the diagnostic process, describe work system factors that influence this process, and identify opportunities to improve the diagnostic process and outcomes.”

With a goal of improving a given process – in this case, the diagnostic process – it’s important to understand how the process should work in theory (which may be very different from how the process actually works in practice). The conceptual model outlined within the report provides an overview of the theoretical diagnostic process at several different levels of detail.

A Process Map is similar to a geographical map in that it can provide different levels of detail while remaining accurate. For example, a map of a country as a whole typically contains only the most major roads, a map of a city will contain far more roads, and an inset providing detail of a section of the city may contain all the roads. All these maps are accurate; but the city map contains more detail than the national map.

Similarly, an overview of the diagnostic process can be summarized in just four steps: patient reporting of a health problem, information gathering and analysis, diagnosis, and treatment. By adding more detail to this process, the responsive nature of the process is revealed – if sufficient information is not gathered to make a working diagnosis, the process returns to the information gathering step. A similar “decision point” is made after treatment – if treatment is found to be ineffective, the process again returns to the information gathering step for another look at the diagnosis.

Even more detail can be provided about the information gathering step. Information gathering typically involves a clinical history/ interview, a physical exam, diagnostic testing and/or imaging, and referral or consultation with other health care professionals. As the information gathering step can be broken down into more detail, so can the diagnostic testing/ imaging step. In more detail, the diagnostic testing/ imaging step involves ordering diagnostic tests and/or imaging, preparation and collection of the specimen/image, examination of the specimen/ image, result interpretation, follow-up, and incorporating the results into the patient’s medical record. (Because of the similarities at a high level between the diagnostic testing and diagnostic imaging processes, they have been combined in the Process Map on the PDF, but a more detailed process would have separate steps for each.)

When analyzing a complex process, such as the diagnosis process, breaking it down into steps allows for an analysis of problems that occur at each step. Next week, our blog will discuss in more detail the impacts from diagnostic error, potential causes of diagnostic error, and the recommendations from the IOM report to improve diagnosis and reduce diagnostic error.

To view the diagnostic process map at several levels of detail, click on “Download PDF” above. Click here to read the Institute of Medicine report “Improving Diagnosis in Health Care.”

 

Root Cause Analysis

Smoke from wildfires in West may impact public health across the US

By ThinkReliability Staff

A significant portion of the United States is currently being affected by wildfires. The Valley and Butte fires in California, two of the worst in that state’s history, have killed five (all civilians found dead in their homes). The Tassajara Fire has resulted in another civilian fatality. The Rough Fire (also in California) has burned more than 141,000 acres. The US Wildfire Activity Public Information Map and National Wildlife Coordinating Group Incident Information System shows dozens more fires across the Western United States.

The wildfires are also impacting the population in areas not directly impacted by the fires. Public safety has been impacted by the deaths and risk for injury. Worker safety has been impacted as well; four firefighters were burned in the Valley fire. Even animal safety has been impacted; animals were left to fend for themselves in many areas that were evacuated rapidly due to changing conditions, leading to risk of injury or death. Tens of thousands of people have been evacuated. Hundreds of thousands of acres have been burned and thousands of buildings destroyed, causing a potential long-term impact on area businesses. More than 15,000 workers have been deployed to assist in fighting the fires.

The wildfires are also affecting air quality in areas not directly impacted by the fires. The smoke from these wildfires is causing environmental and health issues including asthma, chronic lung disease and even heart attacks. Janice Nolan, the assistant vice president for national policy at the American Lung Association says of recent air quality, “It’s really bad. I hadn’t seen ‘code maroon’ days, which is the most hazardous air quality, in years.” (The Air Quality Index reports the quality of outdoor air in color categories. Maroon, or “hazardous” represents a level of air pollution that means the entire population is likely to experience serious health effects. Lower categories indicate when members of more sensitive groups may experience health concerns.)

Health issues can occur when smoke is breathed in and enters the respiratory system. The organic particles that make up smoke can be so small they can bypass the body’s natural defenses (such as mucus and hair in the nose). The particles can even enter the bloodstream. This occurs any time a person is exposed to smoke. Says Sylvia Vanderspek, the chief air quality planner for the California Air Resources Board, “If you can smell smoke, then basically you’re breathing it.”

An average person can breathe in about 35 micrograms of particulate matter for only 24 hours before experiencing health problems. Unfortunately, the California air quality board has measured levels of particulate matter up to 34 micrograms in a day . . . and the fires have been burning for weeks and may continue for weeks more. Weather conditions impact not only the wildfires themselves but also where the smoke from those fires goes. Weather conditions this summer have meant that smoke issues have been seen into the Midwest.

The only really effective protection against health impacts from smoke is to stay inside with air conditioning on recirculate if in an affected area (based on the local air quality index). This has meant schools are holding indoor recess and sports practices and outdoor festivals have had to cancel performances. Idaho is considering establishing clean air shelters so the population can avoid breathing in smoke. Regrettably, most air masks won’t help, as they don’t protect against the tiny particles of concern. Instead, health officials reiterate that if the air quality in your area is poor, stay indoors to protect your health.

Root Cause Analysis

Child Paralyzed by Vaccine-Derived Polio

By Kim Smiley

There has been amazing progress in the effort to eradicate polio, but recent cases of the disease are a harsh reminder that the work isn’t complete and now isn’t the time to be complacent.  Public health officials are planning three mass vaccination rounds in less than 120 days after a child was recently paralyzed by polio in Mali.  In addition to this case, the World Health Organization (WHO) announced that two children in western Ukraine were also paralyzed by polio.

The last case of polio was detected in Mali in 2011.  A Cause Map, a visual root cause analysis, can be used to analyze how the child contracted polio as well as help in understanding the overall impacts of this case.  The first step in a Cause Map is to fill in an outline with the basic background information, including listing how the issue impacts the different overall goals.  This issue, like most, impacts more than a single goal.  For example, the child being paralyzed is an impact to the patient safety goal, but the potential for an outbreak of polio is an impact to the public safety goal.

Once the impacts to the goals are defined, the Cause Map itself is built by asking “why” questions and including the answers in cause boxes.  The Cause Map visually lays out all the cause-and-effect relationships that contributed to an issue.  So why was the child paralyzed?  The child was infected with vaccine-derived polio because he was exposed to the disease and wasn’t immune to it, likely because he didn’t receive all four of the required doses of vaccine.  Vaccine rates in Guinea, where the child was from, dropped during the Ebola outbreak.

In this region of the world, oral polio vaccine is used and it contains weakened, but live, strains of polio virus.  After being administered oral polio vaccine, a child will excrete live virus for a period of time.  The live virus can replicate in the environment and there is the potential for it to mutate into a more dangerous form of polio, which is what causes vaccine-derived polio.

Cases of vaccine-derived polio are very rare, but are a known risk of using oral polio vaccine.  The injectable vaccine uses dead polio virus that cannot mutate, but there are other important factors that come into play.  The oral polio vaccine is cheaper and is simpler to administer than the injectable vaccine because medical professionals are needed to give injections.

The use of oral vaccines also eliminates the risk of spreading blood borne illnesses.  Because there are no needles involved, there is no risk of needles being shared between patients.  The oral vaccine also provides greater protection for the community as a whole, especially in regions with poor sanitation.  When a child is fully immunized with the oral polio vaccine this ensures immunity in the gut so that the polio virus is not excreted after exposure.  This is not true with the injectable polio vaccine; an immunized child exposed to “wild” polio would not be infected, but may still excrete polio virus after exposure and potentially spread it to others.  One negative of using the oral polio vaccine is that in rare cases (estimated to be about one in about 2.7 million) the weakened polio virus can cause paralysis in a child receiving their first dose of the vaccine.  Concern over paralysis is one of the reasons that developed nations generally use the injectable polio vaccine.

Polio is highly contagious and public health officials are planning an aggressive vaccine campaign to reduce the risk of an outbreak now that a case of polio has been verified in Mali. The plan is to have three mass vaccination rounds in less than 120 days, a level of effort aided by the many World Health Organization and United Nations staff that are still in the area as part of the response to the Ebola outbreak.  Thankfully, Guinea has not reported any cases of Ebola for several months so officials can devote significant resources to the mass polio vaccine effort.

Root Cause

Filter to protect against blood clots implicated in deaths

By ThinkReliability Staff

An NBC investigation released September 3, 2015 raised concerns about the use of a specific retrievable inferior vena cava (IVC) filter, known as the Recovery. The issues behind the concerns are complex and some appear to impact more than one type of filter. A visual root cause analysis, known as a Cause Map, can clearly lay out all the causes associated with an issue, ensuring that all potential solutions can be considered.

The first step in a problem-solving process is to define the problem. Here the specific issue being investigated is the deaths and serious injuries associated with the failure of the Recovery filter. The Recovery was introduced in 2003 and was first implicated in a death in 2004. The Recovery aims to prevent blood clots from reaching the heart or lungs in patients who are unable to tolerate blood thinners and have been placed in a variety of healthcare facilities. An important difference between the expected and actual use of these filters is that studies have found that most are not removed in a timely manner.

The use of Recover filters has impacted the patient safety goal because at least 27 deaths have been related to its use. There are at least 117 lawsuits associated with these problems, impacting the compliance goal. Hundreds of additional non-fatal problems have also been reported, impacting the patient services goal. The operations goal is impacted by the filters not being removed. Lastly, the inadequate holding power of the arms of the filter (meant to hold it in place) can be considered an impact to the property goal.

The analysis begins with one of the impacted goals. Here, the primary concern is the impact to patient safety. The patient deaths result from the filter being pushed into a patient’s heart or lungs. This results from filter migration. In order for the filter to migrate, the force on the filter exceeds the holding power of the arms of the filter. Holding power can be reduced due to improper placement, filter fracture/ failure due to fatigue (a National Institutes of Health, or NIH, study found that 40% of filters fracture within 5.5 years) or design issues. Although these issues can impact any type of blood filter, the Recovery was found to have the lowest resistance to migration of filters examined. Force on the filter can be increased due to exertions, such as bowel movements or respiration, and/or large blood clots. Because these patients are known to have risk factors for blood clotting, this is a particular concern.

The time a filter is in place increases the risk of filter migration. The longer a filter is in place, the more likely it is to be impacted by the concerns discussed above. The use of these filters has been increasing. According to the US Food and Drug Administration (FDA), only 2,000 of these type of filters were installed in 1979; now about 250,000 are installed every year in the US. The devices used are approved by the FDA, though in the case of the Recovery, there are questions about the legitimacy of the review process; a “signer” on the application says her signature was forged. However, studies have found that evidence-based guidelines for implantation of these filters is not being followed, potentially leading to inappropriate use.
These filters (though designed to be temporary) are not being removed. A retrospective review of filter implantations published in the American College of Surgeons Surgery News found that only 1.6% of retrievable filters were removed during the 3-year study period. In 4.2% of cases each, filters were unable to be removed due to technical difficulties or thrombus within the filter. In most cases, though, it appears there was no attempt to remove the filter, believed to be due to a lack of physician oversight.

According to a FDA safety communication, physicians that implant a retrievable filter must remove it as soon as “feasible and clinically indicated”. This is true for all retrievable IVC filters, not just the Recovery. However, implanted Recovery filters are a particular concern – they are more prone to problems and haven’t been sold since 2005. If you believe you have an implanted filter, talk to your doctor about next steps.

To view a downloadable PDF with the causes of the filter issues, click on “Download PDF above. To learn more:

NBC Investigation

NIH Study

ACS Surgery Study

FDA Safety Communication

Root Cause Analysis

Saving lives by helping parents remember

By ThinkReliability Staff

Vaccination programs that increased the worldwide availability of vaccines have resulted in an estimated 7 million children surviving who would otherwise have died of preventable disease since the year 2000. Preventable diseases are those that can be prevented with a proper vaccination schedule.

However, about 1 in 5 children miss recommended vaccinations, leading to an estimated 1.5 million deaths that still happen every year from preventable diseases. Although the vaccines are getting to medical facilities across the world, children still need to be brought to the vaccines.   Parents may choose not to have their children vaccinated, typically due to a concern about the side effects (as occurred in the Disneyland measles outbreak, the subject of a previous blog.)   In some cases, parents just forget about the increasingly complex vaccination schedule.

People forget things; it’s a fact of life. But when parents forget about recommended vaccines, preventable disease and potentially death can be the result. Various solutions have been implemented across the world to make sure that all children receive all recommended vaccines. Potential solutions are evaluated on how easy they are to implement and how effective their planned result. Ideal solutions (“low-hanging fruit” or “slam dunks”) are solutions that are very effective and simple to implement.

The effectiveness and ease of implementation of solutions is dependent upon the circumstances. For example, calling parents to remind them of their child’s vaccine schedule is pretty effective – but it’s far easier to implement in a developed country than in a developing country. Thus the same solution – a phone call – appears in the “low hanging fruit” quadrant in developed countries, and in the “capital project” for developing countries. Click on “Download PDF” above to see how a solutions matrix may look for this issue.

Other solutions that have been implemented across the globe to help ensure children get all their recommended vaccines include:

– An anklet that fits around a newborn’s ankle with a punch-out reminder for each vaccine that costs only 10 cents each and has been tested in Peru & Ecuador (91% of 150 mothers surveyed said the bracelets helped them remember)

– Town criers in the villages of Burkina Faso made announcements about meningitis vaccines and community health workers went door-to-door answering questions about the vaccine (11 million people aged 1 to 29 were vaccinated within 10 days)

– PATH, a nonprofit that works on vaccines, provides poster templates advertising the importance of vaccines

– Rotary International had vaccine announcements added to the skirts of women in Kenya

– In India, an extensive polio vaccination program including transit and follow-up teams which led to the country being removed from the endemic polio list (see our previous blog)

All of these solutions have the potential to reduce deaths from preventable disease by increasing vaccination rates. In this case, as in many others, the most effective solutions need to be selected carefully. “Cultures, leaders and messaging are different in each country. So you have to study and use what’s most likely to work in order to build trust that the vaccine will be helpful,” says Amrita Gill-Bailey a team leader at Johns Hopkins Center for Communication Programs.

Root Cause Analysis

The difficulty of removing titanium rings

By Kim Smiley

Titanium rings have been growing in popularity because of their durability, strength, light weight and hypoallergenicity.  But unfortunately, the strength of titanium rings can become a problem if one ever needs to be cut off.  When a finger swells with a ring on it, blood flow to the finger is restricted and can cause tissue death in the finger so the issue of how to quickly and safely remove a ring can be quite serious.

Dr. Andrej Salibi, a plastic surgeon at Sheffield Teaching Hospitals in the U.K., recently described a case where a patient came to the ER after his finger swelled following a soak in a hot tub.  Normally, removing a ring from a swollen finger is a quick and relatively easy procedure, but in this case the patient was wearing a titanium ring and all the usual methods used to remove rings failed. Typically, a doctor would grab the ring cutter at this point and simply cut the ring off, but the titanium ring was too strong for a traditional ring cutter.  The fire department was called and attempted to use its own specialized cutting gear, but that also couldn’t cut through the titanium ring.  The patient had to be admitted to the hospital and spent (what I assume was a very uncomfortable) night with his hand elevated.

The next morning, the doctors decided to try something new – bolt cutters.  The bolt cutters finally cut through the metal, but the doctors still had to find a way to pull the metal apart. Using some large, heavy-duty paperclips, two doctors were able to pull the ring far enough apart that the man could slip his finger out.  Thankfully, the man’s finger is going to be fine with no long-term damage.

The bolt cutter solution worked so well, the doctors involved actually published a letter to share the idea with other physicians.  Bolt cutters are commonly available in a many hospitals, but not something that ER doctors may initially think to use.  There is other specialized equipment like dental saws or diamond-tipped saws which may be able to cut through titanium rings, but they aren’t generally readily available in a hospital setting and require more manpower to use.  The potential for accidentally injuring a patient’s finger during the removal process is also higher than with a simple bolt cutter.

Sometimes a simple solution can be the best solution and as this case study demonstrates, it is also important to document and share lessons learned.  Solving a single problem is a good thing, but sharing solutions so that the wheel doesn’t have to be reinvented the next time the problem is encountered is even better.  Maybe some doctor will read the letter published by the doctors involved in this case and a future patient will be spared an extra night of discomfort and unnecessary time in the hospital.

If you are in the market for a ring, you may want to consider carefully whether titanium is the right metal choice.  If you do choose titanium, you may want to stick with pure grade because it is significantly softer and easier to cut than aircraft grade, with has other metals mixed in.  It is also a good idea to remove all rings when working around machinery or if you notice your fingers swelling.

To view a Cause Map of this example, click on “Download PDF” above.

Root Cause

Medical Device Vulnerable to Hacking

By Kim Smiley

The Food and Drug Administration (FDA) made headlines when they issued a warning that a computerized pump used for infusion therapy, Hospira Symbiq Infusion System, has cybersecurity vulnerabilities. Hacking is scary enough when talking about a laptop, but the stakes are much higher if someone had the ability to alter the dosage of critical medication.

A Cause Map, a visual format for performing root cause analysis, can be used to analyze this issue.  The first step in the Cause Mapping process is to fill in an Outline with the basic background information, including how the issue impacts the overall goals.  Defining the impacts to the goals helps define the scope of an issue.  Once the Outline is completed, one of the impacted goals is used as the starting point to building the Cause Map itself.  For example, the potential risk of serious injury or death is an impact to the patient safety goal and would be the first cause box on the Cause Map.  The rest of the Cause Map is built by asking “why” questions and documenting the answers in cause boxes to intuitively lay out the cause-and-effect relationships.

So why is there potential for injury or death with the use of the Hospira Symbiq Infusion System?  It is possible for a patient to receive the incorrect dosage of medication because the system could be accessed remotely by an unauthorized user who could theoretically change the settings.  There have been no reported cases where this infusion pump system has been hacked, but both Hospira and an independent researcher have confirmed that it is possible.

This system is vulnerable to hacking because it is designed to communicate with hospital networks and the design has a software bug that could allow it to be accessed remotely via a hospital’s network.  The infusion system was designed to interface with hospital networks to help reduce medication dosage errors because the dosage information wouldn’t need to be entered multiple times.

The final step in the Cause Mapping process is to develop solutions to help reduce the risk of similar errors in the future.  In this specific example, the FDA has strongly encouraged healthcare facilities to transition to alternative infusion systems as soon as possible.  Hospira discontinued this specific design of infusion system in 2013, reportedly due to unrelated issues, but it is still available for sale by third-party companies and used by many healthcare facilities. There will not be a software patch provided or any other means to make the Hospira Symbiq Infusion System less vulnerable to hacking so the only option going forward will be to switch to a different infusion system. During the time required to transition to new equipment, the FDA has provided specific steps that can be taken to reduce the risk of unauthorized system access that can be read here.

Root Cause

Attack on Hospital Staff Indicates Systematic Safety Issues

By ThinkReliability Staff

On July 13, 2015, a security counselor at a Minnesota psychiatric hospital was attacked and seriously injured by a patient. Even one injury to an employee is highly undesirable and should initiate a root cause analysis in order to reduce the risk of these types of events recurring. In the case of this hospital, this employee injury is one in a long line. In 2014, 101 staff injuries were reported at the hospital. From January to June of 2015, 68 staff injuries were reported. Clearly this is an extensive – and growing – problem at the site. According to Jennifer Munt, a spokeswoman for a union which represents 790 workers, “Workers at the security hospital feel like getting hurt has become part of the job description.”

An incident like this one can be captured within a Cause Map, or visual root cause analysis. The first step in the method is to define the problem in a problem outline. The problem outline captures the what, when and where of an incident, as well as the impact to the goals. Another important piece of information that is included is the frequency of similar events. Capturing the frequency helps provide the scope of the problem.

Understanding the details for one specific incident will likely reveal systematic issues that are impacting other similar incidents. That is definitely true in this case. Beginning with an impacted goal and asking “why” questions results in developing cause-and-effect relationships. Each cause that is determined to have contributed to an issue can lead to a possible solution. Each cause added to the Cause Map provides additional possible solutions, which, when implemented, can reduce the risk of future similar incidents.

In this case, we begin with the employee safety goal. An employee was seriously injured because of an assault by a patient at the hospital. The assault resulted from two causes, which were both required and so are joined with an “AND”. First, violent patients are housed at the facility. There were no other facilities available for the patient and the hospital is required to admit mentally ill county jail inmates because of a Minnesota law (known as the “48 hour rule” because of the time limit on admissions).

Second, clearly there was inadequate control of the patient. According to the union, limitations on the use of restraints, which are only allowed when a patient poses an “imminent risk”, mean that staff members feel that they cannot restrain patients until after they’ve been threatened – or assaulted. The union also says that inadequate staffing is leading to the increase in assaults. Specifically, union officials say at least 54 more staff members are required for the facility to be fully staffed.

The issues have caught the attention of state safety regulators and government. Multiple solutions have already been incorporated, including use of cameras, a separate admissions unit for new patients and protective equipment for staff. Additional staff is also being hired. The patient involved in the attack is isolated and under constant supervision. There’s no word yet on whether the use of mobile restraints, as requested by the union, will be allowed.

Says Jaime Tincher, Chief of Staff for Minnesota Governor Mark Dayton, “These are important first steps; however we will continue to assess what additional resources are needed to improve safety and treatment at this facility.” No less would be expected for ongoing issues that have such a significant impact on employee safety.

Root Cause

New study finds that cholera vaccine helps protect community

By Kim Smiley

There are an estimated 3 to 5 million cases of cholera worldwide each year, believed to cause more than 100,000 deaths annually.  Cholera is rare in developed nations, but has been pandemic in Asia, Africa and Latin America for decades.  Researchers continue to search for an effective method to prevent cholera outbreaks.  A recent study found that a cheap oral vaccine is an effective tool to help prevent the spread of cholera.  The vaccine is not a perfect solution, but the study found that when two-thirds of the population was given the vaccine, cholera infections in an urban slum were reduced by nearly 40 percent.

The problem of cholera infections can be analyzed by building a Cause Map.  A Cause Map is a visual root cause analysis that intuitively lays out the cause-and-effect relationships of the multiple causes that contribute to an issue.  A Cause Map is built by asking “why” questions and documenting the answers in cause boxes.  To see how a Cause Map of this issue could be built, click on “Download PDF” above.

So why are so many people infected with cholera each year? Cholera is not generally passed from person to person and is predominantly spread through drinking water contaminated with cholera bacterium.  The feces of an infected individual carry cholera bacterium.  Cholera outbreaks occur in areas where there is a person infected with cholera in a location with poor sanitation infrastructure and inadequate water treatment.

Many efforts to reduce the number of cholera cases have focused on providing clean drinking water and providing sanitization equipment.  A recent study looked at three populations in Bangladesh: one was only given the vaccine, the second was given the vaccine, a hand-washing station and taught how to sterilize drinking water, and no intervention was done on the third population. The results showed that the vaccine alone was nearly as effective at preventing cholera as providing the vaccine along with a hand-washing station and instructions on sterilizing drinking water.  In the study, people were given two doses of the vaccine which costs about $3.70.

In an ideal world everyone would have access to clean, safe drinking water, but the resources required to build the needed infrastructure are not likely to be available any time in the near future.  Having a relatively cheap vaccine that is proven to slow the spread of cholera during an outbreak should prove to be a powerful tool in situations where access to clean water is limited.

Root Cause

How One Hospital Improved Heart Attack Care

By ThinkReliability Staff

The heart is responsible for pumping blood through the body, but it also requires blood flow to continue functioning. When the blood supply to the heart is cut off, it’s known as a heart attack and it can be deadly. According to the Centers for Disease Control and Prevention (CDC), about 15% of people who have a heart attack will die from it. Time is of the essence when treating heart attacks. Again according to the CDC, “The more time that passes without treatment to restore blood flow, the greater the damage to the heart.”

Treatment to restore blood flow is generally a balloon (which pushes aside the blockage) and a stent (which holds the artery open). In the United States, this is performed in a hospital. Although hospitals can’t control the amount of time it takes to get a heart attack victim TO the hospital, they can control the time from when a patient enters the hospital until treatment is begun. This is known as the door to balloon (or D2B) time.

A national campaign to improve the speed of heart attack treatment was launched. At that time, the typical heart attack process went like this: a patient suffered a heart attack and (hopefully) 911 was called. An ambulance picked up the patient and delivered them to a hospital. Once the patient arrived at the hospital, an electrocardiogram (EKG) was taken and transmitted to a cardiologist, who determined whether or not the patient was suffering from a heart attack. If it was a heart attack, an interventional cardiologist and other members of the heart attack team were called and made their way to the hospital. The patient was taken through a consent and surgical prep process, and then then balloon and stent were installed. At this time, the national goal was for half of patients to receive a stent and balloon within 90 minutes of arrival at a hospital.

One of the hospitals to take up the challenge was Our Lady of Lourdes Medical Center in New Jersey. In 2007, heart attack treatment was on par or better than other hospitals, with half of patients treated within 93 minutes. (In many locations it took more than 2 hours.) By 2011, treatment time was down to 71 minutes. The head of the cardiovascular disease program challenged the staff to continue to decrease the time and staff members set up a “D2B task force”. This task force looked at each step in the process for potential improvements. Some individual steps were shortened. The forms required for consent were reduced as much as possible. The time spent individually calling in all the members of the cardiac care team was reduced by having a single call ring to all their pagers. Those on the team that were on call were limited to being 30 minutes away from the hospital.

Other steps, instead of being performed one after the other, were performed simultaneously. Instead of waiting for the patient to arrive at the hospital for an EKG, it is taken in the ambulance and transmitted to the emergency room. Each step required for surgical prep is performed as much as possible simultaneously by a team. Additionally, one surgical room is reserved for heart attack patients and is kept stocked with necessary supplies.

Now the median D2B time is 50 minutes. This was demonstrated on March 29, when a patient arrived at the medical center at 1:54 AM and whose D2B time was 55 minutes. This was unusually long for the center. What caused the difference? Because the patient was a 49-year-old woman with ambiguous symptoms, the emergency room doctor waited until the patient arrived at the hospital for another EKG to verify the heart attack before the heart attack team was called.

From 2003 to 2013 the death rate from coronary heart disease has fallen 38%. Some of this drop is attributed to better control of cholesterol and blood pressure, but some is surely due to quicker treatment at most US hospitals.

The “before” and “after” process map that shows the flow of heart attack treatment at Our Lady of Lourdes Medical Center can be diagrammed visually to show how the process flows. To view the process map, the problem outline and timeline of the treatment of the heart attack patient on March 29, 2015, please click on “Download PDF” above. Or click here to read more.