How to Establish a Multi How to Establish a Multi Hospital STEMI - - PowerPoint PPT Presentation

How to Establish a Multi How to Establish a Multi‐ ‐ Hospital STEMI Transfer System Hospital STEMI Transfer System

• Dr. Greg Mishkel for the Doctors of

Prairie Cardiovascular and in collaboration with our Community & Springfield Hospitals

Barriers to PPCI STEMI Care in Central Illinois

• Limited facilities
• Long inter-hospital travel distances
• Limited ACLS EMS accessibility
• Variability in ED services (locum tenens)

Barriers to PPCI STEMI Care in Central Illinois

• Limited facilities
• Long inter-hospital travel distances
• Limited ACLS EMS accessibility
• Variability in ED services (locum tenens)

MI: Evolution of care in Central Illinois

• 1990’s early adoption/promotion of iv

thrombolyis = “drip & ship”

• 2000 adoption of mechanical

reperfusion

• 2002: Establish Institutional processes

for acute MI care

• 2005: DANAMI/PRAGUE/MHI model:

Inter-hospital transfer to TWO Springfield hospitals (St. John’s Hospital, Memorial Medical Center) = PRAIRIE STAT HEART PROGRAM

2005: 6 Referral Centers Mean Transfer Distance: 46 miles (range:28-88) 4: Helicopter, 2: Ambulance

2009 2009

So how was this done?

• Physician leadership, physician buy in
• Full time co‐ordinator/facilitator (communications, logistics,

deal with “SNAFU’s”, educational events)

• Hospital commitment (funding, quality, cath

lab personnel)

• Establish effective high quality ER STEMI program



Establish lines of communication (ERswitchboardcath lab)



Treatment guidelines



Monitor outcomes, modify procedures



Reduce readmissions

• Build on success of local program to entice outside programs to

be “part of the team”

• Regular (annual?) of all

participants (we include the switchboard

• perators) in educational forums/updates to share

results/successes/challenges

What do all of these first 3 requirements have in common

• PEOPLE NOT STRUCTURES



Dofasco Steel my first summer job in Hamilton, Ontario



“Our product is Steel…Our Strength is People”

So how was this done?

• Physician leadership, physician buy in
• Full time co‐ordinator/facilitator (communications, logistics, deal

with “SNAFU’s”, educational events)

• Hospital commitment (funding, quality, cath

lab personnel)

• Establish effective high quality ER STEMI program (St. John’s

* 90)



Establish lines of communication (ERswitchboardcath lab)



Treatment guidelines



Monitor outcomes, modify procedures



Reduce readmissions

• Build on success of local program to entice outside programs to

be “part of the team”

• Regular (annual?) of all

participants (we include the switchboard

• perators) in educational forums/updates to share

results/successes/challenges

STEMI: Where We Started at our hospital

• Doing well: performing above the average hospital for STEMI care

in Crusade and NRMI registries, but wanted to be exceptional

• Formation of AMI Team in 2003 to target performance above the top 10% of

Crusade/Action registry hospitals

• Formal Intervention started late 2003/early 2004
• Obstacles to performance improvement included distance of new ED

from cath lab, lack of standardized protocols and medical record documentation.

AMI Team Strategic Goals

• Achieve D2B time of <90 minutes for 100% of STEMI patients
• Implement standardized, evidence based and guideline driven

pathways of care to improve quality

• Achieve 100% compliance with admission and discharge

medications for all AMI patients

• Achieve results above the top 10% of Action registry hospitals for

STEMI care

• EKG done within 5 minutes for patients with chest pain
• ED Door to cath

lab arrival of < 30 minutes

• Cath

Lab arrival to balloon dilatation of < 25 minutes

• Implement pre‐hospital ECG

Methods

• Formation of a multidisciplinary AMI team with quarterly meetings in Fall of

2003

• ED meds bundled‐ASA, Beta Blocker, Heparin, and Nitroglycerin
• ED physician empowered to concurrently activate cardiologist and

cath lab team upon diagnosis of STEMI with STAR 90 page

• Cardiologist meets and evaluates patient in cath

lab, not ED

• Accountability and tracking form following patient through process allowing

evaluation of performance of various phases of the D2B process

• Implementation of guideline driven treatment protocol and procedural

protocol

• Weekday night team resides in hospital
• Benchmarking of performance with other centers using Action and MIDAS

registries.

AMI Team

• Dr. Charles Lucore, Chairman, Department of Cardiology
• Dr. Linda Nordeman, Chairman, Department of Emergency Medicine
• Dr. Greg Mishkel

and Frank Mikell, PCCL

• Dr. John Nester, Springfield Clinic
• Dr. John Byrnes, Emergency Room
• Cardiac Catheterization Lab Representatives: Sheryl Friedrich et

al

• Emergency Department Representatives: Amy Jones et al
• Cardiac Nursing Representatives: Jennifer Cullen et al
• Quality Resource Management Representatives: Diane Tebrugge

et al

• Health Information Management Representatives: Heather Shankland

et al

AMI Door to Cath Lab Tracking Sheet

To be completed only for ST elevation and/or LBBB on 1st 12‐lead EKG patients

• Arrival Time__________
• EKG Time___________

Tech__________

• Time Cardiologist paged__________

ED Physician________

• Time Cardiologist returns page_______

Cardiologist_________

• Cath

Lab notified__________ Cath lab responds_____

• Pt prepared for cath

lab_________ ED Nurse__________

• Time Cath

Lab calls for patient________

• Pt leaves ED___________
• Cath

lab arrival time________

• Balloon inflation time________

Complications that may delay process (pt requires intubation, pt arrests, or requires additional stabilization, atypical presentation) _________________________________________________________ _________________________________________________________

Acute Myocardial Infarction Discharge Medications 2003 – May 2009

(Data from NRMI 4, Action, MIDAS Comparative Performance System (CPMS))

65 70 75 80 85 90 95 100 2003 2004 2005 2006 2007 2008 2009 Aspirin Beta Blocker Ace Inhibitor Statin/lipid

Top 10% (Action STEMI rpt) ASA 100% Beta Blocker 99% Ace/ARB 95% Statin 97%

ACE #s do not always screen for LVEF < 40% from NRMI report

ASA 99% Beta Blocker 98% Ace/ARB 97% Statin 99%

STEMI Myocardial Infarction In-Hospital Events (last 12 months)

• St. John’s

National Avg. Top 10%

Death Rate (%) 2.8% 5.9% 5.8%

Door to Balloon Time (minutes)

54 71 59

Bleeding Requiring Transfusion (%)

2.3% 6.3% 7.4%

Stroke

0.60% 0.80% 0.60%

Length of Stay (days)

3.6 4.4 4.6

Source: 2nd Qtr 08 - 1st Qtr 2009 ACTION Registry (Get With the Guidelines) Gold Performance Achievement Award for 2009

So how was this done?

• Physician leadership, physician buy in
• Full time co‐ordinator

(communications, logistics, deal with “SNAFU’s”, educational events)

• Hospital commitment (funding, quality, cath

lab personnel)

• Establish effective high quality ER STEMI program



Establish lines of communication (ERswitchboardcath lab)



Treatment guidelines



Monitor outcomes, modify procedures



Reduce readmissions

• Build on success of local program to entice outside programs to be

“part of the team”

• Devise (based on local needs) an integrated/consistent one call,
• ne

protocol

• Regular (annual?) of all

participants (we include the switchboard

• perators) in educational forums/updates to share

results/successes/challenges

Door In-Door Out ECG Decision Treatment Initiate STAT Heart Arrange Transfer Ideal Goal: <30 minutes Departure-Door 2 Transfer Air Ambulance <30 minutes <30 minutes Door 2-Balloon Cath Lab Arrival Diagnostic Cath PCI Goal: Door-Balloon: ≤ 90 min.

Global Components of Process of Transfer STEMI Care

Community Facility Transport Tertiary Facility

3- 5 min

• Suspected MI (Step1)
• 12 Lead ECG/STEMI Identified (Step 2)
• Determine Bleeding Risk (Step 3)

5-10 min Activate Stat Heart Team Call for quickest available transport (Step 4) Ambulance/Helicopter Call Springfield Hospital Activate Stat Heart Team

15-20 min

Community Stat Heart Team

ED MD 2-RN Ancillary staff

Springfield Stat Heart Team

Cardiologist Coordinator Cath Lab Security Admitting Administrative Rep ER contact Contraindication Protocol Air/Ground Transport

30 minute Transport

time NOT Available

Low Bleeding Risk

Thrombolytic Protocol Air/Ground Transport

High Bleeding Risk

PCI Protocol Air/Ground Transport

30 minute Transport

time Available

Goal: Out the Door in < 30 minutes

Prairie Stat Heart Protocols

Lisa Page, RN

Goal out the door in 30 minutes or less

5-12 minutes



Activate STAT Heart team at community hospital (staff pre-assigned duties)



First call -staff calls quickest transport air or ground

(base on mileage between hospitals)



Second call – Springfield Hospital receiving pt. Stat Heart team activated in Springfield.



Automatic - accepting Prairie cardiologist and bed assigned. 0-3 minutes



Patient presents with chest pain or associated symptoms



TREAT ALL patients as potential Stat Heart until deemed otherwise 3-5 minutes



ECG done



ECG to ED physician for quick diagnosis.



ED physician determines if STAT Heart criteria is met.

12-20 minutes

• Nurses start IV’s & give standard meds (ASA, Lopressor, NTG)
• Physician determines if patient is high bleeding risk (contraindication

questions)

• Transport time < 30 min. helicopter/ambulance - PCI protocol
• Transport time > 30 min. helicopter/ambulance - Thrombolytic protocol
• Helicopter or ambulance transfer - Contraindication protocol if pt. is high risk

for bleeding (80 yrs or older, on Coumadin etc.)

• Give protocol meds

20-30 minutes



EMS transport arrives, packages pt., brief report (transport team is educated on process)



Departure



Call receiving Springfield Hospital with departure page

So how was this done?

• Physician leadership, physician buy in
• Full time co‐ordinator

(communications, logistics, deal with “SNAFU’s”, educational events)

• Hospital commitment (funding, quality, cath

lab personnel)

• Establish effective high quality ER STEMI program



Establish lines of communication (ERswitchboardcath lab)



Treatment guidelines



Monitor outcomes, modify procedures



Reduce readmissions

• Build on success of local program to entice outside programs to be “part
• f the team”
• Devise (based on local needs) an integrated/consistent one call,
• ne

protocol

• Regular (annual?) of all

participants (we include the switchboard

• perators) in educational forums/updates to share

results/successes/challenges

SO HOW ARE WE DOING? STAT Heart Population: 2005‐2009 N approx. 600

Comparison Of STEMI Process of Care For Inter‐hospital Transfer: Door‐Balloon Times

4.2

16.2

8.6

26.4

13

59

64

89

20

64

10 20 30 40 50 60 70 80 90

NRMI 3/4 NCDR 2005- 2006 Stat Heart- Spr.2008 Stat Heart- Carb.2008 Total Stat Heart

< 90 min. < 120 min.

% PTS

(n=4278) (n=15,049) (n=338) (n=382) (n=44)

In‐Hospital Clinical Outcomes

Length of hospitalization (mean ± SD days): 3.6 ± 2.5 vs. 5 ± 6.3; p=0.0001

7 3.7 2.6 2.1 1.2 3 1.1 0.3 0.05 1.1 0.9 8 5.9 3.7

2 4 6 8 10

Death Non-Shock Death Re-infarction Stroke Composite

Meta-analysis Stat Heart/07 Stat Heart 8/08 % PTS

Comparison Of 30‐day Clinical Outcomes NRMI vs. Stat Heart: Springfield Hub

(n=1472) (n=188)

PROCEDURAL KEYS PROCEDURAL KEYS to

to Success

Success

1.

EARLY RECOGNITION OF MI starts the “interventional cascade” beginning with QUICK call to helicopter or ambulance for transport

2.

A SINGLE call to activate Stat Heart Process in Springfield 3.

Standardized Protocol/ Orders (PCC and ED physician agree to adhere to standard orders as written)

4.

Standardized communications via pager identifies MI, patient departure, 15 minute arrival

5.

Cath lab nurse calls after receiving departure page for brief report-cath lab nurse calls community hospital nurse. Cardiologist and team awaits arrival in cath lab.

6.

Communication ON-GOING throughout the process from beginning to end

7.

Rapid transportation via ground or air is mandatory. Regular meetings with these providers

8.

Education provided to all Stat Heart team members 9.

Data collection to promote process improvement and quality

10.

Feedback and reports given promptly (immediately after each case)

11.

Public education (regarding Sx of MI, program in their area)

12.

Debrief with Stat Heart team members at regular intervals and especially after failures (problems compound with out intervention)

13.

No Blame Environment!

14.

Continue to innovate. Don’t tolerate failure, don’t rest on success (EKG’s in the field, paramedic

education, earlier initiation of Rx)

15.

D2B time is important, but it’s LIVES SAVED THAT REALLY COUNTS. Mortality reflects the proof in the pudding

Conclusions Stat Heart (Rural Inter-Hospital Transfer)

• Regional STEMI Program: feasible/safe with reproducible,

favorable and comparable process measure outcomes to U.S. Registry, despite program growth among broad range

• f hospital systems.
• Between 2005-2009, the utilization of this coordinated,

rural inter-hospital STEMI transfer program, appears to associated with shorter hospitalization and improved in- hospital clinical outcomes, as compared to non- standardized pre-STAT Heart STEMI care.

• Regional STEMI Program: feasible/safe with reproducible,

favorable and comparable process measure outcomes to U.S. Registry, despite program growth among broad range

• f hospital systems.
• Between 2005-2009, the utilization of this coordinated,

rural inter-hospital STEMI transfer program, appears to associated with shorter hospitalization and improved in- hospital clinical outcomes, as compared to non- standardized pre-STAT Heart STEMI care.

Conclusions Stat Heart (Rural Inter-Hospital Transfer)

Improvements

• Procedural Time (wide inter-procedural/inter-operator

variability)

• “Standardization” of cardiac cath lab process
• Implementation of pre-hospital ECG: Reduce door-in/door-out

time

• Emphasis on program maintenance and improvement
• Avoid complacency (delays): meetings, updates, teamwork

(transport, ED’s, ancillary staff, cath lab, administration, etc)

• Program-wide commitment to collection, interpretation and

dissemination of data

• Nimble program: modifiable process/treatment changes
• RN Coordinator: Education, education, education!!

Improvements

• Procedural Time (wide inter-procedural/inter-operator

variability)

• “Standardization” of cardiac cath lab process
• Implementation of pre-hospital ECG: Reduce door-in/door-out

time

• Emphasis on program maintenance and improvement
• Avoid complacency (delays): meetings, updates, teamwork

(transport, ED’s, ancillary staff, cath lab, administration, etc)

• Program-wide commitment to collection, interpretation and

dissemination of data

• Nimble program: modifiable process/treatment changes
• RN Coordinator: Education, education, education!!

Minneapolis Heart Institute

Timothy D. Henry, MD, FACC

EMS COMPONENTS OF A SYSTEM

Non PCI Capable PCI Capable

Only 50% of STEMI use EMS in the US 10% Pre-hosp ECG

• 1. PREHOSPITAL
• 2. TRIAGE
• 3. TRANSFER

• 42.0% PCI hospital is closest facility
• 79.0% within 60 minute prehospital

time

Primary PCI: Access

Nallamothu et al. Circulation 2006;113:1189

Red– Zone II (90-120 mins) Blue– Zone I (< 90 mins)

Zone1 Protocol Aspirin 325 mg Aspirin 325 mg Clopidogrel 600mg Clopidogrel 600mg UFH UFH Beta Beta-

• blocker

blocker PCI PCI

Red– Zone II (90-120 mins) Blue– Zone I (< 90 mins)

Zone 2 Protocol Aspirin 325 mg Aspirin 325 mg Clopidogrel 600mg Clopidogrel 600mg UFH UFH TNK TNK ½ ½ dose dose Beta Beta-

• blocker

blocker PCI PCI

Protocol focus: Simple Fast Reduce variability

MHI Level 1 MI: Door – Balloon Times

10 20 30 40 50 60 70 80 90 100 ANW Zone 1 Zone 2 NRMI 3/4 < 90 mins <120mins

% of patients

Kaplan-Meier Survival Curve Kaplan-Meier Survival Curve

50 100 150 200 250 300 350 0.0 0.2 0.4 0.6 0.8 1.0 Days Survival Probability ANW Zone 1 Zone 2

p = 0.31

“Level 1” Heart Attack System

Sioux Falls

A national quality improvement effort led by the ACC and IHI A national quality improvement effort led by the ACC and IHI which aims to reduce 30 which aims to reduce 30‐ ‐day, all day, all‐ ‐cause re cause re‐ ‐admission rates for admission rates for patients discharged with cardiac conditions. patients discharged with cardiac conditions. Enroll now Enroll now to participate in the October 22 to participate in the October 22nd

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