ST Elevation Myocardial Infarction ST Elevation Myocardial - - PowerPoint PPT Presentation

ST Elevation Myocardial Infarction ST Elevation Myocardial Infarction

Quality Care Achieved Through Quality Care Achieved Through Regional Partnerships Regional Partnerships

Ruth Foggett, Regional PPCI Co-ordinator,

Trillium Health Centre

Charlene Sandilands, Director,

Cardiac Health System, Trillium Health Centre

Judy Underwood-Wiens, Manager,

Cardiac Catheterization Lab, Trillium Health Centre

• Dr. K.R. Watson, Director,

Cardiac Catheterization Lab, Trillium Health Centre

Trillium Health Centre Trillium Health Centre

HWY 401 HWY 10 HWY 403 Q E W WILLIAM OSLER HC PEEL SITE TRILLIUM - QUEENSWAY SITE TRILLIUM - MISSISSAUGA SITE

• ST. JOSEPH'S

HEALTH CENTRE CREDIT VALLEY HOSPITAL WILLIAM OSLER HC ETOBICOKE SITE

L4V L5L M8W

L5E

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L5G L5W L5R L4W L5V L4Z L5T

M9C L5S

L5P

M9B L4Y

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66265

L5H L5K L5J

• Healthcor Inc. 2002

Trillium Health Centre

Primary FSA - Trillium has greatest percent of total market share. Secondary FSA - Trillium has second greatest percent of total market share.

Primary Secondary Primary and Secondary Service Areas

• 9

L I N E R O A D H U R O N T A R I O S T R E E T DERRY ROAD

Aim Aim

To provide 24/7 access to Primary Percutaneous Coronary Intervention (PPCI) for all Regional ST Elevation Myocardial Infarction (STEMI) patients by EMS Direct transfer from the field to Trillium Catheterization Lab in less than 90 minutes.

ST ↑ ST ↑ ST ↑

→ →

Cath LabCath Lab

Terminology Terminology

ST Elevation Myocardial Infarction or STEMI is a type of Heart Attack which can be identified on an ECG by specific acute ECG changes called ST elevation. A Primary Percutaneous Coronary Intervention (PPCI) is a procedure where a balloon catheter with a Stent is used to open the blocked coronary artery in someone having a Myocardial

• Infarction. This procedure is done in the Cardiac Catheterization

Lab.

ST ↑ ST ↑ ST ↑

ECG

Rationale Rationale

In 2004, American Heart Association/American College of Cardiology guidelines identified Primary Percutaneous Coronary Intervention (PPCI) as the initial treatment of choice for patients with ST Elevation Myocardial Infarction (STEMI) when timely access to a Cardiac Intervention Centre is possible. Time from first patient contact “Door” to reperfusion of the blocked coronary artery being ≤ 90 minutes. STEMI patients who have timely PPCI have: higher coronary reperfusion rates (>90%) lower reocclusion, stroke and mortality rates.

STEMI Patient Access to PPCI STEMI Patient Access to PPCI

Regional Direct PPCI Process First contact: EMS ACP Chest Pain? ECG STEMI ECG? Calls Interventionalist Team activated prior to transport ER PPCI Process

ER Registration RN Assessment

Chest Pain? ECG STEMI ECG?

ER Physician assesses

Calls Interventionalist Team activated

Team needs 30 minutes travel time

STEMI Access to PPCI STEMI Access to PPCI

ER PPCI

First patient contact “Door” to First Device % < 90 minutes 60%

EMS Regional Direct PPCI

First patient contact “Door” to First Device % < 90 minutes > 90%

Regional Partnership Plan Regional Partnership Plan

Stage 1: Halton EMS & Halton Healthcare Initiated December 14, 2008 Initiated December 14, 2008 Stage 2: Toronto EMS & South Etobicoke Initiated May 4, 2009 Initiated May 4, 2009 Stage 3: Peel EMS & Credit Valley Hospital Initiated August 10, 2009 Initiated August 10, 2009 Stage 4: Peel EMS & William Osler Health Centre (North Peel/Etobicoke) Initiated March 2010 Initiated March 2010

Time is Muscle Time is Muscle

Regional Plan Regional Plan

Memorandum of Understanding (MOU)

Roles & responsibilities of EMS, the Regional Hospital & Trillium

Internal/External Processes in Place

EMS Code STEMI process Trillium internal Code STEMI process Regional hospital process to accommodate repatriated patients

Education Plan

Physician, staff & EMS education

Communication

Regional Cardiovascular Steering Committee EMS/Sunnybrook-Osler Centre for Pre-hospital Care Workgroup Trillium Cardiac STEMI Workgroup

Outcome Monitoring & Feedback

Individual Case Feedback Reports Quarterly feedback Report

EMS Direct PPCI Flowmap EMS Direct PPCI Flowmap

Patient with Chest Pain ECG done by EMS ACP & Zoll ECG identifies STEMI ECG changes

Calls Trillium Communications (905) 848-7557 “Halton EMS calling for Interventional Cardiologist for Code “STEMI” Interventionalist Accepts EMS transports patient to THC Cath Lab THC Internal Code STEMI activated

Trillium Plan Trillium Plan

A Bed to support ‘No Refusal’ principal

PPCI bed in CCU with automatic decant process

Code “STEMI” Communication Process

Provides internal priority response

A “STEMI” RN

Facilitates timely patient flow & continuity

• f care from ER, to the Cath Lab, to CCU.

Repatriation

Patient repatriation to bypassed hospital in 6 - 12 hours RN resources for patient accompaniment .

Staff Education

Road show for all stakeholders

Porter Bed Desk Registration Emergency Communications Security Patient Care Coordinator Hospitality Associate CCU Cath Lab Interventionalist STEMI Team

Tools Tools

EMS Direct Case Study EMS Direct Case Study

Incident History Incident History: :

52 year old male complaining of retrosternal crushing chest pain (7/10). No radiation or SOB. Felt like heartburn. Pale, diaphoretic in severe

• distress. Came on while bowling.

Previous Lateral MI with Rescue PCI & Stent 2007

ECG ECG

Cardiac Arrest x 2 en route Cardiac Arrest x 2 en route

Pre & Post PPCI Pre & Post PPCI EMS Arrival at patient to First Device 80 min EMS Arrival at patient to First Device 80 min

Blocked Right Coronary Open Artery Post PPCI

Outcomes Outcomes

7%

98% 98% 71 88% 88%

43

Jan/Feb/ Jan/Feb/ Mar Mar 2010 2010

Trillium Trillium PPCI PPCI PPCI Direct (New Process) PPCI Direct (New Process) Total 140 Patients Total 140 Patients

2007/ 2007/ 2008 2008 2008/ 2008/ 2009 2009 Jan/Feb/ Jan/Feb/ Mar Mar 2009 2009 Apr/May/ Apr/May/ Jun Jun 2009 2009 Jul/Aug/ Jul/Aug/ Sep Sep 2009 2009 Oct/Nov/ Oct/Nov/ Dec Dec 2009 2009

Number of PPCI Patients

135 137 10 14 34 39

% of Patients ≤ 90 Minutes from EMS Arrive at Patient ("Door“) to First Device Target 90%

47% 60%

90% 90% 92% 92% 93% 93% 93% 93%

Average "Door" to First Device (Minutes)

106 97

80 68 68.5 65.9

EMS Arrive at Patient (“Door”) to EMS Arrival at Trillium Target ≤ 60 Minutes

N/A N/A

100% 100% 100% 100% 100% 100% 100% 100%

Number of False Positives/NonSTEMI Target ≤ 10%

N/A N/A 0% 7% 8.8% (9)

Lessons Learned Lessons Learned

Leadership Process

Best practice, flexible, innovative processes needed to meet both the goals of the initiative & the specific needs of each partner.

Partnership

Each stage involved the development of new partnerships (3 different EMS teams, 3 regional hospitals with 7 sites) Staged approach, took time & commitment to develop the MOU & processes.

Teamwork

Each individual’s expert contribution was important in the complex process to meet stringent time targets United behind a common vision a diverse team of committed, United behind a common vision a diverse team of committed, individuals can accomplish great things and exceed their goals! individuals can accomplish great things and exceed their goals!

Communication

Excellent communication network with all stakeholders resulted in prompt resolution of challenges.

Partnership & Teamwork Partnership & Teamwork

William Osler Health Centre William Osler Health Centre

Together Improving Regional Cardiac Care

Peel, Halton & Toronto EMS

Thank you Thank you

Background Background

May 2005 24/7 access to PPCI for all STEMI patients presenting to Trillium’s Emergency Department began. December 2008 24/7 EMS Direct transport

• f STEMI patients from

the field to the Trillium Catheterization Lab for PPCI.

Future Future

Development of consistent regional process for Indirect PPCI Code STEMI patients. Development of process for Primary Care Paramedics presenting to Trillium Emergency with STEMI patient. Refine Repatriation & internal Code STEMI process. Ongoing Quarterly Regional outcome reports to ensure continuous monitoring & quality patient outcomes.

Outcomes

utcomes

January 1, 2009 January 1, 2009 – – March 31 2010 (140 patients) March 31 2010 (140 patients) 9 Patients experienced Cardiac Arrest prior to arrival at Trillium Outliers due to:

Patient’s clinical condition (cardiac arrest) Communication issues Technically difficult patients (anatomy)

16 False Positive due to:

Pericarditis Apical Ballooning / Cardiomyopathy Coronary Spasm Non-specific ECG change

5 Expired (3.6 mortality rate at discharge) 140 ER visits averted