STEMI Boot CampSTEMI Boot Camp

…South Dakota Style!…South Dakota Style!

David R. Burt, MD,University of

Virginia

1

Presenter Disclosure Information

David Burt, MD

FINANCIAL DISCLOSURE:None

UNLABELED/UNAPPROVED USES DISCLOSURE:None

www.projectupstart.comwww.projectupstart.com

Today’s Goal:Today s Goal:We are going to discuss STEMI We are going to discuss STEMI

Systems Engineering: This involves a discussion of the optimization of a discussion of the optimization of the Essential Elements of Reperfusion as they relate to pre-Reperfusion as they relate to prehospital STEMI Care.

GOAL Optimization NOT GOAL: Optimization, NOT improvement!

Your Speaker: Currently at the University of Virginia

Director: UVA Chest Pain Center

Mr. Jefferson’s UniversityCenter

Director: UVA C di l O t h Cardiovascular Outreach (STEMI, etc.)

Active in the American Heart Association, The Society of Chest Pain Society of Chest Pain Centers, and The Virginia Heart Attack Coalition

Prior to VirginiaPrior to Virginia…

Associate Medical Director of Emergency and Cardiovascular Services: Grand Rapids, Michigan

Directed emergency cardiology interfaces for a multi-center hospital system with over 200,000 total emergency department

visits

Chaired STEMI quality improvement program/committee at main campus

Initiated development of regional STEMI networks and a 11-county pre-hospital ECG plan

Worked shifts in both PCI and non-PCI emergency departments

Served as a flight physician for AeroMed Air Transport

Developed Project UPSTART, a no cost STEMI quality improvement program

Prior to MichiganPrior to Michigan…

Devils Lake = Home

2 1

4 3

FYI: ND has 4 PCI centers

4 3

FYI: ND has 4 PCI centers…

North Dakota – The Four “F’s”North Dakota The Four F s

F1) Freezing…

Coldest temp inDevils Lake last Devils Lake last year?

-32 degrees (below zero)

N th D k t Th F “F’ ”North Dakota – The Four “F’s”

F2) Farming…

Life in the “Vast Lane”

N th D k t Th F “F’ ”North Dakota – The Four “F’s”

F3) Fishing (ice) Snow plow on Devils Lake…

Ice HouseIce House

Ice = 3 5’Ice = 3.5

North Dakota The Four “F’s”North Dakota – The Four F s

F4) And Flooding…

1997 Red River of the North flooding Grand Forks, 1997 Red River of the North flooding Grand Forks, ND

Photo: “Come Hell or High Water” (left) won Pulitzer Prize

The Big Picture!The Big Picture!

Provider of: STEMI System Blueprints…p

12

Lessons from the Trenches

Why “STEMI Boot Camp”?Why STEMI Boot Camp ?

The US Marines: Every Marine IS a rifleman

STEMI 2010: Every STEMI provider must

fp

know the basics of the system

Boot Camp: In order to improve a team-based process you must t th “ ll th li k ”strengthen “all the links”

STEMI BootCamp The 5 “R’s” of Reperfusion”

David R. Burt, MDUniversity of Virginia

2010 STEMI BootCamp…p

“Good is the Enemy of Great”Good is the Enemy of Great

16

STEMI Systems EngineeringSTEMI Systems Engineering

Change “hope” to “expectation” Change hope to expectation Process standardization is key

E d d t t i bl End-arounds are not sustainable Providers sometimes fail

STEMI Systems EngineeringSTEMI Systems Engineering

Education is a relationship Education is a relationship You can’t improve what you don’t

measuremeasure Don’t reinvent the wheel Base your system on “Joe the

STEMI patient”

STEMI Systems EngineeringSTEMI Systems Engineering

Champions get exhausted but Champions get exhausted, but systems do not

STEMI Care Continuums and chains STEMI Care Continuums and chains break at their weakest linkG t id f t id b t l Get rid of stupid obstacles

Its all about the packet,

STEMI Systems EngineeringSTEMI Systems Engineering

Optimize your “First Contact Optimize your First Contact Provider” education process

Never underestimate the power of a Never underestimate the power of a cold beerG d l k d t b ild t Good luck does not build systems but bad luck has broken plenty!

Remember the screening ECG!

R b M t f th TiRemember…Most of the Time

…the easy ones are easy!are easy!

S fSo, make more of them easy!

22

Hope, Optimism & Expectation…

When Grandma has a heart attack and When Grandma has a heart attack and we hope for “nearly perfect” care, that’s optimismthat s optimism

When Grandma has a heart attack and When Grandma has a heart attack and we have a system in place designed to deliver nearly perfect care that’s to deliver nearly perfect care, that s expectation

The “STEMI Care Continuum”The “STEMI Care Continuum”

THE PATIENTTHE PATIENT EMS personnelEMS personnel ED triage personnelED triage personnel

M di l C dM di l C d

Recognition!

Medical CommandMedical Command ED nursing staffED nursing staff ED physician ED physician

Relationships ED physician ED physician EMS transfer staffEMS transfer staff Paging system personnelPaging system personnel Paging system personnelPaging system personnel Cath lab staffCath lab staff CardiologistCardiologist Quality Improvement staffQuality Improvement staff Reperfusion!

AHA: STEMI System BlueprintsAHA: STEMI System Blueprints

Mission: Lifeline Recommendations for Mission: Lifeline Recommendations for Criteria for STEMI Systems of Care

The criteria are divided into: Non-PCI Hospital/STEMI Referral Center Non PCI Hospital/STEMI Referral Center PCI Hospital/STEMI-Receiving Center

sectionssections EMS STEMI Systems of Care STEMI Systems of Care

D2B: PCI Engineeringg g

1 ED physician activates cath lab1. ED physician activates cath laba. Via Field Interpretationb. Via Referral Interpretationb a e e a te p etat oc. Via ED Interpretation

2. One call activates the cath lab3. Cath lab team ready in 20-30 minutes4. Prompt data feedbackp5. Senior management commitment6. Team-based approach6. Team based approach

STEMI Builder’s ToolkitSTEMI Builder s Toolkit

www projectupstart comwww.projectupstart.com

Today: The 5 Essential Elements Today: The 5 Essential Elements f STEMI S t O ti i tif STEMI S t O ti i tiof STEMI System Optimizationof STEMI System Optimization

R1R1 RelationshipsRelationshipsR2R2 RecognitionRecognitionR2R2 RecognitionRecognitionR3R3 ReperfusionReperfusionppR4R4 RealReal--time data collectiontime data collectionR5R5 R t & fi tR t & fi tR5R5 Reassessment & refinementReassessment & refinement

More on this later!

Hot off the Press: System Delay and Mortality i STEMI P ti tin STEMI Patients

Long term mortality based on total systems time (time from fi f i ) d i d i 3 hi h l first contact to reperfusion) was determined in 3 high volume Danish PCI centers

Total of 6209 patients from 1/02 to 12/08 undergoing primary PCI within 12 hours of symptom onsetPCI within 12 hours of symptom onset

median follow up was 3.4 years Each hour of delay time was independent predictor of MI

Pre hospital systems delay OR 1 1 (95% CI 1 02 1 18 – Pre-hospital systems delay OR 1.1 (95% CI 1.02-1.18, p=0.02)

– Door to balloon delay OR 1.14 (95% CI 1.05-1.24, p=0.001)p 0.001)

– Total systems delay OR 1.1 (95% CI 1.04-1.16, p=0.002)

Terkelsen CJ JAMA 2010;304:763-771

System Delay and Mortality in STEMI Patients

30 835

Same old Story!

23.3

28.130.8

25

30Same old Story!

15.415

20Mortality, %

5

10

15

0

5

0 to 60 min 61 to 120 121 to 180 181 to 360min min min

Terkelsen CJ JAMA 2010;304:763-771

Think Always: Recognition Think Always: Recognition (Or First (Or First Medical Contact)Medical Contact) to Reperfusion (Rto Reperfusion (R22R)R)Medical Contact)Medical Contact)…. to Reperfusion (R…. to Reperfusion (R22R) R)

Not Just D2B!Not Just D2B! RR22R: The time interval from STEMI R: The time interval from STEMI

Recognition on ECG Recognition on ECG (regardless of (regardless of location)location) to final Reperfusion to final Reperfusion (regardless (regardless of the strategy)of the strategy)!!

System Goal: How can we minimize RSystem Goal: How can we minimize R22R R on each patient?on each patient?pp–– Earlier Recognition at any STEMI “portal”Earlier Recognition at any STEMI “portal”–– Earlier Reperfusion Earlier Reperfusion --including thrombolytics!including thrombolytics!

Endpoints: Recognition and Reperfusion

All attempts at reducing STEMI treatment times must STEMI treatment times must ultimately focus on improving one (or both) of these ( )endpoints.

The goal: (very) early Recognition followed by g yearly Reperfusion.

“Joe the STEMI Patient”Joe the STEMI Patient

STEMI Systems STEMI Systems Engineering:

“Optimize Average”( d d )(standardization)

& Measure it!& Measure it!(real-time data

ll ti )collection)

The Cardinal Rule: Once STEMI isThe Cardinal Rule: Once STEMI is identified it must trigger a clear

response downstream!response downstream!

ECG Acquisition

EMS Evaluation

Communication

!Decision!

STEMI A N dl i th H t kSTEMI: A Needle in the Haystack STEMI cases are STEMI cases are few and far between

But, no STEMI can be treated until it’sfi t id tifi d first identified

So you just have So, you just have to do a lot of ECG’s! …Its a cost of

d i ! doing business!

“STEMI Vi i ” J S N !“STEMI Vision” –Just Say No!95%+ of EMS calls are NOT STEMI!95%+ of EMS calls are NOT STEMI!

Ab PainMVA Need ride

Etoh Chest Pain

Altered

STEMI

Weak/dizzy???

STEMI: Who Said 90 Minutes is Good Enough?

During a STEMI, do everything possible to minimize time to possible to minimize time to reperfusion.

We must think “before the door and beyond the balloon.”

STEMI 2010: “60 is the New 90”STEMI 2010: 60 is the New 90100100 Mortality Mortality Reduction (%)(%)

8080

tion,

(%)

tion,

(%) Critical TimeCritical Time--dependent Perioddependent Period

Goal: Myocardial SalvageGoal: Myocardial Salvage

A-B – No Benefit

Shifts in Potential Outcomes

TimeTime--independent Periodindependent PeriodGoal: Open InfarctGoal: Open Infarct related Arteryrelated Artery

DD

4040

6060

ty R

educ

tty

Red

uct

D-B – Harm

A-B – No BenefitA-C – BenefitB-C – Benefit

Goal: Open InfarctGoal: Open Infarct--related Arteryrelated Artery

CC

2020Mor

talit

Mor

talit D-C – Harm

BB AA

i.e. 44 is better than 66!!!

001212 2424

Time From Symptom Onset to Reperfusion TherapyTime From Symptom Onset to Reperfusion Therapy

Extent of Salvage(% of area at risk)

00 44 88 1616 2020

Gersh BJ, et al. Gersh BJ, et al. JAMAJAMA. 2005;293:979. 2005;293:979--986.986.

Time From Symptom Onset to Reperfusion TherapyTime From Symptom Onset to Reperfusion Therapy(hours)(hours)

STEMI 2012: “60 is the New 90”STEMI 2012: “60 is the New 90”STEMI 2012: 60 is the New 90STEMI 2012: 60 is the New 90

<30 Minutes <30 Minutes : First Medical Contact : First Medical Contact (Recognition) to Thrombolytic administration(Recognition) to Thrombolytic administration(Recognition) to Thrombolytic administration(Recognition) to Thrombolytic administration

<90 Minutes <90 Minutes : First Medical Contact to on: First Medical Contact to on--site site PCI (AHA/ACC recs) ?????PCI (AHA/ACC recs) ?????PCI (AHA/ACC recs) ?????PCI (AHA/ACC recs) ?????

<90 Minutes<90 Minutes : First Medical Contact followed by : First Medical Contact followed by i ti t f ilit t ff ilit t f t PCIt PCI bl f ilit bl f ilit interinter--facility transferfacility transfer to a PCIto a PCI--capable facility capable facility

***BUT realistically <60 Minutes should be the ***BUT realistically <60 Minutes should be the yygoal for Contact/Recognition to Reperfusion @ a goal for Contact/Recognition to Reperfusion @ a STEMI Receiving Facility (PCI Center)!STEMI Receiving Facility (PCI Center)!

Thrombolytics vs PCIThrombolytics vs PCI

Both are excellent: Nothing cures chest pain like a quarter ounce of chest pain like a quarter ounce of metal or a teaspoon of “Drano for the vein”the vein

Faster is almost always better!Think “sequentially” If not A then B,

don’t waste time trying to make “A” work!

Plan A1: PCI in a Timely Manner!Plan A1: PCI in a Timely Manner!

Plan A2: STAT ThrombolyticsPlan A2: STAT Thrombolytics

A1 = A2

Key Concept: STEMI ConduitsKey Concept: STEMI ConduitsKey Concept: STEMI ConduitsKey Concept: STEMI Conduits

Each possible STEMI treatment Each possible STEMI treatment Each possible STEMI treatment Each possible STEMI treatment pathway within a systempathway within a system

Three types of STEMI conduits:Three types of STEMI conduits:–– Internal, (no EMS involvement)Internal, (no EMS involvement)––Mixed (EMS field involvement)Mixed (EMS field involvement)–– InterInter--facility (EMS facility (EMS -- interinter--facility facility

transport)transport)

Local STEMI Local STEMI systems (usually) Overlap…systems (usually) Overlap…

S i i h i t llS i i h i t llSo, improving each one internally So, improving each one internally will improve the entire region…statewill improve the entire region…state

PagePageCulpeper

AugustaUVA

Luckily, Each Local STEMI System…Luckily, Each Local STEMI System…

Serves just three STEMI cohorts:Serves just three STEMI cohorts:

1) Patients that walk up to the front 1) Patients that walk up to the front door of that facility (walkdoor of that facility (walk--ins)ins)door of that facility… (walkdoor of that facility… (walk ins)ins)

2) Patients brought in by EMS (from 2) Patients brought in by EMS (from the field)the field)the field)the field)

3) Patients received from a Non3) Patients received from a Non--PCI PCI facility or those sent to a PCI facility facility or those sent to a PCI facility facility or those sent to a PCI facility facility or those sent to a PCI facility (inter(inter--facility transfers)facility transfers)

Example I: The University Example I: The University p yp yof Virginia Systemof Virginia System

The University of Virginia The University of Virginia –– a PCI hub a PCI hub hospital (R2R goal: 60 minutes)hospital (R2R goal: 60 minutes)hospital (R2R goal: 60 minutes)hospital (R2R goal: 60 minutes)

18 EMS agencies (more or less) 18 EMS agencies (more or less) Culpeper Regional a nonCulpeper Regional a non PCI hospitalPCI hospital Culpeper Regional, a nonCulpeper Regional, a non--PCI hospitalPCI hospital Augusta Medical Center, a non PCI Augusta Medical Center, a non PCI

hospitalhospitalhospitalhospital Page Memorial, a non PCI hospitalPage Memorial, a non PCI hospital

Example II: The Culpeper Example II: The Culpeper p p pp p pRegional HospitalRegional Hospital

Culpeper Regional, a nonCulpeper Regional, a non--PCI hospital with PCI hospital with Cu p p g o a , a oCu p p g o a , a o C osp aC osp a14 ED beds that is 44 miles from a PCI 14 ED beds that is 44 miles from a PCI centercenter

The University of Virginia, a PCI hub The University of Virginia, a PCI hub hospital (Rhospital (R22R goal 60 min tes)R goal 60 min tes)hospital (Rhospital (R22R goal: 60 minutes)R goal: 60 minutes)

6 EMS agencies (more or less)6 EMS agencies (more or less) 6 EMS agencies (more or less)6 EMS agencies (more or less)

A Few ExamplesA Few Examples…

A First Thing on a MondayA. First Thing on a Monday 64 year64 year--old male presents to large old male presents to large yy p gp g

community ED Monday at 9 a.m. with community ED Monday at 9 a.m. with severe chest pain. severe chest pain. “Just like my prior heart attacks – except worse!” He is He is ea t attac s e cept o se e se ssweaty and pale.sweaty and pale.

PMH: Diabetes prior MI x 2 smokes 2 PMH: Diabetes prior MI x 2 smokes 2 PMH: Diabetes, prior MI x 2, smokes 2 PMH: Diabetes, prior MI x 2, smokes 2 PPD, and medication noncompliant.PPD, and medication noncompliant.

ll d “ d G ”ll d “ d G ” Tells ED resident “Doc, I need an EKG!”Tells ED resident “Doc, I need an EKG!”

ECG tech is right thereECG tech is right there ECG tech is right there…ECG tech is right there…

Good or Bad?Good or Bad?

T t t Mili f th DTreatment Milieu of the Day EKG… STEMI! (AAMI) a.k.a tombstonesEKG… STEMI! (AAMI) a.k.a tombstones

ED Crowding? Only a “few” patients waitingED Crowding? Only a “few” patients waiting

ED attending? Shown EKG in <2 minutesED attending? Shown EKG in <2 minutes ED attending? Shown EKG in <2 minutesED attending? Shown EKG in <2 minutes

Cath Lab? Just opening for businessCath Lab? Just opening for business

Cardiologist? In the parking lot!Cardiologist? In the parking lot!

Reperfusion time (DTB)? 21 minutesReperfusion time (DTB)? 21 minutesp ( )p ( )

OUTCOME? Patient healthy enough to leave AMA the OUTCOME? Patient healthy enough to leave AMA the next day (needs to smoke his Camels) next day (needs to smoke his Camels) BUTBUT does does promise to switch to the filtered versionpromise to switch to the filtered versionpromise to switch to the filtered version…promise to switch to the filtered version…

M t f th TiMost of the Time

…the easy ones are easy!are easy!

S fSo, make more of them easy!

STEMI Fact: “S S“STEMI” is a Simple Disease!

STEMI management depends on optimizing rapid recognition of a rare optimizing rapid recognition of a rare but distinct phenomena on a piece of paper followed by the timely paper followed by the timely reopening of a tubular conduit via mechanical or chemical means! mechanical or chemical means!

AKA: “Got STEMI open Artery!!!”AKA: “Got STEMI, open Artery!!!”

B Later that DayB. Later that Day Monday night, (same day, same ED, and Monday night, (same day, same ED, and y g , ( y, ,y g , ( y, ,

same doctor) same doctor) -- multiple patients in triage. multiple patients in triage. All beds are full and multiple trauma codes All beds are full and multiple trauma codes are in progress.are in progress.a e p og essa e p og ess

38 year38 year--old female presents to triage staff old female presents to triage staff with assault and heartburn Small lac to with assault and heartburn Small lac to with assault and heartburn. Small lac to with assault and heartburn. Small lac to face, +ETOH. (3) prior visits for similar face, +ETOH. (3) prior visits for similar complaints.complaints.

Sent to waiting room and social work Sent to waiting room and social work consulted.consulted.

Brought back to treatment area several Brought back to treatment area several hours later with increased indigestion and hours later with increased indigestion and

Assault/ETOHAssault/ETOH…. Patient presented by resident as an Patient presented by resident as an p yp y

assault / ETOH / laceration repair. assault / ETOH / laceration repair.

Upon exam patient minimizes “heartburn” Upon exam patient minimizes “heartburn” Upon exam patient minimizes heartburn Upon exam patient minimizes heartburn to ED attending (EKG ordered anyways).to ED attending (EKG ordered anyways).

EKG l t d b t t t d t ED EKG l t d b t t t d t ED EKG completed but not presented to ED EKG completed but not presented to ED attending for signoff. Put in patient’s box.attending for signoff. Put in patient’s box.

On recheck, patient has BP of 78/40; On recheck, patient has BP of 78/40; shortly proceeds to arrest in the hallway.shortly proceeds to arrest in the hallway.

Hallway CareHallway Care…

Patient defibrillated and intubated in hallway after prolonged arresty p g

EKG NOW examined, and shows AMI with p ofo nd ecip ocal changesprofound reciprocal changes

Cath team called in - ready in 59 minutes Cath team called in ready in 59 minutes (delay secondary to weather)

D2B Time? 332 minutes

ECG i th Ch t P i t A t!ECG in the Chart… Prior to Arrest!

No physician signature!

Wh t h d?What happened?

The same environmentThe same environment

The same day!The same day! The same day!The same day!

The same physician!The same physician!p yp y

The system failed. It allowed the . It allowed the individual provider errors and individual provider errors and individual provider errors and individual provider errors and circumstances to aggregate into a major circumstances to aggregate into a major failure.failure.

STEMI Fact: If it Can Go Wrong, it Will ( l )Will (sooner or later)

Leave nothing to h !chance!

Approach STEMI Approach STEMI systems building like a system’s engineer…

Don’t try to error-proof your providers Erroryour providers. Error-proof your system!

C One More CaseC. One More Case Gerber Memorial Hospital Gerber Memorial Hospital pp(the house that baby food built)(the house that baby food built)

A nonA non--PCI Center “out in the sticks”PCI Center “out in the sticks” A nonA non PCI Center out in the sticksPCI Center out in the sticks

47 ground miles from nearest PCI center47 ground miles from nearest PCI center

Ground transport time variable but usually Ground transport time variable but usually an hour or morean hour or more

Air transport: 21 minutesAir transport: 21 minutes

Situation: Packers are Losing!Situation: Packers are Losing!

44 year44 year--old maleold maleyy

Sudden onSudden on--set of chest pain while set of chest pain while watching watching watching watching the Green Bay Packers gamethe Green Bay Packers game

PMH N (d t t th d t )PMH N (d t t th d t ) PMH: None (does not go to the doctor)PMH: None (does not go to the doctor)

Pain began about an hour agoPain began about an hour ago Pain began about an hour agoPain began about an hour ago

Works as an attorney in FremontWorks as an attorney in Fremont

EMS Obtains an ECGEMS Obtains an ECG

Treatment?Treatment?

Transfer for PCI versus immediate on-Transfer for PCI versus immediate onsite thrombolytics?

AA–– AgeAge–– Time on onsetTime on onset–– Treatment options availableTreatment options available

Ri k b fitRi k b fit–– Risks vs. benefitsRisks vs. benefits

Decision made to transfer Decision made to transfer patient for emergent PCIpatient for emergent PCI

Air transport notified immediately!Air transport notified immediately!

No lag to decision!

Air transport notified immediately!Air transport notified immediately!

Problem!Problem!

No Landing Zone at the PCI C !Center!

Helicopter had crashed on the landing Helicopter had crashed on the landing p gp gzone two hours priorzone two hours prior

Next nearest LZ is 20 minutes from the Next nearest LZ is 20 minutes from the Next nearest LZ is 20 minutes from the Next nearest LZ is 20 minutes from the PCI labPCI lab

N t t il bl PCI t i 60 N t t il bl PCI t i 60 Next nearest available PCI center is 60 Next nearest available PCI center is 60 (air) minutes away(air) minutes away

Now what would YOU do?Now what would YOU do?

Transfer for PCI versus onTransfer for PCI versus on site site Transfer for PCI versus onTransfer for PCI versus on--site site thrombolytics?thrombolytics?

Time versus Muscle

STAT

DelayedPCI?

STATLytics?

Immediate Decision Made!Immediate Decision Made!

TNK per protocol TNK per protocol -- 7 minutes later!7 minutes later!

EMS ground transport arranged (urgently)EMS ground transport arranged (urgently)

At departure, patient continue to have pain At departure, patient continue to have pain and STand ST--elevationelevation

Pain resolved in route to PCI center Pain resolved in route to PCI center

PCI next day shows a partially occluded PCI next day shows a partially occluded PCI next day shows a partially occluded PCI next day shows a partially occluded artery; DES stent placedartery; DES stent placed

Patient home in 48 hours; EF of 55%Patient home in 48 hours; EF of 55% Patient home in 48 hours; EF of 55%Patient home in 48 hours; EF of 55%

Again, no lag to decision!Again, no lag to decision!

System Engineering + Provider Excellence = Success!

A properly designed system allowed for early Recognition followed by for early Recognition followed by rapid Reperfusion, even though the “standard plan” was not “available” “standard plan” was not “available” for this patient

d d (Required: An optimized system (a good plan) combined with individual

id ll ( i i d provider excellence (training and experience)!

Lesson: Plan & Train Concurrently!Lesson: Plan & Train Concurrently!

During “change management”, the mandate (plan) usually comes from “the top down.” ( ) y

For optimal success, “the plan” must also be accompanied b training and ed cationaccompanied by training and education

Those “working in the trenches” need Those working in the trenches need to be given the tools and skills (and responsibility) to accomplish the missionp y) p

I Oth W d “Git R D !”In Other Words: “Git-R-Done!”

“Improving STEMI care involves standardizing the

process and enhancing d i i ki d ”decision-making speed.”

Larry the Cable Guy

Don’t Re-invent the Wheel!Don t Re-invent the Wheel!

Convergent Evolution: all wings look the same (bird/bat/flying squirrel, etc.)

System’s engineering theory: form (should) f ll f f ifollow from function

Lesson: All high gperformance STEMI systems share similar but not identical processes

Work Smarter Not Harder!Work Smarter, Not Harder!

“The 80/20 rule”

Learn where to apply your time.The key is efficient effort on select

points.

So, What Can We Do “Tomorrow”?

“STEMI Boot Camp: Lessons of Combat”Combat

–Important concepts in STEMI carep p–Required for STEMI system excellence–May be implemented quickly–Produce immediate results –Minimal funding required–Mission: Lifeline compliant strategies–Tested…over and over…and over

STEMI LingoSTEMI Lingo…

STEMI Relative Value Unit: STEMI RVU

A practice or concept that is extremely important within the “STEMI Care Continuum” i th hi h RVUis worth high RVUs

I.E. Reperfusion

Today: The 5 Essential Elements Today: The 5 Essential Elements f STEMI S t O ti i tif STEMI S t O ti i tiof STEMI System Optimizationof STEMI System Optimization

R1R1 RelationshipsRelationshipsR2R2 RecognitionRecognitionR2R2 RecognitionRecognitionR3R3 ReperfusionReperfusionppR4R4 RealReal--time data collectiontime data collectionR5R5 R t & fi tR t & fi tR5R5 Reassessment & refinementReassessment & refinement

The “5 R’s of Reperfusion”:The “5 R’s of Reperfusion”:The 5 R s of Reperfusion :The 5 R s of Reperfusion :

True “Essential Elements” of STEMI care True “Essential Elements” of STEMI care True Essential Elements of STEMI care True Essential Elements of STEMI care Perfection of each of these will optimize Perfection of each of these will optimize

any local STEMI Systems of Careany local STEMI Systems of Carea y oca S Syste s o Ca ea y oca S Syste s o Ca e They provide focus points for immediate They provide focus points for immediate

improvementimprovementpp True “Pareto Points” of STEMI Care!True “Pareto Points” of STEMI Care! Efficient improvement with less effort!Efficient improvement with less effort! Efficient improvement with less effort!Efficient improvement with less effort!

Optimize each R!Optimize each R!Optimize each R! Optimize each R!

A focus on optimizing each of the “5 A focus on optimizing each of the “5 A focus on optimizing each of the 5 A focus on optimizing each of the 5 R’s” will allow rapid improvement of R’s” will allow rapid improvement of any local STEMI system in the most any local STEMI system in the most y yy yefficient manner possible efficient manner possible

A precise application of the Pareto A precise application of the Pareto Effect (the 80/20 rule)!Effect (the 80/20 rule)!( )( )

Optimizing Each Essential Optimizing Each Essential El i C i i lEl i C i i lElement is Critical Element is Critical

Failure to optimize each of the 5 R’s will Failure to optimize each of the 5 R’s will Failure to optimize each of the 5 R s will Failure to optimize each of the 5 R s will lead to delay at some later timelead to delay at some later time

Each step is critical to sustainable successEach step is critical to sustainable success

Implementation of systematic change sets Implementation of systematic change sets the stage for provider gap closure the stage for provider gap closure the stage for provider gap closure the stage for provider gap closure

An optimized system minimizes provider An optimized system minimizes provider An optimized system minimizes provider An optimized system minimizes provider delays and enhances provider excellencedelays and enhances provider excellence

The 5 R’s: The 5 Essential Elements of The 5 R’s: The 5 Essential Elements of STEMI S t O ti i tiSTEMI S t O ti i tiSTEMI System OptimizationSTEMI System Optimization

R1R1 RelationshipsRelationshipsR2R2 RecognitionRecognitionR2R2 RecognitionRecognitionR3R3 ReperfusionReperfusionppR4R4 RealReal--time Data Collectiontime Data CollectionR5R5 R t & R fi tR t & R fi tR5R5 Reassessment & RefinementReassessment & Refinement

Relationships: The Most Important R!Relationships: The Most Important R!

Without question, the most Without question, the most important factors in successful important factors in successful important factors in successful important factors in successful optimization of a local STEMI optimization of a local STEMI systems is development of systems is development of systems is development of systems is development of strong relationships at all levels, strong relationships at all levels, --both formal and informal both formal and informal both formal and informal both formal and informal

Remember the RRemember the R22R Continuum?R Continuum?

Cemented by Relationships!Cemented by Relationships!y py p EMS first contact personnelEMS first contact personnel ED triage personnelED triage personnel

Recognition!

ED nursing staffED nursing staff ED physician ED physician EMS transfer staffEMS transfer staff

Relationships EMS transfer staffEMS transfer staff Paging system personnelPaging system personnel Cath lab staffCath lab staff Cath lab staffCath lab staff CardiologistCardiologist Quality Improvement staffQuality Improvement staff

Reperfusion!

The 5 R’s: The 5 Essential Elements The 5 R’s: The 5 Essential Elements f STEMI S t O ti i tif STEMI S t O ti i tiof STEMI System Optimizationof STEMI System Optimization

R1R1 RelationshipsRelationshipsR2R2 Recognition (where it all begins)Recognition (where it all begins)R2R2 Recognition (where it all begins)Recognition (where it all begins)R3R3 ReperfusionReperfusionR4R4 RealReal--time data collectiontime data collectionR5R5 Reassessment & refinementReassessment & refinementR5R5 Reassessment & refinementReassessment & refinement

Recognition:Recognition:Recognition:Recognition:

Implement an optimal STEMI Implement an optimal STEMI Implement an optimal STEMI Implement an optimal STEMI screening process at each “STEMI screening process at each “STEMI portal”portal”portalportal

G l G l E h E h lif i ti t i lif i ti t i Goal: Goal: Each Each qualifying patient receives qualifying patient receives a timely screening ECG!a timely screening ECG!

All portals All portals --fixed or floatingfixed or floatingpp gg

Excuse Me, Sir (Madam)Are You Having a STEMI?

Got STEMI?STEMI?

44 year-old male with a flare-up of his GERD. Wife was at the annual AHA Gala last night and wants him checked outwants him checked out.

58 year-old learning-impaired female with nausea and vomiting for one hournausea and vomiting for one hour.

32 year-old female with pleuritic chest pain. Additional PMH unknown IntoxicatedAdditional PMH unknown. Intoxicated.

“Fred Sanford Syndrome”Fred Sanford Syndrome …

Recognition…Recognition…

Print ItPrint It Post ItPost It Expect ItExpect It Measure ItMeasure It

Look Familiar?Look Familiar?

South Dakota: Work with EMS to South Dakota: Work with EMS to Design a PreDesign a Pre--hospital STEMIhospital STEMIDesign a PreDesign a Pre hospital STEMI hospital STEMI

ALERT ProtocolALERT Protocol

ff Consider EMS a floating “STEMI portal”Consider EMS a floating “STEMI portal” Up to 50% of STEMI patients may use this Up to 50% of STEMI patients may use this

“pre“pre--hospital portal system”hospital portal system”prepre hospital portal systemhospital portal system Simple protocols will address most needsSimple protocols will address most needs More on this laterMore on this later

The 5 R’s: The 5 Essential Elements The 5 R’s: The 5 Essential Elements f STEMI S t O ti i tif STEMI S t O ti i tiof STEMI System Optimizationof STEMI System Optimization

R1R1 RelationshipsRelationshipsR2R2 RecognitionRecognitionR2R2 RecognitionRecognitionR3R3 ReperfusionReperfusionppR4R4 RealReal--time data collectiontime data collectionR5R5 R t & fi tR t & fi tR5R5 Reassessment & refinementReassessment & refinement

ReperfusionReperfusionReperfusionReperfusion

A precision reperfusion plan in place for A precision reperfusion plan in place for A precision reperfusion plan in place for A precision reperfusion plan in place for each STEMI portal each STEMI portal

A “STEMI ALERT Process for every portal”A “STEMI ALERT Process for every portal”--including preincluding pre--hospital portalshospital portals--including inincluding in--house recognitionhouse recognitiongg gg--including interincluding inter--facility transfersfacility transfers

1) Design a STEMI ALERT Plan for 1) Design a STEMI ALERT Plan for Each “Fixed” Portal!Each “Fixed” Portal!

f ll d hf ll d h--carefully customized to each carefully customized to each specific “portal”specific “portal”--instantly accessibleinstantly accessibleyy--simplesimple--incorporates realincorporates real--time data time data collection (more on that later)collection (more on that later)collection (more on that later)collection (more on that later)

GOAL:GOAL:Neutralize the effects of chaos Neutralize the effects of chaos theory, paralysis by analysis and theory, paralysis by analysis and other STEMI system maladies!other STEMI system maladies!other STEMI system maladies!other STEMI system maladies!

B l i t tiBe real in your expectations

Establish realistic goals and t t t t t i b d b th treatment strategies based on both science (the guidelines) AND a

li ti i l f th it ti realistic appraisal of the situation (your experience)

Combine guidelines with experience to design an experience to design an approach to fit your system

Repeat: Set Realistic Goals!Repeat: Set Realistic Goals!

Develop strategies based on the best available science applied to your situation

Have an agreement to change if current practices are not supported by current resultspractices are not supported by current results

Establish realistic “STEMI conduits” based on aEstablish realistic STEMI conduits based on a “Joe STEMI” approach

Thi k B d th B ll !Think Beyond the Balloon!

A small town in North Dakota: 83 ground miles from the nearest PCI centercenter

2005 strategy: transfer for PCI. Optimized air transport time: One Optimized air transport time: One hour

Result: Could not meet ACC/AHA Result: Could not meet ACC/AHA goal of 90 minutes to PCI

2009 St t A h t 2009 Strategy: A change to thrombolytics with a goal of Recognition to Reperfusion (Drano) f f ll d b f

2010: A Much Better Fit!2010: A Much Better Fit!100

80

ctio

n (%

)ct

ion

(%)

EE

A – B — no benefit

Potential outcomes

40

60

lity

Red

uclit

y R

educ

DDE – D — harm

C A – C — benefitB – C — benefit

20Mor

taM

orta

B A

01 3 6 12 24

HoursHours

Extent of salvage (% of area at risk)

Time to treatment is critical HoursHoursTime to treatment is critical Opening the artery is the primary goal (PCI > lysis)

Gersh BJ, et al. Gersh BJ, et al. JAMAJAMA. 2005;293:979.. 2005;293:979.

The 5 R’s: The 5 Essential Elements The 5 R’s: The 5 Essential Elements f STEMI S t O ti i tif STEMI S t O ti i tiof STEMI System Optimizationof STEMI System Optimization

R1R1 RelationshipsRelationshipsR2R2 RecognitionRecognitionR2R2 RecognitionRecognitionR3R3 ReperfusionReperfusionppR4R4 RealReal--time Data Collectiontime Data CollectionR5R5 R t & R fi tR t & R fi tR5R5 Reassessment & RefinementReassessment & Refinement

Boot Camp LessonBoot Camp Lesson

Recognize (and accept) that accurate l ti d t ll ti i ti l t real-time data collection is essential to

monitor improvements and affect hchange.

You can’t improve what you don’t You can t improve what you don t measure!

Y M t M E h STEMI!You Must Measure Each STEMI!Measuring a minimum number of carefully Measuring a minimum number of carefully selected quality improvement parameters on each STEMI ALERT in your system (as it occurs) is absolutely essential for sustainable success and improvement!

The “5 R’s”: Essential ElementsThe “5 R’s”: Essential ElementsThe 5 R s : Essential ElementsThe 5 R s : Essential Elements

RealReal--time Data Collection:time Data Collection:

Data collected during each STEMI Data collected during each STEMI ALERT to continually measure the ALERT to continually measure the ALERT to continually measure the ALERT to continually measure the process process

You can’t improve what you don’t You can’t improve what you don’t measuremeasure

Sample Data Sample Data Date ED Attending:Patient Name ED Resident:

ED Copy (Yellow) Time Study for STEMI Alerts STAYS IN ED

Patient Sticker

Date ED Attending:Patient Name ED Resident:

ED Copy (Yellow) Time Study for STEMI Alerts STAYS IN ED

Patient Sticker

Sheet for STEMISheet for STEMIa e a e es de

Patient MR # CCU Fellow (pic #1309):

ED Nurse: ED Team Manager Phone #: 531-5839Cath Lab: 2-0976 CCU: 4-2582

Time of Onset of CP Symptoms

Time Patient Arrived ED

TIMEINDICATOR

a e a e es de

Patient MR # CCU Fellow (pic #1309):

ED Nurse: ED Team Manager Phone #: 531-5839Cath Lab: 2-0976 CCU: 4-2582

Time of Onset of CP Symptoms

Time Patient Arrived ED

TIMEINDICATOR

Time ECG Read by ED Attending

Time Cath Lab Activated

Time of 1st EKG

If not, Time CCU Fellow Paged

Time ED STEMI Alert InitiatedDid ED Attending Activate Cath Lab? Y N (circle one)

Time ECG Read by ED Attending

Time Cath Lab Activated

Time of 1st EKG

If not, Time CCU Fellow Paged

Time ED STEMI Alert InitiatedDid ED Attending Activate Cath Lab? Y N (circle one) RealReal--time time

datadataCCU Fellow Arrival Time

Attending Arrival Time

Time Cath Lab Team Calls for Patient

Time Patient Left ED

Time CCU Fellow Responds to Page

Time Patient Arrived in Cath Lab Room

CCU Fellow Arrival Time

Attending Arrival Time

Time Cath Lab Team Calls for Patient

Time Patient Left ED

Time CCU Fellow Responds to Page

Time Patient Arrived in Cath Lab Room

datadata SimpleSimple EasyEasy Attending Arrival Time

Lido Time

Access time

Time of 1st wire across lesion

Time of 1st Balloon Inflation

FORM TO STAY IN ED. Place in Mailbox of Barbara Craighead. DO NOT SEND WITH PATIENT.Comments / Suggestions:

Attending Arrival Time

Lido Time

Access time

Time of 1st wire across lesion

Time of 1st Balloon Inflation

FORM TO STAY IN ED. Place in Mailbox of Barbara Craighead. DO NOT SEND WITH PATIENT.Comments / Suggestions:

EasyEasy

Comments / Suggestions:Comments / Suggestions:

Collected in Collected in every STEMIevery STEMI

NOT PART OF THE MEDICAL RECORDNOT PART OF THE MEDICAL RECORD

yy

Inter-facilityfacility

Real-time data in

ti !action!

UPSTARTInter-facility Data

Sheet BSheet B

Re l Time D t t PartnerReal-Time Data at Lynchburg!

PartnerSites

Data: Short Term BenefitsData: Short Term Benefits

Collecting (accurate) data on each STEMI:

Demonstrates changes in the process on a day to day basisday-to-day basis.

Allows for careful, accurate, case-specific Allows for careful, accurate, case specific feedback to individuals.

C t f d f lCreates a sense of urgency and usefulness.

Data: Long Term BenefitsData: Long Term Benefits…

Repeated measurement of your process over time give an accurate process over time give an accurate picture of what is actually happening!

If your best efforts at optimizing your primary treatment strategy, do not primary treatment strategy, do not meet the Guidelines, maybe you shoulder reconsider your primary shoulder reconsider your primary strategy!

“Tier I” vs “Tier II” DataTier I vs Tier II Data

Tier II:Registry-quality d t ll ti

Tier I:Real-time

data collection

“How did we do?”

data collection

“H d i ?” How did we do?“How are we doing?”

A itChart Biopsy

As it occurs

Tier I Data: Real-time InfoTier I Data: Real-time Info

Focused on key system juncture pointspoints

Collected as the process occursDoes not have to be minutely

accurateMinimal data points (12-14) one page

maxmaxReliant on clinical staff for collectionAllows for immediate QI activity

Tier II Data: Registry QualityTier II Data: Registry Quality

A more complete data seti C IE: Action, CDR

Focused on the process and the patient Valuable longitudinal data Usually not transferred patient More time consuming (chart biopsy) Not as helpful for real-time improvement Difficult to complete in “real-time”

Action: Tier II DataAction: Tier II Data A more complete data set A more complete data set Focused on the process Longitudinal data collection Longitudinal data collection More time consuming Not as helpful in Not as helpful inreal-time improvement Difficult to complete Difficult to complete& collect in “real-time”

The 5 R’s: The 5 Essential Elements The 5 R’s: The 5 Essential Elements f STEMI S t O ti i tif STEMI S t O ti i tiof STEMI System Optimizationof STEMI System Optimization

R1R1 RelationshipsRelationshipsR2R2 RecognitionRecognitionR2R2 RecognitionRecognitionR3R3 ReperfusionReperfusionR4R4 RealReal--time data collectiontime data collectionR5R5 Reassessment & RefinementReassessment & RefinementR5R5 Reassessment & RefinementReassessment & Refinement

The “5 R’s”: Essential ElementsThe “5 R’s”: Essential ElementsThe 5 R s : Essential ElementsThe 5 R s : Essential Elements

Reassessment and Refinement:Reassessment and Refinement:Reassessment and Refinement:Reassessment and Refinement:You now have a standardized, You now have a standardized, accessible process that is carefully accessible process that is carefully accessible process that is carefully accessible process that is carefully measured each time it occursmeasured each time it occurs

And, a standardized process + ongoing And, a standardized process + ongoing measurement allows for measurable, measurement allows for measurable, rapid and sustainable rapid and sustainable improvement!improvement!

STEMI Continuum RelationshipsSTEMI Continuum Relationships

Allow for rapid improvementAllow for rapid improvementAllow for rapid improvementAllow for rapid improvementand sustained resultsand sustained results

Recognition!

Relationships

If periodically maintainedIf periodically maintainedIf periodically maintainedIf periodically maintained

Reperfusion!

Review: The 5 Essential Elements Review: The 5 Essential Elements f STEMI S t O ti i tif STEMI S t O ti i tiof STEMI System Optimizationof STEMI System Optimization

R1R1 RelationshipsRelationshipsR2R2 RecognitionRecognitionR3R3 ReperfusionReperfusionR4R4 RealReal--time Data Collectiontime Data Collection

ffR5R5 Reassessment & RefinementReassessment & Refinement

R1R1 R l ti hi ( i )R l ti hi ( i )…R1…R1 Relationships (again)Relationships (again)

Let’s Have Some Fun with This!Let’s Have Some Fun with This!Let s Have Some Fun with This!Let s Have Some Fun with This!

Consider “Relationships” Consider “Relationships” –– the most the most Consider Relationships Consider Relationships the most the most important Essential Element…important Essential Element…

Do some of the following questions Do some of the following questions look familiar?look familiar?look familiar?look familiar?

Questions That Drive Questions That Drive R l ti hi D l tR l ti hi D l tRelationship DevelopmentRelationship Development

Is your hospital a part of a formal regional Is your hospital a part of a formal regional Is your hospital a part of a formal regional Is your hospital a part of a formal regional STEMI system?STEMI system?

Do regularly scheduled meetings occur Do regularly scheduled meetings occur Do regularly scheduled meetings occur Do regularly scheduled meetings occur involving EMS providers and reps from all involving EMS providers and reps from all facilities within your regional STEMI facilities within your regional STEMI y gy gsystem?system?

Can you name your partner facilities?Can you name your partner facilities?y y py y pDoes your hospital have a contact person Does your hospital have a contact person within each of these facilities?within each of these facilities?

Relationships….Relationships….

Do you have mechanisms (such as an EMS STEMI Do you have mechanisms (such as an EMS STEMI St B d) t t tl l t EMS k b t St B d) t t tl l t EMS k b t Story Board) to constantly let EMS know about Story Board) to constantly let EMS know about cases gone right?cases gone right?

Do you involve patient advocates (STEMI Do you involve patient advocates (STEMI Do you involve patient advocates (STEMI Do you involve patient advocates (STEMI survivors) to help improve your STEMI system?survivors) to help improve your STEMI system?

Do you provide regular written feedback to EMS Do you provide regular written feedback to EMS id i hi ?id i hi ?providers within your system?providers within your system?

Does your system have a formalized method of Does your system have a formalized method of providing caseproviding case--specific feedback to providers of the specific feedback to providers of the providing caseproviding case specific feedback to providers of the specific feedback to providers of the entireentire STEMI care continuum? STEMI care continuum?

Relationships….Relationships….Do you feel comfortable contacting Do you feel comfortable contacting each facility to discuss STEMI issues each facility to discuss STEMI issues yyand/or individual cases?and/or individual cases?

Do you know the names of the EMS and Do you know the names of the EMS and transport provider organizations within transport provider organizations within transport provider organizations within transport provider organizations within your area?your area?

Do you invite EMS personnel to your Do you invite EMS personnel to your AMI quality improvement meetings?AMI quality improvement meetings?

Relationships at All Levels!Relationships at All Levels!

STEMI AMI meetingsSTEMI AMI meetingsEMS STEMI Story BoardEMS STEMI Story BoardPrompt data feedbackPrompt data feedbackppEMS personnel visiting the Cath LabEMS personnel visiting the Cath LabCardiologists on EMS rideCardiologists on EMS ride alongsalongsCardiologists on EMS rideCardiologists on EMS ride--alongsalongsCardiologists to ED physician Cardiologists to ED physician “ t d t ”“ t d t ”“customer updates”“customer updates”First Contact Provider EducationFirst Contact Provider Education

Relationships At All Levels!Relationships At All Levels!Relationships… At All Levels!Relationships… At All Levels!

STEMI AMI meetingsSTEMI AMI meetings STEMI AMI meetingsSTEMI AMI meetings EMS STEMI Story BoardEMS STEMI Story Board Prompt data feedbackPrompt data feedback Prompt data feedbackPrompt data feedback EMS personnel visiting the cath labEMS personnel visiting the cath lab Cardiologists on EMS rideCardiologists on EMS ride alongsalongs Cardiologists on EMS rideCardiologists on EMS ride--alongsalongs Cardiologists to ED physician phone callsCardiologists to ED physician phone calls Cold beverages in a restaurantCold beverages in a restaurant Cold beverages in a restaurant…….Cold beverages in a restaurant…….

Another Example: RecognitionAnother Example: RecognitionAnother Example: RecognitionAnother Example: Recognition

Quiz Question: As far as any Quiz Question: As far as any Quiz Question: As far as any Quiz Question: As far as any potential STEMI patient is potential STEMI patient is

d h i thd h i th t t concerned, who is theconcerned, who is the most most important personimportant person in your STEMI in your STEMI

Care Continuum?Care Continuum?

!Wh D Th t Fi t ECG!!Wh D Th t Fi t ECG!!Whoever Does That First ECG!!Whoever Does That First ECG!

Would Your Institution MISS This?Would Your Institution MISS This?Would Your Institution MISS This?Would Your Institution MISS This?

Maybe... Who Wins the ECG Maybe... Who Wins the ECG Race Friday at 3am?Race Friday at 3am?

STEMI?

STEMI?? STEMI???

Recognition: How is Recognition: How is YourYour Hospital Doing? Hospital Doing? T k Thi Sh t Q i Pl !T k Thi Sh t Q i Pl !Take This Short Quiz, Please!Take This Short Quiz, Please!

1)1) Do you have a written “Screening ECG Protocol” Do you have a written “Screening ECG Protocol” y gy gat your institution?at your institution?

2)2) Is it visibly posted in your ED & triage Is it visibly posted in your ED & triage 3)3) Do ED and triage staff follow it 24/7?Do ED and triage staff follow it 24/7?3)3) Do ED and triage staff follow it 24/7?Do ED and triage staff follow it 24/7?4)4) Have you trained your staff regarding their key Have you trained your staff regarding their key

role in the screening ECG?role in the screening ECG?5)5) Do you have multiple backup pathways in place Do you have multiple backup pathways in place

to ensure that the screening ECG gets done to ensure that the screening ECG gets done during busy times?during busy times?g yg y

6)6) Is each ECG immediately shown to a physician?Is each ECG immediately shown to a physician?

How Did You Do?How Did You Do?How Did You Do?How Did You Do?

Unless you answered “yes” to all Unless you answered “yes” to all Unless you answered yes to all Unless you answered yes to all questions, your institution is at risk of questions, your institution is at risk of overlooking the previous ECG If not overlooking the previous ECG If not overlooking the previous ECG. If not overlooking the previous ECG. If not today, then next Friday.today, then next Friday.

Solution:Solution: Work on optimizing Work on optimizing Recognition until you can answer yes Recognition until you can answer yes Recognition until you can answer yes Recognition until you can answer yes to all six questions to all six questions --24/7 24/7

The Project UPSTARTThe Project UPSTART“Screening ECG Protocol”

…..Easily utilized at STEMI portals at STEMI portals Everywhere!

Combine with processoptimization to pensure RecognitionSuccess!

How about Pre-hospital Recognition?

Recognition (PreRecognition (Pre--hospital)hospital)Recognition (PreRecognition (Pre hospital)hospital)11) ) Yes/NoYes/No Do your EMS providers utilize preDo your EMS providers utilize pre--hospital ECGhospital ECG

id if STEMI id if STEMIto identify a STEMIto identify a STEMI22) What percent of your EMS providers are trained to ) What percent of your EMS providers are trained to

obtain a 12 Lead ECG? obtain a 12 Lead ECG? 3)3) What percent of your EMS vehicles are ECGWhat percent of your EMS vehicles are ECG capable? capable? 3)3) What percent of your EMS vehicles are ECGWhat percent of your EMS vehicles are ECG--capable? capable?

4)4) How is the activation of “STEMI Alert” usually made onHow is the activation of “STEMI Alert” usually made onprepre--hospital ECG’s done within your system? hospital ECG’s done within your system? prepre hospital ECG s done within your system? hospital ECG s done within your system?

Yes/NoYes/No ECG interpretation is done by EMS personnel ?ECG interpretation is done by EMS personnel ?Yes/NoYes/No Determination of STEMI primarily based on Determination of STEMI primarily based on

machine algorithm interpretation?machine algorithm interpretation?g pg pYes/NoYes/No ECG transmitted for physician overECG transmitted for physician over--read?read?

5)5)Yes/NoYes/No Do preDo pre--hospital providers immediately contacthospital providers immediately contactan ED physician once they obtain an ECGan ED physician once they obtain an ECGsuspicious for STEMI?suspicious for STEMI?

Reperfusion: A Reperfusion Plan at Reperfusion: A Reperfusion Plan at E STEMI P lE STEMI P lEvery STEMI PortalEvery STEMI Portal

Each time a STEMI is recognized (either preEach time a STEMI is recognized (either pre-- Each time a STEMI is recognized (either preEach time a STEMI is recognized (either prehospital or inhospital or in--hospital) a carefully developed plan hospital) a carefully developed plan specific to that site should be reflexively specific to that site should be reflexively triggered. It should be simple, precise, written triggered. It should be simple, precise, written triggered. It should be simple, precise, written triggered. It should be simple, precise, written down and instantly accessible.down and instantly accessible.

N k t i ll dN k t i ll d No rocket science allowedNo rocket science allowed

Example: Open a STEMI ALERT Example: Open a STEMI ALERT Packet for every STEMI Packet for every STEMI

A trigger for reperfusionA trigger for reperfusion

“Got STEMI =Open Packet!”“Got STEMI =Open Packet!”

Education meets conditioningEducation meets conditioning

Fully teachable to all ED staff Fully teachable to all ED staff and (most) ED physicians!and (most) ED physicians!

Real time Data CollectionReal time Data Collection…

Mandatory for Mandatory for optimization!

Hint: Hardwire it into your basic ySTEMI ALERT Process and minimize your workload…

Reassessment and RefinementReassessment and Refinement…Hold a meeting

Have people show up

Present Data

Act on the DataAct on the Data

Hint: Publicize your successes loudly and successes loudly and correct your failures quietly!

The 5 R’s: A ReviewThe 5 R’s: A ReviewThe 5 R s: A ReviewThe 5 R s: A ReviewR1 Relationships:R1 Relationships: Working within the Working within the pp gg

STEMI care continuumSTEMI care continuum R2 Recognition:R2 Recognition: Fine tune the Recognition Fine tune the Recognition

processprocessprocessprocess R3 Reperfusion:R3 Reperfusion: A STEMI ALERT Process A STEMI ALERT Process

at every portalat every portal R4 RealR4 Real--time Data Collection:time Data Collection: RealReal--time time

measurement of each STEMImeasurement of each STEMI R5 Readjustment and Refinement:R5 Readjustment and Refinement: OnOn R5 Readjustment and Refinement:R5 Readjustment and Refinement: OnOn--

going process adjustment based on going process adjustment based on accurate dataaccurate data

You Have Now Come Full CircleYou Have Now Come Full CircleYou Have Now Come Full CircleYou Have Now Come Full Circle

Optimizing the 5 Essential Elements Optimizing the 5 Essential Elements Optimizing the 5 Essential Elements Optimizing the 5 Essential Elements will allow you to quickly improve care will allow you to quickly improve care in your entire local STEMI System of in your entire local STEMI System of in your entire local STEMI System of in your entire local STEMI System of CareCare

The system you create will maintain The system you create will maintain The system you create will maintain The system you create will maintain a standardized process and ongoing a standardized process and ongoing data collection allowing you to data collection allowing you to data collection, allowing you to data collection, allowing you to efficiently maintain your process.efficiently maintain your process.

The 5 R’s Made Easy (Easier)The 5 R’s Made Easy (Easier)The 5 R s Made Easy (Easier)….The 5 R s Made Easy (Easier)….

www projectupstart comwww projectupstart comwww.projectupstart.comwww.projectupstart.com

A noA no--cost quality improvement tool cost quality improvement tool developed to efficiently improve developed to efficiently improve

locallocal--level STEMI care via level STEMI care via optimization of the five Essential optimization of the five Essential

Elements of ReperfusionElements of Reperfusion

www.projectupstart.comwww.projectupstart.com

All Questions Accepted!All Questions Accepted!All Questions Accepted!All Questions Accepted!David R. Burt, MDAssistant ProfessorDepartment of Emergency Medicine University of Virginia Health SystemUniversity of Virginia Health Systemdavidrburt@virginia.eduOffice: 434.924.2428Office: 434.924.2428