STEMI Care DeliveryReport Out

Lean Defined

A Process Management Philosophy centered around creating more value with less work by driving out waste so that all work adds some form of value while serving the needs of our

patients

STEMI Lean Team

Project SponsorsDr. John Seccombe, Physician SponsorPaula Hafeman, Leadership Sponsor

Physician SupportDr. Kenneth Johnson, Emergency DeptDr. Zhaowei Ai, Heart and Vascular

Department SupportJennifer Gerdmann, Emergency DeptJim Callender, Cath Lab Dan Doran, Cath Lab Brad Lepinski, Heart and Vascular

James Pelch, Project LeaderLeigh Messmann, Project Manager /FacilitatorLaNaeh Wallander, Project Coordinator

Definitions

• Door to Balloon (D2B)– the amount of time between a heart attack patient’s arrival at the hospital to the time he/she receives PCI

• PCI (percutaneous coronary intervention) – family of medical procedures that uses mechanical means to treat patients with partially restricted blood flow through the artery of the heart.

• Reperfusion Therapy – techniques to restore blood flow to part of the heart muscle

• STEMI (ST segment elevation myocardial infarction) – a severe heart attack caused by a prolonged period of blocked blood supply causing heart cells to die

• LBBB (left bundle branch block) - a cardiac conduction abnormality; activation of the left ventricle is delayed, which results in the left ventricle contracting later than the right ventricle

Background• Door-to-Balloon is a time measurement in

emergency cardiac care, specifically in the treatment of STEMI– Delays in treating a myocardial infarction increase the

likelihood and amount of cardiac muscle damage

• ACC and the AHA recommend a D2B interval of no more than 90 minutes– Nov 2006: ACC launches Door to Balloon (D2B)

Initiative– May 2007: AHA launches ‘Mission: Lifeline’ Initiative

• Currently fewer than 50% of STEMI patients receive reperfusion with primary PCI within the recommended timeframe

Problem Definition and Goal Setting

• We typically recognize problems based on perception• What we see happening (The Point of

Recognition)

• Our job function causes us to determine “problems” based on our responsibility

• We often become confused between the true problem, symptoms of the problem, and causes of the problem

Project Objective

• Apply proven strategies to improve door to balloon times and improve clinical outcomes for STEMI patients

– Scope narrowed to first EKG to Cath Lab door ED and pre-hospital EKG 95% patients </= 50 minutes 75% patients </= 30 minutes

ED EKG

Hands EKG to Physician

LBBB identified

No acute STEMI / other

treatment needed

EMS EKGSTEMI

identified

Current Stream Map: STEMI and LBBB

Initiate standard order set Transport patient

from ED to Cath LabActivate

Cardiologist to Cath Lab

Continue patient work

up

LBBB identified

Activate Cath Lab

staffSTEMI identified

Old / New / Indeterminate

YES

NO

Patient arrives at

hosp and is registered

Hosp quick Reg patient

Room patient in ED

Physician present: Yes/No

Tech reads computer

impression

Has Charge Nurse locate

physician

Obtain old EKG from

HUC New

Old

EKG filed

Call and speak with Cardiologist

0-40 min

Indeterminate

Cath Lab Ready to

accept patient:Yes / No

Cardiologist comes to see

patient:Yes / No

No

Yes (1)

Yes

Yes

No

Initiate standard order set

1

1

ED-EKG(Time Stamp)

EKG printed and ready for Physician by

HUC

Tech hands EKG to

Physician

New LBBB identified

No acute STEMI / other treatment

needed

EMS-EKG

STEMI identified

Activate Cardiologist to

Cath Lab

Future Stream Map: STEMI and LBBB

Initiate standard order

set

Cath Lab ready to accept patient

Transport patient from ED to Cath

LabActivate

Cardiologist to Cath Lab

Activate Cath Lab staff

Cath Lab ready:

Yes / No

YES

NO

Place patient in ED Room

Quick Reg patient

LBBB identified

Activate Cath Lab staff

Old LBBB identified

LBBB identified –

indeterminate age

STEMI identified

Cardiac symptoms present:Yes/No

YES

NO

STEMI A3

Sharing Information and Telling the Story

Key Strategies

1. Systems for activating Cath Lab and Cardiologist

2. Protocols for handoff from ED to Cath Lab

3. Aggressive approach when presented with LBBB of indeterminate age

4. Protocols to allow activation based on pre-hospital ECG

Cath Lab / Cardiologist Activation

• One number assigned for urgent caths Utilized by on call Prevea Cardiologists

• Mandatory response time Second contact made if no response

within 3 minutes If no reply after 5 minutes, next

provider group will be contacted

Hand Off Protocols

• Immediate transfer to Cath Lab once they are prepared to accept patient

• ED Standard Order Set updated to include only those of critical importance to patient care Lab/Imaging should be performed as part of

the management of STEMI patientsHowever, they should not delay implementation of reperfusion therapy

– Work up to cease once Cath Lab ready– Imaging may be necessary if potential

contraindication is suspected, such as aortic dissection

Left Bundle Branch Blocks

• Implement more aggressive treatment protocols for LBBBs of indeterminate age– When coupled with cardiac symptoms, Cath

Lab/Cardiologist activation will occur

• Synergistic Relationship between ED Physicians and Cardiologists– Requires unhesitating decisions from ED

physicians – Unreserved approval and cooperation from

Cardiologists

Activation Based on Pre-Hospital EKG

• Pre Hospital 12 lead EKGs will result in immediate Cardiologist / Cath Lab activation– Patient will be transferred directly to cath lab

if ready upon arrival– Patient will need to stop in ED in event Cath

Lab/Cardiologist not present/ready• lab/imaging will be performed as part of the

management of patient care until Cardiologist/Cath Lab ready

90 Minutes is Arbitrary

• Need to move beyond the 90 minute controversy

– Focus on consistency and speed– Time is muscle– Foster organizational commitment– Long term, continuous improvement

Increasing Loss of Myocytes

Increasing Loss of Myocytes

Symptom

RecognitionCall to Medical

System

Emergency

Dept

Pre-Hospital

Cath Lab

Delays in Initiation of Reperfusion Therapy

Ongoing Initiatives:• Patient education /media campaign• Greater use of 911 / pre-hospital Tx• Improve Door to EKG times• Examine Cath Lab protocols for possible

improvements• Incorporate systemic cooling methods

Questions?