Time is Myocardium

Myocardium can recover if artery is opened early.

Our goal: To provide state of the art diagnosis, transfer, and treatment options to get the patient from the initial presentation in the field, clinic settings or walk-in to the MSCH ED (First Medical Contact) to having an open artery in the cath lab in ideally 90 minutes or less.

Quality Awards - Quality Awards - AHA Mission: Lifeline AHA Mission: Lifeline RecognitionRecognition

• Bronze (Receiving) Bronze (Receiving) 1 calendar quarter/90 consecutive days1 calendar quarter/90 consecutive days

• Silver (Receiving) Silver (Receiving) 4 calendar quarters/12 consecutive months4 calendar quarters/12 consecutive months

• Gold (Receiving) Gold (Receiving) 8 consecutive quarters/24+ consecutive 8 consecutive quarters/24+ consecutive

monthsmonths

Mission: Lifeline Recognition Measures

4

Achievement Measures STEMI- Receiving Center

Percentage of STEMI patients with a door-to-balloon (first device used) within 90 minutes, non-transfer

Percentage of STEMI patients with first medical contact to balloon inflation (first device used) within 90 minutes, non-transfer

Percentage of reperfusion –eligible patients receiving any reperfusion (PCI or fibrinolysis) therapy)

Percentage of STEMI patients receiving aspirin within 24 hours

Percentage of STEMI patients on aspirin at discharge

Percentage of STEMI patients on Beta Blocker at discharge

Percentage of STEMI patients with LDL>100 who receive statins or lipid lowering drugs

Percentage of STEMI patients with LVSD on ACEI/ARB at discharge

Percentage of STEMI patients that smoke with smoking cessation counseling at discharge   

Mission: Lifeline is a national, community-based initiative designed to meet the needs of the STEMI patient throughout the continuum of care, beginning with the patient’s entry

into the system (from symptom onset) through each component of the system, and return to the local community and physician for rehabilitative care.

Barriers to Meeting First Medical Contact

• EMS/Clinic: Atypical ACS symptoms with subtle EKG changes

• Delay during intercept with stable patient near PCI center – consider if intercept is necessary

• Mandates to closest hospital regardless of PCI capability• Long EMS transports from many rural areas• EMS transport availability/delays due to weather• Clinic: Unfamiliar with STEMI process• Lack of awareness of lapsed time and impact on

outcomes

Meeting FMC to Device Times

• Standardization (protocol)

• Consistency

• Education

• Feedback

• Celebrate!

Rescue One Background

Standardization/Consistency• Protocol created to promote consistency for

STEMI patient care based on ACC guidelines

• Initiated in Ministry Health Care at St. Joseph’s Hospital in Marshfield in 2006

• Established at Ministry St. Clare’s in 2007• Rescue 1 is for STEMI and complete heart block

patients

• One call for your transport and specialist consultation needs for transport and admission

• Connect will dispatch the closest appropriate vehicle for the critically ill or injured

• Connect records all phone calls

• Connect will coordinate medical transportation regardless of originating location or destination

• Connect will dispatch the ambulance or helicopter prior to receiving an accepting physician to speed patient movement

• Connect with activate Rescue One group page

Rescue 1 Page

ER Team

CCU Team

Cath Lab Team

Telecom courtesy notification to CV Surg/Pastoral Care/Security

Lab Admitting notified

Ministry Connect

888- 411-1DOC(1362)

Transport Arrangements

Interventional Cardiologist Called

Spirit EMS Transport Helicopter

•Mobile Intensive Care Unit

•Critical care nurse

•Critical care paramedic

•ICU monitoring for adults/pediatrics and neonates

•Invasive and noninvasive monitoring

•Advanced intervention

Path of Least Resistance…

• Processes need to be efficient• Processes need to be consistently followed• Make it easy:

♥ Algorithms

♥ Stickers with phone number for phones

♥ One phone number to call

♥ Build relationships by engagement

Meeting FMC to Device Times

• Entire STEMI team participates STEMI processes and outcomes• Team includes EMDS, EMS, ED MD’s & staff, Cardiologists, Cath

Lab, Heart Registry Manager, Management & Administration, etc.• Implement and continuing education of STEMI protocols• Educate STEMI Goals for best outcomes• Audit STEMI data for potential process improvement opportunities• Review data with STEMI teams-provide education & kudos• Provide timely STEMI feedback of process and outcomes to

provider and EMS involved• EMS 12 lead transmission capability• EMS Triage and Destination protocols• EMS personnel educated on 12 lead interpretation-communicate

results to Receiving Center• Regular multi-disciplinary meetings to review outcomes and quality

improvement data

Meeting Clinic FMC to Device Times

Challenges with FMC in clinic settings:• Lack of Recognition of EHAC signs & symptoms • Delay from check-in to FMC• Low volume situation – need consistent, annual EHAC/STEMI

education• Lack of understanding of how to initiate an urgent STEMI response• Subtle 12-Lead EKG’s can be missed• Delay with ordering additional testing

Meeting Clinic FMC to Device Times

Process Improvements• Annual education to Clinic Providers & Staff on EHAC, especially

atypical signs & symptoms• Work with clinics on identification of key words to initiate a triage

process at the check-in desk• Provide annual EHAC/STEMI education to clinic personnel with

review of guidelines• Create algorithms for the clinic to respond to STEMI-Educate• Algorithms for onsite clinics vs offsite clinics• Integrate time-savers into the algorithms:

-Subtle12-Lead EKG’s – phone # to call for assistance with interp.

-Reduce what clinic needs to do on protocol, keep it simple• Provide laminated copies of algorithms for posting in each dept.

On-site Clinic to ED/Cath Lab

Onset of STEMI

symptoms at clinic/other

Call “911” to SCH operator

Request “First “First ResponderResponder

For Acute MI”For Acute MI”

If unstable, call “Code Blue”

Clinic Provider--Call ED MD at 1-2970 to inform of STEMI/other

(ED will call Rescue One)

ED to initiate Rescue 1 Page

Patient to ED with First Responders

Cath Lab will meet patient in ED and go direct to cath lab, if appropriate.

Cardiologist will call Clinic Provider

To Cath Lab

Off-site Clinic to ED/Cath Lab

Onset of STEMI

symptoms at

clinic/other

Clinic Provider – Call Ministry Connect (888)411- 1362

Request: “Rescue One to SCH”

Ministry Connect Initiates Rescue One

Clinic Provider to Call “911” for local EMS – transport arranged **Need to state patient is accepted at SCH**

Cardiologist notified. Cardiologist will call clinic provider. Patient arrives to ED.

Decision to stop in ED or direct to Cath Lab, as appropriate

Saint Clare’s ED or direct to Cath Lab

Meeting FMC to Device Times – EMDS/EMS

Education

EMDS and EMSEMDS Goal: • Dispatch EMS = 1 minute

EMS Goals: • EMS 12 lead transmission capability• EMS personnel educated on 12 lead interpretation communicate results to Receiving Center/Activate Rescue One

• EMS patient arrival to EKG goal ≤ 10 minutes • Field/Clinic FMC to ED Door goal ≤ 30 minutes• Field w/Cardiac Arrest goal return of circulation to nearest hospital

including transport time < 45 minutes

Meeting FMC to Device Times – EMDS/EMS

EMDS/EMS Process Improvements• Implement & Educate consistent protocols• 24/7 Immediate acceptance of STEMI patients

♥ One phone call to ED physician-ED activates Rescue One

♥ Stop in ED (FMC) or direct to Cath Lab (hospital transfers)

♥ Pre-hospital expectations (i.e. ASA)

♥ Paperwork needed (i.e. EKG, etc.)• Provide education on guidelines for best outcomes, protocol,

their data, STEMI patient care, time-savers, etc.

STEMI Process Improvement Metrics

• Chest Pain to 911 Call

• 911 Call to 1st EKG

• 911 to Reperfusion

• First Medical Contact to 1st 12-lead EKG

• First Medical Contact to Cath Lab Activation

• First Medical Contact to Reperfusion

• Percent of 12-lead EKG’s transmitted by EMS

• EMS STEMI’s identified in the field

• Cath Lab Notification to Arrival

• Cardiologist Notified to Arrival

• 1st 12-lead EKG to Patient Arrival to Cath Lab

• D2D (per GWTG) < 90 minutes

Meeting FMC to Device Times – EMDS/EMS

North-central WI Regional EMS Time-Savers:

• EMDS, once educated on goals, have reduced 911 call to dispatch EMS from average 5 minutes reduced to 1-2 minutes

• EMDS education on Early Heart Attack Care (EHAC)• EMS, once educated on goals, have reduced field FMC “at patient” to EKG from

average 18 minutes (2010), reduced to average 10 minutes• Increased EMS ability to transmit 12-Lead EKG to ED through LifeNet system• Education for EMS on 12-Lead EKG interpretation (in progress)• Ability of EMS to recommend activation of Rescue One pre-hospital arrival• Evaluate whether intercept close to PCI center is needed or will cause

unnecessary delay• Pre-hospital activation of Rescue One • Most EMS are stocking RTS Defib pads (work in progress)• EMS starts second IV, if possible• EMS assists ED staff with preparation for cath lab procedure

Meeting FMC to Device Times – MSCH ED

• Consistency is Key!• Communication between EMS & ED• Rescue One STEMI process consistent• 24/7 Acceptance – no diversions for STEMI• Field/Clinic to ED – always stop in ED• ED door in-door out (DIDO): Goal ≤ 30 minutes• ED early Activation of Rescue One• Immediate Interventional Cardiologist/Cath Lab Team

response. Call back within 1-5 minutes.

Meeting FMC to Device Times – MSCH ED

Communication between physicians• ED Physicians and Cardiologists must communicated and agree on

the protocols• ED physician carries a designated phone for immediate access• Cultivate relationships:

- Engage referring physicians/EMS in processes

- ED MD’s & Cardiologists respecting referring physicians decisions and evaluation

- Educate STEMI providers on guidelines for best patient outcomes

- Create an environment of transparency to be able to discuss issues and strive for process improvements

Meeting FMC to Device Times – MSCH ED

• Consistency is absolutely essential to meet FMC to Device Times– One Process for all Rescue Ones– One Medical Protocol– ED Physician is information conduit

• Teamwork is essential to minimize times• Feedback always positive or constructive in

nature

Meeting FMC to Device Times – MSCH ED

• Consistency– Cath Lab activation process the same regardless of

location of origin of patient• Allows for process familiarity for relatively small number of

STEMI patients presenting primarily to our ED; significantly large number of transferred STEMI patients

– Rescue One Treatment Protocol the same for all patients regardless of location of origin or cardiologist on duty

Meeting FMC to Device Times – MSCH ED

• Consistency– Rescue One protocol is a standard protocol agreed

upon by all interventional cardiologist in system• Every cardiologist may not completely agree to every aspect

of protocol, every cardiologist is accepting of the protocol• Protocol similar to protocol of other PCI center’s protocol

– Reduces confusion in ED– Reduces need to contact cardiologist prior to initiating

therapies– Reduces impression of negative feedback

Meeting FMC to Device Times – MSCH ED

• Consistency– Transfer Rescue One calls involve ED Physician as

accepting physician• Familiar with process

– Rescue One process initiated by ED physicians not cardiologists

– Once Rescue One activated process moves forward until at least cardiologist has examined the patient

Meeting FMC to Device Times – MSCH ED

• Consistency– EMS contacts ED with patient care report and ED

physician initiated Rescue One process• Reduces burdens on EMS providers

– Do not have to remember different protocols for different hospitals

– Improved data interpretation/filtering: ED knows EMS providers

– In conjunction with transmitted EKG allows for improved accuracy of cath lab activation

– Shifts false positive activation “blame” to ED physician

Meeting FMC to Device Times – MSCH ED

• Pre-Hospital EKG’s– Encourage services of all levels to obtain and if

possible transmit EKG’s• EMT-Basic/Advanced EMT can obtain but cannot interpret

12-lead EKGs

– Encourage early radio reports for potential STEMI regardless of EKG findings

– Focus on symptomatic ***ACUTE MI*** EKGs for pre-hospital cath lab activation

– Focus on “Did the patient need a emergent/urgent cath based on clinical picture?” versus “Was a culprit lesion found?”

Meeting FMC to Device Times – MSCH ED

• Pre-Hospital EKG’s– Pre-hospital CCL activation significantly reduced D +

B time• 73 ± 19 minutes field STEMI• 130 ± 66 minutes non-field STEMI• 141 ± 49 minutes historical STEMI

– Significant reductions in door-to-CCL and CCL-to-balloon times as well

– Jason P. Brown, Ehtisham Mahmud, James V. Dunford, Ori Ben-Yehuda, Effect of Prehospital 12-Lead Electrocardiogram on Activation of the Cardiac Catheterization Laboratory and Door-to-Balloon Time in ST-Segment Elevation Acute Myocardial Infarction, The American Journal of Cardiology, Volume 101, Issue 2, 15 January 2008, Pages 158-161, ISSN 0002-9149, http://dx.doi.org/10.1016/j.amjcard.2007.07.082. (http://www.sciencedirect.com/science/article/pii/S0002914907018735)

Meeting FMC to Device Times – MSCH ED

• Examination CCL activation at 14 primary angioplasty hospitals to determine rate of inappropriate activation. – 3973 activations (29% by EMS, 71% by emergency

physicians) over 1 year– Appropriate CCL activations occurred for 3377

patients (85%)• 2598 patients (76.9% of appropriate activations) receiving

PPCI

Meeting FMC to Device Times – MSCH ED

• Reasons for inappropriate activations • ECG reinterpretations (427 patients; 15%)• Patient was not a CCL candidate (169 patients;

28%)• Rate of cancellation because of reinterpretation of

EMS ECG: 6% of all activations• Rate of cancellation because of reinterpretation of

emergency physicians' ECG:4.6%• Rates of Cardiac Catheterization Cancelation for ST Elevation Myocardial Infarction after Activation by Emergency

Medical Services or Emergency Physicians: Results from the North Carolina Catheterization Laboratory Activation Registry (CLAR) J. Lee Garvey, Lisa Monk, Christopher B. Granger, Jonathan R. Studnek, Mayme Lou Roettig, Claire C. Corbett, and James G. Jollis; Circulation. 2011;CIRCULATIONAHA.110.007039published online before print December 6 2011, doi:10.1161/CIRCULATIONAHA.110.007039

Meeting FMC to Device Times – MSCH ED

• Teamwork– Interventional Cardiologist sees every Rescue One

patient upon or soon after arrival• Questionable cases are discussed between cardiologist and

ED physician

– Cath Lab team comes to ED when cath lab is ready for patient and escorts patient to cath lab

– Shared task completion among nurses and shared decision making among physicians

Meeting FMC to Device Times – MSCH ED

• Feedback– Interventional cardiologist calls ED physician with

results of catheterization• Feedback is always positive or constructive in nature• Absence of negative feedback reduces reluctancy to activate

cath lab for marginal cases

– Program sends feedback on times and outcomes to ED Manager and other key staff

• Feedback is forwarded to EMS services by EMS Medical Director

Adjusted Associations between Hospital

Strategies and Door-to-Balloon Times.

Bradley EH et al. N Engl J Med 2006;355:2308-2320.

Meeting FMC to Device Times – Cardiologist/Cath Lab Team

• Consistent expectations and process 24/7• Interventional Cardiologist & Cath Lab Team arrival from

initial page ≤ 30 minutes• Interventional Cardiologist immediately involved• Cath Lab team members to ED stat to assume care of

patient and continue remaining protocol-ED immediately turns over care to cath lab team

• Plan for simultaneous Rescue One (after hours)• If there is a question on proceeding with procedure,

evaluate in the cath lab and make determination there• Acceptance of false Rescue One activation-misdiagnosis

Meeting FMC to Device Times – Cardiologist/Cath Lab Team

• Rescue One Group Page – one page activates entire team

• Call back to switchboard 1-5 minutes• FMC – RN & Tech report direct to ED• Scrub (1st Assist) readies sterile field in lab• ED starts R1 prep, CL team assumes care upon

arrival where pt. taken immediately to cath lab• Cath Lab door to device: Goal ≤ 30 minutes

Patient Feedback Process

• Cath lab diagram• Post-cath call back to ED

MD and/or referring MD• Next day process

review/call ER• Follow-up of event by

email to clinical staff involved in event

• Periodic data review specific for group (i.e staff/provider meetings)

Celebrate STEMI team achievements!

First Medical Contact & EMS First Medical Contact & EMS Engagement TechniquesEngagement Techniques

Questions?