Www.projectupstart.com An Introduction. Project UPSTART The Use of Procedural Standardization to...

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An Introduction


Project UPSTART

The Use of Procedural Standardization to Reduce “Recognition to Reperfusion” (R2R)

Time in STEMI

“Excellence in R2R”


A Framework for Improvement

Project UPSTART is an unique quality improvement program that lets you quickly and easily improve the care of your patients suffering from STEMI.

A toolbox for building systems of care for STEMI

Avoid reinventing the wheel!


A Tool Kit for STEMI Systems…

Provides forms, protocols, templates provider education and other necessary “components”

Designed to improve locals systems of careFacilitates inter-facility collaboration and data

sharingCompliant with the concepts and principles

endorsed within the American Heart Associate and its Mission: Lifeline Initiative


Mission: Lifeline(The Big Picture)

5


…Think of Project UPSTART as a

Mission: Lifeline-compliant “Recognition to Reperfusion”

Toolbox!


Optimizes Recognition and Reperfusion

All attempts at reducing STEMItreatment times must ultimatelyfocus on improving one (or both) of these endpoints.

The goal: early recognition followed by early reperfusion.“


Example #1

Large Community PCI hospital

Multiple cardiology groups, etc

Current reperfusion mean (door to PCI)

+/_ 52 Minutes

(stable over last three years)


Example #2

A Large University PCI Center

UPSTART go-live: 9.11.06

Reperfusion (DTB) times declined from 83 minutes to 58 minutes within one month of implementation


Quiz: Have These Issues Occurred in Your STEMI system?

A veteran nurse working triage neglects to obtain an ECG on an “atypical” STEMI patient?

Your temporary ED physician forgets to immediately call EMS, delaying inter-facility transport?

A thrombolytic checklist was not instantly available when needed to assess a patient?

A STEMI patient was sent to the PCI lab without an IV?

Important STEMI QI data has not been routinely available for quality improvement analysis?


History Repeats…Unless you Learn from Previous Mistakes!

Project UPSTART incorporates many best practice concepts directly into a simple, repeatable approach to STEMI care that is based on just 4 key actions:

Error-proof your providers by error-proofing the system!


STEMI System Theory: A Review

To efficiently improve your local STEMI system:

First, you must first define who your local STEMI system actually involves and its physical boundaries…..

Next, you must define what processes are most important within that system

Finally, you must fix what needs fixing!


Luckily we can help you!

The next few slide discuss important concepts in helping you define your local Elemental STEMI Subsystem (ESS) system and outlining the Essential Elements of Reperfusion that must be the focus of your improvement efforts.

This has all been done before, by someone!


Key Concept: The “Elemental STEMI Subsystem” (ESS)

The smallest combination of EMS and STEMI treatment facilities that can function “alone” as a self functioning “STEMI system of care”

By definition, the ESS is the “elemental building block” of all STEMI systems –no matter how large that “system” may be

??


An Individual ESS…

Has only three basic components:

1) All EMS organizations that transport STEMI patients to or from a facility

2) That facility and its internal “in house” STEMI management processes

3) “Outside” facilities that either send or receive STEMI patients to or from that facility….


A Typical Elemental STEMI Subsystem


Elemental STEMI Subsystems (usually) Overlap…

So, improving each one internally will improve the entire region!

Non-PCINon-PCI PCIPCI

PCIPCI Non-PCINon-PCI


Take Home Point?

Define your local ESS and concentrate on improving each important process within its boundaries

Non-PCINon-PCI PCIPCI

PCIPCI !Your ESS!


STEMI Optimization = Perfecting the Basics!

Now you know where you need to concentrate your efforts: your ESS.

So, what do you fix first?

In other words, where can you get the most “bang for your buck?”


The 5 R’s: The 5 Essential Elements of STEMI System Optimization

R1 Relationships

R2 Recognition

R3 Reperfusion

R4 Real-time Data Collection

R5 Reassessment & Refinement


Concentrate on the “5R’s”

In order to improve your system in a time efficient manner you must improve each one of these critical process until they are running smoothly.

Project UPSTART was designed to help you in this process!


Four Key Steps


Would your institution make that same mistake on a busy Friday night?


Let check: Please answer the following questions to assess Recognition at your institution:

1) Do you have a written “Screening ECG Protocol” for your institution?

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

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

ensure that the screening ECG gets done during busy times?


How did you do?

Unless you answered “yes” to all five questions, your institution is at risk at missing that same ECG. If not today, then next Friday.

Solution: Improve your STEMI recognition process


Solution:

-Print it’

-Post it’

-Use it’

-Reinforce it

-Educate staff at: www

.projectupstart.com!

The Project UPSTART“Screening ECG Protocol”


Benefits of UPSTART

Builds on the experience of others –no need to “reinvent the wheel”.

Offers a variety of tools, forms and instructions for rapid improvement of existing processes

Carefully designed for ease of implementationConnects all links of the “STEMI chain” together

from EMS to the cath lab


Four Key Steps


Provide a toolThe Screening ECG Protocol

Post it everywhere

Teach compliance (via education)

End result?Minimize missed STEMI!

STEP 1: Optimize STEMI Recognition!


2: Open a STEMI ALERT Packet for every STEMI

“Got STEMI –Open Packet!”

Opening the packet serves as a focus for action

Staff automatically open a packet for every STEMI


The STEMI ALERT Packet

A carefully designed STEMI ALERT Packet is the key to success

It places all the required information for a successful “STEMI ALERT” instantly at your fingertips


The STEMI ALERT Packet

A carefully designed STEMI ALERT Packet is the key to success.

All the required information for success is instantly at your fingertips.


A standard STEMI Alert Packet includes three checklists:

Physician Checklist Nurse Checklist STEMI Scribe Checklist


And two Data Collection Sheets

Data Sheet A Data Sheet B


How it works…..

Prior to implementation, each site decides what is the generalized best approach to treating STEMI at that particular institution. All important details are then incorporated into the checklists within the STEMI ALERT Packet.


What type of details?

MedicationsPhone numbers Treatment algorithmsPatient assessment promptsED cath lab activation criteriaThrombolytics checklistsCath lab preparation tasks

**Whatever is felt important!


Now put your packets somewhere visible

The next time a STEMI occurs, your staff should know to open the packet!

Put conditioning to work for you!


Physician Checklist

Sample PCI

with details

Who to call

Medications

Assessment

Phone numbers

Memory prompts


Nurse Checklist

Sample PCI

site

Focus?

-patient

preparation for

additional

treatment or

transfer


Stemi Scribe

Recording times

Data collection

Monitoring communication


Next: No measurement = No improvement!

The function of Data Sheets A and B are to measure key intervals during the STEMI alert. This data drives ongoing improvement

Data Sheet B always follows the patient and contains a record of total time from recognition to reperfusion

Data Sheet A stays in the ED


Step 3: Complete Data Sheets A & B during each STEMI ALERT


Date Sheet A

Stays in the ED

Provides information

for efficient feedback


Data Sheet B:Sent to the cath labor to the receiving facility

Provides data on arrival

When completed has datapoints from the entire case


Step 4: Data Management!

After the STEMI ALERT is complete, Data sheets A and B are delivered to their respective sites. “A” stays in the ED and “B” follows the patient.

This accurate data is very helpful

Our standard is to measure R2R times on each patient!


Same 4-step process at every facility! Data sheet B links them together!


Review the “Four Key Steps”


Can you do these 4 steps at your facility?

Then you can implement UPSTART!

-STEMI Alert Packet forms are easily customized

-All other forms are from templates as well

-When possible, items are standardized

-Staff education can be done via the internet


Implementation

1) Develop an individualized STEMI ALERT Packet for your institution

2) Train your staff at www.projectupstart.com

3) Place the STEMI ALERT Packets in your ED

4) Go live! The process will continue improving using the data collection loops built into the process

http://www.projectupstart.com/


Provider Education

Train all ED staff prior to “go live’

Takes one hour or less

A combination of a written tutorial, on-line video and short written test

Available at www.projectupstart.com


The Project UPSTART website:Your link to the UPSTART world!


Links to all required forms

More Powerpoints! Training videos!

The common access point for provider training

Simple and clear information in an easily accessibly form


Example: Additional forms…….

ED Activation of the Cath Lab

ED Thromblytics Guide

EMS Guide Sheet

Cath Lab Checklist

Implementation Manual

UPSTART Follow-up Sheet




Questions?


David R. Burt, MD

University of Virginia

[email protected]

(434) 924-2428

http://www.projectupstart.com/

mailto:[email protected]

Date post:	16-Dec-2015
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