STEMI Boot Camp III
-Tools of the Trade
David R. Burt, MD
University of Virginia
STEMI Tool Kits…
-Tactical Concepts
Objectives:
…Help you build a better system
Now that you better understand the
basic principles and theory behind
STEMI system construction we want
to discuss the tools available (at all
levels) to help you optimize your
individual Elemental STEMI
subsystem!
Remember: Building a Better
System Requires Education…
 FACT:
Educating a provider will not
fix a “broken” system… but it helps!
 BUT:
Fixing a system can support an
“uncertain” provider
 THEREFORE:
Fixing the system and
educating the provider ensures
success!
I. The (Really) Big Picture
National,
community-based
initiative
Goals
•
•
STEMI System Blueprints
…courtesy of the AHA…
5
Working at all levels to improve care
for STEMI patients
6
AHA: STEMI System Blueprints
Mission: Lifeline Recommendations for
Criteria for STEMI Systems of Care
The criteria are divided into:
 Non-PCI Hospital/STEMI Referral Center
 PCI Hospital/STEMI-Receiving Center
sections
 EMS
 STEMI Systems of Care
Please visit the Mission: Lifeline portion
of the American Heart Association
website for all types of ideas for
improving STEMI systems of care
8
II. D2B: PCI-center
systems engineering
The Door to Balloon Initiative (D2B),
organized and spearheaded by the
American College of Cardiology
(ACC), was extremely successful in
helping optimize STEMI care at PCI
centers via its attention to systems
level improvement as the key to
sustainable success
D2B: PCI Engineering
1.
2.
3.
4.
5.
6.
ED physician activates cath lab
One call activates the cath lab
Cath lab team ready in 20-30
minutes
Prompt data feedback
Senior management commitment
Team-based approach
D2B: PCI-center systems engineering
For more information
on D2B, please
visit the ACC
website.
III. Project UPSTART: STEMI
System Builder’s Toolkit
Project UPSTART: A Reperfusion
Toolkit for All Situations
Project UPSTART was designed as an
integrated set of concepts, processes
and procedures that can be used to
help efficiently address issues that
are common in any local STEMI
system
So, Optimize Recognition
and Reperfusion…
 All
attempts at reducing
STEMI treatment times must
ultimately focus on improving
one (or both) of these
endpoints.
 The
goal: early Recognition
followed by early
Reperfusion.
…By Remembering
“Joe the STEMI Patient”
Systems
Engineering:
-Optimizing the
average!

Design your system
with optimism but
base it on realism

And Remembering the 80/20 Rule!
Review: Efficient Improvement
First, define and understand your local
Elemental STEMI Subsystem
Next, optimize the 5R’s within your
local ESS & build a solid selfimproving, sustainable system
Finally, devote time to fine-tuning
each STEMI conduit within your ESS
First, Define and
Understand Your ESS!
Non-PCI
PCI
Non-PCI
PCI
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
A Typical Elemental STEMI
Subsystem
Homework: Sketch Your ESS Here
Please!
Homework/Notes:
Next, work on the “5R’s”
Within your ESS
In order to improve your system in a
time efficient manner you must
improve each one of these critical
processes until they are running
smoothly.
Review: The 5 Essential Elements
of STEMI System Design
R1
R2
R3
R4
R5
Relationships
Recognition
Reperfusion
Real-time Data Collection
Reassessment &
Refinement
Homework/Notes:
What 2 Essential Elements do you feel
need the most work within your
current system? (circle 2)
R1
R2
R3
R4
R5
Relationships
Recognition
Reperfusion
Real-time Data Collection
Reassessment &
Refinement
Finally, now sweat the small stuff!
-fine-tune each STEMI conduit within
your ESS.
Homework: Sketch one of your
problem STEMI Conduits here…
Review: Efficient Improvement
First, define and understand your local
Elemental STEMI Subsystem
Next, optimize the 5R’s within your
local ESS & build a solid selfimproving, sustainable system
Finally, devote time to fine-tuning
each STEMI conduit within your ESS
Final Result: A Simple Plan
Homework/Notes:
 Is
the current STEMI ALERT Plan in
my institution this simple and
defined?
 How can I simplify it?
The Payoff? More of Them Are
“Easy”
An example…..
Logging, Bad Burgers & Angels
34 year-old male is logging trees in
remote area
 Increased heartburn after “gut bomb”
lunch
 Pain worsens; His boss calls rural EMS,
who arrange to meet them at a local “Kum
and Go”.
 EMS does ECG in parking lot: it looks
“bad”
 Idea: fax ECG to UVA Medical Command

DX: Acute Inferior Wall MI!
 EMS
departs for UVA after faxing
ECG
 In route to UVA patient goes into
ventricular arrest and becomes
unresponsive
 Defibrillated once and revives
 EMS contacts UVA in route; discusses
ECG with the on-duty ED physician
 UVA Cath lab activated, ED on
Standby…
ED Antics
 Arrives
in ED …..’”groggy and
painful”
 2nd IV placed/Groin prepped/Monitor
 Pacer Pads placed
 Beta Blocker, Heparin and Plavix
 Clothes off, consented, and down the
hall
 ED door in to door out? 8 Minutes!
Cath Lab Precision…
 Cath
lab staff ready at bedside!
 Lido time: Cath door + 2
 Access time: door+ 12
 Cath lab door to device: +18
 Cath Lab door-to-balloon: + 21
 Total R2R time: 59 minutes from 1st
ECG at the gas station
 Total DTB time: 29 minutes
Post Cath…
 Cardiac
echo shows only a minimally
depressed ejection fraction
 Patient feeling much better!
 Admits to 5 days of increasing
“heartburn”
 PMH: Dad died at 50 of massive
MI…
 Refers to his EMS providers as the
“two special angels who saved his
life!”
Madison County, VA -2 “EMS Angels”
So, Start Somewhere…Today
Don’t wait for
perfection
 Start fixing the
process now
 Change items that
really matter
 Start by optimizing
the 5 R’s!

R1) Relationships!
STEMI System
Cement
Recognition!
Relationships
Reperfusion!
Homework:
 Write
down three relationships within
your ESS that currently need
attention
 Note:
Please refer to the Project
UPSTART system assessment quiz for
additional information on STEMI
system relationships
R2) Recognition:
Develop
optimal
STEMI recognition
practices at each
STEMI “portal”
Goal: Each
qualifying patient
receives a timely
screening ECG!
Optimize Recognition at Every
Portal!
I. EMS: “Mobile” STEMI Portals
Think Logically!
EMS “STEMI Vision” –Just Say No!
95%+ of EMS calls are NOT STEMI!
Weak/dizzy
Ab Pain
MVA
STEMI
Altered
LOC
???
EMS ECG: Keep it Simple!
 Provide
EMS personnel with ECG
machines
 Provide clear “if/then” protocols for
all EMS possibilities
 Provide ECG acquisition training
 Provide ECG interpretation training
 Provide feedback and education
 Consider transmission technology
First Step: Got STEMI? – Call the
ED!




EMS/ED
communication on
every potential STEMI
is a must
Either with/without
ECG transmission
Ties the ED and EMS
together
Will capture most
cases of STEMI prior
to arrival
I think I got one!
Simple Protocols at Each Portal
Example of a simple 3-step protocol
1) In situations where EMS personnel
have obtained a pre-hospital ECG
suspicious for STEMI.
2 EMS personnel should immediately contact
Med Com, clearly identify the incoming
patient as a possible STEMI, and request to
talk directly with the attending ED physician.
3) This step should occur for each suspected
STEMI case—even if EMS is unable
to transmit the ECG to UVA.
Simple protocols at each portal
ECG Transmission: Nice but not
essential!
ECG Transmission:
“Icing on the Cake”
Transmission may be
useful in certain
situations but does
not replace more
important essentials
such as protocol
development, EMS
training and a focus
on ECG acquisition as
the key 1st step!
Three Options for
Interpretation
Consider Destination Protocols
– The concept of diverting STEMI
patients to PCI-capable centers,
bypassing non-PCI centers does
have potential in certain
circumstances!
Homework/Notes:
 Do
the EMS agencies within my ESS
sphere have site-specific STEMI
recognition protocols?
Don’t Forget EMS Education!
An EMS STEMI Storyboard
Throws in a little
“real time
relationship
building”
 Highlights the role
of EMS within the
STEMI Care
Continuum.

ED Recognition: Accept No
Excuses!
 Implement
a standardized protocol
 Educate staff on their role
 Give them the resources and backup options to do this
 Expect success!
 Visit the Project UPSTART website for
more ideas and discussion on
Recognition
ED Recognition…
-Provide a tool
-Educate staff
-Post reminders
-Expect compliance
-Every ECG seen by
A physician
-Backup plans in place
Homework/Notes:
 What
do I need to do to optimize the
Recognition process in my ED?
Don’t Forget Education!

Remember, train and educate your “First
Contact Providers” regarding their role as
“STEMI “Gatekeepers”
I.E. The Provider
Training Module @
www.projectupstart.com

Notes:
Do all ED providers in my Emergency
Department receive regular training
regarding their role in the STEMI
Recognition and Reperfusion
process?
R3) Reperfusion
STEMI is not rocket
science!
Two Endpoints (R2R)
Early Recognition
…Followed by
Emergent Reperfusion
Generals: Plan the war…..
….and then get out of the way!


Pre-planning is
essential in STEMI
network development
During a STEMI
ALERT, however
replace planning with
action!
Q: What triggers the “STEMI
Response in your ED?
STEMI fact: When the
unexpected occurs,
staff members perform
best when they have a
“trigger to action.”
…The Red STEMI Alert
Packet-Open one for
every STEMI!
A: Take a “Leap of Faith”
Simplify your life:
Put a STEMI ALERT
Packet at every
STEMI portal within
your Elemental
STEMI Subsystem.
Put a STEMI ALERT Packet in
your ED!
A carefully
designed
STEMI ALERT
Packet is the
key to success.
Put one in your
institution
Building your Packet
Go to www.projectupstart.com and
access “STEMI Boot Camp”
 The
“easy button” for STEMI ALERT
Packet construction
 Forms, templates, provider
education, UPSTART Color Guide,
real-world examples, PowerPoint
manuals, publicity, etc
Standard STEMI Alert Packet
A STEMI ALERT Packet
Includes 3 Checklists:

Physician
Checklist
Nurse
Checklist


STEMI Scribe
Checklist
…And Two Simple Data Sheets

Data Sheet A

Data Sheet B
The STEMI ALERT Packet
Opening of the packet allows the
combination of provider checklists and
data collection sheets to guide the process
& collect valuable quality improvement
data as the STEMI occurs
 With a packet, this happens reliably,
almost every time!
 Without a packet, where is your trigger?

Non-PCI centers: Focus on the
handoff…….
Inter-facility
transport is usually
the uncertain link
with any give
STEMI case at a
Non-PCI center
Transport time is your “Jokers
Wild!”
Transportation issues at
Non-PCI centers are
numerous
– Air vs. ground
– Weather
– Local EMS
availability
– Limitation of local
resources
Non-PCI centers –time meets
patient!


Spend a great deal
of time on refining
your inter-facility
transport options
They are the key
component of NonPCI center STEMI
ALERT Plans
Homework/Notes:
 Do
I have a STEMI ALERT Packet in
my Emergency Department?
 How long do I think it will take to put
one in place?
Building your Packet
Go to www.projectupstart.com and
access “STEMI Boot Camp”
 The
“easy button” for STEMI ALERT
Packet construction
 Forms, templates, provider
education, UPSTART Color Guide,
real-world examples, PowerPoint
manuals, publicity, etc
R4 ) Real-time data collection
R1
R2
R3
R4
R5
Relationships
Recognition
Reperfusion
Real-time data collection
Reassessment & refinement
The Hawthorne effect
 You
can’t improve
what you don’t
measure!
Back to the Data Sheets

Data Sheet A

Data Sheet B
The Real Life Data Chain
 Use
of a real-time data sheet allows
sharing of data between facilities and
within institutions in real time
 Result? Very efficient QI
 Cements providers and transition
 Prompts excellence
Homework/Notes:
 Do
I have a real-time Data collection
system within my ESS?
 When could we start?
R5) Reassessment & refinement
R1
R2
R3
R4
R5
Relationships
Recognition
Reperfusion
Real-time Data Collection
Reassessment & Refinement
Refinement and Reassessment
 Invigorate
your STEMI committee
 Investigate every case
 Look at all STEMI cases, not just
CMS qualifiers
 Work within your ESS
 Make feedback a priority
 Continually reassess Essential
Elements within your ESS
STEMI Construction hints
Blueprints: Mission: Lifeline
 Environment: your local ESS
 Construction plan: optimize the 5R’s
 Finish Coat: perfect each STEMI conduit
 Toolkits: Project UPSTART, D2B, etc
 Continuing Ed: ongoing education for
your First Contact Providers

Homework
What is my next step in improving my
local system?
Summary:
 Optimize
the 5 Essential Elements of
Reperfusion within your system
 Concentrate on the basics first then
seek refinement
 Never undervalue relationships as
the ultimate key!
STEMI Boot Camp materials…
 Please
access the “STEMI Boot Camp
link at www.projectupstart.com for
more information and complete
access to all STEMI Boot Camp
materials you may need to begin
optimizing your local system
www.projectupstart.com
Questions?
David R. Burt, MD
Assistant Professor
Department of Emergency Medicine
University of Virginia Health System
davidrburt@virginia.edu
O: 434.924.2428