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 - AHA Mission: Lifeline Recognition
• Bronze (Receiving)
1 calendar quarter/90 consecutive days
• Silver (Receiving)
4 calendar quarters/12 consecutive months
• Gold (Receiving)
8 consecutive quarters/24+ consecutive
months
Mission: Lifeline Recognition Measures
Achievement Measures STEMI- Receiving Center
Percentage of STEMI patients with a door-to-balloon (first device used) within 90 minutes, nontransfer
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
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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
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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
Cath Lab
Team
CCU
Team
Transport
Arrangements
ER
Team
Rescue 1
Page
Telecom
courtesy
notification to
CV Surg/Pastoral
Care/Security
Lab
Admitting
notified
Ministry Connect
888- 411-1DOC(1362)
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
Responder
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)
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
ED to
initiate
Rescue 1
Page
Off-site Clinic to ED/Cath Lab
Onset of
STEMI
symptoms
at
clinic/other
Clinic Provider to
Call “911” for local
EMS – transport
arranged **Need to
state patient is
accepted at SCH**
Decision to stop in ED or
direct to Cath Lab, as
appropriate
Clinic Provider –
Call Ministry
Connect
(888)411- 1362
Request:
“Rescue One to
SCH”
Ministry
Connect
Initiates
Rescue
One
Cardiologist notified.
Cardiologist will call
clinic provider. Patient
arrives to ED.
Saint Clare’s ED or direct to Cath Lab
Meeting FMC to Device Times – EMDS/EMS
Education
EMDS and EMS
EMDS 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
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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:
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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
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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 prehospital 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-toballoon 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-toBalloon 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 Engagement
Techniques
Questions?