Improving D2B Time in ST-Elevation Myocardial Infarction

1. Improving D2B Time in ST-Elevation Myocardial Infarction Sun Scolieri, MD Assistant Professor of Medicine UPMC Cardiovascular Institute

2. History at UPMC Presbyterian Data collection began in Jan 2004 and analysis revealed: Average time to intervention first 6 months: 447 minutes No standardization of process Multiple layers involved in facilitating a patient from the Emergency Department door to the Cardiac Catheterization Laboratory with successful intervention. Commitment to minimize D2B time at UPMC Presbyterian Original goal <120 minutes, later reduced to <90 minutes Variety of measures implemented July through September 2006 at UPMC Presbyterian ED/Cardiology

3. Process Flow Pre Initiative Patient arrives in ED with Chest Pain Triage via ED RN EKG Completed Assessment by ED Physician Chest Pain Team Called Assessment by Cardiology Attending/Fellow Cardiology Assessment Team contacts Interventional Cardiologist Decision for Cardiac Catheterization Cath Lab Call Team notified � 30 minute window to arrive at hospital Transported to Cath Lab Procedure and Intervention

4. Improvement Plan Task force initiated including: ED and Cardiology Physicians ED and Cardiology Management and Staff Emergency Medical Services Personnel and Management Team MedCall Referral Management

5. Tracking System Initiated Tracking form developed and implemented. Emergency Department initiates form as soon as patient arrives. ED staff completes form and sends with patient upon transport. Cath Lab Staff completes remaining portion of the form and Manager collects and tallies information.

7. Before and After D2B Initiative Emergency Department BEFORE Patient (pt) arrives with c/o CP EKG was done by ED staff and presented to either the resident, ED attending or left in room awaiting MD evaluation Upon PCI decision; pt waited in ED for cath lab team arrival before further preparation RN would go to McKesson to retrieve cardiac medications many times during ED treatment phase AFTER After initial EKG is completed, EKG is taken immediately to ED attending physician for review Upon PCI decision; pt is changed to gown, procedural translucent EKG leads are placed, and groin prepped by ED staff All Cardiac meds for AMI are available in one box in the McKesson called �AMI Kit� to increase efficiency

8. Before and After Decision-Making Process BEFORE Assessment by the ED Physician Chest Pain Team called Assessment by Cardiology Fellow Cardiology Fellow pages Cardiology attending on-call Cardiology Attending on-call makes decision to contact Interventional Cardiologist Interventional Cardiologist pages Cath Lab on-call Team AFTER Assessment by ED Physician Chest Pain Team, Interventional Cardiologist, Cardiology Fellow and Cath Lab on-call team paged simultaneously.

9. Before and After Cath Lab Protocols BEFORE Cath Lab paged only after full ED and Cardiology assessment Travel time 30 minutes Search for Parking in PUH Garage Prepare procedure room Call for patient when all three staff members as well as Cardiologist and Fellow have arrived AFTER Cath Lab called in based on ED physician assessment. Travel time 30 minutes Park in Emergency Department spaces No room preparation needed � room left �ready� for emergency patient First staff member present calls for patient � ED staff will stay and assist if patient transported before rest of call team arrives.

10. Assessment Post Event

11. Sample Feedback Email

12. Guideline Applied Practice~Door-To-Balloon GAP-D2B Goal To achieve a door-to-balloon time of < 90 minutes for at least 75% of non-transfer primary PCI patients with ST-segment elevation myocardial infarction in all participating hospitals performing primary PCI.

13. Difference? We analyzed non-transfer patients with STEMI presenting between July 2005 and May 2007 at UPMC Presbyterian Hospital. The baseline group consisted of 63 consecutive STEMI patients between July 2005 and August 2006, and we compared these to 31 consecutive STEMI patients enrolled after protocol implementation, between September 2006 and May 2007.

18. ACC: Evidence-based Strategies 1. Pre-hospital ECG to activate the cath lab 2. ED physician activates the cath lab 3. One call activates the cath lab 4. Cath lab team ready in 20-30 minutes 5. Prompt data feedback 6. Senior management commitment 7. Team-based approach

19. How to make it work 1) Commitment from leadership of involved departments to make improvement of D2B highest priority. 2) Empowerment of emergency physician to directly activate cardiac cath team 3) Single call activation system for in-house cardiology, cath lab staff, interventional fellow and attending. 4) Defined time expectations for triage to ECG time, decision to activate cath lab, transfer time. 5) Detailed real time feedback of each component of D2B to all caregivers involved within 1 day of patient encounter.

20. Thank You Joon Sup Lee, MD Suresh Mulukutla, MD Vincent Mosesso, MD Donald Yealy, MD Charissa Pacella, MD Kitty Zell, BSN Peg Richards, BSN MedCall/ Referral center Emergency Services ER staff and personnel Cath lab staff and personnel Administrative support