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An Introduction. Project UPSTART. The U se of P rocedural Sta ndardization to R educe “Recognition to Reperfusion” (R2R) T ime in STEMI “Excellence in R2R”. A Framework for Improvement.

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An introduction l.jpg

An Introduction

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  • The Use of Procedural Standardization to Reduce “Recognition to Reperfusion” (R2R)Time in STEMI

  • “Excellence in R2R”

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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!

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A Tool Kit for STEMI Systems…

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

  • Designed to improve locals systems of care

  • Facilitates inter-facility collaboration and data sharing

  • Compliant with the concepts and principles endorsed within the American Heart Associate and its Mission: Lifeline Initiative

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Mission: Lifeline(The Big Picture)

  • National, community-based initiative

  • Goals

    • Improve quality of care and outcomes in heart attack patients

    • Improve health care system readiness and response


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Think of Project UPSTART as a Mission: Lifeline-compliant “Recognition to Reperfusion” Toolbox!

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Optimizes 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.

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Example #1

  • Large Community PCI hospital

  • Multiple cardiology groups, etc

  • Current reperfusion mean (door to PCI)

  • +/_ 52 Minutes

  • (stable over last three years)

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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

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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?

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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!

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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!

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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!

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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


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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….

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Elemental STEMI Subsystems (usually) Overlap…So, improving each one internally will improve the entire region!





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Take Home Point?Define your local ESS and concentrate on improving each important process within its boundaries

!Your ESS!




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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?”

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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

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Concentrate on the “5R’s” Optimization

  • 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!

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Four Key Steps Optimization

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

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

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

  • Is it visibly posted in your ED and triage areas?

  • Do ED and triage staff follow it 24/7?

  • Have you trained your staff regarding their role (and importance) in the screening ECG?

  • Do you have multiple backup pathways in place to ensure that the screening ECG gets done during busy times?

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How did you do? Recognition at your institution:

  • 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

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Solution Recognition at your institution::

  • -Print it’

  • -Post it’

  • -Use it’

  • -Reinforce it

  • -Educate staff at: www


The Project UPSTART

“Screening ECG Protocol”

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Benefits of UPSTART Recognition at your institution:

  • 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 implementation

  • Connects all links of the “STEMI chain” together from EMS to the cath lab

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Four Key Steps Recognition at your institution:

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STEP 1: Optimize STEMI Recognition! Recognition at your institution:

  • Provide a tool

  • The Screening ECG Protocol

  • Post it everywhere

  • Teach compliance (via education)

  • End result?

  • Minimize missed STEMI!

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2: Open a STEMI ALERT Packet for every STEMI Recognition at your institution:

  • “Got STEMI –Open Packet!”

  • Opening the packet serves as a focus for action

  • Staff automatically open a packet for every STEMI

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The STEMI ALERT Packet Recognition at your institution:

  • 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

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The STEMI ALERT Packet Recognition at your institution:

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

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

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A standard STEMI Alert Packet includes three checklists: Recognition at your institution:

  • Physician Checklist

Nurse Checklist

STEMI Scribe Checklist

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And two Data Collection Sheets Recognition at your institution:

Data Sheet A

Data Sheet B

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How it works….. Recognition at your institution:

  • 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.

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What type of details? Recognition at your institution:

  • Medications

  • Phone numbers

  • Treatment algorithms

  • Patient assessment prompts

  • ED cath lab activation criteria

  • Thrombolytics checklists

  • Cath lab preparation tasks

  • **Whatever is felt important!

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Now put your packets somewhere visible Recognition at your institution:

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

  • Put conditioning to work for you!

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Physician Recognition at your institution:Checklist

  • Sample PCI

  • with details

  • Who to call

  • Medications

  • Assessment

  • Phone numbers

  • Memory prompts

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Nurse Recognition at your institution:Checklist

  • Sample PCI

  • site

  • Focus?

  • -patient

  • preparation for

  • additional

  • treatment or

  • transfer

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Stemi Scribe Recognition at your institution:

  • Recording times

  • Data collection

  • Monitoring communication

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Next: No measurement = No improvement! Recognition at your institution:

  • 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

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Step 3: Complete Data Sheets A & B during each STEMI ALERT Recognition at your institution:

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  • Date Sheet A Recognition at your institution:

  • Stays in the ED

  • Provides information

  • for efficient feedback

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  • Data Sheet B: Recognition at your institution:

  • Sent to the cath lab

  • or to the receiving facility

  • Provides data on arrival

  • When completed has data

  • points from the entire case

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Step 4: Data Management! Recognition at your institution:

  • 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!

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

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Review the “Four Key Steps” them together!

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Can you do these 4 steps at your facility? them together!

  • 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

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Implementation them together!

  • 1) Develop an individualized STEMI ALERT Packet for your institution

  • 2) Train your staff at

  • 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

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Provider Education them together!

  • 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

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The Project UPSTART website: them together!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

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Example: Additional forms……. them together!

  • ED Activation of the Cath Lab

  • ED Thromblytics Guide

  • EMS Guide Sheet

  • Cath Lab Checklist

  • Implementation Manual

  • UPSTART Follow-up Sheet

Www projectupstart com l.jpg them together!

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Questions? them together!


  • David R. Burt, MD

  • University of Virginia


  • (434) 924-2428