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Rural Healthcare Quality Network WEB CONFERENCE

Rural Healthcare Quality Network WEB CONFERENCE. A Rural-Urban Partnership for Emergency Cardiac Care June 4, 2008. In memory of William F. Stifter, MD January 26 th 1944 to May 17 th 2008. Cardiologist with Heart Clinics Northwest

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Rural Healthcare Quality Network WEB CONFERENCE

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  1. Rural Healthcare Quality Network WEB CONFERENCE A Rural-Urban Partnership forEmergency Cardiac Care June 4, 2008

  2. In memory of William F. Stifter, MDJanuary 26th 1944 to May 17th 2008 Cardiologist with Heart Clinics Northwest Served as liaison between Lincoln Hospital and Sacred Heart to help create the Cardiac Level 1 regional response system

  3. Presenters • Kris Becker, RN, Director, Cardiac Service Line, Sacred Heart Medical Center, Spokane • Myron Bloom, MD, Medical Director, Rural Healthcare Quality Network • Gerard Fischer, Vice President, Sacred Heart Medical Center, Spokane • Tom Martin, CEO, Lincoln Hospital, Davenport • Mike Ring, MD, Medical Director Cardiac Service Line and Cardiac Catheterization Laboratory, Sacred Heart Medical Center, Spokane • Marilynn Snider, RN, Vice President of Clinical Services, Lincoln Hospital, Davenport • Rachel Zamora, RN, Chief Flight Nurse of MedStar, Spokane

  4. Regional Cardiac Program Offers Lifesaving Speed

  5. “Level One STEMI” Treatment ProtocolMyron E Bloom, MD, MMMMedical DirectorRural Healthcare Quality NetworkTIME COUNTS

  6. Definitions • STEMI – ACS myocardial infarction with the ST segment of the ECG showing elevation • D2N – door to needle time • D2B – door to balloon time • 10PCI – Primary Percutaneous Coronary Intervention - balloon angioplasty usually with a stent

  7. ACC / AHA 2004 recommendation30 minutes to Thrombolytic if patient can not get PCI within 90 minutes of first Emergency Room Door Because Time is Muscle A ONE SIZE FITS ALL TYPE OF STATEMENT

  8. So how are we doing presently? In the US • 37% of all STEMI patients are not reperfused (23% get lytics & 39% get 10PCI) • Average D-N time is 33 minutes but only 1/3rd of STEMI 10PCI under 90 minutes and <5% of transfer in 10PCI under 90 minutes NRMI 5 database median time of 143 minutes! Time is muscle, especially first 2-3 hours! Average time from onset to arrival is 3 hrs like it was 10 years ago And most downstream heart muscle is dead by 4-5 hr MUST EDUCATE THE PUBLIC

  9. Will show evidence that: • 10PCI is safer and offers better outcome than lytics • 2-3 per 100 STEMI mortality benefit with less re-thrombosis or bleeding • Time delay to thrombolytic &/or PCI deleteriously affects outcome • Strategy expedites treatment & optimizes outcome based on • Clinical factors: time of Sx onset, age, STEMI location • Minimum time of transport • Standardized Recipe for STEMI • Transfer immediately for 10PCI or after lytics

  10. Long-term Outcome of Primary PercutaneousCoronary Intervention vs Pre-hospital and In-Hospital Thrombolysis for Patients With ST-Elevation Myocardial InfarctionJAMA, October 11, 2006 26,205 consecutive STEMI patients in Sweden 1999 to 2004 10PCI Pre H T In H T 30 day mortality 4.9% 7.6 % 11.4%; 1 year mortality 7.6% 10.3% 15.9% Primary PCI was also associated with shorter hospital stay and less re-infarction than either PHT or IHT.

  11. Door-to-Balloon Time With Primary Percutaneous Coronary Intervention for Acute Myocardial Infarction Impacts Late Cardiac Mortality in High-Risk Patients and Patients Presenting Early After the Onset of Symptoms J Am Coll CardJanuary 2006 10PCI In-hospital outcomes by Door-to-Balloon Time <90 90-120 120-180 >180 p Value Mortality (%) 4.9 6.1 8.0 12.2 0.0001 Reinfarction (%) 2.9 2.4 2.9 2.2 0.84 Stroke (%) 0.8 1.0 1.1 1.9 0.31 (384) (493) (750) (673) 2,322 consecutive patients with STEMI from 1984 through 2003 treated with primary PCI without previous thrombolytic therapy.

  12. EFFECT OF DOOR-TO-BALLOON TIME ON MORTALITY IN PATIENTS WITH ST- SEGMENT ELEVATION MYOCARDIAL INFARCTIONJ Am Coll CardJune 200629,222 patients presenting within 6 hrs of STEMI symptom onset who had PCI at 395 hospitals. • Median D2B of 102 min & inpatient mortality of 4.55%. • Longer D2B times associated with increasing mortality, regardless of the interval from symptom onset to presentation, or presence of high-risk features. • from 3.0% with D2B of 90 minutes or less, • to 7.4% with intervals greater than 150 minutes. • The odds ratio for inpatient mortality was 1.08 for every 30-minute increase in D2B time.

  13. PCI v. Fibrinolytic therapy in AMI: 2003Is timing (almost) everything?Am J Cardiol. 2003; 92: 824–826 “No mortality advantage for primary PCI versus fibrinolytic therapy when door-to-balloon time exceeded door-to-needle time by 62 minutes.”

  14. Delays in reperfusion for STEMI… Circulation. 2006; 114: 2019–2025 multivariate analysis of 192,000 STEMI cases by 3 variables: age, type of STEMI, and time since Sx onset The survival advantage of PCI is lost when DB-DN time exceeds: Patients under 65 under 2 hrs after 2 hrs of Sx Anterior MI @ 40 min. @ 43 min. Nonanterior MI @ 58 min. @ 103 min Patients over 65 under 2 hrs after 2 hrs of Sx Anterior MI @ 107 min @ 148 min. Nonanterior MI @168 min. @ 179 min.

  15. DB-DN time when mortality benefit is lostmaximum delay between D12B and D12N times

  16. So what happens when you call?"We found that delays to reperfusion occurred while waiting to talk to the cardiologist,” "Also, the recommendations for a specific patient often depended on who the cardiologist was, and the time of day and day of the week.“ Quotes by Minneapolis Heart Institute Cardiologists

  17. What to do? Develop a Strategy Two Cardiology Centers of Excellence published their strategies in the same issue of Circulation (August 2007) Mayo Clinic - 10PCIorLytic Based on time to presentation AN Minnesota Heart Institute – 10PCI or Lytic & PCI Based on time to cath lab

  18. The Mayo Clinic STEMI ProtocolAugust 2007 issue of Circulation 258 presented directly to Mayo for Primary PCI median D2B 71 min. 236 rural transfers from up to 150 miles 105 Sx >3 hours transferred for Primary PCI median D2B 116 min. 131 Sx <3 hours full-dose fibrinolytic median D2N 25min (70%<30m) In-hospital mortality “said to be similar” - ? Mayo 10PCI 6.6% (95% CI, 3.9 to 10.3) Transfer 10PCI 5.7% (95% CI, 2.1 to 12.0) Thrombolytic 3.1% (95% CI, 0.8 to 7.6)

  19. Minnesota Heart Institute Protocol based on Predicted minimum expected time to PCI Clopidogrel 600 mg, UFH, BB, NTG but no IIb/IIIa Zone One – “within 60 miles 60 minutes” expected arrival PCI ~ 90 minutes – no lytic! Zone Two - “beyond 60 miles 60 minutes” expected arrival PCI > 90 minutes – ½ dose lytic facilitated PCI if no contraindication!

  20. MHI Level One Program Report Card3/03-11/06 1345 consecutive STEMI patients 1048 were transferred Median D2B time No lytic zone 1 <60 mi 95 min partial lytic zone 2 <210 mi 120 min MORTALITY IN HOSPITAL 4.2% 30 Day MORTALITY 4.9% 1 Year CARDIOVASCULAR 5.6% unselected high-risk patient population with 12.3% in cardiogenic shock, 10.8% cardiac arrest and 14.6% over 80 years age

  21. Failure to Reperfuse Rescue PCI Now defined using the ECG as Less than 50% reduction in STE at 90 minutes after lytic in the single lead that showed the greatest elevation ACC/AHA STEMI Guidelines 07 IIa recommendation and for the others that reperfused Routine cath by 6 - 24 hours

  22. TRANSFER-AMI: 30 day End Points Both groups got full dose TNK, ASA, LMWH or UFH andIIb IIIa & clopidogrel at the clinician's discretion (American College of Cardiology 2008 Scientific Sessions.)

  23. Expedite Reperfusion – “Minutes is Muscle” • “Symptoms to Test” Time • Expedite Transport, Triage and ECG • Educate the public • Pre-hospital assessment tool, ECG and ED “Cardiac Alert” • Expedite ECG – Set standard for door to ECG time • “Test to Treatment” Time • Empower the emergency room provider to make initial treatment decision for STEMI – your patient until arrives there • Standardized Protocols based on • Predetermined expected transport times for PCI • Then Immediate transfer to cath lab facility

  24. What is a Cardiac Level 1 Response?Mike Ring, MD and Kris Becker, Cardiac Service Line Director

  25. Program Highlights • Standardized Protocol • Rural hospital or field interpretation of ECG • One phone call to activate 24/7 • Individualize transportation • Education provided to all players • Public education • Data collection to promote accountability, process improvement and research • Communication!!

  26. Protocol development Based on ACC Guidelines and/but… • Cardiology Community consensus

  27. Activation of Cardiac Level 1 • Recognize signs/symptoms of AMI • ECG < 10 minutes • If STEMI or New/presumed new LBBB • Activate • MedStar/transport agency • Cardiologist • And specify “Cardiac Level I”

  28. Level 1 Activation • Cardiologist notifies receiving hospital • MedStar also contacts operator at DMC or SHMC • Cardiac Level 1 page/notification at DMC or SHMC: • Cath Lab Crew and Supervisor • ED Charge Nurse • CICU and ACU Charge Nurse • Chaplaincy • Security • Hospital Transporter • Level 1 Coordinator • Administrative/Nursing Supervisor • Admitting

  29. Cardiac Level 1 Protocol Form • History & Physical • Checklist for medications • Data for performance improvement • Hand off transfer tool • MedStar • Cath Lab • Admitting

  30. Data & Medical History

  31. Level 1 Medications

  32. Back of Level 1 Form • Assistance with ECG interpretation • Fax and phone numbers of ED • Thrombolytic Indications and Contraindications • Post-thrombolytic guidelines

  33. ü ü ü ü ü ü ü ü ü ü ü ü

  34. Lessons learned • We adopted same nomenclature for STEMI’s originating in our own ED • First bed is the cath lab • Adapt to your environment • ONE protocol for the region • Just do it!

  35. Names to know… • Jamie Gant, RN nurse manager for cardiac admit unit and CV nursing, helped establish the program at Sacred Heart • Deanna Jones, RN hired into the newly created role of Cardiac Level 1 coordinator

  36. Rural Rapid Response-Marilynn Snider,Vice President of Clinical ServicesLincoln Hospital District #3

  37. Best Practice in Action Goal: Striving to coordinate and integrate processes which facilitate delivery of the best and fastest reperfusion therapy for STEMI.

  38. Establish the team Senior Leadership: Successful strategy is motivated by leadership and commitment to provide resources and attention to the project.

  39. Partnerships: Lincoln Hospital SHMC MedStar RHQN Champions: Cardiologist Rural Physician RN leadership

  40. Rural Hospital Strategies • Establish partnerships • Initiate AMI Rapid Response Team • Implement written AMI protocol and educate staff • RN 12 lead EKG education and training

  41. Sustainability • Quality Improvement Data Collection with feedback mechanism to staff, i.e. dashboard. • Communication and feedback staff to staff and hospital to hospital. • Continue regional/state/national development of STEMI project

  42. Community Education

  43. Solidifying relationships with urban healthcare systems • Continue ongoing relationships by communicating quickly and effectively • Sharing goals and meeting challenges

  44. The Role of TransportMedStar—Rachel Zamora, RN Chief flight Nurse, MedStar

  45. MedStar Communication Center • Request “Cardiac Level 1” transport • May assist with contacting cardiologist • MedStar team enroute • Provide updates: • Flight team • Referring facility • Receiving facility and cardiologist

  46. MedStar Flight Team • Standardized approach to patient care • Heparin and Tridil infusions prepared enroute • Focused physical assessment • Minimal verbal report • Pilot to remain with aircraft

  47. Referring Facility • Accompany flight team to & from helipad • Room cleared of obstacles • Patient in hospital gown only • IV sites with rapid disconnect • Assistance with patient transfer • Family members - brochure • Patient belongings

  48. 2006 2007 Northwest MedStar Times

  49. Rural Hospital Outreach Education • Provide hospital and EMS classes • Cardiac Level 1 ECG Class • 2 hour class • Reviews Cardiac Level 1 protocol • 12 Lead ECG interpretation skills • STEMI • STEMI look-a-likes • Case Studies

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