1. STEMI Care Delivery Report Out

2. Lean Defined
A Process Management Philosophy centered around creating more value with less work by driving out waste so that all work adds some form of value while serving the needs of our patients

3. STEMI Lean Team Project Sponsors Dr. John Seccombe, Physician Sponsor
Paula Hafeman, Leadership Sponsor
Physician Support
Dr. Kenneth Johnson, Emergency Dept
Dr. Zhaowei Ai, Heart and Vascular
Department Support
Jennifer Gerdmann, Emergency Dept
Jim Callender, Cath Lab
Dan Doran, Cath Lab
Brad Lepinski, Heart and Vascular
James Pelch, Project Leader
Leigh Messmann, Project Manager /Facilitator
LaNaeh Wallander, Project Coordinator

4. Definitions
Door to Balloon (D2B)– the amount of time between a heart attack patient’s arrival at the hospital to the time he/she receives PCI
PCI (percutaneous coronary intervention) – family of medical procedures that uses mechanical means to treat patients with partially restricted blood flow through the artery of the heart.
Reperfusion Therapy – techniques to restore blood flow to part of the heart muscle
STEMI (ST segment elevation myocardial infarction) – a severe heart attack caused by a prolonged period of blocked blood supply causing heart cells to die
LBBB (left bundle branch block) - a cardiac conduction abnormality; activation of the left ventricle is delayed, which results in the left ventricle contracting later than the right ventricle

5. Background
Door-to-Balloon is a time measurement in emergency cardiac care, specifically in the treatment of STEMI
Delays in treating a myocardial infarction increase the likelihood and amount of cardiac muscle damage
ACC and the AHA recommend a D2B interval of no more than 90 minutes
Nov 2006: ACC launches Door to Balloon (D2B) Initiative
May 2007: AHA launches ‘Mission: Lifeline’ Initiative
Currently fewer than 50% of STEMI patients receive reperfusion with primary PCI within the recommended timeframe

6. Problem Definition and Goal Setting
We typically recognize problems based on perception
What we see happening (The Point of Recognition)
Our job function causes us to determine “problems” based on our responsibility
We often become confused between the true problem, symptoms of the problem, and causes of the problem

7. Project Objective
Apply proven strategies to improve door to balloon times and improve clinical outcomes for STEMI patients
Scope narrowed to first EKG to Cath Lab door
ED and pre-hospital EKG
95% patients </= 50 minutes
75% patients </= 30 minutes

11. Sharing Information and Telling the Story
STEMI A3
Sharing Information and Telling the Story

12. Key Strategies Systems for activating Cath Lab and Cardiologist
Protocols for handoff from ED to Cath Lab
Aggressive approach when presented with LBBB of indeterminate age
Protocols to allow activation based on pre-hospital ECG

13. Cath Lab / Cardiologist Activation
One number assigned for urgent caths
Utilized by on call Prevea Cardiologists
Mandatory response time
Second contact made if no response within 3 minutes
If no reply after 5 minutes, next provider group will be contacted

14. Hand Off Protocols
Immediate transfer to Cath Lab once they are prepared to accept patient
ED Standard Order Set updated to include only those of critical importance to patient care
Lab/Imaging should be performed as part of the management of STEMI patients
However, they should not delay implementation of reperfusion therapy
Work up to cease once Cath Lab ready
Imaging may be necessary if potential contraindication is suspected, such as aortic dissection

15. Left Bundle Branch Blocks
Implement more aggressive treatment protocols for LBBBs of indeterminate age
When coupled with cardiac symptoms, Cath Lab/Cardiologist activation will occur
Synergistic Relationship between ED Physicians and Cardiologists
Requires unhesitating decisions from ED physicians
Unreserved approval and cooperation from Cardiologists

16. Activation Based on Pre-Hospital EKG
Pre Hospital 12 lead EKGs will result in immediate Cardiologist / Cath Lab activation
Patient will be transferred directly to cath lab if ready upon arrival
Patient will need to stop in ED in event Cath Lab/Cardiologist not present/ready
lab/imaging will be performed as part of the management of patient care until Cardiologist/Cath Lab ready

17. 90 Minutes is Arbitrary Need to move beyond the 90 minute controversy
Focus on consistency and speed
Time is muscle
Foster organizational commitment
Long term, continuous improvement

18. Increasing Loss of Myocytes
Delays in Initiation of Reperfusion Therapy
Ongoing Initiatives:
Patient education /media campaign
Greater use of 911 / pre-hospital Tx
Improve Door to EKG times
Examine Cath Lab protocols for possible
improvements
Incorporate systemic cooling methods
Cath Lab
Emergency Dept
Increasing Loss of Myocytes
Pre-Hospital
Call to Medical
System
Symptom
Recognition

19. Questions?