1. An Introduction

2. Project UPSTART
The Use of Procedural Standardization to Reduce “Recognition to Reperfusion” (R2R) Time in STEMI
“Excellence in R2R”

3. 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!

4. 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

5. 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
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.
Mission: Lifeline uses a community-based, multidisciplinary, patient-centric approach.
Mission: Lifeline is addressing systems of care for STEMI on multiple levels and through many collaborating organizations, starting with the STEMI patient and continuing through EMS, ED, STEMI Referral, and STEMI Receiving hospitals; implications for policy makers and third party payers are also being addressed within Mission: Lifeline.  
To meet the overarching goal, Mission: Lifeline will bring together the necessary partnerships between:
Patients and care givers
EMS
Physicians, nurses and other providers
Non-PCI capable (STEMI-referral) hospitals
PCI capable (STEMI-receiving) hospitals
Departments of health
EMS regulatory authority/Office of EMS
Rural health associations
Quality improvement organizations
State and local policymakers
Third-party payers
Health systems 5 5

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

7. 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. “

8. (stable over last three years)
Example #1
Large Community PCI hospital
Multiple cardiology groups, etc
Current reperfusion mean (door to PCI)
+/_ 52 Minutes
(stable over last three years)

9. 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

10. 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?

11. 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!

12. 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!

13. This has all been done before, by someone!
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!

14. 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 ??

15. Has only three basic components:
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….

16. A Typical Elemental STEMI Subsystem

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

18. Take Home Point? Define your local ESS and concentrate on improving each important process within its boundaries
Non-PCI
PCI
PCI
!Your ESS!

19. 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?”

20. 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

21. Concentrate on the “5R’s”
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!

22. Four Key Steps

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

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

25. How did you do?
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

26. Solution: The Project UPSTART “Screening ECG Protocol” -Print it’
-Post it’
-Use it’
-Reinforce it
-Educate staff at: www
.projectupstart.com!

27. Builds on the experience of others –no need to “reinvent the wheel”.
Benefits of UPSTART
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

28. Four Key Steps

29. STEP 1: Optimize STEMI Recognition!
Provide a tool
The Screening ECG Protocol
Post it everywhere
Teach compliance (via education)
End result?
Minimize missed STEMI!

30. 2: Open a STEMI ALERT Packet for every STEMI
“Got STEMI –Open Packet!”
Opening the packet serves as a focus for action
Staff automatically open a packet for every STEMI

31. The STEMI ALERT Packet
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

32. The STEMI ALERT Packet
A carefully designed STEMI ALERT Packet is the key to success.
All the required information for success is instantly at your fingertips.

33. A standard STEMI Alert Packet includes three checklists:
Physician Checklist
Nurse Checklist
STEMI Scribe Checklist

34. And two Data Collection Sheets
Data Sheet A
Data Sheet B

35. How it works…..
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.

36. Patient assessment prompts ED cath lab activation criteria
What type of details?
Medications
Phone numbers
Treatment algorithms
Patient assessment prompts
ED cath lab activation criteria
Thrombolytics checklists
Cath lab preparation tasks
**Whatever is felt important!

37. Now put your packets somewhere visible
The next time a STEMI occurs, your staff should know to open the packet!
Put conditioning to work for you!

38. Physician Checklist Sample PCI with details Who to call Medications
Assessment
Phone numbers
Memory prompts

39. Nurse Checklist Sample PCI site Focus? -patient preparation for
additional
treatment or
transfer

40. Stemi Scribe Recording times Data collection Monitoring communication

41. Next: No measurement = No improvement!
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

42. Step 3: Complete Data Sheets A & B during each STEMI ALERT

43. for efficient feedback
Date Sheet A
Stays in the ED
Provides information
for efficient feedback

44. or to the receiving facility Provides data on arrival
Data Sheet B:
Sent to the cath lab
or to the receiving facility
Provides data on arrival
When completed has data
points from the entire case

45. This accurate data is very helpful
Step 4: Data Management!
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!

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

47. Review the “Four Key Steps”

48. Can you do these 4 steps at your facility?
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

49. Implementation
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

50. Train all ED staff prior to “go live’ Takes one hour or less
Provider Education
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

51. The Project UPSTART website: 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

52. Example: Additional forms…….
ED Activation of the Cath Lab
ED Thromblytics Guide
EMS Guide Sheet
Cath Lab Checklist
Implementation Manual
UPSTART Follow-up Sheet

54. University of Virginia drb5p@virginia.edu (434) 924-2428
Questions?
David R. Burt, MD
University of Virginia
(434)