2. Time is Myocardium Myocardium can recover if artery is opened early.
Our goal: To provide state of the art diagnosis, transfer, and treatment options to get the patient from the initial presentation in the field, clinic settings or walk-in to the MSCH ED (First Medical Contact) to having an open artery in the cath lab in ideally 90 minutes or less.
Jan

3. Quality Awards - AHA Mission: Lifeline Recognition
Bronze (Receiving)
1 calendar quarter/90 consecutive days
Silver (Receiving)
4 calendar quarters/12 consecutive months
Gold (Receiving)
8 consecutive quarters/24+ consecutive months
Jan

4. Mission: Lifeline Recognition Measures
Achievement Measures STEMI- Receiving Center
Percentage of STEMI patients with a door-to-balloon (first device used) within 90 minutes, non-transfer
Percentage of STEMI patients with first medical contact to balloon inflation (first device used) within 90 minutes, non-transfer
Percentage of reperfusion –eligible patients receiving any reperfusion (PCI or fibrinolysis) therapy)
Percentage of STEMI patients receiving aspirin within 24 hours
Percentage of STEMI patients on aspirin at discharge
Percentage of STEMI patients on Beta Blocker at discharge
Percentage of STEMI patients with LDL>100 who receive statins or lipid lowering drugs
Percentage of STEMI patients with LVSD on ACEI/ARB at discharge
Percentage of STEMI patients that smoke with smoking cessation counseling at discharge
Jan 4 4

5. 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.
Jan

6. Barriers to Meeting First Medical Contact
EMS/Clinic: Atypical ACS symptoms with subtle EKG changes
Delay during intercept with stable patient near PCI center – consider if intercept is necessary
Mandates to closest hospital regardless of PCI capability
Long EMS transports from many rural areas
EMS transport availability/delays due to weather
Clinic: Unfamiliar with STEMI process
Lack of awareness of lapsed time and impact on outcomes
Jan

7. Meeting FMC to Device Times
Standardization (protocol)
Consistency
Education
Feedback
Celebrate!
Jan

8. Rescue One Background Standardization/Consistency
Protocol created to promote consistency for STEMI patient care based on ACC guidelines
Initiated in Ministry Health Care at St. Joseph’s Hospital in Marshfield in 2006
Established at Ministry St. Clare’s in 2007
Rescue 1 is for STEMI and complete heart block patients
Jan

9. Connect records all phone calls
One call for your transport and specialist consultation needs for transport and admission
Connect will dispatch the closest appropriate vehicle for the critically ill or injured
Connect records all phone calls
Connect will coordinate medical transportation regardless of originating location or destination
Connect will dispatch the ambulance or helicopter prior to receiving an accepting physician to speed patient movement
Connect with activate Rescue One group page
Nathan

10. Rescue 1 Page Transport Arrangements Ministry Connect
Cath Lab Team
Transport Arrangements
CCU Team
ER Team
Rescue 1 Page
Ministry Connect
DOC(1362)
Nathan
Interventional Cardiologist Called
Telecom courtesy notification to CV Surg/Pastoral Care/Security
Admitting notified
Lab

11. Nathan

12. Spirit EMS Transport Helicopter
Mobile Intensive Care Unit
Critical care nurse
Critical care paramedic
ICU monitoring for adults/pediatrics and neonates
Invasive and noninvasive monitoring
Advanced intervention
Nathan

13. Path of Least Resistance…
Processes need to be efficient
Processes need to be consistently followed
Make it easy:
♥ Algorithms
♥ Stickers with phone number for phones
♥ One phone number to call
♥ Build relationships by engagement
Jan Or Nathan

14. Meeting FMC to Device Times
Entire STEMI team participates STEMI processes and outcomes
Team includes EMDS, EMS, ED MD’s & staff, Cardiologists, Cath Lab, Heart Registry Manager, Management & Administration, etc.
Implement and continuing education of STEMI protocols
Educate STEMI Goals for best outcomes
Audit STEMI data for potential process improvement opportunities
Review data with STEMI teams-provide education & kudos
Provide timely STEMI feedback of process and outcomes to provider and EMS involved
EMS 12 lead transmission capability
EMS Triage and Destination protocols
EMS personnel educated on 12 lead interpretation-communicate results to Receiving Center
Regular multi-disciplinary meetings to review outcomes and quality improvement data
Jan

15. Meeting Clinic FMC to Device Times
Challenges with FMC in clinic settings:
Lack of Recognition of EHAC signs & symptoms
Delay from check-in to FMC
Low volume situation – need consistent, annual EHAC/STEMI education
Lack of understanding of how to initiate an urgent STEMI response
Subtle 12-Lead EKG’s can be missed
Delay with ordering additional testing
Jan

16. Meeting Clinic FMC to Device Times
Process Improvements
Annual education to Clinic Providers & Staff on EHAC, especially atypical signs & symptoms
Work with clinics on identification of key words to initiate a triage process at the check-in desk
Provide annual EHAC/STEMI education to clinic personnel with review of guidelines
Create algorithms for the clinic to respond to STEMI-Educate
Algorithms for onsite clinics vs offsite clinics
Integrate time-savers into the algorithms:
-Subtle12-Lead EKG’s – phone # to call for assistance with interp.
-Reduce what clinic needs to do on protocol, keep it simple
Provide laminated copies of algorithms for posting in each dept.
Jan

17. On-site Clinic to ED/Cath Lab
Clinic Provider--Call ED MD at to inform of STEMI/other
(ED will call Rescue One)
Request “First Responder
For Acute MI”
If unstable, call “Code Blue”
Call “911” to SCH operator
Onset of STEMI symptoms at clinic/other
Patient to ED with First Responders
Cath Lab will meet patient in ED and go direct to cath lab, if appropriate.
Cardiologist will call Clinic Provider
ED to initiate Rescue 1 Page
State to operator that you have AMI. The Cardiologist will call the clinic physician. ED staff will need to call the Rescue One
Jan
To Cath Lab

18. Off-site Clinic to ED/Cath Lab
Clinic Provider – Call Ministry Connect (888)
Request: “Rescue One to SCH”
Clinic Provider to Call “911” for local EMS – transport arranged **Need to state patient is accepted at SCH**
Onset of STEMI symptoms at clinic/other
Ministry Connect Initiates Rescue One
Cardiologist notified. Cardiologist will call clinic provider. Patient arrives to ED.
Decision to stop in ED or direct to Cath Lab, as appropriate
Must state “Rescue One to SCH” to Ministry Connect. When calling 911, need to state patient is accepted at SCH.
Jan
Saint Clare’s ED or direct to Cath Lab

19. Meeting FMC to Device Times – EMDS/EMS
Education
EMDS and EMS
EMDS Goal:
Dispatch EMS = 1 minute
EMS Goals:
EMS 12 lead transmission capability
EMS personnel educated on 12 lead interpretation
communicate results to Receiving Center/Activate Rescue One
EMS patient arrival to EKG goal ≤ 10 minutes
Field/Clinic FMC to ED Door goal ≤ 30 minutes
Field w/Cardiac Arrest goal return of circulation to nearest hospital including transport time < 45 minutes
Jan

20. Meeting FMC to Device Times – EMDS/EMS
EMDS/EMS Process Improvements
Implement & Educate consistent protocols
24/7 Immediate acceptance of STEMI patients
♥ One phone call to ED physician-ED activates Rescue One
♥ Stop in ED (FMC) or direct to Cath Lab (hospital transfers)
♥ Pre-hospital expectations (i.e. ASA)
♥ Paperwork needed (i.e. EKG, etc.)
Provide education on guidelines for best outcomes, protocol, their data, STEMI patient care, time-savers, etc.
EMDS & EMS education: Once they know the goals, they strive to meet them. Discuss time-savers (2 IV’s, groin prep, defib pad RTS placement).
Jan

21. STEMI Process Improvement Metrics
Chest Pain to 911 Call
911 Call to 1st EKG
911 to Reperfusion
First Medical Contact to 1st 12-lead EKG
First Medical Contact to Cath Lab Activation
First Medical Contact to Reperfusion
Percent of 12-lead EKG’s transmitted by EMS
EMS STEMI’s identified in the field
Cath Lab Notification to Arrival
Cardiologist Notified to Arrival
1st 12-lead EKG to Patient Arrival to Cath Lab
D2D (per GWTG) < 90 minutes
Jan

22. Meeting FMC to Device Times – EMDS/EMS
North-central WI Regional EMS Time-Savers:
EMDS, once educated on goals, have reduced 911 call to dispatch EMS from average 5 minutes reduced to 1-2 minutes
EMDS education on Early Heart Attack Care (EHAC)
EMS, once educated on goals, have reduced field FMC “at patient” to EKG from average 18 minutes (2010), reduced to average 10 minutes
Increased EMS ability to transmit 12-Lead EKG to ED through LifeNet system
Education for EMS on 12-Lead EKG interpretation (in progress)
Ability of EMS to recommend activation of Rescue One pre-hospital arrival
Evaluate whether intercept close to PCI center is needed or will cause unnecessary delay
Pre-hospital activation of Rescue One
Most EMS are stocking RTS Defib pads (work in progress)
EMS starts second IV, if possible
EMS assists ED staff with preparation for cath lab procedure
Jan

23. Meeting FMC to Device Times – MSCH ED
Consistency is Key!
Communication between EMS & ED
Rescue One STEMI process consistent
24/7 Acceptance – no diversions for STEMI
Field/Clinic to ED – always stop in ED
ED door in-door out (DIDO): Goal ≤ 30 minutes
ED early Activation of Rescue One
Immediate Interventional Cardiologist/Cath Lab Team response. Call back within 1-5 minutes.
Dr. Clark

24. Meeting FMC to Device Times – MSCH ED
Communication between physicians
ED Physicians and Cardiologists must communicated and agree on the protocols
ED physician carries a designated phone for immediate access
Cultivate relationships:
- Engage referring physicians/EMS in processes
- ED MD’s & Cardiologists respecting referring physicians decisions and evaluation
- Educate STEMI providers on guidelines for best patient outcomes
- Create an environment of transparency to be able to discuss issues and strive for process improvements
Dr. Clark

25. Meeting FMC to Device Times – MSCH ED
Consistency is absolutely essential to meet FMC to Device Times
One Process for all Rescue Ones
One Medical Protocol
ED Physician is information conduit
Teamwork is essential to minimize times
Feedback always positive or constructive in nature
Dr. Clark

26. Meeting FMC to Device Times – MSCH ED
Consistency
Cath Lab activation process the same regardless of location of origin of patient
Allows for process familiarity for relatively small number of STEMI patients presenting primarily to our ED; significantly large number of transferred STEMI patients
Rescue One Treatment Protocol the same for all patients regardless of location of origin or cardiologist on duty
Dr. Clark

27. Dr. Clark

28. Dr. Clark

29. Meeting FMC to Device Times – MSCH ED
Consistency
Rescue One protocol is a standard protocol agreed upon by all interventional cardiologist in system
Every cardiologist may not completely agree to every aspect of protocol, every cardiologist is accepting of the protocol
Protocol similar to protocol of other PCI center’s protocol
Reduces confusion in ED
Reduces need to contact cardiologist prior to initiating therapies
Reduces impression of negative feedback
Dr. Clark

30. Meeting FMC to Device Times – MSCH ED
Consistency
Transfer Rescue One calls involve ED Physician as accepting physician
Familiar with process
Rescue One process initiated by ED physicians not cardiologists
Once Rescue One activated process moves forward until at least cardiologist has examined the patient
Dr. Clark

31. Meeting FMC to Device Times – MSCH ED
Consistency
EMS contacts ED with patient care report and ED physician initiated Rescue One process
Reduces burdens on EMS providers
Do not have to remember different protocols for different hospitals
Improved data interpretation/filtering: ED knows EMS providers
In conjunction with transmitted EKG allows for improved accuracy of cath lab activation
Shifts false positive activation “blame” to ED physician
Dr. Clark

32. Meeting FMC to Device Times – MSCH ED
Pre-Hospital EKG’s
Encourage services of all levels to obtain and if possible transmit EKG’s
EMT-Basic/Advanced EMT can obtain but cannot interpret 12-lead EKGs
Encourage early radio reports for potential STEMI regardless of EKG findings
Focus on symptomatic ***ACUTE MI*** EKGs for pre-hospital cath lab activation
Focus on “Did the patient need a emergent/urgent cath based on clinical picture?” versus “Was a culprit lesion found?”
Dr. Clark

33. Meeting FMC to Device Times – MSCH ED
Pre-Hospital EKG’s
Pre-hospital CCL activation significantly reduced D + B time
73 ± 19 minutes field STEMI
130 ± 66 minutes non-field STEMI
141 ± 49 minutes historical STEMI
Significant reductions in door-to-CCL and CCL-to-balloon times as well
Jason P. Brown, Ehtisham Mahmud, James V. Dunford, Ori Ben-Yehuda, Effect of Prehospital 12-Lead Electrocardiogram on Activation of the Cardiac Catheterization Laboratory and Door-to-Balloon Time in ST-Segment Elevation Acute Myocardial Infarction, The American Journal of Cardiology, Volume 101, Issue 2, 15 January 2008, Pages , ISSN , (
Dr. Clark

34. Meeting FMC to Device Times – MSCH ED
Examination CCL activation at 14 primary angioplasty hospitals to determine rate of inappropriate activation.
3973 activations (29% by EMS, 71% by emergency physicians) over 1 year
Appropriate CCL activations occurred for 3377 patients (85%)
2598 patients (76.9% of appropriate activations) receiving PPCI
Dr. Clark

35. Meeting FMC to Device Times – MSCH ED
Reasons for inappropriate activations
ECG reinterpretations (427 patients; 15%)
Patient was not a CCL candidate (169 patients; 28%)
Rate of cancellation because of reinterpretation of EMS ECG: 6% of all activations
Rate of cancellation because of reinterpretation of emergency physicians' ECG:4.6%
Rates of Cardiac Catheterization Cancelation for ST Elevation Myocardial Infarction after Activation by Emergency Medical Services or Emergency Physicians: Results from the North Carolina Catheterization Laboratory Activation Registry (CLAR) J. Lee Garvey, Lisa Monk, Christopher B. Granger, Jonathan R. Studnek, Mayme Lou Roettig, Claire C. Corbett, and James G. Jollis; Circulation. 2011;CIRCULATIONAHA published online before print December , doi: /CIRCULATIONAHA
Dr. Clark

36. Meeting FMC to Device Times – MSCH ED
Teamwork
Interventional Cardiologist sees every Rescue One patient upon or soon after arrival
Questionable cases are discussed between cardiologist and ED physician
Cath Lab team comes to ED when cath lab is ready for patient and escorts patient to cath lab
Shared task completion among nurses and shared decision making among physicians
Dr. Clark

37. Meeting FMC to Device Times – MSCH ED
Feedback
Interventional cardiologist calls ED physician with results of catheterization
Feedback is always positive or constructive in nature
Absence of negative feedback reduces reluctancy to activate cath lab for marginal cases
Program sends feedback on times and outcomes to ED Manager and other key staff
Feedback is forwarded to EMS services by EMS Medical Director
DR. Clark

38. Bradley EH et al. N Engl J Med 2006;355:2308-2320.
Adjusted Associations between Hospital Strategies and Door-to-Balloon Times.
Bradley EH et al. N Engl J Med 2006;355:
Dr. Clark 38

39. Meeting FMC to Device Times – Cardiologist/Cath Lab Team
Consistent expectations and process 24/7
Interventional Cardiologist & Cath Lab Team arrival from initial page ≤ 30 minutes
Interventional Cardiologist immediately involved
Cath Lab team members to ED stat to assume care of patient and continue remaining protocol-ED immediately turns over care to cath lab team
Plan for simultaneous Rescue One (after hours)
If there is a question on proceeding with procedure, evaluate in the cath lab and make determination there
Acceptance of false Rescue One activation-misdiagnosis
Dr. Clark

40. Meeting FMC to Device Times – Cardiologist/Cath Lab Team
Rescue One Group Page – one page activates entire team
Call back to switchboard 1-5 minutes
FMC – RN & Tech report direct to ED
Scrub (1st Assist) readies sterile field in lab
ED starts R1 prep, CL team assumes care upon arrival where pt. taken immediately to cath lab
Cath Lab door to device: Goal ≤ 30 minutes
Dr. Clark

41. Patient Feedback Process
Cath lab diagram
Post-cath call back to ED MD and/or referring MD
Next day process review/call ER
Follow-up of event by to clinical staff involved in event
Periodic data review specific for group (i.e staff/provider meetings)
Dr. Clark or Jan

42. Celebrate STEMI team achievements!
Dr. Clark, Nathan and Jan

43. First Medical Contact & EMS Engagement Techniques
Questions?
All