2Project UPSTARTThe Use of Procedural Standardization to Reduce “Recognition to Reperfusion” (R2R) Time in STEMI“Excellence in R2R”
3A 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 STEMIAvoid reinventing the wheel!
4A Tool Kit for STEMI Systems… Provides forms, protocols, templates provider education and other necessary “components”Designed to improve locals systems of careFacilitates inter-facility collaboration and data sharingCompliant with the concepts and principles endorsed within the American Heart Associate and its Mission: Lifeline Initiative
5Mission: Lifeline (The Big Picture) National, community-based initiativeGoalsImprove quality of care and outcomes in heart attack patientsImprove health care system readiness and responseMission: 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 giversEMSPhysicians, nurses and other providersNon-PCI capable (STEMI-referral) hospitalsPCI capable (STEMI-receiving) hospitalsDepartments of healthEMS regulatory authority/Office of EMSRural health associationsQuality improvement organizationsState and local policymakersThird-party payersHealth systems55
6…Think of Project UPSTART as a Mission: Lifeline-compliant “Recognition to Reperfusion” Toolbox!
7Optimizes Recognition and Reperfusion All attempts at reducing STEMItreatment times must ultimatelyfocus on improving one (or both) ofthese endpoints.The goal: early recognition followedby early reperfusion.“
8(stable over last three years) Example #1Large Community PCI hospitalMultiple cardiology groups, etcCurrent reperfusion mean (door to PCI)+/_ 52 Minutes(stable over last three years)
9Example #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
10Quiz: 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?
11History 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!
12STEMI 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 systemFinally, you must fix what needs fixing!
13This 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!
14Key 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??
15Has only three basic components: An Individual ESS…Has only three basic components:1) All EMS organizations that transport STEMI patients to or from a facility2) That facility and its internal “in house” STEMI management processes3) “Outside” facilities that either send or receive STEMI patients to or from that facility….
17Elemental STEMI Subsystems (usually) Overlap… So, improving each one internally will improve the entire region!Non-PCIPCIPCINon-PCI
18Take Home Point? Define your local ESS and concentrate on improving each important process within its boundariesNon-PCIPCIPCI!Your ESS!
19STEMI 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?”
20The 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
21Concentrate 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!
23Would your institution make that same mistake on a busy Friday night?
24Do 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?
25How 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
27Builds on the experience of others –no need to “reinvent the wheel”. Benefits of UPSTARTBuilds on the experience of others –no need to “reinvent the wheel”.Offers a variety of tools, forms and instructions for rapid improvement of existing processesCarefully designed for ease of implementationConnects all links of the “STEMI chain” together from EMS to the cath lab
29STEP 1: Optimize STEMI Recognition! Provide a toolThe Screening ECG ProtocolPost it everywhereTeach compliance (via education)End result?Minimize missed STEMI!
302: Open a STEMI ALERT Packet for every STEMI “Got STEMI –Open Packet!”Opening the packet serves as a focus for actionStaff automatically open a packet for every STEMI
31The STEMI ALERT PacketA carefully designed STEMI ALERT Packet is the key to successIt places all the required information for a successful “STEMI ALERT” instantly at your fingertips
32The STEMI ALERT PacketA carefully designed STEMI ALERT Packet is the key to success.All the required information for success is instantly at your fingertips.
33A standard STEMI Alert Packet includes three checklists: Physician ChecklistNurse ChecklistSTEMI Scribe Checklist
34And two Data Collection Sheets Data Sheet AData Sheet B
35How 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.
36Patient assessment prompts ED cath lab activation criteria What type of details?MedicationsPhone numbersTreatment algorithmsPatient assessment promptsED cath lab activation criteriaThrombolytics checklistsCath lab preparation tasks**Whatever is felt important!
37Now 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!
38Physician Checklist Sample PCI with details Who to call Medications AssessmentPhone numbersMemory prompts
39Nurse Checklist Sample PCI site Focus? -patient preparation for additionaltreatment ortransfer
40Stemi Scribe Recording times Data collection Monitoring communication
41Next: 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 improvementData Sheet B always follows the patient and contains a record of total time from recognition to reperfusionData Sheet A stays in the ED
42Step 3: Complete Data Sheets A & B during each STEMI ALERT
43for efficient feedback Date Sheet AStays in the EDProvides informationfor efficient feedback
44or to the receiving facility Provides data on arrival Data Sheet B:Sent to the cath labor to the receiving facilityProvides data on arrivalWhen completed has datapoints from the entire case
45This 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 helpfulOur standard is to measure R2R times on each patient!
46Same 4-step process at every facility! Data sheet B links them together!
48Can 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
49Implementation1) Develop an individualized STEMI ALERT Packet for your institution2) Train your staff at3) Place the STEMI ALERT Packets in your ED4) Go live! The process will continue improving using the data collection loops built into the process
50Train all ED staff prior to “go live’ Takes one hour or less Provider EducationTrain all ED staff prior to “go live’Takes one hour or lessA combination of a written tutorial, on-line video and short written testAvailable at
51The Project UPSTART website: Your link to the UPSTART world! Links to all required formsMore Powerpoints! Training videos!The common access point for provider trainingSimple and clear information in an easily accessibly form
52Example: Additional forms……. ED Activation of the Cath LabED Thromblytics GuideEMS Guide SheetCath Lab ChecklistImplementation ManualUPSTART Follow-up Sheet