STEMI Care Delivery Report Out

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Questions?