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

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

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

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

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

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

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

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

Rescue 1 Page Transport Arrangements Ministry Connect Cath Lab Team Transport Arrangements CCU Team ER Team Rescue 1 Page Ministry Connect 888- 411-1DOC(1362) Nathan Interventional Cardiologist Called Telecom courtesy notification to CV Surg/Pastoral Care/Security Admitting notified Lab

Nathan

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

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

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

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

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

On-site Clinic to ED/Cath Lab Clinic Provider--Call ED MD at 1-2970 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

Off-site Clinic to ED/Cath Lab Clinic Provider – Call Ministry Connect (888)411- 1362 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

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

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

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

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

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

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

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

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

Dr. Clark

Dr. Clark

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

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

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

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

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 158-161, ISSN 0002-9149, http://dx.doi.org/10.1016/j.amjcard.2007.07.082. (http://www.sciencedirect.com/science/article/pii/S0002914907018735) Dr. Clark

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

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.110.007039published online before print December 6 2011, doi:10.1161/CIRCULATIONAHA.110.007039 Dr. Clark

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

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

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;355:2308-2320. Dr. Clark 38

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

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

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 email to clinical staff involved in event Periodic data review specific for group (i.e staff/provider meetings) Dr. Clark or Jan

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

First Medical Contact & EMS Engagement Techniques Questions? All