STEMI/Stroke Boot Camp Lessons from the Trenches

My Roots (North of Everywhere) Devils Lake = Home Devils Lake = Home FYI: ND has 4 PCI centers…

North Dakota – The Four “F’s” F1) Freezing… Coldest temp in Devils Lake last year? -32 degrees (below zero)

North Dakota – The Four “F’s” F2) Farming… Life in the “Vast Lane”

North Dakota – The Four “F’s” Snow plow on Devils Lake… Ice House Ice = 3.5’ F3) Fishing (ice)

North Dakota – The Four “F’s” F4) And Flooding… 1997 Red River of the North flooding Grand Forks, ND Photo: “Come Hell or High Water” (left) won Pulitzer Prize

Why “STEMI Boot Camp”? The US Marines: Every Marine IS a rifleman STEMI 2010: Every STEMI provider must know the basics of the system Boot Camp: In order to improve a team-based process you must strengthen “all the links”

 Sudden complete obstruction of a blood vessel to the heart that results in muscle destruction. ST elevation myocardial infarction

STEMI: Flagship Product or “Canary in a Coal Mine?” Got STEMI? STEMI patients: Small numbers but highly visible versus a barometer of the entire system?...or both?

Today’s Goal: We are going to discuss STEMI Systems Engineering: This involves a discussion of the optimization of the Essential Elements of Reperfusion as they relate to pre-hospital STEMI Care. GOAL: Optimization, NOT improvement!

In simpler words…… “Git -R- done!” Larry the Cable Guy’s opinion about STEMI treatment decision making at a non-PCI center.

The “STEMI Care Continuum” Cemented by Relationships! THE PATIENT THE PATIENT EMS personnel EMS personnel ED triage personnel ED triage personnel Medical Command Medical Command ED nursing staff ED nursing staff ED physician ED physician EMS transfer staff EMS transfer staff Paging system personnel Paging system personnel Cath lab staff Cath lab staff Cardiologist Cardiologist Quality Improvement staff Quality Improvement staff Reperfusion! Recognition! Relationships

The Cardinal Rule: Once STEMI is identified  it must trigger a clear response downstream! ECG Acquisition Communication EMS Evaluation !Decision!

I. Remember…Most of the Time …the easy ones are easy! So, make more of them easy!

II. STEMI Fact: If it Can Go Wrong, it Will (sooner or later) Leave nothing to chance! Approach STEMI systems building like a system’s engineer… Don’t try to error- proof your providers. Error-proof your system!

III. STEMI 2010: There is NO New Frontier! Every STEMI case has the same fixed endpoints (R2R) Model success, but don’t copy it! (???) Adapt principles to the situations not vice versa!

So, what's new in STEMI??? 2011: ACC/AHA update on STEMI So, what has changed in STEMI science?

Not Much! Time Still Equals Muscle! ACC/AHA 2007 STEMI Focused Update Circulation 2007; on line, December 10. IIIIIIaIIb IIIIIIaIIb STEMI patients presenting to a hospital without PCI capability and who cannot be transferred to a PCI center for intervention within 90 minutes of first medical contact should be treated with fibrinolytic therapy within 30 minutes of hospital presentation, unless contraindicated.

STEMI 2010: “60 is the New 90” Gersh BJ, et al. JAMA. 2005;293: Time From Symptom Onset to Reperfusion Therapy (hours) Mortality Reduction, (%) Mortality (%) Mortality Reduction (%) Extent of Salvage (% of area at risk) D-B – Harm A-B – No Benefit Shifts in Potential Outcomes A-C – Benefit B-C – Benefit D-C – Harm 04 D C B A i.e. 44 is better than 66!!!

Recognition to Reperfusion (R2R) STEMI Engineering Lingo: Time interval from STEMI Recognition (regardless of location) to Reperfusion (regardless of the chosen strategy)! Focused on actions not location Engineers: Think “Before the Door” and “Options Beyond Angiography”

Recognition to Reperfusion TRUTH: Without early recognition there can be no progress towards early reperfusion The focus must be on the earliest possible recognition followed by fast and precise reperfusion Again, it all begins with Recognition!

Thought Provoking Question As far as your next potential STEMI patient is concerned, who is THE most important person in the STEMI Care Continuum?

It’s Whoever Does That First ECG! No Recognition = No Reperfusion!

Use of the prehospital ECG improves door-to-balloon times in ST segment elevation myocardial infarction irrespective of time of day or day of week. Cleveland Clinic Florida Hypothesis: use of the prehospital ECG, coupled with an emergency department initiated "Cath Alert" system,could neutralize D2B delays related to time of day or day of week. RESULTS: D2B - mean 69 mins. 78% achieving the recommended D2B of 90 mins. Afolabi BAAfolabi BA, et al OLD NEWS!

Would You Miss This?

Recognition: How is Your System Doing? 1) Do you have a written “Screening ECG Protocol” within your institution & system –including EMS? 2) Is it visibly posted in your ED/triage areas & EMS vehicles? 3) Do ED, EMS and triage staff follow it 25/8? 4) Have you specifically trained your staff regarding their key role in obtaining the screening ECG? 5) Do you have multiple backup pathways in place to ensure that the screening ECG gets done during busy times? 6) Is each ECG immediately shown to a physician?

However, it is as it is…. Several reasons why pre-hospital STEMI care will always remain a challenge…

Rokos et al. J Am Coll Cardiol Intv, 2009; 2: All Americans are Not Distributed Equally!

PCI within 60 minutes?

“STEMI Vision” –Just Say No! 95%+ of EMS calls are NOT STEMI! Ab Pain MVA Weak/dizzy ??? Altered Need ride Etoh STEMI Chest Pain

Quiz: STEMI Finances 101  How much is an EMS provider in Missouri reimbursed for: A) Learning to do an ECG? B) Completing an ECG on Grandma? C) Interpreting an ECG D) Discussing the ECG with MedCom? 2) How much does a helicopter flight cost?

STEMI: A Needle in the Haystack STEMI cases are few and far between Without Recognition there can be no Reperfusion So, you have to do a lot of ECG’s! ! …Its a cost of doing business!

The “STEMI/Sick Patient” Paradox… Sick EMS patients (usually) look sick (trauma, VFIB, hypoxia, asystole) Motto: Keep ‘em alive, & diagnose ‘em after arrival! …Not so with STEMI!

The EMS Environment…Chaos Theory Run Rampant! Multiple patients types and illnesses Everyone thinks they are the “emergency” Dramatic does not mean emergent Constant provider turnover Improvising is often an essential skill Multitasking required

STEMI Systems of Care PCI capable Non-PCI SYSTEM OF CARE CENTER OF CARE Patient & Community EMS ED STEMI Referral STEMI Receiving Awareness Activate EMS Avoid delay 12-lead ECG inter- hospital transport Activate team No diversion Treatment protocols and clinical pathways Jacobs. Circulation 2007;116:

Transport Time: “Jokers Wild!” Transportation issues Air vs. ground Local EMS issues Inter-facility issues Weather People factors

EMS STEMI Care: Lessons Learned… Situational decision making important Standardization and flexibility are key Essential Elements must be simplified PROVIDER SKILLS and PLANS first TECHNOLOGY second!

Think Globally, Act Locally EMS STEMI solutions must be locally driven based on national suggestions Change items that really matter.

So, Where Do We Start?

REVIEW: Once STEMI is identified  it must trigger a clear response downstream! ECG Acquisition Communication EMS Evaluation !Decision!

EMS: The Big Picture Ensure that every patient has timely access to an EMS provider who has: ECG equipment… ECG acquisition training, A Screening ECG Protocol to follow A Downstream communication plan A STEMI ALERT plan to activate

STEMI Engineering: Recognition Rigid adherence to a Screening ECG Protocol is crucial! “All portals at All times” Forgetting the screening ECG is simply not permitted!

Lesson: Avoid “Fred Sanford Syndrome” Developing optimal STEMI recognition practices at every STEMI portal Goal: Every qualifying patient receives a timely screening ECG!

Solution? Print It Post It Expect It Measure It

All Patients (in Your EMS Catchment Area)…Do They… have timely access to an EMS provider with: ECG equipment…? ECG acquisition training…? A Screening ECG Protocol to follow…? A downstream communication plan…? An area-specific STEMI ALERT plan to activate…?

4 a.m. Sunday night, Raining… Grandma’s house …44 miles out…

ECG done! Three key questions now matter! How is the ECG interpreted? How is this info relayed ahead? How will this info change the destination facility or facility response?

Once STEMI is identified  it MUST trigger a clear response downstream! ECG Acquisition Communication EMS Evaluation !Decision!

Three Options for EMS Evaluation Evaluation = Interpretation

A. Computer Interpretation (Evaluation) Most ECG machines use similar algorithms Can Detect % of STEMI cases 90% Specific Not as accurate as transmission but maintains a low false positive rate

B. On-site Provider (Evaluation) The most variable situation Highly dependent on provider skill Highest rate of false positives Can work with intensive training Not feasible in many areas

C. Transmission of the ECG for Physician Over-read The “Gold Standard” Highest accuracy rate Costly Prone to failure Terrain dependent Greatest potential to prevent false starts Often looked at unrealistically

Which is Better? All three options are appropriate, depending on: EMS provider availability Financial resources EMS ECG recognition skills Location of local PCI centers, etc Geography and terrain

Regardless, Downstream Communication is Essential! Acquisition Training + Equipment =Capability Patient + Screening ECG Protocol = Possibility Acquisition + Evaluation = Information Information + Communication =Decision Decision + Plan = Definitive Action

Got STEMI? –Call the ED! EMS/ED communication on every potential STEMI is a must Either with OR without ECG transmission I think I got one!

Downstream Communication EMS direct activation of the cath lab EMS/ED discussion via radio Transmission of the ECG for physician over-read EMS Diverts to a PCI center EMS/EMS rendezvous

Transmission: Nice, but not required!

Next Step? After downstream communication is attempted or complete procede with a pre-determined STEMI ALERT plan.

D: Logging, Bad Burgers & “Angels” 34 year-old male is logging trees in remote area Increased heartburn after “gut bomb” lunch Later, his boss starts driving him to the hospital Pain worsens; His boss calls rural EMS, who arrange to meet them at a local “KwikMart”. EMS does ECG in parking lot: it looks “bad” Idea: fax ECG to MedCom before departure

DX: Acute Inferior Wall MI! EMS departs for PCI center “Joe” at KwikMart faxes the ECG In route patient goes into VFIB arrest Defibrillated once with good results… EMS contacts PCI center in route; discusses ECG with the ED physician (…NO TRANSMISSION) Cath lab activated, ED on Standby…

ED Antics Arrives in ED …..’”groggy and painful” 2 nd IV placed/Groin prepped/Monitor Pacer pads placed Beta Blocker, Heparin and Plavix Clothes off, consented, and down the hall 8 Minutes ED door in to door out? 8 Minutes!

Cath Lab Precision… Cath lab staff ready at bedside! Lido time: Cath door + 4 Access time: D+ 12 Cath lab door to device: D+18 Cath Lab door-to-balloon: D+ 21 R 2 R time: 59 min. from 1st ECG Total DTB time: 21 minutes

Post Cath

Post Cath… Cardiac echo shows only a minimally depressed ejection fraction Patient feeling much better! Admits to 5 days of increasing “heartburn” PMH: Dad died at 50 of massive MI… Refers to his EMS providers as the “two special angels who saved his life!”

Madison County, VA “EMS Angels”

EMS and STEMI: A review Ensure that every patient has timely access to an EMS provider who has: ECG equipment… ECG acquisition training, A Screening ECG Protocol to follow A Downstream communication plan A STEMI ALERT plan to activate

Systems Engineering Science Is a precise application of the Pareto Effect (the 80/20 rule)! Concentrate the majority of effort on optimizing those actions most critical for sustained success in your process STEMI systems of care improvement has clearly care has defined essential elements 68www.projectupstart.com

Key Concept: The 5 Essential Elements of STEMI System Optimization R1Relationships R2Recognition R3Reperfusion R4Real-time Data Collection R5Reassessment & Refinement

The “5 R’s”: Essential Elements Are true “Essential Elements” of STEMI care Perfecting each of these five processes is critical in optimizing any local STEMI system Incorporate everything we have learned today Provide focus for improvement 70www.projectupstart.com

Optimize each R! A focus on optimizing each one of the “5 R’s” will allow rapid improvement of any local STEMI system (ESS) in the most efficient manner possible A precise application of the Pareto Effect (the 80/20 rule)! 71www.projectupstart.com

Optimizing Each Essential Element is Critical Failure to optimize each of the 5 R’s will lead to error at some later time Each step is critical to sustainable success Failure to implement systematic change sets the stage for provider error at some later stage An optimized system minimizes provider error and enhances provider excellence 72www.projectupstart.com

The 5 R’s of STEMI: The 5 R’s of STEMI: R1Relationships R2Recognition R3Reperfusion R4Real-time Data Collection R5Reassessment & Refinement 73www.projectupstart.com

R1) Relationships: The Most Important R! Without question, the most important factors in successful optimization of a local STEMI systems is development of strong relationships at all levels. 74www.projectupstart.com

Remember the R2R Continuum? Cemented by Relationships! EMS first contact personnel ED triage personnel ED nursing staff ED physician EMS transfer staff Paging system personnel Cath lab staff Cardiologist Quality Improvement staff Reperfusion! Recognition! Relationships 75www.projectupstart.com

The 5 R’s: The 5 Essential Elements of STEMI System Optimization The 5 R’s: The 5 Essential Elements of STEMI System Optimization R1Relationships R2Recognition R3Reperfusion R4Real-time data collection R5Reassessment & refinement 76www.projectupstart.com

The “5 R’s”: Essential Elements R2) Recognition: Implement an optimal STEMI screening process at each “STEMI portal” Goal: Each qualifying patient receives a timely screening ECG! All portals fixed or floating 77www.projectupstart.com

Solution? Print It Post It Expect It Measure It 78www.projectupstart.com

The 5 R’s: The 5 Essential Elements of STEMI System Optimization The 5 R’s: The 5 Essential Elements of STEMI System Optimization R1Relationships R2Recognition R3Reperfusion R4Real-time data collection R5Reassessment & refinement 79www.projectupstart.com

The “5 R’s” R3) Reperfusion: A concise reperfusion plan in place for each STEMI portal A “STEMI ALERT Process for every portal” -including pre-hospital portals -including interfacility transfers 80www.projectupstart.com

1) Design a STEMI ALERT Plan for Each “Fixed” Portal! -carefully customized to each specific “portal” -instantly accessible -simple -incorporates real-time data collection Goal: neutralize the effects of Chaos Theory, paralysis by analysis and other STEMI system maladies! 81www.projectupstart.com

2) Work with EMS to Design a Pre-hospital STEMI ALERT Protocol Consider EMS a floating “STEMI portal” Up to 50% of STEMI patients may use this “pre- hospital portal system” Simple protocols will address most needs More on this later 82www.projectupstart.com

The 5 R’s: The 5 R’s: R1Relationships R2Recognition R3Reperfusion R4Real-time data collection R5Reassessment & refinement 83www.projectupstart.com

The “5 R’s”: Essential Elements R4) Real-time Data Collection: Real-time data collection to measure and assess each STEMI Alert You can’t improve what you don’t measure 84www.projectupstart.com

Sample Data Sheet for STEMI Tier I data Simple Easy Collected in every STEMI 85www.projectupstart.com

The 5 R’s: The 5 R’s: R1Relationships R2Recognition R3Reperfusion R4Real-time data collection R5Reassessment & Refinement 86www.projectupstart.com

The “5 Rs”: R5) Reassessment and Refinement: Continual process improvement based on accurate data collected during a standardized & finely-tuned process is now possible! And, a standardized process + ongoing measurement allows for rapid and sustainable improvement 87www.projectupstart.com

Quality Improvement Science A standardized process (if accurately measured) allows for rapid and sustainable improvement If the data is acted on! No action will limit improvement! Improvement occurs via relationships! 88www.projectupstart.com

STEMI Continuum Relationships Allow for rapid improvement and sustained results If periodically maintained Reperfusion! Recognition! Relationships 89www.projectupstart.com

Review: The 5 Essential Elements of STEMI System Optimization Review: The 5 Essential Elements of STEMI System Optimization R1Relationships R2Recognition R3Reperfusion R4Real-time Data Collection R5Reassessment & Refinement R6Relationships (again) 90www.projectupstart.com

Questions That Drive Relationship Development Is your hospital a part of a formal regional STEMI system? Does regular scheduled meetings occur involving all levels of providers and participating facilities of your regional STEMI system? Can you name your major partner facilities? Does your hospital have a contact person within each of these facilities? 91www.projectupstart.com

Questions that Drive Relationship Development Do you have mechanisms (such as an EMS STEMI Story Board) to constantly let EMS know about cases gone right? Do you involve patient advocates (STEMI survivors) to help improve your STEMI system? Do you provide feedback to your EMS providers regarding the pre-hospital ECG process within your system? Does your system have a formalized method of providing case specific feedback to providers of the entire STEMI care continuum – including EMS/ED/Cardiology/the Cath Lab/QI? 92www.projectupstart.com

STEMI: The Big Picture What's going on outside of Bath County?

Mission: Lifeline – The Umbrella

Improving the System of Care for STEMI Patients 95

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virginiaheartattackcoalition.org

To work collaboratively to improve systems of care for the early recognition and treatment of all Virginia residents having heart attacks

virginiaheartattackcoalition.com American Heart Association EMS Cardiology Emergency Medicine Individuals Institutions …..Everyone working together!

VHAC Regions

Coalition Structure Full Coalition (All Stakeholders) VHAC Task Force VHAC Steering Team Project Teams - Reporting back to Task Force Interdisciplinary Regional Teams linked to geographical regions Steering Team VHAC Task Force Full Coalition (All Stakeholders)

virginiaheartattackcoalition.org The official VHAC website Your link to the STEMI Universe Connection point for VA STEMI care Collaboratively compiled by your local VA STEMI providers Bookmark please!

Graduation - Congratulations! Recognition Reperfusion Bath County STEMI Boot Camp!

Questions??? David R. Burt, MD University of Virginia Health System Assistant Professor of Emergency Medicine