1. Time Delay In Management Of STEMI In Big Hospitals – Causes & Remedies DIRECTOR OF CARDIOLOGY :- Deenanath Mangeshkar Hospital CHIEF CARDIOLOGIST :- Joshi Hospital/Ratna Hospital CONSULTANT CARDIOLOGIST :- N.M. Wadia of Cardiology DR. SHIREESH SATHE INTERVENTIONAL CARDIOLOGIST 17 th May 2008

3. TIME IS MUSCLE

4. Time Is Myocardium and the Wavefront of Necrosis CM Gibson 2002

5. STEMI – Important Time Intervals Window Period – Onset of symptoms to thrombolysis - < 6 hrs Door to needle time – ER/Casualty to thrombolysis – 30 min Symptoms to balloon time - < 12 hrs. Door to Balloon time(D2B) – ER/Casualty/CCU to PAMI – 90min PCI related delay -60 min

6. Symptom Recognition Call to Medical System ED Cath Lab PreHospital Delay in Initiation of Reperfusion Therapy Treatment Delayed is Treatment Denied Antman et al, J Am Coll Cardiol 2004;44:671–719. Increasing Loss of Myocytes

13. Management of acute myocardial infarction Aims: Prevent death Minimise patient’s discomfort and distress Limit the extent of myocardial damage Strategy: Re-establish myocardial reperfusion before irreversible damage occurs: –mechanically (percutaneous coronary intervention) –pharmacologically (induction of thrombolysis by fibrinolytic agent) Time is muscle Management

15. Reperfusion Options for STEMI Patients Step One: Assess Time and Risk. Time Since Symptom Onset Time Required for Transport to a Skilled PCI Lab Risk of STEMI Risk of Fibrinolysis Antman et al, J Am Coll Cardiol 2004;44:671–719.

16. Door to Needle Time < 30 min Infusion Vs Bolus Thrombolysis

17. OBSTACLES LEADING TO DELAYS –Physician Prompt recognition of STEMI Distinction b/n STEMI and Non-STEMI Response time –ED MD seeing patient –IC answering page Reluctance to activate lab w/o certainty Desire to have other MD’s fellows see all patients first Concern about: –alternative etiology (Dissection, PE, etc.) –comorbid conditions (coagulopathy, anemia, etc.) –Communication and coordination b/n ED and IC Lack of trust (being in other person’s shoes) –Nursing “obstinence” Transport readiness Meds administration “Control” issues

19. Door to Balloon Times: Achieving 90 Minutes and Less

20. D2B Alliance Goal Goal: –To achieve a door-to-balloon time of ≤ 90 minutes for at least 75% of non-transfer primary PCI patients with STEMI.

21. Importance of Prompt Treatment Prompt treatment increases the likelihood of survival for patients with myocardial infarction with ST-segment elevation (Berger et al., 1999; Cannon et al., 2000, McNamara et al., 2006). McNamara et al., JACC, 2006

22. One-Call Activation Of System for Emergent PCI In Acute ST-Elevation Myocardial Infarction

28. Tracking document DOOR TO BALLOON TIME Door to EKG EKG to decision ( to proceed to PCI) Decision to left ED Left ED to case start Case start to first balloon inflation

29. Door to Balloon Times Among Patients Transferred in NRMI 4 NRMI 4 Transfer-In Annual Data Report 2002 Door to Data: 50 th : 8 Min. 25 th : 4 Min. 75 th : 16 Min. Door to Data: 50 th : 8 Min. 25 th : 4 Min. 75 th : 16 Min. Data to Cath Lab Arrival: 50 th : 137 Min. 25 th : 87 Min. 75 th : 220 Min. Data to Cath Lab Arrival: 50 th : 137 Min. 25 th : 87 Min. 75 th : 220 Min. Cath Lab to Balloon: 50 th : 39 Min. 25 th : 29 Min 75 th : 53 Min. Cath Lab to Balloon: 50 th : 39 Min. 25 th : 29 Min 75 th : 53 Min. 8 8 137 39 Total Door to Balloon Time: 198 minutes (25 th : 137; 75 th : 281) Percent of Patients with Door to Balloon Time < 90 Min.: 4.8% Total Door to Balloon Time: 198 minutes (25 th : 137; 75 th : 281) Percent of Patients with Door to Balloon Time < 90 Min.: 4.8% Sample Size: 1,292; Time Period: October 2000 – September 2001 Gibson CM, 2002

31. Hospital Variation in Door to Balloon Times

32. Where are we now? Recommended StrategyUS ED activates cath lab Days49.0% Nights57.1% Single call27.9% Cath team in 30 mins72.2% Prompt data feedback56.4% Data as of 4/27/2007; N=876; response rate to enrollment survey = 75%

33. Also… Optional StrategyUS Activate lab based on pre-hospital ECG while patient en route28.5%

35. Single Most Challenging Problem Reported by Responding Hospitals (N=522)

36. D2B Alliance Goal Present D2B Times achieved 120 min 33 % 33% 33% Goal for future < 90 % - 70%

37. D2B Alliance Evaluation Plan January – June 2008: Resurvey hospitals Summer 2008: NCDR Registry GWTG Analysis Winter 2008/2009: CMS/HQA Data Analysis

38. Strategy: systems & roles Use of ambulance ECG – for clear STEMI – for early alert Direct activation of Cath Lab by ED – for clear STEMI ED target < 10 minutes for ECG, < 20 minutes to notify Cath Lab Clear expectations for staff Cath Lab arrival time Pre-stocked STEMI cart in Cath Lab

39. Door-to-Balloon Time-Saving Tips Strategy 1.Mandate that cath lab personnel 19.3 minutes respond to the lab within 20 min of the initial page. 2.EMS notification to ED and emergency 15.4 minutes physician activates cath lab based upon field 12 lead ECG. 3.24- hour in-house cardiologist 14.6 minutes 4.Cath lab team personnel all on single 13.8 minutes “ group page” similar to the mechanism to activate trauma team pagers 5. Allow emergency physician to activate cath lab 8.2 minutes without prior approval by cardiologist 6. Provide immediate feedback to staff involved 8.6 minutes about their performance for each emergency cath lab case Time saved

41. THANK YOU