1. D2B Strategies and the Role of the Emergency Department John J. Kelly DO, FACEP Associate Chair, Emergency Medicine Albert Einstein Medical Center Associate Professor of Emergency Medicine Jefferson Medical College

2. Key Components “Achieving D2B Times That Meet Quality Guidelines: How Do Successful Hospitals Do It?” Rapid Triage Identification of ACS (Prehospital) Rapid EKG and CXR (Maintain Broad Differential Diagnosis) Rapid Safety Net and Emergency Cardiac Meds One Call to Activate Cath Lab Team Immediate “Package” for Transport Rapid Safe Transport to Cath Lab Succinct and Safe Handoff to Cath Lab (Bradley EH, JAmCollCard. 2005;46:1236-1241)

3. Bradley EH, NEJM 355;22 Nov 2006 “Strategies for Reducing D2B” “Substantial variation in prevalence of specific strategies to expedite Door to Balloon Time”

4. Bradley EH, NEJM 355;22 Nov 2006 “Strategies for Reducing D2B” “Strong Associations” saving 10-15 minutes Emergency Physician activates CathLab “One Call” by Emergency Physician Cath Lab staffed within 30minutes of page Attending Cardiologist in hospital EKG transmitted by EMS to activate Cath Lab Real-time D2B Data Feedback to staff

5. Bradley EH, NEJM 355;22 Nov 2006 “Strategies for Reducing D2B” No Significant Effect: Policies/Practice for EKG Process Policies/Practice for Transport to Cath Lab Practices in Cath Lab (including relocation of Cath Lab)

6. ED Challenges with D2B: Door to EKG Triage and CAD Screening/EKG Our EDs are overcrowded across the country Difficult Historians Atypical presentations: young, female, elderly “I feel weak” How many EKGs for that one STEMI? This is a vague indicator for the Core Measure

7. Door to EKG Challenges Interestingly, “hospital policy on the performance and assessment of EKG in the ED did not have a significant effect on D2B” (Bradley, NEJM 355;22 Nov06); included Criteria for EKG, Formal Training in Triage Assessment of ACS, Dedicated EKG Techs, Dedicated Triage Space for EKG AEMC Data concludes the same

8. ED D2B Challenges: 90 Minute Deadline Increases Errors: CathAlert Safety Systems Strategies Simplicity EKG and CXR verification by ED and Cath Lab Patient Involvement/Constant explanation Checklists and Algorithms on Intranet (EDWIN) Teamwork with perfect communication Medication Safety (Heparin and Lytics)

9. ED Challenges with D2B When a patient looks like they are having AMI….. They get more care! However…when they do not look like an AMI….. Patient complexity and unique circumstances will make D2B more difficult to achieve…..

10. ED D2B Challenges: Preserving Professionalism between Specialty Colleagues D2B Process 0700-1800: easy! After-hours and Weekends: tougher! Adversarial anecdotal reports from EM/Cards “More Time Produces More Information” Unfortunately, call must be made < 20 minutes We must be kind to one another as we help our patient False-Alarm Cath Alerts: Inevitable

11. D2B and the Role of EM: What We Know Treatment is more rapid if EM makes treatment decision without involvement of Cardiology (ThatcherJL:JInvasiveCardiol 2003;15:693-8) (JacobyJ:JInvasiveCardiol 2005;17:154-5) (KhotUN:Circulation 2007;116:67-77) Coordination with EMS saves time! (CantoJG:JAmCollCardiol 1997;29:498-505) (CurtisJP:JAmCollCardiol 2006;47:1544-52) (CantoJG:Circulation 2002;106:3018-23)

12. D2B and the Role of EM: What We Know Real-time Feedback to the Team is Good! Cath Team must be ready in 30 minutes. Other Strategies may be impractical or too expensive (In-Hospital Cardiologist)

13. D2B and the Role of EM: What We Know “Achieving Rapid D2B Times: How Top Ten Hospitals Improve Complex Clinical Systems” Put together a great team with uncompromising clinical leaders. (Bradley EH, Circulation 2006;113:1079-1085)