STEMI/Stroke Boot Camp Lessons from the Trenches.

STEMI/Stroke Boot Camp

Lessons from the Trenches

My Roots (North of Everywhere)

Devils Lake = Home

FYI: ND has 4 PCI centers…

North Dakota – The Four “F’s”

F1) Freezing…

Coldest temp inDevils Lake last year?

-32 degrees (below zero)

F2) Farming…

Life in the “Vast Lane”

Snow plow on Devils Lake…

Ice House

Ice = 3.5’

F3) Fishing (ice)

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”The “STEMI Care Continuum” Cemented by Relationships! Cemented by Relationships!

THE PATIENTTHE PATIENT EMS personnelEMS personnel ED triage personnelED triage personnel Medical CommandMedical Command ED nursing staffED nursing staff ED physician ED physician EMS transfer staffEMS transfer staff Paging system personnelPaging system personnel Cath lab staffCath lab staff CardiologistCardiologist Quality Improvement staffQuality 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!

STEMI 2010: “60 is the New 90”

Gersh BJ, et al. Gersh BJ, et al. JAMAJAMA. 2005;293:979-986.. 2005;293:979-986.

100100

1212 2424Time From Symptom Onset to Reperfusion TherapyTime From Symptom Onset to Reperfusion Therapy

(hours)(hours)

Mortality Mortality Reduction (%) (%)

Extent of Salvage(% of area at risk)

D-B – Harm

A-B – No Benefit

Shifts in Potential

Outcomes

A-C – BenefitB-C – Benefit

D-C – Harm

88 1616 2020

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 QuestionThought 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 It’s Whoever Does That First ECG!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 BA , et al

OLD NEWS!

Would You Miss This?Would You Miss This?

Recognition: How is Recognition: How is YourYour System Doing? System Doing?

1)1) Do you have a written “Screening ECG Protocol” Do you have a written “Screening ECG Protocol” within your institution & system –including EMS?within your institution & system –including EMS?

2)2) Is it visibly posted in your ED/triage areas & EMS Is it visibly posted in your ED/triage areas & EMS vehicles?vehicles?

3)3) Do ED, EMS and triage staff follow it 25/8?Do ED, EMS and triage staff follow it 25/8?4)4) Have you specifically trained your staff regarding their Have you specifically trained your staff regarding their

key role in obtaining the screening ECG?key role in obtaining the screening ECG?5)5) Do you have multiple backup pathways in place to Do you have multiple backup pathways in place to

ensure that the screening ECG gets done during busy ensure that the screening ECG gets done during busy times?times?

6)6) Is each ECG immediately shown to a physician?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; 2:339-346

All Americans are Not Distributed Equally!

“STEMI Vision” –Just Say No!

95%+ of EMS calls are NOT STEMI!

Ab PainMVA

Weak/dizzy

???Altered

Need rideEtoh

Chest Pain

Quiz: STEMI Finances 101

1) 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 ECGD) 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

PCIPCIcapable

Non-PCINon-PCIcapable

SYSTEMSYSTEM OF CARE OF CARE

CENTER OF CENTER OF CARECARE

Patient &Community

STEMI Referral

STEMI Receiving

Awareness

Activate EMS

Avoid delay

12-lead ECG

9-1-1 inter-hospital transport

Activate team

No diversion

Treatment protocols and clinical pathways

Jacobs. Circulation 2007;116:217-230.

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 75 - 80% 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” 2nd IV placed/Groin prepped/Monitor Pacer pads placed Beta Blocker, Heparin and Plavix Clothes off, consented, and down the hall ED door in to door out? 8 Minutes8 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 R2R 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 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

68 www.projectupstart.com

Key Concept: The 5 Essential Elements of STEMI System Optimization

R1R1 RelationshipsRelationshipsR2R2 RecognitionRecognitionR3R3 ReperfusionReperfusionR4R4 Real-time Data CollectionReal-time Data CollectionR5R5 Reassessment & RefinementReassessment & Refinement

The “5 R’s”: Essential ElementsThe “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

Optimize each R! 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)!

Optimizing Each Essential Optimizing Each Essential Element is Critical 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

The 5 R’s of STEMI:The 5 R’s of STEMI:

R1RelationshipsR2RecognitionR3ReperfusionR4Real-time Data CollectionR5Reassessment & Refinement

R1) R1) Relationships:Relationships: The Most The Most Important R!Important R!

Without question, the most important factors in successful optimization of a local STEMI systems is development of strong relationships at all levels.

Remember the R2R Continuum?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

The 5 R’s: The 5 Essential Elements The 5 R’s: The 5 Essential Elements of STEMI System Optimizationof STEMI System Optimization

R1RelationshipsR2RecognitionR3ReperfusionR4Real-time data collectionR5Reassessment & refinement

The “5 R’s”: Essential ElementsThe “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

Solution?Solution?

Print It Post It Expect It Measure It

The 5 R’s: The 5 Essential Elements The 5 R’s: The 5 Essential Elements of STEMI System Optimizationof STEMI System Optimization

The “5 R’s”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

1) Design a STEMI ALERT Plan 1) Design a STEMI ALERT Plan for Each “Fixed” Portal!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!

2) Work with EMS to Design a Pre-hospital 2) Work with EMS to Design a Pre-hospital STEMI ALERT ProtocolSTEMI 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

The 5 R’s:The 5 R’s:

The “5 R’s”: Essential The “5 R’s”: Essential ElementsElements

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

Sample Data Sample Data Sheet for STEMISheet for STEMI

Tier I data Simple Easy

Collected in every STEMI

Date ED Attending:

Patient Name ED Resident:

Patient MR # CCU Fellow (pic #1309):

ED Nurse: ED Team Manager Phone #: 531-5839Cath Lab: 2-0976 CCU: 4-2582

Time of Onset of CP Symptoms

Time ECG Read by ED Attending

Time Cath Lab Activated

CCU Fellow Arrival Time

Attending Arrival Time

Lido Time

Access time

Time of 1st wire across lesion

Time of 1st Balloon Inflation

FORM TO STAY IN ED. Place in Mailbox of Barbara Craighead. DO NOT SEND WITH PATIENT.Comments / Suggestions:

ED Copy (Yellow) Time Study for STEMI Alerts STAYS IN ED

Patient Sticker

Time Cath Lab Team Calls for Patient

Time Patient Arrived ED

Time of 1st EKG

Time Patient Left ED

Time CCU Fellow Responds to Page

If not, Time CCU Fellow Paged

NOT PART OF THE MEDICAL RECORD

Time Patient Arrived in Cath Lab Room

Time ED STEMI Alert Initiated

INDICATOR

Did ED Attending Activate Cath Lab? Y N (circle one)

Date ED Attending:

Patient Name ED Resident:

Patient MR # CCU Fellow (pic #1309):

ED Nurse: ED Team Manager Phone #: 531-5839Cath Lab: 2-0976 CCU: 4-2582

Time of Onset of CP Symptoms

Time ECG Read by ED Attending

Time Cath Lab Activated

CCU Fellow Arrival Time

Attending Arrival Time

Lido Time

Access time

Time of 1st wire across lesion

Time of 1st Balloon Inflation

FORM TO STAY IN ED. Place in Mailbox of Barbara Craighead. DO NOT SEND WITH PATIENT.Comments / Suggestions:

ED Copy (Yellow) Time Study for STEMI Alerts STAYS IN ED

Patient Sticker

Time Cath Lab Team Calls for Patient

Time Patient Arrived ED

Time of 1st EKG

Time Patient Left ED

Time CCU Fellow Responds to Page

If not, Time CCU Fellow Paged

NOT PART OF THE MEDICAL RECORD

Time Patient Arrived in Cath Lab Room

Time ED STEMI Alert Initiated

INDICATOR

Did ED Attending Activate Cath Lab? Y N (circle one)

The 5 R’s:The 5 R’s:

R1 RelationshipsR2 RecognitionR3 ReperfusionR4 Real-time data collectionR5 Reassessment & Refinement

The “5 Rs”: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

Quality Improvement ScienceQuality 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!

STEMI Continuum RelationshipsSTEMI Continuum Relationships

Allow for rapid improvement

and sustained results

If periodically maintained

Reperfusion!

Recognition!

Relationships

Review: The 5 Essential Elements Review: The 5 Essential Elements of STEMI System Optimizationof STEMI System Optimization

R1 RelationshipsR2 RecognitionR3 ReperfusionR4 Real-time Data CollectionR5 Reassessment & RefinementR6 Relationships (again)

Questions That Drive Questions That Drive Relationship DevelopmentRelationship DevelopmentIs 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?

Questions that Drive Questions that Drive Relationship DevelopmentRelationship 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?

STEMI: The Big Picture

What's going on outside of Bath County?

Mission: Lifeline – The Umbrella

Improving the System of Care for STEMI Patients

http://www.americanheart.org/downloadable/heart/1238103222717ML_Criteria.pdfhttp://www.americanheart.org/downloadable/heart/1238103222717ML_Criteria.pdf

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 ForceVHAC

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, MDDavid R. Burt, MDUniversity of Virginia Health SystemUniversity of Virginia Health System

Assistant Professor of Emergency MedicineAssistant Professor of Emergency Medicine

drb5p@virginia.edu

434.924.2428434.924.2428

STEMI/Stroke Boot Camp Lessons from the Trenches.

stemi recognition

stemi case

rifleman stemi

stemi patients

stemi provider

stemi fact

stemi science

stemi systems engineering

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