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Overview of the Winnipeg CODE STEMI Project Implemented May 2008

Overview of the Winnipeg CODE STEMI Project Implemented May 2008. Dr.J.Tam MD, FRCP(C), FACC Section Chief Cardiology WRHA and University of Manitoba Lillian Hall, RN, BHScN, CNCC (Canada) WRHA Cardiac Sciences Quality Manager Lorraine Avery, RN, MN, CNCC (Canada)

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Overview of the Winnipeg CODE STEMI Project Implemented May 2008

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  1. Overview of the Winnipeg CODE STEMI Project Implemented May 2008 Dr.J.Tam MD, FRCP(C), FACC Section Chief Cardiology WRHA and University of Manitoba Lillian Hall, RN, BHScN, CNCC (Canada) WRHA Cardiac Sciences Quality Manager Lorraine Avery, RN, MN, CNCC (Canada) Regional CNS WRHA Cardiac Sciences

  2. Agenda • Introduction/Background • Goals of the Safer Healthcare Initiative • Milestones • Data Review/Outcomes • PCI Statistics • AMI Crude Mortality Rates at SBGH • SBGH Primary PCI times – Days only • Lessons learned • Next steps

  3. Interventional Cardiology in Manitoba • 1500 PCI’s per year • Six Interventional Cardiologists (2-3 days week in lab and then on call 1-6) • SBGH: 2 full time labs which includes the on call room • HSC: 0.6 lab (shared with pediatrics) 3 days per week • Covers all of Manitoba, Northwestern Ontario and Nunavut • Services 1.3 million people

  4. Introduction/Background • Regional standardize Acute MI care since 2001 • Safer Health Care Team established 2005 • Inclusion of WRHA Transport Team • Emergency Medical Services • WRHA Cardiac Sciences and Emergency Programs • Original group consisted of 2 other WRHA facilities • Retrospective audit Regional (April-June 2005) reveals several hot spots: • Door to needle time TNK (N = 24 cases) • Door to first balloon inflation PCI (N = 24 cases) • Smoking cessation (Non-STEMI & STEMI N = 65 cases)

  5. Goals of the SHC Initiative • To improve processes of care to decrease time to therapy for STEMI patients • Improve patient outcomes • Decrease in-hospital mortality • Integrated and coordinated pre-hospital component to STEMI care within the WRHA.

  6. Key Milestones • March 2006: Pre implementation data collection done • May 2006: Patient Discharge Sheet implemented that identified key standards of STEMI care • Fall 2006: WRHA AMI Care Map re-authored and implemented (6 sites) • Dec 2006: The Next Steps Heart Fair established at SBGH • Jan 2007: Concurrent auditing of Primary PCI times using standardized concurrent tracking tool • April 2007: Authored two algorithms: - Indications for primary PCI - Indications for rescue PCI post fibrinolytic • Jan 2007: Processes to improve times to first ECG in the ED at SBGH

  7. Key Milestones • April 2008: Authored 2 STEMI treatment algorithms • April 2008: Physician standard orders re-authored to reflect the new STEMI standards of care • May 2008: Pre hospital care phase 1 started - communication with EMS and STEMI Cardiologist • June 2008: LEAN demonstrator project at SBGH for Suspect ACS in emergency • July 2008: Full implementation of pre hospital care • August 2008: Re-authored the WRHA Suspect ACS Care Map

  8. Recognized STEMI <3hours

  9. Recognized STEMI 3-6 hours

  10. First Code STEMIWednesday, May 21, 2008 • Symptom onset to balloon time 112 minutes • EMS (first medical contact) to balloon time 70 minutes • Hospital arrival to balloon time 32 minutes Symptom onset at 1215 EMS Scene arrival at 1257 EMS 12 lead at 1305 (15 lead); 1320; 1329 Call to Cardiologist at 1315 Cath lab notified at 1340 Arrived at lab at 1335 In Angio Suite at 1345 Balloon inflation at 1407 Reason for Primary PCI Weekday daytime primary PCI Complex LAD/septal lesions but good angio table to balloon time in spite of complexity of lesion

  11. Second Code STEMIThursday June 5, 2008 • Symptom onset to balloon time 152 minutes • EMS (first medical contact) to balloon time 79 minutes • Hospital arrival to balloon time 38 minutes Symptom onset at 0750 EMS dispatched at 0856 EMS Scene arrival at 0903 EMS 12 lead at 0915 (Inferior STEMI) Call to Cardiologist at 0922 Destination arrival at 0944 Arrived at lab at 0949 In Angio Suite at 0954 Balloon inflation at 1022 Reason for Primary PCI Weekday daytime primary PCI

  12. Third Code STEMIFriday, June 6, 2008 • Symptom onset to balloon time 99 minutes • EMS (first medical contact) to balloon time 76 minutes • Hospital arrival to balloon time 44 minutes Symptom onset at 1115 EMS Scene arrival at 1138 EMS 12 lead at 1203 (Anterior STEMI) Call to Cardiologist at 1201 Destination arrival at 1210 Arrived at lab at 1215 In Angio Suite at 1220 Balloon inflation at 1254 Reason for Primary PCI Weekday daytime primary PCI

  13. Comparison EMS Contact to Open Artery Pre and Post Implementation of the STEMI Protocol Pre Post # cases 30 cases 15 cases Average 109 minutes 76 minutes Median 88 minutes 72 minutes Longest >>90 min 89 minutes

  14. Lessons Learned • Implementation of the new EMS Patient Care Electronic (PCR) Record was delayed • Needed to purchase monitors capable of performing a 12 lead that were compliant with PHIA regulations • The monitors needed to have the capability of integrating with the PCR • Timing transmission of the 12 lead from the Zoll Monitor – to the PCR – to the blackberry • Training of the EMS (N =350) was a bit early (Dec 2007) since phase 1 didn’t go live until May 21, 2008

  15. Lessons Learned • Support for initiative from all key stakeholders – well established • Ability to transform evidence into practice • Integration of revisions to standards example ACS and AMI Care Maps

  16. Next Steps • Code STEMI Team at SBGH to respond to Code STEMI’s at the SBGH ED (Dec 2008) • Dialogue with other key stakeholders outside of the WRHA • Continue to ensure a seamless approach to patient care throughout the WRHA • Continue to work with key stake holders to improve STEMI care

  17. Website Address http://www.cardiacsciences.mb.ca Under city wide hospital forms left sided tab: • STEMI Algorithms • Indications for Primary PCI • Indications for Rescue PCI • AMI Care Map (SBGH), order set • Code STEMI Poster

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