CODE STEMI

1. CODE STEMI Presented by: P. Barber, J. Bautista, S. Fenley, and A. Hill Faculty: Lisa Lee and Donna Fesler College of Nursing University of Oklahoma EBP Symposium April 21, 2011

2. STEMI Specific type of heart attack Any coronary artery that becomes 100% blocked Distal part of heart muscle receives NO oxygen Heart muscle dies

3. Myocardial Infarction Non-ST-Segment Elevation Myocardial Infarction (NSTEMI) ST-Segment Elevation Myocardial Infarction (STEMI)

4. Identifying a STEMI Cardiac Markers ?Troponin, ?CPK 12-Lead Electrocardiogram

5. Identifying a STEMI

6. Identifying the Problem STEMI is the most deadly form of a heart attack No in-patient code STEMI protocol Longer hospital stay Delay in reperfusion Higher mortality rates

7. PICO QUESTION Does implementing an inpatient code STEMI protocol, among hospitalized patients 18 years of age and older, versus not having an inpatient STEMI protocol, improve patient mortality?

8. Statistics 400,000 people experience a STEMI 30% do not receive timely reperfusion 70% are not eligible for fibrinolytics and do not receive PCI (American Heart Association, 2011)

9. Current Practice ED Inpatient Literature review NO published evidence of a STEMI protocol AHA guidelines Most hospitals have adopted and many fail to meet door to balloon time within 90 minutes

10. Review of Literature No published evidence-based practice literature exists on STEMI protocols designed for inpatients, with other morbidities, that develop a STEMI while hospitalized

11. Review of Literature Registered nurse review of several studies Identified strategies to reduce door-to-balloon time (DTBT ) Delays increased hospital mortality rate regardless of time delay between onset of symptoms and arrival at facility (Farwell, 2010)

12. Review of Literature 2009 ACC/AHA Guidelines: Updates to current guidelines are of expert opinion based off evidence (Kushner et al., 2009)

13. Review of Literature DTBT of <90 minutes achieved in 70 out of 72 patients Sixty-five of the 72 patients survived to hospital discharge (Levis et al., 2010)

14. Review of Literature National Registry of Myocardial Infarction (NRMI) 29,222 STEMI patients from 395 hospitals DTBT vs. in-hospital deaths Increasing mortality was seen Degree of urgency should not depend on risk factors (McNamara et al., 2006)

15. Review of Literature Study performed at an urban teaching hospital Achieved decreased DTBT of 90 minutes or less Applied strategies in-house initiative comply with AHA STEMI guidelines Unique study largest urban teaching hospital feasibility of reducing DTBT (Parikh et al., 2009)

16. Review of Literature 2005-2006 data from American College of Cardiology National Cardiovascular Data Registry Final study sample of 43,801 patients Time to PCI was measured in 15 minute increments Longer door-to-balloon times had an increase in mortality rates Suggests an “as soon as possible” approach (Rathore et al., 2009)

17. Review of Literature Follow-up study based on Danish medical registries Three high-volume PCI centers in Western Denmark 6,209 STEMI patients treated with primary PCI System delay associated with mortality (Terkelsen et al., 2010)

18. Review of Literature Mayo Clinic implemented STEMI protocol in 2004 Compared pre-protocol and post-protocol DTBT DTBT 90 minutes vs. 71 minutes ? treatment times = ? morality rates (Ting et al., 2007)

19. Benefits of STEMI Protocol Decreased morbidity and mortality Incorporates EBP into clinical practice Efficient interdisciplinary performance Nationwide, organized approach No more communication gaps Increased readiness

20. Barriers to Implementation Resistance to change Various interests Challenges Education

21. Recommended Interventions Achieve DTBT within 90 minutes recommendation Implement hospital-wide STEMI protocol Conduct retrospective case studies to evaluate outcomes 4. Educate ALL staff regarding early interventions 5. Join a national registry

22. Evaluation Quality improvement processes to analyze data Chart review of inpatient STEMI for reperfusion times Compare reperfusion time and mortality rate variables Pre /post tests with online education, annual competencies 5. Report cases to data registry and receive feedback regarding improvement

23. Suggestions for Further Study Actual number of inpatient STEMIs Recognition of initial symptoms Inpatient STEMI protocol Mortality rates PCI reperfusion times

24. Any Questions?

25. References American Heart Association. (2011). Mission: Lifeline. Retrieved from http://www.heart.org/HEARTORG/HealthcareProfessional/ Mission-Lifeline-Home-Page_UCM_305495_SubHomePage.jsp Farwell, A.L. (2010). Saving muscle: Evidence-based strategies for reducing door-to-balloon-times for ST-segment elevation myocardial infarction patients. Journal of Emergency Nursing, 36(3), 231-37.  Kushner, F.G., Hand, M., Smith, S.C., King, S. B., Anderson, J.L., Antman, E.M.,… Williams, D.O. (2009). 2009 focused updates: ACC/AHA guidelines for the management of patients with ST-elevation myocardial infarction (updating the 2004 guideline and 2007 focused update) and ACC/AHA/SCAI guidelines on percutaneous coronary intervention. (updating the 2005 guideline and 2007 focused update). A report of the American College of Cardiology Foundation/American Heart Association task force on practice guidelines. Circulation: Journal of the American Heart Association. doi:10.11.1161/CIRCULATIONAHA.109.192663      

26. References Levis, J.T., Mercer, M.P., Thanassi, M., and Lin, J. (2010). Factors contributing to door-to-balloon times of < 90 minutes in 97% of patients with ST-elevation myocardial infarction: our one-year experience with a heart alert protocol. The Permanente Journal, 14(3), 1-11. McNamara, R.L., Wang, Y., Herrin, J., Curtis, J.P., Bradley, E.H., Magid, D.J., … Krumholz, H.M. (2006). Effect of door-to-balloon time on mortality in patients with ST-segment elevation myocardial infarction. Journal of the American College of Cardiology, 47(11), 2180-6. doi:10.1016/j.jacc.2005.12.072 Parikh, S.V., Treichler, D.B., DePaola, S., Sharps, J., Valdes, M., Addo, T., … Das, S.R. (2009). Systems-based improvement in door-to-balloon times at a large urban teaching hospital: A follow-up study from parkland health and hospital system. Circulation: Cardiovascular Quality & Outcomes, 2(2), 116-22. doi:10.1161.CIRCOUTCOMES.108.820134    

27. References Rathore, S.S., Curtis, J.P., Chen, J., Wang, Y., Nallamothu, B.K., Epstein, A.J., … Harold, H.H. (2009). Association of door-to-balloon time and mortality in patients admitted to hospital with ST elevation myocardial infarction: national cohort study. British Medical Journal, 338:b1807, 1-7. doi:10.1136/bmj.b1807 Terkelsen, C.J., Sorensen, J.T., Maeng, M., Jensen, L.O., Tilsted, H.H., Trautner, S., … Lassen, J.F. (2010) System delay and mortality among patients with stemi treated with primary percutaneous coronary intervention. JAMA: The Journal of the American Medical Association, 304(7), 763-71.

28. References Ting, H.H., Rihal, C.S., Gersh, B.J., Haro, L.H., Bjerke, C.M., Lennon, R.J., … Bell, M.R. (2007). Regional systems of care to optimize timeliness of reperfusion therapy for ST-elevation myocardial infarction. Circulation: Journal of the American Heart Association, 116(7), 729-36. doi:10.1161/CIRCULATIONAHA.107.699934