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Bev McCullough Quality Improvement Manager, RHQN

The New Washington State Emergency Cardiac and Stroke System: Developing a Best Practice Plan for Your Community. Bev McCullough Quality Improvement Manager, RHQN. Kim Kelley, MSW Planning Coordinator, WA State DOH.

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Bev McCullough Quality Improvement Manager, RHQN

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  1. The New Washington State EmergencyCardiac and Stroke System: Developinga Best Practice Plan for Your Community Bev McCulloughQuality Improvement Manager, RHQN Kim Kelley, MSWPlanning Coordinator, WA State DOH

  2. The Washington State Emergency Cardiac and Stroke System:Creating Opportunities Together Kim Kelley, MSW Cardiac/Stroke Systems Coordinator WA State Department of Health Kim.kelley@doh.wa.gov

  3. The Continuum of Care System Evaluation Prehospital Hospital Secondary Prevention/ Rehabilitation Prevention

  4. Creating Opportunities Together… Working together across the continuum we can coordinate care and find efficiencies in the system to reduce time to treatment and improve outcomes for our patients.

  5. Washington’s Population is Aging Annual Change in Population Ages 65 and Over

  6. Risk Factors Are Increasing

  7. The Chain of Events Physical Inactivity Poor Diet Tobacco Use Chronic Stress (Risk Factors) Diabetes Hypertension High Cholesterol Obesity (Diseases & Conditions) (Events/Deaths) Healthy Communities Emergency Cardiac and Stroke System Medical/Health Homes

  8. The Bottom Line A rapidly aging population and increasing rates of obesity, diabetes, and high blood pressure mean more people at risk for heart attack, cardiac arrest and stroke.

  9. Emergency Cardiac and Stroke Care in Washington Problem: effective treatments are available--but too many people don’t get them at all or in time • Only 4% strokes get t-PA • Only 35 of 95 hospital administered t-PA • Estimated 39% of heart attacks get PCI • Only 55% of hospitals give lytics under 30 min • OHCA survival rates very low

  10. The Solution An organized system to get the right patient to the right place in the right time, just like we do for trauma.

  11. D2B Time and Mortality

  12. SSHB 2396 Passed 2010

  13. System Components • EMS protocols for the identification, treatment, and triage of ACS and stroke patients • Hospital categorization • Commitment to implement best practices to improve outcomes • Data driven quality improvement across the system

  14. Hospital Categorization Program • 65 of 95 hospitals applied by 1/31/11 • 12 more applied by 5/31/11 • Notice of categorization sent to all hospitals. List sent to Regional Councils, EMS Councils • Lists will be on ECS website soon

  15. STROKE CENTERS AND COVERAGE AREA 2007 I

  16. STROKE CENTERS AND COVERAGE AREA 2011

  17. CARDIAC CENTERS AND COVERAGE AREA 2007

  18. CARDIAC CENTERS AND COVEREAGE AREA 2011

  19. Quality Improvement SHB 2396: • Requires QI of participating hospitals • Allows the trauma QI programs to evaluate emergency cardiac and stroke care delivery

  20. ECS System Measures and Goals • 15 minutes on-scene time for EMS • 30 minutes in transfer hospital (AMI) • 30 minutes door-to-needle (lytics, AMI) • 60 minutes door-to-t-PA (stroke) • 90 minutes first medical contact (EMS or transfer hospital) to definitive treatment • 120 minutes symptom onset to definitive treatment • Participating hospital within 1 hour from every citizen • Cardiac arrest goals - to be determined

  21. Outcomes • Discharge status • Length of stay • 30-day readmission/30-day mortality • Immediate and one-year mortality • Function at 3 months • Quality of life • Ejection fraction • Neurologic status

  22. What You Can Do… • Make your hospital part of the prevention cycle. • Educate your communities: CPR, signs and symptoms of heart attack and stroke, and to call 9-1-1 immediately. • Become cardiac and stroke centers and implement best practices.

  23. What You Can Do… • Work with your EMS partners and fellow hospitals to create comprehensive regional systems. • Collect data and use it to figure out what works and what doesn’t. • Participate in the statewide ECS TAC.

  24. Kim Kelley Cardiac/Stroke Systems Coordinator 360-236-3613 Kim.kelley@doh.wa.gov Thank you!

  25. A STEMI Story-Celebrating Successful Partnershipspresented to:WSHARural Hospital Summer WorkshopJune 28th, 2011Chelan, WApresented by: Paul Nurick, CEORhonda Holden, RN, MSNKittitas Valley Community Hospital

  26. Kittitas County

  27. 2006 STEMI Metrics

  28. Why the delays? • Every patient taken to Kittitas Valley for initial assessment and stabilization • EKG’s done by Respiratory Therapy only • Chest X-Ray obtained “per protocol” • EMS left the hospital, then were called back to transport patient to YRMCC Lab • No partnerships established and varying “trust” of the assessment of our EMS providers • Patients from KVCH taken to Yakima Reg. ED, reassessed & then cardiac cath team called

  29. A New Program Emerges • A focus on “what is right for the patient” • All partners at the table to develop standardized protocols and training of EMS providers • EKG performed in the field- if obvious STEMI and stable, EMS bypasses KVCH • EMS notifies YRMCC directly - cath lab notified • EMS bypasses Yakima ED - go directly to cath lab

  30. Changes at KVCH • Only unstable STEMI patients transported to KVCH • Implemented a STEMI Alert • Eliminated “wasteful” steps- Chest X-Ray • Multiple staff trained to perform EKG • EMS remains on scene when possible, ready to transport to YRMCC Cath Lab • One call to YRMCC- single line for referrals

  31. Cheryl’s Story • The call is dispatched for a patient experiencing chest pain. Volunteers from Cle Elum Fire Department respond, along with two off duty Medic One paramedics. • Paramedics are on scene at 12:51(<8 minutes from time of initial call). • Patient diaphoretic and short of breath; reporting 10/10 substernal pain radiating to both arms. • Transport from scene at 13:08.

  32. Cheryl’s Initial 12-Lead

  33. En route to Yakima Regional At 13:10 • 12-Lead ECG transmitted to YRMCC • STEMI protocol initiated. By 13:28, Cheryl received • x3 NTG SL, • 25mcg Fentanyl IVP • 324 ASA PO, 600mg Plavix IVP and • 5000 units Heparin IVP • Patient reports being pain free by 13:30.1336 Cath Team Called in to YRMCC • 1415 Medic Unit arrived at YRMCC • 1418 entered cath lab with team waiting for her

  34. Cheryl’s Coronary Artery Upon arrival at cath lab: Reperfusion at 15:15

  35. What’s Next • Transfer success of the STEMI Program to our Stroke Program • EMS performs a FAST exam in the field and notifies KVCH of a “Stroke Alert” • Developed a joint NIHSS- EMS initiates the NIHSS in the ambulance, ED staff utilize the same form to assess patient on arrival • Patients taken directly to our CT, EMS reports to ED provider and RN cares for patient in CT • “Door to CT” time <25 min in 75% of patients • Average Door to CT Read = 30 minutes

  36. Made possible by:

  37. But our favorite picture is: Cheryl and attending paramedic Beth Williams; Winter, 2011.

  38. Thank You Partners Upper Kittitas County Medic One- HD #2 Cle Elum Fire Department Kittitas Valley Community Hospital Kittitas County EMS (KITTCOM Dispatch) Kittitas Valley Fire & Rescue Yakima Regional Medical & Cardiac Center Virginia Mason Medical Center (Stroke)

  39. Rural “Best Practice”:Community Education Tom Martin, Administrator Lincoln Hospital Davenport, WA

  40. Initial Level One Newspaper Ad

  41. Cardiac Level One Brochure

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