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AMI Virtual Learning Collaborative

Atlantic Node. AMI Virtual Learning Collaborative. Building on LS1-B. A ct. P lan. S tudy. A ct. S tudy. D o. D o. P lan. S tudy. D o. A ct. P lan. Closing Congress!! March 25-2010. Learning Session 1A October 07-09 1B October 21-09. Learning Session 2 January 06-2010.

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AMI Virtual Learning Collaborative

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  1. Atlantic Node AMI Virtual Learning Collaborative Building on LS1-B

  2. Act Plan Study Act Study Do Do Plan Study Do Act Plan Closing Congress!! March 25-2010 Learning Session 1A October 07-09 1B October 21-09 Learning Session 2 January 06-2010 Learning Session 3 February 10-10 Learning Collaborative Plan: for change Do: make changes Study: impact of change Act: on changes that work Action Period #1 Action Period #2 Action Period #3

  3. Team Self Evaluation Atlantic Node

  4. LS1-B Re-Cap Atlantic Node • Measures, data collection, worksheets and submission • Model for Improvement: Team, AIM, Measures, Changes • PDSA Cycles

  5. Atlantic Node

  6. What Worked Well Atlantic Node • The interactive aspect and the examples • Use to this format & it is easy to use! • This was a new format for me so the process is slow enough to follow

  7. What Worked Well Atlantic Node • Convenient and a good use of my time • Slide info together with handouts • People sharing their work from today. The brave ones!

  8. Improvement Opportunities Atlantic Node • More sharing by all and more questions.  • Keep things moving along at a faster pace, less breaks.

  9. Atlantic Node Comments/Questions

  10. IMPROVING DOOR TO NEEDLE TIMESTRH STEPHENVILLE EXPERIENCE AMER QURESHI MD, FRCPC

  11. DISCLOSURE Ihave no relevant financial relationships to disclose.

  12. OBJECTIVES FIBRINOLYTICS IN STEMI DOOR TO NEEDLE TIME STRH – EXPERIENCE & EFFORTS TO IMPROVE DOOR TO NEEDLE TIME

  13. CVD - MORTALITY CVD : 32.3% MEN 34.1% WOMEN 18.0% HOSPITALISATION HEART ATTACKS 49,220 - 2007-08 1678 (3.4%) 2nd MI HEART ATTACKS ~ 18000 DEATHS Canadian Institute for Health Information: Health Indicators 2009

  14. ACUTE MYOCARDIAL INFARCTION 30 DAY – MORTALITY 2003-2004 10.2% 2007-2008 9.1% MORTALITY ↓ - 11% 20 - 44 YRS. 41% > 65YRS. 11% Canadian Institute for Health Information: Health Indicators 2009

  15. ACUTE MYOCARDIAL INFARCTION ↓ MORTALITY ♂ > ♀ 4 TIMES AGE 20 - 44 YRS ♂ > ♀ 1.5 TIMES AGE > 65 YRS Canadian Institute for Health Information: Health Indicators 2009

  16. Rates of Hospitalized AMI Events by Age & SexCanada 2007-2008 Rate per 100,000 population Canadian Institute for Health Information: Health Indicators 2009

  17. AMI – INCIDENCE AMI PER 100,000 IN CANADA Canadian Institute for Health Information: Health Indicators 2009

  18. AMI PROVINCIAL INCIDENCE 2007-2008 Canadian Institute for Health Information: Health Indicators 2009

  19. ACC/AHA 2007 UPDATE OF 2004 GuidelinesManagement of Patients With ST-ElevationMyocardial Infarction

  20. ACC/AHA 2009 Focused UpdatesSTEMI and PCI Guidelines

  21. AMI – CARE INITIATIVE ASPIRIN ON PRESENTATION FIBRINOLYTIC BETABLOCKER ACEI / ARB STATIN ASPIRIN AT DISCHARGE SMOKING CESSATION COUNSELLING

  22. THROMBOLYTIC Tx & MORTALITY TIME TO THROMBOLYTIC AND 35 DAY MORTALITY Boersma E, Simoon ML, Lancet 1996; 348:771

  23. TIME IS MYOCARDIUM TIMELY FIBRINOLYTIC Tx: LIMIT INARCT SIZE PRESERVE LV FUNCTION IMPROVE SURVIVAL

  24. DOOR TO NEEDLE TIME ACC/AHA 2004 TASK FORCE ON STEMI REC. - DNT < 30min. ACC/AHA 2007 REC. WAS NOT CHANGED NRMI eval. >1000 US Hospitals 1999-2002 68,000 pts given Fibrinolytic Tx 46% < 30 min 33% ↓ DNT by >1 min 32% ↑ DNT by >1 min National Registry of Myocardial Infarction, McNamara RL; Herrin J; J Am Coll Cardiol. 2006 Jan 3;47(1):45-51

  25. FIBRINOLYTIC Tx ABSOLUTE CONTRAINDICATIONS: ICH Cerebral Vascular lesion Malignant I/C Neoplasm CVA within last 3 months Suspected Aortic Dissection Active Bleeding or Bleed. Diathesis Severe closed head/facial trauma

  26. FIBRINOLYTIC Tx RELATIVE CONTRAINDICATIONS: Poorly controlled HTN, BP syst. >180 mmHg CVA > 3 mo Traumatic/prolonged CPR >10 min Major Surgery within last 3 wks. Internal Bleeding in recent 2-4 weeks Non compressible Vascular puncture Pregnancy Anticoagulation Active PUD

  27. BLEEDING WITH FIBRINOLYTIC GUSTO-1 Severe Bleeding 1.8% F > M Moderate Bleeding 11.4% Bleeding mostly procedure related sec. to CABG or PCI. Spontaneous bleeding was GIT 1.8%

  28. BLEEDING WITH FIBRINOLYTIC GUSTO-1

  29. BLEEDING WITH FIBRINOLYTIC ASSENT - 2 Tenecteplase vs Alteplase Rate of Stroke 1.8% - 1.7% ICH at 30 days 1% - 1% Non cerebral bleed 26.4% - 29% Need for BT 4.3% - 5.5%

  30. BLEEDING WITH FIBRINOLYTIC Pooled analysis of >200,000 pts recv. Fibrinolytic Tx Risk of stroke 1.34% ICH 0.59% Non Trial community 12793 pts Risk of Stroke 1.2% ICH 0.7% Huynh T; Cox JL; Massel D; Davies C; Hilbe J; Am Heart J 2004 Jul;148(1):86-91.

  31. Cooperative Cardiovascular ProjectPredictors of ICH with Thrombolytic Tx. Risk Factors: Age 75 years Black race Female sex Prior history of stroke BP syst. >160 mmHg Weight 65 kg for women 80 kg for men INR >4 or PT >24 Use of Alteplase (versus other thrombolytic agent) Risk score Rate of ICH 0 or 1 0.69 2 1.02 3 1.63 4 2.49 5 4.11 Each risk factor is worth 1 point if present, 0 points if absent Brass, LM, Lichtman, JH, Wang, Y, et al. Stroke 2000; 31:1802

  32. Time is Myocardium 60 min delay in DNT → 43 lives lost at 5yrs per 1000 pts treated 15 min delay in DNT → 11 lives lost /1000 pts FIBRINOLYTIC ADMIN. IN ER ↓ DNT by 20 min. Quantification of Thrombolytic Tx. Ramles JM, J Am Coll Cardiol 1997;30: 181-86

  33. DNT GLOBAL REGISTRY OF ACUTE CORONARY EVENT 1999 – 2006 DNT ↓ 40 → 34 minutes 52% still had DNT > 30 min. in 2006 American Heart Journal - Volume 158, Issue 2 (August 2009)

  34. Causes of delay in DNT Pre – Hospital/ER presentation Patient related factors Transport After Presentation to Hospital / ER Registration Triage EKG Physician Evaluation - Diagnosis Decision to give drug

  35. Time to presentation to ER Patient’s failure to recognize symptoms and seek evaluation accounts for up to 2/3 of the time delay in DNT. Insufficient knowledge/awareness Poor coping mechanism Attributing symptoms to other cause Hesitation to go to ER and being wrong about the cause of symptoms

  36. EFFECTEnhanced Feedback for Effective Cardiac Treatment Ontario ED July 2000 – March 2001 AMI 3088 Door – EKG 12 min (Median time) Door – Needle 40 min (Median time) 45.9% EKG < 10 min 36.6% DNT < 30 min 30 day Mortality 12.1% Ann. Emerg. Med 2009;53: 736-745

  37. EFFECTEnhanced Feedback for Effective Cardiac Treatment Ontario ED July 2000 – March 2001 NEGATIVE PREDICTORS -  DNT Inapp. low acuity Triage score 50.3% Nondiagnostic 1st EKG P/C Shortness of breath Time of day/ day of week Mode of arrival POSITIVE PREDICTORS - ↓ DNT Chest Pain Ann. Emerg. Med 2009;53: 736-745

  38. EFFECTEnhanced Feedback for Effective Cardiac Treatment NEGATIVE PREDICTORS -  DNT Inappropriately low CTAS 44% with criteria for STEMI – low CTAS ↓ 15 min ↑ median DNT Odds of getting bench mark time for EKG & Fibrinolytic were about half as good for the Pts.with inapp. CTAS, when compared with appropriately triaged score AMI Pts. Ann. Emerg. Med 2009;53: 736-745

  39. STRH - EXPERIENCE ASPIRIN ON PRESENTATION FIBRINOLYTIC BETABLOCKER ACEI / ARB STATIN ASPIRIN AT DISCHARGE SMOKING CESSATION COUNSELLING

  40. CHALLENGES AT STRH DELAYED PRESENTATION MODE OF ARRIVAL TRIAGE EKG AVAILIBILITY CLOCK ASYNCHRONY ER PHYSICIAN REQUIRING CONSULTATION PT. RELUCTANCE TO HAVE TNK ALTERNATIVE DIAGNOSIS W/U PROPER DOCUMENTATION

  41. STRH efforts to decrease DNT LONG TERM: PUBLIC EDUCATION ↑ AWARENESS RECOGNITION OF SYMPTOMS NEED TO SEEK EVAL ASAP UTILISE EMS APPROPRITELY EMS SERVICES: ASPIRIN ASAP WHEN INDICATED EKG FIBRINOLYTIC AFTER DIAGNOSTIC EKG

  42. STRH EFFORTS TO DECREASE DOOR TO NEEDLE TIME EXPEDITIOUS TRIAGE LOW THRESHOLD FOR ACS EKG ASAP < 5 MIN ASPIRIN ASAP CLOCKS SYNCHRONISATION PROPER DOCUMENTATION MEDICAL STAFF CME SESSIONS TNK ASAP PATIENT EDUCATION

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