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An Introduction

An Introduction. Project UPSTART. The U se of P rocedural Sta ndardization to R educe “Recognition to Reperfusion” (R2R) T ime in STEMI “Excellence in R2R”. A Framework for Improvement.

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An Introduction

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  1. An Introduction www.projectupstart.com

  2. Project UPSTART • The Use of Procedural Standardization to Reduce “Recognition to Reperfusion” (R2R)Time in STEMI • “Excellence in R2R” www.projectupstart.com

  3. A Framework for Improvement • Project UPSTART is an unique quality improvement program that lets you quickly and easily improve the care of your patients suffering from STEMI. • A toolbox for building systems of care for STEMI • Avoid reinventing the wheel! www.projectupstart.com

  4. A Tool Kit for STEMI Systems… • Provides forms, protocols, templates provider education and other necessary “components” • Designed to improve locals systems of care • Facilitates inter-facility collaboration and data sharing • Compliant with the concepts and principles endorsed within the American Heart Associate and its Mission: Lifeline Initiative www.projectupstart.com

  5. Mission: Lifeline(The Big Picture) www.projectupstart.com • National, community-based initiative • Goals • Improve quality of care and outcomes in heart attack patients • Improve health care system readiness and response 5

  6. …Think of Project UPSTART as a Mission: Lifeline-compliant “Recognition to Reperfusion” Toolbox! www.projectupstart.com

  7. Optimizes Recognition and Reperfusion • All attempts at reducing STEMI • treatment times must ultimately • focus on improving one (or both) of • these endpoints. • The goal: early recognition followed • by early reperfusion. • “ www.projectupstart.com

  8. Example #1 • Large Community PCI hospital • Multiple cardiology groups, etc • Current reperfusion mean (door to PCI) • +/_ 52 Minutes • (stable over last three years) www.projectupstart.com

  9. Example #2 • A Large University PCI Center • UPSTART go-live: 9.11.06 • Reperfusion (DTB) times declined from 83 minutes to 58 minutes within one month of implementation www.projectupstart.com

  10. Quiz: Have These Issues Occurred in Your STEMI system? • A veteran nurse working triage neglects to obtain an ECG on an “atypical” STEMI patient? • Your temporary ED physician forgets to immediately call EMS, delaying inter-facility transport? • A thrombolytic checklist was not instantly available when needed to assess a patient? • A STEMI patient was sent to the PCI lab without an IV? • Important STEMI QI data has not been routinely available for quality improvement analysis? www.projectupstart.com

  11. History Repeats…Unless you Learn from Previous Mistakes! • Project UPSTART incorporates many best practice concepts directly into a simple, repeatable approach to STEMI care that is based on just 4 key actions: • Error-proof your providers by error-proofing the system! www.projectupstart.com

  12. STEMI System Theory: A Review • To efficiently improve your local STEMI system: • First, you must first define who your local STEMI system actually involves and its physical boundaries….. • Next, you must define what processes are most important within that system • Finally, you must fix what needs fixing! www.projectupstart.com

  13. Luckily we can help you! • The next few slide discuss important concepts in helping you define your local Elemental STEMI Subsystem (ESS) system and outlining the Essential Elements of Reperfusion that must be the focus of your improvement efforts. • This has all been done before, by someone! www.projectupstart.com

  14. Key Concept: The “Elemental STEMI Subsystem” (ESS) The smallest combination of EMS and STEMI treatment facilities that can function “alone” as a self functioning “STEMI system of care” By definition, the ESS is the “elemental building block” of all STEMI systems –no matter how large that “system” may be ?? www.projectupstart.com

  15. An Individual ESS… Has only three basic components: 1) All EMS organizations that transport STEMI patients to or from a facility 2) That facility and its internal “in house” STEMI management processes 3) “Outside” facilities that either send or receive STEMI patients to or from that facility…. www.projectupstart.com

  16. A Typical Elemental STEMI Subsystem www.projectupstart.com

  17. Elemental STEMI Subsystems (usually) Overlap…So, improving each one internally will improve the entire region! PCI Non-PCI PCI Non-PCI www.projectupstart.com

  18. Take Home Point?Define your local ESS and concentrate on improving each important process within its boundaries !Your ESS! PCI Non-PCI PCI www.projectupstart.com

  19. STEMI Optimization = Perfecting the Basics! • Now you know where you need to concentrate your efforts: your ESS. • So, what do you fix first? • In other words, where can you get the most “bang for your buck?” www.projectupstart.com

  20. The 5 R’s: The 5 Essential Elements of STEMI System Optimization www.projectupstart.com R1 Relationships R2 Recognition R3 Reperfusion R4 Real-time Data Collection R5 Reassessment & Refinement

  21. Concentrate on the “5R’s” • In order to improve your system in a time efficient manner you must improve each one of these critical process until they are running smoothly. • Project UPSTART was designed to help you in this process! www.projectupstart.com

  22. Four Key Steps www.projectupstart.com

  23. Would your institution make that same mistake on a busy Friday night? www.projectupstart.com

  24. Let check: Please answer the following questions to assess Recognition at your institution: • Do you have a written “Screening ECG Protocol” for your institution? • Is it visibly posted in your ED and triage areas? • Do ED and triage staff follow it 24/7? • Have you trained your staff regarding their role (and importance) in the screening ECG? • Do you have multiple backup pathways in place to ensure that the screening ECG gets done during busy times? www.projectupstart.com

  25. How did you do? • Unless you answered “yes” to all five questions, your institution is at risk at missing that same ECG. If not today, then next Friday.Solution: Improve your STEMI recognition process www.projectupstart.com

  26. Solution: • -Print it’ • -Post it’ • -Use it’ • -Reinforce it • -Educate staff at: www • .projectupstart.com! The Project UPSTART “Screening ECG Protocol” www.projectupstart.com

  27. Benefits of UPSTART • Builds on the experience of others –no need to “reinvent the wheel”. • Offers a variety of tools, forms and instructions for rapid improvement of existing processes • Carefully designed for ease of implementation • Connects all links of the “STEMI chain” together from EMS to the cath lab www.projectupstart.com

  28. Four Key Steps www.projectupstart.com

  29. STEP 1: Optimize STEMI Recognition! • Provide a tool • The Screening ECG Protocol • Post it everywhere • Teach compliance (via education) • End result? • Minimize missed STEMI! www.projectupstart.com

  30. 2: Open a STEMI ALERT Packet for every STEMI • “Got STEMI –Open Packet!” • Opening the packet serves as a focus for action • Staff automatically open a packet for every STEMI www.projectupstart.com

  31. The STEMI ALERT Packet • A carefully designed STEMI ALERT Packet is the key to success • It places all the required information for a successful “STEMI ALERT” instantly at your fingertips www.projectupstart.com

  32. The STEMI ALERT Packet • A carefully designed STEMI ALERT Packet is the key to success. • All the required information for success is instantly at your fingertips. www.projectupstart.com

  33. A standard STEMI Alert Packet includes three checklists: • Physician Checklist Nurse Checklist STEMI Scribe Checklist www.projectupstart.com

  34. And two Data Collection Sheets Data Sheet A Data Sheet B www.projectupstart.com

  35. How it works….. • Prior to implementation, each site decides what is the generalized best approach to treating STEMI at that particular institution. All important details are then incorporated into the checklists within the STEMI ALERT Packet. www.projectupstart.com

  36. What type of details? • Medications • Phone numbers • Treatment algorithms • Patient assessment prompts • ED cath lab activation criteria • Thrombolytics checklists • Cath lab preparation tasks • **Whatever is felt important! www.projectupstart.com

  37. Now put your packets somewhere visible • The next time a STEMI occurs, your staff should know to open the packet! • Put conditioning to work for you! www.projectupstart.com

  38. Physician Checklist • Sample PCI • with details • Who to call • Medications • Assessment • Phone numbers • Memory prompts www.projectupstart.com

  39. Nurse Checklist • Sample PCI • site • Focus? • -patient • preparation for • additional • treatment or • transfer www.projectupstart.com

  40. Stemi Scribe • Recording times • Data collection • Monitoring communication www.projectupstart.com

  41. Next: No measurement = No improvement! • The function of Data Sheets A and B are to measure key intervals during the STEMI alert. This data drives ongoing improvement • Data Sheet B always follows the patient and contains a record of total time from recognition to reperfusion • Data Sheet A stays in the ED www.projectupstart.com

  42. Step 3: Complete Data Sheets A & B during each STEMI ALERT www.projectupstart.com

  43. Date Sheet A • Stays in the ED • Provides information • for efficient feedback www.projectupstart.com

  44. Data Sheet B: • Sent to the cath lab • or to the receiving facility • Provides data on arrival • When completed has data • points from the entire case www.projectupstart.com

  45. Step 4: Data Management! • After the STEMI ALERT is complete, Data sheets A and B are delivered to their respective sites. “A” stays in the ED and “B” follows the patient. • This accurate data is very helpful • Our standard is to measure R2R times on each patient! www.projectupstart.com

  46. Same 4-step process at every facility! Data sheet B links them together! www.projectupstart.com

  47. Review the “Four Key Steps” www.projectupstart.com

  48. Can you do these 4 steps at your facility? • Then you can implement UPSTART! • -STEMI Alert Packet forms are easily customized • -All other forms are from templates as well • -When possible, items are standardized • -Staff education can be done via the internet www.projectupstart.com

  49. Implementation • 1) Develop an individualized STEMI ALERT Packet for your institution • 2) Train your staff at www.projectupstart.com • 3) Place the STEMI ALERT Packets in your ED • 4) Go live! The process will continue improving using the data collection loops built into the process www.projectupstart.com

  50. Provider Education • Train all ED staff prior to “go live’ • Takes one hour or less • A combination of a written tutorial, on-line video and short written test • Available at www.projectupstart.com www.projectupstart.com

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