STEMI-OUR System of Care: A Big Town Perspective with a Small Town Compassion

1. STEMI-OUR System of Care: A Big Town Perspective with a Small Town Compassion Door-to-Balloon (D2B) Intensive Analysis Wm. Todd Gray, D.O., F.A.C.C. June 3, 2011

4. Our Vision

8. Door 2 Balloon-GOAL • Identification of STEMI’s earlier which included partnerships with our local EMS. • D2B < 90 minutes for 100% of patients (non-transfers) • Facility internal goal of <69 minutes for 100% of patients (non-transfers) • Improve documentation of delay when time > 90 minutes, especially if delay occurred within our Cardiac Catherization Lab

9. Changing “Time” • At DRMC our 1st priority was to offer the best to our growing community. This included looking at our current process for cardiac patients. • “Best Practices” were involved in every aspect of implementing our current Door 2 Balloon(D2B) Dashboard.

10. GOAL Door 2 Balloon “SWEET” • S-STEMI • W-Within • E-Emergent • E-Event • T-Time

11. S-STEMIInitial identification-EMS • Partnership with local EMS providers: 19/19 local EMS have ability to transmit 12 lead EKG’s directly to ED physician/staff • Transmission of 12 lead EKG directly to physician's phones • Ability to call STEMI directly from field and allow bypassing of ED and go directly to Cath Lab. • Since implementation 1st Q 2011 Median Time--- 59 minutes

14. W-Within Response TimeInitiatives = Saving MuscleIn the beginning……. • In 2007 our Cardiologists Median Arrival Time=34 minutes • In 2007 our Interventionists Arrival Time=64 minutes • 2008-Implementation of Interventional Call (Eliminated call to Cardiologist) • 2010-“I-Card Only” parking spaces and badge only access direct to Cath Lab • Cath Lab (30 min goal) • Reduce calls required to activate Cath Lab Team—5555(pager system) GOAL= 30 mins

15. W-Within GOAL= 30 mins Response Time Initiatives Cath Lab (30 min goal) Reduce calls required to activate Cath Lab Team—5555

16. E-Emergent • 2008-Developed and Implemented “STEMI BOX” • Consent • Code STEMI D2B checklist • Atomic Clock • Clippers • Acute STEMI medications(i.e. ASA) • IV’s and Lab Tubes • 2010-Code STEMI Order Set • 2010-Currently all lab results print to Cath Lab

17. E-Emergent • Skinny “STEMI BOX” - October 2008(Triage Nurse initiates for walk-in patients to ED) • Consent • Code STEMI D2B checklist • Atomic Clock • Aspirin • In 2010 DRMC implemented an algorithm for our In-House STEMI process.

18. E-Event-D2 EKG TimeDoor 2 EKG-2007- 4 minsDoor 2 EKG-2010-3 mins

19. E-Event-D2 Cath Lab(2007&2010)Door 2 Cath Lab-2007-54.5 minsDoor 2 Cath Lab-2010-36 mins

20. T-Time-D2B(2007 & 2010)D2B 2007-88 minsD2B 2010-66 mins

21. Code STEMI Process ED Interventional Cardiologist Called Directly by ED Doctor Code STEMI HUC--5555 • Team members calls HUC to say Cath team on way. • Off-hours night Supervisors turns on cath lab

22. Event & Time- Data

25. D2B SWEET—Process Improvement • Process for Transfer STEMIs identified • Collection of Transfer Data -2nd Q 2010 • Request Transfer facility to arrival DRMC-2010 ~Median 52 minutes • DRMC door to intervention-2010 ~ Median 41 minutes • Process for In-Patient Chest Pain identified-2010 ~ Median >90 minutes-STEMI occurred after CABG earlier in day

29. Why “DRMCs” Process WORKS • Prompt data feedback – 100% review of all Code STEMI on a daily basis • Immediate notification of team members to review process for any outliers • Team-based approach—Weekly D2B meetings to review STEMI’s by the D2B sub-committee • Administrative support • Concurrent review • Physician review of cases at CV Meetings

36. ED Staff EMS Physician Interventional Cardiologist Administration EMS Cath Lab Staff Ancillary Staff Nursing Staff