The New Washington State Emergency Cardiac and Stroke System: Developing a Best Practice Plan for...

The New Washington State Emergency

Cardiac and Stroke System: Developing

a Best Practice Plan for Your Community

Bev McCulloughQuality Improvement Manager, RHQN

Kim Kelley, MSWPlanning Coordinator, WA State DOH

The Washington State Emergency Cardiac and Stroke System:

Creating Opportunities Together

Kim Kelley, MSWCardiac/Stroke Systems

CoordinatorWA State Department of Health

Kim.kelley@doh.wa.gov

The Continuum of Care

Prevention

Prehospital

Hospital Secondary Prevention/ Rehabilitati

on

System Evaluatio

n

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.

Creating Opportunities Together…

Washington’s Population is AgingAnnual Change in Population Ages 65 and Over

Risk Factors Are Increasing

0

5

10

15

20

25

30

35

40

1990 1992 1994 1996 1998 2000 2002 2004 2006 2008

Ag

e-ad

juste

d P

erc

ent

Obesity

Diabetes

High Cholesterol

Hypertension

The Chain of Events

Emergency Cardiac and Stroke System

Physical Inactivity

Poor Diet

Tobacco Use

Chronic Stress

(Risk Factors)

Diabetes

Hypertension

High Cholestero

l

Obesity

(Diseases &

Conditions)

(Events/Deaths)

Medical/Health Homes

Healthy Communities

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.

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

The Solution

An organized system to get the right patient to the right place in the right

time, just like we do for trauma.

D2B Time and Mortality

SSHB 2396 Passed 2010

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

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

STROKE CENTERS AND COVERAGE AREA 2007

I

STROKE CENTERS AND COVERAGE AREA 2011

CARDIAC CENTERS AND COVERAGE AREA 2007

CARDIAC CENTERS AND COVEREAGE AREA 2011

Quality Improvement

SHB 2396:

•Requires QI of participating hospitals•Allows the trauma QI programs to evaluate emergency cardiac and stroke care delivery

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

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

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.

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.

Kim KelleyCardiac/Stroke Systems Coordinator

360-236-3613Kim.kelley@doh.wa.gov

Thank you!

A STEMI Story-Celebrating Successful

Partnershipspresented to:

WSHA Rural Hospital Summer Workshop

June 28th, 2011Chelan, WA

presented by: Paul Nurick, CEO

Rhonda Holden, RN, MSNKittitas Valley Community Hospital

Kittitas County

Kittitas Valley Community Hospital (KVCH) to Door to Balloon at Yakima RegionalMedical & Coronary Center (YRMCC)

> 2.5 Hours Goal < 90 minutes

KVCH Throughput > 60 Minutes Goal < 30 minutes

KVCH Door to EKG > 15 Minutes Goal < 5 minutes

2006 STEMI Metrics

• 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

Why the delays?

• 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

A New Program Emerges

• 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

Changes at KVCH

2006 2007 2008 2009 20100

20

40

60

80

100

120

140

160

180

KVCH, YRMCC - Kittitas County EMS STEMI Metrics Today

Avg Door to BalloonAvg KVCH ThroughputAvg. Transport TimesAvg KVCH Door to EKG

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.

Cheryl’s Story

Cheryl’s Initial 12-Lead

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

En route to Yakima Regional

Cheryl’s Coronary Artery

Upon arrival at cath lab:

Reperfusion at 15:15

• 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

What’s Next

Made possible by:

But our favorite picture is:

Cheryl and attending paramedic

Beth Williams; Winter, 2011.

Upper Kittitas County Medic One- HD #2Cle Elum Fire DepartmentKittitas Valley Community HospitalKittitas County EMS (KITTCOM Dispatch)Kittitas Valley Fire & RescueYakima Regional Medical & Cardiac CenterVirginia Mason Medical Center (Stroke)

Thank You Partners

Rural “Best Practice”:Community Education

Tom Martin, AdministratorLincoln HospitalDavenport, WA

Initial Level One Newspaper Ad

Cardiac Level One Brochure

Stroke Billboard/Poster

Lincoln’s Stroke Program

Developing a program for the future

Lincoln Hospital bridges the gap in rural healthcare with robotic doctor (Davenport, Wash. )— Lincoln Hospital has announced the placement of a remote physician presence robot that will expand the delivery of specialized health care to patients in their service area. On September 20 the robot will be active at Lincoln

Co-Managing Complex Patients

The Accountable Health Home

RHC & CAHTertiary and

Specialty Services

Optimizing Quality Outcomes, Cost and Access

Lincoln’s Robot:Part of the Team

Washington Rural Emergency Cardiac and Stroke

Systems……

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.

Creating Opportunities Together…

Questions?

Thank you to Kim, Paul, Rhonda and Tom!