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Improving STEMI Care: Overcoming Hospital Barriers
Eva Kline-Rogers, MS,RN,NPUniversity of Michigan, Ann Arbor, MI
Friday, June 3, 3011No Conflict of Interest to Disclose
Hospitalizations in the U.S. Due to Acute Coronary Syndromes (ACS)
Acute Coronary Syndromes*
1.57 Million Hospital Admissions - ACS
UA/NSTEMI† STEMI
1.24 million Admissions per year
.33 million Admissions per year
Heart Disease and Stroke Statistics – 2007 Update. Circulation 2007; 115:69-171. *Primary and secondary diagnoses. †About 0.57 million
NSTEMI and 0.67 million UA.
3
1990199219941996199820002002
1990ACC/AHA
AMI R.
Gunnar
1994AHCPR/NHLBI
UA E. Braunwald 1996 1999
Rev Upd ACC/AHA AMI T. Ryan
2004 2007 Rev Upd ACC/AHA STEMI E. Antman
2000 2002 2007 Rev Upd RevACC/AHA UA/NSTEMI E. Braunwald; J. Anderson
20042007
Evolution of Guidelines for ACS
2009
2009Upd
ACC/AHA STEMI/PCIF. Kushner
4
STEMI Care
Patients / Families Healthcare Providers
First Responders EMS
ED Cath Lab
Acute Care Discharge
Outpatient
Crossing the Quality Chasm…Key Ingredients
n Building organizational support for change
n Applying evidence to health care delivery
n Using information technology
n Aligning incentives with quality
n Preparing the workforce
6
Improving STEMI Care Systems
Time Continuum
PreventionRisk Reduction Strategies
Acute Event Management
Short-Term Management
Long-Term
Evolution of PCI for STEMI
Evolution of Percutaneous Coronary Intervention
Balloon Angioplasty
30-60%
Enabled Non-Surgical
Approach to Coronary
Artery Disease
Bare-metal stents
10-40%
Reduced Elastic Recoil and Negative Remodeling
Drug-eluting stents
<10%Reduced
Restenosis Rates
Increasin
g C
om
plexity
Technology Advantage Restenosis Rates
van der Hoeven, BL., et al., International Journal of Cardiology 2005; 99:9-17.
PCI vs Fibrinolysis
22 Randomized Clinical Trials
Keeley E, Lancet, 2003P = .001 P = .0001 P = .002 P = .0001
6.8%
2%
14%
5%
2.5%1%
8%7%
0%
5%
10%
15%
Death ReMI CVA D/MI/CVA
Fibrinolysis PCI
Skilled PCI lab available with surgical backupDoor to Balloon < 90 minutes
• High Risk from STEMICardiogenic shock, Killip Class > 3
Contraindications to fibrinolysis, including increased risk of bleeding and ICH
Late presentation > 3 hours from symptom onset
Diagnosis of STEMI is in doubt
PCI Generally Preferred (Class IA):
Core Measure: Time to PCI
Ab
solu
te b
enef
itp
er 1
000
trea
ted
pat
ien
ts
0
0
20
40
60
80
3 6 9 12 15 18 21Time to treatment (h)
Boersma E, Lancet, 1996
Time to TreatmentMeta-analysis of Lytic Trials
(N = 50,246)
Time matters
Delay in Seeking Treatment
n Median delay times 2 - 6.4 hours• NRMI = 2.2• REACT = 2.4• African-Americans 2006 = 4.4
Moser et al., 2005; Banks et al., 2006; Leupker et al., 200; Goff et al., 1999; Goldberg et al., 2002; Dracup et al., 2003; Moser et al., 2006
Education Intervention StudiesMoser et al
Study N Intervention Outcome
Ho (1989) Seattle
401 pre489 post
2 months;TV, radio, newspapers
Delay not reduced; ambulance use did not change
Moses (1991) Midwest
Not stated
2 months; TV, newspapers, brochures, public talks, posters
Delay not reduced
Education Intervention StudiesMoser et al
Study N Intervention Outcome
Herlitz (1989) Sweden
2126 pre435 during
3 weeks; radio, printed matter
Delay reduced; no change in ambulance use (started with long delay times)
Bett (1993) Australia
556 pre253 post
1 week multi-media ‘event’
Delay not reduced
Gaspoz (1996) Switzerland
1100 pre1295 during
1 yr; radio, media ‘events, ads, posters, leaflets
Delay reduced, primarily in confirmed MIs & men; no change in women
Education Intervention StudiesMoser et al
Study N Intervention Outcome
Meischke (1998) Seattle
1343 control,4101 in experimental groups
(randomized, controlled)4 groups=control, information, emotional, social
Delay not reduced; 911 use was higher
Luepker/REACT (2000)5 US regions
10 paired communities
Mass & small media, focused sessions, used Leventhal’s framework
Delay not reduced; improved ambulance use
Predictors of Prehospital DelayClinical Factors
Moser, et al.
DELAY TIMEDecrease Increase
Sudden onset severe chest pain
Hemodynamic instability
Large infarct size
History of angina
History of diabetes
Gradual pain onset or pain comes and goes
Predictors of Prehospital DelayConsultation
Moser et al.
Decrease Increase
Friend
Co-worker
Stranger
Spouse
Other relative
Physician
Self-treat
DELAY TIME
New Approaches Needed to Interventions to Decrease Patient Delay
n Changing patient and provider perspectives about the chronicity of cardiac disease• Increase saliency of message
n Include social, cognitive, and emotional context of decision-making in messages
n Deputize witnesses to take actionn Make every provider an “interventionist” and
every encounter an intervention– Moser et al
20
Improving STEMI Care Systems
Time Continuum
PreventionRisk Reduction Strategies
Acute Event Management
Short-Term Management
Long-Term
21
Recommendations for Triage and Transfer for PCI (for STEMI)
III IIaIIaIIa IIbIIbIIb IIIIIIIIIIII IIaIIaIIa IIbIIbIIb IIIIIIIIIIII IIaIIaIIa IIbIIbIIb IIIIIIIIIIIaIIaIIa IIbIIbIIb IIIIIIIII
NEW
Recommendation
Each community should develop a STEMI system of care following the standards developed for Mission Lifeline including:
• Ongoing multidisciplinary team meetings with EMS, non-PCI-capable hospitals (STEMI Referral Centers), & PCI-capable hospitals (STEMI Receiving Centers)
22
Recommendations for Triage and Transfer for PCI (for STEMI) (cont.)
III IIaIIaIIa IIbIIbIIb IIIIIIIIIIII IIaIIaIIa IIbIIbIIb IIIIIIIIIIII IIaIIaIIa IIbIIbIIb IIIIIIIIIIIaIIaIIa IIbIIbIIb IIIIIIIII
NEW
Recommendation
STEMI system of care standards in communities should also include:
• Process for prehospital identification & activation
• Destination protocols to STEMI Receiving Centers
• Transfer protocols for patients who arrive at STEMI Referral Centers and are primary PCI candidates, and/or are fibrinolytic ineligible and/or in cardiogenic shock
30-30-30 GoalE2B≤90 Conceptual
Framework< 30 minutes for Emergency Med Services (EMS)
< 30 minutes for the Emergency Department (ED)
< 30 minutes for the Cardiac Cath Lab (CCL)
www.E2Bchallenge.com Industry supported QI-initiative launching
October 15 at EMS Expo.08 in Las Vegas
Other Regional/State Plans
Other States and Regions State & Regional EffortsUnderway or Planned
A Life-Saving InitiativeNational, community-based initiative
Goals
• Improve quality of care and outcomes in heart attack patients
• Improve health care system readiness and response
25
AHA (www.heart.org)
MUSKEGON
OTTAWAIONIA
KENT
MONTCALM
NEWAYGO
Spectrum Health Reed City Hospital
Spectrum Health Kelsey Hospital
Spectrum Health United Hospital
Carson City Hospital
Ionia County Memorial Hospital
Metro Health Hospital
Saint Mary's Healthcare
Mercy General Health Partners
Memorial Medical Center of West Michigan
ALLEGAN BARRY
LAKEMASON
MECOSTAOCEANA
OSCEOLA
Allegan General Hospital
Mecosta County Medical Center
Pennock Health Services
Holland Hospital
Borgess - Pipp Hospital
North Ottawa Community Hospital
Gerber Memorial Health Services
Zeeland Community Hospital
Sheridan Community Hospital
Hackley Lakeshore Hospital
Hackley Hospital
Spectrum Health Hospital Service Areasand Other Acute Care Hospitals
County BoundariesCounty BoundariesCounty BoundariesCounty BoundariesCounty BoundariesCounty BoundariesCounty BoundariesCounty BoundariesCounty Boundaries
Primary Service AreaPrimary Service AreaPrimary Service AreaPrimary Service AreaPrimary Service AreaPrimary Service AreaPrimary Service AreaPrimary Service AreaPrimary Service Area
Secondary Service AreaSecondary Service AreaSecondary Service AreaSecondary Service AreaSecondary Service AreaSecondary Service AreaSecondary Service AreaSecondary Service AreaSecondary Service Area
Spectrum HealthSpectrum HealthSpectrum HealthSpectrum HealthSpectrum HealthSpectrum HealthSpectrum HealthSpectrum HealthSpectrum HealthGrand Rapids Area HospitalsGrand Rapids Area HospitalsGrand Rapids Area HospitalsGrand Rapids Area HospitalsGrand Rapids Area HospitalsGrand Rapids Area HospitalsGrand Rapids Area HospitalsGrand Rapids Area HospitalsGrand Rapids Area Hospitals
Spectrum Health Butterworth HospitalSpectrum Health Butterworth HospitalSpectrum Health Butterworth HospitalSpectrum Health Butterworth HospitalSpectrum Health Butterworth HospitalSpectrum Health Butterworth HospitalSpectrum Health Butterworth HospitalSpectrum Health Butterworth HospitalSpectrum Health Butterworth Hospital
Spectrum Health Blodgett HospitalSpectrum Health Blodgett HospitalSpectrum Health Blodgett HospitalSpectrum Health Blodgett HospitalSpectrum Health Blodgett HospitalSpectrum Health Blodgett HospitalSpectrum Health Blodgett HospitalSpectrum Health Blodgett HospitalSpectrum Health Blodgett Hospital
Helen DeVos Children's HospitalHelen DeVos Children's HospitalHelen DeVos Children's HospitalHelen DeVos Children's HospitalHelen DeVos Children's HospitalHelen DeVos Children's HospitalHelen DeVos Children's HospitalHelen DeVos Children's HospitalHelen DeVos Children's Hospital
KEYKEYKEYKEYKEYKEYKEYKEYKEY
Hospitals in Spectrum
Health STEMI Network
Zeeland (23 miles)
25-30 min ground
10 min helicopter
UM – Greenville (32 miles)
45 min ground
12 min helicopter
Gerber (45 miles)
60 min ground
15 min helicopter*
*transport from hospital to helipad required Courtesy of Denise Busman MSN, RN October, 2008
The STEMI ALERT Packet
n A carefully designed STEMI ALERT Packet is the key to success.
n All the required information for success is instantly at your fingertips.
n GOT STEMI? Open packet!
www.projectupstart.comCourtesy of David Burt, MD
28
Improving STEMI Care Systems
Time Continuum
PreventionRisk Reduction Strategies
Acute Event Management
Short-Term Management
Long-Term
Systems that Work“Effective Strategies” linked to
significantly shorter DTB timesn Systems for activating cath labn Systems for handoff from EDn Systems for interaction with EMSn Systems for data feedback
Bradley EH, NEJM, 2006
Effective Strategies
Bradley EH, NEJM, 2006
Fewer Than 5% Have All Strategies
05
101520253035404550
0 1 2 3 4
Number of strategies
Per
cen
t
N Engl J Med
D2B Alliance
Evidence-based Strategies that Reduce Delays
1. ED physician activates the cath lab2. One call activates the cath lab3. Cath lab team ready in 20-30 minutes4. Prompt data feedback5. Senior management commitment6. Team-based approachPre-hospital ECG to activate the cath lab if feasibleACC D2B Initiative: web site with resources
including tools, webinars, contactsACC D2B Initiative: web based, interactive, tools, resources
Over 1,000 hospitals enrolled(out of 1400 that perform PPCI)
Changes in reported use of strategies Recommended Strategy* Baseline Follow-upEM activation 52% 60%Single call 31% 37%Cath team arrives in 30 minutes 81% 89%Prompt data feedback 61% 79%Activate from pre-hospital ECG in the field 33% 41%D2B Team 64% 85%
* All differences are significant P< 0.001
D2B in STEMI
n Research has shown us how we can improve D2B times.
n The D2B Alliance initiative has been instrumental in disseminating the “evidence-based strategies” and organizational improvements.
n D2B times have improved across the country.• Public reporting, competition, D2B and other
initiatives
Relative Impact of post-MI Interventions (RRR)
n Smoking Cessation -50%
n Lipid Lowering -30-40%
n ASA -25%
n Beta Blockers -20%
n ACE inhibitors -20%
Source AHA GWTGs supporting literature
Working with others to make a difference in Michigan
Guidelines Applied Into Practice (GAP)
American College of Cardiology
Greater Detroit Area Health Council
MichiganPRO
10 Michigan Hospitals
Results: Late Indicators and Discharge Document
0
20
40
60
80
100
Perc
ent
(%)
SmokingCounseling
DietaryCounseling
Chol Rx
53 55
6762
90
68
9286
67
* p < 0.05 ** p < 0.01
(159) (150) (76) (475) (473) (205) (112) (144) (65)
******
Pre
No Tool
Tool
Tobacco Counseling Referrals: Inpatient CardiologyAverage Referrals Pre-: 20.6/month Post-: 32.2/month
0
10
20
30
40
50
2/13 - 3/12 3/13-4/12 4/13 - 5/12 5/13-6/12 6/13 - 7/12 7/13 - 8/12
Tobacco CounselorReferrals from MDs/RNs -
7B/C/D
New Order Sets5/13/02
Month of Year - 2002
# of
Ref
erra
ls p
er m
onth
100 100
0
20
40
60
80
100
ASA at D/C B-Blocker at Discharge
2000-2001BCBS of Michigan QualityAssessment: UM % Eligible Patients Receiving Rx
2000-2001BCBS of Michigan QualityAssessment: UM % Eligible Patients Receiving Rx
Percent (%)
n=50n=50
Creating a System for STEMI Care
n Create common goals based on evidence-national guidelines, e.g. D2B
n Design care tools that emphasize goals
n Create methods to measure performance (registries)
n Create a method to feedback results (registries)
n Reformulate the aims
n Sustain the Gain
Substantial variation across hospitals in 2005
010
20
30
40
Hospitals
50 100 150 200Door-to-balloon time (minutes)
Source: National Registry of Myocardial Infarction, 2005
How do the best hospitals do it?
010
20
30
40
Hospitals
50 100 150 200Door-to-balloon time (minutes)
Source: National Registry of Myocardial Infarction, 2005
BMC2 & PrimaryPCI Sites
Multivariate model for in-hospital Mortality (BMC2 Data)
VARIABLE ODDS RATIO
95% CI P
<90 minutes 0.41 0.18-0.91
0.027
Age >80 4.10 1.55-10.8 0.004
Prior MI 2.35 1.21-4.55 0.011
Creatinine > 2.0 mg/dl 4.38 2.12-1.15 <0.0001
EF <50% 2.77 1.15-6.68 0.022
# Diseased Vessels 2.33 1.20-4.52 0.012
Cardiac Arrest 4.42 2.22-8.79 <0.0001
Cardiogenic Shock 10.89 5.67-20.95 <0.0001
Female Gender 1.85 0.97-3.50 0.06Moscucci et al, AHA, 2004
Percent Increase in D2B Time ≤ 90 Minutes
10.4
14.915.8
20.3
15.8
10.5
0
19.4
(1.5)(0.7)
(4.6)
13.7
-10
-5
0
5
10
15
20
25
Study Status of Hospital
Ch
an
ge i
n P
erc
en
tag
e o
f P
ati
en
ts w
ith
Do
or
to
Ball
oo
n <
90 m
in
Improving Systems at Your Hospital
n Project Support and Approval n Team Leadern Create Teamn Site Assessmentn Identify Targets for Improvementn Identify Barriersn Data Monitoring and Feedback
Creating a Team
n Select Team Leadern Multidisciplinary Team Members
• Effective teams• Ineffective teams
n Share common goal/rationale and evidence for effective strategies
Assessment of Time Intervals
n Door – ECGn ECG – Physician Evaluationn Physician Evaluation – Lab Activationn Lab activation – Patient calledn Patient called – Transport activatedn Transport timen Lab Arrival – Sheath inn Sheath in - Balloon inflated
Site Assessment Survey
n All AMI Patients• Who activates cath lab?• How is it activated?• Who transports patients to cath lab?• How long does it take to transport?
n Cath Lab• Who places sheath?• Standardized protocol for angiography?• Is there a protocol for cath lab staff response time?
5 mins or less21%
6-10 min28%
11-15 mins10%
16-20 mins10%
21-25 mins14%
26-30 mins0%
above 30 mins17%
5 mins or less
6-10 min
11-15 mins
16-20 mins
21-25 mins
26-30 mins
above 30 mins
Time to EKG in ED(N = 29)
Creating Change in Complex Environments
n Lessons learned from GAP AMI projects• Team approach• Embedding guidelines into practice• Champions
n Lessions learned from regional QI initiatives• Tailored interventions• Overcoming Barriers
CQI Process
n C=Continuous• Staff members dynamic• Regression to the mean• Data for discovery
54
Project Overview
In-situ simulation training and assessment process to train healthcare teams in moving a patient from the emergency department to the cardiac catheterization lab during an acute cardiac event.
55
Improving ACS Care Systems
Time Continuum
PreventionRisk Reduction Strategies
Acute Event Management
Short-Term Management
Long-Term
Improving STEMI Care
n Create common goals based on evidence-national guidelines
n Create systems that emphasize these goals (Mission Lifeline)
n Design care tools that emphasize goals/measure performance (standard orders/discharge docs – easier with EMR but need process for updating)
n Create a method to feedback results (registries: NCDR, ACTION, others)
n Regional QI Efforts
n Early patient f/u providing simple, consistent messages