Reperfusion Therapies 2007

Pennsylvania CHAPTERIn cooperation with Highmark and Independence Blue Cross(Blue Plans headquartered in Pittsburgh and Philadelphia)

The Mission of the American College of Cardiology……

- “to foster optimal cardiovascular care and disease prevention through

professional education, promotion of research, leadership in the development of

standards and guidelines and the formulation of health care policy.”

Reperfusion Therapies 2007

Strategies for Developing

Integrated D2B Programs

For STEMI


Pennsylvania CHAPTER

In cooperation with Highmark and Independence Blue Cross(Blue Plans headquartered in Pittsburgh and Philadelphia)

Donald R. Fischer, M.D., MBASenior Vice PresidentChief Medical Officer

Highmark

Michael A. Madden, M.D.Medical Director

Quality and Medical Performance Management

Highmark

Highmark Lori Armel

Karen BalsamoFlo Campbell

Deborah J. DonovanLynette EndersDouglas HochPaul Hoffman

Trina Thompson

Carey Vinson, M.D.Medical Director

Highmark

THANK

YOU

Victor Caraballo, M.D.Senior Medical Director

Quality ManagementIndependence Blue Cross

Kathleen T. DonohueIndependence Blue Cross

Steven J. Brown, M.D.Medical Director

Professional Networks

Phil GehmanProvider Improvement

Project LeaderIndependence Blue Cross

Teamwork



Pennsylvania Chapter –American College of Cardiology

Maria EliasAssociation Executive

American College of CardiologyJason Byrd

Jayne JordanAmy Stern

THANK

YOU

Tracy Allgier-BakerDirector of Continuing Education

Penn State College of Medicine

Bonnie Bixler, M.Ed.Director of Special Projects

Penn State Continuing EducationCollege of Medicine

Lori L. FitterlingJulie Graham

Penn State Continuing Education

Teamwork


P4P Programs


PROFESSIONALS for

PERFUSION


Welcome and Introduction

Michael A. Madden, M.D. : Highmark

Richard L. Snyder, M.D. : IBC

Daniel Edmundowicz, M.D. : Pa-ACC



The Vision:

Improving D2B Time for STEMI




"The secret of success in life is for a (wo)man to be ready for (her) his opportunity when it comes."

-Benjamin Disraeli

"Education brings about opportunity, and in turn inspiration." -Bill Frist

"A pessimist sees the difficulty in every opportunity; an optimist sees the opportunity in every difficulty."

-Winston Churchill

ACC-D2B



Primary PCI should be performed as quickly as possible, with a goal of a medical contact-to-balloon or door-to-balloon time within 90 minutes.

ACC/AHA/SCAI 2005 Guideline Update for Percutaneous Coronary Interventions

In July 2005 the Penn State Heart & Vascular Instituteas part of a quality improvement initiative reviewed

D2B for STEMI patients:

Door-to-ECG : 36 min (mean); range : 10-132 minECG-to-PCI : 109 min (mean); range : 71-363 minDoor-to-Balloon time : 145 min (mean)

ACC-D2B



Door-to-Balloon time : 145 min (mean)

"Kubler-Ross Stages in Facing Reality of the Quality Chasm"

1. The data are wrong2. The data are right, but it’s not a problem3. The data are right, but it’s not my problem4. I accept the burden of quality improvement

Donald Berwick, Institute of Medicine Crossing the Quality Chasm SummitWashington D.C., January 2004

ED Nurse initiates acute care

Heart Alert Intake Worksheet

Idealized Workflow

Presenting symptoms suggestive of ACS

ECG performed within 10 minutes

ECG reviewed by ED attending

CARDIOLOGIST PAGED

STEMI “confirmed”STEMI “confirmed”

Penn State Heart & Vascular Institute



Y.O.U.R. Medical Center

HOSPITAL ADMINISTRATIONHVI /EM LEADERSHIP

ADMISSSIONSCOMMUNICATIONS

NURSINGANCILLARY SERVICES

PARAMEDICSLIFE LION

PHYSICIANS MD NETWORK

FELLOWSINTERVENTIONAL CRNPCVOU SUPPORT STAFF

CARDIAC CATH LAB STAFFSIM LAB

I.T. SERVICES



ED Physician Empowerment

Heart Alert Paging System Activated

ED Attending ActivatesHeart Alert System

Attending to AttendingCase discussion

Classic STEMIPossible STEMI

Cardiology Attendingpaged

Heart Alert Paging System

1. Interventional Cardiologist [on-call]2. Cath Lab “Charge” [organize room]3. Cardiology Fellow [on-call]4. Cath Lab call-team5. Interventional Nurse Practitioner6. Hospital Admissions7. Research Nurse(s)8. ED Charge Nurse9. Radiology Technologist

“RESPONDERS”

01/01/2007 06:30 HEART ALERTED- ROOM 19

RESPOND STAT


http://www.pagersonline.com/Pagers/PF1500.html

1. Is family present Y / N 2. Is a translator necessary? : No / Yes :_________________(language)3. Vitals: BP_______; HR_______; RR_______4. Jugular venous distention : No / Yes: _________ 5. Pulmonary : rales ____; wheezes_____6. Cardiac auscultation: murmurs ______; gallops ______7. Pulses: femoral: R_____; L_____; Radial: R____; L___8. Symptoms: Chest Pain _______; time of onset______; Shortness of breath _______;9. Allergies- No / YES: ______________________________; Iodine______; Shellfish_____10. Prior : Cardiac cath______; Angioplasty______; CABG_____;11. Height_________________12. Weight ________________13. Dentures Yes / No14. Time of Last Meal ____________________15. Hearing Aid Yes / No16. Contacts Yes / No 17. IV Meds (circle if administered): Dopamine, Dobutamine,, Nitroglycerin, Heparin, Aspirin

ED MD______________ED NURSE___________

Date ______Time______

Cath Lab: ext 6416Patient ID Sticker


Heart Alert Intake Worksheet

Fax: 717-531-1074

Triage to ECG

ECG toHeart AlertActivation

PCI


Heart Alert Program- GOALS

Heart AlertActivation toCath LabTeam arrival

Patient’sArrival to Cath Lab

10 min 10 min 30 min 5 min 35 min

Door-to-BalloonTime:90 min

Steven Ettinger, Charles Chambers, Ian Gilchrist, Mark Kozak, Craig Lauder & Lawrence Sinoway

March 25, 2007

Quality Improvement: Reducing Door-to-Balloon Time (D2B) in Patients With ST-segment Elevation Myocardial Infarction:

Heart Alert Program

PENN STATE HEART & VASCULAR

INSTITUTE

Triage to ECG

ECG toHeart AlertActivation

PCI


Heart Alert Program

Heart AlertActivation toCath LabTeam arrival

Patient’sArrival to Cath Lab

9.0 min 3.9 min 19.6 min 12.8 min 28.5 min

2007Door-to-Balloon

Time:73.8 min (mean)

(86% within 90 min)

Door-to-BalloonTime:

85.7 min (mean)(140 patients enrolled)



March, 2007- Pa-ACC, Highmark and IBC working group organized to plan Reperfusion Therapies 2007-

The Vision:1. Review current pathways and protocols2. Recognize best-practice models3. Recognize D2B times < 90 min are achievable4. Recognize together we can and we will make a difference

Medical Directors' Institute : October 18- 20, 2006 Leesburg, Virginia

Created in 2002 by the ACC with the intention of developing a collaborative approach to issues such as paying for quality, utilization of imaging technology, health information systems and value in healthcare.



State Program

We can do better………….

Optimize STEMI Care



Regionalize STEMI Care

EDUCATION

Pa-ACC D2B



Now you know what it is like to develop a “Door-to-Balloon” program

Step back and run into thiswall head first……….

www.d2balliance.com

www.d2balliance.com

www.d2balliance.com

www.d2balliance.com

www.d2balliance.com

www.d2balliance.com

www.d2balliance.com

Harlan M. Krumholz, M.D., F.A.C.C.Yale University School of Medicine

ACC- GAPChair, Door-to-Balloon Work Group



http://info.med.yale.edu/intmed/cardio/index.html

D2B ProgramEmergency Medical Services

Expert Panel:• Donald Durbeck

• Vincent N. Mosesso Jr.

• Judd E. Hollander

• David Neubert

• Andrew Miller

D2B ProgramEmergency Medical Services

9:05- 9:15 am: Can STEMI Patients Transferred for Primary Angioplasty Receive Treatment Within 90- minutes in a Rural Setting? – Geisinger Medical Center

9:20- 9:30 am: Improving STEMI Care in Eastern Pennsylvania: The Lehigh Valley Hospital and Health Network MI-Alert Program – Lehigh Valley Hospital

9:35- 9:45 am: Reducing D2B Time in STEMI by Utilizing EMS Cath Lab Activation From the Field & Intradepartmental Emergency Physician Activation: An 11-year 24/7/365 Experience – Mercy Hospital of Pittsburgh

9:50- 10:00 am: Improving D2B Time in STEMI– Presbyterian Shadyside

10:05- 10:15 am: Delay to Electrocardiogram in STEMI Patients Does Not Preclude Meeting 90-minute D2B Time – Albert Einstein Medical Center

November 21-23, 2008 Kiss this Date Goodbye on

your Calendar!Why?

Because you do not want to miss this meeting!

2008 Annual Pa-ACC Chapter Meeting

November 21-23, 2008

The Hotel Hershey

Sure to be a SWEET Event!

John J. Kelly, D.O., F.A.C.E.P. Albert Einstein Medical Center

Associate ChairmanDepartment of Emergency Medicine

D2B Strategies and the Role of the Emergency Department



D2B ProgramEmergency Medicine

Expert Panel:• John Doherty

• Craig Lauder

• Paul Casale

• Andrew Waxler

• Michael Rossi

• Howard Herrmann

D2B ProgramEmergency Medicine

11:15 - 11:25 am: – Cardiac Reperfusion Team Protocol Decreases D2B Time at Hamot Medical Center- Hamot Medical Center

11:30 - 11:40 am: D2B Time: Every Minute Counts – Conemaugh Memorial Medical Center

11:45- 11:55 am: Emergency Physician Activation of the Catheterization Lab Reduces D2B Times with Few False Activations – Hahnemann University

Douglas Kupas, M.D.Commonwealth EMS Medical Director

Bureau of EMSPennsylvania Department of Health

EMS and D2B Strategies: The Pennsylvania Perspective



Howard C. Herrmann, M.D., F.A.C.C.Director, Interventional Cardiology andCardiac Catheterization Laboratories

University of Pennsylvania

Is There a Role For Facilitated PCI in 2007 ?



http://pennhealth.com/

D2B ProgramInterventional Cardiology

Expert Panel:• Ian Gilchrist

• A.J. Conrad Smith

• Nelson Wolf

• Charles Chambers

• James Blankenship


1:40 - 1:50 pm: – Processes to Decrease D2B Times for STEMI Patients in a Community Hospital- Saint Vincent Health Center

1:55 - 2:05 pm: Overall Catheterization Laboratory Normal Angiography Rate Does Not Increase with ER Activation of Primary Coronary Interventions (PCI) for STEMI – Chester County Hospital

2:10- 2:20 pm: Are Women Undergoing Primary PCI at Increased Risk for Death? Insights from the Lehigh Valley Hospital and Health Network MI-ALERT Program – Lehigh Valley Hospital

2:25- 2:35 pm: Interdisciplinary Collaboration to Reduce D2B Time – Abington Memorial Hospital


2:40 - 2:50 pm: – D2B Time: The Pinnacle Health Experience- Pinnacle Health

2:55 - 3:05 pm: Overcoming the Hurdles: Improving D2B in the LVHHN MI-ALERT Program – Lehigh Valley Hospital

3:10- 3:20 pm: Time to Treatment During Primary PCI is Related to Transport Distance and Speed of Interventionalist – Geisinger Medical Center


Strategies for Developing

Integrated D2B Programs

For STEMI


CONCLUDING REMARKS


If you don’t know the data, you can’t get better.

Reperfusion strategies are essential

Quality is a Culture

Educate – Standardize - Regionalize

State Organizations should collaborate


Mission: LifelineMarch 2006- AHA multidisciplinary conference

•STEMI patient care

•Implementation Plan:

–EMS system assessment and improvement

–Establishing local initiatives

–Evaluating existing models

–Explore the possibility of developing a National STEMI Center Certification Program/Criteria


AHAStroke- Recommendations for the establishment of stroke systems of care

Brain Defense- A Stroke Prevention and Treatment Strategy for Pennsylvania –

•Presented to the General Assembly of the Commonwealth of PA – Joint State Government Commission – November 2002


Statewide Systems ChangeDevelop Taskforce/Committee under Department of Health CVD ConsortiumDevelop plan and progress markersAssess resources / capabilitiesFocus on long term outcomes


Improving OutcomesThrough a Culture of a

Collaborative Environment


&

THANK YOU


Documents

Reperfusion Therapies 2007