STEMI Boot Camp IIISTEMI Boot Camp III

-Tools of the Trade-Tools of the Trade

David R. Burt, MDUniversity of Virginia

STEMI Tool Kits…STEMI Tool Kits…

-Tactical Concepts-Tactical Concepts

Objectives:Objectives:

……Help you build a better systemHelp you build a better system

Now that you better understand the Now that you better understand the basic principles basic principles andand theory behind theory behind STEMI system construction we want STEMI system construction we want to discuss the tools available (at all to discuss the tools available (at all levels) to help you optimize levels) to help you optimize youryour individual Elemental STEMI individual Elemental STEMI subsystem!subsystem!

Remember: Building a Better Remember: Building a Better System Requires Education…System Requires Education…

FACT: Educating a provider will not FACT: Educating a provider will not fix a “broken” system… but it helps!fix a “broken” system… but it helps!

BUT: Fixing a system can support an BUT: Fixing a system can support an “uncertain” provider“uncertain” provider

THEREFORE: Fixing the system THEREFORE: Fixing the system and and educating the provider ensures educating the provider ensures success!success!

I. The (Really) Big PictureI. The (Really) Big Picture

STEMI System Blueprints …STEMI System Blueprints …courtesy of the AHA…courtesy of the AHA…

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Working at all levels to improve care Working at all levels to improve care for STEMI patientsfor STEMI patients

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AHA: STEMI System BlueprintsAHA: STEMI System Blueprints

Mission: Lifeline Recommendations for Mission: Lifeline Recommendations for Criteria for STEMI Systems of CareCriteria for STEMI Systems of Care

The criteria are divided into:The criteria are divided into: Non-PCI Hospital/STEMI Referral Center PCI Hospital/STEMI-Receiving Center sectio

ns    

EMS STEMI Systems of Care

Please visit the Mission: Lifeline portion Please visit the Mission: Lifeline portion of the American Heart Association of the American Heart Association website for all types of ideas for website for all types of ideas for improving STEMI systems of careimproving STEMI systems of care

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II. D2B: PCI-center II. D2B: PCI-center systems engineeringsystems engineering

The Door to Balloon Initiative (D2B), The Door to Balloon Initiative (D2B), organized and spearheaded by the organized and spearheaded by the American College of Cardiology American College of Cardiology (ACC), was extremely successful in (ACC), was extremely successful in helping optimize STEMI care at PCI helping optimize STEMI care at PCI centers via its attention to systems centers via its attention to systems level improvement as the key to level improvement as the key to sustainable successsustainable success

D2B: PCI EngineeringD2B: PCI Engineering

1.1. ED physician activates cath labED physician activates cath lab2.2. One call activates the cath labOne call activates the cath lab3.3. Cath lab team ready in 20-30 Cath lab team ready in 20-30

minutesminutes4.4. Prompt data feedbackPrompt data feedback5.5. Senior management Senior management

commitmentcommitment6.6. Team-based approachTeam-based approach

D2B: PCI-center systems engineeringD2B: PCI-center systems engineering

For more information For more information on D2B, please on D2B, please visit the ACC visit the ACC website.website.

III. Project UPSTART: STEMI III. Project UPSTART: STEMI System Builder’s ToolkitSystem Builder’s Toolkit

Project UPSTART: A Reperfusion Project UPSTART: A Reperfusion Toolkit for All SituationsToolkit for All Situations

Project UPSTART was designed as an Project UPSTART was designed as an integrated set of concepts, processes integrated set of concepts, processes and procedures that can be used to and procedures that can be used to help efficiently address issues that help efficiently address issues that are common in are common in any local any local STEMI STEMI systemsystem

So, Optimize Recognition So, Optimize Recognition and Reperfusion…and Reperfusion…

All attempts at reducing STEMI All attempts at reducing STEMI treatment times must ultimately treatment times must ultimately focus on improving one (or both) focus on improving one (or both) of these endpoints. of these endpoints.

The goal: early The goal: early Recognition followed by early followed by early Reperfusion.

……By Remembering By Remembering “Joe the STEMI Patient”“Joe the STEMI Patient”

Systems Systems

Engineering: Engineering:

-Optimizing the-Optimizing the

average!average!

Design your system Design your system

with optimism butwith optimism but

base it on realismbase it on realism

And Remembering the 80/20 Rule!And Remembering the 80/20 Rule!

Review: Efficient ImprovementReview: Efficient Improvement

First, define and understand your local First, define and understand your local Elemental STEMI SubsystemElemental STEMI Subsystem

Next, optimize the 5R’s within your Next, optimize the 5R’s within your local ESS & build a solid self-local ESS & build a solid self-improving, sustainable systemimproving, sustainable system

Finally, devote time to fine-tuning each Finally, devote time to fine-tuning each STEMI conduit within your ESSSTEMI conduit within your ESS

First, Define and Understand Your ESS!

Non-PCINon-PCI PCIPCI

PCIPCI

Non-PCINon-PCI

Key Concept: The “Elemental Key Concept: The “Elemental STEMI Subsystem” (ESS)STEMI Subsystem” (ESS)

The smallest combination of EMS The smallest combination of EMS and STEMI treatment facilities that and STEMI treatment facilities that can function “alone” as a self can function “alone” as a self functioning “STEMI system of care”functioning “STEMI system of care”

By definition, the ESS is the By definition, the ESS is the “elemental building block” of all “elemental building block” of all STEMI systems –no matter how large STEMI systems –no matter how large that “system” may bethat “system” may be

??

A Typical Elemental STEMI A Typical Elemental STEMI Subsystem Subsystem

Homework: Sketch Your ESS Here Homework: Sketch Your ESS Here Please!Please!

Homework/Notes:Homework/Notes:

Next, work on the “5R’s” Next, work on the “5R’s” Within Within youryour ESS ESS

In order to improve your system in a In order to improve your system in a time efficient manner you must time efficient manner you must improve each one of these critical improve each one of these critical processes until they are running processes until they are running smoothly.smoothly.

Review: The 5 Essential Elements Review: The 5 Essential Elements of STEMI System Designof STEMI System Design

R1R1 RelationshipsRelationshipsR2R2 RecognitionRecognitionR3R3 ReperfusionReperfusionR4R4 Real-time Data CollectionReal-time Data CollectionR5R5 Reassessment & Reassessment & RefinementRefinement

Homework/Notes:Homework/Notes:

What 2 Essential Elements do you feel What 2 Essential Elements do you feel need the most work within your need the most work within your current system? (circle 2)current system? (circle 2)

R1R1 RelationshipsRelationshipsR2R2 RecognitionRecognitionR3R3 ReperfusionReperfusionR4R4 Real-time Data CollectionReal-time Data CollectionR5R5 Reassessment & Reassessment &

RefinementRefinement

Finally, Finally, nownow sweat the small stuff! sweat the small stuff!-fine-tune each STEMI conduit within -fine-tune each STEMI conduit within

your ESS.your ESS.

Homework: Sketch one of your Homework: Sketch one of your problem STEMI Conduits here…problem STEMI Conduits here…

Review: Efficient ImprovementReview: Efficient Improvement

First, define and understand your local First, define and understand your local Elemental STEMI SubsystemElemental STEMI Subsystem

Next, optimize the 5R’s within your Next, optimize the 5R’s within your local ESS & build a solid self-local ESS & build a solid self-improving, sustainable systemimproving, sustainable system

Finally, devote time to fine-tuning each Finally, devote time to fine-tuning each STEMI conduit within your ESSSTEMI conduit within your ESS

Final Result: A Simple PlanFinal Result: A Simple Plan

Homework/Notes:Homework/Notes:

Is the current STEMI ALERT Plan in Is the current STEMI ALERT Plan in my institution this simple and my institution this simple and defined?defined?

How can I simplify it?How can I simplify it?

The Payoff? More of Them Are The Payoff? More of Them Are “Easy”“Easy”

An example…..

Logging, Bad Burgers & AngelsLogging, Bad Burgers & Angels

34 year-old male is logging trees in remote 34 year-old male is logging trees in remote areaarea

Increased heartburn after “gut bomb” Increased heartburn after “gut bomb” lunchlunch

Pain worsens; His boss calls rural EMS, Pain worsens; His boss calls rural EMS, who arrange to meet them at a local “Kum who arrange to meet them at a local “Kum and Go”.and Go”.

EMS does ECG in parking lot: it looks “bad”EMS does ECG in parking lot: it looks “bad” Idea: fax ECG to UVA Medical CommandIdea: fax ECG to UVA Medical Command

DX: Acute Inferior Wall MI!DX: Acute Inferior Wall MI!

EMS departs for UVA after faxing ECGEMS departs for UVA after faxing ECG In route to UVA patient goes into In route to UVA patient goes into

ventricular arrest and becomes ventricular arrest and becomes unresponsiveunresponsive

Defibrillated once and revives Defibrillated once and revives EMS contacts UVA in route; discusses EMS contacts UVA in route; discusses

ECG with the on-duty ED physicianECG with the on-duty ED physician UVA Cath lab activated, ED on UVA Cath lab activated, ED on

Standby…Standby…

ED AnticsED Antics

Arrives in ED …..’”groggy and Arrives in ED …..’”groggy and painful”painful”

22ndnd IV placed/Groin prepped/Monitor IV placed/Groin prepped/Monitor Pacer Pads placedPacer Pads placed Beta Blocker, Heparin and PlavixBeta Blocker, Heparin and Plavix Clothes off, consented, and down the Clothes off, consented, and down the

hallhall ED door in to door out? ED door in to door out? 8 Minutes!

Cath Lab Precision…Cath Lab Precision…

Cath lab staff ready at bedside!Cath lab staff ready at bedside! Lido time: Cath door + 2Lido time: Cath door + 2 Access time: door+ 12 Access time: door+ 12 Cath lab door to device: +18 Cath lab door to device: +18 Cath Lab door-to-balloon: + 21Cath Lab door-to-balloon: + 21 Total RTotal R22R time: 59 minutes from 1R time: 59 minutes from 1stst

ECG at the gas stationECG at the gas station Total DTB time: 29 minutesTotal DTB time: 29 minutes

Post Cath…Post Cath…

Cardiac echo shows only a minimally Cardiac echo shows only a minimally depressed ejection fractiondepressed ejection fraction

Patient feeling much better!Patient feeling much better! Admits to 5 days of increasing Admits to 5 days of increasing

“heartburn”“heartburn” PMH: Dad died at 50 of massive MI… PMH: Dad died at 50 of massive MI… Refers to his EMS providers as the Refers to his EMS providers as the

“two special angels who saved his “two special angels who saved his life!”life!”

Madison County, VA -2 “EMS Angels”Madison County, VA -2 “EMS Angels”

So, Start Somewhere…TodaySo, Start Somewhere…Today

Don’t wait for Don’t wait for perfection perfection

Start fixing the Start fixing the process now process now

Change items that Change items that really matterreally matter

Start by optimizing Start by optimizing the 5 R’s!the 5 R’s!

R1) Relationships!R1) Relationships!

STEMI SystemSTEMI System

CementCement

Reperfusion!

Recognition!

Relationships

Homework:Homework:

Write down three relationships within Write down three relationships within your ESS that currently need your ESS that currently need attentionattention

Note: Please refer to the Project Note: Please refer to the Project UPSTART system assessment quiz for UPSTART system assessment quiz for additional information on STEMI additional information on STEMI system relationshipssystem relationships

R2) Recognition:

Develop optimal Develop optimal STEMI recognition STEMI recognition practices at each practices at each STEMI “portal”STEMI “portal”

Goal: Each Goal: Each qualifying patient qualifying patient receives a timely receives a timely screening ECG!screening ECG!

Optimize Recognition at Every Optimize Recognition at Every Portal!Portal!

I. EMS: “Mobile” STEMI PortalsI. EMS: “Mobile” STEMI Portals

Think Logically!

EMS “STEMI Vision” –Just Say No!EMS “STEMI Vision” –Just Say No!

95%+ of EMS calls are NOT STEMI!95%+ of EMS calls are NOT STEMI!

STEMI

Ab Pain MVA

Weak/dizzy

???AlteredLOC

EMS ECG: Keep it Simple!EMS ECG: Keep it Simple!

Provide EMS personnel with ECG Provide EMS personnel with ECG machinesmachines

Provide clear “if/then” protocols for Provide clear “if/then” protocols for all EMS possibilities all EMS possibilities

Provide ECG acquisition trainingProvide ECG acquisition training Provide ECG interpretation trainingProvide ECG interpretation training Provide feedback and educationProvide feedback and education Consider transmission technologyConsider transmission technology

First Step: Got STEMI? – Call the First Step: Got STEMI? – Call the ED!ED!

EMS/ED EMS/ED communication on communication on every potential STEMI every potential STEMI is a mustis a must

Either with/without Either with/without ECG transmissionECG transmission

Ties the ED and EMS Ties the ED and EMS togethertogether

Will capture Will capture mostmost cases of STEMI prior to cases of STEMI prior to arrivalarrival

I think I got one!

Simple Protocols at Each PortalSimple Protocols at Each Portal

Example of a simple 3-step protocolExample of a simple 3-step protocol

1) In situations where EMS personnel 1) In situations where EMS personnel have obtained a pre-hospital ECG have obtained a pre-hospital ECG suspicious for STEMI.suspicious for STEMI.

2 EMS personnel should immediately contact Med Com, 2 EMS personnel should immediately contact Med Com, clearly identify the incoming patient as a possible STEMI, clearly identify the incoming patient as a possible STEMI, and request to talk directly with the attending ED and request to talk directly with the attending ED physician.physician.

3) This step should occur for each suspected STEMI case—3) This step should occur for each suspected STEMI case—

even if EMS is unable to transmit the ECG to even if EMS is unable to transmit the ECG to UVA.UVA.

Simple protocols at each portalSimple protocols at each portal

ECG Transmission: Nice but not ECG Transmission: Nice but not essential!essential!

ECG Transmission:ECG Transmission:

““Icing on the Cake”Icing on the Cake”

Transmission may be Transmission may be useful in certain useful in certain situations but does not situations but does not replace more replace more important essentials important essentials such as protocol such as protocol development, EMS development, EMS training and a focus training and a focus on ECG acquisition as on ECG acquisition as the key 1the key 1stst step! step!

Three Options for Three Options for InterpretationInterpretation

Consider Destination Protocols

– The concept of diverting STEMI The concept of diverting STEMI patients to PCI-capable centers, patients to PCI-capable centers, bypassing non-PCI centers does bypassing non-PCI centers does have potential in certain have potential in certain circumstances!circumstances!

Homework/Notes:Homework/Notes:

Do the EMS agencies within my ESS Do the EMS agencies within my ESS sphere have site-specific STEMI sphere have site-specific STEMI recognition protocols?recognition protocols?

Don’t Forget EMS Education!Don’t Forget EMS Education!

An EMS STEMI StoryboardAn EMS STEMI Storyboard

Throws in a little Throws in a little “real time “real time relationship relationship building”building”

Highlights the role Highlights the role of EMS within the of EMS within the STEMI Care STEMI Care Continuum.Continuum.

ED Recognition: Accept No ED Recognition: Accept No Excuses!Excuses!

Implement a standardized protocolImplement a standardized protocol Educate staff on their roleEducate staff on their role Give them the resources and back-up Give them the resources and back-up

options to do thisoptions to do this Expect success!Expect success! Visit the Project UPSTART website for Visit the Project UPSTART website for

more ideas and discussion on more ideas and discussion on RecognitionRecognition

-Provide a tool-Educate staff-Post reminders-Expect compliance-Every ECG seen by

A physician-Backup plans in place

ED Recognition…ED Recognition…

Homework/Notes:Homework/Notes:

What do I need to do to optimize the What do I need to do to optimize the Recognition process in my ED?Recognition process in my ED?

Don’t Forget Education!Don’t Forget Education!

Remember, train and educate your “First Remember, train and educate your “First Contact Providers” regarding their role as Contact Providers” regarding their role as “STEMI “Gatekeepers”“STEMI “Gatekeepers”

I.E. The Provider I.E. The Provider Training Module @Training Module @

www.projectupstart.comwww.projectupstart.com

Notes:Notes:

Do all ED providers in my Emergency Department receive regular training regarding their role in the STEMI Recognition and Reperfusion process?

R3) ReperfusionR3) Reperfusion

STEMI is not rocket science!

Two Endpoints (R2R)

Early Recognition…Followed byEmergent Reperfusion

Generals: Plan the war….. Generals: Plan the war….. ….and then get out of the way!….and then get out of the way!

Pre-planning is essential Pre-planning is essential in STEMI network in STEMI network developmentdevelopment

During a STEMI ALERT, During a STEMI ALERT, however replace however replace planning with action!planning with action!

Q: What triggers the “STEMI Q: What triggers the “STEMI Response in your ED?Response in your ED?

STEMI fact: When the STEMI fact: When the unexpected occurs, unexpected occurs, staff members perform staff members perform best when they have a best when they have a “trigger to action.” “trigger to action.”

……The Red STEMI Alert The Red STEMI Alert Packet-Open one for Packet-Open one for every STEMI!every STEMI!

A: Take a “Leap of Faith”A: Take a “Leap of Faith”

Simplify your life:Simplify your life:

Put a STEMI ALERT Put a STEMI ALERT Packet at every Packet at every STEMI portal within STEMI portal within your Elemental your Elemental STEMI Subsystem.STEMI Subsystem.

Put a STEMI ALERT Packet in Put a STEMI ALERT Packet in your ED!your ED!

A carefully A carefully designed STEMI designed STEMI ALERT Packet is ALERT Packet is the key to the key to success.success.

Put one in your Put one in your institutioninstitution

Building your PacketBuilding your Packet

Go to Go to www.projectupstart.com and and access “STEMI Boot Camp”access “STEMI Boot Camp”

The “easy button” for STEMI ALERT The “easy button” for STEMI ALERT Packet constructionPacket construction

Forms, templates, provider Forms, templates, provider education, UPSTART Color Guide, education, UPSTART Color Guide, real-world examples, PowerPoint real-world examples, PowerPoint manuals, publicity, etcmanuals, publicity, etc

Standard STEMI Alert PacketStandard STEMI Alert Packet

A STEMI ALERT Packet A STEMI ALERT Packet Includes 3 Checklists:Includes 3 Checklists:

Physician Physician ChecklistChecklist

Nurse Nurse ChecklistChecklist

STEMI Scribe STEMI Scribe ChecklistChecklist

……And Two Simple Data SheetsAnd Two Simple Data Sheets

Data Sheet Data Sheet AA

Data Sheet Data Sheet BB

The STEMI ALERT PacketThe STEMI ALERT Packet

Opening of the packet allows the Opening of the packet allows the combination of provider checklists and combination of provider checklists and data collection sheets to guide the process data collection sheets to guide the process & collect valuable quality improvement & collect valuable quality improvement data as the STEMI occursdata as the STEMI occurs

With a packet, this happens reliably, With a packet, this happens reliably, almost every time!almost every time!

Without a packet, where is your trigger?Without a packet, where is your trigger?

Non-PCI centers: Focus on the Non-PCI centers: Focus on the handoff…….handoff…….

Inter-facility Inter-facility transport is usually transport is usually the uncertain link the uncertain link with any give with any give STEMI case at a STEMI case at a Non-PCI centerNon-PCI center

Transport time is your “Jokers Transport time is your “Jokers Wild!”Wild!”

Transportation issues at Transportation issues at Non-PCI centers are Non-PCI centers are numerousnumerous– Air vs. groundAir vs. ground– WeatherWeather– Local EMS Local EMS

availabilityavailability– Limitation of local Limitation of local

resourcesresources

Non-PCI centers –time meets Non-PCI centers –time meets patient!patient!

Spend a great deal Spend a great deal of time on refining of time on refining your inter-facility your inter-facility transport optionstransport options

They are the key They are the key component of Non-component of Non-PCI center STEMI PCI center STEMI ALERT PlansALERT Plans

Homework/Notes:Homework/Notes:

Do I have a STEMI ALERT Packet in Do I have a STEMI ALERT Packet in my Emergency Department?my Emergency Department?

How long do I think it will take to put How long do I think it will take to put one in place?one in place?

Building your PacketBuilding your Packet

Go to Go to www.projectupstart.com and and access “STEMI Boot Camp”access “STEMI Boot Camp”

The “easy button” for STEMI ALERT The “easy button” for STEMI ALERT Packet constructionPacket construction

Forms, templates, provider Forms, templates, provider education, UPSTART Color Guide, education, UPSTART Color Guide, real-world examples, PowerPoint real-world examples, PowerPoint manuals, publicity, etcmanuals, publicity, etc

R4R4 ) Real-time data collection ) Real-time data collection

R1R1 RelationshipsRelationshipsR2R2 RecognitionRecognitionR3R3 ReperfusionReperfusionR4R4 Real-time data collectionReal-time data collectionR5R5 Reassessment & refinementReassessment & refinement

The Hawthorne effectThe Hawthorne effect

You can’t improve You can’t improve

what you don’t what you don’t

measure!measure!

Back to the Data SheetsBack to the Data Sheets

Data Sheet Data Sheet AA

Data Sheet Data Sheet BB

The Real Life Data ChainThe Real Life Data Chain

Use of a real-time data sheet allows Use of a real-time data sheet allows sharing of data between facilities and sharing of data between facilities and within institutions within institutions in real timein real time

Result? Very efficient QIResult? Very efficient QI Cements providers and transitionCements providers and transition Prompts excellencePrompts excellence

Homework/Notes:Homework/Notes:

Do I have a real-time Data collection Do I have a real-time Data collection system within my ESS?system within my ESS?

When could we start?When could we start?

R5) Reassessment & refinementR5) Reassessment & refinement

R1R1 RelationshipsRelationshipsR2R2 RecognitionRecognitionR3R3 ReperfusionReperfusionR4R4 Real-time Data CollectionReal-time Data CollectionR5R5 Reassessment & RefinementReassessment & Refinement

Refinement and ReassessmentRefinement and Reassessment

Invigorate your STEMI committeeInvigorate your STEMI committee Investigate every caseInvestigate every case Look at all STEMI cases, not just CMS Look at all STEMI cases, not just CMS

qualifiersqualifiers Work within your ESSWork within your ESS Make feedback a priorityMake feedback a priority Continually reassess Essential Continually reassess Essential

Elements within your ESS Elements within your ESS

STEMI Construction hintsSTEMI Construction hints

Blueprints: Mission: LifelineBlueprints: Mission: Lifeline Environment: your local ESSEnvironment: your local ESS Construction plan: optimize the 5R’sConstruction plan: optimize the 5R’s Finish Coat: perfect each STEMI conduitFinish Coat: perfect each STEMI conduit Toolkits: Project UPSTART, D2B, etcToolkits: Project UPSTART, D2B, etc Continuing Ed: Continuing Ed: ongoingongoing education for your education for your

First Contact ProvidersFirst Contact Providers

HomeworkHomework

What is What is mymy next step in improving my next step in improving my local system?local system?

Summary:Summary:

Optimize the 5 Essential Elements of Optimize the 5 Essential Elements of Reperfusion within your systemReperfusion within your system

Concentrate on the basics first then Concentrate on the basics first then seek refinementseek refinement

Never undervalue relationships as Never undervalue relationships as the ultimate key!the ultimate key!

STEMI Boot Camp materials…STEMI Boot Camp materials…

Please access the “STEMI Boot Camp Please access the “STEMI Boot Camp link at link at www.projectupstart.com for for more information and complete more information and complete access to all STEMI Boot Camp access to all STEMI Boot Camp materials you may need to begin materials you may need to begin optimizing your local systemoptimizing your local system

www.projectupstart.comwww.projectupstart.com

Questions?Questions?

David R. Burt, MDAssistant ProfessorDepartment of Emergency Medicine University of Virginia Health Systemdavidrburt@virginia.eduO: 434.924.2428