The Importance of Door In Door Out Time DIDOwcm/@mwa/...The literature s\൨ows the PCI, or percutaneous coronary intervention, is the preferred method of reperfusion. In fact, both

$Page 1: The Importance of Door In Door Out Time DIDOwcm/@mwa/...The literature s\൨ows the PCI, or percutaneous coronary intervention, is the preferred method of reperfusion. In fact, both$
REFERRAL HOSPITAL

The Importance of Door In Door Out Time

DIDO

For patients with ST-segment elevation myocardial infarction (STEMI), percutaneous coronary intervention (PCI) is the preferred method of reperfusion1

Both the American College of Cardiology / American Heart Association (ACC/AHA) and the European Society of Cardiology (ESC) recommend a door-to-balloon time of less than 90 minutes2

1 Antman EM et al; 2007 focused update of the ACC/AHA 2004 guidelines for the management of patients with ST-elevation myocardial infarction: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. Circ: 2008:117(2):296-329 2 Kushner FG et al; ACC/AHA Task Force on Practice Guidelines. 2009 Focused Updates: ACC/AHA guidelines for the management of patients with ST-elevation myocardial infarction: report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. Circ: 2009; 120:2271-2306

Time to Treatment is critical for STEMI patients

Presenter

Presentation Notes

Just to summarize what you have been hearing about all day. Time to treatment is critical for STEMI patients. The literature shows the PCI, or percutaneous coronary intervention, is the preferred method of reperfusion. In fact, both the American College of Cardiology and the American Heart Association, as well as the European Society of Cardiology, recommend that a STEMI patient receive PCI within 90 minutes or less.

Improving door-to-balloon time for primary PCI has been shown to decrease mortality

Time to treatment is critical for STEMI patients

Presenter

Presentation Notes

The longer it takes to get a STEMI patient to treatment, then the greater the chances are of a negative outcome. There is a direct relationship between improving door-to-balloon time and decreasing mortality.

TIME MINUTES MEAN MYOCARDIUM •1/3 pts with STEMI will die within 24 hours •Majority of deaths within the first 2 hours •Average patient does not seek care for 2

hours •Each minute a patient remains in VF, survival

odds decrease 7-10% •Patients with STEMI should use ambulance

Presenter

Presentation Notes

There are numerous factors to consider in decreasing a patients time to definitive treatment. We will touch on some of these but will focus on decreasing the Door in Door out time at a PCI referral hospital.

STEMI SYSTEM OF CARE AHA 2010 Guidelines recommend a System of Care approach

to effectively handle STEMI patient care1:

Goal: get a STEMI patient to appropriate treatment

as quickly as possible.

1 O’Connor RE et al; Part 10: Acute Coronary Syndromes: 2010 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. Circ: 2010,122;S787-S817

Presenter

Presentation Notes

Because there are so many factors to consider, the latest guideline recommendations from the American Heart Association recommend a system of care approach to effectively handle STEMI patient care. This means bringing together communities, EMS providers, referral hospitals, cardiology, and PCI hospitals to build a system that can handle those complexities. The end goal is to identify a STEMI patient quickly and then get them to the appropriate treatment as quickly as possible. In order to do this the system must work efficiently.

Rapid access to appropriate treatment

Provide critical data to hospital teams quickly Transport patient to most appropriate facility

Early identification of a STEMI patient Advanced warning and activation of Cath Lab and teams

Early diagnosis of a STEMI patient Remotely review and diagnose difficult rhythms

Improve (reduce) door-to-balloon metrics Meet Core Measure / CMS benchmarks Meet chest pain accreditation key elements

Same Goal, Differing Needs

EMS Care Team

Hospital Care Team

Cardiology

Hospital Administration

Patient

Presenter

Presentation Notes

Each element has the same goal, but with differing needs... [Go through the elements]

PREHOSPITAL 12-LEAD ECG

The prehospital 12-lead ECG is a critical tool in identifying and diagnosing a STEMI patient and shortening the time to treatment1 AHA/ACC recommends that EMS acquire a 12-lead ECG as soon as possible for all patients exhibiting symptoms of ACS1 Along with early Cath Lab activation, it can be the single most important factor in reducing door-to-balloon time2

1 O’Connor RE et al; Part 10: Acute Coronary Syndromes: 2010 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. Circ: 2010,122;S787-S817 2 Brown JP et al; Effect of Prehospital 12-Lead Electrocardiogram on Activation of the Cardiac Catheterization Laboratory and Door-to-Balloon Time in ST-Segment Elevation Acute Myocardial Infarction. Am J Cardiol 2008;101:158-161

Presenter

Presentation Notes

The key tool EMS has to identify and diagnose STEMI is a prehospital 12-lead ECG.

SOUTH DAKOTA HAS MADE A COMMITMENT TO IT’S EMS SYSTEMS TO FACILITATE THE PLACEMENT OF 12 LEAD EKGS IN EVERY AMBULANCE SERVICE IN THE STATE.

Presenter

Presentation Notes

We now also need to focus on the other elements of the STEMI system.

HOSPITAL ROUTING COMPLEXITY

Self transport to hospital

Referral Hospital

ED

PCI Hospital

EMS transport

Cath Lab

Patient routing and Cath Lab activation decisions are able to be made before patient arrival, helping reduce time to treatment.

Presenter

Presentation Notes

When we look at the hospital, there is actually quite a bit of complexity when it comes to getting a STEMI patient to the appropriate care quickly. Whether a patient self-transports to the hospital or whether they call 911, they will most likely enter the care system at the ED. It is important to ask what kind of ED? Is this an ED associated with a PCI center, or is this an ED at a referral hospital, a hospital that does not have PCI capability? The goal is to get the patient to the cath lab as quickly as possible. If we are already at a PCI facility, that is relatively easy. But if they are at a referral hospital, it involves a transfer to a PCI hospital. How do you minimize delay in transfer to a PCI facility?

REFERRAL AND PCI HOSPITALS

Referral Hospitals are measured on Door-In to Door-Out (DIDO) times

PCI Hospitals are measured on Door-to-Balloon (D2B) times

Presenter

Presentation Notes

PCI hospital are measured on door-to-balloon times, from the door of the hospital to the time that the artery has been opened. Referral hospitals, on the other hand, are measured on DIDO times, or door-in to door-out.

REFERRAL HOSPITALS

DIDO Performance measure used to measure efficiency of

referral hospital’s care and transfer for STEMI patients1 Measures the time it takes to receive a patient, make a

STEMI diagnosis, and transfer them to a PCI facility • ACC/AHA recommendation: 30 minutes1

Performance measure recorded by CMS2

1 Wang TY et al. Association of Door-In to Door-Out Time With Reperfusion Delays and Outcomes Among Patietns Transferred for Primary PCI. JAMA 2011;305(24):2540-2547 2 Krumholz MA et al. ACC/AHA 2008 performance measures for adults with ST-elevation and non-ST-elevation myocardial infarction. J Am Coll Cardiol. 2008;52(24):2046-2099 2 http://www.qualitynet.org/dcs/ContentServer?c=Page&pagename=QnetPublic%2FPage%2FSpecsManualTemplate&cid=1228768402492

Presenter

Presentation Notes

DIDO time is really a measure of efficiency for referral hospitals. It measures how much time it takes to receive a patient, make a STEMI diagnosis, and then transfer them to a PCI facility. The goal is 30 minutes, as recommended by the American Heart Association and American College of Cardiology. This is a measure that is being tracked by the centers of medicare and medicaid. While is it not yet a benchmark that is used in value-based purchasing decisions, the expectation is that it will be soon.

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REFERRAL HOSPITALS

30 minute DIDO is difficult to achieve - Examples Example 1 - ACTION registry assessment:1 14,821 STEMI patients transferred for primary PCI

(2007-2010) Only 11% of patients had a DIDO of

less than 30 minutes

1 Wang TY et al. Association of Door-In to Door-Out Time With Reperfusion Delays and Outcomes Among Patients Transferred for Primary PCI. JAMA 2011;305(24):2540-2547

Presenter

Presentation Notes

For a referral hospital to achieve a DIDO time of 30 minutes is actually quite difficult, and it doesn’t happen very often. Here are two very recent examples. The first is an assessment that was done using the ACTION registry. Looking at close to 15,000 patients from 2007 to 2010, only 11% of patients has a DIDO time of less than 30 minutes.

REFERRAL HOSPITALS Example II - Miedema Study:

2,028 STEMI patients analyzed from 2003-2008 64% of patients had a DIDO time > 45 minutes

Cause of Delay Patients

No delay 36%

Awaiting Transport 26%

ED Delay 14%

Nondiagnostic ECG 9%

Diagnostic Dilemma 9%

Cardiac arrest 6%

1 Miedema MD et al. Causes of Delay and Associated Mortality in Patients Transferred with ST-Segment Elevation Myocardial Infarction. Circ. 2011;124

Presenter

Presentation Notes

The second example is the recently published Miedema study. This study looked at just over 2,000 patients from 2003 to 2008 and found that 64% of patients had a DIDO time of over 45 minutes. What is interesting about this study is that it looked at the reasons for delay and found 5 main categories of delay: [list categories] As you can see the 2 categories with highest percentage of patients that had a transfer delay were Awaiting Transport and ED Delay, Those 2 together were 40%. Pre-hospital ECGs can impact both of these categories. But the referral hospital needs to act aggressively when that STEMI ECG arrives. (The last 3 together were only 24%) Just looking at your processes and addressing those 2 things could make a significant difference in decreasing DIDO times at referral hospitals and directly impact the outcomes of the patients involved. A non-diagnostic ECG was noted if the 12-lead ECG looked normal but a subsequent 12-lead showed STEMI. This is a perfect example of why a baseline 12-lead is so important and being notified of any changes to that baseline.

STEMI-referral hospital treatment and triage algorithm.

Aguirre F V et al. Circulation 2008;117:1145-1152

Copyright © American Heart Association

Presenter

Presentation Notes

For any hospital having a plan or algorithm in place can help to decrease the DIDO time. This is an Example of a STEMI-referral hospital treatment and triage algorithm . (LBBB indicates left bundle-branch block)

STEMI-REFERRAL HOSPITAL PROCESS MEASURES 1. Symptom onset to door 1 (ie, symptom onset to STEMI-

referral hospital ED presentation) 2. Door 1 to medical contact (ie, STEMI-referral hospital ED

presentation to initial physician or nurse contact) 3. Door 1 to ECG (ie, STEMI-referral hospital ED presentation to

acquisition of 12-lead ECG) 4. Door 1 to decision (ie, STEMI-referral hospital ED

presentation to ED physician’s call to initiate transfer) 5. Door 1 to needle (ie, STEMI-referral hospital ED presentation

to initiation of intravenous fibrinolytic; acquired only from fibrinolytic-treated patients)

6. Door 1 to departure (ie, STEMI-referral hospital ED presentation to ED departure).

Helicopter transfer is preferred if the interhospital transport time is >30 minutes

Presenter

Presentation Notes

These are examples of process measures your facility can look at and work on improving your processes. It requires looking at your process and performing an honest evaluation of those processes. The first step is to map out your process as it currently happens. This should be done by someone unfamiliar with your “routines”. They follow a patient from arrival to discharge from the ED and “map out the process”. Measuring the time it takes for each step in the patients care. Then you can look at that process and identify where you can “cut out some time”. Develop a plan to make the changes and educate staff. After a few weeks follow a patient through the process again and see if you have decreased any time. Cutting out just a few minutes in several processes can make significant differences and decrease your DIDO time.

SYMPTOM ONSET TO DOOR 1

Community Education EMS providers, nurses and Primary Care

providers are the experts in their own communities.

Get in front of your small groups and educate about Signs and Symptoms of Heart Attack and the importance of calling 911

Put literature around waiting rooms and educate your patients and neighbors

DOOR 1 TO MEDICAL CONTACT

Is your Physician, PA or NP in house How and when do you contact them when a

chest pain patient comes in to your ED How long does it take them to get to the ED Can they receive an EKG by e-mail or Smart

Phone

DOOR 1 TO ECG

What symptoms trigger you to get an ECG Can you obtain one prior to the Doctor seeing

the patient Who does ECGs in your facility Goal of obtaining ECG within 5 minutes of

patient arrival Goal needs to be less than 10 minutes Door to

ECG reviewed by physician/PA/NP

Presenter

Presentation Notes

Develop a list of symptoms that trigger an ECG. Post it in your ER for staff to see. If in doubt, just do it! Educate your EMS providers and provide them the same list. Chest pain, upper back pain, epigastric distress, left arm, neck jaw, sweaty, weakness, nausea, even flu like symptoms. If the ambulance has transmitted an ECG the physician should be either in the ER or on their way. They need to have been notified before the patient arrives. Leave the patient on the ambulance cart if it is a STEMI and they will be transporting the patient! Moving a patient from cart to bed and back again is a huge waste of critical time. You can even make it a practice to do your ECG before moving the patient whenever you are doing an ECG. This can dramatically decrease your door to ECG times. They don’t cost you anything to obtain. The machine sits right there. Is it assigned to one job description? Are they inhouse 24/7? Anyone can be trained to do ECGs. Machines are very sophisticated – they have diagrams to help. Admissions, housekeeping, nurses, nurse aides – anyone, be creative, think outside the box. Who is in house 24/7? Use them!

DOOR 1 TO DECISION

What do you do if the physician is not in-house and you have a STEMI sitting in front of you?

Do you have the numbers right by the phone in the ED so it can be made quickly?

Most PCI centers have one-call systems so you only have one number to dial and they will contact Cardiology and help you arrange transport if needed.

Early activation of air transport is very important when ground transport will be more than 30 minutes.

Presenter

Presentation Notes

Transmitting data to the PCI hospital about the patients symptom onset, history, allergies, medications and treatment received impacts the preparations made for the patient at the receiving hospital. If the hospital is within your healthcare system some of these can be found in the Electronic Medical Record, but others may need to be faxed if it cannot met transmitted any other way.

DOOR 1 TO NEEDLE

If transport time will be prolonged (more than 30 minutes) you may need to infuse Thrombolytics.

Goal is 10 minutes from door to start of infusion. Notify Receiving hospital ASAP of Non-Reperfused Lytic Patient In rural facilities weather and time of day may

effect decision on how to manage the patient.

DOOR 1 TO DEPARTURE

Weather, staff, co-morbidities, time of day may all effect best management strategies.

Time to ECG Goal < 5 minutes Time to Ambulance Commitment Goal < 10

minutes Time to Ambulance Arrival Goal < 10 minutes Time to Ambulance Departure Goal < 5 minutes Total Time in ED Goal < 30 minutes

Presenter

Presentation Notes

Here is an example. Your situation may be different. Look at how long each step takes and try to find a way to decrease one so there is more time for the others.

STEMI SYSTEM OF CARE

1 Miedema MD et al. Causes of Delay and Associated Mortality in Patients Transferred with ST-Segment Elevation Myocardial Infarction. Circ. 2011;124

“The development of a regional STEMI system that includes transfer of patients from non-PCI centers is an important strategy to improve timely access to primary PCI.”1

Receiving data from Referral Hospitals helps the team prepare resources

Sharing data between ED and Cath Lab helps enable Cath Lab activation decision

Presenter

Presentation Notes

So for referral hospital, being part of a STEMI system of care is an important strategy as it helps improve timely access to care for STEMI patient by speeding up the transfer process.

CONCLUSIONS

Patients requiring transfer for PCI have the longest treatment times, and most do not reach 90 minute first door to device goal.

STEMI reperfusion can be markedly accelerated by establishing a single plan with standardized processes

SUMMARY

Primary Percutaneous Coronary Intervention (PCI) is the most complex, multi-disciplinary, and time-sensitive therapeutic intervention in the world of medicine. Our process is measured in Minutes Our outcomes are measured in terms of

Mortality Teamwork and smooth Transitions are

essential

Documents

The Importance of Door In Door Out Time DIDOwcm/@mwa/...The literature s\൨ows the PCI, or percutaneous coronary intervention, is the preferred method of reperfusion. In fact, both