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STEMI Care Delivery Report Out Lean Defined A Process Management Philosophy centered around creating more value with less work by driving out waste so that all work adds some form of value while serving the needs of our patients STEMI Lean Team Project Sponsors Dr. John Seccombe, Physician Sponsor Paula Hafeman, Leadership Sponsor Physician Support Dr. Kenneth Johnson, Emergency Dept Dr. Zhaowei Ai, Heart and Vascular Department Support Jennifer Gerdmann, Emergency Dept Jim Callender, Cath Lab Dan Doran, Cath Lab Brad Lepinski, Heart and Vascular James Pelch, Project Leader Leigh Messmann, Project Manager /Facilitator LaNaeh Wallander, Project Coordinator Definitions • Door to Balloon (D2B)– the amount of time between a heart attack patient’s arrival at the hospital to the time he/she receives PCI • PCI (percutaneous coronary intervention) – family of medical procedures that uses mechanical means to treat patients with partially restricted blood flow through the artery of the heart. • Reperfusion Therapy – techniques to restore blood flow to part of the heart muscle • STEMI (ST segment elevation myocardial infarction) – a severe heart attack caused by a prolonged period of blocked blood supply causing heart cells to die • LBBB (left bundle branch block) - a cardiac conduction abnormality; activation of the left ventricle is delayed, which results in the left ventricle contracting later than the right ventricle Background • Door-to-Balloon is a time measurement in emergency cardiac care, specifically in the treatment of STEMI – Delays in treating a myocardial infarction increase the likelihood and amount of cardiac muscle damage • ACC and the AHA recommend a D2B interval of no more than 90 minutes – Nov 2006: ACC launches Door to Balloon (D2B) Initiative – May 2007: AHA launches ‘Mission: Lifeline’ Initiative • Currently fewer than 50% of STEMI patients receive reperfusion with primary PCI within the recommended timeframe Problem Definition and Goal Setting • We typically recognize problems based on perception • What we see happening (The Point of Recognition) • Our job function causes us to determine “problems” based on our responsibility • We often become confused between the true problem, symptoms of the problem, and causes of the problem Project Objective • Apply proven strategies to improve door to balloon times and improve clinical outcomes for STEMI patients – Scope narrowed to first EKG to Cath Lab door ED and pre-hospital EKG 95% patients </= 50 minutes 75% patients </= 30 minutes Current Stream Map: STEMI and LBBB YES ED EKG Hands EKG to Physician Activate Cardiologist to Cath Lab LBBB identified NO Has Charge Nurse locate physician Obtain old EKG from HUC Old / New / Indeterminate Initiate standard order set Activate Cath Lab staff STEMI identified Physician present: Yes/No Tech reads computer impression 1 Labs and s m ed New Indeterminate Cath Lab Ready to accept patient: Yes / No 1 t ntac to c o How sician: phy e, etc.. pag Call, 0-40 min Yes Call and speak with Cardiologist Yes (1) Old LBBB identified Patient arrives at hosp and is registered No acute STEMI / other treatment needed EMS EKG STEMI identified Hosp quick Reg patient EKG filed Room patient in ED Continue patient work up Yes No ot ED n to y d a e r port trans No Cardiologist comes to see patient: Yes / No Initiate standard order set Transport patient from ED to Cath Lab Future Stream Map: STEMI and LBBB ED-EKG (Time Stamp) EKG printed and ready for Physician by HUC Tech hands EKG to Physician Activate Cath Lab staff STEMI identified New LBBB identified LBBB identified – indeterminate age Activate Cardiologist to Cath Lab YES Initiate standard order set Cath Lab ready to accept patient Transport patient from ED to Cath Lab Cardiac symptoms present: Yes/No NO Old LBBB identified No acute STEMI / other treatment needed LBBB identified Place patient in ED Room NO Quick Reg patient EMS-EKG STEMI identified Activate Cath Lab staff Activate Cardiologist to Cath Lab YES Cath Lab ready: Yes / No STEMI A3 Sharing Information and Telling the Story Key Strategies 1. Systems for activating Cath Lab and Cardiologist 2. Protocols for handoff from ED to Cath Lab 3. Aggressive approach when presented with LBBB of indeterminate age 4. Protocols to allow activation based on prehospital ECG Cath Lab / Cardiologist Activation • One number assigned for urgent caths Utilized by on call Prevea Cardiologists • Mandatory response time Second contact made if no response within 3 minutes If no reply after 5 minutes, next provider group will be contacted Hand Off Protocols • Immediate transfer to Cath Lab once they are prepared to accept patient • ED Standard Order Set updated to include only those of critical importance to patient care Lab/Imaging should be performed as part of the management of STEMI patients However, they should not delay implementation of reperfusion therapy – Work up to cease once Cath Lab ready – Imaging may be necessary if potential contraindication is suspected, such as aortic dissection Left Bundle Branch Blocks • Implement more aggressive treatment protocols for LBBBs of indeterminate age – When coupled with cardiac symptoms, Cath Lab/Cardiologist activation will occur • Synergistic Relationship between ED Physicians and Cardiologists – Requires unhesitating decisions from ED physicians – Unreserved approval and cooperation from Cardiologists Activation Based on Pre-Hospital EKG • Pre Hospital 12 lead EKGs will result in immediate Cardiologist / Cath Lab activation – Patient will be transferred directly to cath lab if ready upon arrival – Patient will need to stop in ED in event Cath Lab/Cardiologist not present/ready • lab/imaging will be performed as part of the management of patient care until Cardiologist/Cath Lab ready 90 Minutes is Arbitrary • Need to move beyond the 90 minute controversy – Focus on consistency and speed – Time is muscle – Foster organizational commitment – Long term, continuous improvement Delays in Initiation of Reperfusion Therapy Ongoing Initiatives: •Patient education /media campaign •Greater use of 911 / pre-hospital Tx •Improve Door to EKG times •Examine Cath Lab protocols for possible improvements •Incorporate systemic cooling methods Increasing Loss of Myocytes Questions?