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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?