ST Elevation Myocardial Infarction ST Elevation Myocardial - PowerPoint PPT Presentation

ST Elevation Myocardial Infarction ST Elevation Myocardial Infarction Quality Care Achieved Through Quality Care Achieved Through Regional Partnerships Regional Partnerships Ruth Foggett, Regional PPCI Co-ordinator , Trillium Health Centre Charlene Sandilands, Director, Cardiac Health System, Trillium Health Centre Judy Underwood-Wiens, Manager, Cardiac Catheterization Lab, Trillium Health Centre Dr. K.R. Watson, Director, Cardiac Catheterization Lab, Trillium Health Centre

Trillium Health Centre Trillium Health Centre

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Aim Aim To provide 24/7 access to Primary Percutaneous Coronary Intervention (PPCI) for all Regional ST Elevation Myocardial Infarction (STEMI) patients by EMS Direct transfer from the field to Trillium Catheterization Lab in less than 90 minutes . → → ST ↑ Cath LabCath Lab ST ↑ ST ↑

Terminology Terminology ECG ST ↑ ST ↑ ST ↑ ST Elevation Myocardial Infarction or STEMI is a type of Heart Attack which can be identified on an ECG by specific acute ECG changes called ST elevation. A Primary Percutaneous Coronary Intervention (PPCI) is a procedure where a balloon catheter with a Stent is used to open the blocked coronary artery in someone having a Myocardial Infarction. This procedure is done in the Cardiac Catheterization Lab.

Rationale Rationale In 2004, American Heart Association/American College of Cardiology guidelines identified Primary Percutaneous Coronary Intervention (PPCI) as the initial treatment of choice for patients with ST Elevation Myocardial Infarction (STEMI) when timely access to a Cardiac Intervention Centre is possible. Time from first patient contact “Door” to reperfusion of the blocked coronary artery being ≤ 90 minutes . STEMI patients who have timely PPCI have: higher coronary reperfusion rates (>90%) lower reocclusion, stroke and mortality rates.

STEMI Patient Access to PPCI STEMI Patient Access to PPCI ER PPCI Process Regional Direct PPCI Process ER Registration First contact: EMS ACP RN Assessment Chest Pain? ECG Chest Pain? ECG STEMI ECG? STEMI ECG? Calls Interventionalist ER Physician assesses Team activated prior to transport Calls Interventionalist Team activated Team needs 30 minutes travel time

STEMI Access to PPCI STEMI Access to PPCI EMS Regional Direct PPCI ER PPCI First patient contact “Door” to First patient contact “Door” to First Device First Device % < 90 minutes 60% % < 90 minutes > 90%

Regional Partnership Plan Regional Partnership Plan Stage 1: Halton EMS & Halton Healthcare Initiated December 14, 2008 Initiated December 14, 2008 Stage 2: Toronto EMS & South Etobicoke Initiated May 4, 2009 Initiated May 4, 2009 Stage 3: Peel EMS & Credit Valley Hospital Initiated August 10, 2009 Initiated August 10, 2009 Stage 4: Peel EMS & William Osler Health Centre (North Peel/Etobicoke) Initiated March 2010 Initiated March 2010 Time is Muscle Time is Muscle

Regional Plan Regional Plan Memorandum of Understanding (MOU) Roles & responsibilities of EMS, the Regional Hospital & Trillium Internal/External Processes in Place EMS Code STEMI process Trillium internal Code STEMI process Regional hospital process to accommodate repatriated patients Education Plan Physician, staff & EMS education Communication Regional Cardiovascular Steering Committee EMS/Sunnybrook-Osler Centre for Pre-hospital Care Workgroup Trillium Cardiac STEMI Workgroup Outcome Monitoring & Feedback Individual Case Feedback Reports Quarterly feedback Report

EMS Direct PPCI Flowmap EMS Direct PPCI Flowmap Patient with Chest Pain ECG done by EMS ACP & Zoll ECG identifies STEMI ECG changes Calls Trillium Communications (905) 848-7557 “Halton EMS calling for Interventional Cardiologist for Code “STEMI” Interventionalist Accepts THC Internal Code STEMI activated EMS transports patient to THC Cath Lab

Trillium Plan Trillium Plan A Bed to support ‘No Refusal’ principal PPCI bed in CCU with automatic decant process Interventionalist Code “STEMI” Communication Process Porter Cath Lab Provides internal priority response A “STEMI” RN Bed Desk CCU Registration Facilitates timely patient flow & continuity STEMI of care from ER, to the Cath Lab, to CCU. Team Hospitality Emergency Repatriation Associate Patient repatriation to bypassed hospital in 6 - 12 hours Patient Care Communications RN resources for patient accompaniment . Coordinator Security Staff Education Road show for all stakeholders

Tools Tools

EMS Direct Case Study EMS Direct Case Study Incident History : : Incident History 52 year old male complaining of retrosternal crushing chest pain (7/10). No radiation or SOB. Felt like heartburn. Pale, diaphoretic in severe distress. Came on while bowling. Previous Lateral MI with Rescue PCI & Stent 2007 ECG ECG Cardiac Arrest x 2 en route Cardiac Arrest x 2 en route Pre & Post PPCI Pre & Post PPCI Blocked Right Coronary Open Artery Post PPCI EMS Arrival at patient to First Device 80 min EMS Arrival at patient to First Device 80 min

Outcomes Outcomes PPCI Direct (New Process) PPCI Direct (New Process) Trillium Trillium PPCI Total 140 Patients PPCI Total 140 Patients 2007/ 2008/ Jan/Feb/ Apr/May/ Jul/Aug/ Oct/Nov/ Jan/Feb/ 2007/ 2008/ Jan/Feb/ Apr/May/ Jul/Aug/ Oct/Nov/ Jan/Feb/ 2008 2008 2009 2009 Mar Mar Jun Jun Sep Sep Dec Dec Mar Mar 2009 2009 2009 2009 2009 2009 2009 2009 2010 2010 Number of PPCI Patients 135 137 10 14 34 39 43 % of Patients ≤ 90 Minutes from 47% 60% 90% 90% 92% 92% 93% 93% 93% 93% 88% 88% EMS Arrive at Patient ("Door“) to First Device Target 90% Average "Door" to First Device 106 97 80 68 68.5 65.9 71 (Minutes) EMS Arrive at Patient (“Door”) N/A N/A 100% 100% 100% 100% 100% 100% 100% 100% 98% 98% to EMS Arrival at Trillium Target ≤ 60 Minutes Number of False N/A N/A 0% 7% 8.8% (9) 7% Positives/NonSTEMI Target ≤ 10%

Lessons Learned Lessons Learned Leadership Process Best practice, flexible, innovative processes needed to meet both the goals of the initiative & the specific needs of each partner. Partnership Each stage involved the development of new partnerships (3 different EMS teams, 3 regional hospitals with 7 sites) Staged approach, took time & commitment to develop the MOU & processes. Teamwork Each individual’s expert contribution was important in the complex process to meet stringent time targets United behind a common vision a diverse team of committed, United behind a common vision a diverse team of committed, individuals can accomplish great things and exceed their goals! individuals can accomplish great things and exceed their goals! Communication Excellent communication network with all stakeholders resulted in prompt resolution of challenges.

Partnership & Teamwork Partnership & Teamwork Peel, Halton & Toronto EMS William Osler Health Centre William Osler Health Centre Together Improving Regional Cardiac Care

Thank you Thank you

Background Background May 2005 24/7 access to PPCI for all STEMI patients presenting to Trillium’s Emergency Department began. December 2008 24/7 EMS Direct transport of STEMI patients from the field to the Trillium Catheterization Lab for PPCI.

Future Future Development of consistent regional process for Indirect PPCI Code STEMI patients. Development of process for Primary Care Paramedics presenting to Trillium Emergency with STEMI patient. Refine Repatriation & internal Code STEMI process. Ongoing Quarterly Regional outcome reports to ensure continuous monitoring & quality patient outcomes.

utcomes O utcomes January 1, 2009 – – March 31 2010 (140 patients) March 31 2010 (140 patients) January 1, 2009 9 Patients experienced Cardiac Arrest prior to arrival at Trillium Outliers due to: Patient’s clinical condition (cardiac arrest) Communication issues Technically difficult patients (anatomy) 16 False Positive due to: Pericarditis Apical Ballooning / Cardiomyopathy Coronary Spasm Non-specific ECG change 5 Expired (3.6 mortality rate at discharge) 140 ER visits averted