AMI StrategyHow to Achieve Door-to-Balloon Times of 90

Minutes and What to Do Next?

Aaron Kugelmass, MDDirector, Cardiac Cath Lab

Associate Division Chief

Henry Ford Hospital

Detroit, Michigan, USA

Overview

• Introduction– The Argument for Primary PCI

• Overview of the Henry Ford Program

• Program Specifics– Process Dictates Outcomes

• Alternative Opportunities

Acute MI: Introduction

• 1.1 million people yearly in the US*

• About 500,000 have STEMI

• 220,000 die from their AMI

• 50% of deaths in the first hour

• Outlook of hospitalized patients better

*AHA: 2001 Heart and stroke statistics

Acute MI: Early ManagementReperfusion

• Pharmacological (Thrombolysis)– Fibrinolytics– Antithrombins– Platelet Inhibitors

• Mechanical (Direct/Primary PCI)• Angioplasty• Stent• Thrombectomy

• Combined– ? Facilitated PCI

Acute MI: Direct PCIAdvantages

• Rapid assessment of anatomy and hemodynamics

• TIMI-3 flow rates 75-95% in infarct artery• Low incidence of hemorrhagic stroke• Can be done in patients with

contraindications for thrombolysis• Results superior to thrombolytics in

randomized trials

PCI vs Lysis Meta Analysis

Keeley E, Lancet 2003; 361: 13–20

Lytics vs Transfer for PCI: DANAMI

Acute MI: Direct PCILimitations

• Only 20% of US hospitals have cath labs and fewer have PTCA facilities

• To achieve results similar to randomized trials the following has to be met:– PTCA within 90 minutes of presentation– Skilled operator (>75 cases/year)– Skilled lab (>200 cases/year)– Surgical back up necessary

Is Time as Critical in Primary PCI?

56.3

12.1

3.9 4.4 4.7

0

2

4

6

8

10

12

14

<2 hrs 2-4 hrs >4 hrs

lyticPCI

30-day mortality

Time from onset of CP to randomizationZijlstra, Eur Heart J 2002;23:550

ACC/AHA Recommendations for Direct PCI in AMI

2004Class I• General:

– Patients presenting within 12 hours; if performed in a timely fashion by individuals skilled in the procedure and supported by experienced personnel in high volume centers

• Specific:– Door To Balloon Time <90 min– < 3hours symptom, PCI if treatment <1 hour, lytics if >1 hour– Symptom >3 hours, PCI preferred <90min– Within 36 hours of MI when patient develops cardiogenic shock,

is <75 years and revascularization can be done within 18 hours of shock onset.

– <12 hours of symptoms and severe CHF or pulmonary edema

(2004) Http://www.acc.org/clinical/guidelines

Primary PCI in the United States

• Minority of US Hospitals Achieve a median Door to Balloon Time of 90 minutes or less

• Majority of MI occur during “Off Hours” (nights and weekends)

• Off Hour Primary PCI is associated with increased door to balloon times and mortality

• Henry Ford 2002– Door to Balloon 218 minutes– Cath Lab to Balloon 60 minutes

Primary PCI PathwayAn Opportunity for Process Improvement

• Patient Presentation to Diagnosis 20 min• Page Fellow, Fellow Responds 10 min• Fellow Proceeds to ER 15 min• Fellow Evaluates Patient 15 min• Fellow Pages CCU Staff, Staff Responds 10 min• + PCI, Fellow Pages Int Staff, Staff Responds 10 min• Fellow goes to Cath Lab, Pages Team 10 min• Patient Stays in ER or Goes to CICU• Cath Team Arrives 60 min• Find Patient and Transport 15 min• Perform PCI 45 min

Total 210 minutes

Process Change

• Centralize Communications

• Focus Clinical Decision Making

• Transfer SEMI Patients Directly to Site of Therapy

• Establish Transport Pathways

• Unite CICU/Cath Lab Nursing Functions

• Improve Door to Balloon Times!

Door-To Balloon TimeHenry Ford Hospital

Detroit

123 min.

N=19

132 min.

N=16

130 min.

N=20

97 min.

N=19

92 min.

N=19

96 min.

N=25 75 min.

N=18

0

20

40

60

80

100

120

140

160

180

200

Q4 2003 Q1 2004 Q2 2004 Q3 2004 Q4 2004 Q1 2005 Q2 2005

Tim

e in

min

ute

s

Door-To Balloon TimeHenry Ford System Wide

2005

218

119

94102

108

7989

0

50

100

150

200

250

PREVIOUS January February March April May June

Syste m wide population consisting of: De troi t, W yandotte , Bi -C ounty, Fairlane , S te rl ing He ights, and W . Bloom fie ld

Tim

e in

min

ute

s

Henry Ford Acute Myocardial Infarction Program

• 6 Emergency Rooms– Henry Ford Hospital 90,000 visits– HF Wyandotte Hospital 72,000– HF Bicounty Hospital 28,000– Fairlane ER 47,000– West Bloomfield ER 22,000– Sterling Heights ER 21,000

• Primary PCI @ Henry Ford Hospital– Large Urban Teaching Hospital in Detroit

Henry Ford ER Locations

Henry Ford Owned (5) Partially Owned (3) HF Medical Center (24)

OAKLANDOAKLANDOAKLANDOAKLANDOAKLANDOAKLANDOAKLANDOAKLANDOAKLAND

WAYNEWAYNEWAYNEWAYNEWAYNEWAYNEWAYNEWAYNEWAYNE

MACOMBMACOMBMACOMBMACOMBMACOMBMACOMBMACOMBMACOMBMACOMB

SJMMSJMMSJMMSJMMSJMMSJMMSJMMSJMMSJMM

CottageCottageCottageCottageCottageCottageCottageCottageCottageBon SecoursBon SecoursBon SecoursBon SecoursBon SecoursBon SecoursBon SecoursBon SecoursBon SecoursNew Center OneNew Center OneNew Center OneNew Center OneNew Center OneNew Center OneNew Center OneNew Center OneNew Center One

HamtramckHamtramckHamtramckHamtramckHamtramckHamtramckHamtramckHamtramckHamtramck

HarbortownHarbortownHarbortownHarbortownHarbortownHarbortownHarbortownHarbortownHarbortownFairlaneFairlaneFairlaneFairlaneFairlaneFairlaneFairlaneFairlaneFairlane

Detroit NWDetroit NWDetroit NWDetroit NWDetroit NWDetroit NWDetroit NWDetroit NWDetroit NW

LakesideLakesideLakesideLakesideLakesideLakesideLakesideLakesideLakeside

Grosse PointeGrosse PointeGrosse PointeGrosse PointeGrosse PointeGrosse PointeGrosse PointeGrosse PointeGrosse Pointe

Detroit EastDetroit EastDetroit EastDetroit EastDetroit EastDetroit EastDetroit EastDetroit EastDetroit East

East JeffersonEast JeffersonEast JeffersonEast JeffersonEast JeffersonEast JeffersonEast JeffersonEast JeffersonEast Jefferson

Ann ArborAnn ArborAnn ArborAnn ArborAnn ArborAnn ArborAnn ArborAnn ArborAnn Arbor

WoodhavenWoodhavenWoodhavenWoodhavenWoodhavenWoodhavenWoodhavenWoodhavenWoodhaven

SouthlandSouthlandSouthlandSouthlandSouthlandSouthlandSouthlandSouthlandSouthland

TaylorTaylorTaylorTaylorTaylorTaylorTaylorTaylorTaylor

CantonCantonCantonCantonCantonCantonCantonCantonCanton

PlymouthPlymouthPlymouthPlymouthPlymouthPlymouthPlymouthPlymouthPlymouth LivoniaLivoniaLivoniaLivoniaLivoniaLivoniaLivoniaLivoniaLivonia

NoviNoviNoviNoviNoviNoviNoviNoviNovi

Royal OakRoyal OakRoyal OakRoyal OakRoyal OakRoyal OakRoyal OakRoyal OakRoyal OakSouthfieldSouthfieldSouthfieldSouthfieldSouthfieldSouthfieldSouthfieldSouthfieldSouthfield

WarrenWarrenWarrenWarrenWarrenWarrenWarrenWarrenWarren

Sterling HeighSterling HeighSterling HeighSterling HeighSterling HeighSterling HeighSterling HeighSterling HeighSterling HeighTroyTroyTroyTroyTroyTroyTroyTroyTroy

HFHHFHHFHHFHHFHHFHHFHHFHHFH

HFBCHHFBCHHFBCHHFBCHHFBCHHFBCHHFBCHHFBCHHFBCH

KingswoodKingswoodKingswoodKingswoodKingswoodKingswoodKingswoodKingswoodKingswood

HFWHHFWHHFWHHFWHHFWHHFWHHFWHHFWHHFWH

HFWBHHFWBHHFWBHHFWBHHFWBHHFWBHHFWBHHFWBHHFWBH

HFHS RegionsHFHS RegionsHFHS RegionsHFHS RegionsHFHS RegionsHFHS RegionsHFHS RegionsHFHS RegionsHFHS Regions

DetroitDownriverMacombPlusOaklandWestern Wayne

20 m, 33 min14 m, 25 min

9 m, 24 min

8 m, 17 min

12 m, 26 min

Door-To Balloon TimeHenry Ford System Wide

2005

218

119

94102

108

7989

0

50

100

150

200

250

PREVIOUS January February March April May June

Syste m wide population consisting of: De troi t, W yandotte , Bi -C ounty, Fairlane , S te rl ing He ights, and W . Bloom fie ld

Tim

e in

min

ute

s

Improving Door to Balloon Time

How Do You Change The Process?

Create A Multi Disciplinary TeamIdentify Advocates

• Cath Lab– Doctors, Nurses, Managers

• CCU– Doctors, Nurses, Managers

• Emergency Room– Doctors, Nurses

• Cardiologists– Staff and Trainees

• Hospital Administration• Ambulance Transport

Changing the Process

• Improve the Process to Meet the Science

• Dissect Complex Activities into Quantifiable Steps– Team members help to redesign the

processes in their areas

• Establish Parallel (not serial) Processes

• Avoid Duplication– Example: IV Compatibility

Changing the Process

• Activation– Simple

• 1 Phone Call- 24 hours a day– Staffed by Decision Maker (MD who accepts patient and

activates team)– Team Activation is Invisible to the Outside

» Coordinator then activates staff members, arranges admission, etc…

Changing the Process

• Transport– Activate transport (ambulance) as early as

possible, usually before activating central team.

– Establish well known dispatch pathway– Minimize emergency room time– Communicate during transport

Changing the Process

• Minimize Steps– Patients Transported Directly to Cath Lab

• Business Hours- Easy• Off Hours

– In House Nurses and MD’s » Staff Cath Lab while Cath Lab Staff Travel to

Hospital» Prep Room and Patient

Changing the Process

• Cath Lab– Focused Pathway to Reperfusion

• 7 F Sheath• Diagnostic Angiography of non-IRV• Guide Catheter for suspected IRV• “Standard” initial PTCA Equipment

– Floppy Wire

– 2.0/2.5 mm Balloon

• Establish Reperfusion First, Optimize Result Later

• Remember the Team!– Call the ER and let them know the results

Cath Lab TimesArrival to Balloon Inflation

60

35

26 25

29

2627

0

10

20

30

40

50

60

70

PREVIOUS January February March April May June

System wide population consisting of: Detroit, Wyandotte, Bi-County, Fairlane, Sterling Heights, and W. Bloomfield

Tim

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min

ute

s

HFH AMI Flow ChartSTART

Remote/satellite ER MD calls HFH AMI phone line (313) 350-2718

CATH Lab Nurse Lab (business hrs) Fellow (off hours) Receives call

Fellow confers with satellite ER doctor. Accepts patient transfer & decides to activate Cath Lab

Coordinator pages the Cath Lab Team - Physician - IC Fellow - Nurses (2) - Technician

Remote ER site prepares patient for transport to HFH, Cath Lab on K2

Patient being transported to HFH Cath Lab. AMR calls Fellow at (313) 350-2718 at greater than or equal to 10 minutes before arrival at HFH

Cath Lab Team calls back to Coordinator - begins drive to HFH

Coordinator notifies Transfer Team & Admitting

CICU Nurse & I5 Fellow report to Cath Lab to meet the patient, prep for procedure Patient arrives through ER

or rear West Pav entrance. Patient taken directly to K2 Cath Lab. CICU nurse and I5 fellow waiting for patient

Cath Lab

Patient’s family directed to W. Clinic 5th fl. CCU waitrm

Cath Lab team arrives

Patient moved to CICU after procedure

Remote ER notifies Ambulance of possible HFH AMI transfer

Action start f inish duration

Remote or satellite ER/EKG assessment 0 5 5

Remote ER calls AMI phone line 5 7 2

CICU Nurse answers the call and takes report 5 7 2

CICU Nurse finds I5 Fellow, I5 Fellow accepts AMI patient transfer from satellite MD and Cath Lab is activated 7 10 3

CICU Nurse pages Cath Lab team 10 12 2

Cath Lab team calls back 12 17 5

Patient being prepared for transfer 10 20 10

CICU Nurse notifies Transfer Team & Admitting 12 25 13

AMI patient transported to HFH Cath Lab 20 65 45

CICU Nurse & I5 Fellow report to Cath Lab to stabilize, assess, prep prior to patient arrival 25 30 5

Cath Lab team transit/arrival 12 57 45

AMI patient arrives at HFH - family directed to CICU wait area 45 65 15

60+ minutes - Cath procedure performed on AMI patient 60 +

0 5 45 50 55 60+25 30 35 40Time (Minutes) 10 15 20

AMI Gann Chart

Changing the Process

• Metrics– Measure Your Lean Processes

• Door to EKG• EKG to Activation

– Transport

– Cath Lab

• Activation to Ambulance Arrival• “Pick Up Time” Ambulance arrival to departure• Transport Time ER departure to cath lab arrival• Cath Prep Time Cath arrival to arterial access• Procedure TimeArterial access to balloon or

reperfusion

Changing the Process

• Feedback– Share Outcomes and Pertinent Metrics with

Participants– Constructive Criticism is the Only Way to

Improve the Process– Success Begets Success

• Foster Participant Pride and Enthusiasm

Alternative Strategies and Next Steps

• Remote 12 lead EKG– EKG in Ambulance

• Transmit EKG from field• Activate Cath Lab field

• Disseminate Primary PTCA Centers– Offsite Surgical Back Up

• Centralize MI Centers– Practice Makes Perfect– Staff Lab 24/7

HFHS Initiatives

• Improve Door to EKG Time• Improve Transport Times

– New ambulance Structure• Activation to Arrival• “PickUp” Times

• Improve Cath Lab Response Times• Remote EKG

– In Field 12 lead EKG with telephonic transmission

Conclusions

• Careful Process Engineering Can Dramatically Reduce Door To Balloon Times– This Requires:

• A Multi-Disciplinary Team and Institutional Commitment

• Careful Metrics to Guide Improvement• Ongoing Feedback to Team Members• Continuous Evaluation to Drive Process

Improvement