Improving STEMI Care: Overcoming Hospital Barriers

Eva Kline-Rogers, MS,RN,NPUniversity of Michigan, Ann Arbor, MI

Friday, June 3, 3011No Conflict of Interest to Disclose

Hospitalizations in the U.S. Due to Acute Coronary Syndromes (ACS)

Acute Coronary Syndromes*

1.57 Million Hospital Admissions - ACS

UA/NSTEMI† STEMI

1.24 million Admissions per year

.33 million Admissions per year

Heart Disease and Stroke Statistics – 2007 Update. Circulation 2007; 115:69-171. *Primary and secondary diagnoses. †About 0.57 million

NSTEMI and 0.67 million UA.

3

1990199219941996199820002002

1990ACC/AHA

AMI R.

Gunnar

1994AHCPR/NHLBI

UA E. Braunwald 1996 1999

Rev Upd ACC/AHA AMI T. Ryan

2004 2007 Rev Upd ACC/AHA STEMI E. Antman

2000 2002 2007 Rev Upd RevACC/AHA UA/NSTEMI E. Braunwald; J. Anderson

20042007

Evolution of Guidelines for ACS

2009

2009Upd

ACC/AHA STEMI/PCIF. Kushner

4

STEMI Care

Patients / Families Healthcare Providers

First Responders EMS

ED Cath Lab

Acute Care Discharge

Outpatient

Crossing the Quality Chasm…Key Ingredients

n Building organizational support for change

n Applying evidence to health care delivery

n Using information technology

n Aligning incentives with quality

n Preparing the workforce

6

Improving STEMI Care Systems

Time Continuum

PreventionRisk Reduction Strategies

Acute Event Management

Short-Term Management

Long-Term

Evolution of PCI for STEMI

Evolution of Percutaneous Coronary Intervention

Balloon Angioplasty

30-60%

Enabled Non-Surgical

Approach to Coronary

Artery Disease

Bare-metal stents

10-40%

Reduced Elastic Recoil and Negative Remodeling

Drug-eluting stents

<10%Reduced

Restenosis Rates

Increasin

g C

om

plexity

Technology Advantage Restenosis Rates

van der Hoeven, BL., et al., International Journal of Cardiology 2005; 99:9-17.

PCI vs Fibrinolysis

22 Randomized Clinical Trials

Keeley E, Lancet, 2003P = .001 P = .0001 P = .002 P = .0001

6.8%

2%

14%

5%

2.5%1%

8%7%

0%

5%

10%

15%

Death ReMI CVA D/MI/CVA

Fibrinolysis PCI

Skilled PCI lab available with surgical backupDoor to Balloon < 90 minutes

• High Risk from STEMICardiogenic shock, Killip Class > 3

Contraindications to fibrinolysis, including increased risk of bleeding and ICH

Late presentation > 3 hours from symptom onset

Diagnosis of STEMI is in doubt

PCI Generally Preferred (Class IA):

Core Measure: Time to PCI

Ab

solu

te b

enef

itp

er 1

000

trea

ted

pat

ien

ts

0

0

20

40

60

80

3 6 9 12 15 18 21Time to treatment (h)

Boersma E, Lancet, 1996

Time to TreatmentMeta-analysis of Lytic Trials

(N = 50,246)

Time matters

Delay in Seeking Treatment

n Median delay times 2 - 6.4 hours• NRMI = 2.2• REACT = 2.4• African-Americans 2006 = 4.4

Moser et al., 2005; Banks et al., 2006; Leupker et al., 200; Goff et al., 1999; Goldberg et al., 2002; Dracup et al., 2003; Moser et al., 2006

Education Intervention StudiesMoser et al

Study N Intervention Outcome

Ho (1989) Seattle

401 pre489 post

2 months;TV, radio, newspapers

Delay not reduced; ambulance use did not change

Moses (1991) Midwest

Not stated

2 months; TV, newspapers, brochures, public talks, posters

Delay not reduced

Education Intervention StudiesMoser et al

Study N Intervention Outcome

Herlitz (1989) Sweden

2126 pre435 during

3 weeks; radio, printed matter

Delay reduced; no change in ambulance use (started with long delay times)

Bett (1993) Australia

556 pre253 post

1 week multi-media ‘event’

Delay not reduced

Gaspoz (1996) Switzerland

1100 pre1295 during

1 yr; radio, media ‘events, ads, posters, leaflets

Delay reduced, primarily in confirmed MIs & men; no change in women

Education Intervention StudiesMoser et al

Study N Intervention Outcome

Meischke (1998) Seattle

1343 control,4101 in experimental groups

(randomized, controlled)4 groups=control, information, emotional, social

Delay not reduced; 911 use was higher

Luepker/REACT (2000)5 US regions

10 paired communities

Mass & small media, focused sessions, used Leventhal’s framework

Delay not reduced; improved ambulance use

Predictors of Prehospital DelayClinical Factors

Moser, et al.

DELAY TIMEDecrease Increase

Sudden onset severe chest pain

Hemodynamic instability

Large infarct size

History of angina

History of diabetes

Gradual pain onset or pain comes and goes

Predictors of Prehospital DelayConsultation

Moser et al.

Decrease Increase

Friend

Co-worker

Stranger

Spouse

Other relative

Physician

Self-treat

DELAY TIME

New Approaches Needed to Interventions to Decrease Patient Delay

n Changing patient and provider perspectives about the chronicity of cardiac disease• Increase saliency of message

n Include social, cognitive, and emotional context of decision-making in messages

n Deputize witnesses to take actionn Make every provider an “interventionist” and

every encounter an intervention– Moser et al

20

Improving STEMI Care Systems

Time Continuum

PreventionRisk Reduction Strategies

Acute Event Management

Short-Term Management

Long-Term

21

Recommendations for Triage and Transfer for PCI (for STEMI)

III IIaIIaIIa IIbIIbIIb IIIIIIIIIIII IIaIIaIIa IIbIIbIIb IIIIIIIIIIII IIaIIaIIa IIbIIbIIb IIIIIIIIIIIaIIaIIa IIbIIbIIb IIIIIIIII

NEW

Recommendation

Each community should develop a STEMI system of care following the standards developed for Mission Lifeline including:

• Ongoing multidisciplinary team meetings with EMS, non-PCI-capable hospitals (STEMI Referral Centers), & PCI-capable hospitals (STEMI Receiving Centers)

22

Recommendations for Triage and Transfer for PCI (for STEMI) (cont.)

III IIaIIaIIa IIbIIbIIb IIIIIIIIIIII IIaIIaIIa IIbIIbIIb IIIIIIIIIIII IIaIIaIIa IIbIIbIIb IIIIIIIIIIIaIIaIIa IIbIIbIIb IIIIIIIII

NEW

Recommendation

STEMI system of care standards in communities should also include:

• Process for prehospital identification & activation

• Destination protocols to STEMI Receiving Centers

• Transfer protocols for patients who arrive at STEMI Referral Centers and are primary PCI candidates, and/or are fibrinolytic ineligible and/or in cardiogenic shock

30-30-30 GoalE2B≤90 Conceptual

Framework< 30 minutes for Emergency Med Services (EMS)

< 30 minutes for the Emergency Department (ED)

< 30 minutes for the Cardiac Cath Lab (CCL)

www.E2Bchallenge.com Industry supported QI-initiative launching

October 15 at EMS Expo.08 in Las Vegas

Other Regional/State Plans

Other States and Regions State & Regional EffortsUnderway or Planned

A Life-Saving InitiativeNational, community-based initiative

Goals

• Improve quality of care and outcomes in heart attack patients

• Improve health care system readiness and response

25

AHA (www.heart.org)

MUSKEGON

OTTAWAIONIA

KENT

MONTCALM

NEWAYGO

Spectrum Health Reed City Hospital

Spectrum Health Kelsey Hospital

Spectrum Health United Hospital

Carson City Hospital

Ionia County Memorial Hospital

Metro Health Hospital

Saint Mary's Healthcare

Mercy General Health Partners

Memorial Medical Center of West Michigan

ALLEGAN BARRY

LAKEMASON

MECOSTAOCEANA

OSCEOLA

Allegan General Hospital

Mecosta County Medical Center

Pennock Health Services

Holland Hospital

Borgess - Pipp Hospital

North Ottawa Community Hospital

Gerber Memorial Health Services

Zeeland Community Hospital

Sheridan Community Hospital

Hackley Lakeshore Hospital

Hackley Hospital

Spectrum Health Hospital Service Areasand Other Acute Care Hospitals

County BoundariesCounty BoundariesCounty BoundariesCounty BoundariesCounty BoundariesCounty BoundariesCounty BoundariesCounty BoundariesCounty Boundaries

Primary Service AreaPrimary Service AreaPrimary Service AreaPrimary Service AreaPrimary Service AreaPrimary Service AreaPrimary Service AreaPrimary Service AreaPrimary Service Area

Secondary Service AreaSecondary Service AreaSecondary Service AreaSecondary Service AreaSecondary Service AreaSecondary Service AreaSecondary Service AreaSecondary Service AreaSecondary Service Area

Spectrum HealthSpectrum HealthSpectrum HealthSpectrum HealthSpectrum HealthSpectrum HealthSpectrum HealthSpectrum HealthSpectrum HealthGrand Rapids Area HospitalsGrand Rapids Area HospitalsGrand Rapids Area HospitalsGrand Rapids Area HospitalsGrand Rapids Area HospitalsGrand Rapids Area HospitalsGrand Rapids Area HospitalsGrand Rapids Area HospitalsGrand Rapids Area Hospitals

Spectrum Health Butterworth HospitalSpectrum Health Butterworth HospitalSpectrum Health Butterworth HospitalSpectrum Health Butterworth HospitalSpectrum Health Butterworth HospitalSpectrum Health Butterworth HospitalSpectrum Health Butterworth HospitalSpectrum Health Butterworth HospitalSpectrum Health Butterworth Hospital

Spectrum Health Blodgett HospitalSpectrum Health Blodgett HospitalSpectrum Health Blodgett HospitalSpectrum Health Blodgett HospitalSpectrum Health Blodgett HospitalSpectrum Health Blodgett HospitalSpectrum Health Blodgett HospitalSpectrum Health Blodgett HospitalSpectrum Health Blodgett Hospital

Helen DeVos Children's HospitalHelen DeVos Children's HospitalHelen DeVos Children's HospitalHelen DeVos Children's HospitalHelen DeVos Children's HospitalHelen DeVos Children's HospitalHelen DeVos Children's HospitalHelen DeVos Children's HospitalHelen DeVos Children's Hospital

KEYKEYKEYKEYKEYKEYKEYKEYKEY

Hospitals in Spectrum

Health STEMI Network

Zeeland (23 miles)

25-30 min ground

10 min helicopter

UM – Greenville (32 miles)

45 min ground

12 min helicopter

Gerber (45 miles)

60 min ground

15 min helicopter*

*transport from hospital to helipad required Courtesy of Denise Busman MSN, RN October, 2008

The STEMI ALERT Packet

n A carefully designed STEMI ALERT Packet is the key to success.

n All the required information for success is instantly at your fingertips.

n GOT STEMI? Open packet!

www.projectupstart.comCourtesy of David Burt, MD

28

Improving STEMI Care Systems

Time Continuum

PreventionRisk Reduction Strategies

Acute Event Management

Short-Term Management

Long-Term

Systems that Work“Effective Strategies” linked to

significantly shorter DTB timesn Systems for activating cath labn Systems for handoff from EDn Systems for interaction with EMSn Systems for data feedback

Bradley EH, NEJM, 2006

Effective Strategies

Bradley EH, NEJM, 2006

Fewer Than 5% Have All Strategies

05

101520253035404550

0 1 2 3 4

Number of strategies

Per

cen

t

N Engl J Med

D2B Alliance

Evidence-based Strategies that Reduce Delays

1. ED physician activates the cath lab2. One call activates the cath lab3. Cath lab team ready in 20-30 minutes4. Prompt data feedback5. Senior management commitment6. Team-based approachPre-hospital ECG to activate the cath lab if feasibleACC D2B Initiative: web site with resources

including tools, webinars, contactsACC D2B Initiative: web based, interactive, tools, resources

Over 1,000 hospitals enrolled(out of 1400 that perform PPCI)

Changes in reported use of strategies Recommended Strategy* Baseline Follow-upEM activation 52% 60%Single call 31% 37%Cath team arrives in 30 minutes 81% 89%Prompt data feedback 61% 79%Activate from pre-hospital ECG in the field 33% 41%D2B Team 64% 85%

* All differences are significant P< 0.001

D2B in STEMI

n Research has shown us how we can improve D2B times.

n The D2B Alliance initiative has been instrumental in disseminating the “evidence-based strategies” and organizational improvements.

n D2B times have improved across the country.• Public reporting, competition, D2B and other

initiatives

Relative Impact of post-MI Interventions (RRR)

n Smoking Cessation -50%

n Lipid Lowering -30-40%

n ASA -25%

n Beta Blockers -20%

n ACE inhibitors -20%

Source AHA GWTGs supporting literature

Working with others to make a difference in Michigan

Guidelines Applied Into Practice (GAP)

American College of Cardiology

Greater Detroit Area Health Council

MichiganPRO

10 Michigan Hospitals

Results: Late Indicators and Discharge Document

0

20

40

60

80

100

Perc

ent

(%)

SmokingCounseling

DietaryCounseling

Chol Rx

53 55

6762

90

68

9286

67

* p < 0.05 ** p < 0.01

(159) (150) (76) (475) (473) (205) (112) (144) (65)

******

Pre

No Tool

Tool

Tobacco Counseling Referrals: Inpatient CardiologyAverage Referrals Pre-: 20.6/month Post-: 32.2/month

0

10

20

30

40

50

2/13 - 3/12 3/13-4/12 4/13 - 5/12 5/13-6/12 6/13 - 7/12 7/13 - 8/12

Tobacco CounselorReferrals from MDs/RNs -

7B/C/D

New Order Sets5/13/02

Month of Year - 2002

# of

Ref

erra

ls p

er m

onth

100 100

0

20

40

60

80

100

ASA at D/C B-Blocker at Discharge

2000-2001BCBS of Michigan QualityAssessment: UM % Eligible Patients Receiving Rx

2000-2001BCBS of Michigan QualityAssessment: UM % Eligible Patients Receiving Rx

Percent (%)

n=50n=50

Creating a System for STEMI Care

n Create common goals based on evidence-national guidelines, e.g. D2B

n Design care tools that emphasize goals

n Create methods to measure performance (registries)

n Create a method to feedback results (registries)

n Reformulate the aims

n Sustain the Gain

Substantial variation across hospitals in 2005

010

20

30

40

Hospitals

50 100 150 200Door-to-balloon time (minutes)

Source: National Registry of Myocardial Infarction, 2005

How do the best hospitals do it?

010

20

30

40

Hospitals

50 100 150 200Door-to-balloon time (minutes)

Source: National Registry of Myocardial Infarction, 2005

BMC2 & PrimaryPCI Sites

Multivariate model for in-hospital Mortality (BMC2 Data)

VARIABLE ODDS RATIO

95% CI P

<90 minutes 0.41 0.18-0.91

0.027

Age >80 4.10 1.55-10.8 0.004

Prior MI 2.35 1.21-4.55 0.011

Creatinine > 2.0 mg/dl 4.38 2.12-1.15 <0.0001

EF <50% 2.77 1.15-6.68 0.022

# Diseased Vessels 2.33 1.20-4.52 0.012

Cardiac Arrest 4.42 2.22-8.79 <0.0001

Cardiogenic Shock 10.89 5.67-20.95 <0.0001

Female Gender 1.85 0.97-3.50 0.06Moscucci et al, AHA, 2004

Percent Increase in D2B Time ≤ 90 Minutes

10.4

14.915.8

20.3

15.8

10.5

0

19.4

(1.5)(0.7)

(4.6)

13.7

-10

-5

0

5

10

15

20

25

Study Status of Hospital

Ch

an

ge i

n P

erc

en

tag

e o

f P

ati

en

ts w

ith

Do

or

to

Ball

oo

n <

90 m

in

Improving Systems at Your Hospital

n Project Support and Approval n Team Leadern Create Teamn Site Assessmentn Identify Targets for Improvementn Identify Barriersn Data Monitoring and Feedback

Creating a Team

n Select Team Leadern Multidisciplinary Team Members

• Effective teams• Ineffective teams

n Share common goal/rationale and evidence for effective strategies

Assessment of Time Intervals

n Door – ECGn ECG – Physician Evaluationn Physician Evaluation – Lab Activationn Lab activation – Patient calledn Patient called – Transport activatedn Transport timen Lab Arrival – Sheath inn Sheath in - Balloon inflated

Site Assessment Survey

n All AMI Patients• Who activates cath lab?• How is it activated?• Who transports patients to cath lab?• How long does it take to transport?

n Cath Lab• Who places sheath?• Standardized protocol for angiography?• Is there a protocol for cath lab staff response time?

5 mins or less21%

6-10 min28%

11-15 mins10%

16-20 mins10%

21-25 mins14%

26-30 mins0%

above 30 mins17%

5 mins or less

6-10 min

11-15 mins

16-20 mins

21-25 mins

26-30 mins

above 30 mins

Time to EKG in ED(N = 29)

Creating Change in Complex Environments

n Lessons learned from GAP AMI projects• Team approach• Embedding guidelines into practice• Champions

n Lessions learned from regional QI initiatives• Tailored interventions• Overcoming Barriers

CQI Process

n C=Continuous• Staff members dynamic• Regression to the mean• Data for discovery

54

Project Overview

In-situ simulation training and assessment process to train healthcare teams in moving a patient from the emergency department to the cardiac catheterization lab during an acute cardiac event.

55

Improving ACS Care Systems

Time Continuum

PreventionRisk Reduction Strategies

Acute Event Management

Short-Term Management

Long-Term

Improving STEMI Care

n Create common goals based on evidence-national guidelines

n Create systems that emphasize these goals (Mission Lifeline)

n Design care tools that emphasize goals/measure performance (standard orders/discharge docs – easier with EMR but need process for updating)

n Create a method to feedback results (registries: NCDR, ACTION, others)

n Regional QI Efforts

n Early patient f/u providing simple, consistent messages