An Introduction www.projectupstart.com

Project UPSTART The Use of Procedural Standardization to Reduce “Recognition to Reperfusion” (R2R) Time in STEMI “Excellence in R2R” www.projectupstart.com

A Framework for Improvement Project UPSTART is an unique quality improvement program that lets you quickly and easily improve the care of your patients suffering from STEMI. A toolbox for building systems of care for STEMI Avoid reinventing the wheel! www.projectupstart.com

A Tool Kit for STEMI Systems… Provides forms, protocols, templates provider education and other necessary “components” Designed to improve locals systems of care Facilitates inter-facility collaboration and data sharing Compliant with the concepts and principles endorsed within the American Heart Associate and its Mission: Lifeline Initiative www.projectupstart.com

Mission: Lifeline (The Big Picture) National, community-based initiative Goals Improve quality of care and outcomes in heart attack patients Improve health care system readiness and response Mission: Lifeline is a national, community-based initiative designed to meet the needs of the STEMI patient throughout the continuum of care, beginning with the patient’s entry into the system (from symptom onset) through each component of the system, and return to the local community and physician for rehabilitative care. Mission: Lifeline uses a community-based, multidisciplinary, patient-centric approach. Mission: Lifeline is addressing systems of care for STEMI on multiple levels and through many collaborating organizations, starting with the STEMI patient and continuing through EMS, ED, STEMI Referral, and STEMI Receiving hospitals; implications for policy makers and third party payers are also being addressed within Mission: Lifeline.   To meet the overarching goal, Mission: Lifeline will bring together the necessary partnerships between: Patients and care givers EMS Physicians, nurses and other providers Non-PCI capable (STEMI-referral) hospitals PCI capable (STEMI-receiving) hospitals Departments of health EMS regulatory authority/Office of EMS Rural health associations Quality improvement organizations State and local policymakers Third-party payers Health systems www.projectupstart.com 5 5

…Think of Project UPSTART as a Mission: Lifeline-compliant “Recognition to Reperfusion” Toolbox! www.projectupstart.com

Optimizes Recognition and Reperfusion All attempts at reducing STEMI treatment times must ultimately focus on improving one (or both) of these endpoints. The goal: early recognition followed by early reperfusion. “ www.projectupstart.com

(stable over last three years) Example #1 Large Community PCI hospital Multiple cardiology groups, etc Current reperfusion mean (door to PCI) +/_ 52 Minutes (stable over last three years) www.projectupstart.com

Example #2 A Large University PCI Center UPSTART go-live: 9.11.06 Reperfusion (DTB) times declined from 83 minutes to 58 minutes within one month of implementation www.projectupstart.com

Quiz: Have These Issues Occurred in Your STEMI system? A veteran nurse working triage neglects to obtain an ECG on an “atypical” STEMI patient? Your temporary ED physician forgets to immediately call EMS, delaying inter-facility transport? A thrombolytic checklist was not instantly available when needed to assess a patient? A STEMI patient was sent to the PCI lab without an IV? Important STEMI QI data has not been routinely available for quality improvement analysis? www.projectupstart.com

History Repeats…Unless you Learn from Previous Mistakes! Project UPSTART incorporates many best practice concepts directly into a simple, repeatable approach to STEMI care that is based on just 4 key actions: Error-proof your providers by error-proofing the system! www.projectupstart.com

STEMI System Theory: A Review To efficiently improve your local STEMI system: First, you must first define who your local STEMI system actually involves and its physical boundaries….. Next, you must define what processes are most important within that system Finally, you must fix what needs fixing! www.projectupstart.com

This has all been done before, by someone! Luckily we can help you! The next few slide discuss important concepts in helping you define your local Elemental STEMI Subsystem (ESS) system and outlining the Essential Elements of Reperfusion that must be the focus of your improvement efforts. This has all been done before, by someone! www.projectupstart.com

Key Concept: The “Elemental STEMI Subsystem” (ESS) The smallest combination of EMS and STEMI treatment facilities that can function “alone” as a self functioning “STEMI system of care” By definition, the ESS is the “elemental building block” of all STEMI systems –no matter how large that “system” may be ?? www.projectupstart.com

Has only three basic components: An Individual ESS… Has only three basic components: 1) All EMS organizations that transport STEMI patients to or from a facility 2) That facility and its internal “in house” STEMI management processes 3) “Outside” facilities that either send or receive STEMI patients to or from that facility…. www.projectupstart.com

A Typical Elemental STEMI Subsystem www.projectupstart.com

Elemental STEMI Subsystems (usually) Overlap… So, improving each one internally will improve the entire region! Non-PCI PCI PCI Non-PCI www.projectupstart.com

Take Home Point? Define your local ESS and concentrate on improving each important process within its boundaries Non-PCI PCI PCI !Your ESS! www.projectupstart.com

STEMI Optimization = Perfecting the Basics! Now you know where you need to concentrate your efforts: your ESS. So, what do you fix first? In other words, where can you get the most “bang for your buck?” www.projectupstart.com

The 5 R’s: The 5 Essential Elements of STEMI System Optimization R1 Relationships R2 Recognition R3 Reperfusion R4 Real-time Data Collection R5 Reassessment & Refinement www.projectupstart.com

Concentrate on the “5R’s” In order to improve your system in a time efficient manner you must improve each one of these critical process until they are running smoothly. Project UPSTART was designed to help you in this process! www.projectupstart.com

Four Key Steps www.projectupstart.com

Would your institution make that same mistake on a busy Friday night? www.projectupstart.com

Do you have a written “Screening ECG Protocol” for your institution? Let check: Please answer the following questions to assess Recognition at your institution: Do you have a written “Screening ECG Protocol” for your institution? Is it visibly posted in your ED and triage areas? Do ED and triage staff follow it 24/7? Have you trained your staff regarding their role (and importance) in the screening ECG? Do you have multiple backup pathways in place to ensure that the screening ECG gets done during busy times? www.projectupstart.com

How did you do? Unless you answered “yes” to all five questions, your institution is at risk at missing that same ECG. If not today, then next Friday. Solution: Improve your STEMI recognition process www.projectupstart.com

Solution: The Project UPSTART “Screening ECG Protocol” -Print it’ -Post it’ -Use it’ -Reinforce it -Educate staff at: www .projectupstart.com! www.projectupstart.com

Builds on the experience of others –no need to “reinvent the wheel”. Benefits of UPSTART Builds on the experience of others –no need to “reinvent the wheel”. Offers a variety of tools, forms and instructions for rapid improvement of existing processes Carefully designed for ease of implementation Connects all links of the “STEMI chain” together from EMS to the cath lab www.projectupstart.com

Four Key Steps www.projectupstart.com

STEP 1: Optimize STEMI Recognition! Provide a tool The Screening ECG Protocol Post it everywhere Teach compliance (via education) End result? Minimize missed STEMI! www.projectupstart.com

2: Open a STEMI ALERT Packet for every STEMI “Got STEMI –Open Packet!” Opening the packet serves as a focus for action Staff automatically open a packet for every STEMI www.projectupstart.com

The STEMI ALERT Packet A carefully designed STEMI ALERT Packet is the key to success It places all the required information for a successful “STEMI ALERT” instantly at your fingertips www.projectupstart.com

The STEMI ALERT Packet A carefully designed STEMI ALERT Packet is the key to success. All the required information for success is instantly at your fingertips. www.projectupstart.com

A standard STEMI Alert Packet includes three checklists: Physician Checklist Nurse Checklist STEMI Scribe Checklist www.projectupstart.com

And two Data Collection Sheets Data Sheet A Data Sheet B www.projectupstart.com

How it works….. Prior to implementation, each site decides what is the generalized best approach to treating STEMI at that particular institution. All important details are then incorporated into the checklists within the STEMI ALERT Packet. www.projectupstart.com

Patient assessment prompts ED cath lab activation criteria What type of details? Medications Phone numbers Treatment algorithms Patient assessment prompts ED cath lab activation criteria Thrombolytics checklists Cath lab preparation tasks **Whatever is felt important! www.projectupstart.com

Now put your packets somewhere visible The next time a STEMI occurs, your staff should know to open the packet! Put conditioning to work for you! www.projectupstart.com

Physician Checklist Sample PCI with details Who to call Medications Assessment Phone numbers Memory prompts www.projectupstart.com

Nurse Checklist Sample PCI site Focus? -patient preparation for additional treatment or transfer www.projectupstart.com

Stemi Scribe Recording times Data collection Monitoring communication www.projectupstart.com

Next: No measurement = No improvement! The function of Data Sheets A and B are to measure key intervals during the STEMI alert. This data drives ongoing improvement Data Sheet B always follows the patient and contains a record of total time from recognition to reperfusion Data Sheet A stays in the ED www.projectupstart.com

Step 3: Complete Data Sheets A & B during each STEMI ALERT www.projectupstart.com

for efficient feedback Date Sheet A Stays in the ED Provides information for efficient feedback www.projectupstart.com

or to the receiving facility Provides data on arrival Data Sheet B: Sent to the cath lab or to the receiving facility Provides data on arrival When completed has data points from the entire case www.projectupstart.com

This accurate data is very helpful Step 4: Data Management! After the STEMI ALERT is complete, Data sheets A and B are delivered to their respective sites. “A” stays in the ED and “B” follows the patient. This accurate data is very helpful Our standard is to measure R2R times on each patient! www.projectupstart.com

Same 4-step process at every facility! Data sheet B links them together! www.projectupstart.com

Review the “Four Key Steps” www.projectupstart.com

Can you do these 4 steps at your facility? Then you can implement UPSTART! -STEMI Alert Packet forms are easily customized -All other forms are from templates as well -When possible, items are standardized -Staff education can be done via the internet www.projectupstart.com

Implementation 1) Develop an individualized STEMI ALERT Packet for your institution 2) Train your staff at www.projectupstart.com 3) Place the STEMI ALERT Packets in your ED 4) Go live! The process will continue improving using the data collection loops built into the process www.projectupstart.com

Train all ED staff prior to “go live’ Takes one hour or less Provider Education Train all ED staff prior to “go live’ Takes one hour or less A combination of a written tutorial, on-line video and short written test Available at www.projectupstart.com www.projectupstart.com

The Project UPSTART website: Your link to the UPSTART world! www.projectupstart.com Links to all required forms More Powerpoints! Training videos! The common access point for provider training Simple and clear information in an easily accessibly form www.projectupstart.com

Example: Additional forms……. ED Activation of the Cath Lab ED Thromblytics Guide EMS Guide Sheet Cath Lab Checklist Implementation Manual UPSTART Follow-up Sheet www.projectupstart.com

www.projectupstart.com www.projectupstart.com

University of Virginia drb5p@virginia.edu (434) 924-2428 Questions? www.projectupstart.com David R. Burt, MD University of Virginia drb5p@virginia.edu (434) 924-2428 www.projectupstart.com