1. Overview of the Winnipeg CODE STEMI Project Implemented May 2008 Dr.J.Tam MD, FRCP(C), FACC Section Chief Cardiology WRHA and University of Manitoba Lillian Hall, RN, BHScN, CNCC (Canada) WRHA Cardiac Sciences Quality Manager Lorraine Avery, RN, MN, CNCC (Canada) Regional CNS WRHA Cardiac Sciences

2. Agenda Introduction/Background Introduction/Background Goals of the Safer Healthcare Initiative Goals of the Safer Healthcare Initiative Milestones Milestones Data Review/Outcomes Data Review/Outcomes –PCI Statistics –AMI Crude Mortality Rates at SBGH –SBGH Primary PCI times – Days only Lessons learned Lessons learned Next steps Next steps

3. Interventional Cardiology in Manitoba 1500 PCI’s per year 1500 PCI’s per year Six Interventional Cardiologists (2-3 days week in lab and then on call 1-6) Six Interventional Cardiologists (2-3 days week in lab and then on call 1-6) –SBGH: 2 full time labs which includes the on call room –HSC: 0.6 lab (shared with pediatrics) 3 days per week Covers all of Manitoba, Northwestern Ontario and Nunavut Covers all of Manitoba, Northwestern Ontario and Nunavut Services 1.3 million people Services 1.3 million people

4. Introduction/Background Regional standardize Acute MI care since 2001 Regional standardize Acute MI care since 2001 Safer Health Care Team established 2005 Safer Health Care Team established 2005 –Inclusion of WRHA Transport Team –Emergency Medical Services –WRHA Cardiac Sciences and Emergency Programs –Original group consisted of 2 other WRHA facilities Retrospective audit Regional (April-June 2005) reveals several hot spots: Retrospective audit Regional (April-June 2005) reveals several hot spots: –Door to needle time TNK (N = 24 cases) –Door to first balloon inflation PCI (N = 24 cases) –Smoking cessation (Non-STEMI & STEMI N = 65 cases)

5. Goals of the SHC Initiative To improve processes of care to decrease time to therapy for STEMI patients To improve processes of care to decrease time to therapy for STEMI patients –Improve patient outcomes –Decrease in-hospital mortality Integrated and coordinated pre-hospital component to STEMI care within the WRHA. Integrated and coordinated pre-hospital component to STEMI care within the WRHA.

6. Key Milestones March 2006: Pre implementation data collection done March 2006: Pre implementation data collection done May 2006: Patient Discharge Sheet implemented that identified key standards of STEMI care May 2006: Patient Discharge Sheet implemented that identified key standards of STEMI care Fall 2006: WRHA AMI Care Map re-authored and implemented (6 sites) Fall 2006: WRHA AMI Care Map re-authored and implemented (6 sites) Dec 2006: The Next Steps Heart Fair established at SBGH Dec 2006: The Next Steps Heart Fair established at SBGH Jan 2007: Concurrent auditing of Primary PCI times using standardized concurrent tracking tool Jan 2007: Concurrent auditing of Primary PCI times using standardized concurrent tracking tool April 2007: Authored two algorithms: April 2007: Authored two algorithms: -Indications for primary PCI -Indications for rescue PCI post fibrinolytic Jan 2007: Processes to improve times to first ECG in the ED at SBGH Jan 2007: Processes to improve times to first ECG in the ED at SBGH

7. Key Milestones April 2008: Authored 2 STEMI treatment algorithms April 2008: Authored 2 STEMI treatment algorithms April 2008: Physician standard orders re-authored to reflect the new STEMI standards of care April 2008: Physician standard orders re-authored to reflect the new STEMI standards of care May 2008: Pre hospital care phase 1 started - communication with EMS and STEMI Cardiologist May 2008: Pre hospital care phase 1 started - communication with EMS and STEMI Cardiologist June 2008: LEAN demonstrator project at SBGH for Suspect ACS in emergency June 2008: LEAN demonstrator project at SBGH for Suspect ACS in emergency July 2008: Full implementation of pre hospital care July 2008: Full implementation of pre hospital care August 2008: Re-authored the WRHA Suspect ACS Care Map August 2008: Re-authored the WRHA Suspect ACS Care Map

8. Recognized STEMI <3hours

9. Recognized STEMI 3-6 hours

12. First Code STEMI Wednesday, May 21, 2008 Symptom onset to balloon time 112 minutes Symptom onset to balloon time 112 minutes EMS (first medical contact) to balloon time70 minutes EMS (first medical contact) to balloon time70 minutes Hospital arrival to balloon time32 minutes Hospital arrival to balloon time32 minutes Symptom onset at 1215 EMS Scene arrival at 1257 EMS 12 lead at 1305 (15 lead); 1320; 1329 Call to Cardiologist at1315 Cath lab notified at1340 Arrived at lab at1335 In Angio Suite at 1345 Balloon inflation at 1407 Reason for Primary PCIWeekday daytime primary PCI Complex LAD/septal lesions but good angio table to balloon time in spite of complexity of lesion

13. Second Code STEMI Thursday June 5, 2008 Symptom onset to balloon time 152 minutes Symptom onset to balloon time 152 minutes EMS (first medical contact) to balloon time79 minutes EMS (first medical contact) to balloon time79 minutes Hospital arrival to balloon time38 minutes Hospital arrival to balloon time38 minutes Symptom onset at 0750 EMS dispatched at0856 EMS Scene arrival at 0903 EMS 12 lead at 0915 (Inferior STEMI) Call to Cardiologist at0922 Destination arrival at0944 Arrived at lab at0949 In Angio Suite at 0954 Balloon inflation at 1022 Reason for Primary PCIWeekday daytime primary PCI

14. Third Code STEMI Friday, June 6, 2008 Symptom onset to balloon time 99 minutes Symptom onset to balloon time 99 minutes EMS (first medical contact) to balloon time76 minutes EMS (first medical contact) to balloon time76 minutes Hospital arrival to balloon time44 minutes Hospital arrival to balloon time44 minutes Symptom onset at 1115 EMS Scene arrival at 1138 EMS 12 lead at 1203 (Anterior STEMI) Call to Cardiologist at1201 Destination arrival at1210 Arrived at lab at1215 In Angio Suite at 1220 Balloon inflation at 1254 Reason for Primary PCIWeekday daytime primary PCI

15. Comparison EMS Contact to Open Artery Pre and Post Implementation of the STEMI Protocol Pre Post #cases30 cases 15 cases Average 109 minutes 76 minutes Median88 minutes 72 minutes Longest>>90 min89 minutes

16. Lessons Learned Implementation of the new EMS Patient Care Electronic (PCR) Record was delayed Implementation of the new EMS Patient Care Electronic (PCR) Record was delayed Needed to purchase monitors capable of performing a 12 lead that were compliant with PHIA regulations Needed to purchase monitors capable of performing a 12 lead that were compliant with PHIA regulations The monitors needed to have the capability of integrating with the PCR The monitors needed to have the capability of integrating with the PCR Timing transmission of the 12 lead from the Zoll Monitor – to the PCR – to the blackberry Timing transmission of the 12 lead from the Zoll Monitor – to the PCR – to the blackberry Training of the EMS (N =350) was a bit early (Dec 2007) since phase 1 didn’t go live until May 21, 2008 Training of the EMS (N =350) was a bit early (Dec 2007) since phase 1 didn’t go live until May 21, 2008

17. Lessons Learned Support for initiative from all key stakeholders – well established Support for initiative from all key stakeholders – well established Ability to transform evidence into practice Ability to transform evidence into practice Integration of revisions to standards example ACS and AMI Care Maps Integration of revisions to standards example ACS and AMI Care Maps

18. Next Steps Code STEMI Team at SBGH to respond to Code STEMI’s at the SBGH ED (Dec 2008) Code STEMI Team at SBGH to respond to Code STEMI’s at the SBGH ED (Dec 2008) Dialogue with other key stakeholders outside of the WRHA Dialogue with other key stakeholders outside of the WRHA Continue to ensure a seamless approach to patient care throughout the WRHA Continue to ensure a seamless approach to patient care throughout the WRHA Continue to work with key stake holders to improve STEMI care Continue to work with key stake holders to improve STEMI care

19. Website Address http://www.cardiacsciences.mb.ca Under city wide hospital forms left sided tab: STEMI Algorithms STEMI Algorithms Indications for Primary PCI Indications for Primary PCI Indications for Rescue PCI Indications for Rescue PCI AMI Care Map (SBGH), order set AMI Care Map (SBGH), order set Code STEMI Poster Code STEMI Poster