1. STEMI-OUR System of Care: A Big Town Perspective with a Small Town Compassion Door-to-Balloon (D2B) Intensive Analysis Wm. Todd Gray, D.O., F.A.C.C. June 3, 2011

4. Our Vision

8. Door 2 Balloon-GOAL  Identification of STEMI’s earlier which included partnerships with our local EMS.  D2B < 90 minutes for 100% of patients (non- transfers)  Facility internal goal of <69 minutes for 100% of patients (non-transfers)  Improve documentation of delay when time > 90 minutes, especially if delay occurred within our Cardiac Catherization Lab

9. Changing “Time”  At DRMC our 1 st priority was to offer the best to our growing community. This included looking at our current process for cardiac patients.  “Best Practices” were involved in every aspect of implementing our current Door 2 Balloon(D2B) Dashboard.

10. GOAL Door 2 Balloon “SWEET”  S-STEMI  W-Within  E-Emergent  E-Event  T-Time

11. S-STEMI Initial identification-EMS  Partnership with local EMS providers: 19/19 local EMS have ability to transmit 12 lead EKG’s directly to ED physician/staff  Transmission of 12 lead EKG directly to physician's phones  Ability to call STEMI directly from field and allow bypassing of ED and go directly to Cath Lab.  Since implementation 1 st Q 2011 Median Time--- 59 minutes

14. W-Within Response Time Initiatives = Saving Muscle In the beginning……. In 2007 our Cardiologists Median Arrival Time=34 minutes In 2007 our Interventionists Arrival Time=64 minutes – 2008-Implementation of Interventional Call (Eliminated call to Cardiologist) – 2010-“I-Card Only” parking spaces and badge only access direct to Cath Lab Cath Lab (30 min goal) – Reduce calls required to activate Cath Lab Team—5555(pager system) GOAL= 30 mins

15. W-Within W-Within Response Time Initiatives Cath Lab (30 min goal) Reduce calls required to activate Cath Lab Team—5555 GOAL= 30 mins

16. E-Emergent  2008-Developed and Implemented “STEMI BOX” Consent Code STEMI D2B checklist Atomic Clock Clippers Acute STEMI medications(i.e. ASA) IV’s and Lab Tubes 2010-Code STEMI Order Set 2010-Currently all lab results print to Cath Lab

17. E-Emergent  Skinny “STEMI BOX” - October 2008(Triage Nurse initiates for walk-in patients to ED) Consent Code STEMI D2B checklist Atomic Clock Aspirin In 2010 DRMC implemented an algorithm for our In- House STEMI process.

18. E-Event-D2 EKG Time Door 2 EKG-2007- 4 mins Door 2 EKG-2010-3 mins

19. E-Event-D2 Cath Lab(2007&2010) Door 2 Cath Lab-2007-54.5 mins Door 2 Cath Lab-2010-36 mins

20. T-Time-D2B(2007 & 2010) D2B 2007-88 mins D2B 2010-66 mins

21. Code STEMI Process ED Code STEMIInterventional Cardiologist Called Directly by ED Doctor HUC--5555 Team members calls HUC to say Cath team on way. Off-hours night Supervisors turns on cath lab

22. Event & Time- Data

25. D2B SWEET—Process Improvement  Process for Transfer STEMIs identified  Collection of Transfer Data -2 nd Q 2010  Request Transfer facility to arrival DRMC-2010 ~Median 52 minutes  DRMC door to intervention-2010 ~ Median 41 minutes  Process for In-Patient Chest Pain identified-2010 ~ Median >90 minutes-STEMI occurred after CABG earlier in day

29. Why “DRMCs” Process WORKS Prompt data feedback – 100% review of all Code STEMI on a daily basis Immediate notification of team members to review process for any outliers Team-based approach—Weekly D2B meetings to review STEMI’s by the D2B sub-committee Administrative support Concurrent review Physician review of cases at CV Meetings

36. EMS Physician Interventional Cardiologist Nursing Staff Ancillary Staff Administration ED Staff EMS Cath Lab Staff