Reperfusion Therapies 2007

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  • 1. The Mission of the American College of Cardiology …… - “to foster optimal cardiovascular care and disease prevention through professional education, promotion of research, leadership in the development of standards and guidelines and the formulation of health care policy.” Pennsylvania CHAPTER In cooperation with Highmark and Independence Blue Cross (Blue Plans headquartered in Pittsburgh and Philadelphia)
  • 2. Reperfusion Therapies 2007 Strategies for Developing Integrated D2B Programs For STEMI Pennsylvania CHAPTER In cooperation with Highmark and Independence Blue Cross (Blue Plans headquartered in Pittsburgh and Philadelphia)
  • 3. Pennsylvania CHAPTER In cooperation with Highmark and Independence Blue Cross (Blue Plans headquartered in Pittsburgh and Philadelphia) Donald R. Fischer, M.D., MBA Senior Vice President Chief Medical Officer Highmark Michael A. Madden, M.D. Medical Director Quality and Medical Performance Management Highmark Highmark Lori Armel Karen Balsamo Flo Campbell Deborah J. Donovan Lynette Enders Douglas Hoch Paul Hoffman Trina Thompson Carey Vinson, M.D. Medical Director Highmark T H A N K Y O U Victor Caraballo, M.D. Senior Medical Director Quality Management Independence Blue Cross Kathleen T. Donohue Independence Blue Cross Steven J. Brown, M.D. Medical Director Professional Networks Phil Gehman Provider Improvement Project Leader Independence Blue Cross Teamwork
  • 4. Pennsylvania CHAPTER In cooperation with Highmark and Independence Blue Cross (Blue Plans headquartered in Pittsburgh and Philadelphia) Pennsylvania Chapter – American College of Cardiology Maria Elias Association Executive American College of Cardiology Jason Byrd Jayne Jordan Amy Stern T H A N K Y O U Tracy Allgier-Baker Director of Continuing Education Penn State College of Medicine Bonnie Bixler, M.Ed. Director of Special Projects Penn State Continuing Education College of Medicine Lori L. Fitterling Julie Graham Penn State Continuing Education Teamwork
  • 5. Reperfusion Therapies 2007 P4P Programs Pennsylvania CHAPTER In cooperation with Highmark and Independence Blue Cross (Blue Plans headquartered in Pittsburgh and Philadelphia) P ROFESSIONALS for P ERFUSION
  • 6. Reperfusion Therapies 2007
    • Welcome and Introduction
    • Michael A. Madden, M.D. : Highmark
    • Richard L. Snyder, M.D. : IBC
    • Daniel Edmundowicz, M.D. : Pa-ACC
    Pennsylvania CHAPTER In cooperation with Highmark and Independence Blue Cross (Blue Plans headquartered in Pittsburgh and Philadelphia)
  • 7. Reperfusion Therapies 2007 The Vision: Improving D2B Time for STEMI Pennsylvania CHAPTER In cooperation with Highmark and Independence Blue Cross (Blue Plans headquartered in Pittsburgh and Philadelphia)
  • 8. Pennsylvania CHAPTER In cooperation with Highmark and Independence Blue Cross (Blue Plans headquartered in Pittsburgh and Philadelphia) "The secret of success in life is for a (wo)man to be ready for (her) his opportunity when it comes." - Benjamin Disraeli "Education brings about opportunity, and in turn inspiration." - Bill Frist "A pessimist sees the difficulty in every opportunity; an optimist sees the opportunity in every difficulty." - Winston Churchill ACC-D2B
  • 9. Pennsylvania CHAPTER In cooperation with Highmark and Independence Blue Cross (Blue Plans headquartered in Pittsburgh and Philadelphia)
    • Primary PCI should be performed as quickly as possible, with a
    • goal of a medical contact-to-balloon or door-to-balloon time
    • within 90 minutes.
      • ACC/AHA/SCAI 2005 Guideline
      • Update for Percutaneous Coronary Interventions
      • In July 2005 the Penn State Heart & Vascular Institute
      • as part of a quality improvement initiative reviewed
      • D2B for STEMI patients:
    Door-to-ECG : 36 min (mean); range : 10-132 min ECG-to-PCI : 109 min (mean); range : 71-363 min Door-to-Balloon time : 145 min (mean) ACC-D2B
  • 10. Pennsylvania CHAPTER In cooperation with Highmark and Independence Blue Cross (Blue Plans headquartered in Pittsburgh and Philadelphia) Door-to-Balloon time : 145 min (mean)
    • "Kubler-Ross Stages in Facing Reality of
    • the Quality Chasm "
    • The data are wrong
    • The data are right, but it’s not a problem
    • The data are right, but it’s not my problem
    • I accept the burden of quality improvement
    Donald Berwick, Institute of Medicine Crossing the Quality Chasm Summit Washington D.C., January 2004
  • 11. ED Nurse initiates acute care Heart Alert Intake Worksheet Idealized Workflow Presenting symptoms suggestive of ACS ECG performed within 10 minutes ECG reviewed by ED attending CARDIOLOGIST PAGED STEMI “confirmed” Penn State Heart & Vascular Institute
  • 12. Pennsylvania CHAPTER In cooperation with Highmark and Independence Blue Cross (Blue Plans headquartered in Pittsburgh and Philadelphia) Y.O.U.R. Medical Center HOSPITAL ADMINISTRATION HVI /EM LEADERSHIP ADMISSSIONS COMMUNICATIONS NURSING ANCILLARY SERVICES PARAMEDICS LIFE LION PHYSICIANS MD NETWORK FELLOWS INTERVENTIONAL CRNP CVOU SUPPORT STAFF CARDIAC CATH LAB STAFF SIM LAB I.T. SERVICES Penn State Heart & Vascular Institute
  • 13. Penn State Heart & Vascular Institute ED Physician Empowerment Heart Alert Paging System Activated ED Attending Activates Heart Alert System Attending to Attending Case discussion Classic STEMI Possible STEMI Cardiology Attending paged
  • 14. Heart Alert Paging System
    • Interventional Cardiologist [on-call]
    • Cath Lab “Charge” [organize room]
    • Cardiology Fellow [on-call]
    • Cath Lab call-team
    • Interventional Nurse Practitioner
    • Hospital Admissions
    • Research Nurse(s)
    • ED Charge Nurse
    • Radiology Technologist
    “ RESPONDERS” 01/01/2007 06:30 HEART ALERT ED- ROOM 19 RESPOND STAT Penn State Heart & Vascular Institute
  • 15.
    • Is family present Y / N
    • Is a translator necessary? : No / Yes :_________________(language)
    • Vitals: BP_______; HR_______; RR_______
    • Jugular venous distention : No / Yes: _________
    • Pulmonary : rales ____; wheezes_____
    • Cardiac auscultation: murmurs ______; gallops ______
    • Pulses: femoral: R_____; L_____; Radial: R____; L___
    • Symptoms: Chest Pain _______; time of onset______; Shortness of breath _______;
    • Allergies- No / YES: ______________________________; Iodine______; Shellfish_____
    • Prior : Cardiac cath______; Angioplasty______; CABG_____;
    • Height_________________
    • Weight ________________
    • Dentures Yes / No
    • Time of Last Meal ____________________
    • Hearing Aid Yes / No
    • Contacts Yes / No
    • 17. IV Meds (circle if administered): Dopamine, Dobutamine,, Nitroglycerin, Heparin, Aspirin
    ED MD______________ ED NURSE___________ Date ______ Time______ Cath Lab: ext 6416 Patient ID Sticker Penn State Heart & Vascular Institute Heart Alert Intake Worksheet Fax: 717-531-1074
  • 16. Triage to ECG ECG to Heart Alert Activation PCI Penn State Heart & Vascular Institute Heart Alert Program- GOALS Heart Alert Activation to Cath Lab Team arrival Patient’s Arrival to Cath Lab 10 min 10 min 30 min 5 min 35 min Door-to-Balloon Time: 90 min
  • 17. Steven Ettinger , Charles Chambers, Ian Gilchrist, Mark Kozak, Craig Lauder & Lawrence Sinoway March 25, 2007 Quality Improvement: Reducing Door-to-Balloon Time (D2B) in Patients With ST-segment Elevation Myocardial Infarction: Heart Alert Program PENN STATE HEART & VASCULAR INSTITUTE
  • 18. Triage to ECG ECG to Heart Alert Activation PCI Penn State Heart & Vascular Institute Heart Alert Program Heart Alert Activation to Cath Lab Team arrival Patient’s Arrival to Cath Lab 9.0 min 3.9 min 19.6 min 12.8 min 28.5 min 2007 Door-to-Balloon Time: 73.8 min (mean) (86% within 90 min) Door-to-Balloon Time: 85.7 min (mean) (140 patients enrolled)
  • 19. Pennsylvania CHAPTER In cooperation with Highmark and Independence Blue Cross (Blue Plans headquartered in Pittsburgh and Philadelphia) March, 2007- Pa-ACC, Highmark and IBC working group organized to plan Reperfusion Therapies 2007- The Vision : 1. Review current pathways and protocols 2. Recognize best-practice models 3. Recognize D2B times < 90 min are achievable 4. Recognize together we can and we will make a difference Medical Directors' Institute : October 18- 20, 2006 Leesburg, Virginia Created in 2002 by the ACC with the intention of developing a collaborative approach to issues such as paying for quality, utilization of imaging technology, health information systems and value in healthcare.
  • 20. Pennsylvania CHAPTER In cooperation with Highmark and Independence Blue Cross (Blue Plans headquartered in Pittsburgh and Philadelphia) State Program We can do better………….
  • 21. Optimize STEMI Care Pennsylvania CHAPTER In cooperation with Highmark and Independence Blue Cross (Blue Plans headquartered in Pittsburgh and Philadelphia) Regionalize STEMI Care EDUCATION Pa-ACC D2B
  • 22. Pennsylvania CHAPTER In cooperation with Highmark and Independence Blue Cross (Blue Plans headquartered in Pittsburgh and Philadelphia) Now you know what it is like to develop a “ Door-to-Balloon” program Step back and run into this wall head first………. www.d2balliance.com www.d2balliance.com www.d2balliance.com www.d2balliance.com www.d2balliance.com www.d2balliance.com www.d2balliance.com
  • 23. Harlan M. Krumholz, M.D., F.A.C.C. Yale University School of Medicine ACC- GAP Chair, Door-to-Balloon Work Group Pennsylvania CHAPTER In cooperation with Highmark and Independence Blue Cross (Blue Plans headquartered in Pittsburgh and Philadelphia)
  • 24. D2B Program Emergency Medical Services
    • Expert Panel :
      • Donald Durbeck
      • Vincent N. Mosesso Jr.
      • Judd E. Hollander
      • David Neubert
      • Andrew Miller
  • 25. D2B Program Emergency Medical Services
    • 9:05- 9:15 am : Can STEMI Patients Transferred for Primary Angioplasty Receive Treatment Within 90- minutes in a Rural Setting? – Geisinger Medical Center
    • 9:20- 9:30 am : Improving STEMI Care in Eastern Pennsylvania: The Lehigh Valley Hospital and Health Network MI-Alert Program – Lehigh Valley Hospital
    • 9:35- 9:45 am : Reducing D2B Time in STEMI by Utilizing EMS Cath Lab Activation From the Field & Intradepartmental Emergency Physician Activation: An 11-year 24/7/365 Experience – Mercy Hospital of Pittsburgh
    • 9:50- 10:00 am : Improving D2B Time in STEMI– Presbyterian Shadyside
    • 10:05- 10:15 am : Delay to Electrocardiogram in STEMI Patients Does Not Preclude Meeting 90-minute D2B Time – Albert Einstein Medical Center
  • 26. November 21-23, 2008 Kiss this Date Goodbye on your Calendar!
    • Why?
    • Because you do not want to miss this meeting!
    • 2008 Annual Pa-ACC Chapter Meeting
    • November 21-23, 2008
    • The Hotel Hershey
    • Sure to be a SWEET Event!
  • 27. John J. Kelly, D.O., F.A.C.E.P. Albert Einstein Medical Center Associate Chairman Department of Emergency Medicine D2B Strategies and the Role of the Emergency Department Pennsylvania CHAPTER In cooperation with Highmark and Independence Blue Cross (Blue Plans headquartered in Pittsburgh and Philadelphia)
  • 28. D2B Program Emergency Medicine
    • Expert Panel :
      • John Doherty
      • Craig Lauder
      • Paul Casale
      • Andrew Waxler
      • Michael Rossi
      • Howard Herrmann
  • 29. D2B Program Emergency Medicine
    • 11:15 - 11:25 am : – Cardiac Reperfusion Team Protocol Decreases D2B Time at Hamot Medical Center- Hamot Medical Center
    • 11:30 - 11:40 am : D2B Time: Every Minute Counts – Conemaugh Memorial Medical Center
    • 11:45- 11:55 am : Emergency Physician Activation of the Catheterization Lab Reduces D2B Times with Few False Activations – Hahnemann University
  • 30. Douglas Kupas, M.D. Commonwealth EMS Medical Director Bureau of EMS Pennsylvania Department of Health EMS and D2B Strategies: The Pennsylvania Perspective Pennsylvania CHAPTER In cooperation with Highmark and Independence Blue Cross (Blue Plans headquartered in Pittsburgh and Philadelphia)
  • 31. Howard C. Herrmann, M.D., F.A.C.C. Director, Interventional Cardiology and Cardiac Catheterization Laboratories University of Pennsylvania Is There a Role For Facilitated PCI in 2007 ? Pennsylvania CHAPTER In cooperation with Highmark and Independence Blue Cross (Blue Plans headquartered in Pittsburgh and Philadelphia)
  • 32. D2B Program Interventional Cardiology
    • Expert Panel :
      • Ian Gilchrist
      • A.J. Conrad Smith
      • Nelson Wolf
      • Charles Chambers
      • James Blankenship
  • 33. D2B Program Interventional Cardiology
    • 1:40 - 1:50 pm : – Processes to Decrease D2B Times for STEMI Patients in a Community Hospital- Saint Vincent Health Center
    • 1:55 - 2:05 pm : Overall Catheterization Laboratory Normal Angiography Rate Does Not Increase with ER Activation of Primary Coronary Interventions (PCI) for STEMI – Chester County Hospital
    • 2:10- 2:20 pm : Are Women Undergoing Primary PCI at Increased Risk for Death? Insights from the Lehigh Valley Hospital and Health Network MI-ALERT Program – Lehigh Valley Hospital
    • 2:25- 2:35 pm : Interdisciplinary Collaboration to Reduce D2B Time – Abington Memorial Hospital
  • 34. D2B Program Interventional Cardiology
    • 2:40 - 2:50 pm : – D2B Time: The Pinnacle Health Experience- Pinnacle Health
    • 2:55 - 3:05 pm : Overcoming the Hurdles: Improving D2B in the LVHHN MI-ALERT Program – Lehigh Valley Hospital
    • 3:10- 3:20 pm : Time to Treatment During Primary PCI is Related to Transport Distance and Speed of Interventionalist – Geisinger Medical Center
  • 35. Reperfusion Therapies 2007 Strategies for Developing Integrated D2B Programs For STEMI Pennsylvania CHAPTER In cooperation with Highmark and Independence Blue Cross (Blue Plans headquartered in Pittsburgh and Philadelphia) CONCLUDING REMARKS
  • 36. Reperfusion Therapies 2007
    • If you don’t know the data, you can’t get better.
    • Reperfusion strategies are essential
    • Quality is a Culture
    • Educate – Standardize - Regionalize
    • State Organizations should collaborate
    Pennsylvania CHAPTER In cooperation with Highmark and Independence Blue Cross (Blue Plans headquartered in Pittsburgh and Philadelphia)
  • 37. Mission: Lifeline
    • March 2006- AHA multidisciplinary conference
      • STEMI patient care
      • Implementation Plan:
        • EMS system assessment and improvement
        • Establishing local initiatives
        • Evaluating existing models
        • Explore the possibility of developing a National STEMI Center Certification Program/Criteria
    Pennsylvania CHAPTER In cooperation with Highmark and Independence Blue Cross (Blue Plans headquartered in Pittsburgh and Philadelphia)
  • 38. AHA
    • Stroke - Recommendations for the establishment of stroke systems of care
    • Brain Defense- A Stroke Prevention and Treatment Strategy for Pennsylvania –
      • Presented to the General Assembly of the Commonwealth of PA – Joint State Government Commission – November 2002
    Pennsylvania CHAPTER In cooperation with Highmark and Independence Blue Cross (Blue Plans headquartered in Pittsburgh and Philadelphia)
  • 39.
    • Statewide Systems Change
    • Develop Taskforce/Committee under Department of Health CVD Consortium
    • Develop plan and progress markers
    • Assess resources / capabilities
    • Focus on long term outcomes
    Pennsylvania CHAPTER In cooperation with Highmark and Independence Blue Cross (Blue Plans headquartered in Pittsburgh and Philadelphia)
  • 40. Improving Outcomes Through a Culture of a Collaborative Environment Pennsylvania CHAPTER In cooperation with Highmark and Independence Blue Cross (Blue Plans headquartered in Pittsburgh and Philadelphia) &
  • 41. THANK YOU Pennsylvania CHAPTER In cooperation with Highmark and Independence Blue Cross (Blue Plans headquartered in Pittsburgh and Philadelphia)