©2011, American Heart Association

STEMI FEEDBACKClosing the “Loop” for process improvement

Rationale

Objective: Seamless and effective participation of each EMS agency,

STEMI sending hospital and STEMI receiving hospital in an

integrated STEMI system of care

• Reinforce agency/department view of being a part of a

comprehensive STEMI system of care

• Reinforce individuals’ views of being a part of a comprehensive

STEMI system of care

STEMI FEEDBACKClosing the “Loop” for process improvement

Rationale

Objective: Timely and consistent uniform delivery of evidence-based

treatment throughout the STEMI continuum of care

• Educate/reinforce timeliness of process

• Educate/reinforcing treatment guidelines

• Provide data and feedback that can be used in identifying

opportunities for improvement and tracking progress

STEMI FEEDBACKClosing the “Loop” for process improvement

Practical Considerations

• Purpose:

– Rationale above

– Improved multi-discipline relationships

• Timeliness of feedback: sooner is better

• Time to devote to producing reports

• Who will write/combined with abstraction?

• Length and format

STEMI FEEDBACKClosing the “Loop” for process improvement

• Distribution

• HIPAA

• Template (Word, Excel, Access)

• 1-2 pages

• Environment in which the “Feedback” is presented

Practical Considerations Cont.

STEMI FEEDBACKClosing the “Loop” for process improvement

Potential Feedback Report Elements

• Info to identify patient, but not to identify patient

• Narrative story providing system perspective and patient

disposition

• Specific times and calculated intervals

• Guideline-based expectation education

• Cool and educational graphics

• Shout-outs

STEMI FEEDBACKClosing the “Loop” for process improvement

Potential Feedback Report Elements Cont.

• Opportunities/Recommendations for improvement

• ECG

• Pre/Post Angiography

• Lesions illustrated anatomically

• “Activation without Intervention” rationale

STEMI FEEDBACKClosing the “Loop” for process improvement

OK…..So…What data do we Collect?

• EVERYTHING

– Keep track of everything you can

– No matter how unimportant it may seem, someone someday will ask

for it

STEMI FEEDBACKClosing the “Loop” for process improvement

Practice

• Rural EMS Service responds to a residence 20 minutes away from their station

• They arrived “at patient” at 1600hrs

– Consent to treat obtained at 1605hrs

– First ECG at 1612hrs revealed ST Elevation in leads V1-V4

– ECG transmission to receiving facility at 1613 hrs.

• EMS Transport initiated at 1618hrs

– Radio report called at 1625hrs with a request for STEMI Team Activation

• EMS Arrived at receiving facility at 1643hrs

• Receiving facility cath team arrived at 1650hrs

• Device activation with restored circulation at 1735hrs

STEMI FEEDBACKClosing the “Loop” for process improvement

• “Every action that is not directly related to treatment after

STEMI identification is a waste of time and myocardium”• David R. Burt, MD, (2014)

A Concept to ponder…

8/6/2014 ©2010, American Heart Association 10

STEMI FEEDBACKClosing the “Loop” for process improvement

Potential Times/Intervals

Times

• Symptom onset

• 911 call

• EMS dispatch

• First Medical Contact

• EKG time

• STEMI Team/Dr. Alert time

Intervals

• 911 to First Medical Contact

• FMC to ECG

• EMS time on scene

• ECG to transmission

• Transmission to Alert

• FMC to door

STEMI FEEDBACKClosing the “Loop” for process improvement

Potential Times/Intervals Cont.

Times

• Door time

• Team/Dr. arrival

• Cath Lab time

• Device or Drug time

• Miles transported

Intervals

• Time in ED

• Sending hospital DIDO

• Door-to-balloon

• Door-to-needle

• FMC-to-balloon

STEMI FEEDBACKClosing the “Loop” for process improvement

Examples of feedback reports

8/6/2014 ©2010, American Heart Association 13

STEMI FEEDBACKClosing the “Loop” for process improvement

DRAFT

STEMI Patient Feedback Form

This information will be sent via secure fax to the EMS crew and/ or Referral hospital within 48 hours of the

patients’ initial presentation.

Patient Initials:

Initial EMS Service: Referral Hospital:

EMS Crew members: Sending Physician:

Date of initial patient presentation: Time of arrival at PCI Receiving Center:

This document was completed by:

Phone # for follow-up questions:

Time 911 was called OR patient presented at referral center

Time of First Medical Contact (time first medical providers is at patient side)

Time of first EKG

Time of arrival at referral facility (actual clock time)

Time of lytic administration (if applicable) (Goal of 30 minutes… refer to poster)

Time of door out from referral facility (DIDO from referral)

Total time at referral facility (time in minutes… MLWY goal is 30 minutes… refer to poster)

Time of arrival at PCI Center

Total transfer time (in minutes) MLWY goal is 60 minutes … refer to poster

Time of device initiation (cath lab intervention time)

Location of occlusion/ Artery opened (which artery was closed)

Overall time from patient entry into healthcare system to open vessel (standard of care goal is 120 minutes or referral facility, 90 minutes for PCI center)

EMS Arrival 14:23

CAT Paged 14:34

Arrival to MCR 14:55

Arrival to Cath Lab

15:06

1st Balloon Time 15:22

D2B Time: 27 Minutes

Pre Post

Date: 05/18/2014 Gender: Female

Chief Complaint: Chest Pain,

epigastric in nature, severe at 9/10 lasting

approx. 2hrs.

EMS Crew:Poudre Valley

Case Synopsis: Angiogram showed 20% occlusion of the left main and 99% occlusion of the LAD. Ejection fraction

was 45-50% with moderate anterior hypokinesis. Patient received 1 drug eluting stent to the ostial LAD. She had an uneventful recovery and was

discharged home in good condition on 5/20/14.

Dr. Oldemeyer would like to praise the EMS crew for their clinical insight with a borderline EKG and low risk patient. The ER doctor was tempted to cancel

the cardiac alert.

Pre Post

Date: 05/18/2014 Gender: Female

Chief Complaint: Chest Pain, epigastric in nature, severe at 9/10 lasting approx. 2hrs.

Primary EMS Crew and/or Referral Hospital:

Poudre Valley EMS

Case Synopsis: Angiogram showed 20% occlusion of the left main and 99% occlusion of the LAD. Ejection fraction was 45-50% with moderate

anterior hypokinesis. Patient received 1 drug eluting stent to the ostial LAD. She had an uneventful recovery and

was discharged home in good condition on 5/20/14.

Dr. Oldemeyer would like to praise the EMS crew for their clinical

insight with a borderline EKG and low risk patient. The ER doctor was tempted to cancel the cardiac alert.

Put your logo here DRAFT

Total time at First Facility

14:23

Arrival at PCI14:34

Total Transfer time

14:55

Arrival to Cath Lab 15:06

1st Balloon Time 15:22

D2B Time: 27 Minutes

911 called or PtArrival 14:23

FMC

14:34

First ECG

14:55

Arrival to First Facility

15:06

Lytic Admin Time 15:22

Door In/Out from first facility: 27

Minutes

STEMI FEEDBACKClosing the “Loop” for process improvement

STEMI FEEDBACKClosing the “Loop” for process improvement

STEMI FEEDBACKClosing the “Loop” for process improvement

STEMI FEEDBACKClosing the “Loop” for process improvement

STEMI FEEDBACKClosing the “Loop” for process improvement

STEMI FEEDBACKClosing the “Loop” for process improvement

STEMI FEEDBACKClosing the “Loop” for process improvement

STEMI FEEDBACKClosing the “Loop” for process improvement

STEMI FEEDBACKClosing the “Loop” for process improvement

STEMI FEEDBACKClosing the “Loop” for process improvement