2019年急性心肌梗塞战略..ppt

AMI StrategyHow to Achieve Door-to-Balloon Times of 90 Minutes and What to Do Next?Aaron Kugelmass,MDDirector,Cardiac Cath LabAssociate Division ChiefHenry Ford HospitalDetroit,Michigan,USAOverviewIntroductionThe Argument for Primary PCIOverview of the Henry Ford ProgramProgram SpecificsProcess Dictates OutcomesAlternative OpportunitiesAcute MI:Introduction1.1 million people yearly in the US*About 500,000 have STEMI220,000 die from their AMI50%of deaths in the first hourOutlook of hospitalized patients better*AHA:2001 Heart and stroke statisticsAcute MI:Early ManagementReperfusionPharmacological(Thrombolysis)FibrinolyticsAntithrombinsPlatelet InhibitorsMechanical(Direct/Primary PCI)AngioplastyStentThrombectomyCombined?Facilitated PCIAcute MI:Direct PCIAdvantagesRapid assessment of anatomy and hemodynamicsTIMI-3 flow rates 75-95%in infarct arteryLow incidence of hemorrhagic strokeCan be done in patients with contraindications for thrombolysisResults superior to thrombolytics in randomized trialsPCI vs Lysis Meta AnalysisKeeley E,Lancet 2003;361:1320Lytics vs Transfer for PCI:DANAMIAcute MI:Direct PCILimitationsOnly 20%of US hospitals have cath labs and fewer have PTCA facilitiesTo achieve results similar to randomized trials the following has to be met:PTCA within 90 minutes of presentationSkilled operator(75 cases/year)Skilled lab(200 cases/year)Surgical back up necessaryIs Time as Critical in Primary PCI?30-day mortalityTime from onset of CP to randomizationZijlstra,Eur Heart J 2002;23:550ACC/AHA Recommendations for Direct PCI in AMI2004Class IGeneral:Patients presenting within 12 hours;if performed in a timely fashion by individuals skilled in the procedure and supported by experienced personnel in high volume centersSpecific:Door To Balloon Time 90 min 3hours symptom,PCI if treatment 1 hourSymptom 3 hours,PCI preferred 90minWithin 36 hours of MI when patient develops cardiogenic shock,is 75 years and revascularization can be done within 18 hours of shock onset.12 hours of symptoms and severe CHF or pulmonary edema(2004)Http:/www.acc.org/clinical/guidelinesPrimary PCI in the United StatesMinority of US Hospitals Achieve a median Door to Balloon Time of 90 minutes or lessMajority of MI occur during“Off Hours”(nights and weekends)Off Hour Primary PCI is associated with increased door to balloon times and mortalityHenry Ford 2002Door to Balloon218 minutesCath Lab to Balloon 60 minutesPrimary PCI PathwayAn Opportunity for Process ImprovementPatient Presentation to Diagnosis20 minPage Fellow,Fellow Responds10 minFellow Proceeds to ER15 minFellow Evaluates Patient 15 minFellow Pages CCU Staff,Staff Responds 10 min+PCI,Fellow Pages Int Staff,Staff Responds 10 minFellow goes to Cath Lab,Pages Team10 minPatient Stays in ER or Goes to CICUCath Team Arrives60 minFind Patient and Transport 15 minPerform PCI45 minTotal 210 minutesProcess ChangeCentralize CommunicationsFocus Clinical Decision MakingTransfer SEMI Patients Directly to Site of TherapyEstablish Transport PathwaysUnite CICU/Cath Lab Nursing FunctionsImprove Door to Balloon Times!Door-To Balloon TimeHenry Ford Hospital DetroitDoor-To Balloon TimeHenry Ford System Wide2005Henry Ford Acute Myocardial Infarction Program6 Emergency RoomsHenry Ford Hospital90,000 visitsHF Wyandotte Hospital 72,000HF Bicounty Hospital28,000Fairlane ER47,000West Bloomfield ER22,000Sterling Heights ER21,000Primary PCI Henry Ford HospitalLarge Urban Teaching Hospital in DetroitHenry Ford ER Locations Henry Ford Owned(5)Partially Owned(3)HF Medical Center(24)20 m,33 min14 m,25 min9 m,24 min8 m,17 min12 m,26 minDoor-To Balloon TimeHenry Ford System Wide2005Improving Door to Balloon TimeHow Do You Change The Process?Create A Multi Disciplinary TeamIdentify AdvocatesCath LabDoctors,Nurses,ManagersCCUDoctors,Nurses,ManagersEmergency RoomDoctors,NursesCardiologistsStaff and TraineesHospital AdministrationAmbulance TransportChanging the ProcessImprove the Process to Meet the ScienceDissect Complex Activities into Quantifiable StepsTeam members help to redesign the processes in their areasEstablish Parallel(not serial)ProcessesAvoid DuplicationExample:IV CompatibilityChanging the ProcessActivationSimple1 Phone Call-24 hours a dayStaffed by Decision Maker(MD who accepts patient and activates team)Team Activation is Invisible to the OutsideCoordinator then activates staff members,arranges admission,etcChanging the ProcessTransportActivate transport(ambulance)as early as possible,usually before activating central team.Establish well known dispatch pathwayMinimize emergency room timeCommunicate during transportChanging the ProcessMinimize StepsPatients Transported Directly to Cath LabBusiness Hours-EasyOff Hours In House Nurses and MDs Staff Cath Lab while Cath Lab Staff Travel to HospitalPrep Room and PatientChanging the ProcessCath LabFocused Pathway to Reperfusion7 F SheathDiagnostic Angiography of non-IRVGuide Catheter for suspected IRV“Standard”initial PTCA EquipmentFloppy Wire2.0/2.5 mm BalloonEstablish Reperfusion First,Optimize Result LaterRemember the Team!Call the ER and let them know the resultsCath Lab TimesArrival to Balloon InflationHFH AMI Flow ChartAMI Gann ChartChanging the ProcessMetricsMeasure Your Lean ProcessesDoor to EKGEKG to ActivationTransportCath LabActivation to Ambulance Arrival“Pick Up Time”Ambulance arrival to departureTransport Time ER departure to cath lab arrivalCath Prep TimeCath arrival to arterial accessProcedure TimeArterial access to balloon or reperfusionChanging the ProcessFeedbackShare Outcomes and Pertinent Metrics with ParticipantsConstructive Criticism is the Only Way to Improve the ProcessSuccess Begets SuccessFoster Participant Pride and EnthusiasmAlternative Strategies and Next StepsRemote 12 lead EKGEKG in AmbulanceTransmit EKG from fieldActivate Cath Lab fieldDisseminate Primary PTCA CentersOffsite Surgical Back UpCentralize MI CentersPractice Makes PerfectStaff Lab 24/7HFHS InitiativesImprove Door to EKG TimeImprove Transport TimesNew ambulance StructureActivation to Arrival“PickUp”TimesImprove Cath Lab Response TimesRemote EKGIn Field 12 lead EKG with telephonic transmissionConclusionsCareful Process Engineering Can Dramatically Reduce Door To Balloon TimesThis Requires:A Multi-Disciplinary Team and Institutional CommitmentCareful Metrics to Guide ImprovementOngoing Feedback to Team MembersContinuous Evaluation to Drive Process Improvement