急性心肌梗塞战略.ppt

AMI Strategy How to Achieve Door-to-Balloon Times of 90 Minutes and What to Do Next?,Aaron Kugelmass, MD Director, Cardiac Cath Lab Associate Division Chief Henry Ford Hospital Detroit, Michigan, USA,Overview,Introduction The Argument for Primary PCI Overview of the Henry Ford Program Program Specifics Process Dictates Outcomes Alternative Opportunities,Acute MI: Introduction,1.1 million people yearly in the US* About 500,000 have STEMI 220,000 die from their AMI 50% of deaths in the first hour Outlook of hospitalized patients better,*AHA: 2001 Heart and stroke statistics,Acute MI: Early Management Reperfusion,Pharmacological (Thrombolysis) Fibrinolytics Antithrombins Platelet Inhibitors Mechanical (Direct/Primary PCI) Angioplasty Stent Thrombectomy Combined ? Facilitated PCI,Acute MI: Direct PCI Advantages,Rapid assessment of anatomy and hemodynamics TIMI-3 flow rates 75-95% in infarct artery Low incidence of hemorrhagic stroke Can be done in patients with contraindications for thrombolysis Results superior to thrombolytics in randomized trials,Direct PTCA vs. Thrombolysis PAMI-1,N Engl J Med 1993; 328:673-679,Primary Angioplasty vs. Thrombolysis: Meta-analysis,Death p=0.02,Death+MI p0.01,Weaver DW, JAMA 1997;278:2093-2098,Primary Angioplasty vs. Thrombolysis: Meta-analysis,Weaver DW, JAMA 1997;278:2093-2098,PCI vs Lysis Meta Analysis,Keeley E, Lancet 2003; 361: 1320,Lytics vs Transfer for PCI: DANAMI,Acute MI: Direct PCI Limitations,Only 20% of US hospitals have cath labs and fewer have PTCA facilities To achieve results similar to randomized trials the following has to be met: PTCA within 90 minutes of presentation Skilled operator (75 cases/year) Skilled lab (200 cases/year) Surgical back up necessary,Is Time as Critical in Primary PCI?,30-day mortality,Time from onset of CP to randomization,Zijlstra, Eur Heart J 2002;23:550,ACC/AHA Recommendations for Direct PCI in AMI 2004,Class I General: 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 centers Specific: Door To Balloon Time 1 hour Symptom 3 hours, PCI preferred 90min Within 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/guidelines,Primary PCI in the United States,Minority of US Hospitals Achieve a median Door to Balloon Time of 90 minutes or less Majority of MI occur during “Off Hours” (nights and weekends) Off Hour Primary PCI is associated with increased door to balloon times and mortality Henry Ford 2002 Door to Balloon 218 minutes Cath Lab to Balloon 60 minutes,Primary PCI Pathway An Opportunity for Process Improvement,Patient Presentation to Diagnosis 20 min Page Fellow, Fellow Responds 10 min Fellow Proceeds to ER 15 min Fellow Evaluates Patient 15 min Fellow Pages CCU Staff, Staff Responds 10 min + PCI, Fellow Pages Int Staff, Staff Responds 10 min Fellow goes to Cath Lab, Pages Team 10 min Patient Stays in ER or Goes to CICU Cath Team Arrives 60 min Find Patient and Transport 15 min Perform PCI 45 min Total 210 minutes,Process Change,Centralize Communications Focus Clinical Decision Making Transfer SEMI Patients Directly to Site of Therapy Establish Transport Pathways Unite CICU/Cath Lab Nursing Functions Improve Door to Balloon Times!,Door-To Balloon Time Henry Ford Hospital Detroit,Door-To Balloon Time Henry Ford System Wide 2005,Henry Ford Acute Myocardial Infarction Program,6 Emergency Rooms Henry Ford Hospital 90,000 visits HF Wyandotte Hospital 72,000 HF Bicounty Hospital 28,000 Fairlane ER 47,000 West Bloomfield ER 22,000 Sterling Heights ER 21,000 Primary PCI Henry Ford Hospital Large Urban Teaching Hospital in Detroit,Henry Ford ER Locations,20 m, 33 min,14 m, 25 min,9 m, 24 min,8 m, 17 min,12 m, 26 min,Door-To Balloon Time Henry Ford System Wide 2005,Improving Door to Balloon Time,How Do You Change The Process?,Create A Multi Disciplinary Team Identify Advocates,Cath Lab Doctors, Nurses, Managers CCU Doctors, Nurses, Managers Emergency Room Doctors, Nurses Cardiologists Staff and Trainees Hospital Administration Ambulance Transport,Changing the Process,Improve the Process to Meet the Science Dissect Complex Activities into Quantifiable Steps Team members help to redesign the processes in their areas Establish Parallel (not serial) Processes Avoid Duplication Example: IV Compatibility,Changing the Process,Activation Simple 1 Phone Call- 24 hours a day Staffed by Decision Maker (MD who accepts patient and activates team) Team Activation is Invisible to the Outside Coordinator then activates staff members, arranges admission, etc,Changing the Process,Transport Activate transport (ambulance) as early as possible, usually before activating central team. Establish well known dispatch pathway Minimize emergency room time Communicate during transport,Changing the Process,Minimize Steps Patients Transported Directly to Cath Lab Business Hours- Easy Off Hours In House Nurses and MDs Staff Cath Lab while Cath Lab Staff Travel to Hospital Prep Room and Patient,Changing the Process,Cath Lab Focused Pathway to Reperfusion 7 F Sheath Diagnostic Angiography of non-IRV Guide Catheter for suspected IRV “Standard” initial PTCA Equipment Floppy Wire 2.0/2.5 mm Balloon Establish Reperfusion First, Optimize Result Later Remember the Team! Call the ER and let them know the results,Cath Lab Times Arrival to Balloon Inflation,HFH AMI Flow Chart,AMI Gann Chart,Changing the Process,Metrics Measure Your Lean Processes Door to EKG EKG to Activation Transport Cath Lab Activation to Ambulance Arrival “Pick Up Time” Ambulance arrival to departure Transport Time ER departure to cath lab arrival Cath Prep Time Cath arrival to arterial access Procedure Time Arterial access to balloon or reperfusion,Changing the Process,Feedback Share Outcomes and Pertinent Metrics with Participants Constructive Criticism is the Only Way to Improve the Process Success Begets Success Foster Participant Pride and Enthusiasm,Alternative Strategies and Next Steps,Remote 12 lead EKG EKG in Ambulance Transmit EKG from field Activate Cath Lab field Disseminate Primary PTCA Centers Offsite Surgical Back Up Centralize MI Centers Practice Makes Perfect Staff Lab 24/7,HFHS Initiatives,Improve Door to EKG Time Improve Transport Times New ambulance Structure Activation to Arrival “PickUp” Times Improve Cath Lab Response Times Remote EKG In Field 12 lead EKG with telephonic transmission,Conclusions,Careful Process Engineering Can Dramatically Reduce Door To Balloon Times This Requires: A Multi-Disciplinary Team and Institutional Commitment Careful Metrics to Guide Improvement Ongoing Feedback to Team Members Continuous Evaluation to Drive Process Improvement,