急性心肌梗塞戰(zhàn)略

1、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, USA,Overview,Introductio

2、nThe Argument for Primary PCIOverview of the Henry Ford ProgramProgram SpecificsProcess Dictates OutcomesAlternative Opportunities,Acute MI: Introduction,1.1 million people yearly in the US*About 500,000 have STEM

3、I220,000 die from their AMI50% of deaths in the first hourOutlook of hospitalized patients better,*AHA: 2001 Heart and stroke statistics,Acute MI: Early ManagementReperfusion,Pharmacological (Thrombolysis)Fibrinoly

4、ticsAntithrombinsPlatelet InhibitorsMechanical (Direct/Primary PCI)AngioplastyStentThrombectomyCombined? Facilitated PCI,Acute MI: Direct PCIAdvantages,Rapid assessment of anatomy and hemodynamicsTIMI-3 flow r

5、ates 75-95% in infarct arteryLow incidence of hemorrhagic strokeCan be done in patients with contraindications for thrombolysisResults superior to thrombolytics in randomized trials,Direct PTCA vs. ThrombolysisPAMI-1

6、,,N Engl J Med 1993; 328:673-679,Primary Angioplasty vs. Thrombolysis: Meta-analysis,Deathp=0.02,Death+MIp<0.01,Weaver DW, JAMA 1997;278:2093-2098,Primary Angioplasty vs. Thrombolysis: Meta-analysis,Weaver DW, JAMA

7、1997;278:2093-2098,PCI vs Lysis Meta Analysis,Keeley E, Lancet 2003; 361: 13–20,Lytics vs Transfer for PCI: DANAMI,Acute MI: Direct PCILimitations,Only 20% of US hospitals have cath labs and fewer have PTCA facilities

8、To 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 necessary,Is Time

9、 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 AMI2004,Class IGeneral: Patients presenting within 12 ho

10、urs; 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 1 hourSymptom >3 hours, PCI preferred <90m

11、inWithin 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:/

12、/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 lessMajority of MI occur during “Off Hours” (nights and weekends)Off Hou

13、r Primary PCI is associated with increased door to balloon times and mortalityHenry Ford 2002Door to Balloon218 minutesCath Lab to Balloon60 minutes,Primary PCI PathwayAn Opportunity for Process Improvement,Patient

14、 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

15、, 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 minutes,Proce

16、ss Change,Centralize CommunicationsFocus Clinical Decision MakingTransfer SEMI Patients Directly to Site of TherapyEstablish Transport PathwaysUnite CICU/Cath Lab Nursing FunctionsImprove Door to Balloon Times!,Door

17、-To Balloon TimeHenry Ford Hospital Detroit,Door-To Balloon TimeHenry Ford System Wide2005,Henry Ford Acute Myocardial Infarction Program,6 Emergency RoomsHenry Ford Hospital90,000 visitsHF Wyandotte Hospital72,0

18、00HF Bicounty Hospital28,000Fairlane ER47,000West Bloomfield ER22,000Sterling Heights ER21,000Primary PCI @ Henry Ford HospitalLarge Urban Teaching Hospital in Detroit,Henry Ford ER Locations,,,,,,20 m, 33 mi

19、n,14 m, 25 min,9 m, 24 min,8 m, 17 min,12 m, 26 min,Door-To Balloon TimeHenry Ford System Wide2005,Improving Door to Balloon Time,How Do You Change The Process?,Create A Multi Disciplinary TeamIdentify Advocates,Cath

20、LabDoctors, Nurses, ManagersCCUDoctors, Nurses, ManagersEmergency RoomDoctors, NursesCardiologistsStaff and TraineesHospital AdministrationAmbulance Transport,Changing the Process,Improve the Process to Meet the

21、 ScienceDissect Complex Activities into Quantifiable StepsTeam members help to redesign the processes in their areasEstablish Parallel (not serial) ProcessesAvoid DuplicationExample: IV Compatibility,Changing the Pr

22、ocess,ActivationSimple1 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 ad

23、mission, etc…,Changing the Process,TransportActivate transport (ambulance) as early as possible, usually before activating central team.Establish well known dispatch pathwayMinimize emergency room timeCommunicate dur

24、ing transport,Changing the Process,Minimize StepsPatients Transported Directly to Cath LabBusiness Hours- EasyOff Hours In House Nurses and MD’s Staff Cath Lab while Cath Lab Staff Travel to HospitalPrep Room and P

25、atient,Changing the Process,Cath LabFocused Pathway to Reperfusion7 F SheathDiagnostic Angiography of non-IRVGuide Catheter for suspected IRV“Standard” initial PTCA EquipmentFloppy Wire2.0/2.5 mm BalloonEstablish

26、 Reperfusion First, Optimize Result LaterRemember the Team!Call the ER and let them know the results,Cath Lab TimesArrival to Balloon Inflation,HFH AMI Flow Chart,AMI Gann Chart,Changing the Process,MetricsMeasure Yo

27、ur 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 arriva

28、l to arterial accessProcedure TimeArterial access to balloon or reperfusion,Changing the Process,FeedbackShare Outcomes and Pertinent Metrics with ParticipantsConstructive Criticism is the Only Way to Improve the

29、 ProcessSuccess Begets SuccessFoster Participant Pride and Enthusiasm,Alternative Strategies and Next Steps,Remote 12 lead EKGEKG in AmbulanceTransmit EKG from fieldActivate Cath Lab fieldDisseminate Primary PTCA C

30、entersOffsite Surgical Back UpCentralize MI CentersPractice Makes PerfectStaff Lab 24/7,HFHS Initiatives,Improve Door to EKG TimeImprove Transport TimesNew ambulance StructureActivation to Arrival“PickUp” TimesI

31、mprove Cath Lab Response TimesRemote EKGIn Field 12 lead EKG with telephonic transmission,Conclusions,Careful Process Engineering Can Dramatically Reduce Door To Balloon TimesThis Requires:A Multi-Disciplinary Team a