急性心肌梗塞戰(zhàn)略.ppt

AMIStrategyHowtoAchieveDoor to BalloonTimesof90MinutesandWhattoDoNext AaronKugelmass MDDirector CardiacCathLabAssociateDivisionChiefHenryFordHospitalDetroit Michigan USA Overview IntroductionTheArgumentforPrimaryPCIOverviewoftheHenryFordProgramProgramSpecificsProcessDictatesOutcomesAlternativeOpportunities AcuteMI Introduction 1 1millionpeopleyearlyintheUS About500 000haveSTEMI220 000diefromtheirAMI50 ofdeathsinthefirsthourOutlookofhospitalizedpatientsbetter AHA 2001Heartandstrokestatistics AcuteMI EarlyManagementReperfusion Pharmacological Thrombolysis FibrinolyticsAntithrombinsPlateletInhibitorsMechanical Direct PrimaryPCI AngioplastyStentThrombectomyCombined FacilitatedPCI AcuteMI DirectPCIAdvantages RapidassessmentofanatomyandhemodynamicsTIMI 3flowrates75 95 ininfarctarteryLowincidenceofhemorrhagicstrokeCanbedoneinpatientswithcontraindicationsforthrombolysisResultssuperiortothrombolyticsinrandomizedtrials DirectPTCAvs ThrombolysisPAMI 1 NEnglJMed1993 328 673 679 PrimaryAngioplastyvs Thrombolysis Meta analysis Deathp 0 02 Death MIp 0 01 WeaverDW JAMA1997 278 2093 2098 PrimaryAngioplastyvs Thrombolysis Meta analysis WeaverDW JAMA1997 278 2093 2098 PCIvsLysisMetaAnalysis KeeleyE Lancet2003 361 13 20 LyticsvsTransferforPCI DANAMI AcuteMI DirectPCILimitations Only20 ofUShospitalshavecathlabsandfewerhavePTCAfacilitiesToachieveresultssimilartorandomizedtrialsthefollowinghastobemet PTCAwithin90minutesofpresentationSkilledoperator 75cases year Skilledlab 200cases year Surgicalbackupnecessary IsTimeasCriticalinPrimaryPCI 30 daymortality TimefromonsetofCPtorandomization Zijlstra EurHeartJ2002 23 550 ACC AHARecommendationsforDirectPCIinAMI2004 ClassIGeneral Patientspresentingwithin12hours ifperformedinatimelyfashionbyindividualsskilledintheprocedureandsupportedbyexperiencedpersonnelinhighvolumecentersSpecific DoorToBalloonTime1hourSymptom 3hours PCIpreferred 90minWithin36hoursofMIwhenpatientdevelopscardiogenicshock is 75yearsandrevascularizationcanbedonewithin18hoursofshockonset 12hoursofsymptomsandsevereCHForpulmonaryedema 2004 Http www acc org clinical guidelines PrimaryPCIintheUnitedStates MinorityofUSHospitalsAchieveamedianDoortoBalloonTimeof90minutesorlessMajorityofMIoccurduring OffHours nightsandweekends OffHourPrimaryPCIisassociatedwithincreaseddoortoballoontimesandmortalityHenryFord2002DoortoBalloon218minutesCathLabtoBalloon60minutes PrimaryPCIPathwayAnOpportunityforProcessImprovement PatientPresentationtoDiagnosis20minPageFellow FellowResponds10minFellowProceedstoER15minFellowEvaluatesPatient15minFellowPagesCCUStaff StaffResponds10min PCI FellowPagesIntStaff StaffResponds10minFellowgoestoCathLab PagesTeam10minPatientStaysinERorGoestoCICUCathTeamArrives60minFindPatientandTransport15minPerformPCI45minTotal210minutes ProcessChange CentralizeCommunicationsFocusClinicalDecisionMakingTransferSEMIPatientsDirectlytoSiteofTherapyEstablishTransportPathwaysUniteCICU CathLabNursingFunctionsImproveDoortoBalloonTimes Door ToBalloonTimeHenryFordHospitalDetroit Door ToBalloonTimeHenryFordSystemWide2005 HenryFordAcuteMyocardialInfarctionProgram 6EmergencyRoomsHenryFordHospital90 000visitsHFWyandotteHospital72 000HFBicountyHospital28 000FairlaneER47 000WestBloomfieldER22 000SterlingHeightsER21 000PrimaryPCI HenryFordHospitalLargeUrbanTeachingHospitalinDetroit HenryFordERLocations 20m 33min 14m 25min 9m 24min 8m 17min 12m 26min Door ToBalloonTimeHenryFordSystemWide2005 ImprovingDoortoBalloonTime HowDoYouChangeTheProcess CreateAMultiDisciplinaryTeamIdentifyAdvocates CathLabDoctors Nurses ManagersCCUDoctors Nurses ManagersEmergencyRoomDoctors NursesCardiologistsStaffandTraineesHospitalAdministrationAmbulanceTransport ChangingtheProcess ImprovetheProcesstoMeettheScienceDissectComplexActivitiesintoQuantifiableStepsTeammembershelptoredesigntheprocessesintheirareasEstablishParallel notserial ProcessesAvoidDuplicationExample IVCompatibility ChangingtheProcess ActivationSimple1PhoneCall 24hoursadayStaffedbyDecisionMaker MDwhoacceptspatientandactivatesteam TeamActivationisInvisibletotheOutsideCoordinatorthenactivatesstaffmembers arrangesadmission etc ChangingtheProcess TransportActivatetransport ambulance asearlyaspossible usuallybeforeactivatingcentralteam EstablishwellknowndispatchpathwayMinimizeemergencyroomtimeCommunicateduringtransport ChangingtheProcess MinimizeStepsPatientsTransportedDirectlytoCathLabBusinessHours EasyOffHoursInHouseNursesandMD sStaffCathLabwhileCathLabStaffTraveltoHospitalPrepRoomandPatient ChangingtheProcess CathLabFocusedPathwaytoReperfusion7FSheathDiagnosticAngiographyofnon IRVGuideCatheterforsuspectedIRV Standard initialPTCAEquipmentFloppyWire2 0 2 5mmBalloonEstablishReperfusionFirst OptimizeResultLaterRemembertheTeam CalltheERandletthemknowtheresults CathLabTimesArrivaltoBalloonInflation HFHAMIFlowChart AMIGannChart ChangingtheProcess MetricsMeasureYourLeanProcessesDoortoEKGEKGtoActivationTransportCathLabActivationtoAmbulanceArrival PickUpTime AmbulancearrivaltodepartureTransportTimeERdeparturetocathlabarrivalCathPrepTimeCatharrivaltoarterialaccessProcedureTimeArterialaccesstoballoonorreperfusion ChangingtheProcess FeedbackShareOutcomesandPertinentMetricswithParticipantsConstructiveCriticismistheOnlyWaytoImprovetheProcessSuccessBegetsSuccessFosterParticipantPrideandEnthusiasm AlternativeStrategiesandNextSteps Remote12leadEKGEKGinAmbulanceTransmitEKGfromfieldActivateCathLabfieldDisseminatePrimaryPTCACentersOffsiteSurgicalBackUpCentralizeMICentersPracticeMakesPerfectStaffLab24 7 HFHSInitiatives ImproveDoortoEKGTimeImproveTransportTimesNewambulanceStructureActivationtoArrival PickUp TimesImproveCathLabResponseTimes