STEMI process slashes PCI time
STEMI process slashes PCI time
Flexible program can be adapted to any ED
Getting chest pain patients with ST-elevation myocardial infarction (STEMI) percutaneous coronary intervention (PCI) within an average of 83 minutes is no small accomplishment. However, the ED at the University of Virginia (UVA) Medical Center in Charlottesville has cut that number to 56 minutes with an internally developed program called Project UPSTART (Use of Procedural STAndardization to Reduce recognition to reperfusion Time). David R. Burt, MD, assistant professor in the University of Virginia (UVA) Department of Emergency Medicine, says that Project UPSTART grew out of his experiences with Spectrum Health in Michigan.
"About five years ago, we started working on STEMI; and through trial and error and staff training, each time we did something else, it got a little better," Burt says. "When I got here, we tried to implement all that we had learned, and reperfusion times dropped tremendously, so I thought we could we package this for any hospital or system."
UVA has done just that. On the Project UPSTART web site (www.projectupstart.com/index.php) visitors can watch a video describing the program, download a provider training module, and access program resources — all at no charge. Because no two EDs are the same, UVA will help department leaders customize the program. "We figure out exactly how STEMI should run at a given facility and condense the information into their own 'STEMI Alert,'" Burt explains.
A key element
The STEMI Alert is a key element of the program, notes Barbara Craighead, RN, BSN, CEN, the chest pain center coordinator. The alerts are packets, which at UVA are available at the team manager's desk and in the chest pain center. "In the packet is a sheet for each key player in STEMI: the primary nurse, the scribe, the resident and attending [who call the hospital operator and set off an official STEMI alert], and the technician." Each sheet outlines the appropriate steps to be taken by that individual.
The packets are customized according to the capabilities of the given ED. For example, in facilities where PCI is not performed, the packet is quite different. For example, Culpeper VA Regional Hospital, which participated in UPSTART, is 42 miles from Burt's facility. "If they can't get air transport, it's very unlikely they can use ground transport and meet the 90-minute national standard, so they automatically default to giving the patient thrombolytics," he explains. "Their packet will say, 'Call air transport, if available, and ship for PCI'; if not, make sure it's OK to give 'lytics' and then send the patient to UVA where they can examine them and determine if they need reperfusion."
An instinctive process
A key to the success of the program, adds Burt, is that it becomes an instinctive process. This process is aided by a clever sign that hangs over the packets: "Got STEMI? Open packet."
Because only about 50% of the STEMI patients are walk-ins, it also was important to include EMS in the process, says Burt. "UPSTART allows us to link very carefully with EMS," he says. "If they obtain an ECG outside of the hospital that shows STEMI, they call Medical Command [which answers and coordinates all radio traffic], who patches them in directly to the physician." If the physician thinks there is a high probability of STEMI, the ED will pre-activate the catheterization lab and give a heads-up to the five team members. "If they are not sure, the ED is still placed on high alert, and we are out there at the door to meet the ambulance and we look at the ECG right there," Burt says. "We staple it to the back of the upstart data collection form to make it part of the permanent medical record."
Those data collection forms serve a dual purpose, says Craighead. "There are two sheets. One stays in the ED and goes on to the cath lab with the patient. It's time-stamped in the cath lab so we can calculate door-to-balloon time and how long they were in the ED." The second sheet is used for quality improvement follow-up, she says.
Sources
For more information on Project UPSTART, contact:
- David R. Burt, MD, Assistant Professor, Department of Emergency Medicine, University of Virginia, Charlottesville. E-mail: [email protected].
- Barbara Craighead, RN, BSN, CEN, Chest Pain Center Coordinator, University of Virginia Medical Center, Charlottesville. Phone: (434) 924-0211.
Education needed for STEMI program Project UPSTART (Use of Procedural STAndardization to Reduce recognition to reperfusion Time), a program for treating STEMI patients developed at the University of Virginia (UVA) Medical Center in Charlottesville, has been an unqualified success. However, implementation couldn't begin before the staff underwent an extensive education program. "Before we started using [the program] packets, we had an education process for the staff," recalls Barbara Craighead, RN, BSN, CEN, the chest pain center coordinator. "Nurses and technicians had to change the way they thought about the presentation of chest pain patients, whether they came here through the door or by ambulance." The way they operate now is as follows: When patients presents with chest pain or other parameters indicating a heart attack, they receive an ECG within five minutes. David R. Burt, MD, assistant professor in the UVA Department of Emergency Medicine, says, "We've emphasized to staff that while presentation could be variable, if they fit the criteria on screening, we require an ECG in five minutes and we will not accept anything less. These staff members are our STEMI gatekeepers." Craighead says she has conducted 20 classes for more than 150 ED staff members over the past three years. The classes are mirrored in the provider training module available to any interested ED free of charge on the Project UPSTART web site (www.projectupstart.com/index.php). "We have a manual we give to each provider. We cover topics like performing 12 lead-ECGs, resuscitation, and the STEMI alert packets," says Craighead. These packets, which have separate instructions for each team member, were reviewed intensely, she adds. Next, Craighead says, "We watch the video and do a post-test." (Editor's note: The video is available on the Project UPSTART web site, www.projectupstart.com. Under "Resources," select "Audio Visual Resources.") Following that session, there is a two-hour, sit-down class with Burt or an attending physician. Also, all RNs are required to have advanced cardiac life support (ACLS) certification. While the UVA staff were being educated, "we started a process so we that could do STEMI anywhere in the department, not just in the chest pain center," Craighead said. A simple process While the education process might seem daunting to other EDs, it is actually simple, says Burt. "That's because everything is a template. You can take the sample STEMI packet back to the hospital and see what you think would be best for you." When you are training your first contact providers, he says, they must understand they are the gatekeepers. They need to understand how important they are to making the program work, Burt says. "If a hospital decides to go live, a letter is sent to the staff asking them to please go to the web site and watch the 14-minute training module, the 20-minute tutorial, and take the two-page post-test, which is proof that they have done the UPSTART training," says Burt. "At the same time, there should be a carefully crafted STEMI packet that the doctors and nurses have worked on in parallel that is appropriate for this ED site." On the day the ED goes live, the staff have been trained and the packets go up on wall. "When that first STEMI rolls in the door, they know what to do," Burt says. Resource To access a sample STEMI packet, go to the Project UPSTART web site (www.projectupstart.com) and click on "Resources." Select "Basic Forms & Processes" and "STEMI Alert Packet (samples)." |
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