vanessa thornton clinical head emergency care
DESCRIPTION
“The Doctor said another 5 minutes and I would have been dead” A regional approach to saving heart muscle. Vanessa Thornton Clinical Head Emergency Care. Background. Time to PCI is an internationally measured indicator of care for patients with ST Elevation Myocardial Infarction (STEMI). - PowerPoint PPT PresentationTRANSCRIPT
“The Doctor said another 5 minutes and I would have been dead”
A regional approach to saving heart muscle
Vanessa ThorntonClinical Head Emergency Care
Background• Time to PCI is an internationally measured
indicator of care for patients with ST Elevation Myocardial Infarction (STEMI).
• Earlier the heart is perfused the better the outcome for heart function.
• The internationally agreed is Time to PCI < than 90mins.
• Since 2010 we have transferred patients to ACH for PCI after 1530 until 0730.
Analysis in 2011PCI performed at
Middlemore Hospital
Auckland City Hospital
<90 minutes
>90 minutes
Auckland City Hospital
Analysis After Hours Patients Left MMH EC within 45 minutes (13/30)
Late Presentation MI
Delay to book ambulance
Failure to view initial ECG
Evolving MIserial ECG’s
No interventionalist available at MMH / waiting
cardiology decision
Delay CCU RN/ICU Dr
Unstable
Treating another condition
AnalysisDoor to ballon time (after hours STEMI Patients) January 2011 to date
0:00
1:30
3:00
4:30
6:00
7:30
9:00
10:30
12:00
1
Do
or
to b
allo
on
tim
e
Mean door to balloon time 2:2016 out of 82 (20%) < 90 minutes
The Patients Voice
08:00-15:30 CN CCU arrange
PCI
Pt Tx to PCI
Chest Pain in the community
GP Ambulance R40
ECG Arrive MMH TC1 or
2
ECG 10 mins
S/B 10 mins
Ref Cardio *3167
Self present to MMH ED
15:30 – 08:00 Cardio discuss
ACH
ACH accepts pt
Cardio informs MMH SMO
EC organise ambulance
Cardio organise CCU escort
Ambulance dispatched
Ambulance arrives
Pt transferred to ambulance
Depart to ACH
Arrive at ACH
CHANGE CONCEPT = SIMPLIFY PROCESS AFTER HOURS
Ref to Medicine
Improving Time to Nurse Seen by
R40 likely STEMI on ECG or STEMI likely at triage
ECG within 10 mins
Notify EM SMO *3703 & monitor registrar
15:30 – 08:00 & weekendsRequest ambulance to wait and ph 9037060 / 0800262266 stating
“Patient still on stretcher of vehicle ‘xx’ and vehicle ‘xx’ is doing the transfer to Auckland Hospital”
(NB St John may request the patient is transferred in a PTS ambulance If one is already on site or if the crew are at
the end of their shift).or
If delay expected or ‘walk in’ patient, book ambulance ph 9037060 / 0800262266 stating “Urgent priority 1 ambulance…patient transfer to Auckland City Hospital cath lab
with escort”.
Transfer to ACH cath lab with CCU RN escort & notify ACH CCU 0212406774 or 3757040.
ICU will assist with unstable patients.
After Hours
On arrival, keep patient on ambulancetrolley & perform ECG
WithinHours
STEMI?
08:00 – 15:30 Mon – Fri?
NoRefer NSTEAC/
chest pain pathway. Transfer patient
onto EC bed & let ambulance go.
Ambulance arrival
Follow blueWalk in arrival
Follow green
Yes
STEMI
CHEST PAIN
Call
*3167 (within hours this connects directly with CCU
CN, after hours this connects with the operator – ask for the on call cardiologist)
STEMI?
NoRefer NSTEAC/
chest pain pathway.
Transfer patient to EC bed &
perform ECG
08:00-15:30 hrs Monday – Friday
Call CCU CN on *3167
Fax ECG to CCU 8176
Transfer patient ASAP to MMH cath lab
Ref STEMI pathway
Show ECG to RMO / SMO
Ambulance DelaysTime from calling for ambulance to depature from
Middlemore Emergency Care
00:00
00:10
00:20
00:30
00:40
00:50
1 3 5 7 9 11 13 15 17 19 21 23 25 27 29 31 33 35
Patient number
Tim
e(h
ou
rs:m
inu
tes
)
Result of Holding Original AmbulanceAfter:70% Patients receive PCI within 90 minutesMean time to PCI 83 minutes
Door to ballon time (after hours STEMI Patients) January 2011 to date
0:00
1:30
3:00
4:30
6:00
7:30
9:00
10:30
12:00
1
Do
or
to b
allo
on
tim
e
Door to ballon time (after hours STEMI Patients) January 2011 to date
0:00
1:30
3:00
4:30
6:00
7:30
9:00
10:30
12:00
1
Do
or
to b
allo
on
tim
e
Other activities• The project aligned itself to the Regional
Cardiac Network.• Continue to measure all the times involved
for the individual patients presenting with a STEMI.
• We audited St Johns from March to June, measuring confidence level of crew in identifying STEMI.
Next Improvement
Challenges – timing?
• St John are in the process of phasing out their old defibrillators.
• Also upgrading their entire national computer system.
• They had other priorities and projects, for example Christchurch.
• Delay to get complete regional transmission.
In Progress
• All the stakeholders are totally committed.• This was always a phased approach• Relocating all MRX defibrillators to
Counties Manukau area.• Training St Johns ambulance and
Emergency Staff.• Upgrading 19 ambulances with
transmission capabilities.
Conclusion• Currently 70% of patients now receive
PCI < 90mins “after hours”• This is up from 20%.• Holding ambulance in EC and improving
time to ECG review has improved after hours care.
• ECG transmission by ambulance to MMH Emergency is the future improvement.