contra costa county servicesthe contra costa county stemi system relies on a close partnership...

Contra Costa CountyEmergency Medical

Services

STEMI Program Coordinator Quality Improvement

Manual 2008

pfrost

pfrost

2009

Contra Costa Emergency

Medical Services STEMI Program

WELCOME STEMI QI COORDINATORS! Inside this manual you will find information and resources to assist you in your new role of STEMI QI Coordinator. If you have questions or need assistance contact Contra Costa EMS QI Coordinator and STEMI Project Manager Pat Frost RN, MS, PNP at [email protected]. The Contra Costa County STEMI System relies on a close partnership between EMS and Hospitals to save lives in Contra Costa County. As the Quality Improvement Lead for your agency/facility it is vital that you understand your role and responsibilities. Contra Costa County has worked with all our EMS stakeholders to design a quality improvement program for our new STEMI system that is responsive, accountable and uses current systems and processes to resolve issues and address concerns. How well this program performs will depend on your active participation in the process. We look forward to working with you and welcome your ideas and suggestions as we implement the STEMI System for Contra Costa County. General Expectations of STEMI QI Program Participants

1. Active participation in STEMI related QI activities a. Meetings. b. Issue identification and resolution. c. Constructive, solution focused feedback.

2. Timely data sharing through appropriate channels. a. Confidentiality. b. Facilitate data collection and reporting.

3. Commitment to improving performance. 4. Commitment to provider and public education. 5. Respectful, effective communication and collaboration.

STEMI Center RN Program Manager Responsibilities The responsibilities of the RN Program Manager are listed under the STEMI Receiving Center Designation Criteria Application and Evaluation Tool available on our EMS website at www.cccems.org.

http://www.cccems.org/

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1. Supports the STEMI Center Medical Director Functions. 2. Acts as EMS-STEMI Program Liaison. 3. Assures EMS Facility STEMI data sharing.

a. Submits STEMI Report for each STEMI patient delivered by EMS within 10 days of the date of patient arrival.

b. Provides EMS data report elements on a quarterly and at year end. Data is due 3 months from previous quarter.

c. Provides EMS data report elements on at year end. Data is due 3 months from end of year.

4. Manages EMS-Facility STEMI QI activities. 5. Authority and accountability for QI/PI for STEMI program. 6. Facilitates timely feedback to hospital and field providers. 7. Assures current written quality improvement plan or program description. 8. Collaborates with the development and implementation of future STEMI system

evaluation. STEMI EMS Provider QI Coordinator Responsibilities

1. Supports Provider Agency and Local EMS agency EMS Medical Director Functions for the Contra Costa County STEMI System.

2. Acts as the EMS-STEMI Program Liaison. 3. Authority and accountability for QI/PI STEMI program. 4. Facilitates timely feedback to hospital and field providers. 5. Assures EMS Provider data sharing.

a. Orients, trains and remediates EMS providers in 12 lead and ePCR documentation in compliance with Contra Costa County EMS Policy and Procedure.

b. Monitors completion and accuracy of prehospital STEMI documentation. c. Responds promptly to requests for data and documentation from Local

EMS agency as needed. 6. Uses EMS event reporting system to identify and document STEMI EMS

provider issues. a. Completes fact finding and reports issue resolution to appropriate parties. b. Identifies appropriate corrective action and remediation to EMS providers

as needed. 7. Participates in monthly EMS agency QI committee meetings to identify and

address STEMI system quality improvement activities.

Thank you for your participation in Contra Costa County’s STEMI System!

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Contra Costa Emergency Medical Service STEMI System

CQI Follow-up FAQ

Who at EMS provides CQI oversight for the Contra Costa STEMI system? Dr. Joe Barger, EMS Medical Director and Pat Frost EMS QI Coordinator and STEMI Project Manager will be providing oversight. Who are the STEMI CQI Coordinators for the STEMI Receiving Centers? Each STEMI Receiving Center has a Program Coordinator whose responsibility is to provide CQI oversight or coordination of their internal STEMI programs. These are the individuals responsible for communicating follow-up on STEMI patients to appropriate parties. A list of those individuals and their contact information is available from Contra Costa EMS. Who are the STEMI CQI Coordinators for the Fire-EMS Community? The CQI coordinators for each agency are responsible for STEMI CQI. These are the individuals responsible for communicating follow-up on STEMI patients to appropriate parties. A list of those individuals and their contact information is available from Contra Costa EMS. How do we assure confidentiality in our STEMI System? Each party involved in STEMI CQI is responsible for adhering to HIPPA and STEMI System Contract CQI standards for patient communication. Each CQI coordinator in the STEMI system signs an EMS confidentially agreement. All communications between CQI coordinators are to be held in strict confidence and appropriate local measures used to protect patient information. Outcome information is to be communicated on a need-to-know basis. For example, only CQI coordinators of the agencies directly involved in patient care are allowed to share patient follow-up information. How does a CQI coordinator get outcome information? Outcome information is obtained through direct communication between the designated CQI coordinators for the Fire-EMS Agency and the STEMI Receiving Center. What is the EMS Agency role in outcome information? The EMS QI coordinator acts as a communication facilitator for all parties in the STEMI system. CQI coordinators are encouraged to copy the EMS QI Coordinator on all communications regarding STEMI follow-up. The EMS Agency is also responsible for collecting and analyzing performance measures and outcome data for the STEMI system. This requires each STEMI Receiving Center Coordinator to complete a STEMI Report within 10 working days of a STEMI event. This information is then compiled as part of the STEMI system

database and is used for process improvement and STEMI system performance measurement. What if I have difficulties getting a response from another CQI coordinator on a STEMI outcome or issue? If you have not been successful with getting information within a reasonable period of time you are to inform the EMS QI coordinator who will assist the parties involved. How does follow-up on STEMI care issues get done, e.g. 12 lead not done, STEMI Alert not called, false positive? The party identifying the STEMI issue should do appropriate fact-finding and constructively share that information with the appropriate CQI coordinator of the other agency. The CQI coordinator receiving the information will then review the case, identify appropriate corrective actions and communicate the follow-up to the STEMI receiving center. How do STEMI care issues and follow-up get documented? Fire-EMS CQI coordinators are to log all STEMI care issues that are brought to their attention into the EMS event reporting database or on a EMS event QI review form. This data or form is then to be shared with the EMS QI coordinator. STEMI Receiving Center CQI coordinators are responsible for documenting STEMI care issues on the STEMI Report form, which is then sent to the EMS QI coordinator within 10 working days. Why do we need to document our CQI follow-up of STEMI care issues? Documentation of STEMI care issues provides valuable information for effective problem solving and identification of system wide issues that may not be picked up through a simple case review process. Trends and themes can be identified. Documentation also serves to support accountability within our STEMI system. How do we capture and recognition exemplary care in our system? Prehospital providers performance recognition is an important part of the CQI coordinator role. All prehospital personnel involved in a “textbook” (doing everything correctly) STEMI calls should be recognized for exemplary care regardless of the outcome to the patient. In addition STEMI receiving centers CQI coordinators will also be actively involved in the recognition process, sharing door-to-intervention times. How do we deal with false positive 12 leads? Even under perfect circumstances the false positive rates can be as high as 15-20%. Factors involved include the limitations of current prehospital 12 lead diagnostic technology and patient factors such as rapid heart rates and pacers. In the event that a 12 lead is found to be a false positive, appropriate fact-finding and feedback to the prehospital provider should occur recognizing these limitations. If the false positive is due to factors beyond the medics control and they have met all other performance measures e.g. STEMI alert called, 12 lead states ***ACUTE MI***, then they are to be praised for doing the right thing in our system. If there is corrective feedback to be shared with the medic then that should be done with a “lessons learned” approach.

Who gives feedback to the medics involved in the care of the STEMI patient? There are many opportunities to give feedback (positive and corrective) within our STEMI system. Feedback is most effective when given in a timely, constructive manner focused on positive corrections when appropriate. The Fire-EMS CQI coordinator should be informed of any corrective feedback given on patient arrival by the STEMI Receiving Center. The Fire-EMS CQI coordinator is responsible for the development of any remediation or corrective actions plans. Outcome information about a STEMI case should be obtained by the Fire-EMS CQI coordinator and relayed to the prehospital providers involved.

STEMIPATIENT

STEMI ISSUE

EMS PROVIDER ISSUE FOLLOWUP

STEMI DATA

EMS PROVIDER QI COORDINATOR

STEMI CENTER RN PROGRAM

MANAGER

EMS EVENT REPORTING

SYSTEM

STEMI CENTERINTERVENTION

REPORT STEMI CENTER ISSUE FOLLOWUP

EMS QI COMMITTEE

Monthly

STEMI QI COMMITTEE

Quarterly

STEMI SYSTEM ISSUE RESOLUTION PATHWAY

EMS QI/STEMI COORDINATOR

Fact

finding

Fact finding

Draft 5.7.08 EMS QI

Emergency Medical Services

Questions? Contact Pat Frost EMS QI Coordinator at [email protected] or 925-313-9554

mailto:[email protected]


Services


Contacts

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F:\EMS Files\Joint Projects\STEMI\STEMI QI Coordinator File\STEMI QI Contacts.doc 7/22/2009

Contra Costa Emergency Medical Services STEMI System CQI Contacts

Organization Lead ** Contacts E-mail

Contra Costa EMS

Joe Barger, MD EMS Medical Director Pat Frost RN, MS, PNP** Assistant Director EMS/STEMI Project Mgr

[email protected] [email protected]

AMR Karen Hamilton, RN** Clinical Education Specialist Monica Teves EMT-P Clinical Education Specialist


San Ramon Valley Fire Andy Swartzell, RN** EMS/QI Coordinator Chris Eberle EMT-P EMS Specialist


Moraga-Orinda Fire Nancy Daniel, RN** QI Coordinator [email protected]

Contra Costa County Fire

Keith Cormier EMT-P EMS Chief Greg Kennedy RN** EMS QI Coordinator Jeanne Mills RN, MICN** EMS QI Coordinator

[email protected] [email protected] [email protected]

Pinole Fire Greg Sekera, EMT-P, RN** EMS QI Coordinator

[email protected]

Rodeo-Hercules Fire Chuck Coleman** RHF EMS QI Coordinator Pam Dodson, RN EMS Prehospital Care Coordinator


Doctors San Pablo Sharri Steiret** Cath Lab Nurse STEMI Program Manager Patrick Evanelgista ED Clinical Director


JMMC- Walnut Creek JMMC-Concord

Pam Lavering RN** Chest Pain Center Coordinator STEMI Program Manager

[email protected]

Kaiser-Walnut Creek Dennis Patrick RN Cardiac Cath Lab STEMI Liasion Chip Longley RN** Nursing Project Coordinator Kathleen Trost RN Perioperative Services Director STEMI Program Manager

[email protected]. [email protected] [email protected]

San Ramon Regional Medical Center

Lisa Nichols RN** Director Cardiac Services STEMI Program Manager

[email protected]

Sutter Delta Medical Center

Earlene Xaveri RN** STEMI Program Coordinator Jeff Retherford Asst Manager, Cardiovascular Lab


** Indicate Lead(s) CQI contact for that agency- communicate STEMI outcome and follow-up through those individual(s). Please send corrections or changes to Pat Frost at [email protected]

















mailto:[email protected]_








Services


STEMI Center Criteria

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21

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Con

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A. C

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pas

t 3 y

ears

will

be

eval

uate

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A

nnua

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tal v

olum

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ases

and

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ary

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ases

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005-

2007

by

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Is

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ume

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2007

at

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ts m

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ased

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. Pr

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repo

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Y

N

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tion

A

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CA

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D

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<90

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Services


STEMI Meeting Materials

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jlatteri

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Services


STEMI EMS Reporting

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EMS Event Provider Actions

Assure patient safetyComplete report form

Deliver report to supervisor

Provider Agency QI Actions

Accept ReportBegin Fact Finding

Determine Nature of EventDetermine Significance of Event

Internal review with consulting partiesDetermine actions required

Implement action planEnter Data for Agency Analysis

Blinded aggregate data to EMS Agencyat agreed intervals

EMS Agency QI ActionsIntake appropriate events for follow-upand/or refer to appropriate agencies for

internal follow-upIf notification only event determine

follow-up actionsFacilitate event interagency event reviewConduct independent review as needed

Determine appropriate actionsCollect data and analyze patient safety

aggregate data

Determine notification

1798.200 Health and Safety Code or EMS Agency notification criteria met?If yes: EMS Agency report made.

1798.200 criteria requires review by provider agency QI processes.

EMS Event Data

Analysis

Provider Agency QI EMS Agency QIIdentify develop and implement

patient safety initiatives designed to benefit EMS system

Contra Costa Emergency Medical ServicesEMS Event Reporting

9/7/07

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C:\Documents and Settings\pfrost\Desktop\EMS event report form.doc

CONTRA COSTA COUNTY EMS EVENT REPORT FORM

Reporting is encouraged by all who encounter an actual or “potential” patient care safety event or recognize exemplary care in the field. These events may be related to systems, operations, devices, equipment, medication or any aspect of patient care and include “great catches” defined as patient safety events that are recognized and prevented before they actually occur. Instructions: 1. Assure patient safety. Inform medical personnel caring for patient as needed.

2. Provide a concise description of the event. 3. Supervisors complete a brief summary of findings and disposition of the event 4. Submit completed form to the QI coordinator.

Patient Name:_______________________ Age______ Incident/PCR#:________________________________ Event Date: ________________ Time: ___________ Location: ___________________________________ Initiated by: (name) ___________________________ Title: _________________ Agency: _____________ Contact Info: _________________________________ Receiving Facility: _____________________________ Other Agency(s) Involved: ___________________ __________________________________________

Other(s) involved (include name, title & agency): ____________________________________________ ____________________________________________ ____________________________________________ _____________________________________________ Witness(es): (persons familiar with incident, include: name, title, department, relationship) __________________________________________ __________________________________________ __________________________________________

Details of Event: (provide facts, observations, and direct statements. (Use addendum if needed) _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ _______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ See addendum Immediate efforts to resolve this issue: _____________________________________________________________ N/A Recommendations to prevent situation in the future: __________________________________________________________ __________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ **********************************************************************************************************************************************************

Could this event cause a community concern or represent a threat to public health and safety? No Yes If yes, contact your supervisor and/or agency QI coordinator ASAP Supervisor Name:_____________________________________________________ Date/Time contacted: _______________ Meets criteria for EMS Agency notification No Yes (If yes contact EMS Agency promptly) EMS notified: Date/ time/individual notified: _________________________________________________________________ Supervisor findings and comments: ______________________________________________________________________________________________________ Submit report to QI Coordinator Report completed by/signature: ______________________________ Date: _______________ PCR attached

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C:\Documents and Settings\pfrost\Desktop\EMS event report form.doc

EMS Event Form Instructions

This form is to be completed for every reported EMS event. o This information should originate from the provider involved and may be submitted

anonymously o Assure that the notification process described in Policy #32 has been followed. o Provide a concise description of the event. o Individuals receiving the report should complete a brief summary of findings and disposition of

the event and submit to the appropriate QI personnel. o Events that need follow-up should be conducted in coordination with QI personnel. o Oversight for the EMS event reporting process is the responsibility of each agency’s QI

coordinator in conjunction with the Contra Costa County Quality Improvement Committee and EMS Agency QI Coordinator.

In reviewing the event consider the following questions

o What are the facts of the events? Be objective. o What factors lead up to or contributed to the event? o What consequences resulted from the event? o Could the event been prevented? How? o What can be learned from the event? o What required actions need to be taken?

EMS Event Criteria requiring Local EMS Agency notification:

o Any EMS event that leads to or has the potential to cause a community concern. o Threat to public health and safety (as defined by the Health and Safety Code 1798.200)

Any of the following actions • Fraud in the procurement of any certificate or license under this division • Gross negligence • Repeated negligent acts • Incompetence • The commission of any fraudulent, dishonest or corrupt act related to the qualification,

functions and duties of prehospital personnel • Conviction of any crime which is substantially related to qualification, functions and

duties of prehospital personnel • Violating or attempting to violate directly or indirectly, or assisting in or abetting the

violation of or conspiring to violate, any provision of this division or regulations adopted by the authority pertaining to prehospital personnel.

• Violating or attempting to violate federal or state statute or regulation which regulates narcotics, dangerous drugs or controlled substances

• Addiction to the excessive use of or misuse of alcohol beverages, narcotics dangerous drugs or controlled substances

• Functioning outside the supervision of medical control in the field care system operating at the local level, except as authorized by any other license or certification

• Demonstration of irrational behavior or occurrence of a physical disability to the extent that a reasonable and prudent person would have reasonable cause to believe that the ability to perform the duties normally expected may be impaired.

• Unprofessional conduct exhibited by any of the following o Mistreatment or physical abuse of any patient resulting from force in excess of

what a reasonable and prudent person trained and acting in a similar capacity while engaged in the performance of their duties would use.

o Failure to maintain confidentiality of patient medical information except as permitted by law Section 56-56.6 of the Civil Code

o Commission of any sexually related offense under section 290 of the penal code.

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Contra Costa Emergency Medical Services

STEMI System Recognition Program

STEMI STARS! Introduction: “STEMI Stars” is Contra Costa Emergency Medical Services STEMI System Recognition Program. The purpose is to recognize exemplary performance in the care of STEMI patients within our STEMI System. This recognition program emphasizes the importance of teamwork within the system and individual contributions to that process. Who is Eligible? EMS Providers, ED personnel, STEMI Team members and other members of the health care team who demonstrate exemplary performance in the care of a STEMI patient event. What is Exemplary Performance? Exemplary performance is the correct, timely and efficient performance by individual(s), which contributes to effective STEMI Team management of the patient. This performance is not tied to patient survival. This is to recognize that in some cases there are aspects that are not in our control. Regardless of patient survival exemplary performance & outstanding effort should continue to be recognized. Who is able to identify Exemplary Performance? All members of the STEMI system team can identify individuals for exemplary performance. Nominations should go to the appropriate STEMI Program Coordinators of the STEMI Receiving Center or the EMS Provider Agency CQI Coordinators. A list of STEMI CQI Coordinators is available from EMS. Who is able to issue a STEMI Star Certificate? STEMI Receiving Center Program Coordinators and Fire-EMS CQI Coordinators may issue a STEMI Star Certificate based on the following criteria. The EMS Agency should be informed of the names of the individuals recognized for the purposes of acknowledging them at intervals in STEMI News. What is the STEMI Star EMS Provider Criteria?

Appropriate and timely STEMI activation and destination determination. 12 lead accurate within technology limits. Prehospital Chest Pain management appropriate for patient condition

o Oxygen, ASA, Nitro, MS, Erectile Dysfunction Medication (ERD) screening Handoff and ePCR documentation complete including 12 lead upload and patient

identifiers listed appropriately on 12 lead hardcopy.

It is appropriate for the entire EMS provider team including EMT’s to be recognized if all of the above criteria are met. Where do STEMI QI Coordinators get a STEMI Star Certificate? These are available from the EMS Agency. STEMI Center Provider Criteria: Each STEMI Center is encouraged to define it’s own criteria for recognition. It is recommended that the STEMI Center Coordinator facilitate this recognition program. STEMI Center Coordinators are welcome to use STEMI Star certificates and create other mechanisms to recognize staff e.g. pins, activities, etc.


Services


STEMI NEWS

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C o n t r a C o s t a E m e r g e n c y M e d i c a l S e r v i c e s

STEMI NEWS June 2009

Contra Costa STEMI System Performance 2009 Quarter 1 (January 1, 2009 to March 31, 2009)

Contra Costa Emergency Medical Services Agency www.cccems.org

Contra Costa STEMI Average Times 2009 Q1

Performance Benchmarks (minutes)

EMS* to Intervention (PCI) Time 75 minutes

National Benchmark < 90 minutes

EMS* Scene Time 12 minutes

Local EMS Performance Goal < 15 minutes

911 Call to Intervention (PCI) Time 83 minutes

National Benchmark < 120 minutes

First + STEMI 12 lead ECG to First PCI Time 71 minutes

EMS* = First Contact with EMS provider

The Contra Costa STEMI System

was launched

on 9/8/08

Team STEMI: CoCo STEMI System Stats Rock!!!!

On June 16th STEMI Center and Prehospital CQI Coordinators sat down to review our STEMI System Quarterly statistics. There is much to celebrate this quarter and at EMS we are blown away by the tremendous efforts of all parties who have collaborated to achieve these results. First responders, transport providers, emergency department and cardiac catheterization personnel working 24/7 to provide an outstanding level of care to Contra Costa. Examples include a recent door intervention time of 21 minutes with pass thru ED (direct to cath lab) process improvement. Several cardiac arrest patients have gone to intervention from the field with excellent outcomes. Fire first responders are improving their 12 lead accuracy to alert facilities prior to transport arrival, giving our STEMI Centers even more time to “ramp up” in order to speed patients to life-saving intervention when they arrive. Corrective feedback to our prehospital providers about patient outcomes is helping improve field decision-making. Kudos to those ED physicians and cardiologists who are taking advantage of “teachable moments” at the time of patient arrival to help our prehospital providers when false activations or confusing clinical presentations occur. It takes a village of dedicated STEMI System Champions to make this all happen. Overall STEMI System Performance Measures such as “911 to Intervention” improved 14 minutes with 100% of patients meeting less than 90 minute door to intervention national benchmark. In addition our quarterly data revealed that Contra Costa prehospital diagnostic 12 lead to intervention times were less than 90 minutes 93% of the time. What that means is that our STEMI system is functioning at a level of excellence that is extraordinary! We could not do this without tremendous teamwork among all our STEMI partners. Even with this high level performance we still have work to do. Preventable prehospital false positives were attributed to artifact in 6 cases. That is why 12 lead accuracy continues to be a strong focus of prehospital STEMI System CQI. For more information about our Quarter 1, 2009 STEMI System performance go to www.cccems.org!

Contra Costa Emergency Medical Services Agency www.cccems.org

STEMI NEWS Case Study... First Responder Activation Many fire first responders have 12 lead capability. Check out this extraordinary effort of all involved! Situation: 71 year old male lying on ground with severe chest pain. Weight about 60 kg. First responder 12 lead ***Acute MI*** uniform PVCs < 6 minute. Background: Chest pain started unprovoked 30 minutes prior to first responder arrival. Medical history positive for glaucoma, no allergies, no medications. Assessment: HR 62 weak irregular, RR 20 labored, B/P 102/72, 97% sat. Pain scale patient unable to rate but states severe. Alert and oriented x4. RX: O2 non-rebreather 15 liters, IV access, ASA 325 mg/po and Nitro 0.4 mg x2, MS x1. STEMI Center activation and transport. Prehospital progression: During transport pain improves now called moderate. VS stable. Feeling nauseated. STEMI Center: ED crew ready on arrival. Patient suddenly arrests during patient handoff. Code called. Patient to cardiac catheterization lab with resuscitation in progress. Outcome: Patient discharged home! STEMI Case Statistics • 18 minute scene time • 14 minute transport time • 32 minute first EMS provider contact to ED time • 28 minute first + STEMI ECG to ED time • 50 minute door to intervention • 78 minute first + STEMI ECG 12 lead to intervention • 82 minute EMS patient contact to intervention

This case is an extraordinary example of how minutes make the difference in complicated STEMI patients. Outstanding teamwork from beginning to end!

Public Education

Starts With Us!

The national goal is to increase the number of

STEMI patients using 911 versus walking or driving in. Over 50% of STEMI patients transport themselves to the hospital and statistically we know that these actions impact patient care adversely. Contra Costa EMS has made the National Institute of Health (NIH) best practice pa-tient education program “Act in Time” with its excellent patient educational materials available on our website. The materials are free and can be duplicated for health fairs, clinics, physician offices or just personal use. We encourage you to download these materials and let your friends and family know that if chest pain occurs….Act in Time by calling 911.

STEP I

• Check your own performance • Self review • Peer review • ED feedback

STEP II

• Review procedures. • Get help from your trainers. • Youtube.com: review Tim Phelan’s outstanding 12 lead clips.

STEP III

• Find a peer expert. • Seek out “lessons learned”. • Screen 12 leads for artifact and repeat as needed.

STEP IV

• Practice skin prep! • Practice lead placement! • Control for patient movement!

Contra Costa STEMI System Top Prehospital Improvement Goal!

Get Rid of Artifact!

The Timeline

911 call

1755

Fire at patient 1758

First 12

lead ECG + STEMI 1802

STEMI ALERT

1805

Transport arrives 1810

Patient en route to ED

1816

EMS/pt arrival ED

1830

Patient Arrests in ED during handoff

1831

Patient to Cath Lab CPR in

progress

First PCI 1920

85 minute 911 Call to Intervention!


Services


STEMI Data

jlatteri

41

STEMI Activation Data

Prehospital ePCR & 12 Lead Data

STEMI Receiving

Center Data

EMS STEMI Data Collation

Case Review

Quarterly STEMI Advisory

Data Review

EMS Provider QI Case Issue Resolution

STEMI Center QI

Case Issue Resolution

STEMI System Evaluation

EMS System

Evaluation (QI)

Contra Costa EMS STEMI QI Workflow

Total Ischemic Time Within 120 minutes

Patient5 min after

symptom onset

Dispatch1 min

EMS on scenewithin 8 minutes

EMS TransportEMS to Balloon within 90 Minutes

HospitalDoor to Needle within 30 minutes

jlatteri

42

Contra Costa Emergency Medical Services 1340 Arnold Drive, Suite 126 Martinez, CA 94553 Phone: 925 646-4690 Fax: 925 313-8389 (confidential fax)

ST ~ Segment Elevation Myocardial Infarction (STEMI) Report

Complete for all: 1. “STEMI Alert” EMS activations 2. EMS transported STEMI patients identified by STEMI Center & not identified as a STEMI by EMS in the

field. (Do not include inter-facility transfers)

Identifying Information Hospital: Patient Name: MR #: PCR#: Gender: M F Age: EMS Transport Provider: AMR San Ramon Valley Fire Moraga-Orinda Fire EMS Agency(s) Preforming 12-lead(s): AMR San Ramon Valley Fire Moraga-Orinda Fire Contra Costa Fire Pinole Fire Rodeo-Hercules Fire Clinical Information ED arrival date: ED arrival time: Field STEMI Alert called in: Yes No Field ECG STEMI confirmed by MD: Yes No Prehospital 12 lead (s) done: Yes No ECG repeated at Hospital: Yes No Patient to Cath Lab: Yes No PCI performed: Yes No First PCI Time: If PCI not done at cath patient disposition

_____ No treatable lesion found _____ Patient expired _____ Patient to OR _____ Other:

Patient met exclusion criteria: Yes No **Exclusion Criteria:

Thrombolytics administered: Yes No Time of thrombolytics if given: EMS Issues/ Case Comments:

Person Completing Form: Date sent to Contra Costa EMS: **Exclusion Criteria include: Cardiopulmonary arrest: Cardiac Arrest, CPR, Code, Defibrillation, ET intubation Respiratory arrest, V-fib; CT scan to r/o bleed; TEE to r/o dissection and Need to control HTN or hypotension, Patient refusal and comfort care. INSTRUCTIONS: Send completed form to CCEMS via confidential fax within 10 days: (925) 313-8389 Keep a copy for your records See e-mail contact on back if CQI communication with CCEMS or EMS providers is desired.PFrost Page 1 2/23/2009

PFrost Page 2 2/23/2009

STEMI CQI Provider Agency & STEMI Center Contacts

Organization

CQI Lead** Contacts

E-mail

Pat Frost RN, MS, PNP** EMS QI Coordinator [email protected] Costa EMS

Joe Barger, MD EMS Medical Director [email protected]

AMR

Karen Hamilton, RN** Clinical Education Specialist Paul Harper EMT-P Clinical Education Specialist Monica Teves Clinical Education Specialist

[email protected] [email protected] [email protected]

San Ramon Valley Fire Andy Swartzell, RN** QI Coordinator [email protected]

Moraga-Orinda Fire Nancy Daniel, RN** QI Coordinator [email protected]

Contra Costa County Fire

Keith Cormier EMT-P EMS Chief Jeanne Mills RN,** QI Coordinator Greg Kennedy RN,**QI Coordinator

[email protected]@[email protected]

Pinole Fire Greg Sekera, EMT-P, RN** Pinole EMS QI Coordinator

[email protected]

Rodeo-Hercules Fire Chuck Coleman EMT-P** RHF EMS QI Coordinator Pam Dodson, RN EMS Prehospital Care Coordinator


Doctors San Pablo Sharri Steiert** Cath Lab Director STEMI Program Manager

[email protected]

JMMC- Walnut Creek JMMC-Concord

Pam Lavering RN** Chest Pain Center Coordinator STEMI Program Manager

[email protected]

Kaiser-Walnut Creek Kathleen Trost RN** Perioperative Services Director STEMI Program Manager Jacqueline R. Manila , CRT, ARRT Systems Administrator Interventional Services


San Ramon Regional Medical Center

Lisa Nichols** Director Cardiac Services STEMI Program Manager

[email protected]

** Indicates CQI leads for that agency/STEMI center. Notes: CQI leads are requested to designate a CQI alternate & inform STEMI CQI

participants when the lead CQI coordinator is not available. Contact EMS if additional CQI support required. Effective feedback is timely, clear and constructive.

Send CQI contact updates to Pat Frost EMS QI at [email protected]




















Contra Costa Emergency

Medical Services

Required Quarterly Data Elements for STEMI Receiving Centers

General Information: Each data element is defined below. Use these reporting indicators as defined to report your STEMI Center Program quarterly data. STEMI Centers are to report data on all qualifying patients and are not required to “break out” prehospital cases. Performance monitoring of the EMS system and Prehospital response will be compiled by the EMS agency. Data elements described below in parentheses e.g. CE812, come from the NCDR Cath PCI Registry and correspond to the core element (CE) field number. Refer to ACC data definition dictionary core element field number for more details at www.ncdr.com. Definition of a PCI procedure includes unsuccessful PCI’s that were attempted beginning with guidewire attempt. These are not coded or billed as a PCI unless an intracoronary device enters the body, but the NCDR considers an “attempted” guidewire crossing, even if unsuccessful, a PCI procedure.

I. DOOR –TO-INTERVENTION

Revised NCDR definition as of August 2007: The algorithm for ST Onset to Balloon/Stent Deployment now includes patients with any admission status who are receiving Primary PCI for STEMI. The algorithm will continue to exclude transfers. The former algorithm for calculating Door-to-Balloon Time [DBT] included only those cardiac patients who arrived via the Emergency Department to receive Primary PCI for treatment of a STEMI. The revised algorithm will include any patient [cardiac or non-cardiac] who is already hospitalized and requires primary PCI to treat a STEMI. A. PCI Interval Definition: Interval from time of arrival at primary hospital (CE 814) to balloon inflation

(or intracoronary treatment device (IC) if balloon is not first device used) (CE816) Goal: 90 minutes (reported as median) B. Percent < 90 minutes

Definition: Percentage of PCI intervals with time <90 minutes. Proportion of STEMI Patients with (D2IC) IC=Intracoronary Device < 90 Minutes.

This document was adapted from “Alameda County EMS Quarterly Data Elements for Cardiac Centers” with permission. Created on 5/14/2009 2:05 PM

http://www.ncdr.com/


Measure Specifications Source: NCDR Numerator PCI patients with PCI indication of “Acute PCI” – Primary PCI for

STEMI (CE812) and Door to balloon time is <-90 minutes Door to balloon time represents the date/time difference between “Arrival Date/Time” (CE814) and “Reperfusion Date/Time. (CE816)”

Denominator PCI Procedures with PCI indication of Acute PCI-Primary PCI for STEMI (CE 812).

Inclusion Criteria Admission Sx Presentation (CE 550) = ACS – ST Elevation MI STEMI; (See revised definition above “The revised algorithm will include any patient [cardiac or non-cardiac] who is already hospitalized and requires primary PCI to treat a STEMI. )

Exclusion Criteria Null Dates/times; Date/time difference between “Arrival Date” and “Reperfusion Date” < or = 0 Transfer Patients treated for STEMI

Clinical Rationale Recommendation

Time to intervention is a critical and well-established determinant of patient outcome for patients with STEMI. Hospital policies and procedures materially affect door-to-door balloon time. This measure is insensitive to differences in case mix. 2005 ACC/AHA Guidelines for the Management of Patients With ST Elevation MI recommends:“Primary PCI should be performed as quickly as possible with a goal of a medical contact to balloon or door-to-balloon interval of within 90 minutes”.

II. STEMI & TOTAL PCI MORTALITY

A. STEMI MortalityDefinition: Actual PCI mortality rate (percentage) for all STEMI patients who received PCI to hospital discharge. Admit Status = Outpatient Referral or ED (CE 320).

STEMI Mortality Measure Specifications Source: NCDR Numerator Number of pts classified as stemi who had a discharge status = Dead

expired (CE 1152) Denominator Primary PCI for STEMI (CE 812) Inclusion Criteria Data submission that passed the inclusion threshold

B. Actual PCI Mortality Rate: Definition : Actual PCI Mortality rate (percentage) for all PCI patients to hospital discharge

Actual PCI Mortality Measure Specifications Source: NCDR Numerator Total PCI patients who expired/dead (CE 1152) Denominator Total number of PCI patients (CE 614) Inclusion Criteria Data submission that passed the inclusion threshold


C. Risk Adjusted PCI Mortality:

Definition: Risk adjusted mortality rate (percentage) for all PCI patients to hospital discharge – NCDR does not define STEMI mortality separate from PCI mortality. NOTE: If you have 0 deaths in a quarter, you will not have RAM calculated for that quarter.

Risk Adjusted PCI Mortality (RAM) Measure Specifications Source: NCDR Numerator PCI admissions who expired Denominator PCI admissions Inclusion Criteria Data submission that passed the inclusion threshold Clinical Rationale/ Recommendation

Although death in patients with serious heart disease is not completely unexpected, that rate (adjusted for case mix/patient risk factors) is sensitive to a number of controllable factors such as case selection, procedural judgment and operator skill, as well as institutional support and overall quality of care. The ACC-NCDR risk adjustment model analyzes multiple elements to account for patient risk factors that are present prior to PCI. Risk adjustment “levels the playing field” among participating institutions and adjusts the “actual” mortality rate based on these factors In other words if you have several very sick patients die your risk adjusted mortality rate would be lower than your actual mortality rate. If you had several very healthy patients die unexpectedly your risk adjusted mortality rate would be higher than your actual mortality rate.

III. COMPLICATIONS IN STEMI PATIENTS

A. Procedural Success Definition: Percentage of STEMI patients in whom PCI’s were performed who had no

complications (Complication definition from NCDR: death, new myocardial infarction, or emergent or salvage CABG) Note, the ACC-NCDR considers a procedure a PCI when attempting to cross a lesion with a guidewire , even when unsuccessful.

Procedural Success Measure Specifications Source: NCDR Numerator Number of patients who experienced stented lesions with post

procedure stenosis <=20% and non-stented lesions with post procedure stenosis of <50% and at least a 20% reduction in pre-to-post stenosis diameter.

Denominator Total # PCI procedures in STEMI patients Inclusion Criteria Total number of PCI procedures that were treated due to STEMI Exclusion Criteria STEMI PCI Patients who experienced emergency/salvage CABG,

periprocedural MI, and/or death during hospitalization Clinical Rationale/ Recommendation

ACC/AHA Guidelines for PCI (2005) description of Angiographic Success: “A successful PCI should achieve angiographic success without major clinical complications (e.g., death, MI, emergency coronary artery bypass surgery) during hospitalization.


B. PCI Vascular Complications Definition: All STEMI patients with PCI who had any vascular complications (Access site occlusion, peripheral embolism, dissection, pseudo aneurysm, AV fistula). Incidence of Vascular Complications (PCI Quality Measure)

Measure Specifications Source: NCDR Numerator Any vascular complication coded as yes in STEMI patients

Denominator Total # PCI procedures in STEMI patients

Inclusion Criteria Vascular/Bleeding complications: bleeding at the percutaneous

entry site, (CE1085) retroperitoneal bleeding (CE1086); GI bleeding (CE1087), GU bleeding (CE 1088), bleeding other unknown (CE 1089) access site occlusion (CE 1092); peripheral embolization (CE 1094); dissection (CE 1096) pseudoaneurysm (CE 1097); AV fistula. (CE 1099)

Clinical Rationale/ Recommendation

Vascular complications can cause significant discomfort and disability for patients. While rates of complication will be sensitive to patients characteristics (and therefore case mix), there is evidence that hospitals can significantly influence overall complication rates. This can be accomplished through monitoring and analyzing the causes of complications, developing policies and procedures that minimize the risk of complications, and developing policies that assure operator and cath team competency.

IV. MI MEDICATIONS (Source: NCDR CE 350 & CE 352)

A. ASA Upon Arrival within 24 hours Definition: All Patients with MI who received ASA within 24 hours of admission

(percentage) Goal: 95% B. Beta Blockers on Arrival within 24 hours

Definition: All Patients with MI who received beta blockers within 24 hours of admission (percentage) Goal: 90%

C. ASA on Discharge Definition: Percentage of all MI patients who received ASA on discharge from hospital. Goal: 95% D. Beta Blockers on Discharge Definition: Percentage of all MI patients who received beta blockers on discharge from

hospital. Goal: 90% E. ACE Inhibitor or ARB on Discharge (Source: Joint Commission Core Measure) Definition: Percentage of all MI patients with an ejection fraction of <40% who received

either an ACE inhibitor or angiotensin receptor blocker on discharge from hospital Goal: 85%


V. Cardiac cath and PCI performance for ALL STEMI patients (“n”)

A. How many had immediate cardiac catheterization, “c”? (reported as c/n and percent)

B. How many had subsequent, immediate PCI, “p”? (reported as p/c and percent)

C. Of the patients who had a cardiac cath but did not have PCI (c-p), what was the reason? (noncritical CAD without a “culprit” lesion)

1. No treatable lesion found (number) 2. Patient expired (number) 3. Patient to OR (number) 4. Other e.g. spasm (number)

VI. Cardiac catheterization (and PCI) NOT performed for STEMI patients (n-c)

A. Why was cardiac cath not performed? 1) Cath lab access (closed or unavailable) (number) 2) Inaccurate/confusing EKG interpretation or clinical (number) scenario 3) Patient/family refusal (number) 4) Patient contraindication (comorbidity; allergy, renal failure) (number) 5) DNR Status 6) Other

VII. RATIONALE AND PROCEDURE

A. STEMI Centers shall submit data on quarterly basis utilizing data from NCDR and Joint Commission Core Measures.

B. As of March 2009 Contra Costa STEMI System will accept preliminary non-risk adjusted data from the NCDR for STEMI Center Quarterly reports. Access to NCDR risk adjustment does not currently support timely inclusion in quarterly reports.

C. Risk Adjusted Quarterly reports should be submitted as soon as this information is available. If preliminary data is reported this is to be noted by the STEMI Center Coordinator and corrected as soon as risk-adjusted data by NCDR is available.

D. Only aggregate data need be submitted.

E. All data will be kept confidential and blinded.

F. All data are subject to confidential privileged discussion at STEMI System Quality Improvement Meetings.

G. Data will be utilized to monitor and improve care provided to Contra Costa County EMS patients in conjunction with STEMI System Quality Improvement members and their constituency groups.


Contra Costa STEMI Center Quarterly Report

STEMI Center Name: Date submitted: Prepared by: Quarter: EMS Data point

NCDR Core element

(CE)

Numbers & Percent should reflect all qualifying patients seen by STEMI Center

(* Risk Adjusted Data is to be submitted when available)

STEMI Center Results

Risk Adjusted

Data*

IA Door-to-Intervention Interval (Report Median) Minutes 90 is Standard (Report Interval/# patients)

IB CE 814 /CE 816

Percentage of Door-to-Intervention Intervals ≤ 90 minutes (Report #patients/total patients)

IIA CE 1152/CE 812 STEMI Mortality (actual) IIB CE 1152/CE614 PCI Mortality (actual) IIC Risk Adjusted PCI Mortality- when available IIIA Procedural Success IIIB CE 1085 –

CE 1099 Vascular Complications

IVA CE350 & CE 352 ASA Upon Arrival Within 24 Hours IVB CE350 & CE 352 Beta Blockers Upon Arrival Within 24 Hours IVC CE350 & CE 352 ASA on Discharge IVD CE350 & CE 352 Beta Blockers On Discharge IVE

Joint Comission Core Measure

ACE Inhibitors or ARB in Patients With EF <40% on Discharge

VA Patient STEMI reports

Of all STEMI patients (sec. IIA), How many had immediate catherization? (% and number)

VB Patient STEMI reports

Of all STEMI patients who had cath, (VA) how many had PCI? (% and number)

VC Patient STEMI reports

Of all STEMI patients who had cath, how many did not have PCI?

1 2 3

VC 1-4

Of above patients in VC what was the reason for not performing PCI? Give number of patients. 1- No treatable lesion found (#) 2- Patient expired (#) 3- Patient to OR (#) 4- Other e.g. spasm (#) 4

1 2 3 4 5

VIA 1-6

For all STEMI patients (sec IIA) in whom cath was NOT performed, what was the reason? (indicate number of pts fitting each category) 1- Cath lab access 2- Cardiac arrest, CPR, Defibrillation, ET intubation, Resp arrest, V fib, defibrillation 3- Patient/family refusal and comfort care 4- Patient contraindication: CT scan to r/o bleed, TEE to r/o dissection, need to control HTN/hypotension 5- DNR status 6- Other

6

Roman numerals and numbers refer to “Required Quarterly Data Elements for STEMI Centers.” This document is available from Contra Costa EMS at www.cccems.org under the STEMI webtab.

Fax this quarterly report to Contra Costa STEMI Project Manager at 925 313-8389 quarterly Q1 due June 1st Q2 due Sept 1st Q3 due Dec 1st and Q4 due Mar 1st annually

http://www.cccems.org/

POLICY #: 25


PAGE: 11 of 33

EFFECTIVE: 8/17/09

STEMI TRIAGE AND DESTINATION REVIEWED: 8/17/09

I. PURPOSE

Utilizing prehospital 12-lead electrocardiograms (P12ECG), patients presenting with ST-segment elevation myocardial infarction (STEMI) shall be triaged and transported, with patient consent, directly to STEMI centers for rapid intervention. This policy outlines the process of triage and transport of STEMI patients.

II. DEFINITIONS Prehospital 12-lead ECG (P12ECG): A 12-lead electrocardiogram obtained by EMS crews or in rare circumstances by a medical facility or office other than a hospital. ST-Segment Elevation Myocardial Infarction (STEMI): A specific finding on P12ECG showing ST-segment elevation of 1 mm or greater in anatomically contiguous leads, indicating this specific type of myocardial infarction. Computer Interpretation of STEMI: With printout of P12ECG done, a patient with a STEMI is identified distinctly with ***Acute MI*** or ***Acute MI Suspected*** by a computerized algorithm present in the monitor-defibrillator unit (wording varies by manufacturer). Other abnormalities of P12 ECG do not signify STEMI. STEMI Receiving Center (SRC): Hospitals designated by Contra Costa EMS as those to which patients with identified STEMI on P12ECG will be transported based on the center’s prompt availability of invasive cardiac care. STEMI Alert: Report from prehospital personnel that notifies a STEMI Receiving Center as early as possible that a patient has a computer-interpreted P12ECG indicating a STEMI. The alert allows the SRC to prepare equipment and personnel for arrival of the patient in order to provide intervention in the most rapid fashion possible.

III. TRIAGE A. Patients with chest pain or other symptoms suggestive of Acute Coronary Syndrome (ACS)

should have a P12ECG performed. 1. Exceptions include patients who are not cooperative with the procedure, or patients in

whom the need for critical resuscitative measures preclude performance of the P12ECG. 2. Paramedic personnel should review the P12ECG tracing in all instances to assure that

little or no artifact exists (steady baseline, lack of other electrical interference, complete complexes present in all 12 leads). Repeat P12ECG may be necessary to obtain an accurate tracing.

B. If computerized interpretation of accurately performed P12ECG indicates either ***Acute MI*** or ***Acute MI Suspected***, the patient qualifies as a candidate for transport to a STEMI Receiving Center. Patients without these findings should be transported per the EMS “Patient Destination Determination” policy.

IV. DESTINATION

A. Patients with an identified STEMI shall be transported to a STEMI Receiving Center (SRC).

1. Patients shall be transported to the closest SRC unless they request another facility. 2. A SRC that is not the closest SRC facility is an acceptable destination if estimated

additional transport time does not exceed 15 minutes.

POLICY #: 25


PAGE: 22 of 33

B. Patients with cardiac arrest who have a STEMI identified by 12-lead ECG before or after arrest shall be transported to the closest SRC.

C. Patients with unmanageable airway en route shall be transported to the closest basic

emergency department

V. STEMI ALERT/PATIENT REPORT A. In patients with identified STEMI, desired destination shall be promptly determined after the P12

ECG is completed and read, and that hospital shall be contracted as soon as possible after destination determined.

B. The STEMI Alert should contain the following essential information: 1. Situation: a. Identify the call as a “STEMI Alert.” b. Give estimated time of arrival (ETA) in minutes. c. Patient age and gender. d. State ECG findings and any urgent concerns. 1) P12ECG shows ***Acute MI*** (ZOLL) or 2) P12ECG shows ***Acute MI Suspected*** (LP12). e. If patient elects to go to a facility that is not STEMI designated inform receiving

facility. 2. Background: a. Presenting/chief complaint and symptoms. b. Pertinent past cardiac history. c. Pacemaker placement. 3. Assessment: a. General impression. b. Pertinent vital signs and physical exam. c. Pain level. 4. Rx-Recap: a. Prehospital treatments given. b. Patient response to prehospital treatments. C. Emergency Room Patient handoff report should repeat STEMI Alert information and include: 1. Patient identification. 2. Presenting complaint. 3. Additional background information: a. Past medical history. b. Advanced directives if known. 4. Allergy and medication history including high risk medications. a. Anticoagulants b. Insulin c. Digoxin

POLICY #: 25


PAGE: 33 of 33

d. Erectile Dysfunction Drugs (ERDs) 5. Previous history of Coronary Artery Surgery or thrombolytic (clot busting) therapy. 6. Cardiologist if known.

VI. DOCUMENTATION A. A copy of the P12ECG (multiple if performed) shall be delivered to the nurse caring for the

patient at arrival in the Emergency Department. B. A copy of the P12ECG (multiple if performed) shall be generated for inclusion in the prehospital

Patient Care Record or incorporated via electronic means into the record. The finding of STEMI on P12ECG and confirmation of the STEMI Alert shall also be recorded in the Patient Care Record.

VII. LIST OF STEMI CENTERS

IN-COUNTY STEMI CENTERS OUT-OF-COUNTY STEMI CENTERS

Doctors Medical Center San Pablo ValleyCare - Pleasanton

John Muir Medical Center – Concord Campus Oakland Summit Medical Center

John Muir Medical Center – Walnut Creek Campus

Kaiser Permanente Medical Center– Walnut Creek

San Ramon Regional Medical Center – San Ramon

Sutter Delta Medical Center - Antioch