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,USA1Overview Introduction The Argument for Primary PCI Overview of the Henry Ford Program Program Specifics Proces
2、s Dictates Outcomes Alternative Opportunities2Acute MI:Introduction 1.1 million people yearly in the US*About 500,000 have STEMI 220,000 die from their AMI 50%of deaths in the first hour Outlook of hospitalized patients better*AHA:2001 Heart and stroke statistics3Acute MI:Early ManagementReperfusion
3、 Pharmacological(Thrombolysis)Fibrinolytics Antithrombins Platelet Inhibitors Mechanical(Direct/Primary PCI)Angioplasty Stent Thrombectomy Combined?Facilitated PCI4Acute MI:Direct PCIAdvantages Rapid assessment of anatomy and hemodynamics TIMI-3 flow rates 75-95%in infarct artery Low incidence of he
4、morrhagic stroke Can be done in patients with contraindications for thrombolysis Results superior to thrombolytics in randomized trials5Direct PTCA vs.ThrombolysisPAMI-1N Engl J Med 1993;328:673-6796Primary Angioplasty vs.Thrombolysis:Meta-analysisDeathp=0.02Death+MIp75 cases/year)Skilled lab(200 ca
5、ses/year)Surgical back up necessary11Is Time as Critical in Primary PCI?30-day mortalityTime from onset of CP to randomizationZijlstra,Eur Heart J 2002;23:55012ACC/AHA Recommendations for Direct PCI in AMI2004Class I General:Patients presenting within 12 hours;if performed in a timely fashion by ind
6、ividuals skilled in the procedure and supported by experienced personnel in high volume centers Specific:Door To Balloon Time 90 min 3hours symptom,PCI if treatment 1 hour Symptom 3 hours,PCI preferred 90min Within 36 hours of MI when patient develops cardiogenic shock,is 75 years and revascularizat
7、ion can be done within 18 hours of shock onset.12 hours of symptoms and severe CHF or pulmonary edema(2004)13Primary PCI in the United States Minority of US Hospitals Achieve a median Door to Balloon Time of 90 minutes or less Majority of MI occur during“Off Hours”(nights and weekends)Off Hour Prima
8、ry PCI is associated with increased door to balloon times and mortality Henry Ford 2002 Door to Balloon218 minutes Cath Lab to Balloon 60 minutes14Primary PCI PathwayAn Opportunity for Process ImprovementPatient Presentation to Diagnosis20 minPage Fellow,Fellow Responds10 minFellow Proceeds to ER15
9、minFellow Evaluates Patient 15 minFellow Pages CCU Staff,Staff Responds 10 min+PCI,Fellow Pages Int Staff,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 minutes15Proces
10、s Change Centralize Communications Focus Clinical Decision Making Transfer SEMI Patients Directly to Site of Therapy Establish Transport Pathways Unite CICU/Cath Lab Nursing Functions Improve Door to Balloon Times!16Door-To Balloon TimeHenry Ford Hospital Detroit17Door-To Balloon TimeHenry Ford Syst
11、em Wide200518Henry Ford Acute Myocardial Infarction Program 6 Emergency Rooms Henry Ford Hospital90,000 visits HF Wyandotte Hospital 72,000 HF Bicounty Hospital28,000 Fairlane ER47,000 West Bloomfield ER22,000 Sterling Heights ER21,000 Primary PCI Henry Ford Hospital Large Urban Teaching Hospital in
12、 Detroit1920Henry Ford ER Locations Henry Ford Owned(5)Partially Owned(3)HF Medical Center(24)20 m,33 min14 m,25 min9 m,24 min8 m,17 min12 m,26 min21Door-To Balloon TimeHenry Ford System Wide200522Improving Door to Balloon TimeHow Do You Change The Process?23Create A Multi Disciplinary TeamIdentify
13、Advocates Cath Lab Doctors,Nurses,Managers CCU Doctors,Nurses,Managers Emergency Room Doctors,Nurses Cardiologists Staff and Trainees Hospital Administration Ambulance Transport24Changing the Process Improve the Process to Meet the Science Dissect Complex Activities into Quantifiable Steps Team memb
14、ers help to redesign the processes in their areas Establish Parallel(not serial)Processes Avoid Duplication Example:IV Compatibility25Changing the Process Activation Simple 1 Phone Call-24 hours a day Staffed by Decision Maker(MD who accepts patient and activates team)Team Activation is Invisible to
15、 the Outside Coordinator then activates staff members,arranges admission,etc26Changing the Process Transport Activate transport(ambulance)as early as possible,usually before activating central team.Establish well known dispatch pathway Minimize emergency room time Communicate during transport27Chang
16、ing the Process Minimize Steps Patients Transported Directly to Cath Lab Business Hours-Easy Off Hours In House Nurses and MDs Staff Cath Lab while Cath Lab Staff Travel to Hospital Prep Room and Patient28Changing the Process Cath Lab Focused Pathway to Reperfusion 7 F Sheath Diagnostic Angiography
17、of non-IRV Guide Catheter for suspected IRV“Standard”initial PTCA Equipment Floppy Wire 2.0/2.5 mm Balloon Establish Reperfusion First,Optimize Result Later Remember the Team!Call the ER and let them know the results29Cath Lab TimesArrival to Balloon Inflation30HFH AMI Flow Chart31AMI Gann Chart32Ch
18、anging the Process Metrics Measure Your Lean Processes Door to EKG EKG to Activation Transport Cath Lab Activation to Ambulance Arrival“Pick Up Time”Ambulance arrival to departure Transport Time ER departure to cath lab arrival Cath Prep TimeCath arrival to arterial access Procedure TimeArterial acc
19、ess to balloon or reperfusion33Changing the Process Feedback Share Outcomes and Pertinent Metrics with Participants Constructive Criticism is the Only Way to Improve the Process Success Begets Success Foster Participant Pride and Enthusiasm34Alternative Strategies and Next Steps Remote 12 lead EKG E
20、KG in Ambulance Transmit EKG from field Activate Cath Lab field Disseminate Primary PTCA Centers Offsite Surgical Back Up Centralize MI Centers Practice Makes Perfect Staff Lab 24/735HFHS Initiatives Improve Door to EKG Time Improve Transport Times New ambulance Structure Activation to Arrival“PickU
21、p”Times Improve Cath Lab Response Times Remote EKG In Field 12 lead EKG with telephonic transmission36p 经常不断地学习,你就什么都知道。你知道得越多,你就越有力量p Study Constantly,And You Will Know Everything.The More You Know,The More Powerful You Will Be写在最后37谢谢你的到来学习并没有结束，希望大家继续努力Learning Is Not Over.I Hope You Will Continue To Work Hard演讲人：XXXXXX 时 间：XX年XX月XX日 38
