急性心肌塞战略

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, usaoverview introduction the argument for primary pci overview of the henry ford program program specifics pro

2、cess dictates outcomes alternative opportunitiesacute 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 statisticsacute mi: early managementreper

3、fusion pharmacological (thrombolysis) fibrinolytics antithrombins platelet inhibitors mechanical (direct/primary pci) angioplasty stent thrombectomy combined ? facilitated pciacute mi: direct pciadvantages rapid assessment of anatomy and hemodynamics timi-3 flow rates 75-95% in infarct artery low in

4、cidence of hemorrhagic stroke can be done in patients with contraindications for thrombolysis results superior to thrombolytics in randomized trialsdirect ptca vs. thrombolysispami-1n engl j med 1993; 328:673-679primary angioplasty vs. thrombolysis: meta-analysisdeathp=0.02death+mip75 cases/year) sk

5、illed lab (200 cases/year) surgical back up necessaryis time as critical in primary pci?30-day mortalitytime from onset of cp to randomizationzijlstra, eur heart j 2002;23:550acc/aha recommendations for direct pci in ami2004class i general: patients presenting within 12 hours; if performed in a time

6、ly fashion by individuals 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 yea

7、rs and revascularization can be done within 18 hours of shock onset. 12 hours of symptoms and severe chf or pulmonary edema (2004) http://clinical/guidelinesprimary pci in the united states minority of us hospitals achieve a median door to balloon time of 90 minutes or less majority of mi

8、 occur during “off hours” (nights and weekends) off hour primary pci is associated with increased door to balloon times and mortality henry ford 2002 door to balloon218 minutes cath lab to balloon 60 minutesprimary pci pathwayan opportunity for process improvementpatient presentation to diagnosis20

9、minpage fellow, fellow responds10 minfellow proceeds to er15 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 pati

10、ent and transport 15 minperform pci45 mintotal 210 minutesprocess 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! door-to balloon timeh

11、enry ford hospital detroitdoor-to balloon timehenry ford system wide2005henry 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 prima

12、ry pci henry ford hospital large urban teaching hospital in detroithenry 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 mindoor-to balloon timehenry ford system wide2005improving door to balloon timehow do you c

13、hange the process?create a multi disciplinary teamidentify advocates cath lab doctors, nurses, managers ccu doctors, nurses, managers emergency room doctors, nurses cardiologists staff and trainees hospital administration ambulance transportchanging the process improve the process to meet the scienc

14、e dissect complex activities into quantifiable steps team members help to redesign the processes in their areas establish parallel (not serial) processes avoid duplication example: iv compatibilitychanging the process activation simple 1 phone call- 24 hours a day staffed by decision maker (md who a

15、ccepts patient and activates team) team activation is invisible to the outside coordinator then activates staff members, arranges admission, etcchanging the process transport activate transport (ambulance) as early as possible, usually before activating central team. establish well known dispatch pa

16、thway minimize emergency room time communicate during transportchanging 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 patientchanging the process cath la

17、b focused pathway to reperfusion 7 f sheath diagnostic angiography 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 resultscath lab time

18、sarrival to balloon inflationhfh ami flow chartami gann chartchanging 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 pre

19、p timecath arrival to arterial access procedure timearterial access to balloon or reperfusionchanging 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 enthusiasmalternative strategies and next steps remote 12 lead ekg ekg in ambulance transmit ekg from