急性心肌梗塞战略课件

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, USAOverviewIntroductionThe Argument for Primary PCIOverview of the Henry Ford ProgramProgram SpecificsProcess

2、Dictates OutcomesAlternative OpportunitiesAcute MI: Introduction1.1 million people yearly in the US*About 500,000 have STEMI220,000 die from their AMI50% of deaths in the first hourOutlook of hospitalized patients better*AHA: 2001 Heart and stroke statisticsAcute MI: Early ManagementReperfusionPharm

3、acological (Thrombolysis)FibrinolyticsAntithrombinsPlatelet InhibitorsMechanical (Direct/Primary PCI)AngioplastyStentThrombectomyCombined? Facilitated PCIAcute MI: Direct PCIAdvantagesRapid assessment of anatomy and hemodynamicsTIMI-3 flow rates 75-95% in infarct arteryLow incidence of hemorrhagic s

4、trokeCan be done in patients with contraindications for thrombolysisResults 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)Skilled lab (200 cases/year)S

5、urgical back up necessaryIs Time as Critical in Primary PCI?30-day mortalityTime from onset of CP to randomizationZijlstra, Eur Heart J 2002;23:550Process ChangeCentralize CommunicationsFocus Clinical Decision MakingTransfer SEMI Patients Directly to Site of TherapyEstablish Transport PathwaysUnite

6、CICU/Cath Lab Nursing FunctionsImprove Door to Balloon Times! Door-To Balloon TimeHenry Ford Hospital DetroitDoor-To Balloon TimeHenry Ford System Wide2005Henry Ford Acute Myocardial Infarction Program6 Emergency RoomsHenry Ford Hospital90,000 visitsHF Wyandotte Hospital72,000HF Bicounty Hospital28,

7、000Fairlane ER47,000West Bloomfield ER22,000Sterling Heights ER21,000Primary PCI Henry Ford HospitalLarge 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

8、 TimeHenry Ford System Wide2005Improving Door to Balloon TimeHow Do You Change The Process?Create A Multi Disciplinary TeamIdentify AdvocatesCath LabDoctors, Nurses, ManagersCCUDoctors, Nurses, ManagersEmergency RoomDoctors, NursesCardiologistsStaff and TraineesHospital AdministrationAmbulance Trans

9、portChanging the ProcessImprove the Process to Meet the ScienceDissect Complex Activities into Quantifiable StepsTeam members help to redesign the processes in their areasEstablish Parallel (not serial) ProcessesAvoid DuplicationExample: IV CompatibilityChanging the ProcessActivationSimple1 Phone Ca

10、ll- 24 hours a dayStaffed by Decision Maker (MD who accepts patient and activates team)Team Activation is Invisible to the OutsideCoordinator then activates staff members, arranges admission, etcChanging the ProcessTransportActivate transport (ambulance) as early as possible, usually before activati

11、ng central team.Establish well known dispatch pathwayMinimize emergency room timeCommunicate during transportChanging the ProcessMinimize StepsPatients Transported Directly to Cath LabBusiness Hours- EasyOff Hours In House Nurses and MDs Staff Cath Lab while Cath Lab Staff Travel to HospitalPrep Roo

12、m and PatientChanging the ProcessCath LabFocused Pathway to Reperfusion7 F SheathDiagnostic Angiography of non-IRVGuide Catheter for suspected IRV“Standard” initial PTCA EquipmentFloppy Wire2.0/2.5 mm BalloonEstablish Reperfusion First, Optimize Result LaterRemember the Team!Call the ER and let them

13、 know the resultsCath Lab TimesArrival to Balloon InflationHFH AMI Flow ChartAMI Gann ChartChanging the ProcessMetricsMeasure Your Lean ProcessesDoor to EKGEKG to ActivationTransportCath LabActivation to Ambulance Arrival“Pick Up Time”Ambulance arrival to departureTransport Time ER departure to cath

14、 lab arrivalCath Prep TimeCath arrival to arterial accessProcedure TimeArterial access to balloon or reperfusionChanging the ProcessFeedbackShare Outcomes and Pertinent Metrics with ParticipantsConstructive Criticism is the Only Way to Improve the ProcessSuccess Begets SuccessFoster Participant Prid

15、e and EnthusiasmAlternative Strategies and Next StepsRemote 12 lead EKGEKG in AmbulanceTransmit EKG from fieldActivate Cath Lab fieldDisseminate Primary PTCA CentersOffsite Surgical Back UpCentralize MI CentersPractice Makes PerfectStaff Lab 24/7HFHS InitiativesImprove Door to EKG TimeImprove Transport TimesNew ambulance StructureActivation to Arrival“PickUp” TimesImprove Cath Lab Response TimesRemote EKGIn Field 12 lead EKG with telephonic transmissionConclusionsCareful Proce