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The New Washington State Emergency
Cardiac and Stroke System: Developing
a Best Practice Plan for Your Community
Bev McCulloughQuality Improvement Manager, RHQN
Kim Kelley, MSWPlanning Coordinator, WA State DOH
The Washington State Emergency Cardiac and Stroke System:
Creating Opportunities Together
Kim Kelley, MSWCardiac/Stroke Systems
CoordinatorWA State Department of Health
The Continuum of Care
Prevention
Prehospital
Hospital Secondary Prevention/ Rehabilitati
on
System Evaluatio
n
Working together across the continuum we can coordinate care and
find efficiencies in the system to reduce time to treatment and improve
outcomes for our patients.
Creating Opportunities Together…
Washington’s Population is AgingAnnual Change in Population Ages 65 and Over
Risk Factors Are Increasing
0
5
10
15
20
25
30
35
40
1990 1992 1994 1996 1998 2000 2002 2004 2006 2008
Ag
e-ad
juste
d P
erc
ent
Obesity
Diabetes
High Cholesterol
Hypertension
The Chain of Events
Emergency Cardiac and Stroke System
Physical Inactivity
Poor Diet
Tobacco Use
Chronic Stress
(Risk Factors)
Diabetes
Hypertension
High Cholestero
l
Obesity
(Diseases &
Conditions)
(Events/Deaths)
Medical/Health Homes
Healthy Communities
The Bottom Line
A rapidly aging population and increasing rates of obesity,
diabetes, and high blood pressure mean more people at risk for heart attack, cardiac arrest and stroke.
Emergency Cardiac and Stroke
Care in Washington
Problem: effective treatments are available--but too many people don’t get them at all or in time
• Only 4% strokes get t-PA• Only 35 of 95 hospital administered
t-PA• Estimated 39% of heart attacks get
PCI• Only 55% of hospitals give lytics
under 30 min• OHCA survival rates very low
The Solution
An organized system to get the right patient to the right place in the right
time, just like we do for trauma.
D2B Time and Mortality
SSHB 2396 Passed 2010
System Components
• EMS protocols for the identification, treatment, and triage of ACS and stroke patients
• Hospital categorization • Commitment to implement best
practices to improve outcomes• Data driven quality improvement
across the system
Hospital Categorization Program
•65 of 95 hospitals applied by 1/31/11•12 more applied by 5/31/11•Notice of categorization sent to all hospitals. List sent to Regional Councils, EMS Councils•Lists will be on ECS website soon
STROKE CENTERS AND COVERAGE AREA 2007
I
STROKE CENTERS AND COVERAGE AREA 2011
CARDIAC CENTERS AND COVERAGE AREA 2007
CARDIAC CENTERS AND COVEREAGE AREA 2011
Quality Improvement
SHB 2396:
•Requires QI of participating hospitals•Allows the trauma QI programs to evaluate emergency cardiac and stroke care delivery
ECS System Measures and Goals
• 15 minutes on-scene time for EMS• 30 minutes in transfer hospital (AMI)• 30 minutes door-to-needle (lytics, AMI)• 60 minutes door-to-t-PA (stroke) • 90 minutes first medical contact (EMS or
transfer hospital) to definitive treatment • 120 minutes symptom onset to definitive
treatment • Participating hospital within 1 hour from every
citizen • Cardiac arrest goals - to be determined
Outcomes
• Discharge status• Length of stay• 30-day readmission/30-day mortality • Immediate and one-year mortality • Function at 3 months• Quality of life• Ejection fraction• Neurologic status
What You Can Do…
• Make your hospital part of the prevention cycle.
• Educate your communities: CPR, signs and symptoms of heart attack and stroke, and to call 9-1-1 immediately.
• Become cardiac and stroke centers and implement best practices.
What You Can Do…
• Work with your EMS partners and fellow hospitals to create comprehensive regional systems.
• Collect data and use it to figure out what works and what doesn’t.
• Participate in the statewide ECS TAC.
A STEMI Story-Celebrating Successful
Partnershipspresented to:
WSHA Rural Hospital Summer Workshop
June 28th, 2011Chelan, WA
presented by: Paul Nurick, CEO
Rhonda Holden, RN, MSNKittitas Valley Community Hospital
Kittitas County
Kittitas Valley Community Hospital (KVCH) to Door to Balloon at Yakima RegionalMedical & Coronary Center (YRMCC)
> 2.5 Hours Goal < 90 minutes
KVCH Throughput > 60 Minutes Goal < 30 minutes
KVCH Door to EKG > 15 Minutes Goal < 5 minutes
2006 STEMI Metrics
• Every patient taken to Kittitas Valley for initial assessment and stabilization
• EKG’s done by Respiratory Therapy only• Chest X-Ray obtained “per protocol”• EMS left the hospital, then were called
back to transport patient to YRMCC Lab• No partnerships established and
varying “trust” of the assessment of our EMS providers
• Patients from KVCH taken to Yakima Reg. ED, reassessed & then cardiac cath team called
Why the delays?
• A focus on “what is right for the patient”• All partners at the table to develop
standardized protocols and training of EMS providers
• EKG performed in the field- if obvious STEMI and stable, EMS bypasses KVCH
• EMS notifies YRMCC directly - cath lab notified
• EMS bypasses Yakima ED - go directly to cath lab
A New Program Emerges
• Only unstable STEMI patients transported to KVCH
• Implemented a STEMI Alert• Eliminated “wasteful” steps- Chest X-Ray• Multiple staff trained to perform EKG• EMS remains on scene when possible,
ready to transport to YRMCC Cath Lab• One call to YRMCC- single line for referrals
Changes at KVCH
2006 2007 2008 2009 20100
20
40
60
80
100
120
140
160
180
KVCH, YRMCC - Kittitas County EMS STEMI Metrics Today
Avg Door to BalloonAvg KVCH ThroughputAvg. Transport TimesAvg KVCH Door to EKG
The call is dispatched for a patient experiencing chest pain. Volunteers from Cle Elum Fire Department respond, along with two off duty Medic One paramedics.
Paramedics are on scene at 12:51(<8 minutes from time of initial call).
Patient diaphoretic and short of breath; reporting 10/10 substernal pain radiating to both arms.
Transport from scene at 13:08.
Cheryl’s Story
Cheryl’s Initial 12-Lead
At 13:10• 12-Lead ECG transmitted to YRMCC • STEMI protocol initiated.By 13:28, Cheryl received • x3 NTG SL,• 25mcg Fentanyl IVP• 324 ASA PO, 600mg Plavix IVP and • 5000 units Heparin IVP• Patient reports being pain free by 13:30.
1336 Cath Team Called in to YRMCC• 1415 Medic Unit arrived at YRMCC• 1418 entered cath lab with team waiting
for her
En route to Yakima Regional
Cheryl’s Coronary Artery
Upon arrival at cath lab:
Reperfusion at 15:15
• Transfer success of the STEMI Program to our Stroke Program
• EMS performs a FAST exam in the field and notifies KVCH of a “Stroke Alert”
• Developed a joint NIHSS- EMS initiates the NIHSS in the ambulance, ED staff utilize the same form to assess patient on arrival
• Patients taken directly to our CT, EMS reports to ED provider and RN cares for patient in CT
• “Door to CT” time <25 min in 75% of patients
• Average Door to CT Read = 30 minutes
What’s Next
Made possible by:
But our favorite picture is:
Cheryl and attending paramedic
Beth Williams; Winter, 2011.
Upper Kittitas County Medic One- HD #2Cle Elum Fire DepartmentKittitas Valley Community HospitalKittitas County EMS (KITTCOM Dispatch)Kittitas Valley Fire & RescueYakima Regional Medical & Cardiac CenterVirginia Mason Medical Center (Stroke)
Thank You Partners
Rural “Best Practice”:Community Education
Tom Martin, AdministratorLincoln HospitalDavenport, WA
Initial Level One Newspaper Ad
Cardiac Level One Brochure
Stroke Billboard/Poster
Lincoln’s Stroke Program
Developing a program for the future
Lincoln Hospital bridges the gap in rural healthcare with robotic doctor (Davenport, Wash. )— Lincoln Hospital has announced the placement of a remote physician presence robot that will expand the delivery of specialized health care to patients in their service area. On September 20 the robot will be active at Lincoln
Co-Managing Complex Patients
The Accountable Health Home
RHC & CAHTertiary and
Specialty Services
Optimizing Quality Outcomes, Cost and Access
Lincoln’s Robot:Part of the Team
Washington Rural Emergency Cardiac and Stroke
Systems……
Working together across the continuum we can coordinate care and find efficiencies in the system to reduce time to treatment and
improve outcomes for our patients.
Creating Opportunities Together…
Questions?
Thank you to Kim, Paul, Rhonda and Tom!
