STEMI is one of the true medical emergencies. We all know that the sooner our patient gets revascularisation, the better they do. We’ve known this for years. In a very nice meta-analysis, Eric Boersma showed how the survival benefit from thrombolysis decayed exponentially with time from symptom onset. That relationship’s so marked that if we were to give thrombolysis to a a patient with STEMI 30 minutes after their symptoms started, we’d save 30 lives for every 1,000 patients treated. If we managed to get there just a minute earlier, we’d save an extra 2 lives per 1,000 patients treated. And if we managed to get the thrombolysis in just 5 minutes earlier, we’d save an extra 11 lives per 1,000 treated. As you can see from the pic below, there’s a similar story with primary PCI.
A few years ago when we were still routinely prescribing thrombolysis for patients with STEMI, Emergency Departments really owned this problem. We had targets and quality indicators and everyone was focused on getting the quickest door to needle time. Now, in the age of primary PCI, you can’t help but feel that we’ve lost ownership of the problem. It’s become the cardiologists’ domain. And maybe – just maybe – we’ve taken our eye off the ball when it comes to getting fast revascularization. In Greater Manchester, our local data suggest there might be some truth in that.
Now, clearly there are reasons why it takes longer to get revascularization if you pass through the ED. The cases tend to be more complex, the diagnoses more subtle, the patients are sicker. You’ve also got the problem that patients simply walk in, unannounced, amid the masses of other patients with more minor ailments. BUT – if there’s one area we should focus on if we want to improve the care we provide for patients with STEMI, clearly it should be for the ‘indirect’ transfers.
Some people might say that everyone should just go directly to the Cath Lab. But that’s just impossible. Patients still walk in to the ED with STEMI. And paramedics won’t spot every diagnosis. The subtle ones – the challenging ones – will still be our domain. And our local data suggest that it’s still a big problem for EDs. Almost half of all patients with STEMI still pass through the ED.
[DDET The DIDO-30 Project]
In Greater Manchester, we think we can do better – so we started the DIDO-30 project. In this project we aim to get the Door In, Door Out (DIDO) times down to below 30 minutes for all patients with STEMI in the ED. How can we do this? Well, part of it is about putting STEMI back on the agenda, getting people to think about it, providing education. And part of it is about thinking through our pathways, identifying where we might make the marginal gains that will make a huge difference to our patients.
[DDET What ‘marginal gains’ can we make?]
There are loads of possibilities. In this mini series, we’ll talk about some of them in detail. To get the ball rolling, let’s talk about something dead simple but dead important – recording ECGs. If you don’t record an ECG quickly, you can’t achieve a good time. Clearly, it’d be ideal if all patients have a 12-lead ECG recorded before they even get to the ED. But that won’t happen when patients continue to self-present with STEMI. International guidelines tell us that an ECG should be recorded within 10 minutes of arrival in the ED.
That gives us quite a challenge, especially given that we’re mainly talking about patients who walk in to the ED. How can we differentiate those with STEMI from the masses of other patients? There are several ways we might achieve that. In this blog post, we’ll look at just one of them…
[DDET ECG at triage]
In Christchurch, New Zealand, they have a great system. When patients walk in to the ED, the first person they see is a triage nurse who completes a primary triage. If the patient’s stable, they then register before a secondary triage takes place. The primary triage makes sure that the sickest patients can be whisked off and treated without any delays. For patients with possible STEMI, that means that a trained nurse will almost certainly identify them and have an ECG recorded right away.
For other departments, there are reasons why primary nurse triage either isn’t feasible or isn’t desirable. At Central Manchester, we can have so many patients arriving that queues build up for triage very easily. We’d rather at least know who those patients are by booking them in quickly. Our target is to achieve triage within 15 minutes of arrival. If we achieve that, you’ll have noticed that 15 is greater than 10 – so we still won’t be able to get an ECG within 10 minutes of arrival for patients with possible STEMI. We dealt with that by arranging for those patients to have an “immediate ECG”.
The immediate ECG
This means that patients who have a primary complaint of non-traumatic chest pain will be given a red card by reception staff, which says “Immediate ECG”. This acts as a kind of baton, which is given to the patient. The patient is then asked to immediately hand the card to a member of the clinical staff. That person must then either record an immediate ECG or hand it on (usually to a Clinical Support Worker). Using this strategy, we managed to go from achieving a door to ECG time of less than 10 minutes in around 30% of our patients to around 70% of our patients.
The ‘immediate ECG’ strategy isn’t without its problems. Staff can get disillusioned by having to rush to record ECGs in patients who clearly look fine. Medically untrained reception staff can’t be expected to know how to identify patients with heart attack, which means you need a simple rule. We restricted our criteria to non-traumatic chest pain in patients aged over 30 years, using evidence gained in the derivation of the Graff decision rule.
[DDET What else could help?]
So far our DIDO-30 project has led to a lot of ideas about how we might improve our Door in, Door Out times. They include:
- Stop clocks, which will be started when patients have a diagnostic ECG for STEMI. The time itself isn’t the most meaningful stat. It’s the fact that the staff have a visual reminder that the clock is ticking!
- Senior ECG sign off. We encountered a number of cases of ECG misinterpretation, often by junior medical staff. We therefore implemented senior sign off, whereby every ECG recorded on arrival is taken to a registrar or consultant for immediate interpretation and action where necessary. This has to go hand in hand with ECG training for the juniors though – and we’re planning to develop an e-learning package so that the juniors can have their competency formally assessed, which would enable them to sign ECGs
- Direct activation of the Cath Lab without involving a cardiologist. We do this for unequivocal cases with no clear contra-indication to immediate PCI
- STEMI leads at each ED. This gives a named person responsibility for improving times – and a link for the regional team
- Regular feedback on local data. This is a work in progress for us. If we can get hold of regular data, disseminating it regularly so that everyone knows how they’re performing can only help
[DDET Treating STEMI is just like Formula One]
I really love the analogy that treating STEMI is just like a Formula One pitstop. Have you seen a Formula One pitstop? If not, check out this video…
This was a world record from Ferrari at the Japanese grand prix in 2013. It took just 1.95 seconds. In that time, they’ve directed the car in, stopped it, jacked it up, changed all four tyres, jacked it down, cleared the driver to go and then he’s driven off. Now, compare that to how they did it in 1950…
To get to 1.95 seconds, the team has to think through every step to cut out wasted time. They have one person guiding the car in and controlling the jack. They have a team of four ‘wheel nut’ guys loosening the wheels, a team of four ‘wheels off’ guys taking off the old wheels and another team of four ‘wheels on’ guys to put on the new ones. They work together so closely and they practice, practice, practice.
When was the last time you practised managing a STEMI in your ED? In situ sim, anyone?!
[DDET The DIDO Challenge]
So, let’s finish with a challenge. What are your ideas to improve DIDO times? How does your ED work like a Ferrari pitstop? How quickly can you record an ECG?
And how quickly can you get from DI to DO?
All the best!
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