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1、AMI Strategy How to Achieve Door-to-Balloon Times of 90 Minutes and What to Do Next?,Aaron Kugelmass, MD Director, Cardiac Cath Lab Associate Division Chief Henry Ford Hospital Detroit, Michigan, USA,Overview,Introduction The Argument for Primary PCI Overview of the Henry Ford Program Program Specif
2、ics Process Dictates Outcomes Alternative Opportunities,Acute 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 statistics,Acute MI: Early Manag
3、ement Reperfusion,Pharmacological (Thrombolysis) Fibrinolytics Antithrombins Platelet Inhibitors Mechanical (Direct/Primary PCI) Angioplasty Stent Thrombectomy Combined ? Facilitated PCI,Acute MI: Direct PCI Advantages,Rapid assessment of anatomy and hemodynamics TIMI-3 flow rates 75-95% in infarct
4、artery Low incidence of hemorrhagic stroke Can be done in patients with contraindications for thrombolysis Results superior to thrombolytics in randomized trials,Direct PTCA vs. Thrombolysis PAMI-1,N Engl J Med 1993; 328:673-679,Primary Angioplasty vs. Thrombolysis: Meta-analysis,Death p=0.02,Death+
5、MI p75 cases/year) Skilled lab (200 cases/year) Surgical back up necessary,Is Time as Critical in Primary PCI?,30-day mortality,Time from onset of CP to randomization,Zijlstra, Eur Heart J 2002;23:550,ACC/AHA Recommendations for Direct PCI in AMI 2004,Class I General: Patients presenting within 12 h
6、ours; if performed in a timely fashion by individuals skilled in the procedure and supported by experienced personnel in high volume centers Specific: Door To Balloon Time 1 hour Symptom 3 hours, PCI preferred 90min Within 36 hours of MI when patient develops cardiogenic shock, is 75 years and revas
7、cularization can be done within 18 hours of shock onset. 12 hours of symptoms and severe CHF or pulmonary edema,(2004) Http:/www.acc.org/clinical/guidelines,Primary 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 duri
8、ng “Off Hours” (nights and weekends) Off Hour Primary PCI is associated with increased door to balloon times and mortality Henry Ford 2002 Door to Balloon 218 minutes Cath Lab to Balloon 60 minutes,Primary PCI Pathway An Opportunity for Process Improvement,Patient Presentation to Diagnosis 20 min Pa
9、ge Fellow, Fellow Responds 10 min Fellow Proceeds to ER 15 min Fellow Evaluates Patient 15 min Fellow Pages CCU Staff, Staff Responds 10 min + PCI, Fellow Pages Int Staff, Staff Responds 10 min Fellow goes to Cath Lab, Pages Team 10 min Patient Stays in ER or Goes to CICU Cath Team Arrives 60 min Fi
10、nd Patient and Transport 15 min Perform PCI 45 min Total 210 minutes,Process 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 Ba
11、lloon Time Henry Ford Hospital Detroit,Door-To Balloon Time Henry Ford System Wide 2005,Henry Ford Acute Myocardial Infarction Program,6 Emergency Rooms Henry Ford Hospital 90,000 visits HF Wyandotte Hospital 72,000 HF Bicounty Hospital 28,000 Fairlane ER 47,000 West Bloomfield ER 22,000 Sterling He
12、ights ER 21,000 Primary PCI Henry Ford Hospital Large Urban Teaching Hospital in Detroit,Henry Ford ER Locations,20 m, 33 min,14 m, 25 min,9 m, 24 min,8 m, 17 min,12 m, 26 min,Door-To Balloon Time Henry Ford System Wide 2005,Improving Door to Balloon Time,How Do You Change The Process?,Create A Mult
13、i Disciplinary Team Identify Advocates,Cath Lab Doctors, Nurses, Managers CCU Doctors, Nurses, Managers Emergency Room Doctors, Nurses Cardiologists Staff and Trainees Hospital Administration Ambulance Transport,Changing the Process,Improve the Process to Meet the Science Dissect Complex Activities
14、into Quantifiable Steps Team members help to redesign the processes in their areas Establish Parallel (not serial) Processes Avoid Duplication Example: IV Compatibility,Changing the Process,Activation Simple 1 Phone Call- 24 hours a day Staffed by Decision Maker (MD who accepts patient and activates
15、 team) Team Activation is Invisible to the Outside Coordinator then activates staff members, arranges admission, etc,Changing 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 transport,
