The Mission of the American College of Cardiology

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Pennsylvania CHAPTER
In cooperation with Highmark and Independence
Blue Cross (Blue Plans headquartered in
Pittsburgh and Philadelphia)

• The Mission of the American College of
  Cardiology
• - to foster optimal cardiovascular care and
  disease prevention through professional
  education, promotion of research, leadership in
  the development of standards and guidelines and
  the formulation of health care policy.

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Reperfusion Therapies 2007
Pennsylvania CHAPTER
In cooperation with Highmark and Independence
Blue Cross (Blue Plans headquartered in
Pittsburgh and Philadelphia)

• Strategies for Developing
• Integrated D2B Programs
• For STEMI

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Pennsylvania CHAPTER
In cooperation with Highmark and Independence
Blue Cross (Blue Plans headquartered in
Pittsburgh and Philadelphia)
Victor Caraballo, M.D. Senior Medical
Director Quality Management Independence Blue
Cross Kathleen T. Donohue Independence Blue
Cross Steven J. Brown, M.D. Medical Director
Professional Networks Phil Gehman Provider
Improvement Project Leader Independence Blue Cross
Donald R. Fischer, M.D., MBASenior Vice
PresidentChief Medical OfficerHighmark
T H A N K Y O U
Michael A. Madden, M.D.Medical DirectorQuality
and Medical Performance ManagementHighmark
Carey Vinson, M.D. Medical Director Highmark
Highmark Lori Armel Karen BalsamoFlo
Campbell Deborah J. Donovan Lynette
Enders Douglas Hoch Paul Hoffman Trina Thompson
Teamwork
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Pennsylvania CHAPTER
In cooperation with Highmark and Independence
Blue Cross (Blue Plans headquartered in
Pittsburgh and Philadelphia)
T H A N K Y O U
Pennsylvania Chapter American College of
Cardiology Maria Elias Association Executive
Tracy Allgier-BakerDirector of Continuing
EducationPenn State College of Medicine Bonnie
Bixler, M.Ed. Director of Special Projects Penn
State Continuing Education College of
Medicine Lori L. Fitterling Julie Graham Penn
State Continuing Education
American College of Cardiology Jason Byrd Jayne
Jordan Amy Stern
Teamwork
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Reperfusion Therapies 2007
Pennsylvania CHAPTER
In cooperation with Highmark and Independence
Blue Cross (Blue Plans headquartered in
Pittsburgh and Philadelphia)

• P4P Programs

PROFESSIONALS for PERFUSION
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Reperfusion Therapies 2007
Pennsylvania CHAPTER
In cooperation with Highmark and Independence
Blue Cross (Blue Plans headquartered in
Pittsburgh and Philadelphia)

• Welcome and Introduction
• Michael A. Madden, M.D. Highmark
• Richard L. Snyder, M.D. IBC
• Daniel Edmundowicz, M.D. Pa-ACC

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Reperfusion Therapies 2007
Pennsylvania CHAPTER
In cooperation with Highmark and Independence
Blue Cross (Blue Plans headquartered in
Pittsburgh and Philadelphia)

• The Vision
• Improving D2B Time for STEMI

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Pennsylvania CHAPTER
In cooperation with Highmark and Independence
Blue Cross (Blue Plans headquartered in
Pittsburgh and Philadelphia)
"The secret of success in life is for a (wo)man
to be ready for (her) his opportunity when
it comes." -Benjamin Disraeli
"Education brings about opportunity, and in turn
inspiration." -Bill Frist
"A pessimist sees the difficulty in every
opportunity an optimist sees the opportunity in
every difficulty." -Winston Churchill
ACC-D2B
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Pennsylvania CHAPTER
In cooperation with Highmark and Independence
Blue Cross (Blue Plans headquartered in
Pittsburgh and Philadelphia)
Primary PCI should be performed as quickly as
possible, with a goal of a medical
contact-to-balloon or door-to-balloon time
within 90 minutes. ACC/AHA/SCAI 2005 Guideline
Update for Percutaneous Coronary Interventions
In July 2005 the Penn State Heart Vascular
Institute as part of a quality improvement
initiative reviewed D2B for STEMI patients
Door-to-ECG 36 min (mean) range 10-132
min ECG-to-PCI 109 min (mean) range 71-363
min Door-to-Balloon time 145 min (mean)
ACC-D2B
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Pennsylvania CHAPTER
In cooperation with Highmark and Independence
Blue Cross (Blue Plans headquartered in
Pittsburgh and Philadelphia)
Door-to-Balloon time 145 min (mean)

• "Kubler-Ross Stages in Facing Reality of
• the Quality Chasm"
• The data are wrong
• The data are right, but its not a problem
• The data are right, but its not my problem
• I accept the burden of quality improvement

Donald Berwick, Institute of Medicine Crossing
the Quality Chasm Summit Washington D.C., January
2004
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Idealized Workflow
Penn State Heart Vascular Institute
Presenting symptoms suggestive of ACS
ECG performed within 10 minutes
ECG reviewed by ED attending
ED Nurse initiates acute care Heart Alert Intake
Worksheet
STEMI confirmed
CARDIOLOGIST PAGED
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Pennsylvania CHAPTER
In cooperation with Highmark and Independence
Blue Cross (Blue Plans headquartered in
Pittsburgh and Philadelphia)
Penn State Heart Vascular Institute
HOSPITAL ADMINISTRATION HVI /EM
LEADERSHIP ADMISSSIONS COMMUNICATIONS NURSING ANCI
LLARY SERVICES PARAMEDICS LIFE LION PHYSICIANS
MD NETWORK FELLOWS INTERVENTIONAL CRNP CVOU
SUPPORT STAFF CARDIAC CATH LAB STAFF SIM LAB I.T.
SERVICES
Y.O.U.R. Medical Center
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ED Physician Empowerment
Possible STEMI
Classic STEMI
Cardiology Attending paged
ED Attending Activates Heart Alert System
Attending to Attending Case discussion
Heart Alert Paging System Activated
Penn State Heart Vascular Institute
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Heart Alert Paging System
RESPONDERS

• Interventional Cardiologist on-call
• Cath Lab Charge organize room
• Cardiology Fellow on-call
• Cath Lab call-team
• Interventional Nurse Practitioner
• Hospital Admissions
• Research Nurse(s)
• ED Charge Nurse
• Radiology Technologist

01/01/2007 0630 HEART ALERT ED- ROOM
19 RESPOND STAT
Penn State Heart Vascular Institute
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Heart Alert Intake Worksheet
Date ______ Time______ Cath Lab ext 6416
Patient ID Sticker
ED MD______________ ED NURSE___________

• Is family present Y / N
• Is a translator necessary? No / Yes
  _________________(language)
• Vitals BP_______ HR_______ RR_______
• Jugular venous distention No / Yes _________
  
• Pulmonary rales ____ wheezes_____
• Cardiac auscultation murmurs ______ gallops
  ______
• Pulses femoral R_____ L_____ Radial R____
  L___
• Symptoms Chest Pain _______ time of
  onset______ Shortness of breath _______
• Allergies- No / YES ____________________________
  __ Iodine______ Shellfish_____
• Prior Cardiac cath______ Angioplasty______
  CABG_____
• Height_________________
• Weight ________________
• Dentures Yes / No
• Time of Last Meal ____________________
• Hearing Aid Yes / No
• Contacts Yes / No
• 17. IV Meds (circle if administered) Dopamine,
  Dobutamine,, Nitroglycerin, Heparin, Aspirin

Fax [phone]
Penn State Heart Vascular Institute
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Penn State Heart
Vascular Institute Heart Alert Program- GOALS
10 min
10 min
30 min
5 min
35 min
ECG to Heart Alert Activation
Heart Alert Activation to Cath Lab Team arrival
Patients Arrival to Cath Lab
Triage to ECG
PCI
Door-to-Balloon Time 90 min
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PENN STATE HEART VASCULAR INSTITUTE
Quality Improvement Reducing Door-to-Balloon
Time (D2B) in Patients With ST-segment Elevation
Myocardial Infarction Heart Alert Program
Steven Ettinger, Charles Chambers, Ian Gilchrist,
Mark Kozak, Craig Lauder Lawrence Sinoway
March 25, 2007
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Penn State Heart
Vascular Institute Heart Alert Program
9.0 min
3.9 min
19.6 min
12.8 min
28.5 min
ECG to Heart Alert Activation
Heart Alert Activation to Cath Lab Team arrival
Patients Arrival to Cath Lab
Triage to ECG
PCI
Door-to-Balloon Time 85.7 min (mean) (140
patients enrolled)
2007 Door-to-Balloon Time 73.8 min (mean) (86
within 90 min)
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Pennsylvania CHAPTER
In cooperation with Highmark and Independence
Blue Cross (Blue Plans headquartered in
Pittsburgh and Philadelphia)
Medical Directors' Institute October 18- 20,
2006 Leesburg, Virginia Created in 2002 by the
ACC with the intention of developing a
collaborative approach to issues such as paying
for quality, utilization of imaging technology,
health information systems and value in
healthcare.
March, 2007- Pa-ACC, Highmark and IBC working
group organized to plan Reperfusion Therapies
2007- The Vision 1. Review current pathways
and protocols 2. Recognize best-practice
models 3. Recognize D2B times achievable 4. Recognize together we can and we
will make a difference
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Pennsylvania CHAPTER
In cooperation with Highmark and Independence
Blue Cross (Blue Plans headquartered in
Pittsburgh and Philadelphia)
We can do better.
State Program
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Pennsylvania CHAPTER
In cooperation with Highmark and Independence
Blue Cross (Blue Plans headquartered in
Pittsburgh and Philadelphia)
Optimize STEMI Care
Regionalize STEMI Care
EDUCATION
Pa-ACC D2B
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Pennsylvania CHAPTER
In cooperation with Highmark and Independence
Blue Cross (Blue Plans headquartered in
Pittsburgh and Philadelphia)
Step back and run into this wall head first.
www.d2balliance.com
www.d2balliance.com
www.d2balliance.com
www.d2balliance.com
www.d2balliance.com
www.d2balliance.com
www.d2balliance.com
Now you know what it is like to develop a
Door-to-Balloon program
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Harlan M. Krumholz, M.D., F.A.C.C.Yale
University School of MedicineACC- GAPChair,
Door-to-Balloon Work Group
Pennsylvania CHAPTER
In cooperation with Highmark and Independence
Blue Cross (Blue Plans headquartered in
Pittsburgh and Philadelphia)
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D2B ProgramEmergency Medical Services

• Expert Panel
• Donald Durbeck
• Vincent N. Mosesso Jr.
• Judd E. Hollander
• David Neubert
• Andrew Miller

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D2B ProgramEmergency Medical Services

• 905- 915 am Can STEMI Patients Transferred for
  Primary Angioplasty Receive Treatment Within 90-
  minutes in a Rural Setting? Geisinger Medical
  Center
• 920- 930 am Improving STEMI Care in Eastern
  Pennsylvania The Lehigh Valley Hospital and
  Health Network MI-Alert Program Lehigh Valley
  Hospital
• 935- 945 am Reducing D2B Time in STEMI by
  Utilizing EMS Cath Lab Activation From the Field
  Intradepartmental Emergency Physician
  Activation An 11-year 24/7/365 Experience
  Mercy Hospital of Pittsburgh
• 950- 1000 am Improving D2B Time in STEMI
  Presbyterian Shadyside
• 1005- 1015 am Delay to Electrocardiogram in
  STEMI Patients Does Not Preclude Meeting
  90-minute D2B Time Albert Einstein Medical
  Center

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November 21-23, 2008 Kiss this Date Goodbye on
your Calendar!

• Why?
• Because you do not want to miss this meeting!
• 2008 Annual Pa-ACC Chapter Meeting
• November 21-23, 2008
• The Hotel Hershey
• Sure to be a SWEET Event!

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John J. Kelly, D.O., F.A.C.E.P. Albert Einstein
Medical CenterAssociate ChairmanDepartment of
Emergency MedicineD2B Strategies and the Role
of the Emergency Department
Pennsylvania CHAPTER
In cooperation with Highmark and Independence
Blue Cross (Blue Plans headquartered in
Pittsburgh and Philadelphia)
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D2B ProgramEmergency Medicine

• Expert Panel
• John Doherty
• Craig Lauder
• Paul Casale
• Andrew Waxler
• Michael Rossi
• Howard Herrmann

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D2B ProgramEmergency Medicine

• 1115 - 1125 am Cardiac Reperfusion Team
  Protocol Decreases D2B Time at Hamot Medical
  Center- Hamot Medical Center
• 1130 - 1140 am D2B Time Every Minute Counts
  Conemaugh Memorial Medical Center
• 1145- 1155 am Emergency Physician Activation
  of the Catheterization Lab Reduces D2B Times with
  Few False Activations Hahnemann University

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Douglas Kupas, M.D.Commonwealth EMS Medical
DirectorBureau of EMSPennsylvania Department of
HealthEMS and D2B Strategies The Pennsylvania
Perspective
Pennsylvania CHAPTER
In cooperation with Highmark and Independence
Blue Cross (Blue Plans headquartered in
Pittsburgh and Philadelphia)
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Howard C. Herrmann, M.D., F.A.C.C.Director,
Interventional Cardiology andCardiac
Catheterization LaboratoriesUniversity of
PennsylvaniaIs There a Role For Facilitated PCI
in 2007 ?
Pennsylvania CHAPTER
In cooperation with Highmark and Independence
Blue Cross (Blue Plans headquartered in
Pittsburgh and Philadelphia)
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D2B ProgramInterventional Cardiology

• Expert Panel
• Ian Gilchrist
• A.J. Conrad Smith
• Nelson Wolf
• Charles Chambers
• James Blankenship

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D2B ProgramInterventional Cardiology

• 140 - 150 pm Processes to Decrease D2B
  Times for STEMI Patients in a Community Hospital-
  Saint Vincent Health Center
• 155 - 205 pm Overall Catheterization
  Laboratory Normal Angiography Rate Does Not
  Increase with ER Activation of Primary Coronary
  Interventions (PCI) for STEMI Chester County
  Hospital
• 210- 220 pm Are Women Undergoing Primary PCI
  at Increased Risk for Death? Insights from the
  Lehigh Valley Hospital and Health Network
  MI-ALERT Program Lehigh Valley Hospital
• 225- 235 pm Interdisciplinary Collaboration to
  Reduce D2B Time Abington Memorial Hospital

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D2B ProgramInterventional Cardiology

• 240 - 250 pm D2B Time The Pinnacle Health
  Experience- Pinnacle Health
• 255 - 305 pm Overcoming the Hurdles Improving
  D2B in the LVHHN MI-ALERT Program Lehigh Valley
  Hospital
• 310- 320 pm Time to Treatment During Primary
  PCI is Related to Transport Distance and Speed of
  Interventionalist Geisinger Medical Center

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Reperfusion Therapies 2007
Pennsylvania CHAPTER
In cooperation with Highmark and Independence
Blue Cross (Blue Plans headquartered in
Pittsburgh and Philadelphia)
CONCLUDING REMARKS

• Strategies for Developing
• Integrated D2B Programs
• For STEMI

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Reperfusion Therapies 2007
Pennsylvania CHAPTER
In cooperation with Highmark and Independence
Blue Cross (Blue Plans headquartered in
Pittsburgh and Philadelphia)

• If you dont know the data, you cant get better.
• Reperfusion strategies are essential
• Quality is a Culture
• Educate Standardize - Regionalize
• State Organizations should collaborate

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Mission Lifeline
Pennsylvania CHAPTER
In cooperation with Highmark and Independence
Blue Cross (Blue Plans headquartered in
Pittsburgh and Philadelphia)

• March 2006- AHA multidisciplinary conference
• STEMI patient care
• Implementation Plan
• EMS system assessment and improvement
• Establishing local initiatives
• Evaluating existing models
• Explore the possibility of developing a National
  STEMI Center Certification Program/Criteria

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AHA
Pennsylvania CHAPTER
In cooperation with Highmark and Independence
Blue Cross (Blue Plans headquartered in
Pittsburgh and Philadelphia)

• Stroke- Recommendations for the establishment of
  stroke systems of care
• Brain Defense- A Stroke Prevention and Treatment
  Strategy for Pennsylvania
• Presented to the General Assembly of the
  Commonwealth of PA Joint State Government
  Commission November 2002

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Pennsylvania CHAPTER
In cooperation with Highmark and Independence
Blue Cross (Blue Plans headquartered in
Pittsburgh and Philadelphia)

• Statewide Systems Change
• Develop Taskforce/Committee under
  Department of Health CVD Consortium
• Develop plan and progress markers
• Assess resources / capabilities
• Focus on long term outcomes

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Pennsylvania CHAPTER
In cooperation with Highmark and Independence
Blue Cross (Blue Plans headquartered in
Pittsburgh and Philadelphia)

• Improving Outcomes
• Through a Culture of a
• Collaborative Environment

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THANK YOU
Pennsylvania CHAPTER
In cooperation with Highmark and Independence
Blue Cross (Blue Plans headquartered in
Pittsburgh and Philadelphia)