D2B Strategies and the Role of the Emergency

DepartmentJohn J. Kelly DO, FACEP

Associate Chair, Emergency MedicineAlbert Einstein Medical Center

Associate Professor of Emergency MedicineJefferson Medical College

Key Components“Achieving D2B Times That Meet Quality

Guidelines: How Do Successful Hospitals Do It?”

Rapid Triage Identification of ACS (Prehospital)

Rapid EKG and CXR (Maintain Broad Differential Diagnosis)

Rapid Safety Net and Emergency Cardiac Meds

One Call to Activate Cath Lab Team

Immediate “Package” for Transport

Rapid Safe Transport to Cath Lab

Succinct and Safe Handoff to Cath Lab

(Bradley EH, JAmCollCard. 2005;46:1236-1241)

Bradley EH, NEJM 355;22 Nov 2006

“Strategies for Reducing D2B”

“Substantial variation in prevalence of specific strategies

to expedite Door to Balloon Time”

Bradley EH, NEJM 355;22 Nov 2006

“Strategies for Reducing D2B”

“Strong Associations” saving 10-15 minutes

Emergency Physician activates CathLab

“One Call” by Emergency Physician

Cath Lab staffed within 30minutes of page

Attending Cardiologist in hospital

EKG transmitted by EMS to activate Cath Lab

Real-time D2B Data Feedback to staff

Bradley EH, NEJM 355;22 Nov 2006

“Strategies for Reducing D2B”

No Significant Effect:Policies/Practice for EKG Process

Policies/Practice for Transport to Cath Lab

Practices in Cath Lab (including relocation of Cath Lab)

ED Challenges with D2B:Door to EKG

Triage and CAD Screening/EKGOur EDs are overcrowded across the countryDifficult HistoriansAtypical presentations: young, female, elderly“I feel weak”How many EKGs for that one STEMI?This is a vague indicator for the Core Measure

Door to EKG Challenges

Interestingly, “hospital policy on the performance and assessment of EKG in the ED did not have a significant effect on D2B” (Bradley, NEJM 355;22 Nov06); included Criteria for EKG, Formal Training in Triage Assessment of ACS, Dedicated EKG Techs, Dedicated Triage Space for EKG

AEMC Data concludes the same

ED D2B Challenges:90 Minute Deadline Increases Errors:CathAlert Safety Systems Strategies

Simplicity

EKG and CXR verification by ED and Cath Lab

Patient Involvement/Constant explanation

Checklists and Algorithms on Intranet (EDWIN)

Teamwork with perfect communication

Medication Safety (Heparin and Lytics)

ED Challenges with D2B

When a patient looks like they are having AMI….. They get more care!

However…when they do not look like an AMI…..

Patient complexity and unique circumstances will make D2B more difficult to achieve…..

ED D2B Challenges:Preserving Professionalism

between Specialty ColleaguesD2B Process 0700-1800: easy!

After-hours and Weekends: tougher!

Adversarial anecdotal reports from EM/Cards

“More Time Produces More Information”

Unfortunately, call must be made < 20 minutes

We must be kind to one another as we help our patient

False-Alarm Cath Alerts: Inevitable

D2B and the Role of EM:What We Know

Treatment is more rapid if EM makes treatment decision without involvement of Cardiology

(ThatcherJL:JInvasiveCardiol 2003;15:693-8) (JacobyJ:JInvasiveCardiol 2005;17:154-5) (KhotUN:Circulation 2007;116:67-77)

Coordination with EMS saves time!

(CantoJG:JAmCollCardiol 1997;29:498-505) (CurtisJP:JAmCollCardiol 2006;47:1544-52) (CantoJG:Circulation 2002;106:3018-23)

D2B and the Role of EM:What We Know

Real-time Feedback to the Team is Good!Cath Team must be ready in 30 minutes.Other Strategies may be impractical or too expensive

(In-Hospital Cardiologist)

D2B and the Role of EM:What We Know

“Achieving Rapid D2B Times: How Top Ten Hospitals Improve Complex Clinical Systems”

Put together a great team with uncompromising clinical leaders.

(Bradley EH, Circulation 2006;113:1079-1085)