Thank you for joining me for this on-demand session, false cath lab activations, but are they a bad thing? To kick us off, have you ever experienced this? 2.16 in the morning, STEMI alert, ETA, 15 minutes, direct to cath lab. And then, 2.31, STEMI alert canceled, how happy is your call team? EKG showing here is left ventricular hypertrophy, one of those rhythms that can mimic an ST elevation. Or, how about this? 17.47, end of your day, STEMI alert, ETA, 20 minutes. So your call team stays, and then about 25 minutes later, STEMI alert canceled. Well, this time your call team is happy, you most likely just paid them two hours of overtime, and now they're getting to leave basically on time. Rhythm shown here is a left bundle branch block, which is one of those other rhythms that can mimic an ST elevation MI. If you've experienced anything like this, then you're in the right place. And first off, I wanna say relax. It's okay to have these false cath lab activations. These are opportunities. This session will help you realize there should never be any negative connotations with these canceled alerts, and the value these false alarms can have on improving EMS care in the field, which ultimately is improving the care for all of the patients we are receiving. Hello, my name is Lisa Foster from Baylor Scott & White Heart Hospital in Plano, Texas. Today, we're going to discuss false activations from EMS and how to turn this into an opportunity for relationship building. My objectives for today are, understand the importance of fostering relationships with EMS, and to identify one strategy for developing a collaborative partnership with EMS. I chose these pictures. The first one is from one of my first presentations I've done with the Quality Summit several years ago. It shows our heart hospital. We were at a point of expansion, building a new tower. The bottom picture shows our heart hospital today. And I'm not sure if you can see the circle in red on the top left of that picture. There's a building there, which has now been knocked down. We've acquired that property, and we are once again expanding. Just like everything, change is always happening. To start, I would like to provide you with a little background. As mentioned, I am from Baylor Scott & White Heart Hospital, Plano, which is a part of Baylor Scott & White Health System, which is comprised of 51 hospitals, providing care to over 7.8 million patients annually. The bottom right demographics are specific to the heart hospitals. We're 100% dedicated heart hospitals, providing both in and outpatient care as a part of Baylor Scott & White. Our three heart hospital locations are very unique, where we are half owned by physicians. We also have three additional facilities that we have MSAs or management agreements with for the cardiology services. The other two pictures are from some of the conferences we provide nationally. Our Dallas PCI is one of the best conferences we've done in the last few years. That is coming up this fall again. And I enjoy the picture on the bottom left, because as we've all been working virtually these last couple of years, you can see here how our presenters were in the facility. Most of the attendance though was done virtual. We still were able to complete our live cases as always. Now, a bit about me. First, I wanna say I am not the chest pain MI registry site manager for our facilities. I'm the Cath PCI RSM, and I'm extremely honored that first I had the opportunity to be on the planning committee for the chest pain MI quality summit topics this year. And then secondly, I was honored once again when I was asked to present on today's topic. I've been in my current role as RSM for Cath PCI for over six years. I'm the RSM for our heart hospital facilities, and I help to manage the Cath PCI registry outcomes for our managed agreement facilities as well. Our heart hospitals perform over 2,500 annual PCIs. From our 2022 quarter one rolling four quarters, the heart hospital in Plano, we had 1,964 patients and a little over 2,000 PCIs. Prior to joining quality, I was the Cath lab manager and co-chest pain coordinator, working very closely at that time with our emergency department and our EMS providers. We went out visiting the EMS facilities, working on relationships. And just about that was the same time when the door to door to balloon initiatives were such a hot topic. Before that, I had a variety of roles within the Cath lab. I have over 25 years experience in total with Cath lab. Needless to say, I love what I do, and I am very committed to Cath labs and improving their outcomes. I'm currently part of a quality improvement department that is slightly different from others, where not only are we abstraction department, but we're also the process improvement department for both within registry and outside of registry. Almost everyone in my department has been nationally recognized, either through posters, podium presentations, or publications. At this year's quality summit, we have submitted two posters, and there are two of us presenting on demand sessions. Again, I want to review our objectives for today. And I also want to give thanks to the Heart Hospital, Baylor Plano, Heart Hospital McKinney, Heart Hospital Denton, as well as our Baylor Centennial Facilities. I'm using much of their data and examples of process improvements that they have put into place. So as we begin, I'm going to provide a bit of history behind how we got here. In 2007, the system of care was first established, looking at the MI patient as a whole. Then the 2013 ACC guidelines for the management of MI moved to looking at regional systems of care and goals for reperfusion, or our door-to-door-to-balloon times. This timeframe focused on the pre-hospital STEMI activations, feedbacks to care providers, as well as public awareness. Then in 2016, Duke Clinical Research Institute, in collaboration with the American Heart, conducted Regional Systems Accelerator 1 and 2 projects. These two studies, conducted independent of each other, resulted in the implementation of Mission Lifeline Accelerator 1 and 2 programs in regions of high population and with complex components of a STEMI system of care. In 2017, our ACC STEMI guidelines included a Class 1 recommendation that all communities should create and maintain a regional system of STEMI care that includes assessment and continuous quality improvement of EMS and hospital-based activities. And along with this came our goal of first medical contact to balloon of less than or equal to 90 minutes. From the same study referenced on the prior slide, 2016 Regional System of Care Demonstration Project from Duke shows us how, during that timeframe of the study, the methods of arrival, personal car versus by EMS. If you look at the slide on the left, this is showing the door-to-balloon time based on how the patient arrived. The green bar graph is by personal vehicle, the blue is by EMS, and the red is the overall door-to-balloon times based on arrival. And you can see by this bar graph that personal vehicle has the longest times. The slide on the right is for the same timeframe. It is showing us the comparison of door-to-balloon in the red by personal vehicle to first medical contact to balloon in the blue, with the door-to-balloon being longer than the first medical contact to balloon. So this data is showing us that our best opportunities for fastest reperfusion is when arriving via EMS. Although the goal of EMS transport to device of less than or equal to 90 minutes sounds feasible, it is challenging. How many of us work with only one EMS provider or one facility? And now in the larger areas, or even sometimes with cell phone use, how often does 911 always facilitate the right EMS to the right facility? How many times has the EKG you receive not look like a STEMI? Your cardiologist says, I still wanna see the patient when they arrive and I wanna get our own EKG. Or the patient rolls in the door, the count hasn't been activated in your EMR, so you can't pull meds out, you can't get the EKG, you can't get things going. Or the cardiologist sees the transmitted EKG, cancels the STEMI alert, then the patient arrives and they are a STEMI. For today, we're gonna focus on how to turn working with our EMS into a positive, cohesive relationship. So let's dig in. To start with, how many of us are working with multiple EMS providers? I moved to the Dallas-Fort Worth area from Davenport, Iowa, where each city basically had one EMS provider housed in maybe three or four locations. And we had two hospitals in the area. The map in the top right corner shows Davenport, Iowa at the time I left, in which they had four EMS stations. The map on the left shows the DFW area with the red dots representing all of the EMS providers we currently have. The green circle is Plano, Texas, where I am at, where we have, I believe, over 20 EMS providers. The next two graphs are showing our own Baylor Heart Hospital Plano data from January through June of 2022 for all of our MIs brought in by EMS. And we've so far, between those six months, had over 14 EMS providers bringing us patients. From the 2013 ACC Clinical Practice Guidelines, the EMS STEMI cancellation rate was about 15%. Using our Baylor Heart Hospital Plano data from January through June of 22, of our 53 STEMIs that we had, 22 arrived via EMS. Within those 22, four were successfully direct to cath lab admits. There were four additional that were attempted that stopped in the emergency department. And two of those were canceled upon arrival. So for our Heart Hospital Plano, our cancellation rate is about 27%. For our Heart Hospital McKinney, it is about 28%. Now our Baylor Centennial facility is under 10% with an overall increase in STEMI transfers. Baylor Centennial is one of our success stories. And I will be referencing much of what they have done as it has also been either rolled out at other facilities or it is in the process. I feel the first step to understanding our false activations is the simple idea of actually being able to track all of the STEMI alerts we have. Not sure about your facility, but I know we often say to each other, did you get a STEMI alert yesterday? I can't find a patient. Without software programs in place such as Pulsera, which does a great job of tracking alerts and other time-sensitive metrics, there are of course many challenges. There's challenges with getting the EKG to the cardiologist for approval. Either it's a HIPAA violation with the method we were sending it, or they have challenges with opening their approved software. This alone is working against our goal of EMS activations. So there's a trust issue already. Someone may forget to hit the STEMI alert button. So there's nothing that's sent out to track. Or there's a direct call to the cardiologist. He activates the STEMI on his own, telling the team in-house. So again, there's not an alert that went out, nothing to track. Or if the alert is canceled in the ED after arrival, then asking the ED staff to document the reason in the EMR. We know this is going to take extra time in their fast case environment. So then if we move to paper tracking, even if it's not in the chart, we know these papers get lost in the shuffle. Or if it's canceled prior to arrival, it might be during off hours. None of us even know there was a STEMI attempted. The first step to being able to successfully track the STEMIs is we must enforce our guidelines or our policies. For example, our policy is that the emergency department secretary is the one to actually activate the STEMI in the system for all of our STEMIs, whether they're through the emergency department, in-house, called in by EMS, et cetera. In the prior slide, I mentioned for our Plano facility that our cancellation rate was at 27%. The data shown here on this slide is from a publication in circulation from 2018, focusing on canceled STEMI activations. The data from 2012 to 2014 was used in this publication where there were 1,332 activations via EMS. You can see the breakdown on the circle graph for causes of cancellation. Most were canceled due to EKGs. On the right is an example of EKGs that can mimic a STEMI. Most often these are the rhythms that may be causing your pulse activations. This is a great place to start looking for trends. It is important to track every chest pain patient brought in to you by EMS, whether it is done through registry or manual. Remember, we don't know what we don't know. Once you start tracking, next you will look for the trends, identify common factors, and then use these opportunities for improvement to develop the relationship. This isn't a one-sided task. It must be a partnership in order to see improvements. As I mentioned, we can use our registry data to help us identify these areas of opportunity. Depending on how close to real time your data is abstracted and uploaded to NCDR, it may also be beneficial to have some sort of a spreadsheet or manual tracking that you also keep. Here are examples of each from our inner system care delivery dashboard and a manual tracking tool. With the chest pain MI registry, as our cases are abstracted or submitted to NCDR, our dashboard is populated with key areas specific to our transferring facilities and our EMS providers. As I mentioned, depending on how real time your abstraction is or how often you submit to NCDR, this is a great resource for identifying trends to address. However, sometimes you may want to see something more in the moment with tracking, which provides us the opportunity to be much more real time with process improvements, which is when we are using our spreadsheets. I will talk through each of these items over the next few slides. Luckily, not everything is manual. Our chest pain MI inner system dashboard offers us two views, one for the transferring facilities and another one for the EMS providers by agencies. I think the greatest benefit with this dashboard is not only our ability to break down that data by EMS locations, but the ability for the EMS providers or agencies to also be able to participate. If the EMS agency has an NCDR chest pain MI account, they can log in from their site and see the populated information for one facility specifically that they deliver to, or they can see the total system wide facilities that they deliver to that also participate in the registry. This can be a great knowledge base for the EMS providers. As you drill into the results posted on the dashboard, you will know there are metrics that are guideline driven while others are informational only, yet most valuable for helping to identify areas of opportunity. Going back to trending and identifying trends in a more manual manner. Here's a real life blinded data example from one of our facilities. There's a great amount of detail here. I don't expect you to take it all in, but to see how the spreadsheet is populated. I also want to say that this too is a shared data process. As abstractors, we work very closely with our chest pain coordinators, our ED leaders and our EMS liaisons. For example, if I'm the first one to catch a STEMI alert, I will start the communication with the chest pain coordinator on times I initially find. The chest pain coordinator, EMS liaison, or whomever else is helping with this process will then add to their spreadsheet along with the key items they want to track along with findings, comments, interventions, notes and feedback completed later. You can see what the spreadsheet looks like as it starts to populate. This is when we start to look for trends or what stands out, such as were canceled alerts from one EMS facility, one specific crew, one specific EKG reason. I know this looks like a totally manual time consuming process. It is, however, very much worth the work. So continuing forward, as we populated our data, we start to see a trend. And yes, these are still real life examples that are blinded. For example, sinus tach, not a STEMI. Sinus tach, right bundle branch block, not a STEMI. Sinus tach with PVCs, not a STEMI. These are opportunities, teaching moments, either in the moment or in the future. Now, if in the moment, remember that taking the moment in the ED to teach is not a reprimand, but a teaching moment. No one wants to be schooled. We want to feel valued. Teaching in the moment in a positive manner builds morale as well as confidence. We have some great ED physicians that are great about explaining to the EMS crew why the EKG may not have met STEMI criteria. I will talk a little further in more detail about the ways to help with the EKGs. As we develop or track the data, we want to then work with our EMS leaders. We've created a dashboard from this data for each EMS agency that we share with them weekly. When we see trends, such as the sinus tach, we work with the chiefs so that they too are aware and can also be working on education being provided from their side. We also want to make sure our processes align with the EMS processes and vice versa. For example, we recently standardized the use of heparin and ticagrelor through our emergency departments for all STEMIs. We quickly brought this information to our EMS providers. As I said, additionally, the education may be provided from the EMS. We've had education provided from them on how to best assist them when our transportation is arriving via helicopter. Education is a great way to help build these relationships. You can see on the slide here the list of several of the items we provide for our EMS. In the pictures here, actually, as we're talking about educating, one of our cardiologists from Barbalor Centennial Facility committed to every Monday for six weeks traveling to the different Frisco Fire Department locations and training the EMS providers on STEMIs, from diagnosing, EKGs, different devices used, as well as PCI education. Earlier, I mentioned that we report weekly to each EMS provider. We also follow up with the individual EMS crew within 48 hours. These are sent via secure email, and they are more personalized to the situation, and of course, always highlighting the good that happens. If you're lucky enough to be working maybe with only one EMS provider, and you have an EMS room in your ED, I have worked in facilities where we were able to hang these feedback forms up in that room, basically having a wall of accolades. As I mentioned, it is important in this relationship to celebrate the good things that happen. Celebrate the success. Oftentimes, these patients may have received CPR in the field. We've created STEMI Excellence Awards and Life-Saving Excellence Awards specific to the cardiac patients brought in by EMS. We reunite the patient with the crew. Certificates are presented along with an Excellence Award coin. These are some of my favorite moments. It's always so emotional when you see that patient reunited with the EMS provider that saved their life. Here are the Excellence Reward coins. The top center we serve together is on one side, and then depending on what type of reward it is is on the other side. We have cardiovascular care, trauma, stroke, going above and beyond. Although I'm based at a heart hospital, most of our Baylor facilities are full-service facilities with trauma, stroke, et cetera. These reward coins have been implemented at our Baylor Centennial location and are being rolled out to other facilities. It's great to see the EMS crew providers getting these, and they are also making it kind of a challenge between themselves to see who can earn what awards. Celebrating success. Dr. Kinsbauter is the cardiologist in this picture, and he's the same one that went out to the variety of EMS stations for the six weeks teaching on EKGs. He earned the Distinguished Colleague of the Year Award, which was presented to him by one of our facility CEOs, the EMS chief, and our EMS liaison. Since that initiative, we've recently identified the need for EKG education to be provided to the EMS at one of our other heart hospital locations serving a different region. We're hoping one of our other cardiologists will be able to rearrange his schedule to teach on sinus tach. Seeing a trend. Sharing the data. Let me help you. Everyone in the medical world has regulatory agencies that we have to follow, and just like us, EMS does as well. They have local, regional, as well as national regulations. Their 2050 national vision is to have seamless data integration for all patients between EMS and healthcare. Additionally, coming in 2023, will be Mission Lifeline's EMS recognition with a bronze, silver, and gold status. This too is another reason to help share the outcomes. As I showed earlier with our chest pain MI dashboard, the EMS can now gain access to their own outcomes through this route. However, it's us working together and sharing the data upfront that I think is really gonna help to build and sustain your relationships. Just like any relationship, once you've set the foundation, you have to sustain it. How are we within Baylor Scott & White facilities that I work with doing this? One thing we've done is we've implemented monthly EMS partnership meetings. These meetings include all of our North Texas facilities and all of the EMS provider agencies, all of our chest pain coordinators, our emergency department leaders, our cardiology medical director, as well as our emergency department medical director and our quality teams. As with most things, for the last two years, we've completed these meetings virtually. And I'm happy to say that we recently started back with both in-person as well as continuing with the virtual option. During our monthly EMS partnership meetings, we complete case reviews, which are done by cardiologists. We provide education, not just cardiac, but stroke, ortho, fire, trauma, as most of our Baylor facilities are full service hospitals. We also have EMS providing education for us and we provide any facility updates we may have and or EMS provides us with any updates from their side. And of course, we always take the time to celebrate. You can see this picture in the bottom center, which is from this year's EMS week. So what else do we do to develop and sustain our relationship with EMS? One of our favorite things is when the EMS brings a STEMI patient in, if their time allows, we encourage them to follow the patient from the ED up to the cath lab for their procedure. EMS providers really do enjoy this and it's a very good learning experience for them. We've also started to partner with our local colleges, EMS schools, and training facilities to include our facilities as part of their EMS clinical time. Not only rotating through the emergency department, but also a scheduled rotation through the cath lab for observations. Another important item in partnership with our EMS is community outreach. The picture with Sacchi is one of our EMS stations that we went to and helped to provide community or bystander CPR training. This is not only great for our relationship with the EMS, but it's also great for the community to see us working together as one. And then once again, EMS week. This year we were lucky enough that even though some of the cath lab staff had the time, they were able to go to the EMS stations to provide our treats and gift baskets. Again, showing them that we are making the effort to come to them. So in wrapping up, I hope that you can now see my vision that having false activations can actually be a good thing. And that you have a better understanding and the importance of building a relationship with your EMS providers, as well as several strategies for developing and sustaining that relationship or partnership. We're all part of this team. To end, I wanna first thank you for taking the time to attend this session, false activations, but are they a bad thing? Here you will find my contact information. Please feel free to reach out to me with any questions. I'm happy to share any of the tools mentioned today. And I would also love to hear from you what some of your best practices are. In my closing moment, I also wanted to share one of the more fun committees I'm now involved with at Baylor Scott and White Heart Hospital Plano. Our positive therapy committee. Kaluwa and Frenchie Hart, trained through canine companions, come to work every day to our facility, supporting our patients, their families, and our staff. I'm very grateful to be a part of Baylor Scott and White Heart Hospitals, and for having had this opportunity to present today. Thank you.

false cath lab activations

relationship building with EMS

EMS care improvement

system of care for MI

faster reperfusion for STEMI patients

challenges in diagnosing STEMI

communication and education between hospitals and EMS