Grampians Region

♥ 47,980 square kilometres

♥ Population of 216,000

♥ Some of the most sparsely populated areas of Victoria

♥ Boarders extend from Bacchus Marsh in the east, to the South Australian border in the west, from Woomelang in the north to Inverleigh in the south

♥ One sub-regional health service (Wimmera Health Care Group – Horsham)

0

41 km

43 km

Kaniva

Goroke

Edenhope(EDH)

89 km

Harrow

30 km

kilometres

25

Nhill(WWHS)

Rainbow

Jeparit

50

39 km

26 km

34 km

Dimboola

Natimuk

Beulah

Hopetoun

30 km

25 km

60 km(DmHS)Rupanyip

Minyip

Warracknabeal(RNH)

Willaura50 km

Lake Bolac

Ararat(EGHS)

33 kmStawell(SRH)

33 km

49 km

Woomelang

Birchip

Donald

57 km

53 km

62 km

Charlton42 km

Wycheproof

31 km

44 km

Elmhurst

48 km

Skipton(B&SHS)

64 km

Horsham(WHCG)

Murtoa

Creswick

Beaufort(B&SHS)

Avoca

Hospital Campuses

Grampians Region (and associated) Hospital Networks

Melton

63 km (to Avoca)

43 km

St Arnaud(EWHS)

67 kms(to Ballarat)

52 km

(SJOG)

48 km

Maryborough(MDHS)

Clunes

Ballarat(BHS)

45kmDaylesford

(HHS)

Ballan

Trentham

Bacchus Marsh(DjHS)

59 km

DmHS - Dunmunkle Health ServiceRupanyup, Minyip, Murtoa

WHCG - Wimmera Health Care GroupHorsham, Dimboola

Bush Nursing Centres (Harrow, Elmhurst, Lake Bolac, Woomelang)

EDH - Edenhope District Hospital

SDH - Stawell District Hospital

WWHS - West Wimmera Health ServiceNhill, Jeparit, Kavina, Rainbow, Goroke, Natimuk,Cooinda Disability Service Nhill

RNH - Rural Northwest Health Warracknabeal, Hopetoun, Beulah

Ballan District Health & Care (Private)

B&SHS - Beaufort & Skipton Health ServiceBeaufort, Skipton

EGHS - East Grampians Health ServiceArarat, Willaura

BHS - Ballarat Health ServicesBallarat, QEGCHHS - Hepburn Health ServiceDaylesford, Creswick, Clunes, TrenthamDjHS - Djerriwarrh Health ServiceBacchus Marsh, Melton

EWHS - East Wimmera Health ServiceSt. Arnaud, Donald, Birchip, Wycheproof, Charlton

105 km Ballarat to Western General Hospital98 km Ballarat to Sunshine Hospital

Maryborough District Health Services campuses atMaryborough, Avoca

Grampians Region continued…

Acute Coronary Syndrome Activity – 2010/2011

♥ 701 ACS Admissions♥ 12% (83) STEMI♥ 44% (307 & 312) each UA and NSTEMI♥ 570 of these through an ED admission pathway

Acute Coronary Syndrome Activity Continued…

♥ 59% (415) of ACS admissions resided within the Ballarat LGA♥ 10% (68) of ACS admissions resided within the Hepburn LGA♥ 7% (47) of ACS admissions resided within the Pyrenees LGA

Acute Coronary Syndrome Activity Continued…

♥ 62% (435) of ACS admissions are male

Acute Coronary Syndrome Activity Continued…

♥ The average age of ACS admissions was 68 years♥ The majority of ACS admissions (70% or 495) fall into the 51 to 80 age range♥ These results need to be considered in relation to population age predictions,

when assessing the impact upon health service resources looking forward

Acute Coronary Syndrome Activity Continued…

♥ 61% (430) of ACS admissions were discharged home♥ 26% (180) were transferred to another facility♥ 5% (36) resulting in death

Acute Coronary Syndrome Activity Continued…

♥ 701 ACS admissions♥ ALOS in hospital for Unstable Angina admissions matched the state average LOS♥ ALOS in hospital for STEMI admissions was less than the SALOS♥ ALOS in hospital for NSTEMI admissions was 2 days longer than the SALOS

Acute Coronary Syndrome – Clinical Performance

♥ 54% of Unstable Angina admissions through ED received a triage category of 1 or 2♥ 75% of STEMI admissions received a triage category of 1 or 2♥ 46% of NSTEMI admissions received a triage category of 1 or 2

Acute Coronary Syndrome – Clinical Performance

Recommendation 1All patients presenting with chest pain for investigation, should have the earliest possible access to 12 Lead ECG> Pre hospital in ambulance> Within 10 minutes of arrival to ED

♥ Snapshot looking at 70 ACS admissions♥ 40% (28) received an ECG within 10 minutes of arrival to ED♥ 30% (21) received an ECG between 11 to 20 minutes of arrival to ED♥ 30% (21) received an ECG greater than 20 minutes following arrival to ED

Acute Coronary Syndrome – Clinical Performance continued…

Recommendation 4All patients with ST segment myocardial infarction (STEMI) who are eligible for thrombolysis or primary PCI receive a reperfusion therapy in accordance with evidence-based clinical practice guidelines> Patients eligible for primary PCI receive a door to balloon time in 90 minutes in 75% of cases

♥ 33 STEMI admissions underwent PCI♥ 39% (13) received a door to balloon time of within 90 minutes♥ 61% (20) received a door to balloon time of greater than 90 minutes

The STEMI Experience at BHSMilestones♥ December 2008 to October 2011

- all diagnostic and interventional work performed on BHS patients occurred at SJOG cath lab

♥ October 31st 2011- BHS Cardiovascular Suite began diagnostic angiography- all interventional work still occurred at SJOG

♥ March 26th 2012- site visit by A/Professor Andrew MacIsaac for credentialing in view of commencing interventional work

♥ June 2012- commenced elective interventional work- PPCI work still carried out at SJOG

♥ September 10th 2012- commenced PPCI work at BHS Cardiovascular Suite

DEIVA Pathway

D Doctor notified within 10 minutes of arrival

E 12 Lead ECG performed within 10 minutes of arrival

I IV Cannula inserted, bedside troponin & other bloods

V Vital signs and cardiac monitoring

A Aspirin 300 mg

Not necessarily in this order Consider: oxygen if saturations < 93% & ongoing pain management

E A R L Y M A N A G E M E N T O F A C U T E C O R O N A R Y

S Y N D R O M E

D D o c t o r n o t i f i e d w i t h i n 1 0 m in u t e s o f a r r i v a l

E 1 2 L e a d E C G w i t h in 1 0 m in u t e s o f a r r i v a l

I IV c a n n u la , b e d s id e t r o p o n in a n d o t h e r b lo o d s

V V i t a l s ig n s a n d c a r d ia c m o n i t o r i n g

A A s p i r i n 3 0 0 m g

* N o t n e c e s s a r i ly in t h is o r d e r * C o n s id e r : o x y g e n i f s a tu r a t io n = 9 3 % a n d o n g o in g p a in m a n a g e m e n t

E a r l y n o t i f i c a t i o n t o a c a r d io lo g is t

STEMI Pathway & Worksheet (PCI) – ED to CVS

♥ 3 tools in 1♥ Pathway, worksheet and audit tool♥ Simple 1 page document♥ Document follows the patient through the pathway♥ MR form to be retained within the patient’s history♥ Ability to identify areas of service delivery we do well, and

areas that require improvement♥ Aligning pathway for thrombolysis♥ Education/communication plan to support implementation♥ Representative of recommended best practice guidelines♥ KPI’s attached to form completion and performance

- MonAMI Project♥ Significance

The STEMI Experience – the first two months of opera tions

Demographic Details

From 10th September to 9th November, 13 patients were transferred to the Cardiovascular Suite at BHS under an ST elevation myocardial infarction criteria. Of these:

• 11 patients underwent primary PCI• 1 of these was an after hours STEMI presentation to SJOG ED (no data available)• 1 patient had an angiogram and a clinical decision was made not to proceed to PCI• 1 patient had an angiogram and was found to have minor disease, therefore also did

not proceed to PCI

The STEMI Experience – the first two months of operations continued…

♥ 9 (69%) cases have presented via AV transfer♥ 3 (33%) of these underwent PHN

The STEMI Experience – the first two months of operations continued…

♥ 83% of presentations had a residency address within the Ballarat LGA

The STEMI Experience – the first two months of operations continued…

♥ The average age of this patient population was 64 years

Model of Service

♥ 54% of STEMI admissions presented to the ED after hours (1800 to 0800 hrs)♥ 46% of STEMI admissions presented to the ED during business hours

Model of Service continued…

♥ 77% of STEMI admissions presented in October

Clinical Performance

♥ All patients have been triaged appropriately according to theirclinical requirements

Clinical Performance continued…

♥ During the first month, 4 (57%) of patients had their first ECG within 10 minsof arrival

♥ This increased to 100% in the second month

Clinical Performance continued…

♥ During the first month of operations, 66% of patients received a D2BT within90 minutes

♥ This increased to 100% during the second month

Improvements to Clinical PerformanceIdentified Gap in Practice

2010/11 Identified Gap Measurement

Improvement in Clinical Performance/Outcomes Sept to Nov 2012

Recommended Guidelines/Goal to be Achieved

Goal Achieved this period

Triage Categorization

25% STEMI admissions through

ED received a triage category 3

100% STEMI admissions to date have received a triage category of 1

or 2

In accordance with national triage standards, and recommended

guidelines, all STEMI admissions did receive a triage category of 2, unless their condition warrants otherwise

√√

Triage to First ECG

Some STEMI admissions were having their first ECG performed greater than 20

mins after arrival to ED

While 57% of patients still received their ECG within the first 10 minutes

after arrival during the Sept/Oct period, this has since increased to 100% during the Oct/Nov period. Collectively, 73% of patients have

received their ECG within the first 10 minutes of arrival to ED since

operations began

All STEMI admissions should receive their first ECG within 10 mins of

arrival to ED, in accordance with

recommended best practice guidelines

√√

Door to Balloon Times

39% of STEMI admissions

received a door to balloon time within the recommended

time frame

During the Sept/Oct period, 66% of patients received a door to balloon time within 90 minutes. This has

since increased to 100% during the Oct/Nov period. Collectively, 80% of

patients have received a door to balloon time within 90 minutes during

the first 2 months of operations.

At least 75% of cases should receive a door to balloon time of less than 90 minutes as per

recommended best practice.

√√

The Case of Patient O

Demographics

♥ Pt O is a 68 year old lady♥ Lives with her husband♥ Family history of cardiac and stroke in parents and siblings

Presenting History

♥ Onset of severe central chest pain at 0930 hrs whilst at rest returning home in the car – radiating down both arms

♥ Associated nausea and vomiting (at home)♥ Pt notified husband 40 minutes later and AV was called

Outcomes

♥ 100% occlusion to LAD♥ Ventilated for 2 days in ICU♥ Induced hypothermia for 24 hours

6 days later, Pt O walked out of hospital, after being discharged home

She was extremely grateful for the care she had received

Where to From Here…

♥ focus on accessing this service in providing best patient outcomesfor residents of the Grampians region

♥ developing collaborative working relationships with our regional colleagues

♥ supporting our regional colleagues through the development of an ACSFramework to assist them in providing care aligned with recommended best practice principles

♥ identifying our regional colleagues as a vital resource in the formation of the Framework

♥ establish a working group consisting of a cross section of staff from regional facilities to assist in developing the Framework

♥ supported implementation of the Framework through education and roadtrips to regional facilities

Be a D E I V A

They will survive …

Thank you to the following key stakeholders for their support:

♥ Fiona Greig (Nurse Unit Manager of CVS)

♥ Ernesto Oqueli (Head of Cardiology)

♥ Anton Freischmidt (Redesign Manager)

♥ Hella Parker (Manager of Cardiac Clinical Network of Victoria)

……and a special thank you toand a special thank you to