Project UPSTART -- STEMI BootCamp

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Customizing Your STEMI ALERT Packet

Welcome to the STEMI ALERT Packet adaptation process! Please read the following information carefully. You will find it extremely valuable as you start to customize the STEMI ALERT Packet to fit your institution and system. The customization process takes minimal time but we have included many hints and suggestions to make the process proceed even more smoothly. Time spent refining your STEMI Alert Packet will be worth the effort.

Included with these instructions are template STEMI ALERT Packet forms in Microsoft Word format. We have included basic forms from both a non-PCI center and a PCI-capable center. To get you started, we have included forms from the University of Virginia (a typical PCI -capable center) and from Culpeper Regional Hospital (a rural non-PCI center). These templates will serve as examples for construction of forms specific to your hospital.

To begin, first print out several copies of each form on white paper. This will allow you to analyze each form carefully and annotate each form with anticipated changes necessary for your institution. This approach is often more productive than making immediate changes to the electronic templates. Once you have your process fairly well thought out, start transferring the details to the electronic forms. The final forms will be printed out on color-coded paper.

The Project UPSTART color guide (.pdf) provides all the information required for ordering the necessary colors of paper (and envelopes). The red envelopes that are utilized for the STEMI ALERT Packet can be printed utilizing the attached JPEG file.

Please spend some time analyzing each form and make sure you understand the STEMI ALERT process and how you feel it should proceed at your site. Thinking about your best-practices process carefully will often point out processes that need improvement. So, think carefully about how things should happen, not as they happen now.

Each STEMI alert packet, regardless of whether it is utilized at a PCI capable or non-PCI institution will usually end up containing versions of the same basic forms. The following forms are the ones found in virtually every STEMI ALERT Packet.

  1. Physician Checklist
  2. Nurse Checklist
  3. STEMI Scribe Checklist
  4. Data Sheet A
  5. Data Sheet B

These five forms form the core of the basic UPSTART STEMI ALERT Packet. The goal of packet customization is to develop a best-practices STEMI ALERT process for your situation and then paste those details within the packet. Keep it simple as its important that you keep instructions clear and that you limit the forms to one side each-with some exceptions.

In addition to the five basic forms, there are several other additional forms that you may use at your institution. These are often used in combination with the above forms to address specific situations and are usually attached to one of the five basic forms or printed on the reverse side.

  1. The ED activation of the cath lab criteria (.pdf) form is usually printed on the back of the blue Physician Checklist. It is utilized at facilities that have the ED physician independently activate the cath lab for clear-cut STEMI cases. Clear activation guidelines make it much easier for the ED physician to decide which cases merit can't fault it in with the cardiologists prior to activation. This usually turns out to be less than 15%. Having activation guidelines in place also assures the cardiologists that questionable cath lab activations will be minimized.
  2. Non-PCI sites may need to administer thrombolytic agents to their STEMI patients. The Thrombolytics Assessment Worksheet (.pdf) provides an easy method of assessing STEMI patients for thrombolytics suitability. This form is derived from accepted criteria and can be readily adjusted to fit institution specifics. It is often printed on blue paper stapled to the blue physician checklist. We also encourage institutions to print their specific thrombolytic protocol on the back of the sheet. That way, the physician at a non-PCI center has instant access to all information required to manage a STEMI ALERT patient -even if they require thrombolytic therapy.
  3. The “EMS ECG collection sheet” helps facilitate physical collection of pre-hospital ECGs. This is important for integrating EMS into the STEMI care continuum that your institution. This form is usually attached to Data Sheet At and clear instructions are placed upon it (and throughout the other STEMI alert checklists) to ensure that EMS and ED staff are prompted to attach any pre-hospital ECGs to this form.

Each STEMI alert packet sheet will be color coded to facilitate instant identification. When a STEMI occurs, a STEMI ALERT Packet is opened immediately. At that point the three checklists guide the STEMI alert process as it occurs and the two data sheets collect basic quality improvement data for later analysis. During each STEMI alert, Data Sheet B always goes to the cath lab with the patient and Data Sheet A and the three checklists (along with the comments, etc that they contain) are put back in the original envelope and sent to a designated ED quality improvement liaison.

In this manner, the ED and the cath lab both receive the same quality improvement data directly without anyone having to make a copy etc. If one data sheet is lost, you still have the other sheet to provide most of the data. Since the ED receives the data immediately, it makes fast feedback much easier than if they have to wait for the cath lab to send them the data. Hence the importance of two data sheets, even though it may at first glance seem redundant. Experience has shown that a dual sheet data collection process is far superior compared to the use of a single data collection sheet.

An important key to the success of this process is an understanding the importance of the many small details that go into these forms. For example, color-coding is important to facilitate instant recognition by ED staff of the correct form. Having all forms printed on white paper does not have this advantage. Similarly, having two data sheets of the same color limits their visibility, and decreases compliance with completion.

It is important that each form contains sufficient information to facilitate a precision STEMI alert each time. However, avoid the temptation to excessively complicate these forms in an attempt to guide the process. This is particularly true with the Physician Checklist.

Another tendency to avoid is the impulse to utilize Data Sheet A and Data Sheet B to collect excessive data. You want to collect only those data points necessary for real-time quality improvement. Data Sheets A and B were not designed to collect registry or research quality information or measure things such as aspirin compliance. The 12-14 total data points collected on a typical UPSTART Data Sheet will provide sufficient quality improvement information on each important interval for you to continually fine-tune your process -without reducing compliance from busy staff.

As you work towards refining the individual components of your site-specific STEMI ALERT Packet, questions often arise. Please feel free to contact us for assistance or advice -particularly early in the process. The reason for this is that there are many details that function together smoothly to produce a refined STEMI ALERT Packet. Some are obvious. However, many of these details and concepts are subtle and much more easily explained over the phone as you work through the form customization process. We have worked with dozens of hospitals via phone call and have been told it is an immensely helpful process!

In summary, if you are in the process of customizing your STEMI alert packet and would like some personal assistance, please feel free to contact me at the e-mail address below or leave me a phone message on my office voicemail. We can then set up a time to talk via phone. I sincerely enjoy working with the motivated people who are striving to improve STEMI care so don't feel shy about contacting me!

Sincerely,

David R. Burt, MD
Assistant Professor of Emergency Medicine
Developer, Project UPSTART
University of Virginia Health System
PO Box 800699
Charlottesville, VA 22908
O: (434) 924-2428
davidrburt@virginia.edu