STEMI Fast Track
Central Chest Institute of Thailand

A. Problem Analysis

 1. What was the problem before the implementation of the initiative?
ST Elevation Myocardial Infarction (STEMI) is acute myocardial infarction recognized by ECG changes, especially a characteristic elevation in the “ST segment.” It is caused by ruptured atherosclerotic plaque and blood clots clinging to blood vessel wall. The blood clots will grow in size and completely block the coronary artery. As a result, there is insufficient blood supply to the heart muscle. If patients receive drugs that dissolve blood clots or dilate vessels in a timely manner, their heart muscle will be saved. However, if the patients go to hospital too late or their coronary artery cannot be dilated, the heart muscle may die and the patients may suffer complications, resulting in death. The most common symptom is chest pain. Other associated symptoms include shortness of breath, fainting, dizziness, and cold hands and feet. For effective treatment, STEMI patients have to be rushed to hospitals for diagnosis and treatment as soon as possible. However, if it takes too long to take patients to the hospitals or the diagnosis is incorrect, slow or substandard, there may be lethal complications, such as life threatening cardiac arrhythmia. In certain cases, patients experience heart failure, mitral regurgitation, hypotension, shock and unconsciousness. According to the 2010 statistics of World Health Organization, worldwide deaths from coronary artery disease (CAD) totaled 7.2 million (representing 12.2% of all global deaths). Between 2005 and 2009, it was found that 1,185 Thai heart disease patients were hospitalized per day; of this number, 470 of them had myocardial infarction. Each hour, two patients passed away, half before reaching the hospital. A country of 65 million people, Thailand had 53,320 patients with CAD (87 per 100,000 persons: WHO, 2008). The rate of deaths from ST Elevation MI (STEMI) was 17% (Thai ACS registry, 2007) whereas the international standard was 7% (Grace, 2002). Certain limitations in Thailand consist of shortage of specialized doctors and nurses, a lack of hospital beds to meet the growing number of patients, unclear and time-consuming patient referral system, and most importantly people’s failure to recognize the disease’s signs and symptoms, causing them to take a long time before making a decision to go to hospital and thus losing an opportunity to receive standard treatment. As a result, many STEMI patients die or suffer complications, some of which develop into chronic diseases, such as heart failure from myocardial infarction, which eventually affects their quality of life, either in terms of career, incomes, personal life, or family. From independent persons, some patients have to depend on their families or the society and live with a chronic illness. Central Chest Institute of Thailand (CCIT) is specialized in treating patients with heart and lung diseases. The institute has gradually evolved throughout its 70-year history, starting from providing treatment for lung disease patients. Currently, it is recognized nationwide as a leading hospital in treating patients with heart and lung diseases as well as patients with acute and chronic complications referred from all over the country. The CCIT is under supervision of the Department of Medical Services, Ministry of Public Health, which is an academic department responsible for invention and dissemination of medical technologies to other hospitals under supervision of the Ministry of Public Health. The CCIT’s capabilities and potentials are equal to those of hospitals in medical schools. However, there are a larger number of patients because the institute is divided into three main divisions, namely cardiology, pulmonary medicine, and cardiothoracic surgery. It has 334 beds. The bed occupancy rate of heart disease patients is higher than 85% and that of patients with critical cardiac illness is higher than 110%. The institute admits more and more patients with STEMI referred from other hospitals each year (257, 323 and 433 patients in 2011, 2012 and 2013, respectively). The institute has performed cardiac catheterization for 5,827 patients, which is the second largest number of Thailand, after Queen Sirikit Heart Center of the Northeast in Khon Kaen Province (6,344 cases). The CCIT serves as the heart disease hub for both public and private hospitals in Region 4 (eight provinces in the upper part of the Central Region of Thailand, responsible for the population of approximately 5 million people). In 2012, there were 1,136 STEMI patients. There is a larger group of people at risk of CAD due to a growing number of senior citizens. Moreover, younger citizens with current cigarette smoking tend to develop the disease and there are more patients with hypertension and diabetes. All of these are risk factors leading to coronary artery disease and eventually acute myocardial infarction.

B. Strategic Approach

 2. What was the solution?
According to statistical data collected by the Central Chest Institute of Thailand (CCIT), there are a number of STEMI patients who are unable to receive a proper treatment due to a lack of patient beds. Moreover, it is impossible to increase the number of beds because of shortage of doctors and nurses specialized in heart diseases. The time taken by other hospitals to refer their STEMI patients to the institute often exceeds the time required for effective use of vasodilators since there are no referral procedures and data established. As a result, the referral system is redundant and time-consuming. It was also found that it usually takes a long time for patients to decide to come to the CCIT since they are uncertain of their symptoms, take time to consult their relatives or associates, or assume that they have gastropathy. Based on international standards, patients being diagnosed with a STEMI must receive medication to open their vessels or balloon dilatation of occluded vessels so call percutaneous coronary intervention as soon as possible for the purposes of saving life and reducing dangerous complications. The Division of Cardiology, led by Kriengkrai Hengrussamee, M.D., deems it essential to determine whether personnel of the CCIT are well prepared and if the number of the personnel is sufficient. Therefore, STEMI Fast Track was internally developed in the CCIT to enhance teams’ capabilities through training courses, seminars and case studies from the Cardiac Care Unit (CCU) team to cardiac catheterization team, cardiac, litter center and referral center, enabling doctors, nurses, cardiothoracic technologists and others to make correct and fast evaluation, diagnosis, and treatment. For example, ECG is performed within 10 minutes of arrival; cardiologist is reported and begins diagnosis within 15 minutes; patient is moved to intensive care unit (ICU) within 20 minutes in order to receive thrombolytic drugs within 30 minutes or balloon angioplasty within 90 minutes; and transfer of patient between units is fast and seamless. Standard treatment will be applied to all patients. The steps of treatment will be reduced from 11 to 6 steps (in case of walk-in patients) and 4 steps (in case of referred patients). Lean management will be adopted for fast and quality connection between related units. A checklist is made before administration of thrombolytic drugs or percutaneous coronary intervention for quickness and reduction of complications after treatment. Upon completion of personnel’s capability enhancement, the number of bed in the cardiac intensive care unit is increased from 6 to 8 and 9 beds with the 10th bed available for STEMI Fast Track patient all the time. The number of patient beds in the intermediate ward was increased to 6 beds to support STEMI patients from the intensive ward. Proactive public relations are carried out at all levels in order to raise people’s awareness of signs and symptoms of STEMI through radios, newspapers, televisions, online media (You tube), cutouts posted in crowded areas, and events for specific target groups, such as housewives in department stores and taxi drivers to enable them to take patients with certain signs and symptoms to proper places in a timely manner. There are also more communication channels, such as 1668 hotline to answer questions and give advice in urgent cases. The 1668 hotline is connected with the existing 1669 EMS hotline. Due to the fact that the CCIT serves as the heart disease hub in Region 4 (covering 43 hospitals in eight provinces), the STEMI Fast Track has been expanded through coordination and cooperation with National Health Security Office (NHSO) who covers the expenditures. In cooperation with NHSO, the institute has formed an STEMI Treatment Development Committee comprising doctors and nurses from all provinces. The committee has organized and attended a number of seminars, reached agreements on standards for effective treatment and correct and fast referral of patients within the region, provided advice, and paid site visits to solve problems during project implementation.

 3. How did the initiative solve the problem and improve people’s lives?
Lean concept has been adopted for management of the STEMI Fast Track project. After a thorough review of project implementation, the Heart Team has determined that it is essential to increase the treatment efficiency by reducing unnecessary steps in order to enable patients to receive treatment as soon as possible. After patients are screened by nurses as having acute myocardial infarction, the patients will be put to an electrocardiography and blood sample will be taken for a cardiac enzyme test immediately. The physician in the emergency room will be reported of the patient’s arrival with the results of electrocardiography. Simultaneously, a physician who is specialized in cardiac illness will be consulted instead of taking the patient to the cardiac inpatient ward first. This allows a faster diagnosis by a specialized physician. Cardiac catheterization personnel will be contacted for preparation of the cardiac catheterization immediately instead of taking the patient to the Cardiac Care Unit (CCU) first. Thus, in case of walk-in patients, the 11 steps of treatment will be reduced to only 6 steps whereas the level of quality of care remains the same and patients are treated faster. In case of patients referred from other hospitals, data on the patients’ first and last names, national ID card number, rights to medical care, electrocardiography results, chest x-ray images, and blood test results must be received before arrival of the patients. Therefore, the patients can have a consultation with cardiologists immediately. Upon being diagnosed by cardiologists, the cardiac catheterization team can be contacted and start working (ready to perform cardiac catheterization within 30 minutes). Patients are able to enter the cardiac catheterization lab as soon as they arrive without having to go through emergency room, medical record room, and CCU. Patients will be admitted even before their arrival (early admission). The steps of treatment can be reduced from 11 to 4 with balloon angioplasty can be performed within 90 minutes of arrival. STEMI Fast Track service is available 24 hours a day, 7 days a week, and 365 days a year. After the proactive public relations, there are ambulance cars that have been trained to transfer patients in a timely manner. The patients or their family members can call 1668 hotline to ask for advice when they are in doubt. There are physicians from community hospitals coming to the institute to ask for advice from or have their diagnosis confirmed by cardiologists. In this regard, they may send the electrocardiography results through Line application or email. Implementation of STEMI Fast Track in CCIT is a success. Balloon angioplasty in STEMI or primary percutaneous coronary intervention is performed faster and on a larger number of patients. The mortality rate is reduced. Therefore, it has been expanded in Region 4 (the upper part of the Central Region) to cover 8 provinces and 5 million people. Finally, the coverage has been extended to people all over the country in 12 regions of public health service network to serve 65 million people with support from public health teams nationwide.

C. Execution and Implementation

 4. In which ways is the initiative creative and innovative?
When the team had reached mutual agreements and become ready (with the number of doctors and nurses specialized in cardiology sufficient to support patients), the STEMI Fast Track was implemented by the team led by Kriengkrai Hengrussamee, M.D., Chief of the Division of Cardiology. The project was announced as a policy of the Central Chest Institute of Thailand in January 2009 with the objective to enable all STEMI patients to receive the same and standard care in a timely manner, be referred to more efficient hospital, and have access to equal, standard, fast, and timely services. Other objectives were to enable people to recognize the signs and symptoms of acute myocardial infarction and to enhance capacities of hospitals in the network to provide standard care and services to patients, either in the countryside or urban areas. When the institute and its personnel were capable of providing standard and timely care and referral services to STEMI patients, the number of bed in CCU was increased to 9 with the 10th bed available for STEMI Fast Tract patient all the time. The number of patient beds in the intermediate ward was also increased to 6 beds to support STEMI patients from the CCU. A clinical practice guideline (CPG) was established for everyone involved, including personnel at the patient admission center, emergency room, CCU, and cardiac catheterization lab as well as personnel of hospitals referring the patients, to have knowledge of the steps and methods for proper care and referral of patients with chest pain, or those without chest pain but nausea, sweating, low body temperature and dizziness, or patients with heart disease, or patients in the hospitals who had the abovementioned signs and symptoms. Workshops were organized at the Central Chest Institute of Thailand and representatives of those hospitals in the network were invited to attend the workshops in order to mutually seek agreements and solve problems, especially in relation to fast and effective referral of patients and transfer of data. Between February and May 2009, data on STEMI Fast Track as well as signs and symptoms of acute myocardial infarction was publicized through newspaper articles, television programs, You tube channel, brochures, and cutouts posted in crowded areas. There were also events held at department stores and data was disseminated to taxi drivers to enable them to properly refer the patients to the right place at the right time. In June 2009, the project was expanded to hospitals in Region 4 by means by organizing a workshop attended by 43 hospitals. A mapping process was performed and attendants jointly determined which hospitals were capable and not capable of administering thrombolytic medications. Four months after commencement, the project was followed up periodically, such as visits of hospitals in Region 4 to mutually solve problems encountered and use data obtained to revise the care procedures and reduce steps in a dynamic manner from 11 to 6 steps (walk-in patients) and 4 steps (referred patients). The care system was assessed by monitoring all established indicators on a monthly basis. Such indicators included the time from arrival of the patients up to balloon angioplasty, which should not exceed 90 minutes, and mortality rate. Since the project was a success, an extension project called “Save 10,000 Hearts” was proposed to the Ministry of Public Health. In this project, the network model used in Region 4 would also be applied and expanded to 12 regions of public health service network nationwide and basic information of STEMI patients would be managed for hospitals in the network and used for improvement of their services. Additional benefit of this extension project would be to obtain data that could be used for evaluating effectiveness of STEMI care and planning the STEMI care development at the national level.

 5. Who implemented the initiative and what is the size of the population affected by this initiative?
STEMI Fast Track stakeholders were as follows: 1) Personnel in and outside the Central Chest Institute of Thailand included physicians, nurses, pharmacists, cardiac catheterization lab team, CCU team, emergency room team, and litter team. Outside personnel were personnel of hospitals in the network, including physicians, nurses, pharmacists, and other concerned persons. After the workshop, all personnel understood that the project would reduce morality and disability rates of STEMI patients. Participation of all stakeholders in the problem-solving process made them proud of taking part in saving patients’ lives, site visits, holding workshops to help network hospitals to have more knowledge and confidence in treating STEMI patients. 2) National Health Security Office (NHSO) partially provided financial support to STEMI Fast Track since 70% of the patients were in the payment system of NHSO and treatment of STEMI required expensive medical equipment. Moreover, most of the patients were referred from other medical facilities in order to be under the care of efficient team. Thus, NHSO supported the Central Chest Institute of Thailand in building and improving the quality of network hospitals in order to enhance the performance and reduce expenses. In addition, NHSO has helped with finding patient beds if the Central Chest Institute of Thailand does not have enough beds and covered the expenses incurred from meetings/workshops for network hospitals, consultation visits, and acquisition of cardiac catheters. Therefore, it is much easier for the Central Chest Institute of Thailand to manage its cardiac catheters. 3) At the policy level, the Central Chest Institute of Thailand has proposed the “STEMI Fast Track” initiative to the Department of Medical Services, Ministry of Public Health. As a result, it has received more personnel and modern equipment. Moreover, a policy has been developed to connect with different hospitals all over the country in an extension project entitled, “Save 10,000 Hearts”. The Department of Medical Services has also allocated a budget to cover such expenses as public relations on signs and symptoms and effective treatment of STEMI, production of video clips to publicize the project on television and radio, public relations events held at department stores, and signboards posted in public places.
 6. How was the strategy implemented and what resources were mobilized?
STEMI Fast Track has effective management of human resources, equipment, instruments, tools, and other resources for utmost benefits as follows: 1) Medical equipment: cardiac catheterization lab is equipped with cardiac catheterization equipment, which is very expensive (about 20-40 million baht each) and has a useful life of about 5 years. The cardiac catheterization lab was formerly used only during official hours so it was not used to the best of its capacity. When STEMI Fast Track initiative was implemented, the cardiac catheterization lab was in service 24 hours a day, meaning that it could be used all the time. 2) Personnel of cardiac catheterization lab: formerly the personnel would operate during their working hours and there were standby personnel to serve emergency patients. However, if there were no patients, there would be no overtime workers in the lab. When STEMI Fast Track initiative was implemented, there were no additional personnel, but the cardiac catheterization would be performed immediately when patients arrived. After working hours, the number of lab personnel was less than that during the working hours. However, the results were still good and this could be seen from the reduced mortality rate of STEMI patients and a higher rate of referred patients. 3) Techniques: STEMI Fast Track is a technique enabling reduction in the mortality rate of patients because doctors would be allowed to perform emergency medicine on cardiac patients only if they have performed 200 cases of cardiac catheterization per year and 100 cases of emergency medicine per year. Good communication technique is essential in this initiative, especially in sending the results of electrocardiography and lab blood test. The initiative uses communication applications enabling users to read electrocardiogram, such as email, Line and WhatsApp (facsimile does not allowed reading of electrocardiogram); therefore, STEMI diagnosis can be made quickly and timely. 4) Budget: the budget spent on this initiative was provided by the Department of Medical Services, Ministry of Public Health, and NHSO. Due to the proposal made by the Central Chest Institute of Thailand, in 2009-2012 the budget received was as follows: - Workshops 608,941 Baht - Site visits 128,274.50 Baht - Preparation of technical documents 195,455 Baht - Preparation of standard documents 50,000 Baht - Data management 50,000 Baht - Development activities of 43 network hospitals 1,020,000 Baht - Balloon Angioplasty, approximately 100,000 baht/patient, 62 patients in 2009, 80 patients in 2010, 247 patients in 2011, and 324 patients in 2012, totaling 71,300,000 Baht

 7. Who were the stakeholders involved in the design of the initiative and in its implementation?
Outputs of this initiative were as follows: 1) Reduction of steps: the 11 steps for STEMI care have been reduced to 6 steps (for walk-in patients) and to 4 steps (for referred patients.) 2) Increase of the numbers of the referred patients; the institute is able to admit more referred patients. In 2008, the institute could admit only 52 referred patients (50%), but the number increased to 62 patients (79%), 80 patients (86%), 247 patients (87%), and 324 patients (92%) in 2009-2012, respectively. 3) Improved treatment results: - STEMI patients receive balloon angioplasty immediately and within 90 minutes of their hospital arrival (meeting international standard) after implementation of the STEMI Fast Track initiative. There were 35 patients (47%) receiving balloon angioplasty in 2008, but the number increased to 61 patients (80%), 78 patients (86%), 175 patients (91%), and 206 patients (90%) in 2009, 2010, 2011 and 2012, respectively. - STEMI patients receive balloon angioplasty within 90 minutes of hospital arrival (meeting international standard) after implementation of the STEMI Fast Track initiative. From an average time of 110 minutes in 2008, STEMI patients were able to receive vasodilators within 61, 53, 55, and 55 minutes after arrival in 2009, 2010, 2011 and 2012, respectively. 4) Site visits for problem-solving were performed in seven hospitals in 2010 and the number increased to 10 hospitals in 2011. 5) The number of network hospital attending the initiative for capability enhancement increased from 33 to 43 hospitals. From 7 hospitals that were able to administer thrombolytic, the number rose to 10 hospitals. From 43 hospitals in Region 4 (8 provinces), clinical practice guideline or CPG is currently adopted by 320 hospitals in 12 networks and 86 provinces nationwide, covering 5 million people in Region 4 and 65 million people all over the country.

 8. What were the most successful outputs and why was the initiative effective?
The activities are monitored and evaluated as follows: 1) Quality and effectiveness of STEMI care in the Central Chest Institute of Thailand - Compliance with CPG by existing physicians, new physicians and overtime physicians has been monitored on a monthly basis. This is to determine how CPG should be improved. For example, if patients arrive with shock, they have to be taken to CCU first. After they are stable, they will then be taken to cardiac catheterization lab for further treatment. - Indicators that reflect quick and timely care, including door to EKG time, door to diagnostic time, door to CCU time, door to thrombolytic time and door to balloon time, are monitored on a monthly basis. This is to determine what should be fixed. For example, if door to CCU time exceeds the limit (20 minutes), transportation of patients must be faster by making Fast Track patient ID tags and having someone get the lift ready to reduce the transportation time. After correction is made, the door to CCU time has never exceeded the limit again. - Bed monitoring: nurses on duty would report the problem of insufficient beds to PCT team on a monthly basis. The problem was solved by making a special bed in CCU available for STEMI patients at all time. Such solution must be agreed among PCT team members. When the beds in CCU are not available, patients will be transferred to the intermediate ward where there are six beds. - Referral monitoring: data is obtained from the patient referral center. In case of problems, such as unclear or incomplete data, referral data forms and referral flow are forwarded to network hospitals and those hospitals that refer their patients to the Central Chest Institute of Thailand. - People’s awareness of STEMI is evaluated from the number of calls made to 1668 hotline, asking about suspicious symptoms and requesting advices. The evaluation is performed on a monthly basis. - Evaluation of potentials of hospitals in the networks is performed through site visits. A total of 10 site visits have been made. There are 10 hospitals capable of administering thrombolytic and 33 hospitals that are not capable of administering thrombolytic. During each site visit, network hospitals brought problems, obstacles and case studies to consideration with specialists from the Central Chest Institute of Thailand. Treatment efficiency indicators, such as door to thrombolytic time and mortality rate of STEMI patients, were also discussed. As a result, network hospitals have had more understanding of and confidence in STEMI care.

 9. What were the main obstacles encountered and how were they overcome?
Obstacles encountered during the implementation are as follows: 1) Insufficiency of patient beds: the problem was solved by an addition of beds in CCU. However, after a certain time, it was found that the additional beds were not enough. The patients under surveillance process were transferred to inpatient ward. As a result, the intermediate ward had to be added to support patients who were moved out of CCU. 2) Noncompliance with CPG: due to the fact that there were new GP and ER physicians from time to time as well as interns on overtime shift, it was necessary to give these new physicians information on the established CPG. 3) For fast communication, mobile and landline telephone numbers were used to transfer STEMI patient data to the Central Chest Institute of Thailand. It was found that data, especially EKG, sent through facsimile machine could not be read because it was not clear. Therefore, the data had to be sent via email, Line or What Sapp and printed out. 4) The results of serum creatinine blood test to measure kidney function is important to determine whether cardiac catheterization can be performed or not because during cardiac catheterization process, contrast media that have to be excrete through kidney will be administered. It was previously required that serum creatinine results had to be accompanied with the referred patients; however, each hospital stated that creatinine test took a long time and exceeded the time limit. Therefore, a new requirement is that the referring hospitals do not need to wait for creatinine blood test results, but they need to take creatinine blood samples and send the test results subsequently (adjustment of service flow). 5) When standard CPG was extended to cover networks all over the country, there were certain district and provincial hospitals that were not capable of administering thrombolytic drugs. Thus, the Central Chest Institute of Thailand proposed a program to organize a national workshop on network care and referral standards and ask successful hospitals at the district and provincial levels to share their experiences, success factors, and management approaches in order to help those hospitals that were incapable of administering thrombolytic drugs to have more confidence in patient safety. The Central Chest Institute of Thailand has prepared laminate sheets of proper sizes showing a flow diagram of STEMI care. These sheets have been distributed to district and provincial hospitals all over the country to be posted in their emergency rooms. 6) STEMI patient data management: the Central Chest Institute of Thailand asked all hospitals in the country to send the STEMI patient data to the STEMI patient data management center at the institute on a monthly basis. In the beginning, only a few hospitals sent the lists of patients to the institute. Thus, the institute had to organize three STEMI patient data management seminars in 2011 for responsible officers of each hospital. The Central Chest Institute of Thailand also advised how each hospital could use such data for the purpose of patient follow-up and as products of the hospital. Later, hospitals were more cooperative in submitting the STEMI patient data. As a result, a national database with the largest STEMI patient data was created to evaluate STEMI care efficiency at the national level. The data would also be used for making national policies.

D. Impact and Sustainability

 10. What were the key benefits resulting from this initiative?
STEMI patients are able to have access to the same standard care equally whether they are in the rural or urban areas. When the initiative covers the whole country, standard STEMI patient referral system is able to save more patients. The mortality rate has reduced from 17% to 9.75%. In 2012, there were a total of 11,605 STEMI patients and 842 of them were saved from death. Apart from survival, the patients had a better quality of life and were able to further benefit society and the country. For example, there was a 47-year-old orthopedic surgeon who was very healthy and capable, working at a general hospital in a province. He performed more than 10 surgeries a week. One morning while he was monitoring a post-surgical patient at the surgery ward, he had chest pain and collapsed in the patient’s bed. A nurse working nearby laid him down in a patient bed, measured his vital signs, and made an emergency report. A doctor working in a nearby ward came to help. At that time, the nurse put him on an electrocardiography test whereas the doctor examined him, read the EKG results and diagnosed him as acute myocardial infarction. The doctor then contacted the Central Chest Institute of Thailand was for a consultation with cardiologist. The patient was referred to the Central Chest Institute of Thailand. During the referral, the patient had a complication of harmful arrhythmia so a CPR was performed about 5 minutes before his arrival. When the patient arrived at the Central Chest Institute of Thailand, he was immediately taken to the cardiac catheterization lab to have a balloon angioplasty. Then, the patient was moved to CCU where he regained consciousness and did not feel chest pain. The patient went home after being hospitalized for seven days. After four months of cardiac recovery program, the patient was able to return to work and save other people’s lives again. Another STEMI patient was a taxi driver. While driving in front of the Central Chest Institute of Thailand, he saw the announcement of STEMI Fast Track initiative and chest pain as an alarm symptom. One day after his passenger got off the taxi, he felt a chest pain so he rushed to the nearest hospital. Then, he was referred to the Central Chest Institute of Thailand. He received cardiac catheterization and balloon angioplasty immediately after arriving at the institute. He got better and was released. Five days after that, he said that he survived because he saw the signboard so he would like to express his thanks to the hospital for posting such signboard. The patient said that if he were dead, his wife and 5-year-old daughter would have a hard time living because he was the head of his family and the one who earned a living for his family. More referred STEMI patients have been admitted to the Central Chest Institute of Thailand. In 2008, the institute was able to admit only 51% of the referred patients, but in 2012 as many as 92% of a total of 324 referred STEMI patients were admitted. The reduced steps have also enabled patients to receive equal and standard care. A larger number of STEMI patients are treated with thrombolytic drugs in a timely manner (within 30 minutes of arrival) (from 17% to 61%) and receive balloon angioplasty in a timely manner (within 90 minutes of arrival) (from 47% to 90%). The referring hospitals were more satisfied with the Central Chest Institute of Thailand (91.33%). As a result of expansion of the initiative to cover 12 service regions and 65 million people nationwide, it was found that the mortality rate of 11,605 STEMI patients reduced from 17% to 9.75%. More patients (from 30.4% to 35.34%) were treated with thrombolytic drugs in a timely manner (within 30 minutes of arrival) and a larger number of patients (from 22.2% to 27.37%) received balloon angioplasty in a timely manner (within 90 minutes of arrival). It can be said that during a period of one year, 841 STEMI patients survived, 4,101 were treated with thrombolytic drugs, and 3,176 received balloon angioplasty. STEMI Fast Track initiative has helped medical personnel to have more capabilities and confidence to serve patients, especially emergency room nurses who are now able to evaluate and suspect whether or not the patients have acute myocardial infarction. If that is the case, the nurses will make a decision to carry out electrocardiography on the patients to reach a more accurate diagnosis. Standard referral system ensures that patients will be safe during transportation. A referring hospital can make a quick decision based on the map showing distances between hospitals in the same service network. Quick and effective transfer of patient data is achieved through the use of cell phone technology. No additional communication devices are required. The data management system has been developed and the national STEMI patient database has been created. The available data is analyzed to find the ways to further improve patient care system

 11. Did the initiative improve integrity and/or accountability in public service? (If applicable)
The Central Chest Institute of Thailand’s STEMI Fast Track initiative won the cardiac network award from NHSO in 2011. In the following year, the institute also won an outstanding network award from various hospitals in 12 regions nationwide. Therefore, we are very proud of our achievements. Moreover, more patients have survived and STEMI patients are able to have equal access to international standard care without discrimination based on race or financial status after commencement of this initiative. Compliments have regularly been received from patients and their family members so the team is motivated to work harder to care for the patients. STEMI Fast Track initiative enables the team (Heart Team) to work smoothly and go to the same direction, either with patients in or outside the hospital, since there is a specific flow and it is possible to communicate with people and hospitals all over the country. Thus, the referral system is effective and timely, and most importantly, it makes patients safe. National Health Security Office (NHSO) who covers treatment expenditures for hospitals nationwide recognizes the advantages of this initiative and is ready to support it because people will benefit greatly from it. In the big picture, although larger expenditures are incurred for treating a greater number of patients, in the long term expenditures for patients with myocardial infarction and chronic illness can be saved since the patients will not need to be treated with expensive medications anymore. Furthermore, the patients will have better quality of life and serve as valuable resources in developing the country. The STEMI Fast Track’s campaign aimed at encouraging people to have immediate care advertised through public media has changed the way Thai people see their doctors. Earlier, Thai patients often went to hug or popular hospitals and sometimes it took too long due to long distance or traffic. Now, they go hospitals nearby. This is because they are aware of effective referral system and understand that if the first hospital that they go is unable to provide required treatment, they will be referred to a capable hospital because it is a policy of a service region to refer patients to a hospital that is capable of providing necessary care. As a result of implementation of STEMI Fast Track, patients are saved and have a better quality of life. The Central Chest Institute of Thailand has proposed the “Save 10,000 Hearts” project to the Department of Medical Services, Ministry of Public Health in 2011. This project is aimed at expanding STEMI Fast Track model to cover all 12 public health service regions with 320 hospitals at all levels from district to provincial, regional and national levels, both private and public hospitals, including those under supervision of Ministry of Public Health, Bangkok Metropolitan Administration, the Royal Thai Police, Ministry of Defense, and universities, participating in the project. From the hospitals from all over the country that have participated in the project in 2011, the impact of STEMI Fast Track can be more clearly seen. More patients have been saved. STEMI Fast Track model in STEMI network has been developed. In this year, 2013, the Ministry of Public Health had a policy to develop STEMI Fast Track nationwide and use it as a national indicator. The STEMI Fast Track model can be applied to other developing countries because it does not require a large budget, but cooperation of the team and concerned sectors as well as that of people (in evaluating their signs and symptoms), to make it a success. When the team succeeds, they will be proud and motivated to keep working.

 12. Were special measures put in place to ensure that the initiative benefits women and girls and improves the situation of the poorest and most vulnerable? (If applicable)
An important factor resulting in success of STEMI Fast Track initiative is that the heart team has the same goal so they are able to solve problems quickly and effectively and the available resources are used most carefully and efficiently. The team members are responsible for their assigned duties. The doctors and nurses serve as case managers that can be reached 24 hours a day. Referral system between all hospitals in the service region is fast and effective. Good communication allows cardiologists to efficiently provide consultation services. STEMI patients’ data is transferred to hospitals capable of administering thrombolytic drugs. In each service network, there is at least one hospital that is capable of coronary artery dilation, either by means of administration of thrombolytic drugs or balloon angioplasty. A central hospital needs to provide fulltime consultation system and perform the site visit to give advice to hospitals under its responsibility (at least twice a year to jointly solve problems encountered). General-Inspector of the ministry should have a continuous and regular follow-up and evaluation system to encourage effective and sustainable STEMI care. One of the lessons learned is that in each service network (about 5 million people), all hospitals in the network must develop a map and determine the travel time from community hospital to central hospital. In the network where such travel time exceeds two hours, the community hospital must be enhanced to be able to administer thrombolytic drugs. All hospitals must have a human resource development system to enable their personnel to be able to evaluate to assist patients, especially in administering thrombolytic drugs and reading electrocardiogram. All hospitals need to have basic medical equipment available, such as defibrillator and electrocardiograph machine, to keep the patients safe. In Thailand, Central Chest Institute of Thailand is the first hospital to perform cardiac catheterization. Tada Chakorn, M.D., former Director of the institute has laid a strong foundation and been known as the master of Thai cardiac catheterization. This initiative has allowed personnel of the Central Chest Institute of Thailand to continue his intent to develop Thailand’s coronary intervention to meet global standards, either for acute or chronic cases, especially in STEMI patients. Management of the Central Chest Institute of Thailand truly understands the development principles, provides support, and helps solving problems encountered during implementation of this initiative all the time. What the Central Chest Institute of Thailand plans to do in the next year is the project entitled, “Save Thais from Heart Attack,” whose objectives are to reduce the mortality rate of patients with acute coronary syndrome, to enhance capabilities and expand treatment services for patients with acute myocardial infarction in all hospitals in the service network (service plan), and to increase acute myocardial infarction patients to have access to timely, standard and fair services. The strategy to be used for implementation of this project is to hold workshops of cardiologists from the region and the Excellent Center committee for cardiac patient care under a policy of the Ministry of Public Health. The project will adopt a form of service network to improve coronary artery disease management of organizations that are members of the network. Training will be held for doctors and nurses from all hospitals in order to enable them to perform diagnosis and treatment of the acute myocardial infarction effectively and timely. Guidelines, documents and manuals on care for patients with coronary artery diseases will be prepared together with a manual on electrocardiogram (EKG) reading. Data management system will be developed in order to allow the use of such data for resource management and national budget planning. Public relations activities will be carried out to improve community and general public’s awareness through a network creation with local administrative organizations to communicate with local people. Data will be disseminated through a number of media. Signboards with information on medical facilities with capabilities to treat coronary artery diseases will be posted. People will be encouraged to give up risky behaviors and be informed of nationwide service points where they can receive care in case of urgency. This is aimed at reducing Thais’ exposure to coronary artery disease and saving them from the coronary artery disease in the future.

Contact Information

Institution Name:   Central Chest Institute of Thailand
Institution Type:   Government Agency  
Contact Person:   Kriengkrai Hengrussamee
Title:   Cardiologist  
Telephone/ Fax:   662 547 0999
Institution's / Project's Website:  
Address:   39 Moo 9 Tiwanon road
Postal Code:   11000
City:   Meang
State/Province:   Nonthaburi

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