| 4. In which ways is the initiative creative and innovative?
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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.
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| 5. Who implemented the initiative and what is the size of the population affected by this initiative?
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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.
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| 6. How was the strategy implemented and what resources were mobilized?
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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
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| 7. Who were the stakeholders involved in the design of the initiative and in its implementation?
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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.
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| 8. What were the most successful outputs and why was the initiative effective?
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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.
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| 9. What were the main obstacles encountered and how were they overcome?
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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.
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