Objective: To achieve our goal of excellent emergency cardiac care, our institution embarked on a Lean process improvement initiative. We sought to examine and quantify the outcome of this project on the care of suspected acute coronary syndrome (ACS) patients in our emergency department (ED). Methods: Front-line ED staff participated in several rapid improvement events, using Lean principles and techniques such as waste elimination, supply chain streamlining, and standard work to increase the value of the early care provided to patients with suspected ACS. A chart review was also conducted. To evaluate our success, proportions of care milestones (first electrocardiogram [ECG], ECG interpretation, physician assessment, and acetylsalicylic acid [ASA] administration) meeting target times were chosen as outcome metrics in this before-and-after study. Results: The proportion of cases with 12-lead ECGs completed within 10 minutes of patient triage increased by 37.4% (p , 0.0001). The proportion of cases with physician assessment initiated within 60 minutes increased by 12.1% (p 5 0.0251). Times to ECG, physician assessment, and ASA administration also continued to improve significantly over time (p values , 0.0001). Post-Lean, the median time from ECG performance to physician interpretation was 3 minutes. All of these improvements were achieved using existing staff and resources. Conclusions: The application of Lean principles can significantly improve attainment of early diagnostic and therapeutic milestones of emergency cardiac care in the ED. RÉ SUMÉObjectif : Pour atteindre notre objectif d'excellence en soins d'urgence cardiaque, notre é tablissement a mis sur pied une initiative d'amé lioration du processus Lean. Nous nous sommes attaché s à é tudier et à quantifier les ré sultats de ce projet en lien avec les soins aux patients soupç onné s d'ê tre atteints de syndrome coronarien aigu (SCA) dans notre service des urgences (SU). Mé thodes : Le personnel de premiè re ligne du SU a participé à plusieurs é vé nements d'amé lioration rapide constitué s des principes et techniques Lean : é limination du gaspillage (temps, ressources), allé gement de la chaîne logistique, travail standard, et ce, pour augmenter la qualité des soins pré coces fournis aux patients chez qui on soupç onne un SCA. Une revue des dossiers a é galement é té mené e. Pour é valuer notre succè s, nous avons choisi, comme mesure des ré sultats dans cette é tude « avant-aprè s », la proportion des é tapes de soins (premier é lectrocardiogramme [ECG], interpré tation de l'ECG, é valuation par le mé decin et administration d'acide acé tylsalicylique [AAS]) respectant le temps visé .

ObjectivePrehospital blood transfusion has been adopted by many civilian helicopter emergency medical services agencies, and early outcomes are positive. The Shock Trauma Air Rescue Society operates six bases in Western Canada and started a blood on board process in 2013 in Regina that has expanded to all bases. Two units of O negative packed red blood cells are carried on every mission. We describe the processes and standard work ensuring safe storage, administration, and stewardship of this important resource.MethodsThe packed red blood cells are stored in an inexpensive, reusable temperature controlled cooler at 1°C–6°C. Close collaboration with local transfusion services and adherence to Canadian transfusion standards contributes to safety and sustainability.ResultsFrom October 1, 2013 to October 10, 2017, the Shock Trauma Air Rescue Society administered blood to 431 patients. Of this total, 62.9% received blood carried on our aircraft. A total of 463 blood box units were administered, and the majority of patients (69.0%) received both units. Blood used in Calgary, Alberta was 100% traceable, and only 1.2% of total units dispensed was wasted. The vast majority of unused units were returned to circulation.ConclusionWe describe the process to set up and monitor a prehospital blood transfusion program. Our standard work and stewardship processes minimize wastage of blood while keeping it readily available for our critically ill and injured patients.

Objective: Ischemic cardiovascular disease is the leading cause of death in Canada. In ST elevation myocardial infarction (STEMI), time to reperfusion is a key determinant in reducing morbidity and mortality with percutaneous coronary intervention (PCI) being the preferred reperfusion strategy. Where PCI is available, delays to definitive care include times to electrocardiogram (ECG) diagnosis and cardiovascular laboratory access. In 2004, the Cardiac Care Network of Ontario recommended implementation of an emergency department (ED) protocol to reduce reperfusion time by transporting patients with STEMI directly to the nearest catheterization laboratory. The model was implemented in Frontenac County in April 2005. The objective of this study was to assess the effectiveness of a protocol for rapid access to PCI in reducing door-to-balloon times in STEMI. Methods: Two 1-year periods before and after implementation of a rapid access to PCI protocol (ending March 2005 and June 2006, respectively) were studied. Administrative databases were used to identify all subjects with STEMI who were transported by regional emergency medical services (EMS) and received emergent PCI. The primary outcome measure was time from ED arrival to first balloon inflation (door-to-balloon time). Times are presented as medians and interquartile ranges (IQRs). Statistical comparisons were made using the Mann–Whitney U test and presented graphically with Kaplan–Meier curves. Results: Patients transported under the rapid access protocol (n = 39) were compared with historical controls (n = 42). Median door-to-balloon time was reduced from 87 minutes (IQR 67–108) preprotocol to 62 minutes (IQR 40–80) postprotocol (p < 0.001). Conclusion: In our region, implementation of an EMS protocol for rapid access to PCI significantly reduced time to reperfusion for patients with STEMI.

We describe the successful use and complications of bolus-dose alteplase to treat strongly suspected pulmonary embolism (PE) with cardiac arrest in a patient initially presenting as ST-elevation myocardial infarcation (MI). Case description is followed by a review of the indications, safety, and dosing of systemic thrombolytic therapy for high-risk PE in the emergency department (ED). Diagnostic and therapeutic approach to PE in critically ill patients is also considered, including the potential utility of point-of-care ultrasound (PoCUS) in the ED.