Agenda - American Heart Associationwcm/@gsa/document… · AGENDA. Regionalization of STEMI Systems Hadley Wilson, MD, FACC ... • Tennova Healthcare • Turkey Creek Medical Center

Agenda 7:00 AM Optional Breakfast and Registration

8:00 AM Welcome & Introductions Dr. Bresee

8:10AM

Why Regionalization is Important Lessons from Regional System Models Elements of the Ideal System Guideline Review of Reperfusion Strategy Data Solutions Shock

Dr. Hadley Wilson Stephanie Starling

9:45 AM BREAK Accelerator

10:00 AM Regional Systems of Care Demonstration Project: Mission: Lifeline STEMI ACCELERATOR

Hadley Wilson, MD, FACC Stephanie Starling

10:30 AM Assessing the Landscape Mapping the Region Regional Faculty/AHA Staff

11:30 AM Challenging Case Studies from the Region EMS/Transfer/Shock Cases

Sunil T. Ramaprasad, MD FACC Mukesh K. Sarma, MD, FACC

12:00 PM LUNCH

1:00 PM Challenging Case Studies Stuart J. Breese, MD

1:30 PM Next Steps Group Discussion

2:00 PM Adjourn

AGENDA

Regionalization of STEMI Systems

Hadley Wilson, MD, FACC Chief of Cardiology, Sanger Heart and Vascular Institute, Charlotte, NC Physician and Regional STEMI System Implementer

Stephanie Starling, RN, BSN, MHA Director of Nursing at Forsyth Medical Center, Winston-Salem, NC Nurse and Regional STEMI System Implementer

Welcome & Introductions

• Regional Leadership

• AHA Local Staff & Affiliate Staff

Welcome

• Blount Memorial

• Fort Sander Regional

• LeConte Medical Center

• Methodist Medical Center

• Morristown Hamblen Healthcare

• Parkwest Medical Center

• Tennova Healthcare

• Turkey Creek Medical Center

• UT Medical Center

• First Call Ambulance Service • Morristown Hablen EMS • Rural Metro EMS – Knox County

Regional Systems of Care CME Objectives

• Describe existing successful STEMI regional plans that are pertinent to a wide array of geographical and political realities.

• Identify collaborative solutions to overcome existing barriers to coordinated regional STEMI care.

• Establish a framework for the accelerated development, enhancement and training of multidisciplinary STEMI teams in their regional practice areas.

• Agree upon best data tool to establish a baseline data for the region and monitor process and outcomes improvement on a quarterly basis.

• Discuss pros and cons of the current system practices.

• Identify available tools to provide feedback for necessary quality improvement for STEMI care.

Why Regionalize?

We already have a system, why regionalize?

• Most effective approach to modifying the system, particularly

EMS and hospitals that refer to more than one PCI center.

If every PCI hospital is has the same message, protocols

change.

• Fill in the existing gaps / chasm in healthcare

Competing hospitals

Loose EMS – hospital affiliations

• Only possible way to overcome the “longest breath hold”… two

hour transfer device times.

Two hours is a long time for a myocyte to hold its breath.

CUMBERLAND

FENTRESS

SCOTT

MORGAN

ROANE

MCMINN MONROE

BLOUNTLOUDON

SEVIER

COCKE

ANDERSON

CAMPBELL

CLAIBORNE

UNION

JEFFERSON

GRAINGER

HAMBLEN

HANCOCK

HAWKINS

KNOX

21 County Service Area

STEMI Door-to-Balloon Times Median Times for Transfer In and Non-Transfer In Patients

Transfer in DTB Times Non-Transfer in DTB Times

96

114

145

53 61

68

Q3 10

98

117

141

55 62 69

Q4 10

93

114

145

57 64

Q1 11

97

119

149

57 64 71

Q2 11

Tim

e (

min

)

50

220

210

60

70

80

90

110

100

120

130

140

150

160

170

200

180

190

240

230

71

40

30

20

250

10

0

ACTION Registry-GWTG DATA: July 1, 2010 – June 30, 2011

JAMA. 2011;305:2540-2547


• Without regional approach to data collection, impossible to improve system coordination.

• Provide a platform for regional care of other cardiovascular emergencies… cardiac arrest, stroke, aortic dissection….


# 1 Reason- Save lives

Time is muscle Relationship among symptom duration,

myocardial salvage, and mortality reduction.

Gersh, B. J. et al. JAMA 2005;293:979-986.

Levels of organization

Hub and spoke model

Regional system

Every hospital and EMS Agency

Individual hospital

Journal of Invasive Cardiology 2011; 23 A:8-12

A system that includes all hospitals within a region,

establishes common hospital and EMS protocols, and shares

common data

Regional system

• Patients walk in to every hospital and call every EMS agency… all need a plan.

• Regional leadership involving all major hospitals is more effective at influencing referring hospitals and EMS agencies.

– If all leading professionals and institutions in a region agree, recommendations more likely to be adopted.

• Single approach enhances rapid treatment.

– everyone knows their role, no hesitation to find out who is on call…. Journal of Invasive Cardiology 2011; 23 A:8-12

Regional system Advantages

Regional System

Barriers / Opportunities • Competition

– most commonly cited reason

• Apathy in Leadership

• Conflicting management plans

– “5 doctors will give you 6 different plans”

• Resources

– “Feet on the street” system coordinators

• Lack of comparable regional data for ongoing quality improvement and immediate feedback loop for all members of the team

Circ Cardiovasc Qual Outcomes. 2012;5:423-428

Regional Cardiovascular Emergency System

• How are we doing

– EMS to device

– Hospital transfer

• Regionalization

• Building regional system

• Mission: Lifeline STEMI SYSTEMS ACCELERATOR Intervention

How patients present • Call 911 EMS

(~50%)

• Walk-in

(~50%)

• Hospital transfer

• - Walk in or EMS to 1st

hospital

(~60% of PCI hospital)

How patients present Treatment goals in minutes

EMS

Walk-in

Hospital

transfer

Current 90 90 120 - 180

Potential <60 <90 <120

Primary PCI should be performed in patients with STEMI presenting to a hospital with PCI capability

within 90 minutes of first medical contact

as a systems goal.

PCI in Specific Clinical Situations: STEMI–

Primary PCI of the Infarct Artery

I IIa IIb III

Primary PCI should be performed in patients with

STEMI presenting to a hospital without PCI

capability


as a systems goal.

I IIa IIb III

Death by guideline goal

NC RACE, Circulation.2012;126:189–195.

60 minute drive time to PCI lab 2001 – 2006 PCI Capable Hospital Expansion

• PCI-capable hospitals

1176 to 1695

• Access to PCI

79.0% to 79.9%

Concannon T, et al. Circ Cardiovasc Qual Outcomes. 2012;5:14-20

10/8/2012

Mission: Lifeline Receiving Center National Report Q12010, Q32011

25

Median time 91 Minutes

©2012, American Heart Association

Regional Cardiovascular Emergency System How are we doing?

• Door to balloon largely solved • Major targets remain

1. Hospital transfer patients (roughly half or all STEMI patients)

First door to device

2. EMS diagnosed patients (roughly half of patients presenting directly to PCI hospitals

First medical contact to device

Regionalization Can Look Very Different Across the Country…….Depending on

Where you are living

RACE

Reperfusion in AMI in Carolina

Emergency Departments

Regionalization of Emergency Cardiac Care

“Most of the important decisions that

impact patient outcomes occur long

before the patients reaches the

cardiologist”

Regionalization of Emergency Cardiac Care

Move care forward…

• EMS does emergency department job

• Emergency department does cardiology

job

• Cardiology lives in the cath. lab / intensive

care unit

Diagnose quickly

Reperfuse quickly

ST Elevation Myocardial Infarction

121 emergency

departments

540 EMS systems

5,240

paramedics

18,000

EMTs

21 primary PCI

labs

Building regional system Process

2) Establish REGIONAL PCI CENTERS

(primary, lytic ineligible, rescue)

Measurement & Feedback

3a) HOSPITAL by hospital

establishment of STEMI plan

(review, consensus, training)

3b) EMS by EMS

establishment of STEMI plan

(review, consensus, training)

5) Improve system

1) Develop leadership,

funding, data structure

Regional Coordinator(s)

Directed by regional leadership to implement

emergency care plans.

Lead establishment of STEMI plan in every hospital

and EMS agency.

Day to day oversight and coordination of system.

Training of EMS, ED, catheterization lab, and QI

personnel

Regular data feedback to hospitals, EMS agencies,

and regional meetings.

Establish a STEMI plan

• Optimal system specifications

by point of care

– EMS

– ED

– Transfer

– Receiving hospital

– Cath. Lab

– Other system issues –

payers, regulations

Develop a regional plan

Available at http://www.nccacc.org/news/news1.html

Non-PCI hospital lab activation protocol

• Symptoms of acute coronary syndrome greater than 15

minutes - less than 12 hours.

• ECG diagnosis

– ST segment elevation in two contiguous leads

or

– Machine interpretation of definite STEMI

**** acute mi****

• No contraindications to acute catheterization

– Active severe bleeding

– Patient inappropriate for procedure (patient or family refusal,

DNR, severe dementia)

• Emergency physician activates Primary PCI hospital as soon

as STEMI is identified using term “code STEMI”

• Pre-arranged critical care transport or EMS dispatch notified of

“code STEMI” for 911 transfer

• Aspirin 325 mg

• Heparin bolus 60 u/kg, no drip

• Limit continuous infusions

• Fax records while patient in transport

EMS lab activation protocol

• Symptoms of acute coronary syndrome

greater than 15 minutes - less than 12

hours.

• ECG diagnosis

– ST segment elevation in two contiguous

leads

or

– Machine interpretation of definite STEMI

**** acute mi****

• No contraindications to acute

catheterization

– Active severe bleeding

– Patient inappropriate for procedure

(patient or family refusal, DNR, severe

dementia)

• Trained paramedic activates Primary PCI

hospital as soon as STEMI is identified

using term “code STEMI”

• Aspirin 325 mg

Develop a regional plan

PCI Hospitals RACE Criteria

Single number cath. lab activation

Accept all STEMI patients regardless of

bed availability

30 minute lab availability 24/7

On site surgery

Ongoing QI and data feedback– AR-G

database

Partial support of a Regional Coordinator

Emergency departments


Nurse first triage

10 minutes to ECG

— Typical symptoms, over age 30

— Atypical symptoms, over age 50

Emergency physician makes reperfusion

decision

Activate lab or initiate fibrinolysis

Care Processes Associated With Quicker

Door-In–Door-Out Times

Hospital processes

Dedicated STEMI reperfusion team with committed leadership

Hospital-specific reperfusion protocol

ED processes

System for obtaining ECGs within 10 min of ED arrival

Single call No. to activate PCI center cardiac catheterization lab

EMS processes

EMS has equipment to perform pre-hospital ECGs

Program for paramedics to recognize STEMI on 12-lead ECGs

Program for paramedics to recognize STEMI on 12-lead ECGs

Keep patient on local stretcher as part of AMI

Circ Cardiovasc Qual Outcomes. 2011;4:382-388.)

Median first door to device time by

drive time and transport mode

In hospital mortality

Munoz NC RACE In press, JACC Interventions

Care Processes Associated With Quicker

Door-In–Door-Out Times

Circ Cardiovasc Qual Outcomes. 2011;4:382-388.

Median door-in–door-out times according to # of processes adopted

EMS


ECG for all possible STEMI patients

— Typical symptoms, over age 30

— Atypical symptoms, over age 50

Paramedic interpretation and cath. lab

activation

— Paramedic read, machine read, or

transmission.

Diversion plan to PCI hospital — Lytic ineligible

— Hospital within 30 to 40 minutes

Pre-Hospital ECG

• ACTION registry - 2007

• 1,941 of 7,098 EMS

transported patients had

pre-hospital ECG

• Trend for lower mortality

0.85 (0.63-1.01)

49

70

82

73

0

10

20

30

40

50

60

70

80

90

Primary PCI <= 90 Lysis <= 30

In hospital Pre hospital

Diercks DB, J Am Coll Cardiol 2009;53:161–6 % treated within goal

4 ways to activate

1)Paramedic read

2)Machine read

3)ECG transmission

4)Walk in with ECG

EMS ECG Cath lab activation

EMS ECG Cath lab activation

10 Regional STEMI Receiving Center Systems Population 20 million, Paramedics 5822

Royal Oak, MI

Minneapolis, MN

Medford, OR

Marin Co, CA

Los Angeles, CA

Orange Co., CA

San Diego, CA

Ventura Co., CA Charlotte, NC

Atlanta, GA

US population density

Rokos et al. JACC Interv.

10 Regional STEMI Receiving Center Systems Population 20 million, Paramedics 5822

Royal Oak, MI

Minneapolis, MN

Medford, OR

Marin Co, CA

Los Angeles, CA

Orange Co., CA

San Diego, CA

Ventura Co., CA Charlotte, NC

Atlanta, GA

US population density

Rokos et al. JACC Interv. In press

10 Regional STEMI Receiving Center Systems Pre-Hospital ECG Activation

Rokos et al. JACC Interv.

D2B < 90 Minutes

D2B<90 min 86%

D2B<60 min 50%

E2B<90 min 68%

Critical Success Factors for Regionalization

• Place patient first, not competition or $$

• Have a “neutral” party coordinate competitive regions (Key-> funding the neutral body)

• Cardiology, ED Medicine, Nursing, EMS leadership, CV Administration & QI

• Empower ED Medicine and EMS to be decision makers & activate the reperfusion plan

• Keep Reperfusion plan simple, parallel processing

• Data drives change-> both immediate and QI quarterly monitoring important

• Nurse or paramedic coordinators / Mission: Lifeline Directors essential to success

Guideline Review of Reperfusion Strategy &

other Important Statements

Primary PCI should be performed in patients

with STEMI presenting to a hospital with PCI

capability


as a systems goal.

PCI in Specific Clinical Situations: STEMI–

Primary PCI of the Infarct Artery

I IIa IIb III

Primary PCI should be performed in patients

with STEMI presenting to a hospital without

PCI capability


as a systems goal.

PCI in Specific Clinical Situations: STEMI–Primary

PCI of the Infarct Artery

I IIa IIb III

Drug Patient has received prior anticoagulant

therapy

Patient has not received

prior anticoagulant therapy

Bivalirudin For patients who have received UFH, wait 30 min,

then give 0.75 mg/kg IV bolus, then 1.75 mg/kg per

hour IV infusion

0.75 mg/kg bolus, 1.75 mg/kg per h

IV infusion

UFH IV GPI planned: additional UFH as needed (e.g.,

2000 to 5000 U) to achieve an ACT of 200 to 250 s

IV GPI planned: 50 to 70 U/kg

bolus to achieve an ACT of 200 to

250 s

No IV GPI planned: additional UFH as needed (e.g.,

2000 to 5000 U) to achieve an ACT of 250 to 300 for

HemoTec, 300 to 350 s for Hemochron

No IV GPI planned: 70 to 100 U/kg

bolus to achieve target ACT of 250

to 300 s for HemoTec, 300 to 350 s

for Hemochron

Dosing of Parental Anticoagulants During PCI

Cardiogenic Shock

Definition of shock • Decreased CO with evidence of insufficient

tissue perfusion in the presence of adequate intravascular volume

– Hemodynamic criteria : SBP < 90, PWP > 18, CI < 1.8

Cardiogenic Shock: Pathophysiology

• Ventricular failure (left in most forms of CS)

• Decrease cardiac output/stroke volume

• Decrease regional and peripheral perfusion

• Release of catecholamines and

neurohormones

• Systemic inflammatory response syndrome

• Continuous and progressive myocardial

dysfunction

Clinical signs

• Oliguria, cool, pale and clammy extremities, altered mental status, pulmonary congestion, tachycardia, elevated lactate, mixed venous saturation of less than 65%

• Pre shock – higher HR, lower BP among patients on

presentation among those who develop CS • STEMI

– Systolic blood pressure <= 90 on presentation

Cardiogenic Shock is a Spectrum

Three High

Dose

2% 3% 7.5%

21%

42%

80%

Pre-Shock

Profound Shock Shock

No Hemodynamic

Support

Needs Partial

Hemodynamic Support

Needs Full

Hemodynamic Support

Mortality Risk with Inotrope Dosing

Adapted from Samuels LE et al , J Card Surg. 1999 Jul-Aug;14(4):288-93

Death, shock on presentation

NC RACE, Circulation.2012;126:189–195

Cardiogenic Shock: Potential Treatment

• Revascularization: PCI / CABG

• Pressors

– Dobutamine, Nitroprusside, ….

• Mechanical support

– IABP / Impella 2.5

• Refractory shock: ventricular assist device, cardiac

transplantation

SHOCK Trial: Long term survival after discharge

- Hochman JAMA 2006

SHOCK Trial: Long term survival after discharge

Excellent or

good health

- Sleeper, Hochman JACC 2004

Most Commonly Used Mechanical Devices

IABP

TandemHeart

Impella

Current Pharmacology & Devices

Inotropes IABP ECMO Tandem-

Heart Impella

Surgical VAD

Advantages

Flow (L/min.)

Coronary Perfusion

LVEDP

<0.5

↑

↑

0.5

↑↑

↓

4

-

↑↑↑↑

3.5

-

↓↓

2.5 - 5.0

↑↑

↓↓↓

6.0

↑↑

↓↓↓↓

Limitations

Arrhythmia

Stroke

Limb ischemia

Bleeding

Cost

+++

-

N.A

N.A

$

-

++

+

++

$

-

++

+++

++++

$$$

-

+

++

+++

$$$

-

+

+

+ / ++

$$$

-

+++

N.A

++++

$$$$$

Data Solutions

Data Ongoing measurement and feedback to

entire team

Focus on benchmarks most amenable to

improvement

Door In Door Out in Non-PCI ED Blinded Hospital Comparison

A

B

G

H

J

K

L

N

O

Q

CD

E

FM

P

R

S

0

20

40

60

80

100

120

Goal = 40 min

Median 69 min

Data Participation in Regional Reports / System

Requirements

1. Regional PCI hospitals enroll in

NCDR ACTION-GWTG Registry

2. PCI hospitals sign up with

Mission: Lifeline

3. PCI hospitals complete

• ML System DCRF

• Accelerator Project DCRF

Regional Systems of Care Demonstration Project:

Mission: Lifeline STEMI Accelerator

National Program Sponsors Through Educational Grants

THE MEDICINES COMPANY

Philips Healthcare

ABIOMED, Inc.

Objectives • Establish a regional standard of emergency

cardiovascular care that includes every hospital and EMS agency.

• Lower cardiovascular mortality by broadly improving the timely treatment of ST elevation myocardial infarction (STEMI) patients.

• Create a sustainable system for treating cardiovascular emergencies including STEMI, cardiac arrest, stroke and aortic dissection.

STEMI ACCELELERATOR Sites

STEMI SYSTEMS ACCELERATOR Intervention Sites

Great Rivers

• Columbus, OH

• Central, PA

• Philadelphia, PA

• Louisville, KY

Midwest

• Detroit

• St. Louis

• E. Wisconsin

• Central Indiana

Founders

• New York City

• N. New Jersey

Greater South East

• East Tennessee

• Tampa

Western States

• Kern County, CA

• Hawaii

South West

• Colorado (East Range)

• Houston

• San Antonio

• Oklahoma City

18/20 Regions; 20 TBD

STEMI SYSTEMS ACCELERATOR Intervention Physician Faculty

Peter Berger, MD - Interventionalist; Geisinger Clinic, Danville, PA

Harry Dauerman, MD- Interventionalist; University of Vermont, Burlington, VT

William Koenig, MD- Emergency Medicine

Medical Director, EMS LA County

Lee Garvey, MD- EMS/ED Medicine; CMC Charlotte, NC

Christopher B. Granger, MD- Cardiologist; Duke University Medical Center, Durham, NC

James G. Jollis, MD- Cardiologist; Duke University Medical Center, Durham, NC

Greg Mishkel,MD - Interventionalist; Prairie Heart , Springfield, MO

Ivan Rokos, MD- Emergency Medicine; Los Angeles, CA.

B. Hadley Wilson, MD- Interventionalist; CMC Charlotte, NC -Sanger Clinic

Implementer Faculty

Claire Corbet, MS, EMT-P; Paramedic and Regional System Implementer- New Hanover Medical Center, NC

Loni Denne, RN, BSN; Nurse and Regional System Implementer (Austin and now Southwest USA; American Heart Association, SR. ML Director.

Russell Grifffin, B.S., LP, FP-C, CCEMT-P, NREMT-P, Director, Dallas Caruth Grant

Mayme Lou Roettig, RN, MSN; CV Clinical Nurse Specialist and Regional & State System Implementer; DCRI- Durham, NC

Stephanie Starling, RN, BSN, MHA; Forsyth Medical Center, Winston-Salem, NC: Regional System Implementer

• Using national level system faculty and local AHA staff to broker competitive entities to regionalize STEMI care for a community.

• Success based on regional local leadership owning the program.

• Unbiased staff to recruit all hospitals to join centralized database.

• Regional Intervention Day – CME/CNE event

• Data- Baseline, Quarterly for 1 year, Post Intervention • Quarterly meetings to share best practices, data review

across the region and identify strategies to improve process

STEMI SYSTEMS ACCELERATOR Intervention

• Voluntary.

• Intervention does not change referral lines.

• Augments existing systems / leaves regional leadership entirely in charge of system.



Data All primary PCI hospitals in the Accelerator Region

> enroll in AR-G (minimal requirement- STEMI only for duration of the project timeline)

> Agree to “systems release” ₋ Hospitals ID’s are blinded

₋ Data may be aggregated (combined) for regional report (M:L Systems Report) and with 19 additional regions in the program.

System data consent release form (DCRF) must be signed and returned to AHA for assignment of a system ID #

Timelines: > July 2012 – enroll and complete release forms > Baseline regional Data July 1, 2012 discharges through

September 31st, 2012 > Quarterly Data through December 31, 2013

STEMI SYSTEMS ACCELERATOR Intervention 5-6 Weeks prior to 1st meeting • Telephone conferences with

AHA local leadership Interventional cardiologist from each PCI hospital Emergency medical director (s)

• Enlist PCI hospitals in AR-G and MOU

Evening prior to 1st meeting • EMS leadership meeting /

conference call Cath. lab activation protocol discussion

• Interventional cardiologist face-to-face dinner

Initial Accelerator / AHA meeting • Outside leadership reviews

regional STEMI system approaches, data plan

• Regional interventional cardiologists and EMS leadership present cases for discussion

1. EMS to cath. lab 2. Inter-hospital transfer 3. Cardiogenic shock

• Regional leaders plan next steps • Working leadership

structure • Common regional protocol • Data plan • Regional coordinator (s) • Funding needs

Follow-up remote • Supplement weekly regional leadership

conference calls. • Telephone consultation regarding region-

specific issues

Follow-up Accelerator meeting • Review progress

Leadership Coordinator Data Regional plan


Timeline Spring 2012

July 2012

July – September 2012

December 2012-January 2013

October-December 2013

Spring 2014

• Select sites

• Enroll and complete release forms

• Regional intervention meetings and baseline data collection

• Follow up visit

• Final data collection

• Presentation of findings at regional and national meetings and in publication

Documents

Agenda - American Heart Associationwcm/@gsa/document… · AGENDA. Regionalization of STEMI Systems Hadley Wilson, MD, FACC ... • Tennova Healthcare • Turkey Creek Medical Center