1/9/2017. Systems of Care in EMS: An Integrated System of Cardiac Care. Describe systems-based response to time-sensitive clinical conditions

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1 Systems of Care in EMS: An Integrated System of Cardiac Care NAEMSP Medical Director s Course January 23, 2017 Jefferson Williams, MD, MPH, FACEP Deputy Medical Director Wake County EMS System Clinical Assistant Professor (Adjunct) UNC Department of Emergency Medicine Disclosures none Objectives Describe systems-based response to time-sensitive clinical conditions Discuss examples of systems of care and how they are measured Discuss the role of EMS participation and leadership in these systems 1

2 What are Systems of Care Proactive integration of EMS Evidence-based assessment and triage protocols (developed together) Coordination and oversight of specialty centers, including availability Quality-based monitoring of process and outcomes (monitoring BY EMS) Verification of specialty center compliance An example: The Chain of Survival 2

3 EMS Medical Directors know: Cardiac Arrest survival rate in your community? Your Utstein number? Bystander CPR rates? First Responder AED utilization? But do you know these? Your STEMI diagnosis over-triage rate? What does the cardiologist think is acceptable? Your median and 90th %tile scene times for STEMI patients? What do YOU think is acceptable? But do you know these? The number of Stroke patients in your community that may benefit from an interventional procedure Whether or not the new interventioncapable stroke center down the road is actually available 24/7 (or should you bypass that one and go to the academic medical center the next county over?) 3

4 The Plan What are Systems of Care and how should EMS participate and lead? RACE and RACECARS as examples STEMI and OHCA Stroke- the next focus? Systems of Care in NC EMS Triage and Destination Plans Peer Review Meetings RACE and RACECARS Broad implementation across regions of evidenced-based best practices Education for ALL team membersbystanders, EMS, ED, Cardiology Common measurement of processes and outcomes 4

5 RACE- Jollis, et al JAMA 2007 QI study that evaluated STEMI process measures in 5 regions in NC before and after implementation of statewide reperfusion system ( like trauma ) Median reperfusion times significantly improved: cath lab, lytics, and transfer 5

6 Regional Systems of Care Demonstration Project STEMI Accelerator IManualAcceleratorTemplate pdf RACECARS Applying the principles of RACE to out of hospital cardiac arrest Implement OHCA best practices on a state-wide basis Education Treatment Structure Measurement 6

7 NC CARES Participation 2010 Green Participating Orange Not Participating 3 Counties / 4 agencies participating 21.5% of NC population captured CARES Participation Green Participating Yellow Partial Participation Orange Not Participating 71 systems participating 88.5% of NC population captured 7

8 8

9 RACECARS Implement OHCA best practices on a state-wide basis Education Treatment Structure Measurement What were the Interventions? Telecommunications Training: Utilizing Arizona and partners on-line training Process to provide them data they collect on-line 2.5 hour training Incorporates HR introduction, Review of NC data, on-line training, call review practice Train the trainer Con Ed across the state 600 trained Approx. 27 counties APCO and NENA state meetings New Resources: Seattle Resus Academy on line 26 9

10 First Responder Adoption of SCA practices to improve outcomes First Responder Critical role in improving survival Active Team Member Perform HP CPR and Defibrillation Improved relationships with EMS Participation in Community Events 10

11 The Association of Rates of Bystander and First-responder Intervention with Survival after Out-of-Hospital Cardiac Arrest in North Carolina, Carolina Malta Hansen, MD, Ph.D. Candidate Duke Clinical Research Institute On Behalf of Kristian Kragholm, James G. Jollis, Matthew Dupre, Bryan McNally, Lisa Monk, Clark Tyson, David A. Pearson, Darrell Nelson, Brent Myers, Emil Fosbol, Benjamin Strauss, Monique Anderson, Christopher B. Granger JAMA July 21, 2015 Volume 314, Number 3 In 4 years ( ) Bystander CPR has increased by 26% (to 49.4%) First responder debrillation has increased by 27% (to 52.1%) Overall survival has increased by 25% (to 10.5%) Favorable neurologic outcome increased by 37% (to 9.7%) By 55% (to 14%) for bystander-initiated CPR Bystander-initiated CPR was associated with this increase! Bystander and first responder CPR and defibrillation were associated with improved survival compared to EMS-initiated CPR and defibrillation 32 Emergency Medical Services Adoption of SCA practices to improve outcomes 11

12 EMS Implemented state wide protocols for SCA Adoption of Pit Crew CPR Training with Fire QA programs to monitor SCA Survival rates CPR quality Plan and participate in community events North Carolina CARES Utstein Survival Rates October 10, % 35.0% 30.0% Percentage 25.0% 20.0% 15.0% 10.0% 5.0% 0.0% Agencies not using Pit Crew CPR 2012 Agencies using Pit Crew CPR 12

13 RACE and RACECARS Broad implementation of best practices for STEMI and cardiac arrest across North Carolina improved processes and outcomes for these patients What s next? Stroke EMS engagement of the medical community re: triage and destination plans Stroke Another condition ready and waiting for systems of care? Primary vs. Comprehensive Stroke Centers Where does intervention fit? Could a System of Care Improve Process? 13

14 Stroke- Background- To Review 1996 to ~ 2012: TPA for Stroke 2008 to 2012: TPA < 3 hrs, TPA hrs TPA is good but not great, can we do better? 2012 to 2014: three RCTs show that first gen intra-arterial (IA) devices/treatment do not have benefit over standard treatment (TPA) Stroke- Moving Forward Dec 2014 April 2015 FIVE trials demonstrate that newer, next generation IAT devices have benefit over standard treatment for patients with large artery occlusions. MR CLEAN ESCAPE EXTEND IA SWIFT PRIME REVASCAT 14

15 Stroke Trials Consistent difference across all 5 trials in terms of good outcome (MRS) favoring interventional vs. control group ~ 14-31% improvement NNT approx 4 for one additional good outcome 15

16 2015 Guidelines Update More recommendations Effectiveness of intervention after 6 hours is uncertain, more research is needed. Patients with TPA contraindications may still be candidates for intervention, more research is needed. CTA is indicated for patients who may be candidates for endovascular therapy Patients should be transported to the closest primary or comprehensive stroke center; Regional Systems of Care should be developed. 16

17 Stroke Stroke So, do we take patients to the closest place that will give TPA and then anticipate transfer? Do we bypass all but interventional stroke centers? Should we screen for LVO in the field? From Wake EMS CME: 17

18 Take-Home Points Time is Brain. The most important thing we do in EMS is RECOGNIZE a possible stroke (stroke screen) and have an accurate LAST KNOWN NORMAL time. Be vigilant- repeat exams. Get family phone # if you can. NEW Stroke TDP, effective June hours from LKW = Current destinations for Stroke/TIA: UNC, Duke, Duke Raleigh, Rex, WMRaleigh, WMCary 4-6 hours from LKW = Duke Raleigh, Duke, UNC Stroke, revisited So, do we take patients to the closest place that will give TPA and then anticipate transfer? Do we bypass all but interventional stroke centers? Should we screen for LVO in the field? YOU Decide, with YOUR System Systems of Care in NC RACE and RACECARS EMS Triage and Destination Plans Peer Review Committees for all EMS Systems 18

19 Systems of Care in NC Systems of Care in NC: Peer Review EMS, Hospitals, Community Process and Outcomes Reporting Transparency Forum for communications and addressing systems issues Systems of Care in Wake County STEMI, Stroke, Trauma/Burn, Peds, OHCA, and FED Triage and Destination Plans Evidence-Based Reporting of QA metrics with a standing Clinical Report at Quarterly Peer Review Meetings Bi-directional Data Exchange 19

20 Systems of Care in Wake County How do Protocols and CME relate to our peer review process and reporting? 20

21 Best Practice #1 : Recognition **WCEMS PEER REVIEW CONFIDENTIAL 911 and EMS Times (example case) 911 call at 1321 EMS en-route 1323 At patient 1332 EKG done 1335 En-route to hospital 1340 STEMI Alert- EKG transmitted via LifeNet 1342 At ED 1401 FMC to balloon ~60 mins Best Practice #2: Scene Time At patient: Time 0 EKG done: Time 3 min En-route to Hospital: Time 8 min Goal: min or less (or justified reason) 21

22 Best Practice #3: EMS Rx: The STEMI Bundle ASA (pt took his own) 12 lead performed and interpreted Goal scene time less than minutes Correct destination (STEMI receiving center) Early notification: STEMI alert via radio or phone EKG transmission if possible and this is what we QA and report to Peer Review Did the patient get aspirin? Did the patient have a 12 lead performed and interpreted correctly? Did the patient go to the proper destination? 22

23 EMS STEMI Evidence Based Medicine Measures Patients Transported by EMS with Suspected or Confirmed STEMI 90% 80% 70% Percentage Performed 60% 50% 40% 30% 20% 10% Mar 2016 n=21 Apr 2016 n=40 May 2016 n=30 June 2016 n=34 July 2016 n=25 Aug 2016 n=44 Sept 2016 n=31 97% 98% The Wake County Clinically Excellent Care 12 Lead EMS System Prompt, Compassionate, ASA Proper Destination Mean Time for Patients with Confirmed STEMI; Combined for All Hospitals Time in Minutes Mar 16 Apr 16 May 16 June 16 July 16 Aug 16 Sept 16 Hospital Arrival to Intervention Scene Departure to Hospital 16 Prompt, 18 Compassionate, Clinically 15 Excellent The Wake County EMS System Care Arrival 1st Patient Contact to Scene Departure Over Triage 3rd Quarter 2016 There were 13 of 100 STEMI calls documented by the hospital as STEMI cancelled, categorized as EMS over triage There were 6 sent for consult only. There were 1 additional calls where EMS did not activate code STEMI All were independently reviewed and determined that all but 2 of the EMS activations were appropriate There were 3 actual over triage 2% overtriage n=100 STEMI calls 23

24 STEMI Feedback Report (edited for privacy- JGW) Recommend ed Targets (mins) Actual Data EMS ECG Time 1030 (ECG with ST changes noted) EMS Transmit Time Transmission Received to Activation N/A ED notified EMS on Scene time ED Door to ECG ED ECG to Activation 10 5 immediate Already activated Total Time in ED Activation to Cath Team Ready Activation to MD Arrive In Lab Door to Balloon First Medical Contact to Balloon Thank you for partnering with XXXXX! STEMI Feedback Report Thank you for partnering with XXXXXX! Summary What are Systems of Care and how should EMS participate and lead? RACE and RACECARS as examples STEMI and OHCA Stroke- the next focus? Systems of Care in NC EMS Triage and Destination Plans Peer Review Meetings 24

25 Take Home Points Implementation of Systems of Care can improve processes and outcomes for YOUR patients EMS Physician Medical Directors should lead interdisciplinary teams to establish common systems of care in your communities 25

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