How to Establish a Multi Hospital STEMI Transfer System

How to Establish a Multi Hospital STEMI Transfer System Dr. Greg Mishkel for the Doctors of Prairie Cardiovascular and in collaboration with our Community & Springfield Hospitals

MI: Evolution of care in Central Illinois 1990 s early adoption/promotion of iv thrombolyis = drip & ship 2000 adoption of mechanical reperfusion 2002: Establish Institutional processes for acute MI care 2005: DANAMI/PRAGUE/MHI model: Inter-hospital transfer to TWO Springfield hospitals (St. John s Hospital, Memorial Medical Center) = PRAIRIE STAT HEART PROGRAM Barriers Barriers to to PPCI PPCI STEMI STEMI Care Care in in Central Central Illinois Illinois Limited Limited facilities facilities Long Long inter-hospital travel travel distances Limited Limited ACLS ACLS EMS EMS accessibility accessibility Variability Variability in in ED ED services services (locum (locum tenens) tenens)

2005: 6 Referral Centers Mean Transfer Distance: 46 miles (range:28-88) 4: Helicopter, 2: Ambulance 2009

So how was this done? Physician leadership, physician buy in Full time co ordinator/facilitator (communications, logistics, deal with SNAFU s, educational events) Hospital commitment (funding, quality, cath lab personnel) Establish effective high quality ER STEMI program Establish lines of communication (ER switchboard cath lab) Treatment guidelines Monitor outcomes, modify procedures Reduce readmissions Build on success of local program to entice outside programs to be part of the team Regular (annual?) of all participants (we include the switchboard operators) in educational forums/updates to share results/successes/challenges

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So how was this done? Physician leadership, physician buy in Full time co ordinator/facilitator (communications, logistics, deal with SNAFU s, educational events) Hospital commitment (funding, quality, cath lab personnel) Establish effective high quality ER STEMI program (St. John s * 90) Establish lines of communication (ER switchboard cath lab) Treatment guidelines Monitor outcomes, modify procedures Reduce readmissions Build on success of local program to entice outside programs to be part of the team Regular (annual?) of all participants (we include the switchboard operators) in educational forums/updates to share results/successes/challenges

STEMI: Where We Started at our hospital Doing well: performing above the average hospital for STEMI care in Crusade and NRMI registries, but wanted to be exceptional Formation of AMI Team in 2003 to target performance above the top 10% of Crusade/Action registry hospitals Formal Intervention started late 2003/early 2004 Obstacles to performance improvement included distance of new ED from cath lab, lack of standardized protocols and medical record documentation.

AMI Team Strategic Goals Achieve D2B time of <90 minutes for 100% of STEMI patients Implement standardized, evidence based and guideline driven pathways of care to improve quality Achieve 100% compliance with admission and discharge medications for all AMI patients Achieve results above the top 10% of Action registry hospitals for STEMI care EKG done within 5 minutes for patients with chest pain ED Door to cath lab arrival of < 30 minutes Cath Lab arrival to balloon dilatation of < 25 minutes Implement pre hospital ECG

Methods Formation of a multidisciplinary AMI team with quarterly meetings in Fall of 2003 ED meds bundled ASA, Beta Blocker, Heparin, and Nitroglycerin ED physician empowered to concurrently activate cardiologist and cath lab team upon diagnosis of STEMI with STAR 90 page Cardiologist meets and evaluates patient in cath lab, not ED Accountability and tracking form following patient through process allowing evaluation of performance of various phases of the D2B process Implementation of guideline driven treatment protocol and procedural protocol Weekday night team resides in hospital Benchmarking of performance with other centers using Action and MIDAS registries.

AMI Team Dr. Charles Lucore, Chairman, Department of Cardiology Dr. Linda Nordeman, Chairman, Department of Emergency Medicine Dr. Greg Mishkel and Frank Mikell, PCCL Dr. John Nester, Springfield Clinic Dr. John Byrnes, Emergency Room Cardiac Catheterization Lab Representatives: Sheryl Friedrich et al Emergency Department Representatives: Amy Jones et al Cardiac Nursing Representatives: Jennifer Cullen et al Quality Resource Management Representatives: Diane Tebrugge et al Health Information Management Representatives: Heather Shankland et al

AMI Door to Cath Lab Tracking Sheet To be completed only for ST elevation and/or LBBB on 1 st 12 lead EKG patients Arrival Time EKG Time Tech Time Cardiologist paged ED Physician Time Cardiologist returns page Cardiologist Cath Lab notified Cath lab responds Pt prepared for cath lab ED Nurse Time Cath Lab calls for patient Pt leaves ED Cath lab arrival time Balloon inflation time Complications that may delay process (pt requires intubation, pt arrests, or requires additional stabilization, atypical presentation)

100 Acute Myocardial Infarction Discharge Medications 2003 May 2009 (Data from NRMI 4, Action, MIDAS Comparative Performance System (CPMS)) 95 90 85 80 75 70 65 2003 2004 2005 2006 2007 2008 2009 ACE #s do not always screen for LVEF < 40% from NRMI report Aspirin Beta Blocker Ace Inhibitor Statin/lipid ASA 99% Beta Blocker 98% Ace/ARB 97% Statin 99% Top 10% (Action STEMI rpt) ASA 100% Beta Blocker 99% Ace/ARB 95% Statin 97%

STEMI Myocardial Infarction In-Hospital Events (last 12 months) St. John s National Avg. Top 10% Death Rate (%) 2.8% 5.9% 5.8% Door to Balloon Time (minutes) 54 71 59 Bleeding Requiring Transfusion (%) 2.3% 6.3% 7.4% Stroke 0.60% 0.80% 0.60% Length of Stay (days) 3.6 4.4 4.6 Source: 2 nd Qtr 08-1 st Qtr 2009 ACTION Registry (Get With the Guidelines) Gold Performance Achievement Award for 2009

So how was this done? Physician leadership, physician buy in Full time co ordinator (communications, logistics, deal with SNAFU s, educational events) Hospital commitment (funding, quality, cath lab personnel) Establish effective high quality ER STEMI program Establish lines of communication (ER switchboard cath lab) Treatment guidelines Monitor outcomes, modify procedures Reduce readmissions Build on success of local program to entice outside programs to be part of the team Devise (based on local needs) an integrated/consistent one call, one protocol Regular (annual?) of all participants (we include the switchboard operators) in educational forums/updates to share results/successes/challenges

Global Components of Process of Transfer STEMI Care Community Facility Transport Tertiary Facility Door In-Door Out Departure-Door 2 Door 2-Balloon ECG Decision Treatment Initiate STAT Heart Arrange Transfer Transfer Air Ambulance Cath Lab Arrival Diagnostic Cath PCI Ideal Goal: <30 minutes <30 minutes <30 minutes Goal: Door-Balloon: 90 min.

3-5 min Suspected MI (Step1) 12 Lead ECG/STEMI Identified (Step 2) Determine Bleeding Risk (Step 3) 5-10 min Activate Stat Heart Team Call for quickest available transport (Step 4) Ambulance/Helicopter Call Springfield Hospital Activate Stat Heart Team 15-20 min Community Stat Heart Team ED MD 2-RN Ancillary staff 30 minute Transport time Available PCI Protocol Air/Ground Transport Low Bleeding Risk 30 minute Transport time NOT Available Thrombolytic Protocol Air/Ground Transport High Bleeding Risk Contraindication Protocol Air/Ground Transport Springfield Stat Heart Team Cardiologist Coordinator Cath Lab Security Admitting Administrative Rep ER contact Goal: Out the Door in < 30 minutes

Prairie Stat Heart Protocols Lisa Page, RN

Goal out the door in 30 minutes or less 0-3 minutes Patient presents with chest pain or associated symptoms TREAT ALL patients as potential Stat Heart until deemed otherwise 3-5 minutes ECG done ECG to ED physician for quick diagnosis. ED physician determines if STAT Heart criteria is met. 5-12 minutes Activate STAT Heart team at community hospital (staff pre-assigned duties) First call -staff calls quickest transport air or ground (base on mileage between hospitals) Second call Springfield Hospital receiving pt. Stat Heart team activated in Springfield. Automatic - accepting Prairie cardiologist and bed assigned.

12-20 minutes Nurses start IV s & give standard meds (ASA, Lopressor, NTG) Physician determines if patient is high bleeding risk (contraindication questions) Transport time < 30 min. helicopter/ambulance - PCI protocol Transport time > 30 min. helicopter/ambulance - Thrombolytic protocol Helicopter or ambulance transfer - Contraindication protocol if pt. is high risk for bleeding (80 yrs or older, on Coumadin etc.) Give protocol meds 20-30 minutes EMS transport arrives, packages pt., brief report (transport team is educated on process) Departure Call receiving Springfield Hospital with departure page

So how was this done? Physician leadership, physician buy in Full time co ordinator (communications, logistics, deal with SNAFU s, educational events) Hospital commitment (funding, quality, cath lab personnel) Establish effective high quality ER STEMI program Establish lines of communication (ER switchboard cath lab) Treatment guidelines Monitor outcomes, modify procedures Reduce readmissions Build on success of local program to entice outside programs to be part of the team Devise (based on local needs) an integrated/consistent one call, one protocol Regular (annual?) of all participants (we include the switchboard operators) in educational forums/updates to share results/successes/challenges

SO HOW ARE WE DOING? STAT Heart Population: 2005 2009 N approx. 600

90 80 70 60 50 40 30 20 10 Comparison Of STEMI Process of Care For Inter hospital Transfer: Door Balloon Times 0 % PTS 4.2 16.2 8.6 26.4 NRMI 3/4 NCDR 2005- (n=4278) 2006 < 90 min. < 120 min. 13 59 Stat Heart- Spr.2008 64 89 Stat Heart- Carb.2008 20 64 Total Stat Heart (n=15,049) (n=338) (n=44) (n=382)

In Hospital Clinical Outcomes Length of hospitalization (mean ± SD days): 3.6 ± 2.5 vs. 5 ± 6.3; p=0.0001

Comparison Of 30 day Clinical Outcomes NRMI vs. Stat Heart: Springfield Hub % PTS 10 Meta-analysis Stat Heart/07 Stat Heart 8/08 (n=1472) (n=188) 8 7 8 6 5.9 4 2 0 3.7 Death 2.6 2.1 1.2 Non-Shock Death 3.7 3 1.1 1.1 0.9 0.3 0.05 Re-infarction Stroke Composite

PROCEDURAL KEYS to Success 1. EARLY RECOGNITION OF MI starts the interventional cascade beginning with QUICK call to helicopter or ambulance for transport 2. A SINGLE call to activate Stat Heart Process in Springfield 3. Standardized Protocol/ Orders (PCC and ED physician agree to adhere to standard orders as written) 4. Standardized communications via pager identifies MI, patient departure, 15 minute arrival 5. Cath lab nurse calls after receiving departure page for brief report-cath lab nurse calls community hospital nurse. Cardiologist and team awaits arrival in cath lab. 6. Communication ON-GOING throughout the process from beginning to end 7. Rapid transportation via ground or air is mandatory. Regular meetings with these providers 8. Education provided to all Stat Heart team members 9. Data collection to promote process improvement and quality 10. Feedback and reports given promptly (immediately after each case) 11. Public education (regarding Sx of MI, program in their area) 12. Debrief with Stat Heart team members at regular intervals and especially after failures (problems compound with out intervention) 13. No Blame Environment! 14. Continue to innovate. Don t tolerate failure, don t rest on success (EKG s in the field, paramedic education, earlier initiation of Rx) 15. D2B time is important, but it s LIVES SAVED THAT REALLY COUNTS. Mortality reflects the proof in the pudding

Conclusions Stat Heart (Rural Inter-Hospital Transfer) Regional STEMI Program: feasible/safe with reproducible, favorable and comparable process measure outcomes to to U.S. Registry, despite program growth among broad range of of hospital systems. Between 2005-2009, the utilization of of this coordinated, rural inter-hospital STEMI transfer program, appears to to associated with shorter hospitalization and improved inhospital clinical outcomes, as as compared to to non- standardized pre-stat Heart STEMI care. in-

Conclusions Stat Heart (Rural Inter-Hospital Transfer) Improvements -- Procedural Time (wide inter-procedural/inter-operator variability) -- Standardization of of cardiac cath cath lab lab process -- Implementation of of pre-hospital ECG: Reduce door-in/door-out time time Emphasis on on program maintenance and and improvement -- Avoid complacency (delays): meetings, updates, teamwork (transport, ED s, ancillary staff, cath cath lab, lab, administration, etc) etc) -- Program-wide commitment to to collection, interpretation and and dissemination of of data data -- Nimble program: modifiable process/treatment changes RN RN Coordinator: Education, education, education!!

Minneapolis Heart Institute Timothy D. Henry, MD, FACC

EMS COMPONENTS OF A SYSTEM 1. PREHOSPITAL 2. TRIAGE 3. TRANSFER Non PCI Capable Only 50% of STEMI use EMS in the US 10% Pre-hosp ECG PCI Capable

Primary PCI: Access 42.0% PCI hospital is closest facility 79.0% within 60 minute prehospital time Nallamothu et al. Circulation 2006;113:1189

Red Zone II (90-120 mins) Blue Zone I (< 90 mins) Zone1 Protocol Aspirin 325 mg Clopidogrel 600mg UFH Beta-blocker PCI

Protocol focus: Simple Fast Reduce variability Red Zone II (90-120 mins) Blue Zone I (< 90 mins) Zone 2 Protocol Aspirin 325 mg Clopidogrel 600mg UFH TNK ½ dose Beta-blocker PCI

MHI Level 1 MI: Door Balloon Times % of patients 100 90 80 70 60 50 40 30 20 10 0 ANW Zone 1 Zone 2 NRMI 3/4 < 90 mins <120mins

Kaplan-Meier Survival Curve Survival Probability 0.0 0.2 0.4 0.6 0.8 1.0 ANW Zone 1 Zone 2 p = 0.31 0 50 100 150 200 250 300 350 Days

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