Improved Care for Acute Improved Care for Acute Myocardial InfarctionMyocardial InfarctionLinking Referral and Linking Referral and

Receiving Centres – How can Receiving Centres – How can We Communicate Better?We Communicate Better?

Dr. James McMeekinDr. James McMeekinAMI FacultyAMI Faculty

Cardiologist, Foothills Medical Centre, Cardiologist, Foothills Medical Centre, Calgary Health RegionCalgary Health Region

Improved Care for Acute Improved Care for Acute Myocardial Infarction- OutlineMyocardial Infarction- Outline

1. History of the Calgary Health Region 1. History of the Calgary Health Region STEMI Project - a system approachSTEMI Project - a system approach

2. Changing reperfusion management in 2. Changing reperfusion management in the STEMI Populationthe STEMI Population

3. New directions- STEMI project in the 3. New directions- STEMI project in the Rural Calgary Health RegionRural Calgary Health Region

History of the CHR STEMI ProjectHistory of the CHR STEMI Project

20032003– STEMI project (STEMI project (STrategic Evaluation and STrategic Evaluation and

Management of ST Elevation MI)Management of ST Elevation MI) initiated by initiated by Cardiology Interventional group Cardiology Interventional group

– willing to be on call 24/7 for Direct PCI for willing to be on call 24/7 for Direct PCI for STEMI populationSTEMI population

– Approached QI Council to make it a QI projectApproached QI Council to make it a QI project

Calgary’s STEMI initiativeCalgary’s STEMI initiativeGoalsGoals

1. Develop a comprehensive management 1. Develop a comprehensive management model for ST Elevation MI model for ST Elevation MI

2. Optimize the use of timely reperfusion 2. Optimize the use of timely reperfusion therapy and use PCI as the primary reperfusion therapy and use PCI as the primary reperfusion therapy whenever possible (60-90 minutes)therapy whenever possible (60-90 minutes)

3. Initiate an early discharge program for low 3. Initiate an early discharge program for low risk patientsrisk patients

4. Improve and coordinate discharge and 4. Improve and coordinate discharge and access to out patient care/community care access to out patient care/community care

1. Develop a comprehensive 1. Develop a comprehensive management model for ST management model for ST

Elevation MIElevation MI

Many players- EMS, ED, Cardiac Cath Lab, CCUMany meetingsMany lessons

35 39 31

32 72 46

0 50 100 150

Minutes

Post pathway

Pre pathway

Mean Times (EMS - Flow)

EMS to ER ER to Catlab Cathlab to Flow

P = 0.02 P < 0.001 P < 0.001

2. Optimize the use of timely reperfusion therapy

3. Initiate an early discharge 3. Initiate an early discharge program for low risk patientsprogram for low risk patients

Develop criteria for a low risk post STEMI Develop criteria for a low risk post STEMI group for discharge on day 2 - 3group for discharge on day 2 - 3

Ensure all discharge planning is covered Ensure all discharge planning is covered whether in hospital or in communitywhether in hospital or in community

Track this low risk group in AMI data baseTrack this low risk group in AMI data base

ObjectivesObjectives1.1. To use the Cadillac trial Risk Score to To use the Cadillac trial Risk Score to

determine risk groups in our STEMI determine risk groups in our STEMI population.population.

2.2. To monitor length of stay (LOS) and To monitor length of stay (LOS) and complication rates in each risk group.complication rates in each risk group.

3.3. To understand reasons (clinical and To understand reasons (clinical and operational) why patients were not operational) why patients were not discharged within the target.discharged within the target.

The Cadillac (Controlled Abciximab Device The Cadillac (Controlled Abciximab Device Investigation to Lower Late Angioplasty Investigation to Lower Late Angioplasty Complications) Risk Stratification Score Complications) Risk Stratification Score

(J Am Coll Cardiol 2005; 45: 1397-1405). (J Am Coll Cardiol 2005; 45: 1397-1405).

Risk FactorRisk Factor

Baseline LVEF Baseline LVEF < 40%< 40%

Renal InsufficiencyRenal Insufficiency

Killip Class ≥2Killip Class ≥2

Final TIMI Flow ≤2Final TIMI Flow ≤2

Age > 65 yearsAge > 65 years

AnemiaAnemia

3 Vessel Disease3 Vessel Disease

Score Range:Score Range:

ScoreScore

44

33

33

22

22

22

_2__2_

0-180-18

Cadillac Risk Score Cadillac Risk Score CharacteristicsCharacteristics

Risk LowRisk Low Intermediate Intermediate High High

Risk Score 0-2 3-5Risk Score 0-2 3-5 ≥6≥6

1 yr mortality <1% 4-5% >12%1 yr mortality <1% 4-5% >12%

D/C Target 2-3 4-5 D/C Target 2-3 4-5 Clinical (Days) Clinical (Days) judgment judgment

JACC 2005;45: 1397-1405

Patient CharacteristicsPatient Characteristics 297 consecutive STEMI patients were assigned risk 297 consecutive STEMI patients were assigned risk

scores between Jan. 25, 2006 and Jan 31, 2007.scores between Jan. 25, 2006 and Jan 31, 2007.

Risk Low (0-2)Risk Low (0-2) Interm (3-5) High (>5) Interm (3-5) High (>5)

nn 148 148 78 78 71 71

Mean Age 58*Mean Age 58* 63** 63** 68* ** 68* **

MaleMale 77% 74% 77% 74% 64% 64%

* **p<.05

Patient CharacteristicsPatient CharacteristicsRISK Group LOW Intermediate HIGHRISK Group LOW Intermediate HIGH

DMDM 15%15% 22% 22% 25% 25%HTNHTN 39%39% 50% 50% 46% 46%SmokerSmoker 41%41% 38% 38% 30% 30%Prev MIPrev MI 11%11% 9% 22% 9% 22%Prev PCIPrev PCI 10%10% 10% 10% 16% 16%Prev CABGPrev CABG 1% 1% 0% 0% 3% 3%Stroke Stroke 3% 3% 6% 7% 6% 7%Killip Class Killip Class ≥≥22 0%* 0%* 13%** 26%* ** 13%** 26%* **

* **p<.05

Length of StayLength of Stay

Low Risk Moderate Risk High Risk

LO

S (

da

y)

0

5

10

15

20

25

30

* **

* **

* **p <.05

*

In Hospital Complications excluding In Hospital Complications excluding DeathDeath

0%

5%

10%

15%

20%

25%

30%

Low 17/148

Intermediate15/78High 21/71

*

*

*p<.05

In Hospital DeathIn Hospital Death

0%

2%

4%

6%

8%

10%

12%

14%

16%

18%

20%

Low 0/148

Intermediate4/78High 13/71

* *

*p<.05

30 Day Complications Including 30 Day Complications Including DeathDeath

0%

10%

20%

30%

40%

50%

60%

Low 27/148Intermdiate 24/78High 40/71

* *

*p<.05

Percent Discharged by TargetPercent Discharged by Target

Risk Group: Low (Risk Group: Low (≤3 d≤3 d) Interm () Interm (≤5d≤5d) High () High (≥6d≥6d) )

28% 28% 50% 50% N/A N/A

Low Risk GroupLow Risk Group104/148 low risk patients were not 104/148 low risk patients were not discharged by the target of 3 days ( 72%)discharged by the target of 3 days ( 72%)

Of the 104 patients , the reason for delay Of the 104 patients , the reason for delay in discharge was analyzed: clinical (65 pts) in discharge was analyzed: clinical (65 pts) and operational issues (39 pts) were and operational issues (39 pts) were identified (system issues with potential for identified (system issues with potential for improvement)improvement)

Clinical Delays to DischargeClinical Delays to Dischargen=65n=65

0

2

4

6

8

10

12

14

Arrythmia 20%

Chest pain 18.5%

MD Discretion-13.8%

Heart Failure 12.3%

Comorbidities 9.2%

Other 9.2%

CABG 7.7%

Pericarditis 6.2%

Vascular 4.6%

.

Operational Delays to DischargeOperational Delays to Discharge n=39/104 n=39/104

02468

101214161820

OPERATIONAL37.5%

Tests-46.1%

Anticoagulation-38%

staged PCI 15%

ConclusionsConclusions1.1. The CRS predicts complications in the The CRS predicts complications in the

risk groups well and ability to discharge a risk groups well and ability to discharge a low risk population, early after STEMI, low risk population, early after STEMI, only modestly well.only modestly well.

2.2. There are operational factors that may There are operational factors that may contribute to prolonged hospital stays. contribute to prolonged hospital stays.

3.3. Targeting these factors with improvement Targeting these factors with improvement strategies may shorten the length of stay. strategies may shorten the length of stay.

4. Improve and coordinate discharge and 4. Improve and coordinate discharge and access to out patient care/community careaccess to out patient care/community care

– Nurse clinicians in CCU identify low risk Nurse clinicians in CCU identify low risk patients through the risk score patients through the risk score

– Patient referred for follow-up and Patient referred for follow-up and medical assessment in a Nurse run medical assessment in a Nurse run STEMI clinic 1 week after dischargeSTEMI clinic 1 week after discharge

– Automatic referral to Cardiac Automatic referral to Cardiac Rehabilitation programRehabilitation program

History of the CHR STEMI ProjectHistory of the CHR STEMI Project

2005-6- moved STEMI ‘Project’ into day to 2005-6- moved STEMI ‘Project’ into day to day operationday operation

Bimonthly meetings –review of results, Bimonthly meetings –review of results, outliers, review the flow diagram when outliers, review the flow diagram when changes needed changes needed

Results still awesome- 80% receive 1Results still awesome- 80% receive 1stst flow within 90 min of presentationflow within 90 min of presentation

Changing reperfusion management Changing reperfusion management in the STEMI Populationin the STEMI Population

Who receives fibrinolytic therapy?Who receives fibrinolytic therapy?

Who receives rescue PCI?Who receives rescue PCI?

What adjuvant therapy is appropriate?What adjuvant therapy is appropriate?

Time is MuscleTime is Muscle

The longer the clot has matured in the The longer the clot has matured in the coronary artery, the more difficult it is for a coronary artery, the more difficult it is for a fibrinolytic agent to work. fibrinolytic agent to work.

Optimal window - first 3 hours after Optimal window - first 3 hours after symptom onset. symptom onset.

During this 3-hour window, fibrinolytic During this 3-hour window, fibrinolytic therapy and primary PCI have about the therapy and primary PCI have about the same efficacy in terms of limiting mortality. same efficacy in terms of limiting mortality.

Time is MuscleTime is Muscle

Beyond the first 3 hours, primary PCI Beyond the first 3 hours, primary PCI becomes the preferred strategy because it becomes the preferred strategy because it can salvage myocardium more effectively can salvage myocardium more effectively than fibrinolytic therapy. than fibrinolytic therapy. The goal is to get the patient quickly to The goal is to get the patient quickly to where pharmacologic reperfusion is where pharmacologic reperfusion is available or to create a situation (system) available or to create a situation (system) where the patient can be transported where the patient can be transported rapidly to a primary PCI center. rapidly to a primary PCI center.

Reperfusion Options for STEMI PtsStep One: Assess Time and Risk

Time Since Symptoms

Time Required to

Initiate Invasive Strategy

Risk of STEMI

Risk of Lysis

PCI FOR AMI STRATEGIESPCI FOR AMI STRATEGIES

Primary PCIPrimary PCI Preferred strategyPreferred strategy

Rescue PCIRescue PCI Clinical benefit in moderate to large Clinical benefit in moderate to large MIMI

Facilitated PCIFacilitated PCI No proven benefitNo proven benefit

Likely harmfulLikely harmful

Immediate PCIImmediate PCI Superior to watchful waitingSuperior to watchful waiting

3. New directions- STEMI project in the 3. New directions- STEMI project in the Rural Calgary Health RegionRural Calgary Health Region

Southern Alberta STEMI initiativeSouthern Alberta STEMI initiative

Early diagnosis of STEMI with field ECGEarly diagnosis of STEMI with field ECGTimely communication between field EMS and Timely communication between field EMS and local hub /emergency dept local hub /emergency dept Use of technology to transmit ECGUse of technology to transmit ECGTreatment pathway is initiated in the field or Treatment pathway is initiated in the field or local centrelocal centreEarly risk stratification with expedited access to Early risk stratification with expedited access to tertiary care for high risk patients tertiary care for high risk patients Streamline referral process to expedite access Streamline referral process to expedite access to angiography/CV serviceto angiography/CV serviceRapid patient repatriationRapid patient repatriation

High RiverHigh River STEMI Emergency STEMI Emergency Department Department January 15, 2008January 15, 2008

(revision due date 3, 6 and 12 (revision due date 3, 6 and 12 months post implementation)months post implementation)

MUSEMUSE

MUSE(Marquette Universal System for ECG’s)

Calgary Health Region’s ElectronicECG Repository

HOW ECG’S ARE TRANSMITTED HOW ECG’S ARE TRANSMITTED TO CALGARY HEALTH REGION’S TO CALGARY HEALTH REGION’S

MUSEMUSE DATABASE DATABASE

MUSE ECG

User with remote access to MUSE WEB can view the ECG “online”

ECG’s TRANSMITTED DIRECTLY FROM EMS PROVIDERS IN THE FIELD - URBAN AND RURAL – TOTAL OF 14 EMS PROVIDERS

MUSE

ECG’s TRANSMITTED FROM CHR RURAL HEALTH CARE FACILITIES (VIA ECG CART OR

BEDSIDE MONITOR) – TOTAL OF 14 SITES

Timeliness: ECG acquisition and ability to view it online

01:22

01:27

BENEFITS OF THE HEART ALERT MUSE BENEFITS OF THE HEART ALERT MUSE INITIATIVEINITIATIVE

Heart Alert’s MUSE initiative affords the Region’s Rural patients

Early consultation

Improved access to care

Access to historical and real time clinical information (ECG transmission)

Pathway PrinciplesPathway Principles

Primary Percutaneous Coronary Primary Percutaneous Coronary Intervention Eligibility CriteriaIntervention Eligibility Criteria

Onset less than 12 HoursOnset less than 12 Hours

Onset defined as beginning of symptoms Onset defined as beginning of symptoms leading to patient seeking medical leading to patient seeking medical attentionattention

Pathway PrinciplesPathway Principles

Onset between 1-3 HoursOnset between 1-3 Hours

Primary Percutaneous Coronary Primary Percutaneous Coronary Intervention if transport to Catheterization Intervention if transport to Catheterization Lab Lab guaranteed within 60 minutesguaranteed within 60 minutes from from EDMD AssessmentEDMD Assessment

Pathway PrinciplesPathway Principles

Onset 3 – 6 HoursOnset 3 – 6 Hours

Primary Percutaneous Coronary Primary Percutaneous Coronary Intervention PreferredIntervention Preferred

Fibrinolytic Therapy may be recommended Fibrinolytic Therapy may be recommended by Cardiac Interventionalist if no by Cardiac Interventionalist if no contraindications or PPCI is delayedcontraindications or PPCI is delayed

Pathway PrinciplesPathway Principles

Onset 6 - 12 HoursOnset 6 - 12 Hours

Primary Percutaneous Coronary Primary Percutaneous Coronary Intervention PreferredIntervention Preferred

Pathway PrinciplesPathway Principles

Onset Greater than 12 Hours, continued Onset Greater than 12 Hours, continued symptoms, ST Elevation and/or symptoms, ST Elevation and/or Hemodynamic InstabilityHemodynamic Instability

Contact Cardiac Interventionalist via Contact Cardiac Interventionalist via SARCC regarding plan of careSARCC regarding plan of care

Angiogram with or without AngioplastyAngiogram with or without Angioplasty

ConclusionsConclusions

System models for Coronary reperfusion System models for Coronary reperfusion are necessary for optimal care in our are necessary for optimal care in our STEMI populationSTEMI populationShould we consider the ‘System Approach Should we consider the ‘System Approach for STEMI Patients’ as a risk indicator for for STEMI Patients’ as a risk indicator for assessment of AMI programs?assessment of AMI programs?Spreading this system model to the rural Spreading this system model to the rural population is our next challenge. Should it population is our next challenge. Should it be considered elsewhere?be considered elsewhere?