Massachusetts STEMI Care
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Transcript of Massachusetts STEMI Care
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Massachusetts STEMI Care
Peter Moyer MD,MPH,FACEP
Dallas June 4 ,2011
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Who I am
• Taught NYC medic classes 5-14 (1977 -84)
• Chair of BU Emergency Medicine 1984-2000
• Medical Director Boston EMS, Fire and Police 2000-2010
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Disclosures
NONE
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STEMI Statistics
•Acute Coronary Syndrome (ACS) will strike 935,000 people a year in the United States•An estimated 250,000 of those will be STEMIs
Heart Disease and Stroke Statistic 2011 Update: A Report From the American Heart Association Statistics Committee and Stroke Statistics Subcommittee. Circulation 2011;123:e18-e209.
04/21/23 5
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Mission: Lifeline & Sudden Cardiac Arrest
Statistics• 325,000 suffer from OOHCA• US survival rates are only 8.4%
Why include SCA?• Experts estimate that up to 50% of OOHCA are STEMI’s• To develop systems of care to improve survival for OOHCA
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STEMI Revascularization Strategy Trends
ACTION Registry-GWTG DATA: July 1, 2009 – June 30, 2010ACTION Registry-GWTG DATA: July 1, 2009 – June 30, 2010
PCI Medically Managed CABG
0%10%20%30%40%50%60%70%80%90%
Q3 2009 Q4 2009 Q1 2010 Q2 2010
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10 Years of STEMI System of Care in Boston
• 1990’s: Paramedic EKG acquisition and interpretation
• 2000:Boston EMS criticized in press for by- passing non PCI hospital with STEMI patient
• 2001-2002: eventual agreement of medical community to take STEMI’s only to PCI centers (STEMI Point of Entry plan)
• 2003: new STEMI POE begun
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Boston’s PCI centers
• PCI centers agreed to:
-perform PCI 24/7/365
-maintain necessary institutional and individual interventionalist volumes
-meet performance criteria:
PCI rather than lysis >90%
D2B < 120 then <90 min 75 %
-submit data to a common data coordinating center
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Initial Obstacles to STEMI plan
-non PCI centers feared loss of revenue
-PCI centers feared public airing of performance
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Solutions
• Shared revenues between PCI and non PCI hospitals
• Blinded performance data (blind broken for failure to meet performance criteria)
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Boston EMS• Third Service
• Fire First Response
• .6 -1.2 Million pop
• 110k calls per year
• 75k transports per year
• 6 STEMI PCI Centers
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Boston EMS
2 tiers:
low paramedic #’s 75
(average intubations/medic/yr : 8.5)
bigger BLS tier 275
give albuterol and nasal naloxone ,test sugar, dispatched to stroke
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Pre hospital EKG-national
EMS transported STEMI’s with and without pre hospital EKG:
• D2B with pre hospital EKG: 79 min
• D2B without pre hospital EKG: 91 min
5/14/11 AR GWTG
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Pre Hospital EKG -Boston
• Boston EMS paramedics read 12 leads and radio and transport to PCI hospital bypassing non PCI hospitals if necessary
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Boston EMS
• Divide 12 leads into: STEMI ,Possible STEMI and non STEMI
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Boston EMS
• Early: 12 lead
Call to hospital
Mention of STEMI in radio call
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Median Times (in minutes) from Door to Balloon
9183.5
7366 63 58 54 53.5
0
20
40
60
80
100
2003 (Q3/Q4) (n=28)
2004 (n=42)
2005 (n=54)
2006 (n=49)
2007 (n=56)
2008(n=35)
2009(n=41)
2010(n=38)
Year
Med
ian
num
ber o
f min
utes
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Trends in elapsed door-to-balloon times,Post PoE (since July 2003)
46%
64%72%
78%
89%
77%
90% 92%
0%
20%
40%
60%
80%
100%
2003 (Q3+Q4)(n=28)
2004(n=42)
2005(n=54)
2006(n=49)
2007(n=56)
2008(n=35)
2009(n=41)
2010(n=38)
Year
% w
ithin
90
min
utes
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Trends in elapsed door-to-balloon times, stratified by day of week
0%
20%
40%
60%
80%
100%
2003 (Q3+Q4)
2004 2005 2006 2007 2008 2009 2010Year
% w
ithin
90
min
ute
s
Mon-Fri
Sat/Sun
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Trends in elapsed door-to-balloon times, stratified by time of day
0%
20%
40%
60%
80%
100%
2003 (Q3+Q4)
2004 2005 2006 2007 2008 2009 2010
Year
% w
ithin
90
min
ute
s
Night Arrival
Day Arrival
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E2B
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Median Times (in minutes) from EMS arrival to Balloon
120111
10393 92 90 87
77
0
20
40
60
80
100
120
140
2003 (Q3/Q4) (n=28)
2004 (n=42)
2005 (n=54)
2006 (n=49)
2007 (n=56)
2008(n=35)
2009(n=41)
2010(n=38)
Year
Med
ian
num
ber o
f min
utes
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• 2008 Web Based Continuous QI system Automated
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Boston’s STEMI QI
1. Clinical Care Benchmarks– IV, O2, ASA, 12L EKG– Prehospital Notification
2. 12L EKG Interpretation– Medical Director Agreement
3. Hospital Follow up– Agreement with 12L EKG evaluation– Cardiac Cath– Door to Balloon; EKG to Balloon Time
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STEMI CARE BenchmarksSTEMI CARE Benchmarks
Prehospital care meets clinical care benchmarks
for STEMI patinet
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Individual Case reviewIndividual Case review
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Hospital Data EntryHospital Data Entry
3333
Prehospital Entry note
given?
If Cardiac Cath, balloon time entered. Able to calculate D2B time or E2B time.
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EMS Feedback ReportEMS Feedback Report
3434
Patient outcome available in
EMS cQI system immediately
after hospital enters data
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Mass STEMI care
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04/21/23 Taken from Quarter 3 2011 ACTION Registry – GWTG 2011 38
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Where is STEMI care headed?
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Systems of CareSystems of CareSystems of CareSystems of Care
III IIaIIaIIa IIbIIbIIb IIIIIIIIIIII IIaIIaIIa IIbIIbIIb IIIIIIIIIIII IIaIIaIIa IIbIIbIIb IIIIIIIIIIIaIIaIIa IIbIIbIIb IIIIIIIII
NEW
RecommendationEach community should develop a STEMI system of care following the standards developed for Mission Lifeline (AHA) including:
§ Ongoing multidisciplinary team meetings with EMS, non-PCI & PCI centers
§ A process for prehosp identification and activation
§ Destination protocols for PCI centers§ Transfer protocols for non-PCI centers
for appropriate patients
ACC/AHA 2009 Joint STEMI/PCI Guidelines Focused Update JACC 2009
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STEMI Systems Coverage
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STEMI Systems of Care
• Integration of Patients, EMS and non PCI centers into PCI Systems
• Data driven with QI feedback from PCI center to ED’s and EMS
• Certificate of Need (CON) and Accreditation
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Patients
• Increase Use of EMS
• Decrease Symptom Onset to Balloon-
Dallas/Caruth’s Symptom Onset to Arterial Reperfusion (SOAR) metric
• Awareness of PCI centers
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04/21/23 Taken from Quarter 3 2011 ACTION Registry – GWTG 2011 45
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EMS
Pre hospital 12 lead EKG’s :
Equip & train all medics
Read Computer interpretation
Transmission
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Wireless Transmission of 12-Lead ECG'sWireless Transmission of 12-Lead ECG'sFrom Ambulance to ERFrom Ambulance to ER
LifeNetLifeNet
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EMS
• Determine hospital destination for STEMI and cardiac arrest patients (resuscitation centers)
-may entail bypassing Non PCI hospitals-
• Cath lab activated on EMS call
• Direct to Cath Lab
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EMS
• New field therapies (ex cooling for arrest )
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EMS
• More Rapid Interfacility
transport
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EMS
Electronic records: NEMSIS
Better QI –systemwide and individual feedack
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PCI centers
• Responsible for:
-STEMI system integration including early return of patient to local facility
-Data management for system
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PCI centers
• Share bundled PCI payment with non PCI hospital
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PCI Centers-eventually (several years)…
Urban PCI centers’ #’s shrink as volume criteria enforced and global health budgets adopted-
fee for service sees STEMI as “revenue”
global budget-sees STEMI care as “cost”
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• PCI centers/population
Boston 6 1M NYC 22 8M Dallas County 13 2.2 M Vancouver 3 3M Nova Scotia 1 1M
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PCI centers with wide geographic draw:
- prehospital as well as non PCI hospital lytics
-air as well as ground ambulances
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Boston MedFlight • Licensed as a critical care serviceLicensed as a critical care service
• 501(c)3 public charity501(c)3 public charity• CAMTSCAMTS
CCT
CCT RN,CCT
paramedic,plus driver/pilot
ALS Team
2 paramedics
BLS Team
2 EMT’s
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Non PCI centers
• Rapid Interfacility Transport
• Share in STEMI bundled payment
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Systems of STEMI care cover all of US
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NYS Regs PCI hospitalsNovember 2009
• Must have a community outreach program
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NY State Regs –EMS
• EMS should transport all STEMI’s to a PCI hospital bypassing non PCI hospitals if necessary
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NYS Regs
• PCI centers must maintain minimal annual volumes:
institution - 150 PCI/yr, at least 36 of which are primary
interventionalist - >3/institution; minimum of 75 PCI /yr/interventionalist, at least 11 of which must be primary
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NY State Regs
• CON for new PCI hospitals: -evidence that existing PCI centers
cannot meet patient needs due to such items as capacity ,geography and or EMS limitations
-meet volume criteria -not jeopardize ability of existing PCI
centers to meet volume criteria -plan for community outreach
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NYS Regs - PCI hospitals
• Integrate EMS and hospital QI data
• Collaborate with EMS in their QI to review prehospital care including review of specific cases
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