NEBRASKA – STEMI CONFERENCE 2015 Dr. Matt Johnson …wcm/@mwa/documents/... · NEBRASKA – STEMI...
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NEBRASKA – STEMI CONFERENCE 2015Dr. Matt Johnson and Dr. Doug Kosmicki
1©2013, American Heart Association
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Dr. Matt Johnson
Putting the State STEMI Guidelines into Practice
Collaboration – Relationships
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©2013, American Heart Association
Point Of Entry Protocol : GOAL
3
Less than 90-120 Minutes
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Mission: Lifeline Nebraska Statewide STEMI Guideline
Why is a Statewide STEMI Guideline so Important?
-Standardized Guidelines in a System of Care ensure that all of our patients are getting the best possible care. “Where a patient lives should not determine if they live.”
-The next logical step in creating a Rural STEMI System in Nebraska. Bringing all of the resources that were made available under the Helmsley Grant together to ensure these resources work together to improve outcomes.
-A consistent message from all PCI centers in the state helps make the decision making process for the rural providers easier and faster.
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Improving the System of Care for STEMI Patients
Why “Rural” Nebraska?
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• Nebraska still has vast rural areas with limited EMS services, and long transports to hospitals with Primary PCI capabilities.
• Mortality is still worse, the farther away you are from a cath lab that performs primary PCI.
• The Metro Areas, and other areas with good ALS EMS presence close to cathlabs, do not have as much need as some other rural areas.
• With limited funding, this project aims to improve care in the rural areas that have traditionally not had as much support or success with STEMI care.
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Improving the System of Care for STEMI Patients
Regional Systems of STEMI Care, Reperfusion Therapy, and Time-to-Treatment Goals
All communities should create and maintain a regional system of STEMI care that includes assessment and continuous quality improvement of EMS and hospital-based activities.
Performance can be facilitated by participating in programs such as Mission: Lifeline and the D2B Alliance.
I IIaIIbIII
Performance of a 12-lead ECG by EMS personnel at the site of FMC is recommended in patients with symptoms consistent with STEMI.
I IIaIIbIII
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Publications to Support STEMI SystemDevelopment
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How is STEMI Defined?
• ST elevation at the J point in at least 2 contiguou s
leads of ≥2 mm (0.2 mV) in men or ≥1.5 mm (0.15 mV) in
women in leads V2–V3 and/or of ≥ 1 mm (0.1mV) in other
contiguous chest leads or the limb leads.
• New or presumably new LBBB at
presentation occurs infrequently, may interfere wit h
ST-elevation analysis, and should not be considered
diagnostic of acute myocardial infarction (MI) in i solation.
• ECG demonstrates evidence of ST depression suspect of a Posterior MI8
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SYSTEM COMPLEXITY
5/3/2015 ©2010, American Heart Association 9
Walk In
Patients
EMS
Non PCI
Hospital
/ CAH
Interfacility
ALS - EMS
PCI
Center
Walk In
Patients
EMS
Cath
Lab
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Improving the System of Care for STEMI Patients
Reperfusion Therapy for Patients with STEMI
*Patients with cardiogenic shock or severe heart failure initially seen at a non–PCI-capable hospital should be transferred for cardiac catheterization and revascularization as soon as possible, irrespective of time delay from MI onset (Class I, LOE: B). †Angiography and revascularization should not be performed within the first 2 to 3 hours after administration of fibrinolytic therapy.
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©2013, American Heart Association
Barriers to Timely Reperfusion
• The patient– Failure to promptly recognize
symptoms– Hesitation to seek medical attention
• Time to transport– Mandated delivery to the closest
hospital, regardless of PCI capabilities– Long transport in rural areas
• Decision process on arrival– Clot-busting drugs vs. PCI– Off hours– Transfer to PCI facility
• Time to implement treatment strategy– Procedural factors– Team assembly
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Improving the System of Care for STEMI Patients
STEMI Accelerator Program Data…
• Presented at AHA Annual
Meeting
• Chicago, November 2014
12Granger, Jollis; Mission Lifeline STEMI Accelerator Project –Presented at: American Heart Association Scientific Sessions; November 19, 2014; Chicago, IL
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Improving the System of Care for STEMI Patients
STEMI Goal Times
• FMC to ECG acquisition < 10 minutes
• PCI capable hospital direct presentation, FMC-
PCI time < 90 minutes
• Non-PCI capable hospital presentation, Door In
Door Out <45 minutes
• Transfer for primary PCI only if FMC-PCI time <
120 minutes...
… Otherwise lytics within 30 minutes of arrival
time followed by urgent transfer
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STEMI Continuum Relationships
Relationships
Recognition – Reperfusion
Real Time Data Collection
Reassessment – Refine process
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Improving the System of Care for STEMI Patients
STEMI Recognition – Once identified it MUST trigger a clear response Downstream.
Rapid Recognition of STEMI on ECG will only improve the process “IF”
Recognition leads to a concrete action occurring do wnstream. (system of care)
Recognition allows early Reperfusion
…but it does not guarantee it.
A System of care is needed to
navigate the rapids and have a
Successful outcome for patients.17
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Dr. Doug Kosmicki
M:L Guidelines - Utilizing them in your settings.
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Disclosure Information
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Improving the System of Care for STEMI Patients
How Much Time do I Have?
First - things - First
Initial ECG within 10 minutes of First Medical Contact
Recommended benchmarks for reperfusion therapy:
� All eligible STEMI patients receiving a Reperfusion (PPCI or fibrinolysis) Therapy
� First Medical Contact (EMS non transfer) to Primary PCI < 90 minutes
� Fibrinolytic eligible STEMI patients with Door-to-Needle time < 30 minutes
� PPCI eligible patients transferred to a PCI receiving center with referring center Door
in- Door out (Length of Stay) < 30 min
� PPCI eligible patients receive a Referring Center ED + Pre-Hospital First Medical
Contact-to-PCI time < 120 minutes (including transport time)
� All STEMI patients without a contraindication receiving Aspirin prior to referring center
ED discharge
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©2013, American Heart Association
• Lack of 24/7 12 Lead ECG capability in the field
• ECG interpretation skills
• False positives
• Lack of protocols to allow rapid identification of a STEMI patient
• Corporate loyalty
• Lack of pre-hospital STEMI activation from the field
• Lack of Multidisciplinary Meetings
• Lack of data collection
• Terrain/Weather
• Interfacility Transport Team response
• ……………………………………..and so on and so on
Identified NE Gaps and Barriers
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Improving the System of Care for STEMI Patients
Mission Lifeline Obstacles you might encounter in im plementing your STEMI System of care
• Building something that did not exist at a state level and or at your local facility
• Misinformed or misunderstanding of the program and how it affects your facility
• Technical issues for EMS and hospitals
• Utilization by EMS of equipment if available
• Availability of ALS services is rural areas
• Limited resources in rural hospital including staffing, time for training and
equipment
• Consistent staffing and knowledge of guidelines and internal protocols
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Improving the System of Care for STEMI Patients
Acute Coronary Syndrome (ACS) FACTS
• The actions of healthcare providers during the first several hours of
a heart attack determine the magnitude of any benefit from
treatment and intervention
• A system that works together efficiently is paramount in reducing
mortality and optimizing the benefit from any acute cardiac care
strategy
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Improving the System of Care for STEMI Patients
Mission: Lifeline Nebraska Statewide STEMI Guideline• Statewide STEMI Guidelines have been approved.
• The introduction letter signed by members of Interventional Cardiology Steering Committee representing 14 cardiology groups in the state.
• This sends a very powerful message on the need for standardized statewide guidelines and willingness to utilize best practice and evidence based recommendations.
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Improving the System of Care for STEMI Patients
Signatures:
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Improving the System of Care for STEMI Patients
Time is Muscle…So Time(s) Are Important!Page 1 – NE STEMI Guideline
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Improving the System of Care for STEMI Patients
NE STEMI Guideline - Page 1 - Continued
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Improving the System of Care for STEMI Patients
NE STEMI Guideline – Page 2
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Improving the System of Care for STEMI Patients
NE STEMI Guideline - Page 2 Continued
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Improving the System of Care for STEMI Patients
NE STEMI Guideline - Page 3
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Improving the System of Care for STEMI Patients
NE STEMI Guideline – Page 3 continued
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Improving the System of Care for STEMI Patients
STEMI Recognition – Once identified it MUST trigger a clear response Downstream.
Rapid Recognition of STEMI on ECG will only improve the process “IF”
Recognition leads to a concrete action occurring do wnstream. (system of care)
Recognition allows early Reperfusion
…but it does not guarantee it.
A System of care is needed to
navigate the rapids and have a
Successful outcome for patients.33