Bill Koenig, MD Medical Director Los Angeles County EMS Agency

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<ul><li> Slide 1 </li> <li> Bill Koenig, MD Medical Director Los Angeles County EMS Agency </li> <li> Slide 2 </li> <li> Establishing a Communitywide System of Care </li> <li> Slide 3 </li> <li> Designated emergency cardiac care centers Triage to PCI centers Data driven quality improvement program Moyer P. Crit Pathways Cardiol 2004;3:53-61 Boston EMS STEMI </li> <li> Slide 4 </li> <li> Slide 5 </li> <li> Primary Percutaneous Coronary Intervention (PCI) is one of the most complex, multi- disciplinary, and time-sensitive therapeutic intervention medicine. Our process is measured in Minutes Our outcomes are measured in terms of Mortality Teamwork and smooth Transitions are essential PCI for STEMI </li> <li> Slide 6 </li> <li> October 30,2010 0930Exercising, CP 0935911 Dispatch 0941ALS Arrives.October 2006: Chest Pain Destination: MAR </li> <li> Slide 7 </li> <li> Interpretive algorithm </li> <li> Slide 8 </li> <li> Communitywide System of Care Organized System of Care Rapid Recognition Public Access Defibrillation Rapid EMS Response 12 Lead ECG Hospital Notification PH Cath Lab Activation V-Fib Cardiac Arrest </li> <li> Slide 9 </li> <li> Unique aspects of System If you have seen one EMS system.. </li> <li> Slide 10 </li> <li> you have seen one EMS System </li> <li> Slide 11 </li> <li> Figure 1. Trends in Emergency Department Operation and Closures in Urban Areas, 1990- 2009 Hsia, R. Y. et al. JAMA 2011;305:1978-1985 Copyright restrictions may apply. Ed Closures </li> <li> Slide 12 </li> <li> L.A. Fire Department cuts some rescue vehicles, paramedic supervisors Facing a $56.5-million budget gap, the department will take 15 fire trucks and six ambulances out of service each day The LA Dilemma: Your Money or Your Life -- What to Cut, Who Will Pay? 911 STEMI Focus Data Base includes all pre-hospital patients taken to an SRC regardless of whether cath lab is activated or undergoes PCI </li> <li> Slide 13 </li> <li> Data Collection is Stemi focused Los Angeles STEMI system: Inclusion criteria into our data base is all patients transported by 911 to an SRC as a STEMI patient, including those that never encounter a Cardiologist or the cath lab. Regulatory Framework Standards and Requirements that are County Based Hospitals participate in other data bases </li> <li> Slide 14 </li> <li> LAC STEMI Receiving Centers (SRC) N=3 0 </li> <li> Slide 15 </li> <li> LAC STEMI Receiving Centers (SRC) N=3 0 EMS NorthEastWest </li> <li> Slide 16 </li> <li> Tipping Points Medical Literature Community Leaders - AHA Conceptual framework presented to system participants Funding AHA and Annenberg Foundation Los Angeles County Board of Supervisors EMS Agency Reviews </li> <li> Slide 17 </li> <li> Stenestrand U. JAMA 2006;296:1749-1756 Mortality reperfusion &gt; 2h from symptom onset In-hospital lysis Pre-hospital lysis Primary PCI </li> <li> Slide 18 </li> <li> The time is now to reevaluate the optimal approach to treatment of patients with acute MI, with an interventional approach being the optimal strategy. The task for cardiologists and other physicians is to make the best possible therapy available to every patient with acute MI. JAMA April 17,2002 Tipping Points </li> <li> Slide 19 </li> <li> Medical Literature Cannon Primary PCI for all (2002 JAMA 287:1987) Topol Regionalizaton--a call forSpecialized centers (2003 Circulation 107:1463) Williams Treatment delayed is treatment denied (2004 Circulation 109:1806) Henry &amp; Larson Triage to heart attack centersis it time for a national policy? (2005 JACC) </li> <li> Slide 20 </li> <li> In-hospital deaths/1000 patients treated compared with D2B </li> <li> 30 &gt;&gt; 30 &gt;&gt; 30 Rule EMS &gt;&gt; ED &gt;&gt; Cath lab </li> <li> Slide 25 </li> <li> Tipping Points Hospital Best Practices Develop </li> <li> Slide 26 </li> <li> Hospital-Based Strategies Associated with Shorter Door-to-Balloon Time and Potential Tools to Implement Them Nallamothu B et al. N Engl J Med 2007;357:1631-1638 Prehospital ECG Activation Expected interval between page and arrival Single Call from ED to Cath Lab Activation Single Call Panel Physician Real time Feedback to EMS, ED Fire Department removes rig from service for cath Cardiologist in hospital 24/7 Senior Management commitment CEO Required to attend agency reviews </li> <li> Slide 27 </li> <li> Hospital-Based Strategies Associated with Shorter Door-to-Balloon Time and Potential Tools to Implement Them Nallamothu B et al. N Engl J Med 2007;357:1631-1638 </li> <li> Slide 28 </li> <li> STEMI: ultra-rapid transport Rokos et al. JACC: Cardiovascular Interventions 2009;2:4:239 </li> <li> Slide 29 </li> <li> Tipping Points Hospitals Systems change Placeholder Placeholder for data from study Placeholder Implementation of 12 lead studied prior to Stemi Center Designation Reduced D2B Funded by AHA/Annenberg Foundation </li> <li> Slide 30 </li> <li> Tipping Point: Funding American Heart Association and Annenberg Foundation $3 million Los Angeles County Board of Supervisors Conceptual Framework was important Retrospect scope : Uniform Equipment Uniform Transmission Interface </li> <li> Slide 31 </li> <li> Conceptual Framework #1 Stemi Patient #2Prehospital team #3 ED Team #4 Interventional team One patient, seamless treatment Hospital Ownership Team Effort Any One Can Champion No Turf time is the Enemy </li> <li> Slide 32 </li> <li> Slide 33 </li> <li> Inclusion Criteria All patients identified as STEMI patients in field and transported to an SRC All Patients Triaged from field even when cath lab not activated All 911 inter-facility transfers for STEMI Independent Base Hospital Data Base Hospital Bordering LA County Included </li> <li> Slide 34 </li> <li> Data Collection Web Based </li> <li> Slide 35 </li> <li> Slide 36 </li> <li> IFT Transfer Form </li> <li> Slide 37 </li> <li> Slide 38 </li> <li> Demographics 2009 2010 Q1Q2Q3Q4Q1Q2Q3Q4 PH ECG Positive 493487447486494468515524 Age65.764.764.865.766.465.16562 Male342312310 329320353362 Female151175137176165148162 </li> <li> Slide 39 </li> <li> median times </li> <li> Slide 40 </li> <li> Slide 41 </li> <li> Hospital destination: median times </li> <li> Slide 42 </li> <li> Cath Lab Activations </li> <li> Slide 43 </li> <li> Interpretive algorithm </li> <li> Slide 44 </li> <li> 12 Lead ECG Quality Artifact </li> <li> Slide 45 </li> <li> 12 Lead ECG Quality Wavy Baseline </li> <li> Slide 46 </li> <li> Slide 47 </li> <li> Evolving role of Medical Control when ***AMI*** doesnt fit Paced LBBB Atrial flutter Artifact </li> <li> Slide 48 </li> <li> Slide 49 </li> <li> Slide 50 </li> <li> STEMI Interfacility Transfers: Median Times </li> <li> Slide 51 </li> <li> Journal of Interventional Cardology January </li> <li> Slide 52 </li> <li> 4 th Quarter 2010: IFT </li> <li> Slide 53 </li> <li> JACC CV Interventions, April 2009; 2:339-46 </li> <li> Slide 54 </li> <li> Rokos et al. JACC: Cardiovascular Interventions 2009;2:4:239 STEMI Systems of Care </li> <li> Slide 55 </li> <li> Door-2-Balloon (D2B) Rokos et al. JACC: Cardiovascular Interventions 2009;2:4:239 </li> <li> Slide 56 </li> <li> Slide 57 </li> <li> AHA Mission: Lifeline May 2009 October 2009 April 2010 Established STEMI system of care Working toward STEMI system of care </li> <li> Slide 58 </li> <li> AHA Mission: Lifeline May 2009 October 2009 April 2010 Established STEMI system of care Working toward STEMI system of care Nevada Utah </li> <li> Slide 59 </li> <li> End </li> </ul>

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