Massachusetts STEMI Care

Peter Moyer MD,MPH,FACEP

Dallas June 4 ,2011

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

Disclosures

NONE

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

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

7

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

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

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

Initial Obstacles to STEMI plan

-non PCI centers feared loss of revenue

-PCI centers feared public airing of performance

Solutions

• Shared revenues between PCI and non PCI hospitals

• Blinded performance data (blind broken for failure to meet performance criteria)

Boston EMS• Third Service

• Fire First Response

• .6 -1.2 Million pop

• 110k calls per year

• 75k transports per year

• 6 STEMI PCI Centers

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

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

Pre Hospital EKG -Boston

• Boston EMS paramedics read 12 leads and radio and transport to PCI hospital bypassing non PCI hospitals if necessary

Boston EMS

• Divide 12 leads into: STEMI ,Possible STEMI and non STEMI

Boston EMS

• Early: 12 lead

Call to hospital

Mention of STEMI in radio call

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

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

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

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

E2B

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

• 2008 Web Based Continuous QI system Automated

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

STEMI CARE BenchmarksSTEMI CARE Benchmarks

Prehospital care meets clinical care benchmarks

for STEMI patinet

Individual Case reviewIndividual Case review

Hospital Data EntryHospital Data Entry

3333

Prehospital Entry note

given?

If Cardiac Cath, balloon time entered. Able to calculate D2B time or E2B time.

EMS Feedback ReportEMS Feedback Report

3434

Patient outcome available in

EMS cQI system immediately

after hospital enters data

Mass STEMI care

04/21/23 Taken from Quarter 3 2011 ACTION Registry – GWTG 2011 38

Where is STEMI care headed?

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

STEMI Systems Coverage

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

Patients

• Increase Use of EMS

• Decrease Symptom Onset to Balloon-

Dallas/Caruth’s Symptom Onset to Arterial Reperfusion (SOAR) metric

• Awareness of PCI centers

04/21/23 Taken from Quarter 3 2011 ACTION Registry – GWTG 2011 45

EMS

Pre hospital 12 lead EKG’s :

Equip & train all medics

Read Computer interpretation

Transmission

Wireless Transmission of 12-Lead ECG'sWireless Transmission of 12-Lead ECG'sFrom Ambulance to ERFrom Ambulance to ER

LifeNetLifeNet

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

EMS

• New field therapies (ex cooling for arrest )

EMS

• More Rapid Interfacility

transport

EMS

Electronic records: NEMSIS

Better QI –systemwide and individual feedack

PCI centers

• Responsible for:

-STEMI system integration including early return of patient to local facility

-Data management for system

PCI centers

• Share bundled PCI payment with non PCI hospital

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”

• PCI centers/population

Boston 6 1M NYC 22 8M Dallas County 13 2.2 M Vancouver 3 3M Nova Scotia 1 1M

PCI centers with wide geographic draw:

- prehospital as well as non PCI hospital lytics

-air as well as ground ambulances

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

Non PCI centers

• Rapid Interfacility Transport

• Share in STEMI bundled payment

Systems of STEMI care cover all of US

NYS Regs PCI hospitalsNovember 2009

• Must have a community outreach program

NY State Regs –EMS

• EMS should transport all STEMI’s to a PCI hospital bypassing non PCI hospitals if necessary

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

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

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