Presenter Disclosure Information

Kevin Daniel, RN, CEN

Clinical Data Supervisor Northside Hospital System

Metro Atlanta Mission Lifeline Quality & Data Co-Chair

Atlanta, Georgia

1

FINANCIAL DISCLOSURE:No relevant financial relationship exists

2

Objectives

• Demonstrate how participating in the ACTION registry improves ED/Hospital performance and patient outcomes by adhering to the AHA/ACC GWTG guidelines.

 • Identify the inclusion and exclusion criteria of the ACTION

registry and Mission: Lifeline using data abstraction guidelines.

542 STEMI patients66% were Direct Presenters

34% were Transfers STEMI Referral to STEMI

Receiving center.

5%

Q2 2013

Q2 2013 Q3 2013 Q4 2013 Q1 2014 Q2 2014 Q3 2014 Q42014 Q120150

50

100

150

200

250

300

350

400

172

267 269

336318

327

376359

99

134

156

188

215 220

185 183

TN Mission LifelineSTEMI Volume

Number of STEMI Patients Direct Presenters Linear (Number of STEMI Patients Direct Presenters)Number of STEMI Patients Transfers In Linear (Number of STEMI Patients Transfers In)

18 HospitalsTN Region

22 HospitalsTN Region

7 min

Q2 2013

Q2 2013 Q3 2013 Q4 2013 Q1 2014 Q2 2014 Q3 2014 Q42014 Q1201555%

57%

59%

61%

63%

65%

67%

69%

71%

73%

72%

65%

64%

65%

67%

68%

65%

66%65% 65%

66% 66%

67% 67%

68% 68%

TN Mission LifelineFirst Medical Contact to PCI <= 90 Mins

FMC to PCI <= 90 mins-R4Q TN System FMC to PCI <= 90 mins-R4Q Nation

Pre-Hospital Activation is key

in reducing ED times &

Achieving FMC to Device in < 90 min

Longest PCI Time

Shortest PCI Time

75th Percentile

Median PCI Time

Average PCI Time

25th Percentile

Box and Whisker Plots

SystemMedian

Time 83mins

Q2 2013 Q3 2013 Q4 2013 Q1 2014 Q2 2014 Q3 2014 Q42014 Q1201570.0

72.0

74.0

76.0

78.0

80.0

82.0

84.0

86.0

76.0

80.0

81.0

85.0

78.0

82.0

85.0

83.0

TN Mission LifelineMedian Time from First Medical Contact to Primary PCI

Direct Presenters Arriving by EMS

Median Time from First Medical Contact to Primary PCI (Mins) Linear (Median Time from First Medical Contact to Primary PCI (Mins))

heart.org/missionlifeline

Click Regional Report Glossary

Critical Process Timelines: First Medical Contact to Device for Non-Transfers Arriving via Ambulance (pages 5-6)Variable Definition Inclusion/Exclusion Criteria

First Medical Contact to Device Activation

(Direct Presentation EMS Only)

Transferred from Outside Facility = No

Means of Transport to First Facility = Ambulance

Median Time in Minutes (current quarter)

o First Medical Contact to Door(Arrival date/time) – (Pre-arrival 1st Medical Contact date/time)

o Door to Arrival at Cath Lab(Cath Lab Arrival date/time) – (Arrival date/time)

o Arrival at Cath Lab to Device Activation(First Device Activation date/time) – (Cath Lab Arrival date/time)

o First Medical Contact to Device Activation (National Median) (First Device Activation date/time) – (Pre-arrival 1st Medical Contact date/time)

All STEMI patients indicated for immediate primary PCI, excluding transfers in, patients with STEMI diagnosed on subsequent ECG, patients administered thrombolytics, documented non-system reason for delay in PCI, and FMC to PCI > 12 hours.

Patients may have missing or negative values for specific time intervals, which excludes them from ONLY the affected intervals. All other intervals with valid date/time data are included in the graph

Includes all direct presenters arriving via Ambulance only; Mobile ICU and Air transport are not included.

First Medical Contact to Device Activation

Transferred from Outside Facility = No

Means of Transport to First Facility = Ambulance

Distribution of Times in Minutes (current quarter)

First Medical Contact to Device Activation(First Device Activation date/time) – (Pre-arrival 1st Medical Contact date/time)

All STEMI patients indicated for immediate primary PCI, and had a reported first device activation date/time after first medical contact, excluding transfers-in, patients with STEMI diagnosed on subsequent ECG, patients administered thrombolytics, documented non- system reason for delay in PCI, and FMC to PCI time > 12 hours.

Includes all direct presenters arriving via Ambulance only; Mobile ICU and Air transport are not included.

Graph on Page 5

Regional Report

Graph on Page 6

Regional Report

EMS = Ambulance only, does not include Mobile ICU or Air transport POV = Personally Operated Vehicle (i.e., self/family

transport)FMC = First Medical Contact

- 7 -Confidential Information (ver

09/24/2013)

3110

3100

3201 3105 & 3106

4030

7101 & 7102 3201

7103 & 7104 7101 & 7102

7103 & 7104

3105 & 3106

7100 & 7109 & 8000 3110

4041 80207110

3100

3110

3100

7103 & 7104

4030 7100 & 7109 & 8000 31104041

80207110

3100

Pre-Hosp ECG obtained on

72% of STEMI pts arriving by EMS

Q2 2013 Q3 2013 Q4 2013 Q1 2014 Q2 2014 Q3 2014 Q42014 Q120150%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

67%

53%57%

64% 65%

73%75%

72%

TN Mission LifelineFirst ECG Obtained Pre Hospital

EMS Arrival

First ECG Obtained Pre Hospital (EMS Arr.) Linear (First ECG Obtained Pre Hospital (EMS Arr.))

26% of STEMI pts who walk in to ED’s are waiting for more than 10 minutes for

their first ECG

26% of STEMI pts who walk in to ED’s are waiting for more than 10 minutes for

their first ECG

Q2 2013 Q3 2013 Q4 2013 Q1 2014 Q2 2014 Q3 2014 Q42014 Q1201565%

70%

75%

80%

85%

90%

87%

79%

81%

75%76%

74%73%

74%

TN Mission LifelineECG w/in 10 mins of Arrival Direct Presentation by POV

ECG w/in 10 mins of Arrival Direct Presentation by POV Linear (ECG w/in 10 mins of Arrival Direct Presentation by POV)

Recommended DIDO 30 min

If expected delays D2B >120 mins give Lytics

Median Time 125

mins

Median Time

• Prehospital activation is the most important thing that EMS can do to increase the chance that a STEMI patient will achieve FMC to device in

< 90 mins.• EMS must work to increase the rate of obtaining

field ECGs in patients with suspected STEMI.• Successful prehospital activation depends on

calling the ED as soon as STEMI is recognized on the field ECG. Transmission of the field ECG is secondary and should not delay a phone call to alert the ED of a “code STEMI”.

Take home points: Direct presentation by EMS

• If there is a nearby STEMI receiving center (24/7 PCI center), EMS should bypass referral centers and go directly to receiving centers.

• Centers that transfer STEMI patients and/or receive these transfer patients must work together to reduce Door-in-door-out time and reduce patient transport times to the STEMI receiving facility.

• If anticipated Door-to-Door-to-Device time > 120 minutes, give fibrinolytic at the first hospital.

Take home points: Transfers