rural nebraska 1 ©2013, american heart association julie smith, rn bsn mha director mission:...

Rural Nebraska

1©2013, American Heart Association

Julie Smith, RN BSN MHADirector Mission: Lifeline Nebraska

2014 NeRHA Conference

Mission: Lifeline

Nebraska STEMI INITIATIVE

WELCOME

04/21/23 ©2013, American Heart Association 2

1. Mission: Lifeline

2. STEMI System of care in Nebraska

3.Grant funding opportunities for local EMS and Critical Access

Hospitals.

4.Education

OBJECTIVES

04/21/23 3

Julie Smith , RN BSN MHA Director Mission: Lifeline Nebraska

American Heart Association, Midwest Affiliate Mobile: (308) 695-6312

[email protected]

Gary W. Myers, MSDirector Mission: Lifeline South DakotaEMS Consultant for Midwest AffiliateAmerican Heart Association, Midwest AffiliateMobile: (605) [email protected]

Kay Brown CSSBBDirector of Quality & Systems Improvement KC, Kansas and Nebraska American Heart Association, Midwest Affiliate

Mobile: (913) [email protected]

AHA NE MISSION: LIFELINE Support


mailto:[email protected]



Brian Krannawitter Government Relations Director

American Heart Association, Midwest Affiliate Office: (952)278-7921 [email protected]

Kristin Waters Communications Director

American Heart Association, Midwest Affiliate Office: (402) 346-0771 [email protected]

Ngia Mua Project SpecialistAmerican Heart Association, Midwest Affiliate Office: 952-278-7934 [email protected]

AHA NE MISSION: LIFELINE Support





Mission: Lifeline is the American Heart Association’s national

initiative to advance the systems of care for patients with ST-segment

elevation myocardial infarction (STEMI) and Out of Hospital Cardiac

Arrest. The overarching goal of the initiative is to reduce mortality

and morbidity for STEMI and OOHCA patients to and improve their

overall quality of care

What is Mission: Lifeline?


Improving the System of Care for STEMI Patients

• Mission: Lifeline will:

– Promote ideal STEMI systems of care

– Help STEMI patients get the life-saving care they need in time

– Bring together healthcare resources into an efficient, synergistic system

– Improve overall quality of care

• The initiative is unique in that it:

– Addresses the continuum of care for STEMI patients

– Preserves a role for the local STEMI-referring hospital

– Understands the issues specific to rural communities

– Promotes different solutions/protocols for rural vs. urban/suburban areas

– Recognizes there is no “one-size-fits-all” solution

– Knows the issues of implementing national recommendations on a community level7

What is Mission: Lifeline?

How is STEMI Defined?

• ST elevation at the J point in at least 2 contiguous 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 (0.1 mV) in other contiguous

chest leads or the limb leads.

• New or presumably new LBBB at presentation occurs

infrequently, may interfere with ST-elevation analysis, and

should not be considered diagnostic of acute myocardial

infarction (MI) in isolation. If doubt persists, immediate

referral for invasive angiography may be necessary.

• ECG demonstrates evidence of ST depression suspect of a

Posterior MI

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What is a Mission: Lifeline STEMI System?

At Least One EMS Agency

At Least One referring Center

At Least one Receiving Center

…working together to decrease time to reperfusion and to reduce death and disability by improving patient outcomes.


Mission: Lifeline – A System of Care

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The Patient and Family:•Recognizing the signs and symptoms of a cardiac emergency•Participate in community based cardiac education •Need to use 911 and EMS•PSA Announcements

Community EMS:•Timely response, assessment, care and deployment of 12-lead ECG technology during a cardiac emergency•Initiate pre-hospital care and prepare for transport to a receiving facility•Acquisition and transmit of 12 lead ECG

STEMI Referring Hospital:•Receive 12 lead ECG•Provider notification and interpretation•Local STEMI Treatment Team activation•Implement early STEMI treatment •Forwarding prehospital 12-lead ECG•Timely arrangements for transfer to interventional care•Feedback

STEMI Receiving Hospital (PCI)•Support referring facilities•Receive 12 lead ECG from referring facility or EMS•Provide consultation•Interventional care•Capturing STEMI data and reporting•Feedback

A System of Care – The Roles

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Mission: Lifeline

Nebraska The Grant

GRANT


Mission: Lifeline Nebraska Grant

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5.3 million dollar initiative to enhance systems of care, save lives, and improve outcomes for heart attack patients in rural Nebraska, called Mission: Lifeline.

The lead funder for this investment in Nebraska is The Leona M. and Harry B. Helmsley Charitable Trust, one of the nation’s largest foundations, providing a grant of $4.1 million to the American Heart Association for the initiative.

Other current funders include the Fund for Omaha through the Omaha Community Foundation, the Ron and Carol Cope Charitable Fund, Aaron and Rachel Wagner, Mid – Nebraska Community Foundation, Valmont Foundation, Pinnacle Bank – Madison Branch and Hamilton County Foundation.

Mission: Lifeline NE Project Roll-out

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1. Three year grant: February 2014 – February 2017

2. Statewide Mission: Lifeline Task Forcea. Leadership

b. Advisory Committees

c. Interventional Cardiology Steering Committee

3. Equipment allocation

4. Protocol Development – Guidelines

5. Provider Education

6. Public Education Campaign

7. Data Collection

8. State STEMI Conference

Mission: Lifeline Nebraska - Timeline

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MAY 2014 – JULY 2014 AUG 2014 – DEC 2014

Mission: Lifeline Director Hired – JULIE SMITH

Contact with all PCI capable facilities -COMPLETED

Met with DHHS / EMS Program director and specialists - COMPLETED

Task Force Group CREATED

Task Force leadership selected - COMPLETED

Kick Off – Task Force Meeting – HELD 7.9.2014

Applications for EMS Services to be finalized and sent to services - COMPLETED

EMS Advisory Committee Meeting and will review and determine eligibility – IN PROGRESS

Award of first round funding for equipment

MOU and contract work for PCI capable hospitals begins. Funding to start fall of 2014

Advisory Committees will begin meeting.- IN PROGRESS

Interventional Cardiology Steering Committee –IN PROGRESS

I

Reporting 1st quarter data for Action Registry participating hospitals.

Second round funding for EMS equipment will begin

Development of Guidelines – NE approved System of Care - IN PROGRESS

Advisory Committees will continue to meet as needed to review data

Mission: Lifeline Statewide Conference

JAN 2015 - MAY 2015 2015 AND BEYOND

Data collection continues

Continued EMS equipment funding

Hospital and EMS recognition

Quality Improvement efforts statewide based on registry data

2nd Annual Mission: Lifeline Statewide Conference

04/21/23 ©2013, American Heart Association

PCI – 24/7

1. Faith Regional Health Services – Norfolk

2. Saint Francis Medical Center - Grand Island

3.Good Samaritan Hospital – Kearney

4.Kearney Regional Medical Center – Kearney

5. Great Plains Regional Medical Center – North Platte

6. Mary Lanning Healthcare – Hastings

PCI – Non 24/7

1. Fremont Area Medical Center – Fremont

2. Regional West Medical Center - Scottsbluff

Rural NE PCI Capable Hospitals


Nebraska PCI Hospitals


NE CAHS



PCI Referring Hospitals

NE Referring Hospitals 65 CAH hospitals

12-L receiving equipment funding available starting 2015

Referring Hospital Education

Plan Development will begin Fall of 2014 with delivery to begin in

Spring of 2015

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Mission: Lifeline Nebraska Frequently Asked Questions for Hospitals

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1. Who is eligible to participate in the NE Mission: Lifeline statewide Taskforce?

2. Will all Hospitals be eligible to receive grant funding?

3. Are all hospitals required to participate in pre-hospital 12-lead transmission and receiving systems?

4. Will hospitals be required to purchase a particular brand of 12-lead ECG receiving

equipment?

5. Will hospitals be eligible for reimbursement for equipment or software already purchased?

6. Will there be education for referring hospitals?

7. Will hospitals be required to participate in any data collection tool?

8. What is the timeline for the grant process?Ineligible Counties

Cass County Douglas County Sarpy County Saunders CountyLancaster County Seward County Washington County

Mission: Lifeline Nebraska Frequently Asked Questions for EMS Agencies

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1. Will all EMS agencies be eligible to receive grant funding?

2. Will EMS agencies be required to purchase a particular brand of equipment?

3. Will EMS agencies be eligible for reimbursement for equipment already purchased?

4. Will EMS agencies only be able to apply for 12-lead monitors?

5. How much funding (amount) can EMS agencies apply for?

6. What is the timeline for the grant process?

Ineligible Counties

Cass County Douglas County Sarpy County Saunders CountyLancaster County Seward County Washington County

Mission: Lifeline

Nebraska Task Force

Taskforce & Committees



M:L NE Meetings and Conferences

Biannual NE M:L Taskforce in person meetings• Monthly Teleconferences• Subcommittee meetings

Annual NE STEMI Summit Conference: • Highlight NE successes and Lessons learned• Hear from clinical experts about new science• Network with peers to advance collaboration• STEMI Survivor Celebration• Recognize System excellence and award achievements

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Nebraska Mission: Lifeline Taskforce

•Composition: All interested volunteers: Nurses/Nursing leaders, EMS Providers, Leadership & Medical Directors, Rural and Urban health care providers from Emergency medicine and Cardiology. State Health Department partners. Other medical professionals and leadership interested in improving emergency cardiovascular care in Nebraska.

Nebraska Mission: Lifeline Chairs•Composition: ED physician, 2 Cardiologists, Maximum 3 members

Interventional Cardiology Steering Committee•Composition: Cardiologist representation from each PCI Hospital

Nebraska Mission: Lifeline Quality Committee•Composition: Quarterly teleconference with Hospital Participants involved in Cardiovascular Care Quality improvement and/or the ACTION-GWTG Registry tool 10-20 members

Mission: Lifeline Nebraska Committee Structure

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Nebraska Mission: Lifeline STEMI Hospital Advisory Committee•Composition: at least 1 nursing and 1 physician representative from each included PCI Hospital, at least 1 representative from each regional non-PCI Hospital, and at least 2 EMS representatives (40 member maximum)

Nebraska Mission: Lifeline EMS Advisory Committee•Composition:

– DHHS EMS regional specialists

– EMS agency representatives from throughout the state

– EMS agency medical directors

– Other EMS representatives (max 18 members)

Nebraska Mission: Lifeline STEMI Conference Planning Committee

Mission: Lifeline Nebraska Committee Structure

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Leadership

Mission: Lifeline

Nebraska Task Force

Leadership

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Improving the System of Care for STEMI Patients28

Dr. Matt Johnson

Matthew Johnson, MD, is an Alma, NE native. Dr. Johnson is an interventional cardiologist withe Bryan Heart Cardiology group at Bryan Health. He providers outreach clinical services to several communities across NE. We are fortunate to have Matt as one of the task force leads. His knowledge of rural Nebraska will be a great resource.

Dr. Doug Kosmicki

Douglas. Kosmicki M.D. is a St. Paul, NE native. Dr. Kosmicki is an interventional cardiologist form the CHI Nebraska Heart Hospital and provides service to both Grand Island and Hasting PCI cath labs. He also serves rural communities providing outreach clinics. Doug will help provide insight from the central / rural areas of the state.

Dr. David Cornutt

Is the Medical Director for Emergency Services at Regional West Medical Center in Scottsbluff Nebraska. He and his wife live on a ranch 80 miles from Scottsbluff. He worked in an urban Emergency department for over 25 years and has in-depth knowledge of STEMI systems of care and is currently the Medical Director for the majority of EMS Services in the Panhandle. David’s rural and ED expertise are an essential part of representation needed.

Chairs 2014-2015

Interventional Cardiology Steering Committee -

Dr. Steve Martin

Steve Martin, MD is a Nebraska Native. Dr. Martin is an interventional Cardiologist and the

medical director for the Cardiovascular Service line for CHI/NHH in Lincoln. He is able to represent the overall CHI system concerning Cardiology here in Nebraska. As the lead for the Interventional Cardiology Steering Committee he will work with statewide interventionists across the state on the statewide guidelines.

LEAD – Cardiology

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INTERVENTIONAL CARDIOLOGIST STEERING COMMITTEE

Dr. Arshad Ali

Interventional Cardiologist

Great Plains Health Center – North Platte

Dr. John Cimino


Bellevue Medical Center – Bellevue

Dr. Azariah Kirubakaran


Faith Regional Health Services – Norfolk

Dr. Rick Markiewicz


Kearney Regional Medical Center - Kearney

Dr. Dan McGowan


Central Nebraska Cardiology - Kearney

Dr. Charles Olson


Methodist Hospital – Omaha

Dr. Drew Purdy


Rapid City Regional Hospital

Rapid City South Dakota

Dr. Steve Diamantis


Fremont Area Medical Center - Fremont

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Hospital Advisory Committee -

Dr. Ed Mlinek

Dr. Ed Mlinek, is the Medical Director for Bryan Medical Centers Emergency Services. In addition, through Bryan Health, he has participated in outreach efforts in rural areas and is familiar with the differing care models in these areas. He has also hosted EMTALA conferences for the Heartland Health Alliance and has been a CIMRO reviewer which has furthered is

understanding of the care provided in the more rural facilities.

The Hospital Advisory Committee has good representation of PCI Capable facilities and CAH across the state.

LEAD – Hospital Advisory

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Mission: Lifeline

Nebraska Task Force

Group Decision Making



Consensus Based Decision Making

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• Consensus Decision-Making– Participants make decisions by agreement rather than by majority vote.

• Inclusiveness– To the extent possible, all necessary interests are represented or, at a minimum, approve of the decision.

• Accountability– Participants usually represent stakeholder groups or interests. They are accountable both to their constituents and to the process.

• Facilitation– An impartial facilitator accountable to all participants manages the process, ensures the ground rules are followed, and helps to maintain a productive climate for communication and problem solving.


• Flexibility– Participants design a process and address the issues in a manner they determine most suitable to the situation.

• Shared Control/Ground Rules– Participants share with the facilitator responsibility for setting and maintaining the ground rules for a process and for creating outcomes.

• Commitment to Implementation – All stakeholders commit to carrying out their agreement.

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Elements of a Consensus-Based Decision

•All parties agree with the proposed decision and are willing to carry it out

•No one will block or obstruct the decision or its implementation

•Everyone will support the decision and implement it.

Levels of Consensus

•I can say an unqualified “yes!”

•I can accept the decision.

•I can live with the decision.

•I do not fully agree with the decision, however, I will not block it and will support it.

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Mission: Lifeline South DakotaStatewide STEMI Guideline

Introduction letter signed by members of Interventional Cardiology Steering Committee representing all 7 PCI centers in the state sends a very powerful message on the need for standardized statewide guidelines.


Data, Public Awareness & Guidelines

Mission: Lifeline

Nebraska Task Force

04/21/23 37


Data

How Does the Nebraska Mission: Lifeline Project Support Data

Colletion?

•The PCI Capable Hospitals in the included rural areas will receive funding support to participate in ACTION Registry-GWTG for three years

•24/7 PCI capable hospitals will also receive FTE support for data abstraction

***Hospitals must agree to enter patients into ACTION Registry to receive any of these dollars

•All Hospitals will also be eligible for funding support for 12-L receiving software

•Non-funded, Metro PCIs are strongly encouraged to participate in ACTION Registry to be part of the state system data.

04/21/23 2012 AHA Mission: Lifeline 39

• Quality Improvement Specialists• Mission: Lifeline Implementation• Provide M:L Reports using AR-G

data

• Keeper of AR-G Data• Operational Support for data

upload• Executes Data Release Consent

Forms• Analyze the AR-G data using

logic specific to ACTION reports• Posts AR-G and M:L Reports

• Analyze the AR-G data using logic specific to M:L

Mission: Lifeline® and ACTION Registry ® - Get With The Guidelines™ Relationship

Mission: Lifeline Reports are generated through the NCDR Registry called ACTION Registry-GWTG. This registry collects the data for the entire STEMI system and is the method for reporting outcomes, successes and understanding gaps.


Quarterly, hospitals will receive a Mission: Lifeline report in the Action Registry Dashboard

04/21/23 41

South Dakota Data Examples


Median time FMC to Primary PCI Overall % within 90 min

Median time FMC to Primary PCI Overall % within 90 min

ML STEMI participating hospitals State Aggregate SD

ML STEMI participating hospitals National Aggregate

2013 Q1 55.0% 59.0%2013 Q2 56.0% 59.0%2013 Q3 61.0% 59.0%2013 Q4 65.0% 60.0%



REC CTR Mission Lifeline Composite Score

REC CTR Mission Lifeline Composite Score



2013 Q1 96.9% 95.1%2013 Q2 97.9% 95.3%2013 Q3 98.3% 96.1%2013 Q4 98.5% 96.3%



SYSTEM Direct Pres % of patients Treated for reperfusion

SYSTEM Direct Pres % of patients Treated for reperfusion

SYSTEM Transfer In % of patients Treated for reperfusion

SYSTEM Transfer In % of patients Treated for reperfusion





2013 Q1 95.0% 90.0% 92.0% 91.0%2013 Q2 98.0% 90.0% 92.0% 91.0%2013 Q3 96.0% 90.0% 94.0% 91.0%2013 Q4 96.0% 90.0% 94.0% 91.0%



RC Median time FMC to Primary PCI (min) Overall

RC Median time FMC to Primary PCI (min) Overall



2013 Q1 86 min 85 min2013 Q2 85 min 85 min2013 Q3 80.5 min 85 min2013 Q4 77 min 84 min

STEMI referring Center Achievement Measures:

1. Percentage of STEMI patients with a door-to-first ECG time <10 minutes

2. Percentage of reperfusion – eligible patients receiving any reperfusion (PCI or

fibrinolysis) therapy

3. Percentage of reperfusion – eligible patients with door-to-needle time within 30

minutes

4. Percentage of reperfusion – eligible patients transferred to PCI center with door-in-

to door-out time within 45 minutes

* Facility goal to make STEMI referring Center ED FMC – to device (balloon)

within 120 minutes (including transport time)

5. Percentage of STEMI patients receiving aspirin within 24 hours

Mission: Lifeline Reports will also capture referring hospital metrics for system improvement


Hospital and System Improvement Strategies

• Know your numbers, data sources and benchmarks

• Understand the performance measures and understand

who is key to success (FMC is a collaborative measure!)

• Develop plan for Q1 to achieve award Q2 – small tests of

change

• Look at your “misses”, Evaluate process change based

on trends

• Provide messaging to champions for hospital key

partners and use your data!

• Communicate

©2010, American Heart Association 47

Mission: Lifeline Statewide STEMI Guideline

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 IIa IIb III

Performance of a 12-lead ECG by EMS personnel at the site of FMC is recommended in patients with symptoms consistent with STEMI.

I IIa IIb III

Guidelines Constructed following the 2013 ACC/AHA Guidelines


Reperfusion therapy should be administered to all eligible patients with STEMI with symptom onset within the prior 12 hours.

Primary PCI is the recommended method of reperfusion when it can be performed in a timely fashion by experienced operators.

I IIa IIb IIIEMS transport directly to a PCI-capable hospital for primary PCI is the recommended triage strategy for patients with STEMI with an ideal FMC-to-device time system goal of 90 minutes or less.*

I IIa IIb III

I IIa IIb III

*The proposed time windows are system goals. For any individual patient, every effort should be made to provide reperfusion therapy as rapidly as possible.



Immediate transfer to a PCI-capable hospital for primary PCI is the recommended triage strategy for patients with STEMI who initially arrive at or are transported to a non–PCI-capable hospital, with an FMC-to-device time system goal of 120 minutes or less.*

In the absence of contraindications, fibrinolytic therapy should be administered to patients with STEMI at non–PCI-capable hospitals when the anticipated FMC-to-device time at a PCI-capable hospital exceeds 120 minutes because of unavoidable delays.

I IIa IIb III


I IIa IIb III



When fibrinolytic therapy is indicated or chosen as the primary reperfusion strategy, it should be administered within 30 minutes of hospital arrival.*

Reperfusion therapy is reasonable for patients with STEMI and symptom onset within the prior 12 to 24 hours who have clinical and/or ECG evidence of ongoing ischemia. Primary PCI is the preferred strategy in this population.


I IIa IIb III

I IIa IIb III




Page 1 –

Initial Treatment Guidelines

Definition of STEMI Patient

Blue section: Arrive by EMS

Starts the flowchart process

Follow the “yes” & “no”

Proceed to Page 2 or Page 3

Key items and goal in RED

South Dakota



Page 2 –

Primary PCI Patients

FMC – PCI less than 120 min.


South Dakota



Page 3 –

Fibrinolysis Patients

Greater than 120 min. to PCI

Door to Needle less than 30 min.

Contraindication to fibrinolysis


South Dakota


Mission: Lifeline Nebraska STEMI EMS Transport Guideline Draft


Mission: Lifeline Nebraska STEMI EMS Transport Guideline

DIDO Goal45 minutes or less!

• Observed in-hospital

mortality was significantly

higher among patients

with DIDO times >30 minutes

than among those with

DIDO times <30 minutes

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

• In 2011, 3,267 Nebraska Residents died from heart disease, according to the Nebraska Department of Health and Human Services.

• Heart disease is the #2 leading cause of death in Nebraska. 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.

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Opportunities for Improvement

Are patients not aware of S&S and calling 911, thus causing a delay in treatment/out of hospital death prior to treatment? This supports the need for enhanced public awareness/education.

Access to care? Do we currently have systems in place in which patients are not able to get to the appropriate facility in a timely fashion, thus supporting the need to improve systems of care so that patients are transported to a facility with a plan in place to treat based on guidelines.

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04/21/23 63

Public Awareness

South Dakota

http://www.youtube.com/watch?v=QMo07hyqugI

http://www.youtube.com/watch?v=Zm5PJUMHPcQ



http://www.youtube.com/watch?v=Zm5PJUMHPcQ

04/21/23 64

Public Awareness

North Dakota

04/21/23 65

Public Awareness

Minnesota


PCI Referring Hospitals

What does pre-hospital STEMI activation look like at your facility? Do

you routinely call for the next leg of transfer pre-arrival?

• What are the greatest barriers in obtaining a door in- door-out of 45 min

or less?

• What are the greatest barriers to obtaining a door to lytic administration

time of < 30 minutes

• What are the greatest barriers to obtaining a door to ECG time of < 10

minutes?

• How do we break down political barriers and develop a unified voice for

NE?66


PCI Receiving Hospitals

• What mechanism is your facility currently utilizing for STEMI Data

Collection, Quality Improvement, Outreach and Feedback?

• What is the level of support for ACTION GWTG – ARG Participation

at your facility?

• What are the greatest barriers within your network to achieving a:

– 90 FMC to Primary PCI reperfusion in your area? (non-transfers)

– 120 FMC to Primary PCI reperfusion in your area? (transfers)

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Going Forward

Bi-Annual Face to Face Taskforce Meeting

Annual NE STEMI Conference

Local, Regional, and State STEMI system of care development, optimizing

the destination plans and protocols and feedback recommendation

development.

Referring Hospital Education Curriculum Development and Delivery –

Learn Rapid STEMI ID and STEMI Provider Manual Distribution

Public Awareness Campaign Assessment, Development, and Delivery

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Going Forward

EMS Education Curriculum

Data Analysis and Quality Improvement

Model sharing

Public Media and Awareness campaign

Sustainability Plan Development

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Questions?

04/21/232012 AHA Mission: Lifeline 70

Thank You!

rural nebraska 1 ©2013, american heart association julie smith, rn bsn mha director mission:...

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