The Challenge to Develop Systems of Care for STEMI Patients:

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The Challenge to Develop Systems of Care for
STEMI Patients AHAs Mission
Lifeline Including Lessons Learned from Stroke
Systems of Care Alice K. Jacobs, M.D. Boston
University Medical Center Boston, MA The are
no conflicts or relationships to disclose.
2
STEMI Patient

• 55 year female--PCI of LAD (angina) at Hospital
  A
• 2 days later 430 PM SSCP--takes TNG 435 PM
  calls 911 443 PM EMS arrives--Hosp A on
  diversion Shock develops during transport 504
  PM Arrive at Hosp B (no PCI capability) 600
  PM Full cardiac arrest CPR initiated 703 PM
  Patient expires

Yr 2000 Hospital A Mount Auburn Hosp,
Cambridge , MA
133 min
Hospital B Cambridge Hospital, Cambridge , MA
Informed Patient Who Did Everything RightThe
System Failed Her
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Trends in STEMI Rx in GRACE N44,372 ACS Pts
113 Hospitals, 14 Countries
Plt0.001
Plt0.001

PNS
NS
Fox. JAMA 20072971892-1900.
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The Reality

• Primary PCI is the preferred reperfusion
  strategy.
• Acute care hospitals in US 4927
• Rural hospitals in US 2178
• ( with PCI capability 4)
• Cath labs in US 1731
• PCI capable 1331
• 70 of patients with contraindications to
  fibrinolytics do not receive primary PCI.

American Hospital Association 2007.
Fox. JAMA 20072971892-1900.
5
Distribution of Total Door-to-Balloon Time in
Transfer Patients in NCDR 2005-06
n15,049 patients n491 hospitals
Median D-to-B 152 min lt 90 min 8.6
36.3
26.4
17.6
8.2
4.3
3.7
2.2
1.3
lt 1
1 to lt2
3 to lt4
5 to lt6
2 to lt3
4 to lt5
6 to lt7
gt 7
Hours
Chakrabarti. JACC. 2008512442-2443.
6

• How do we increase the number of patients with
  timely access to primary PCI?

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12 lead ECG
PCI center
Hospital w/o PCI
Bypass Model
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STEMI Triage Plan Treatment Registry
Boston EMS Bypass
Registry/Data center DSMB Minimal standards
( gt36 10 PCI, gt90 cath, d-b lt90min)

• Point of Entry
• Twelve lead ECG in field
• ECG categorized as STEMI, possible STEMI,
  or non-STEMI
• Early notification (STEMI Alert) transport
  to PCI hospital
• Patient bypasses Emergency Department
• Receiving hospital never on diversion
• Non-STEMI transport to nearest hospital (PCI
  capable or not)

Moyer. Crit Pathways in Cardiol 2004353-61.
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Median Door-to-Balloon Times (2003-2007)
Boston EMS Bypass STEMI Triage Plan Treatment
Registry
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Door-to Balloon Time ? 90 Minutes (2003-2007)
Boston EMS Bypass STEMI Triage Plan Treatment
Registry
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Hospital w/o PCI
Hospital w/o PCI
PCI center
Treat Transfer Model
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Hospital Transfer Twin Cities Program
60 - 210 miles
lt 60 miles
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Twin Cites Pilot Integrated Transfer Program

• standardized treatment protocol
• training of all personnel
• tool kits with check lists, transfer forms,
  standing orders, adjunctive meds
• comprehensive feedback and quality assurance
  plan

Henry. Circulation. 2007116721-728.
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Patient Placement
Security/Dispatch
Pt Placement Supervisor
TelecommunicationsDirector
ER Charge RN
Minneapolis Heart Institute
Chaplaincy
CV Holding Room
Level 1 Page
MCA Coordinator
CV/OR Manager
Answering Service
CV Operations
ED Com Physician
CCU Charge RN
Admitting Director
STEMI Program Manager
House Supervisor
17
Minneapolis Heart InstituteMedian
Door-to-Balloon Time
Minutes
N421
N627
N297
Henry. Circulation. 2007116721-728.
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Regional STEMI Systems
Mayo Clinic
CReSCEnDO MI
Creating a Rationale System of Care for the
Evaluation, Diagnosis, and Optimal Treatment of
STEMI Patients
RACE
Reperfusion of Acute MI in North Carolina
Emergency Departments
Southern California STEMI Consortium
Geisinger Health System
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Current Limitations to Implementing Regional
STEMI Centers

• gt 50 of patients do not use EMS

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Current Limitations to Implementing Regional
STEMI Centers

• gt 50 of patients do not use EMS

• Majority EMS systems do not do 12 lead ECG

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Current Limitations to Implementing Regional
STEMI Centers

• gt 50 of patients do not use EMS

• Majority EMS systems do not do 12 lead ECG

• Geographic distribution of hospitals

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Heart Disease is not evenly distributed
by population...
Heart Disease
US Population
23
Current Limitations to Implementing Regional
STEMI Centers

• gt 50 of patients do not use EMS

• Majority EMS systems do not do 12 lead ECG

• Geographic distribution of hospitals

• Prolonged transfer in rural setting

• Hospital EDs frequently on diversion

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Volume of Annual Visits per Operating Emergency
Department 1995-2005
33 of hospitals report time on diversion
50 metropolitan 9 rural
CDC Division of Health Care Statistics. June 29,
2007
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Current Limitations to Implementing Regional
STEMI Centers

• gt 50 of patients do not use EMS

• Majority EMS systems do not do 12 lead ECG

• Geographic distribution of hospitals

• Prolonged transfer in rural setting

• Hospital EDs frequently on diversion

• Financial disincentives for transfer

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Current Limitations to Implementing Regional
STEMI Centers

• gt 50 of patients do not use EMS

• Majority EMS systems do not do 12 lead ECG

• Geographic distribution of hospitals

• Prolonged transfer in rural setting

• Hospital EDs frequently on diversion

• Financial disincentives for transfer

• Current transfer times are unacceptable

27

• Community-based National initiative
• Improve quality of care outcomes in STEMI
• Improve health care system readiness and
  response to STEMI

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History

• May 2004
• Advisory Working Group (AWG) recruited to
  explore the issue of increasing the number of
  STEMI patients with timely access to primary PCI
• June 2005
• Presented market research conducted by Price
  WaterhouseCoopers to AWG
• March 2006
• AWG Consensus Statement Published in Circulation
• Market research results
• Stakeholder Call To Action

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Circulation 20061132152-2163.
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History

• April 2006
• Stakeholder Summit held in Boston
• 25 organizations in attendance at 3-day
  conference
• Writing groups meet
• Winter 2007
• Drafts of STEMI Systems of Care manuscripts
  finalized. During reviews, AHA actions began to
  take shape.
• April 2007
• Mission Lifeline cross-functional team recruited

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• May 30, 2007
• Conference Proceedings published in Circulation
  and Mission Lifeline Launched

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Administrative Structure
Elliott Antman, MD Gray Ellrodt, MD Mary Hand,
MSPH, RN Bob Harrington, MD Tim Henry, MD Jean
McSweeney, PhD, RN Neil Meltzer George Mensah,
MD Robert OConnor, MD Eric Peterson, MD David
Williams, MD

• Assess EMS Systems and Strategies for
  Improvement
• Evaluate Existing Models
• Establish Local Initiatives
• Explore Possibility of National STEMI
  Certification

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AHA Staff
Mission Lifeline
State Health Alliances
State Advocacy
Quality Improvement
Communications
Cultural Health Initiatives
ECC
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EMS System Assessment and Improvement

• The American Heart Association
• is participating in a needs assessment in
  collaboration with EMS organizations
• and will analyze the effectiveness of EMS
• for STEMI patients as part of a STEMI system of
  care.

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EMS System Survey
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EMS Assessment for STEMI

• Designed for all EMS County organizations
• TEST Phase from May 12 through June 6, 2008
  distributed by State Health Alliance staff in
  eight test states CA, DE, KS, MO, NC, PA, TX,
  and WY
• After test phase, the assessment was distributed
  to all fifty states via NASEMSO and other EMS
  organizations.
• 4962 responses from EMS agencies being analyzed

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Evaluate Existing Models

• The American Heart Association is reviewing
  existing local and regional STEMI Systems of Care
  models.

Have You Registered Your STEMI System with
Mission Lifeline??

• - Administration - Locale (Urban, Rural) -
  Processes of Care - Financial Considerations -
  Disparities in care
• - Resource allocation

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Have You Registered Your STEMI System with
Mission Lifeline?
39
Have You Registered Your STEMI System with
Mission Lifeline?
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Establish Local Initiatives

• The American Heart Association is
• convening a task force at state and local levels
  to identify ways to implement national
  recommendations for STEMI systems in local
  communities.

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Establishing Local Initiatives
Task force members

• Patients and care givers
• Physicians, nurses and other providers
• Payers
• EMS
• PCI capable and non-PCI capable hospitals

• Department of Health
• Rural health association
• Quality improvement organizations
• State and local policymakers

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Explore Possibility of National STEMI
Certification Program

• The American Heart Association will develop
  recommendations for a STEMI recognition and
  certification program. Possible models include
• - Hospital certification (STEMI referral
  and receiving centers)
• - EMS System Certification
• - Regional System Certification

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How will we measure our impact?
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Patient Flow Through STEMI System and Data
Collection
STEMI PT
5
6
Pt self-transport to non PCI hosp
Pt self-transport to PCI hosp
1
Hybrid NEMSISML EMS
911-EMS
7
8
2
3
4
Hosp ANon PCI
Hosp BPCI
Hosp CNon PCI
Hosp DPCI
Interhospitaltransfer
ML Bridging Form
Not participating in ACTION/GWTG CMS or NCDR
Cath PCI only
ACTION-GWTGNCDR-PCI
CMS Data Only
Long Term Follow up--? sources
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Activate EMS Avoid delay
Patient
Consider integrated payment No penalty to patients
12-lead ECG 9-1-1 interhospital transport
Payer
EMSED
Activate team No diversion
STEMI Referral
SYSTEM OF CARE
CENTER OF CARE
Treatment protocols and clinical pathways
Policy Makers
STEMI Receiving
CENTER OF CARE
Protocols and toolkits STEMI Center
Certification Quality improvement measures

Jacobs. Circulation 2007116217-230.
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NHAAP CDC
Patient
NAEMT NAEMSP NASEMSO NEMSIS ACEP American
Ambulance Assn AACCN ENA
CMS Aetna UnitedHealth Networks
Payers
EMSED
AHRQ FDA JCAHO
Evaluation Outcomes
STEMIReferral
ACTION/GWTG NRHA SCAI Society of Chest Pain
Centers ACP STS AACCN ENA
Policy Makers
Center of Care
STEMIReceiving
PCI capable
CMS
Adapted from Jacobs. Circulation 2007116217-230
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www.americanheart.org/missionlifeline
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www.americanheart.org/missionlifeline
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Stroke Systems of Care

• Previously disjointed system
• Progress with Primary Stroke Centers
• Volunteer Committee formed in 2004
• Recommendations for the Establishment of Stroke
  Systems of Care (Stroke, 2005)
• Primary Prevention
• EMS / Pre-Hospital
• Acute Treatment
• Sub-Acute / Secondary Prevention
• Rehabilitation

52
State Stroke Systems Planning (SSSP)

• 2004
• ASA identifies health impact potential
• Multi-year initiative to coordinate SSSP
• Allocates staff resources to coordinate
• 2005
• Coordinates with state stakeholder group
• Assesses the states stroke system
• Evaluates available state resources
• Identifies priority areas to improve

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State Stroke Systems Planning (SSSP)

• 2006
• Implements improvement activities in
  collaboration with state partners
• 2007
• Continues collaboration with state partners
• Reassess states stroke systems - Spring 2007
• 2 year change within each state

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SSSP Progress Markers

• Overall System Coordination
• State stakeholder group
• State plan with stroke specific components
• All EMS healthcare providers that care for
  stroke patients complete annual stroke assessment
  education

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SSSP Progress Markers

• Primary Prevention
• 1 state awareness campaign per year
• State public policy supports environment of
  stroke prevention (i.e. clean indoor act)
• Hospitals conduct education programs on stroke
  prevention recognition

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SSSP Progress Markers

• EMS
• 911 coverage is available for at least 90 of the
  states population
• Standardized stroke protocols
• Stroke triage assessment tool
• Stroke transport protocols with the intent to
  transport to a primary stroke center

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SSSP Progress Markers

• Acute Care
• State map of acute stroke capable hospitals
• System access across the state which may include
  telemedicine
• Assessed at least once every 2 years
• 100 of stroke hospitals establish clinical
  pathways for stroke patients

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SSSP Progress Markers

• Secondary Prevention
• 100 of stroke hospitals have QI program
• 100 of stroke hospitals use a standardized
  discharge packet to educate survivor and family
• 100 of stroke hospitals use a standardized
  protocol for screening for rehabilitation

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SSSP Progress Markers

• Rehabilitation
• State adopts a standardized screening evaluation
  tool
• Post stroke care resources and services
  identified, published, promoted
• Mechanisms to ensure patients are referred to
  appropriate facilities for post-stroke care

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Stroke Systems of Care

• What Weve Learned
• On Progress Markers Initiative
• Data get-able defendable
• Progress since SSSP inception
• Importance of integration alliances
• On States
• The number of states that have successfully
  completed different progress markers
• Which states may be more advanced in the Stroke
  Systems of Care model
• Use to study best practice or as resource to
  help other states

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SSSP Completed Progress Markers
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SSSP Completed Progress Markers
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Map of Acute Stroke Hospitals

• Progress Marker 13
• Ability to create state and national maps of
  hospitals and stroke treatment capabilities
• Progress Marker 15
• Ability to determine the percent of the
  population that live within 1 hour of acute
  stroke capable hospital
• Opportunities
• Overlay with data from CDC Census for more
  accurate data evaluation and gap analysis

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Stroke Systems of Care
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Stroke Systems of Care
66
Stroke Systems of Care
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STEMI Systems of Care
12 lead ECG
STEMI or STROKE
PCI center PSC Comprehensive Stoke Center
Hospital w/o PCI No PSC
Stroke Systems of Care