Its All About the Decision (EMS) Circa 1840: STEMI It starts with - - PowerPoint PPT Presentation

It’s All About the Decision (EMS)

Circa 1840: STEMI… It starts with an ECG…

David R. Burt, MD Virginia Heart Attack Coalition

Circa 2012: Collaborative Circa 2012: Collaborative Circa 2012: Collaborative Circa 2012: Collaborative Strategery Strategery Strategery Strategery

The “STEMI Bill of Rights” succinctly

• utlines ten fundamental concepts so

essential in principal that each one should be individually addressed within every STEMI System of Care

2012: STEMI Bill of Rights

Background: Background: Background: Background:

After the framing of the US Constitution was complete, The Bill of Rights was drafted by our Founding Fathers to underscore essential Rights that were deemed so fundamental in the preservation of personal liberty as to merit individual discussion....

2013: “The Other 15%” Initiative

Goal: Partner with OEMS to achieve 100% PHECG in Virginia

85% 15%

2

Yes No

2015: Rapid Reperfusion is STILL THE treatment for STEMI

Antman EM et al. Circulation, 2004

Symptom Recognition Call to Medical System ED PreHospital Delay in Initiation of Reperfusion Therapy

Increasing Loss of Myocytes

Cath Lab

Reperfusion delay increases both short and long-term mortality!

The Cardinal Rule: Once STEMI is identified

• it must trigger a clear

response downstream!

ECG Acquisition EMS/ED Communication EMS ECG Evaluation

!Decision!

Fact: Viewing the PH ECG can reduce time to Reperfusion

• Treatment decisions can be made pre-arrival
• The ER is aware of the incoming patient
• The hospital reperfusion system can be

activated immediately

• Patients can be routed to the best destination

......all contribute to faster treatment!

Current PH ECG Transmission:

• Fax the pre-hospital ECG to the ER

– Slow, tech bottlenecks

• Snap a photo and text/email it to the doctor

– Unreliable due to poor cell service in field, hospital rules, broadband bottlenecks

• Use a commercial/proprietary system

– Expensive, unreliable, compatibility issues

STEMISEND: A possible solution

• A low-cost (free) app to

acquire & send an ECG image for real-time viewing

• Works with all ECG sources
• No proprietary technology

involved!

• Works with any cell phone

network

• Performance can be improved

significantly with cell phone boosters.

STEMISEND: The system…

EMS

• btains

ECG (any source) STEMISEND acquires ECG image ECG image sent to server mailbox ECG image accessed by receiving facility Physician views ECG Reperfusion decision!

Cell Network

3 Simple Goals:

• 1. Simplify the process

– Creation of STEMISEND front-end app

• 2. Level the playing field

– Optimize cell signal environments

• 3. Try to break it!!

– Extensive Beta Testing. EMS involved. Field

• conditions. Sunday at 4am. Try to provoke
• failure. Drop the phone. Can a doctor use it?

The Skit

A walkthrough of the process

Designing and Executing a Beta Test

• Analyze geography to identify suspected signal limited

environments

• Analyze most recent census data to identify

populations centers, populations most at risk for STEMIs

• Work with local EMS providers to identify signal limited

environments

• Design routes to be driven through identified areas
• Periodically, stop the vehicle. Test STEMISEND on each

cell network both boosted and without the cell

• booster. Test the commercial systems in the same

conditions.

STEMISEND Field Testing

STEMISEND: Initial Testing in Albemarle and Orange Counties (No Booster)

Conclusion:

• At 3-5 bars of cell

service, STEMISEND performance (on 3 networks) is equivalent to commercial systems

• At 1-2 bars, all

systems show decreased success

Point of equivalent performance (approx. 3 bars)

1 2 3 4 5 0.0 0.1 0.2 0.3 0.4 0.5 0.6 0.7 0.8 0.9 1.0

Environment Bar Strength (accordingto iPhone) Average Durationof Transmission (within 120s)

Comparative Efficacy of STEMI Send for Major Carriers (Boosted )

• s. Commercial Systems

Carrier 1 Unboosted Carrier 2 Unboosted Carrier 3 Unboosted Commercial System1 Commercial System2

2015: The Great Equalizer…

STEMISEND: Initial Testing in Albemarle and Orange Counties (With Booster)

1 2 3 4 5 0.0 0.1 0.2 0.3 0.4 0.5 0.6 0.7 0.8 0.9 1.0

Environment Bar Strength (according to iPhone) Rate of Absolute Reliability (Success within 120s)

Comparative Efficacy of STEMI Send for Major Carriers (Unboosted) vs. Commercial Systems

Boosted Carriers Commercial System 1 Commercial System 2

Conclusion: Extremely effective!

• A STEMISEND + Booster

system is equivalent or superior to commercial systems at all signal strengths

> 93% at any signal strength > 0

STEMISEND: Recent Testing Across Central Virginia

= No Transmission = Transmission (booster only) = Transmission

STEMISEND: Recent Testing Across Central Virginia

Farmville Catchment Area Test Results

• Nottoway County:

Farmville Catchment Area Test Results

• Nottoway County:

Boosted Data

Farmville Catchment Area Test Results

• Lunenburg County

Farmville Catchment Area Test Results

• Lunenburg County

Boosted Data

Sentara-Rockingham Catchment Area Testing

• Rockingham County

– To east and west of county, highly mountainous terrain provides severely signal limited environments – North, South, and Center of county relatively flat, have much more reliable service

Sentara-Rockingham Catchment Area Testing

• Rockingham County

Sentara-Rockingham Catchment Area Testing

• Rockingham County

Current Rockingham-Sentara ECG Transmission Issues

Email Forwarding Chains

Destination Inbox

Summary:

• In “Signal Rich” environments (3-5 bars)

STEMISEND (unboosted) is comparable to commercial systems

• With use of a cell phone booster, STEMISEND

is comparable/superior to commercial systems (in all signal strength environments)

• Strong correlation between signal bars and

probable success (non-boosted environments)

• Extreme simplicity and low cost are assets

Absolute vs. Relative Dead Zone

• Conclusion: looking for areas of rapid change

between full service, relative, and absolute dead zones.

Summary:

• STEMISEND unboosted is comparable to

existing commercial systems in a 3-5 bar environments

– Regardless of provider or iPhone model

• STEMISEND plus booster equalizes

performance across all cell signal environments if ANY cell signal exists

• In ALL instances, STEMISEND is comparable or

superior to commercial systems

STEMISend: The Future

• Culpeper, Virginia catchment area beta test

will begin in June.

– Widespread EMS involvement in testing – Remote loading of app to phones – Preferential eval of SLE sites – Standardization of Installation

CVILLE System Deployment Plan

Phase I: Testing the system at UVa

• UVa EMS crews
• In and around UVa
• 911 contracts in three counties
• Pegasus aeromedical
• UVa as initial receiving destination

Phase II: Testing the system locally

• Multiple receiving destinations
• Hospital agnostic application
• Multiple agencies and types
• ALS/BLS
• Career/Volunteer

Phase III: Full system roll-out

• Open enrollment of agencies and hospitals
• Customized application for each EMS agency
• Voluntary hospital participation
• ECGs delivered to destination email/fax of their choice

Future Goals

• Set up a Public Demo Version on the iTunes

App Store

– Anyone can download, send images to the server – Access server to see the latest image

• If interested, contact STEMISEND team to

build your agency a custom version of STEMISEND with preprogrammed hospital ECG image Destinations

Interested? Try it yourself!

• To Download STEMISEND PDV:

– See Dr. David Burt or Zack Ballinger after this presentation – Sign your name and email. We will email you the required information.

• General Process –after that:

– Email Zack your UDID (easily attainable on iTunes) – Zack will email you a STEMISEND version specific to your phone – Simply Add to your iTunes library, sync, and snap!

Questions?

• App, booster, and other materials are

available for demonstrations after this presentation.

• Feel free to ask Dr. Burt, Zack, Will, or Tristan

any questions you may have.

Contact Information

David R. Burt, MD University of Virginia davidrburt@virginia.e du O: (434) 924-8488 Zack Ballinger University of Virginia zcb9cb@virginia.edu 571-223-9982 Will Barnhardt University of Virginia, Medic V wfbz@hscmail.virginia.edu Tristan Jones University of Virginia taj3tp@virginia.edu

STEMISEND:

• A low-cost (free) app
• Works with all ECG sources
• No proprietary technology!
• Works with any cell phone

Performance improved significantly with boosters.

• www.STEMISend.com