Level 1 Heart Attack Program at the Minneapolis Heart Institute 8 - PowerPoint PPT Presentation

Level 1 Heart Attack Program at the Minneapolis Heart Institute 8 years later-Lessons Learned Timothy D. Henry, MD Director of Research Minneapolis Heart Institute Foundation

56 yr old riverboat captain from LA 54 miles from Lock and Dam #3 to MHI

56-yr old riverboat captain from LA • 1:30am - Onset of SOB and diaphoresis. Ship stops at lock and dam #3 in Red Wing, MN • 02:26 - Red Wing fire department on scene • 02:38 - 12 lead ECG shows STEMI. Called Helicopter and gave ASA and NTG

Treatment Times • 03:09 – Helicopter on scene • 03:20 – Helicopter leaves. Cath team activated • 03:38 – Helicopter arrives at MHI • 04:02 – Patient in cath lab • 04:19 – Artery open Door-to-balloon: 41 minutes Prehospital EKG to balloon: 101 minutes

Summary • D-B: 41 mins; Prehosp EKG-B: 101 mins • 56 y.o. male without chest pain • Middle of the night • 3 competing health care systems • From a riverboat in the Mississippi river 54 miles from the closest cath lab

EMS COMPONENTS OF A SYSTEM 1. PREHOSPITAL 2. TRIAGE Non PCI 3. TRANSFER Capable PCI 50% use EMS Capable 50% Pre-hosp ECG

Clinical Practice in 2011: Standard of Care • PCI centers should do PCI (in a timely manner <90 min) • Short distance transfer pts should have PCI (in a timely manner <120) • Long distance transfer or pts with expected delay remains an area of controversy!!

Introduction • Primary PCI is superior to fibrinolysis • In high volume PCI centers • If performed in a timely manner: <120 min, possibly longer

Primary PCI vs Lysis for STEMI – Meta-analysis of 23 trials Short Term Events P<0.0001 16 14 14 12 P=0.0003 P<0.0001 10 8 PTCA 7 8 7 Thrombolytic p=0.0004 5 6 P<0.0001 3 4 1 2 2 1 0.05 0 Death Re MI Total ICH Death + CVA Re-MI + CVA Keeley, Lancet Jan 2003

Age Adjusted Mortality by Time Stenestrand et al. JAMA 2006;296:1749-56

Introduction • Primary PCI is superior to fibrinolysis • Major limitation is availability • <25% of US hospital have cath labs • 2/3 of 1.5 million AMI patients present to hospitals without cath labs

Introduction • Primary PCI is superior to fibrinolysis • Major limitation is availability • Transfer for primary PCI is superior to fibrinolysis in European trials

Conclusion • Transfer for Primary PCI is the best strategy if door-balloon times <120 minutes (ideally < 90 minutes) • Excellent Safety • Can it be done outside Europe?

Transfer for Primary PCI in US Door to Balloon Times • Air PAMI – Median: 155 minutes • NRMI – 3/4 – Median: 180 minutes – 15% <120 minutes – 4% <90 minutes

STEMI – Door to Balloon and Door to Needle Times: Cumulative 12 Month Data 100% 81% 80% 57% 60% 40% High performing institutions are engaged in QI Monitoring 18% 20% 0% DTB <= 90 min - DTB <= 90 min - DTN <= 30 min - All Non-Transfer In Transfer In ACTION Registry-GWTG DATA: January 1 – December 31, 2008 DTB = 1 st Door to Balloon for Primary PCI DTN = Door to Needle for Lytics

Even in Denmark! • “For field -triaged, transferred, and all EMS-transported patients, the proportion treated with a system delay <120 min was 72%, 35%, 48% respectively” Terkelsen et al, JAMA 304:2010

Primary PCI: Access • 42.0% PCI hospital is closest facility • 79.0% within 60 minute prehospital time Nallamothu et al. Circulation 2006;113:1189

Strategies to Improve Timely Access to PCI in STEMI EMS (Strategy O) far superior to hospital based strategies Quality adjusted life years saved vs. cost Concannon et al. Circ Cardiovasc Qual Outcomes 2010;3:506-513

“ When I present the DANAMI-2 experience to a US audience, the most frequent comment is that in the US system it is very, very difficult to implement such a strategy. ” Henning Anderson (DANAMI-2 PI)

National Heart Attack Alert Program (1993) recommend that emergency departments (ED) develop protocols for STEMI and monitor quality measures including time to treatment intervals. The ACC/AHA guidelines on STEMI recommend hospital specific protocols to rapidly assess and treat STEMI patients.

111 Minnesota Hospitals without catheterization labs surveyed. 104 responded to survey (94% response rate)

Guideline or Standing Orders in the Emergency Department? • 64% of hospitals surveyed have a written guideline for the management of AMI • 57% have standing orders in the ED for management of AMI • 32% of hospitals had neither guideline or standing orders in the ED for management of AMI AEM 2005;12:522

Quality Assessment of AMI • Only 50% of hospitals have a formal QA process that reviews all STEMIs • QA process measures: – Door to drug intervals – 53% – ASA in the ED – 46% – Beta-blockers in the ED – 35% AEM 2005;12:522

Major Complaint! • Inconsistent treatment approach It depends on Who we talk to and When we talk to them

“ Humanity ’ s greatest advances are not in its discoveries – but in how those discoveries are applied ... ” Bill Gates, June 7, 2007 Harvard Commencement Address

“MHI Level 1 MI” Program • Based on the Trauma system • Goals – Standardize care – Improve outcomes – Research network of community/rural hospitals – Implementation of new data – Quality improvement program • To allow safe transfer of STEMI pts for Primary or Facilitated PCI, with a door (1st medical contact) to balloon time <120 min. AHJ 2005;150:373

Level 1 MI Program • STEMI diagnosis by emergency MD • Single phone call to activate system • Currently 31 hospitals trained • 1692 consecutive patients over 54 months (775 Zone 1, 557 Zone 2, 360 AN) • Currently 50+ patients/month • Inclusion: STEMI < 24 hours or New LBBB • Exclusion: None (including out-of-hospital cardiac arrest and cardiogenic shock) Henry et al. Circulation 2007;116:721

Red – Zone II (90-120 mins) Blue – Zone I (< 90 mins) Zone1 Protocol Aspirin 325 mg Clopidogrel 600mg UFH Beta-blocker PCI

Protocol focus:  Simple  Fast Red – Zone II (90-120 mins)  Reduce variability Blue – Zone I (< 90 mins) Zone 2 Protocol Aspirin 325 mg Clopidogrel 600mg UFH TNK ½ dose Beta-blocker PCI

ED physician activates the protocol

One phone call to activate the system “ We have a Level 1 MI patient ” Simultaneous calls to Cardiologist and transport

Level 1 MI Emergency Department Kit • ASA tablets in package • Clopidogrel tables in package • Metoprolol bolus x3 • Heparin bolus • Heparin drip and tubing • Alcohol swabs • Calculator • Standing orders with fibrinolytic calculations • Blood vials • PCS forms (Physician Certification Statement for Transfer) • Transfer datasheet • Standing orders AHJ 2005;150:373

Patient Security/Dispatch Pt Placement Telecommunications Placement Supervisor Director ER Charge RN Chaplaincy CV Holding Room MCA Coordinator Level 1 Page CV/OR Manager Answering Service CV Operations ED Com Physician CCU Charge RN Admitting Director STEMI Program House Supervisor Manager

Phone # for stat call back Take off of EKG ED Physicians “ Circle ” answers Attach lab sheet No need to write out Nurse to simply initial Reminder of fax

Mode of Transfer Helicopter – 69% Ground ALS – 31%

“ Hot loads ”

TRAINING Mock Drills Group Pager Follow Up Challenge

Individualized Transfer plans require creativity: Where is the helipad?

“ 15 minutes out ”

“ Real time Feedback ”

Demographics • Age: Median = 61 ≥ 65 = 42%, ≥ 80 = 14% • Sex: Male 72% • Diabetes: 15% • HTN: 56% • Smoking: 62% (current 38%) • Previous MI: 18% • Previous revascularization: 19% • Cardiogenic shock: 12% • Cardiac Arrest: 11% • Required ET intubation prior to PCI: 7% Henry et al. Circulation 2007;116:721

Level 1 MI Treatment Times Minutes In door 1 Transport In door 2 - Total In door (median) outdoor 1 time balloon to balloon Zone I 49 22 21 95 (n=775) (36,66) (16,31) (16,28) (82,116) Zone II 60 35 19 122 (n=557) (48,83) (26,49) (15,25) (101,151) AN NA NA 65 65 (n=360) (47,83) (47,83) DANAMI 50 32 26 108 (n=567) (39-65) (20-45) (20-38)

MHI Level 1 MI: Door – Balloon Times 100 90 < 90 mins 80 % of patients <120mins 70 60 50 40 30 20 10 0 ANW Zone 1 Zone 2 NRMI 3/4

Mortality n=1692 Total CV related In hospital 75 (4.4%) 67 (4.0%) 30 day 89 (5.3%) 76 (4.5%) 1 year* 89 (7.7%) 69 (6.0%) * Pts. With 1 year complete follow up included Henry et al. Circulation 2007;116:721

Kaplan-Meier Survival Curve 1.0 0.8 p = 0.31 Survival Probability 0.6 ANW Zone 1 Zone 2 0.4 0.2 0.0 0 50 100 150 200 250 300 350 Days Henry et al. Circulation 2007;116:721

Discharge Medications ANW Zone 1 Zone 2 ASA 99% 98% 99% Clopidogrel 97% 96% 98% Statin 89% 89% 89% Beta-blocker 95% 93% 93% ACE Inhibitor 73% 83% 84% Includes all discharge with PCI & AMI