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

• 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

Treatment Times

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

Non PCI Capable PCI Capable

50% use EMS 50% Pre-hosp ECG

• 1. PREHOSPITAL
• 2. TRIAGE
• 3. TRANSFER

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

2 4 6 8 10 12 14 16 Death Re MI Total CVA ICH Death + Re-MI + CVA PTCA Thrombolytic

Keeley, Lancet Jan 2003 P=0.0003 P<0.0001 p=0.0004 P<0.0001 P<0.0001

Short Term Events

5 7 3 7 1 2 8 14 1 0.05

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
• utside 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

81% 18% 57% 0% 20% 40% 60% 80% 100% DTB <= 90 min - Non-Transfer In DTB <= 90 min - Transfer In DTN <= 30 min - All

DTB = 1st Door to Balloon for Primary PCI DTN = Door to Needle for Lytics

STEMI – Door to Balloon and Door to Needle Times: Cumulative 12 Month Data

ACTION Registry-GWTG DATA: January 1 – December 31, 2008

High performing institutions are engaged in QI Monitoring

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

• 42.0% PCI hospital is closest facility
• 79.0% within 60 minute prehospital time

Primary PCI: Access

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

Concannon et al. Circ Cardiovasc Qual Outcomes 2010;3:506-513

Quality adjusted life years saved vs. cost

“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

• f 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

Red– Zone II (90-120 mins) Blue– Zone I (< 90 mins)

Zone 2 Protocol Aspirin 325 mg Clopidogrel 600mg UFH TNK ½ dose Beta-blocker PCI

Protocol focus: Simple Fast Reduce variability

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

• 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

Level 1 MI Emergency Department Kit

AHJ 2005;150:373

Level 1 Page

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

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”

Mock Drills Group Pager Follow Up Challenge

TRAINING

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 (median) In door 1

• utdoor 1

Transport time In door 2 - balloon Total In door to balloon

Zone I

(n=775)

Zone II

(n=557)

AN

(n=360)

DANAMI

(n=567)

49

(36,66)

60

(48,83)

NA 50

(39-65)

22

(16,31)

35

(26,49)

NA 32

(20-45)

21

(16,28)

19

(15,25)

65

(47,83)

26

(20-38)

95

(82,116)

122

(101,151)

65

(47,83)

108

MHI Level 1 MI: Door – Balloon Times

10 20 30 40 50 60 70 80 90 100 ANW Zone 1 Zone 2 NRMI 3/4 < 90 mins <120mins

% of patients

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

50 100 150 200 250 300 350 0.0 0.2 0.4 0.6 0.8 1.0 Days Survival Probability ANW Zone 1 Zone 2

p = 0.31

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

Insights into Mortality Rates

• Decrease in Eligible but untreated
• Short Sx to Hosp (community ed?)
• Short Door to Balloon times
• High % Meds on admission
• High % Meds on DC
• Patency rates (Clopidogrel/Lytics)

Mission: Lifeline Updates

PCI in STEMI Patients with Cardiogenic Shock and/or Cardiac Arrest (N= 3568 )

<0.0001 9/340 (2.7%) 43/98 (43.9%) >80 years old, n=438 <0.0001 12/513 (2.3%) 45/146 (30.8%) 70-80 years old, n=659 <0.0001 5/1938 (0.3%) 66/331 (19.9%) <70 years old, n=2269 p-value No Cardiogenic shock and/or cardiac arrest n=2999 Cardiogenic shock and/or cardiac arrest n=576 In hospital mortality

Urban vs Rural Use of EMS

64.7% 40.4% 64.8% 37.0% 64.6% 49.1% 62.0% 34.6% 68.9% 48.3% Total N=1263 Male F emale < 65 years ≥ 65 years Urban R ural

What is the prevalence and etiology of “False Positive” Cath Lab Activation?

STEMI

Larson, DM et al JAMA 2007;298(23):2754-2760

The Clinical Challenge

Denying Reperfusion Falsely Declaring an Emergency

Larson, DM et al JAMA 2007;298(23):2754-2760

STEMI Diagnosis N=1,345 Angiography N=1,335

5 died prior to angio 5 Case canceled

Multiple potential culprits N=10 (0.7%) Clear culprit N=1138 (85.3% No Angiographic Culprit N=187 (14%)

“False Positive” Cath lab Activations

Larson, DM et al JAMA 2007

Key Components

1) Standardized protocol 2) Individualized transfer arrangements 3) Single phone call (empower the ED) 4) Extensive training 5) Feedback/quality assurance

Minneapolis Heart Institute ACUTE CARDIOVASCULAR CARE STANDARDIZED SYSTEMS

• Out of Hospital Cardiac Arrest

– Cooling protocol

• Aortic Dissection
• Critical Limb Ischemia
• NSTEMI
• Stroke

Cooling Outcomes

Abbott Northwestern Hospital

53/96 55.2%

• Survival by diagnosis

– STEMI: 33/50 66.0% – Other: 20/46 43.5%

• Survival by initial rhythm

– VF/VT: 47/75 62.6% – PEA/Asystole: 5/19 26.3%

Alive at hospital discharge with favourable neurological recovery

Circulation 2011;124:206-14

MHI CARDIOLOGISTS BENEFITS OF A RN COORDINATOR Thanks to Barb Unger!!!

“Level 1” Heart Attack System

Sioux Falls

CAN IT BE DONE OUTSIDE MINNESOTA?

Adair Adams Allamakee Appanoose Audubon Benton Black Hawk Boone Bremer Buchanan Buena Vista Butler Calhoun Carroll Cass Cedar Cerro Gordo Cherokee Chickasaw Clarke Clay Clayton Clinton Crawford Dallas Davis Decatur Delaware Des Moines Dickinson Dubuque Emmet Fayette Floyd Franklin Fremont Greene Grundy Guthrie Hamilton Hancock Hardin Harrison Henry Howard Humboldt Ida Iowa Jackson Jasper Jefferson Johnson Jones Keokuk Kossuth Lee Linn Louisa Lucas Lyon Madison Mahaska Marion Marshall Mills Mitchell Monona Monroe Montgomery Muscatine O'Brien Osceola Page Palo Alto Plymouth Pocahontas Polk Pottawattamie Poweshiek Ringgold Sac Scott Shelby Sioux Story Tama Taylor Union Van Buren Wapello Warren Washington Wayne Webster Winnebago Winneshiek Woodbury Worth Wright

Primary Secondary Tertiary

Zone 1 (0-60 miles from PCI Center)

120 min

Zone 2 (60-210 miles from PCI Center)

120 min

Survival by Geographic Region

p=0.22

Survival by Zone of Presentation

p=0.20

Blue = 30 miles- 15 min flight time (each way) Red= 60 miles- 23 min flight time (each way) GEISINGER: RURAL PENNSYLVANIA

GEISINGER RESULTS

Patients Transferred to GMC

2004

(n = 110)

2005

(n = 134)

2006

(n = 143)

2007

(n = 63)

D2B (Minutes) 189 113 105 96

LA County

• 12 lead ECG machines

placed into all paramedic vehicles

• All paramedics ACLS

certified

• Specialized cardiac

receiving centers designated

• Performance and
• utcomes data

collected

LA County Rate of D2B ≤ 90min

(Rokos et al, 2009 JACC Intv., 2:339)

0% 20% 40% 60% 80% 100% 120% pre- SRC Dec (19) Jan (39) Feb (51) Mar (75) Apr (57) May (68) Jun (60) Jul (49) Aug (58)

Rate (%) of D2B 90 Min. 90%

Pre-SRC is 2005 (Green). Post-SRC is Dec-06 to Aug-07 (Blue) for 30 SRCs

N = 476

Options for Patients with Prolonged Transfer Times

1. Full dose fibrinolytic with elective transfer or for rescue 2. Full dose fibrinolytic with routine transfer and rescue as needed 3. Pharmaco-invasive PCI 4. Primary PCI (no matter how long it takes) 5. All of the above: Depending on the time of day and which cardiologist is on call!

Henry, Larson. JACC Cardiovasc Interv 2009;2:931-3

Meta-Analysis Contemporary Trials

Piscione F et al, Eur Heart J 2010

11.6 24.4 4.4 10.7 25.6 50.6 9.3 20.3 11.0 17.1 6.0 16.0

10 20 30 40 50 60

CAPITAL-AMI CARESS-in-AMI SIAM-III GRACIA-1 TRANSFER-AMI NORDISTEMI

Routine Early PCI Selective Invasive Approach

N=170 N=598 N=163 N=499 N=1059 N=266

Ischemic Event Rate (%)

Options for Patients with Prolonged Transfer Times

1. Full dose fibrinolytic with elective transfer or for rescue 2. Full dose fibrinolytic with routine transfer and rescue as needed 3. Pharmaco-invasive PCI 4. Primary PCI (no matter how long it takes) 5. All of the above: Depending on the time of day and which cardiologist is on call!

Henry, Larson. JACC Cardiovasc Interv 2009;2:931-3

TOP 10 LESSONS LEARNED!

• 1. Do it the same way every time!

STANDARDIZE!

• 2. KEEP IT SIMPLE!
• 3. TEAMWORK-LISTEN-TEAMWORK
• 4. MORE THAN D2B!!!!!!!!
• 5. FEEDBACK, FEEDBACK AND MORE

FEEDBACK!

TOP 10 LESSONS LEARNED!

• 6. Cardiologists need to get over it!
• 7. Now ED docs need to get over it!!
• 8. Key people with energy: CAN DO!!
• 9. There will be CHALLENGES!

NO CHALLENGE is TOO BIG!!

10.Its more Important than I thought! JUST DO IT!!!!!

40 yr old male

• 7:30 am. Onset of chest pain when

chasing raccoon out of garage

• History of HTN, Smoking
• Called 911. BLS with ALS intercept.

ASA and Nitroglycerin enroute

• 8:14 am. Arrives at ED. Still having

chest pain 3/10. BP: 148/80. HR: 62

Initial ECG at 8:15 am

Primary PCI, Triage, and Transfer for STEMI

Timothy D. Henry, MD Director of Research Minneapolis Heart Institute Foundation

• You've carefully thought out all the angles.
• You've done it a thousand times.
• It comes naturally to you.
• You know what you're doing, its what you've

been trained to do your whole life.

• Nothing could possibly go wrong, right?

Think Again!

Relative Risks of Transfer for Primary PCI vs Fibrinolysis

Dalby et al. Circ 2003;108:1809-14