Regional STEMI Transfer Systems: Regional STEMI Transfer Systems: - - PowerPoint PPT Presentation

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Regional STEMI Transfer Systems: Regional STEMI Transfer Systems: - - PowerPoint PPT Presentation

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Regional STEMI Transfer Systems: Regional STEMI Transfer Systems: Regional STEMI Transfer Systems: the Mayo and NC RACE the Mayo and NC RACE the Mayo and NC RACE Experiences Experiences Experiences Dr. Henry H. Ting, Mayo Clinic College of

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Regional STEMI Transfer Systems: the Mayo and NC RACE Experiences Regional STEMI Transfer Systems: Regional STEMI Transfer Systems: the Mayo and NC RACE the Mayo and NC RACE Experiences Experiences

  • Dr. Henry H. Ting, Mayo Clinic College of Medicine
  • Dr. James G. Jollis, Duke University Medical Center
  • Dr. Henry H. Ting, Mayo Clinic College of Medicine
  • Dr. Henry H. Ting, Mayo Clinic College of Medicine
  • Dr. James G.
  • Dr. James G. Jollis

Jollis, Duke University Medical Center , Duke University Medical Center

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SLIDE 2

Henry H. Ting, MD MBA Mayo Clinic Rochester, Minnesota

  • Jan. 28, 2010

Henry H. Ting, MD MBA Henry H. Ting, MD MBA Mayo Clinic Mayo Clinic Rochester, Minnesota Rochester, Minnesota

  • Jan. 28, 2010
  • Jan. 28, 2010

Mayo Clinic STEMI System Mayo Clinic STEMI System for Transferred Patients for Transferred Patients “ “FAST TRACK FAST TRACK” ”

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SLIDE 3

Disclosures Disclosures Disclosures

  • No financial disclosures
  • No conflicts of interest
  • No off-label use
  • No financial disclosures

No financial disclosures

  • No conflicts of interest

No conflicts of interest

  • No off

No off-

  • label use

label use

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SLIDE 4

D2B – “Sustain The Gain” D2B D2B – – “ “Sustain The Gain Sustain The Gain” ”

Nestler DM. Circ Cardiovasc Qual Outcomes. 2009;2:508-513.

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SLIDE 5

64 min 30 min

PH ECG and Door-to-Balloon PH ECG and Door PH ECG and Door-

  • to

to-

  • Balloon

Balloon

Ting HH. Presented at AHA November 2009

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SLIDE 6

Patients Transferred for Primary PCI Patients Transferred for Primary PCI Patients Transferred for Primary PCI

1.3 8.6 26.4 36.3 17.6 8.2 4.3 2.2 3.7

20 40 60 <1 <90 min 1 to <2 2 to <3 3 to <4 4 to <5 5 to <6 6 to <7 7 to <12

Patients Patients (%) (%) Total door Total door-

  • to

to-

  • balloon time (hours)

balloon time (hours)

Chakrabarti A, J Am Coll Cardiol 2008;51:2442-2443.

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SLIDE 7

Reperfusion Strategies for Transferred STEMI Patients Reperfusion Strategies for Reperfusion Strategies for Transferred STEMI Patients Transferred STEMI Patients

1.

Interhospital transfer for primary PCI

2.

Pharmaco-invasive approach with lytics and early PCI

3.

Lytic facilitated PCI

4.

Prehospital triage for primary PCI

1. 1.

Interhospital Interhospital transfer for primary PCI transfer for primary PCI

2. 2.

Pharmaco Pharmaco-

  • invasive approach with lytics and early PCI

invasive approach with lytics and early PCI

3. 3.

Lytic facilitated PCI Lytic facilitated PCI

4. 4.

Prehospital triage for primary PCI Prehospital triage for primary PCI

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SLIDE 8

Reperfusion Strategies for Transferred STEMI Patients Reperfusion Strategies for Reperfusion Strategies for Transferred STEMI Patients Transferred STEMI Patients

1.

Interhospital transfer for primary PCI

2.

Pharmaco-invasive approach with lytics and early PCI

3.

Lytic facilitated PCI

4.

Prehospital triage for primary PCI

1. 1.

Interhospital Interhospital transfer for primary PCI transfer for primary PCI

2. 2.

Pharmaco Pharmaco-

  • invasive approach with lytics and early PCI

invasive approach with lytics and early PCI

3. 3.

Lytic facilitated PCI Lytic facilitated PCI

4. 4.

Prehospital triage for primary PCI Prehospital triage for primary PCI

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SLIDE 9
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SLIDE 10

Minnesota Wisconsin Iowa

Rochester

100 200

Duluth

  • St. Cloud

Minneapolis/

  • St. Paul

Ting HH, et al. Circulation 2007;116:729-736

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SLIDE 11
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SLIDE 12

Cumulative probability Cumulative probability Door-to-balloon/door-to-needle time (minutes) Door-to-balloon/door-to-needle time (minutes)

0.00 0.25 0.50 0.75 1.00 60 120 180 240

Regional Hospital Primary PCI Regional Hospital Fibrinolysis Regional Hospital Primary PCI Regional Hospital Fibrinolysis

Regional STEMI Patients Treated with Primary PCI or Fibrinolytic Therapy Regional STEMI Patients Treated with Primary Regional STEMI Patients Treated with Primary PCI or Fibrinolytic Therapy PCI or Fibrinolytic Therapy

25 min 110 min

Ting HH, et al. Circulation 2007;116:729-736

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SLIDE 13

Mortality and Door-to-Needle / Door-to-Balloon Mortality and Mortality and Door Door-

  • to

to-

  • Needle / Door

Needle / Door-

  • to

to-

  • Balloon

Balloon

3.5 5.6 6.6 11.5 13.5 1.1

4 8 12 16 20 <30 30-60 60-90 90-120 120-180 >180

In-hospital Mortality (%) In-hospital Mortality (%) Door-to-balloon / Door-to-needle time (minutes) Door-to-balloon / Door-to-needle time (minutes)

P=0.01 P=0.01

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SLIDE 14

Door-in Door-out (DIDO) at 1st Hospital and 1st Door-to-balloon Time

143 87 50 100 150 200 250 DIDO >30 min DIDO <=30 min

Median 1st Door-to-balloon (min)

P < 0.0001

Ting HH, et al. AHA November 2009

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SLIDE 15

Pharmaco-Invasive Strategy Pharmaco Pharmaco-

  • Invasive Strategy

Invasive Strategy

  • Definition:

Broad use of rescue PCI after failed fibrinolysis, as well as an early PCI within 3-24 hours

  • f successful fibrinolysis
  • Definition:

Definition: Broad use of rescue PCI after failed Broad use of rescue PCI after failed fibrinolysis, as well as an early PCI within 3 fibrinolysis, as well as an early PCI within 3-

  • 24 hours

24 hours

  • f successful fibrinolysis
  • f successful fibrinolysis
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SLIDE 16

30-day 1° Endpoint and Components 30 30-

  • day 1

day 1° ° Endpoint and Components Endpoint and Components

Endpoint Endpoint Standard Standard

N=498 (%) N=498 (%)

Pharmaco Pharmaco-

  • Invasive

Invasive

N=512 (%) N=512 (%)

P value P value

1 1  end point end point 16.6 16.6 10.6 10.6 0.0013 0.0013 Death Death 3.6 3.6 3.7 3.7 0.94 0.94 Re Re-

  • infarction

infarction 6.0 6.0 3.3 3.3 0.044 0.044 Recurrent ischemia Recurrent ischemia 2.2 2.2 0.2 0.2 0.019 0.019 Death/MI/ischemia Death/MI/ischemia 11.7 11.7 6.5 6.5 0.004 0.004 New/worsening CHF New/worsening CHF 5.2 5.2 2.9 2.9 0.069 0.069 Cardiogenic shock Cardiogenic shock 2.6 2.6 4.5 4.5 0.11 0.11

Cantor WJ. N Engl J Med 2009;360:2705

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SLIDE 17

30-day 1° Endpoint and Components 30 30-

  • day 1

day 1° ° Endpoint and Components Endpoint and Components

Endpoint Endpoint Standard Standard

N=498 (%) N=498 (%)

Pharmaco Pharmaco-

  • Invasive

Invasive

N=512 (%) N=512 (%)

P value P value

1 1  end point end point 16.6 16.6 10.6 10.6 0.0013 0.0013 Death Death 3.6 3.6 3.7 3.7 0.94 0.94 Re Re-

  • infarction

infarction 6.0 6.0 3.3 3.3 0.044 0.044 Recurrent ischemia Recurrent ischemia 2.2 2.2 0.2 0.2 0.019 0.019 Death/MI/ischemia Death/MI/ischemia 11.7 11.7 6.5 6.5 0.004 0.004 New/worsening CHF New/worsening CHF 5.2 5.2 2.9 2.9 0.069 0.069 Cardiogenic shock Cardiogenic shock 2.6 2.6 4.5 4.5 0.11 0.11

Cantor WJ. N Engl J Med 2009;360:2705

Median time from lytics to PCI was 3.9 hours

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SLIDE 18

Pharmaco-Invasive Strategy: NORDISTEMI Pharmaco Pharmaco-

  • Invasive Strategy:

Invasive Strategy: NORDISTEMI NORDISTEMI

Bohmer E. JACC 2010; 55:102-110

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SLIDE 19

Pharmaco-Invasive Strategy: NORDISTEMI Pharmaco Pharmaco-

  • Invasive Strategy:

Invasive Strategy: NORDISTEMI NORDISTEMI

Bohmer E. JACC 2010; 55:102-110

Median time from lytics to PCI was 2.7 hours

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SLIDE 20

3 6 1.8 1 2 4 6 8 In-hospital Death Total Stroke Hemorrhagic Stroke % Primary PCI Facilitated PCI 3 6 1.8 1 2 4 6 8 In-hospital Death Total Stroke Hemorrhagic Stroke % Primary PCI Facilitated PCI

ASSENT-4 Trial

Primary vs. Full-dose TNK Fibrinolytic-Facilitated PCI

ASSENT-4 Trial

Primary vs. Full-dose TNK Fibrinolytic-Facilitated PCI

P =0.01 P <0.0001 P =0.0037

DSMB terminated study after 1667 / 4000 enrolled because of higher in-hospital mortality observed for facilitated PCI

Van de Verf, Lancet 2006;367:569-578

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SLIDE 21

3 6 1.8 1 2 4 6 8 In-hospital Death Total Stroke Hemorrhagic Stroke % Primary PCI Facilitated PCI 3 6 1.8 1 2 4 6 8 In-hospital Death Total Stroke Hemorrhagic Stroke % Primary PCI Facilitated PCI

ASSENT-4 Trial

Primary vs. Full-dose TNK Fibrinolytic-Facilitated PCI

ASSENT-4 Trial

Primary vs. Full-dose TNK Fibrinolytic-Facilitated PCI

P =0.01 P <0.0001 P =0.0037

DSMB terminated study after 1667 / 4000 enrolled because of higher in-hospital mortality observed for facilitated PCI

Van de Verf, Lancet 2006;367:569-578

Median time from lytics to PCI was 1.9 hours

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SLIDE 22

Prehospital Triage Model Prehospital Triage Model Prehospital Triage Model

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SLIDE 23

Proximal LAD

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SLIDE 24

Prehospital Triage Model Prehospital Triage Model Prehospital Triage Model

1.

Paramedics acquire and interpret PH ECG

2.

If “Definite STEMI”, then 1-call activation of cath lab and helicopter auto-launch to intercept patient at regional hospital (or intercept enroute)

3.

Bypass ED evaluation at regional hospital & PCI hospital

4.

Patient transported directly to cath lab

5.

Explicit diversion criteria to deviate from #2-4

1. 1.

Paramedics acquire and interpret PH ECG Paramedics acquire and interpret PH ECG

2. 2.

If If “ “Definite STEMI Definite STEMI” ”, then 1 , then 1-

  • call activation of cath lab

call activation of cath lab and helicopter auto and helicopter auto-

  • launch to intercept patient at

launch to intercept patient at regional hospital (or intercept regional hospital (or intercept enroute enroute) )

3. 3.

Bypass ED evaluation at regional hospital & PCI hospital Bypass ED evaluation at regional hospital & PCI hospital

4. 4.

Patient transported directly to cath lab Patient transported directly to cath lab

5. 5.

Explicit diversion criteria to deviate from #2 Explicit diversion criteria to deviate from #2-

  • 4

4

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SLIDE 25
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SLIDE 26

Description Time Time Interval (minutes) Symptom Onset 05: 30 9-1-1 Call 06: 05 35 EMS On-Scene 06: 09 4 PH ECG Acquired 06: 16 7 STEMI Protocol Activation 06: 17 1 Transport to Local Com munity Hospital 06: 22 5 Arrival at Door 1 06: 26 4 Departure from Door 1 06: 37 11 Arrival at Door2 07: 10 33 First PCI Device 07: 27 17 Time Intervals Duration (minutes) * Door 1 In-to-Door 1 Out 11 * Door 2-to-First PCI Device 17 * Door 1-to-First PCI Device 61 * First EMS Contact-to-First PCI Device 82 * Symptom Onset-to-First PCI Device 117

Pitta SR. Circ Cardiovasc Qual Outcomes. 2010;3:93-97

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SLIDE 27
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SLIDE 28

North Carolina's Statewide STEMI System

James G. Jollis, MD, FACC Duke University

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SLIDE 29

RACE RACE Reperfusion in AMI in Carolina Emergency Departments

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SLIDE 30

How patients present

  • Call 911 EMS
  • (~50%)
  • Walk-in
  • (~50%)
  • Hospital transfer
  • - Walk in or EMS to 1st

hospital

  • (~60% of PCI hospital)
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SLIDE 31

How patients present

EMS Walk-in Hosp. transfer

Current 90 90 180 Potential <60 <90 <120

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SLIDE 32

121 emergency departments

500 EMS systems

5,240 paramedics 18,000 EMTs 21 primary PCI labs

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SLIDE 33

Integrated, Systematic Integrated, Systematic AMI Care AMI Care

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SLIDE 34

RACE

Process

2) Establish REGIONAL PCI CENTERS (primary, lytic ineligible, rescue)

Measurement & Feedback

3a) HOSPITAL by hospital establishment of STEMI plan (review, consensus, training) 3b) EMS by EMS establishment of STEMI plan (review, consensus, training) 4) Improve system 1) Develop leadership, funding, data structure

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SLIDE 35

Establish a plan

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SLIDE 36

Regional coordinators Regional coordinators

RACE

Interventions

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SLIDE 37
  • OPERATIONS MANUAL
  • Optimal system specifications

by point of care – EMS – ED – Transfer – Receiving hospital – Cath. Lab – Other system issues – payers, regulations

Available at www.race-er.org

RACE

Interventions

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SLIDE 38

RACE

Interventions

  • Emergency Department
  • Coordination and training of entire staff
  • Registration (nurse first)
  • Designated area for immediate
  • Standing STEMI protocol agreed upon by entire

emergency and cardiology staff

  • Emergency physician leads team
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SLIDE 39
  • PCI Hospitals
  • Single number cath lab activation
  • Accept all STEMI patients regardless
  • f bed availability
  • Ongoing QI and data feedback– NRMI

database

  • RACE Regional Coordinator

Responsible for improving process in every hospital - EMS system in the region

RACE

Interventions

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SLIDE 40
  • EMS

1) In the field ECG for all chest pain patients 2) 15 minute scene time 3) Hospital pre-notification 4) Standing STEMI plan / destination protocols

RACE

Interventions

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SLIDE 41

JAMA JAMA Nov. 2007

  • Nov. 2007
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SLIDE 42

108 85 90 74 106 149 30 60 90 120 150 180

All patients Direct presenters Transfer for PCI hospitals

Pre Post

P<0.001* P<0.001 median times in minutes P=0.01

RACE results

PCI hospitals: Door to device

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SLIDE 43

120 97 71 45 29 35 30 60 90 120 150 180

Door-in door-out, all hospitals Door-in door-out, transfer hosps Fibrinolysis, door- to-needle

Pre Post

P<0.001* P<0.001 median times in minutes P=0.002

* Remained significant in analysis accounting for clustering

RACE results

Non-PCI hospitals: Reperfusion times

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SLIDE 44

10 PCI centers 16 Transfer for PCI 28 Lytics 11 Mixed Asheville Winston-Salem Durham-Chapel Hill- Greensboro Charlotte East Carolina

Each non-PCI center was assessed for reperfusion designation based on resources, transfer ability, and transfer time to PCI center

RACE Centers and Regions

65 hospitals (10 PCI, 55 non PCI)