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STEMI/Stroke Guidelines for MS Barry Bertolet, MD Vice President MHCA November 8, 2014 1.

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Presentation on theme: "STEMI/Stroke Guidelines for MS Barry Bertolet, MD Vice President MHCA November 8, 2014 1."— Presentation transcript:

1 STEMI/Stroke Guidelines for MS Barry Bertolet, MD Vice President MHCA November 8, 2014 1

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3 Goals for STEMI First Medical Contact (FMC) to PCI < 90 minutes Door to ECG time < 10 minutes Door In / Door Out Time < 30 minutes FMC to Non-PCI hospital to PCI < 120 minutes EMS specific Ideal for all chest pain patients to have in-field ECG Pre-hospital Activation of STEMI network Diversion to STEMI hospital 3

4 STEMI Core Measures MeasureCMSTJC Aspirin at arrival  Aspirin at DC  ACE/ARB/LVSD  BB at DC  Median Time to Lysis  Median Time to PCI  Primary PCI w/in 90 min  Statin at DC  Median time to Transfer  -- Median time to ECG  -- 4

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6 FMC to Device (Direct Presentation Arriving Via EMS) Minutes 6

7 Arrival at First Hospital to Device (Transfer In for PCI) Minutes 7

8 ED Arrival to First In-hospital EKG Minutes 8

9 EKG Within 10 Min of Arrival Direct Presentation, Arriving via POV Percent 9

10 Time Spent at Referral Facility Minutes 10

11 Time From Referring to Receiving Hospital Minutes 11

12 In-hospital Mortality Percent 12

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17 Atlantic Trial Overall, 1,862 patients were randomized to ticagrelor 180 mg in the ambulance vs in the cath lab. The mean age was 61 years, 19% were women, 19.5% had a body mass index ≥30 kg/m 2, and 12.7% had diabetes. Radial access was obtained in 68%, aspiration thrombectomy was performed in 52%, stenting was performed in 84% (of which 51% was a drug-eluting stent), unfractionated heparin was used in 67%, and glycoprotein IIb/IIIa inhibitor was used before PCI in 30%. 17

18 Atlantic Trial The first co-primary endpoint, proportion of participants who did not have ≥70% resolution of ST-segment elevation before PCI, occurred in 86.8% of the ambulance group vs. 87.6% of the catheterization laboratory group (p = 0.63). ST-segment resolution appeared to be improved by ticagrelor administration in the ambulance among those who did not receive morphine (p for interaction = 0.005). 18

19 Atlantic Trial The second co-primary endpoint, proportion of participants who did not have TIMI flow 3 before PCI, occurred in 82.6% of the ambulance group vs. 83.1% of the catheterization laboratory group (p = 0.82). – Death, MI, or urgent revascularization: 4.3% vs. 3.6% (p = 0.42), respectively – Definite stent thrombosis at 30 days: 0.2% vs. 1.2% (p = 0.02), respectively – Non-CABG major bleeding (TIMI criteria): 1.3% vs. 1.3% (p = 0.91), respectively 19

20 Gut Check While we have improved, we have not reached our goals or even the national averages. Due to the rural nature of our state, EMS holds the key for us to make the greatest improvements. 20

21 Why Do We Care? Myocardial infarction is the leading cause of death in the United States and in Mississippi. Approximately 450, 000 people in the United States die from coronary disease per year – and that rate of death is highest in Mississippi. The survival rate for U.S. patients hospitalized with MI is approximately 95%, but this survival dependent upon the delivery of timely and effective therapy.

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23 May, 2003

24 Regional Differences in MI Care (Circ Cardiovasc Qual Outcomes. 2009) Bottom 3 Hospitals with Highest Heart Attack Death Rates – Southwest, Mississippi Regional (MS) -- 24.9% Hospital Damas Inc. (PR) -- 24.5% Jefferson Regional Medical (PA) -- 23.9% The percentage of people who died following heart attack or heart failure within 30 days of hospital admission jumped significantly in the worst performing states: – Oklahoma – Arkansas – Tennessee – Missouri – Louisiana – Mississippi

25 D2B Scorecard Pay For Performance

26 Start the Clock! Time is muscle! Timely care is now defined from time of first medical contact (EMS) to that of the infarct-related artery being opened (angioplasty) being less than 90 minutes.

27 Time Is Muscle The Wavefront of Necrosis

28 Cannon CP et al, JAMA 2000 Mortality and DTB Times

29 Acute MI Stent Therapy

30 Clearly we can do better…

31 EMS Requirements  Equip all ambulances in state with ECG machines by 2012  Ambulance services should obtain EKG within 15 minutes for  typical chest pain in anyone > 30 years, and  atypical chest pain in all patients 50 and older  EMS should interpret and transfer ECG to affiliated ED  EMS personnel need training / certification in ECG interpretation of STEMI  eLearning: Rapid STEMI ID

32 EMS Requirements  + EKG patients directly to PCI hospital if 90 minutes window obtainable from first med contact to PCI AND patient is hemodynamically stable  + EKG patients directly to PCI hospital if 90 minutes window obtainable from first med contact to PCI BUT patient is hemodynamically UNSTABLE  Go to nearest ED  Activate Air Transport immediately for transfer to PCI center

33 EMS Requirements  If no pre-hospital ECG available for a chest pain patient who arrives at a non-PCI hospital  Keep the patient on the EMS stretcher until ECG performed  If EKG results + transfer to PCI hospital with SAME ambulance if patient hemodynamically stable

34 EMS Territorial Boundaries Broken  It is imperative for EMS to be able to cross county lines when necessary for reperfusion.  EMS services should cross-cover for adjacent EMS in another county.  A “Heart Attack” should take priority over many non- life threatening medical conditions.

35 Pre-Hospital Activation

36 STEMI Network (24/7) PCI Centers Jackson St. Dominic MBHS UMMC CMMC Hattiesburg Forrest General Hospital Wesley Meridian Jeff Anderson Hospital Rush Hospital Tupelo North Mississippi Medical Center Oxford Baptist Memorial Hospital North Mississippi South Haven Baptist Memorial Hospital Desoto Corinth Magnolia Regional Health Center Vicksburg River Region Hospital Greenville Delta Regional Medical Center Columbus Baptist Memorial Hospital Golden Triangle Pascagoula Singing River Health Systems Gulfport Gulfport Memorial Hospital McComb South West Regional Medical Center

37 Interventional Cardiac Catheterization Laboratory Facility Designation 24/7 capability within 30 minutes of notification Acceptance of all patients regardless of bed availability. Hospital has on-site cardiac surgery back up and meets procedural volume standards of at least 200 PCIs and 36 primary PCIs per year.

38 Interventional Cardiac Catheterization Laboratory Facility Designation Interventional cardiologist volume of at least 75 PCIs per year and 11 primary PCIs per year. Ongoing data monitoring in ACTION-GWTG Concurrent feedback to the EMS

39 In-Hospital Mortality by Age and Guidelines Adherence: Observations from CRUSADE - Boden et al, AHA 2005 Adj. OR: 0.71 (0.67-0.75)0.79 (0.75-0.83) Age Group

40 American College of Cardiology Benchmark <90 minutes Minimizing Time to Treatment from Arrival in the ED to treatment in the Cath Lab Saving Lives Mortality Rate Source: NRMI; Solucient Bottom Line Results Carolinas Medical Center

41 What Can You Do? STEMI is like Trauma – highest priority Essentially there are four time-sensitive emergencies – Trauma – STEMI – Stroke – Sepsis 41

42 What Can You (EMS) Do? Perform In-field ECG Learn to read ECG for STEMI Pre-activate Cath Lab Divert to STEMI hospital 42

43 What Can You (EMS) Do? If arrive at Non-PCI hospital with chest pain patient – Leave patient on stretcher and wait for ECG – Be prepared to transport patient to PCI hospital – Remember Door In / Door Out time is 30 minutes 43

44 What Can You (EMS) Do? Get Certified! AHA is offering EMS certification in 2014 for STEMI care 44

45 Goals for STEMI First Medical Contact (FMC) to PCI < 90 minutes Door to ECG time < 10 minutes Door In / Door Out Time < 30 minutes FMC to Non-PCI hospital to PCI < 120 minutes EMS specific Ideal for all chest pain patients to have in-field ECG Pre-hospital Activation of STEMI network Diversion to STEMI hospital 45

46 Mississippi State Department of Health – Bureau of Emergency Medical Services Mississippi Mississippi Stroke System of Care Plan

47 Mississippi State Department of Health – Bureau of Emergency Medical Services Background Stroke deaths rates in Mississippi are 23.8% above the national average Stroke is fifth leading cause of death in Mississippi 20% of all stroke deaths affect people under the age of 65 MSTAHRS Report 2010

48 Mississippi Stroke Rates 2000-2006 48 Mississippi Stroke Hospitalization Rate Mississippi Stroke Death Rate Age-adjusted rate per 1,000 17. 69- 18. 20 18. 21 - 18. 75 18. 78 - 19. 81 19. 91 - 22. 18

49 Mississippi State Department of Health – Bureau of Emergency Medical Services Background Collaborative effort: –Mississippi Healthcare Alliance (MHCA) –AHA Mission Lifeline –Mississippi Hospital Association –Mississippi State Department of Health

50 Phases of EMS Management of the Stroke Patient Activation of 911 system EMS response On scene assessment and stabilization Selection of appropriate destination Transport Pre-arrival stroke alert to receiving emergency department (as early as possible) Delivery of patient and information PI feedback

51 Scene Assessment General assessment – Consider alternative causes of neurologic deficit Focused neurologic assessment to include FAST – Face – Arm – Speech – Time Sensitivity 80%/specificity 30% Time of onset - may not be available at hospital

52 Treatment Stabilization – Standard protocols (check vital signs, ECG, glucose, hydration and treat as needed) – Scene time should be minimized but prehospital care should not be sacrificed for less scene time

53 Select Appropriate Destination Transport to the nearest hospital with an appropriate level of stroke care – Level may vary as resources change – Utilize knowledge of local facilities Window of opportunity – 4 ½ hours to completion of fibrinolytic treatment (earlier more effective than later) Useful time – 3 ½ hours until time of arrival at stroke capable hospital

54 Level 1- Comprehensive Referral Stroke Center Consists of a core team of personnel, infrastructure & expertise to diagnose & treat stroke patients who require intensive medical, surgical, & interventional vascular care. The team consists of a neurologist, neurosurgeon & endovascular specialists Fully equipped ED for rapid diagnosis and treatment using standard CT imaging within 25 minutes and ability to have results reported within 25 minutes of test completion Lab services available 24/7 with appropriate result reporting Neurology, Neurosurgery and Endovascular specialists are available 24/7 Intensive Care capability available with critical care specialist available 24/7 Has complete rehab services (physical therapy, occupational therapy & speech therapy) staffed by trained professionals and available for all patients within 24 to 48hrs of admission Will be readily available for transfer of patient from field or lower care facility Maintenance of adequate helicopter landing site on campus Operating room and appropriate support staff should be made available 24/7 for emergency surgery when necessary Radiologic and diagnostic imaging with expedited reporting available 24/7. This should include angiography with endovascular capabilities, CT, CTA, MRI, MRA, MRV, US, TTE, TEE, etc. Must participate in the AHA GWTG Stroke Registry. A multi-disciplinary quality improvement team including EMS should meet to review data and lead quality improvement initiatives at least quarterly. Stroke team members must document at least 8 CME hours annually. Community and professional educational projects should be ongoing. 54

55 Level 2- Referral Stroke Center (MUST HAVE ALL REQUIREMENTS OF LEVEL 1 EXCLUDING ENDOVASCULAR CAPABILITIES) Consists of a core team of personnel, infrastructure & expertise to diagnose & treat stroke patients who require intensive medical & surgical care. The team consists of a diagnostic radiologist, neurologist & neurosurgeon. Fully equipped ED for rapid diagnosis and treatment using standard CT imaging within 25 minutes and ability to have results reported within 25 minutes of test completion Lab services available 24/7 with appropriate result reporting Radiology, Neurology & Neurosurgery specialists are available 24/7 Intensive Care capability available with critical care specialist available 24/7 Has complete rehab services (physical therapy, occupational therapy & speech therapy) staffed by trained professionals and available for all patients within 24 to 48hrs of admission Will be readily available for transfer of patient from field or lower care facility Maintenance of adequate helicopter landing site on campus Operating room and appropriate support staff should be made available 24/7 for emergency surgery when necessary Radiologic and diagnostic imaging with expedited reporting available 24/7. This should include angiography with endovascular capabilities, CT, CTA, MRI, MRA, MRV, US, TTE, TEE, etc. Must participate in the AHA GWTG Stroke Registry. A multi-disciplinary quality improvement team including EMS should meet to review data and lead quality improvement initiatives at least quarterly. Stroke team members must document at least 8 CME hours annually. Community and professional educational projects should be ongoing. 55

56 Level 3- Transferring Stroke Capable (MUST HAVE THE ABILITY TO DIAGNOSE AND STABILIZE PATIENT FOR TRANSFER TO LEVEL 1 OR 2 REFERRING CENTER) ED physician, other qualified physician or physician extender available 24/7 to diagnose and initiate appropriate treatment Rapid diagnosis and treatment using standard CT imaging within 25 minutes and ability to have results reported within 25 minutes of test completion Lab services available 24/7 with appropriate result reporting Neurology specialists should be available 24/7 to direct IV TPA administration. TPA must be stocked and readily available. Transition plans must be established for rapid transfer of patient to Level 1 or 2 Stroke Center Must participate in the AHA GWTG Stroke Registry. A multi- disciplinary quality improvement team including EMS should meet to review data and lead quality improvement initiatives at least quarterly. Community and professional educational projects are present 56

57 Level 4- Non Stroke Hospital Facility is able to assess and evaluate for possible stroke but cannot treat Rapid transfer of patient to Level 1 or 2 Stroke Center should be facilitated May be bypassed in EMS Plan of Care 57

58 Stroke EMS Protocol Drip and Ship Protocol

59 EMS Stroke Protocol Development/Goals: –Review EMS stroke protocols across the state –Identify barriers to implementation –Raise awareness for acute stroke treatment –Standardize pre-hospital stroke care in MS –Maximize rate of acute stroke treatment by directing care to most appropriate facilities –Maximize the number of facilities that can treat acute stroke

60 Acute Stroke Interventions Rationale: IV Alteplase Intervention IA Alteplase Clot retrieval Early treatment = better outcomes

61 Ischemia Penumbra A stroke results in death of neuronal tissue. There is surrounding brain that is at risk of death if blood flow is not restored. This potential region of infarct or stroke is termed the Ischemic Penumbra.

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63 Stroke = death of brain cells

64 Treatment Window Protocol sensitive to treatment window for IV Alteplase. –Initial Alteplase trial defined a 3 hour window NINDS trial (NEJM 1995, 333: 1581-1588) –Subsequent trial revealed benefit in the 3 to 4.5 hour window ECASS-3 trial (NEJM 2008, 359: 1317-1329) Protocol also allows for EMS diversion for higher level of care outside this window –Comprehensive Stroke Center (Intervention)

65 4.5 hour Window Treatment using Alteplase to 4.5 hours –Supported by Advisory statement of AHA/ASA –Statement of Affirmation by American Academy of Neurology Stroke 2009, 40: 2945-2948

66 4.5 hour window Joint policy Statement of American College of Emergency Physicians and American Academy of Neurology –Level A evidence for treatment within 3 hours –Level B evidence for treatment 3 to 4.5 hours [Ann Emerg Med. 2013;61:225-243.]

67 tPA dose for Acute Ischemic Stroke AIS 0.9 mg/kg IV infused over 1 hour –≤100 kg: Administer 10% of total dose as initial bolus over 1 minute; THEN 0.81 mg/kg as continuous infusion over 60 min; not to exceed total dose of 90 mg –>100 kg: Administer 9 mg (10% of 90 mg) as IV bolus over 1 min; THEN 81 mg as a continuous infusion over 60 min

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71 Don’t Delay Meta-analysis of over 58K ischemic stroke patients treated with IV tPA with 4.5 hours of onset Every 15 minute acceleration in start of IV tPA: –4% greater odds of walking independently at discharge –3% greater odds of discharge home –4% lower odds of death –4% lower odds of symptomatic hemorrhagic transformation JAMA 2013 309(23): 2480-8

72 Updated Acute Ischemic Stroke Guidelines (Jan 2013) AHA Limited number of radiographic and laboratory tests are required prior to administering IV tPA: –Blood glucose check –Non-contrast head CT These recommendations are directed at meeting a door to treatment time of <60 min.

73 Better outcome with early t-PA treatment

74 Number of Patients Who Benefit and Are Harmed per 100 Patients tPA Treated in Each Time Window --Lansberg et al, Stroke 2009

75 Ways to minimize Ischemia and save the Penumbra Treat stroke early with thrombolysis (t-PA) –0-4.5 hours (earlier treatment superior!) –Treat stroke with invasive measure (IA t-PA, clot retrieval) 4.5 hours-? (6hours and even longer for certain vessels) Maintain cerebral perfusion pressure –Allow permissive hypertension

76 Blood Pressure Management American stroke association Ischemic stroke current recommendation: –SBP <220, DBP < 120 : no treatment unless end organ involvement –SBP >220 or DBP 121-140: Nicardipine or labetalol –DBP > 140 : Nitroprusside Stroke 2003: 34: 1056-1083

77 Appendix D: Pre-hospital Stroke Protocol 1) Initial assessment, transport ASAP: ABCs Obtain time of symptom onset (Last time known well) ___________; Source of information _____________________________________; Contact information _______________________________________. 2) Administer high concentration oxygen, as needed, to maintain O2 Sat >94 percent. 3) Position patient with head/shoulders elevated to 15-30 degrees (unless contraindicated). 4) Maintain NPO. 5) Blood glucose < 60, treat per protocol. 6) Do not treat high blood pressure without physician approval. 7) Perform Stroke Scale – Cincinnati Stroke Scale. 8) Transport patient to the appropriate facility: –a. Transport patient to the closest hospital capable of treating the patient with IV Alteplase (Stroke Capable or Primary/Comprehensive Stroke Center). Hospitals not able to diagnose and treat stroke patients (Level 4 hospitals) may be by- passed. EMS may use discretion based on transport time or other unforeseen factors. –b. Consider transport of the stroke patient with severe symptoms (hemiplegia, aphasia, neglect, stably intubated) to a Comprehensive Stroke Center if symptom onset to hospital arrival time is greater than 3 hours and less than 6 hours. –c. Transport patient to the closest appropriate facility if unstable (e.g., cardiac arrest, unstable airway). 9) IV NS KVO once en route. 10) EKG once en route. 11) Notify receiving facility of estimated arrival time of acute stroke patient, Stroke Scale finding, and time of onset.

78 Transport Guidelines Transport patient to the closest hospital capable of treating the patient with IV Alteplase (Stroke Capable or Primary/Comprehensive Stroke Center). Hospitals not able to diagnose and treat stroke patients (Level 4 hospitals) may be bypassed. EMS may se discretion based on transport time or other unforeseen factors. Consider transport of the stroke patient with severe smptoms (hemiplegia, aphasia, neglect, stably intubated) to a Comprehensive Stroke Center if symptom onset to hospital arrival time is greater than 3 hours and less than 6 hours. Transport patient to closest appropriate facility if unstable (e.g., cardiac arrest, unstable airway)

79 Appendix E: Alteplase (t-PA) “Drip and Ship” Transfer Protocol for Ischemic Stroke ******************************Use only Alteplase*************************************** 1) Symptom onset time: __________________ (Last time known well). 2) Document BP < 180/105 prior to departure: ___________________. 3) Initial NIHSS ________________; NIHSS at departure: ______________ (scored by ER physician/staff). 4) Activate EMS for transfer (consider air transport). 5) Two (2) peripheral IVs (18 gauge, AC or higher, if possible). 6) Time t-PA initiated: Total dose: __________, weight (kg) __________. a. Bolus dose time: __________, Dose __________ mg. b. Infusion dose time: __________, Dose __________ mg. (1 hour infusion) c. Completion time: __________. 7) After t-PA infusion completed, start NS at 80cc/hr to infuse remaining t-PA in tubing. 8) O2 as necessary to maintain O2 sat > 94%. 9) HOB 15-30 degrees (unless contraindicated). 10) If IV infusion blood pressure medication has been initiated, record: a. Medication __________; current dose __________. b. Titration instructions to maintain BP < 180/105: ____________________________________________________. c. Hold infusion blood pressure medication for BP < 140/80. 11) Vitals and neuro checks every 5 minutes. 12) Hypertension: If BP > 180/105. a. HR > 60: Labetalol 10mg IV over 2 minutes, repeat as needed after 5 minutes. May repeat 3 times. b. HR < 60: Nicardipine (Cardene) 5 mg/hour (at a concentration of 0.1 mg/ml); increased by 2.5 mg/hour every 15 minutes to a maximum of 15 mg/hour; consider reduction to 3 mg/hour after response is achieved. 13) Stop t-PA for: –A. Neurologic deterioration. –B. Airway Edema. –C. Time discontinued: _____________.

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81 Summary and Future Challenges Maximize use of IV Alteplase Establish networks of hospitals Direct appropriate patients for intervention Few Neurology/Stroke specialists Vastly different resources in state regions Networking of stoke centers with stroke ready hospitals Tele-stroke services

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