Presentation on theme: "Interfacility Transfers: The Joker’s Wild of STEMI Care Systems"— Presentation transcript:
1 Interfacility Transfers: The Joker’s Wild of STEMI Care Systems January 19, 2011Dr. Peter O’Brien, Centra Health, LynchburgDr. Michael Kontos, VCU, RichmondDr. David Burt, UVa, Charlottesville1
2 Part I: STEMI Transfers: The Jokers WILD Pete O’BrienVHAC
3 Part II: STEMI Fireside Chat Dr. Pete O’BrienDr. Mike KontosDr. David R Burt
4 Drs. Burt, Kontos, and O’Brien: Nothing to Disclose
5 Provider of: STEMI System Science, Resources, Collaboration … The Big PictureNATIONALLY…Mission: Lifeline is a national, community-based initiative designed to meet the needs of the STEMI patient throughout the continuum of care, beginning with the patient’s entry into the system (from symptom onset) through each component of the system, and return to the local community and physician for rehabilitative care.Mission: Lifeline uses a community-based, multidisciplinary, patient-centric approach.Mission: Lifeline is addressing systems of care for STEMI on multiple levels and through many collaborating organizations, starting with the STEMI patient and continuing through EMS, ED, STEMI Referral, and STEMI Receiving hospitals; implications for policy makers and third party payers are also being addressed within Mission: Lifeline. To meet the overarching goal, Mission: Lifeline will bring together the necessary partnerships between:Patients and care giversEMSPhysicians, nurses and other providersNon-PCI capable (STEMI-referral) hospitalsPCI capable (STEMI-receiving) hospitalsDepartments of healthEMS regulatory authority/Office of EMSRural health associationsQuality improvement organizationsState and local policymakersThird-party payersHealth systemsProvider of: STEMI System Science, Resources, Collaboration …55
7 ….In Virginia … www.virginiaheartattackcoalition.org The Virginia Heart Attack Coalition (VHAC) is a volunteer collaboration dedicated to improving care of heart attack patients throughout Virginia via the implementation and promotion of Mission: Lifeline guidelines and by fostering cooperation and coordination among the Commonwealth's STEMI care providers.
9 System Delay and Mortality in STEMI Patients Same old Story!Terkelsen CJ JAMA 2010;304:
10 Interhospital Transfer for PCI 20On-site fibrinolysisTransfer for PCI151412.110Mortality (%)108.48.5188.8.131.52.55A major issue that many community hospitals face is how to meet the tight timeframes for transferring patients to PCI-capable centers. The data from the five trials listed on this slide suggest that establishing rapid transfer protocols for PCI is worth the effort, as the PCI groups had lower mortality rates in 4 out of 5 of the trials.LIMI1PRAGUE-12AIR-PAMI3PRAGUE-24DANAMI5(n=150)(n=200)(n=137)(n=850)(n=1129)1. Vermeer F, et al. Heart ;82:2. Widimsky P, et al. Eur Heart J. 2000;21:3. Grines CL, et al. J Am Coll Cardiol. 2002;39:4. Widimsky P, et al. Eur Heart J. 2003;24:5. Andersen HR, et al. N Engl J Med. 2003;349:10Vermeer F, Oude Ophuis AJM, vd Berg EJ, et al. Prospective randomised comparison between thrombolysis, rescue PTCA, and primary PTCA in patients with extensive myocardial infarction admitted to a hospital without PTCA facilities: a safety and feasibility study. Heart.1999;82:Widimsky P, Groch L, Zelizko M, et al. Multicentre randomized trial comparing transport to primary angioplasty vs immediate thrombolysis vs combined strategy for patients with acute myocardial infarction presenting to a community hospital without a catheterization laboratory. The PRAGUE Study. Eur Heart J. 2000;21:Grines CL. Westerhausen DR Jr, Grines LL, et al. A randomized trial of transfer for primary angioplasty versus on-site thrombolysis in patients with high-risk myocardial infarction. The Air Primary Angioplasty in Myocardial Infarction Study. J Am Coll Cardiol. 2002;39:Widimsky P, Budesinsky T, Vorac D, et al. Long distance transport for primary angioplasty vs immediate thrombolysis in acute myocardial infarction. Final results of the randomized national multicentre trial – PRAGUE-2. Eur Heart J. 2003;24:Andersen HR, Nielsen TT, Rasmussen K, et al. A comparison of coronary angioplasty with fibrinolytic therapy in acute myocardial infarction. N Engl J Med. 2003;349:
11 60 AHA : System Goals 90 MINUTES 90 FIRST MEDICAL CONTACT MINUTES DOOR To NEEDLE :Fibrinolytics ORDOOR IN 2 DOOR OUTDOOR To BALLOONPrimary PCIEMS To BALLOONPrimary PCI6030MINUTES90 MINUTES90MINUTES4/13/2017
12 Point Of Entry Protocol : GOAL Considerations EMS has to make when deciding to transport to the nearest facility or to the farther away PCI facility….Patient condition (hypotension w s/s of acute coronary syndrome = PCI facility), Patient preference (utilize informed consent), Fibrinolytic Checklist (If patient is ineligible to receive fibrinolytics, then transport to PCI facility), EMS resources, Highest level of certification, Subtle EKG findings, Medical Control support for by pass of nearest non-PCI facility, Local facility support of by-pass protocols….. And the list goes on.Less than 90 Minutes
14 Riddle me this Batman!! JOKER runs Amok!! EMS and Self-Driven/Emergent Triage Decisions, Bypass?Referral Facility Recognition, System ActivationLytic Administration -OR- Transfer for PCIDrip, Ship, or Drip and Ship???Interfacility Transport - Ground, AirReceiving Facility – “Automatic” Acceptance, One Call Activation, Direct to Cath lab, Stop in EDSystem Optimization and Feedback, multiple EMS agencies, providers, institutions, etc14
15 Point of Entry Protocol Hospitalw/o PCINationally 50% of patients use EMS and that leaves the other 50% not utilizing EMS to access care.PCI centerHospitalw/o PCI
18 ACTION REGISTRY DATAThis slide is a combination of the 2 D2B slides. Although there are improvements nationally, these numbers only reflect those programs participating in ARG ~ 425 facilities nationwide. 82 or 20% of these facilities are from the Mid Atlantic Affiliate. A median of 112 minutes still demonstrates that more than 50% of the Transfer STEMI patients receive PCI in over 112 minutes (1.9 hours), 32 minutes over the recommended 90 minutes. The current Non-Transfer STEMI patient goal of 90 has been and is being met.4/13/2017National ARG Data and GWTG
19 Recommendations for Triage and Transfer for PCI (for STEMI) Each community should develop a STEMI system of care following the standards developed for Mission Lifeline including:Ongoing multidisciplinary team meetings with EMS, non-PCI-capable hospitals (STEMI Referral Centers), & PCI-capable hospitals (STEMI Receiving Centers)NEWRecommendationIIIaIIbIIIC1919
20 Recommendations for Triage and Transfer for PCI (for STEMI) (cont.) STEMI system of care standards in communities should also include:Process for prehospital identification & activationDestination protocols to STEMI Receiving CentersTransfer protocols for patients who arrive at STEMI Referral Centers and are primary PCI candidates, and/or are fibrinolytic ineligible and/or in cardiogenic shockNEWRecommendationIIIaIIbIIIC2020
21 AHA: STEMI System Blueprints Mission: Lifeline Recommendations for Criteria for STEMI Systems of CareThe criteria are divided into:EMSNon-PCI Hospital/STEMI Referral Center PCI Hospital/STEMI Receiving CenterSystems
22 The Ideal EMS Agency EMS equipped with 12 Lead capability EMS educated to recognize STEMIPrearranged transport destination protocolsBy Pass Non-PCIPCIFibrinolytic ChecklistEMS utilization for Interfacility TransfersCath Lab Activated on Paramedic InterpretationOn paramedic’s description /interpretationWith or Without EKG TransmissionEMS actively attends Multidisciplinary MeetingsEMS involvement at a state levelGuidelines for EMS.
23 The Ideal STEMI-Referral Hospital In an ideal system:Standardized POE protocols dictate transport of STEMI patients directly to a STEMI-receiving hospital based on:Patients presenting to a STEMI-referral hospital are treated according to standardized triage and transfer protocolsIncentives are provided to rapidly:Treat STEMI patients in accordance with ACC/AHA guidelinesTransfer to a STEMI-receiving hospital for primary PCI using:Reperfusion checklistsStandard pharmacological regimens and order setsClinical pathwaysThere is rapid and efficient data transfer, data collection and feedbackIntegrated plans for return of the patient to the community for care are providedIn the ideal system, standardized point-of-entry (POE) protocols would dictate those STEMI patients to be transported directly to a STEMI-receiving hospital based on specific criteria for risk, contraindications to fibrinolysis, and the proximity of the nearest PCI service.Standardized triage and transfer protocols are in place for patients presenting to a STEMI-referral hospital.Alignment of patient outcome and financial incentives are provided to:Rapidly treat STEMI in accordance with ACC/AHA guidelines;Transfer to a STEMI-receiving hospital for primary PCI using reperfusion checklist in regions that do not readily have access to STEMI-receiving hospitals, standardized pharmacological regimens, order sets and clinical pathways;There is rapid and efficient data transfer, data collection and feedback; andIntegrated plans for return to the community for care are provided.
27 Collaborative Initiatives Participate in Drafting of UNIVERSAL interfacility transport practice standardPre-Determined Transport Decision SchemePatient Care in EDPatient Care during transportNO DRIPSEarly activation of the Code STEMIProvides updateLytics given or not?More prep time allows thepatient to be taken directly to cath lab
28 Ideal STEMI-Receiving Hospital STEMI protocols adopted and followed to include single call activation.Criteria for EMS activation.24/7 coverage with expectation that Primary PCI is the standard reperfusion strategyED activation of cath labVolume/Quality standardsCCL staff/MD to report in 30 minutes or lessUniversal Acceptance—No Diversion!!
29 Ideal Receiving Cont’d STEMI-receiving hospital’s administration puts their support in writing (AHA Memorandum of Understanding..MOU)Lead multidisciplinary/multiagency team meeting to regularly identify processes done well and to collaboratively fix those that need improvementA continuing education program is designed and institutedA consistent mechanism for monitoring performance, process measures and patient outcomes is established—ACTION REGISTRY/GWTG
30 SAMPLE ML Report from Action Registry Facilities who participate in Action Registry and are registered with Mission: Lifeline will receive quarterly Mission:Lifeline reports and be eligible for Mission: Lifeline recognition4/13/20173030
31 Financial Sensitivities Learn local EMS resources/limitationsWork as a team to address needsOffer 12 Lead STEMI identification classesProvide MD level updates on lytic adminFeedback assures appropriate Non-PCI Facility BypassGoal is to get the STEMI patient back to their local community for rehab and follow upInvolve Non-Invasive Cardiologists on multiple levels
32 Mortality With 1° PCI vs Time For every 10 minutes delay in PCI-> 1% of the advantage is lost 15Circle sizes = sample size of individual studySolid line = weighted meta-regression10P=.006Absolute Risk Difference in Death (%)562 minFavors PCIFavors lysisTiming is everything when it comes to reperfusion strategies for acute MI. According to Nallamothu and Bates: “The mortality benefit associated with primary percutaneous coronary intervention in ST-segment elevation myocardial infarction may be lost if door-to-balloon time is delayed by >1 hour as compared with fibrinolytic therapy door-to-needle time. Interventional cardiology laboratories endeavoring to achieve the benefits of primary percutaneous coronary intervention seen in randomized clinical trials should aim to match their short door-to-balloon times.”This slide shows the absolute risk reduction in 4- to 6-week mortality rates with primary PCI as a function of PCI-related time delay. Circle sizes reflect the relative sample size of the individual study (the larger the circle, the larger the study). Values of absolute risk that exceed 0 represent benefit and values that are less than 0 represent harm. The solid line represents a weighted meta-regression.As time delays in PCI increase past 62 minutes, the lines separate, indicating that absolute mortality reduction in favor of primary PCI decrease significantly until its benefit relative to fibrinolysis is lost. Every 10-minute delay in PCI delivery is associated with a one percent reduction in mortality difference in favor of fibrinolytics. After a 62-minute time delay in PCI delivery, the two reperfusion strategies appear to become equivalent in terms of mortality rates and then diverge in favor of fibrinolytics. The survival advantage of PCI may be negated if door-to-balloon time is delayed by more than one hour, compared with fibrinolysis door-to-needle time.These findings support the recommendations of the European Society of Cardiology and the ACC/AHA, which suggest that delivery of primary PCI should not delay time to treatment for STEMI by more than 60 minutes.-520406080100PCI-Related Time Delay (Door-to-Balloon minus Door-to-Needle)For every 10-min delay to PCI: 1% reduction in mortality difference vs lytics.Nallamothu BK, Bates ER. Am J Cardiol. 2003;92:32Antman EM, Anbe DT, Armstrong PW, et al, American College of Cardiology, American Heart Association, Canadian Cardiovascular Society. ACC/AHA guidelines for the management of patients with ST-elevation myocardial infarction—executive summary. A report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Writing Committee to revise the 1999 guidelines for the management of patients with acute myocardial infarction). J Am Coll Cardiol. 2004;44:Nallamothu BK, Bates ER. Percutaneous coronary intervention versus fibrinolytic therapy in acute myocardial infarction: is timing (almost) everything? Am J Cardiol. 2003;92:
33 TRANSFER-AMI: Efficacy Kaplan Meier Curves for Primary Endpoint Primary end point: composite of death, reinfarction, recurrent ischemia, newor worsening CHF, or shock within 30 dayspharmaco-invasive group=11.0% vs. standard treatment group=17.2%17.2%Cumulative Incidence11.0%p=0.004Death & reinfarction not different between groups at 6 monthsDaysRR= 0.64, 95 CI% ( )Cantor et al. N Engl J Med 2009;360:263333
34 Figure 1. The results of the primary outcome from contemporary randomized trials comparing a pharmacoinvasive strategy with conservative care after initiating fibrinolytic therapy. In these trials, conservative care was defined as either an ischemia-guided or a delayed invasive approach.
35 Recommendations for Triage and Transfer for PCI (for STEMI) (cont.) NEWRecommendationIt is reasonable to transfer high risk patients who receive fibrinolytic therapy as primary reperfusion therapy at a non-PCI capable facility to a PCI-capable facility as soon as possible where either PCI can be performed when needed or as a pharmacoinvasive strategy.IIIaIIbIIIBHigh risk based on definitions used in CARESS-IN-AMI and TRANSFER-AMI3535
36 Nearest Facility ~vs~ PCI Facility If any of the contraindications are met, then TRANSPORT TO A PCI FACILITY. If a relative contraindication is met, discuss and decide what is in the patient’s best interest.
37 Acute STEMI Protocol for Halifax Regional(for acute ST elevation MI or new LBBB)The Cardiovascular Group of Central Virginia and the Stroobants Heart Center of Centra Health1. Notify Transport of need for emergent transfer to LGH.2. Call (or ) and ask for Cardiologist on call.Please be prepared to provide via phone:Patient’s nameAgeWeight, HeightEKG interpretationBrief report (i.e., treatment to this point, V, medications)3. ASA 325 mg chew and swallow4. Plavix 300 mg5. Lovenox 30 mg IV.6. Lovenox 1 mg/kg sub Q (up to 100 mg.)7. Administer IV Thrombolytic therapy (if no contraindications)8. IV fluids TKO.9. If full dose TNK is not given, then give Integrilin 180 mcg ug V bolus Repeat bolus in 10 minutes.If possible, avoid drips such as IV nitroglycerin that may delay transport and time to treatment.“Code STEMI…When time equals muscle, every minute counts!”Centra Health 1/05/20104/13/20173737