1. Reducing D2B Time in STEMI By Utilizing EMS Cath Lab Activation From The Field & Intradepartmental Emergency Physician Activation: An 11 Year 24/7/365 Experience Eric Brader MD FAAEM 10/07

2. Overview CW - Gusto IIb showed minor benefit for PTCA. Huge built in time advantage for lytics. Hang TPA vs get a cardiologist and a cath lab. CW - Gusto IIb showed minor benefit for PTCA. Huge built in time advantage for lytics. Hang TPA vs get a cardiologist and a cath lab. Streamlined every aspect of STEMI care after reviewing our Gusto IIb data to improve outcomes Streamlined every aspect of STEMI care after reviewing our Gusto IIb data to improve outcomes Instituted at a tertiary teaching hospital with largely private medical staff - 4/1/96 - 24/7/365 Instituted at a tertiary teaching hospital with largely private medical staff - 4/1/96 - 24/7/365 Results relatively constant in time with exception of 02/03 Results relatively constant in time with exception of 02/03 D2B is a poor measure of how our healthcare systems treat STEMI’s - FC2B is better - First Contact means EMS. D2B is a poor measure of how our healthcare systems treat STEMI’s - FC2B is better - First Contact means EMS. Used “to cath lab (CL) times” not “2B” because we want to focus on pre-cath lab process Used “to cath lab (CL) times” not “2B” because we want to focus on pre-cath lab process Currently treat 75 STEMI/yr, peaked in 2000 - 180, 1st 12 months - 14. Currently treat 75 STEMI/yr, peaked in 2000 - 180, 1st 12 months - 14. Nonstatistical experience Nonstatistical experience

3. Methods /Data/Limitations Retrospective review of QA data - 96/06/07 data and Gusto IIb data Retrospective review of QA data - 96/06/07 data and Gusto IIb data Years 2 -10 unable to be abstracted sufficiently due to software database change no longer supported by IS Years 2 -10 unable to be abstracted sufficiently due to software database change no longer supported by IS Mann Whitney U test - group sample sizes 5-20 Mann Whitney U test - group sample sizes 5-20 Loss of 0’s - no ED record/data loss - statistical inferences strong enough without. Loss of 0’s - no ED record/data loss - statistical inferences strong enough without. Elimination of 3 cases due to confounding issues Elimination of 3 cases due to confounding issues

4. STEMI Arrivals Walk ins/EMS no 12 lead Walk ins/EMS no 12 lead EMS 12 lead EMS 12 lead Interfacility Transfers Interfacility Transfers

5. Walk ins/No 12 lead EMS Transport ED chest pain patients got 12 lead EKGs in non- prioritized fashion ED chest pain patients got 12 lead EKGs in non- prioritized fashion If STEMI - PCP wanted called first If STEMI - PCP wanted called first Cardiologists were hit or miss Cardiologists were hit or miss Lytics vs CL Lytics vs CL ED 12 lead prioritized (10min) ED 12 lead prioritized (10min) ED physician trigger ED physician trigger STEMI Call List (10min) STEMI Call List (10min) 10 Minutes to respond or 2nd call was paged 10 Minutes to respond or 2nd call was paged Cath lab personnel must be within within 30 minutes of the hospital Cath lab personnel must be within within 30 minutes of the hospital No lytics, no PCPs No lytics, no PCPs OLD/GUSTO IIb NEW

6. Non 12 lead EMS/Walk ins OLD - Gusto IIb 42 minutes in the ED to initiate definitive STEMI treatment and 75 additional minutes to get the patient to the cath lab. NEW - 16 minutes to initiate definitive STEMI treatment and a total of 33 additional minutes to get to the cath lab in 2007 Net reduction in this subset 68 minutes due to nonEMS improvements. Cardiology deja vu all over again with PTCA - remember lytics!

7. 12 Lead EMS Arrivals No 12 lead EKGs done by EMS No 12 lead EKGs done by EMS Patients taken to closest facility Patients taken to closest facility 12 leads performed on scene 1st & transmitted from scene 12 leads performed on scene 1st & transmitted from scene Our medics taught how to read EKGs along with PTCA benefit (8hr course) with annual refresher(<5% false act) Our medics taught how to read EKGs along with PTCA benefit (8hr course) with annual refresher(<5% false act) Other system medics - less or none (false activations as bad as 50%) Other system medics - less or none (false activations as bad as 50%) Cath lab activated from field by medics through our command physician Cath lab activated from field by medics through our command physician Patients given destination informed consent by medics including helicopter scene run Patients given destination informed consent by medics including helicopter scene run Paramedics may take patient directly from the field to the cath lab - 0’s Paramedics may take patient directly from the field to the cath lab - 0’s Followup & Heart Saver Sundays Followup & Heart Saver Sundays OLD/Gusto IIb NEW

8. Chest Pain Protocol Initiate resuscitation if needed Initiate resuscitation if needed Do “Room Air” 12 Lead first - before IV or meds - FC2B is the most important factor - the worst thing that could happen is that the patient could arrest Do “Room Air” 12 Lead first - before IV or meds - FC2B is the most important factor - the worst thing that could happen is that the patient could arrest Initiate destination discussion on scene Initiate destination discussion on scene Activate cath lab from scene to maximize prep time - have been more successful with helicopter scene runs than ground transports Activate cath lab from scene to maximize prep time - have been more successful with helicopter scene runs than ground transports

9. Prehospital 12 Lead Without Prehospital Activation ‘07 No prehospital 12 lead 16 minutes post arrival to activate cath lab 16 minutes post arrival to activate cath lab D2CL - 49 minutes D2CL - 49 minutes Prehospital 12 lead but no activation 5 minutes post arrival to activate cath lab 5 minutes post arrival to activate cath lab D2CL - 45 minutes D2CL - 45 minutes NSD - D2CL Only reason to do prehospital 12 lead without field activation is to influence destination.

10. “Don’t Fool Around With That EKG In The Field - Get Them To The ER!!!” Additional time on STEMI scene time to do 12 lead - 3 minutes Additional time on STEMI scene time to do 12 lead - 3 minutes EMS transported CP patient with first 12 lead done in ED - 12 minutes EMS transported CP patient with first 12 lead done in ED - 12 minutes “Quit fooling around with 12 leads in the ED and let the medics do it for you in the field!!!!!” “Quit fooling around with 12 leads in the ED and let the medics do it for you in the field!!!!!”

11. Prehospital 12 Lead With Prehospital Activation ‘07 Prehospital 12 lead but no prehospital activation 5 minutes post arrival to activate cath lab 5 minutes post arrival to activate cath lab D2CL - 45 minutes D2CL - 45 minutes Prehospital 12 lead with prehospital activation D2CL - 27 minutes D2CL - 27 minutes P<.05 D2CL faster with prehospital activation

12. Prehospital 12 Lead With Prehospital Activation Via Ground Transport ‘07 Over 10 minutes pre- arrival to activate cath lab D2CL – 18 minutes D2CL – 18 minutes Missing zeroes Missing zeroes P<.01 faster than 12 lead without EMS activation P<.01 faster than 12 lead without EMS activation P<.01 faster than 10 or less minute activation EMS activation P<.01 faster than 10 or less minute activation EMS activation 10 or less minutes prearrival to activate cath lab D2CL - 34 minutes D2CL - 34 minutes P<.05 faster than EMS 12 lead without activation P<.05 faster than EMS 12 lead without activation Average chest pain patient in our system overall -16 minutes on scene & 18 minute transport. If all patients were to activate from the scene (goal) we should have ~ 50% 0’s/ D2CL<10min.

13. Direct EMS Referral Vs EMS-Nontertiary-Tertiary Referral

14. Comparison Direct EMS Referral Vs Transport To Non-tertiary Facility And Transfer 06/07 FC2CL time EMS direct referral - 70 minutes FC2CL time EMS direct referral - 70 minutes D2CL – 23 minutes D2CL – 23 minutes Missing 0’s Missing 0’s FC2CL time EMS to nontertiary to tertiary hospital - 3 hours and 5 minutes! FC2CL time EMS to nontertiary to tertiary hospital - 3 hours and 5 minutes! D2CL - 2 minutes D2CL - 2 minutes “Our” D2B times were great! “Our” D2B times were great! All five STEMI patients transported to a nontertiary hospital without a 12 lead were women All five STEMI patients transported to a nontertiary hospital without a 12 lead were women P<.01 - FC2CL faster in direct referral model by115 minutes

15. Conclusions Prehospital 12 lead - when used as a triage tool - reduced FC2CL by ~90 minutes Prehospital 12 lead - when used as a triage tool - reduced FC2CL by ~90 minutes EP trigger with ED process improvements reduced D2CL by ~60 minutes EP trigger with ED process improvements reduced D2CL by ~60 minutes Prehospital 12 lead with prehospital activation - reduced FC2CL an additional 18+ minutes but has the potential for ~30 minutes reduction if done from scene. Prehospital 12 lead with prehospital activation - reduced FC2CL an additional 18+ minutes but has the potential for ~30 minutes reduction if done from scene. Prehospital activation & EP trigger reduce FC2CL by ~120 minutes. Prehospital activation & EP trigger reduce FC2CL by ~120 minutes. 90% US pop lives within 60 minutes of a CL! 90% US pop lives within 60 minutes of a CL!

16. Lessons Learned/Advice Waxing and waning performance – (ZKZ disease - cheap and stupid won’t work) - Need approp cath lab staffing, EMS training, EMS follow up, EMS recognition Waxing and waning performance – (ZKZ disease - cheap and stupid won’t work) - Need approp cath lab staffing, EMS training, EMS follow up, EMS recognition You will discharge CG shock pts with normal EKG/echoes & 3 day LOS You will discharge CG shock pts with normal EKG/echoes & 3 day LOS 90% of our prehospital STEMIs are inferior and a high percentage proximal RCAs (RV dysfunction EMS teaching) 90% of our prehospital STEMIs are inferior and a high percentage proximal RCAs (RV dysfunction EMS teaching) 5-10% CP calls are STEMI’s 5-10% CP calls are STEMI’s The big question(s)? The big question(s)?

17. The Big Question(s)? Will nontertiary hospital administrators accept negative impact? Will nontertiary hospital administrators accept negative impact? Will tertiary hospital administrators be willing to support a 24/7 operation and discipline “rogue” cardiologists who will threaten to take patients elsewhere? Will tertiary hospital administrators be willing to support a 24/7 operation and discipline “rogue” cardiologists who will threaten to take patients elsewhere? Will cardiologists accept less money and less sleep for the benefit of patients? Will cardiologists accept less money and less sleep for the benefit of patients? We changed the system to be patient focused for trauma patients – we need to do it for STEMI patients. We changed the system to be patient focused for trauma patients – we need to do it for STEMI patients.

18. Thank You