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Don’t Die of Embarrassment: Activating Individuals & Communities In a Heartbeat November 9, 2006 Mary Harkins Becker, MD Medical Director Cardiovascular.

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Presentation on theme: "Don’t Die of Embarrassment: Activating Individuals & Communities In a Heartbeat November 9, 2006 Mary Harkins Becker, MD Medical Director Cardiovascular."— Presentation transcript:

1 Don’t Die of Embarrassment: Activating Individuals & Communities In a Heartbeat November 9, 2006 Mary Harkins Becker, MD Medical Director Cardiovascular Health MaineHealth

2 The In a Heartbeat Goal: Reduce mortality and morbidity that result from AMI. Reduce mortality and morbidity that result from AMI. For STEMI patients: For STEMI patients: –increase the number of patients receiving timely primary PCI, facilitated PCI or lytic therapy when indicated across the state.

3 Why does time matter so much?

4 Time = Muscle

5 Our Patient 52 year old police chief 52 year old police chief Notes tightness across his chest with aching in both arms and profuse sweating Notes tightness across his chest with aching in both arms and profuse sweating Calls 911 Calls 911

6 Time = Muscle Optimally, treatment occurs within one hour of the onset of symptoms. Optimally, treatment occurs within one hour of the onset of symptoms. Mortality increases with every 30 minute delay in treatment. Mortality increases with every 30 minute delay in treatment.

7 Benefits of Early Treatment Survival rates improve by up to 50% if treatment is begun within 1 hour. Survival rates improve by up to 50% if treatment is begun within 1 hour. Survival rates improve by 23% if treatment is begun within 3 hours. Survival rates improve by 23% if treatment is begun within 3 hours. Early treatment yields better long term cardiac function. Early treatment yields better long term cardiac function. –The difference between having heart failure or not –The difference between returning to work or not

8 The sooner the patient is treated, the more heart muscle can be saved.

9 The sooner the patient is treated the better his chances of surviving with a good quality of life.

10 AMI Leading cause of disability and death Leading cause of disability and death 50% of patients will die untreated 50% of patients will die untreated Much progress toward better outcomes Much progress toward better outcomes Minimal progress toward getting patients to the hospital sooner Minimal progress toward getting patients to the hospital sooner –In 2006 a minority of patients receive optimally timed treatment

11 The weakest link in the chain is patient delay in seeking care

12 Symptom onset to Treatment time includes: Symptom onset to decision to seek medical care Symptom onset to decision to seek medical care Decision to seek care to hospital arrival Decision to seek care to hospital arrival Hospital arrival to treatment Hospital arrival to treatment

13 Why Patients Delay Demographic factors associated with delay in seeking care: Demographic factors associated with delay in seeking care: Increasing age, being female, low education level, low socioeconomic status, black race Clinical factors associated with delay: Less severe or atypical symptoms, chronic medical problems

14 Why Patients Delay Social Factors associated with delay in seeking care: Social Factors associated with delay in seeking care: Location, onset at home Location, onset at home –Most AMIs begin at home Living alone or being alone Living alone or being alone Feelings of embarrassment and the concern of a false alarm Feelings of embarrassment and the concern of a false alarm

15 Why Patients Delay Cognitive Factors associated with a delay in seeking care: Cognitive Factors associated with a delay in seeking care: Mismatch between expected and actual symptoms Mismatch between expected and actual symptoms -Not every patients grabs his chest and drops to the floor -Not every patients grabs his chest and drops to the floor

16 Why Patients Delay Patients who believe their symptoms are related to their heart seek care faster Patients who believe their symptoms are related to their heart seek care faster Studies show the US public is quite familiar with the association between chest pain and AMI Studies show the US public is quite familiar with the association between chest pain and AMI –Less aware that AMI can and often does present as a constellation of symptoms –Less aware that symptoms are often not severe

17 Why Patients Delay Overall women have a greater delay in seeking care than men do Overall women have a greater delay in seeking care than men do Women present differently than men Women present differently than men Misconception on the part of patients and providers that women do not have AMIs Misconception on the part of patients and providers that women do not have AMIs –Changing a patients perceived risk has been shown to shorten delay times

18 Why Patients Delay Self-care strategies: Self-care strategies: –Waiting –Taking meds (ASA, NTG, antacids, etc.)  A frequent cause of delay in those with a past h/o MI

19 Why Patients Delay Denial Denial –Frequently cited as a cause –No relationship found between denial and delay –Rather, many patients are indecisive about how to respond to their symptoms

20 Why Patients Delay Provider associated delay! Provider associated delay! –Some studies show this accounts for more time than patient delay –Most patients believe calling their doctor, not EMS is the right course of action –Providers assume their patients know to call 911 –Some providers are not aware of the consequences of patient delay

21 Why Patients Delay Lack of knowledge about treatment options Lack of knowledge about treatment options –Patients who know about lytic therapy were more likely to seek therapy sooner –Physicians vs. nonphysicians with AMI  Median delay was 1.8 vs. 4.9 hours

22 How do AMI patients get to the hospital? We know that nationally only 50% of patients arrive by EMS. We know that nationally only 50% of patients arrive by EMS. –Perhaps less in Maine We know that patients who arrive by EMS have shorter treatment times. We know that patients who arrive by EMS have shorter treatment times.

23 Advantages of Calling 911 Brings emergency personnel who can: Arrive fast and start medical care Arrive fast and start medical care Send information to the emergency department before the patient’s arrival Send information to the emergency department before the patient’s arrival Restart or shock the heart if patient goes into cardiac arrest Restart or shock the heart if patient goes into cardiac arrest

24 Symptom onset to hospital arrival time can be shorten by increase use of EMS

25 Symptom onset to hospital arrival time: how are we doing?

26 Symptom Onset to ED Arrival National National –90-360 minutes –50% are > 120 minutes State of Maine?? State of Maine?? MaineHealth: MaineHealth: –Reported as median 7/04-6/05 110 min (median) 7/05-6/06 85 min (median)

27 MaineHealth Symptom Onset to ED Arrival Times by hospital Minutes to ED arrival vs. hospitals across the system reported as median times (7/06-6/06) Minutes to ED arrival vs. hospitals across the system reported as median times (7/06-6/06)

28 Patient delay is the biggest contributor to delaying treatment for STEMI.

29 Patients need to recognize their symptoms and call 911 quickly How can we help them do this?

30 REACT Trial RCCT, 20 cities, 1995-97 RCCT, 20 cities, 1995-97 Methods Methods –Mass media –Targeted community organizations –Public and professional education Results Results –No improvement in hospital arrival time –20% increase in use of 911 for chest pain pts

31 “Call Fast, Call 911” Message Message –Symptom recognition –Act quickly, new time sensitive treatments –Call 911 Methods Methods –Mass media direct mailing and PSAs Results Results –No improvement in arrival time –Patients at high risk (h/o prior MI) did increase their use of 911

32 HASK Project Seattle, 2004 Seattle, 2004 Method Method –Door to door EMS visit to distribute a heart attack education tool –Effectiveness measured by phone survey Results Results –Modest increase in likelihood to use 911 and in symptom recognition

33 Public Interventions to Reduce Delays in Seeking Treatment Broad based community education programs have yielded disappointing results Broad based community education programs have yielded disappointing results –Little or no decrease in patient delay –Some marginal increase in the use of 911 Most success with high risk populations Most success with high risk populations

34 Learning from the Literature 1. target high risk populations 1. target high risk populations 2. target the social, cognitive and emotional factors that contribute to delay 2. target the social, cognitive and emotional factors that contribute to delay 3. include use of 911 in the message 3. include use of 911 in the message 4. explore new methods of delivering the message 4. explore new methods of delivering the message

35 Public Education Community Engagement What are the messages?

36 Act in Time -developed by NHLBI and AHA

37 Message # 1  Recognize the symptoms: –Chest discomfort –Jaw, arm, back or neck discomfort –Shortness of breath –Breaking out in a cold sweat –Nausea –Light-headedness

38 Message # 2  Symptoms of a heart attack can vary person to person –Not every patient experiences the ‘Hollywood Heart Attack’ of crushing chest pain and a drop to the floor –Heart attacks often begin as vague symptoms that slowly intensify

39 Message # 3 Women die of heart attacks as often as men do Women die of heart attacks as often as men do

40 Message # 4  If you think you or someone near to you is having a heart attack, call 911 –Do not wait more than 5 minutes before calling 911

41 Message # 5  Your best chance of survival is to get to a hospital quickly –Quick action and medical treatment restore blood flow and save heart muscle. –Dead heart muscle cannot be restored. –Ideally treatments should begin within one hour after symptoms start.

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44 In a Heartbeat Community Engagement Workgroup (ACE) Goal: For the public to recognize signs of Heart Attack and to Call 9-1-1 immediately

45 Workgroup Members Represent: American Heart Association American Heart Association Community Groups: Community Groups: –Healthy Maine Partnerships –Healthy Communities Emergency Medical Services Emergency Medical Services Health Systems Health Systems State Government State Government –Maine Quality Forum –Maine CDC Cardiovascular Health Program

46 Outreach Strategy Target high risk populations and their family, friends, coworkers Target high risk populations and their family, friends, coworkers Develop set of consistent messages to deliver statewide Develop set of consistent messages to deliver statewide Work with: Work with: –EMS and medical professionals –Advocacy, community, and social groups –Schools and youth

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48 Short Term Strategies: Public Outreach Create toolkit to promote common set of messages statewide Create toolkit to promote common set of messages statewide –Standard PowerPoint –Handouts –Collateral items Orient EMS, medical professionals and others to tools developed Orient EMS, medical professionals and others to tools developed

49 Short Term Strategies: Public Outreach Organize, promote and sustain speaker’s bureau Organize, promote and sustain speaker’s bureau Partner with Maine HeartSafe Communities Partner with Maine HeartSafe Communities –Recognition program for EMS –Includes community outreach Develop viral marketing campaign through existing social networks Develop viral marketing campaign through existing social networks

50 Short Term Strategies: Public Outreach Launch competition for students to create PSAs Launch competition for students to create PSAs –Middle school – videos on laptops –High school – media classes Develop and implement evaluation plan that includes process and outcome measures Develop and implement evaluation plan that includes process and outcome measures

51 Short Term Strategies: Provider Outreach Partner with PCPs, PHOs, FQHCs and hospitals to: Partner with PCPs, PHOs, FQHCs and hospitals to: –Encourage patients to call 9-1-1, not clinical office if AMI signs –Distribute AMI information to patients through PCPs and case managers –Enhance existing public outreach at annual events, community education –Include AMI information in staff education

52 Short Term Strategies: Provider Outreach Include AMI urgency, signs and need to call 9-1-1 in CPR trainings Include AMI urgency, signs and need to call 9-1-1 in CPR trainings Work with AHA to inform clinicians through Annual Scientific Session Work with AHA to inform clinicians through Annual Scientific Session

53 Long Term Strategies Continue to convene ACE Workgroup with diverse statewide representation Continue to convene ACE Workgroup with diverse statewide representation Sustain through joint collaboration: Sustain through joint collaboration: –Maine Quality Forum –Maine CDC Cardiovascular Health Program –Office of Maine Emergency Medical Services

54 Long Term Strategies Implement ACE recommendations Implement ACE recommendations Explore additional strategies and funding Explore additional strategies and funding – including larger scale media Monitor implementation Monitor implementation Evaluate short term strategies to assess effectiveness Evaluate short term strategies to assess effectiveness

55 What Can You Do? Consider becoming an ACE member Consider becoming an ACE member Provide feedback and offer your ideas Provide feedback and offer your ideas Agree to partner on strategies Agree to partner on strategies Outreach begins with You! Outreach begins with You! Tell someone you love about signs of heart attack and need to Call 9-1-1 Tell someone you love about signs of heart attack and need to Call 9-1-1

56 Contact: Maine Quality Forum: Maine Quality Forum: (www.mainequalityforum.gov) www.mainequalityforum.gov ACE Workgroup Chair: ACE Workgroup Chair: Debra Wigand Maine CDC CVH Program Debra.a.wigand@maine.gov 207-287-4624

57 Getting Started Initial support from: Initial support from: –Central Maine Healthcare –Eastern Maine Medical Center –MaineHealth


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