1. PCP CODE STEMI– Do the Clothes Fit? May 16, 2013 OBHG/MAC Annual General Meeting Richard Verbeek, Medical Director

2. 2 Coroner’s Recommendation 2012 Paramedics should bypass to PCI centre with STEMI patient if < 60 min transport Not stated whether this includes PCPs

3. 3 Toronto - only in areas with limited ACPs (Simcoe) - 45 min – Toronto, Peel, Halton – No PCP bypass London – under REB approved protocol – 45 min Ottawa – “routine” – 60 min Hamilton– under REB approved protocol – 45 - 60 min Thunder Bay – in Thunder Bay only Sudbury – Nearest hospital; no Bypass Oshawa – all areas if ACP not available – 60 min Ontario PCP CODE STEMI - “Patterns” of Practice

4. 4 “Supports” for CODE STEMI “Lots” Interfacility transfer for PCI better for survival than local fibrinolysis – DANAMI – Andersen NEJM 2003 + several others AHA 2010 Guidelines – Bypass reasonable if E2B < 90 min and transport < 30 min (Class IIa; LOE B) – Lemay, Dionne, Maloney NEJM 2008 E2B 108 min vs 91 min with ACP bypass (23 min) – Cheskes, Verbeek PEC 2011 E2B 107 min vs 70 min with ACP bypass (32 min) E2B = EMS contact to balloon time

5. 5 Published studies mostly US or European based where: – Paramedic = Advanced Care Paramedic – MD often on board All studies reviewed used terms such as paramedic, ALS provider, EMS provider No study specifically mentioned BLS provider, EMT, PCP AHA - Prehospital ECG acquisition has historically been limited to EMT-paramedic. Ting, Circulation 2008 European Society of Cardiology Steg Eur Heart J 2012 – should be at least one person on board trained in advanced life support. “Tears in the fabric” for PCP CODE STEMI

6. 6 Emperor of “PCP CODE STEMI”

7. 7 MAC “Thread Bare” View on PCP CODE STEMI

8. The “Dirty Laundry” of Paramedicine Mast pants – No Benefit Bickell – Ann Emerg Med 1987 Mattox - J Trauma 1989 Chang - J Trauma 1995 Prehospital Advanced Cardiac Life Support – No Benefit Stiell - NEJM 2004 Prehospital Advanced Trauma Life Support – No Benefit Eckstein - J Trauma 2000 Sethi - Cochrane Collaboration 2005 Stiell - CMAJ 2008 TCP for symptomatic bradycardia – No Benefit Sherbino - Resuscitation 2006 Pediatric Intubation – No Benefit Gausche - JAMA 2000 Intubation after Traumatic Brain Injury – HARMFUL! Wang - Ann Emerg Med 2004 Stiell - CMAJ 2008

9. The “Dirty Laundry” of Paramedicine ROC Studies – No Benefit ITD in Cardiac Arrest - Aufderdheide NEJM 2011 Early vs Late Analyze in Cardiac Arrest – Stiell NEJM 2011 Hypertonic Saline in Trauma Shock - Bulger JAMA 2010 Hypertonic Saline In TBI - Bulger Ann Surgery 2011 Supraglottic Airway in Cardiac Arrest – HARMFUL! Wang, Verbeek - Resuscitation 2012 Autopulse in Cardiac Arrest – No Benefit Dukelow – OBHG meeting 2013 Epinephrine for Cardiac Arrest – No Benefit or HARMFUL! Olaasvengen, Wik - JAMA 2009 Jacobs - Resuscitation 2011 Hagihara - JAMA 2012 Prehospital CPAP – No Benefit Cheskes, Thomson – PEC (Ab) 2013 Willmore, Stiell, Dionne - PEC (Ab) 2013 Prpic – OBHG meeting 2013

10. 10 “Dressings” for PCP CODE STEMI Cantor, Hoogeveen Am Heart J 2012 134 “consecutive” PCP CODE STEMI bypass patients – HR 60-160; BP >100; transport time 43 min – End Point = ability to safely transfer Results – Of patients who made it to PCI lab only one patient required ACP skills (rapid A-flutter) – One patient multiple episodes of VF successfully defibrillated by PCP but required intubation in ED – not described as requiring ACP skills Limitation - Did not account for patients who may have been diverted during transport

11. 11 Cantor, Hoogeveen Am Heart J 2012 Conclusion – Hemodynamically stable STEMI patients can be safely transported by PCPs My conclusion: STEMI patients who arrive safely can be safely transported by PCPs (includes those who require multiple defibrillation attempts and are intubated in the ED)

12. 12 “Garments” of Hope? Froats, Reed, Dionne, Maloney PEC (Ab) 2013 – 45 consecutive patients undergoing PCP CODE STEMI Bypass – 30 min transport – 20 (44%) had adverse event 15 transient abnormal VS with no intervention 4 adverse events would have benefited from ALS intervention At least one cardiac arrest – No adverse events in patients with initially normal VS

13. 13 “Garments” of Hope? Ryan, Verbeek PEC 2013 – 342 consecutive patients undergoing ACP CODE STEMI bypass – ACP contact time 28 min – 88 (26%) had adverse event majority were abnormal VS with no intervention 1 dopamine; 1 epi; 1 atropine adverse events similar in patients with normal VS – 9 cardiac arrests

14. 14 “Garments” of Hope? Alsayed, Verbeek – Work in progress – PCP CODE STEMI transport to nearest hospital = 14 min – Additional predicted time if direct to PCI centre = 6 min – Additional time if via nearest hospital to PCI centre = 90 min (range 70min-5hr)

15. 15 Conclusions STEMI bypass programs were developed using ALS model Ontario is the only place where PCP “commonly” do CODE STEMI bypass Only literature looking at out-of-hospital safety is from Ontario Preliminary data provides a hint that there may be a safety signal Some patients will die during bypass (?coroner OK) PCP CODE STEMI bypass is not a standard of care We are world experts and collectively responsible for providing the evidence to justify PCP CODE STEMI bypass

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18. 18 Does CODE STEMI Triage Improve Mortality? Dieker – JACC 2010 – 581 pt 454 direct vs 127 interfacility E2B = 69 min vs 118 min No patients died during transport One year mortality 7% vs 13% (p = 0.03) direct transport was not an independent predictor of survival in multivariable regression analysis

19. 19 Does CODE STEMI Triage Improve Mortality? Ortolani – Eurointervention 2011 – 1619 pt 524 direct vs 1095 interfacility (all comers) E2B = 62 min vs 78 min??? 1 yr mortality 15% vs 13% (p = 0.23) direct transport was not an independent predictor of survival in multivariable regression analysis (predictors were age, PCI TIMI flow grade 3, Killip class 1)

20. 20 Does CODE STEMI Triage Improve Mortality? LeMay, Maloney, Dionne, Trickett, – JACC 2012 – 1389 pt 822 direct vs 567 interfacility E2B = 66 min vs 117 min 180 day mortality 5% vs 11.5% direct transport was an independent predictor of survival in multivariable regression analysis (OR 1.9) NB - did not control for time-to-balloon intervals NB - ACP model

21. My personal transformation After you've done a thing the same way for two years, look it over carefully. After five years, look at it with suspicion. And after ten years, throw it away and start all over. ~Alfred Edward Perlman, New York Times, 3 July 1958