1. AHA Mission Lifeline : Wyoming (ML:WY)
Michael D. Eisenhauer, MD
Co-Chairman, Wyoming Initiative
1 February 2013

2. What is Mission: Lifeline?
Mission: Lifeline is the American Heart Association’s national initiative to advance the systems of care for patients with ST-segment elevation myocardial infarction (STEMI) and those resuscitated after experiencing an Out-of-Hospital Sudden Cardiac Arrest (SCA). The overarching goal of the initiative is to reduce mortality and morbidity for STEMI and SCA patients and to improve their overall quality of care
This is the American Heart Association of Mission Lifeline.
11/8/2018
©2010, American Heart Association

3. Mission: Lifeline Wyoming what will it look like here?
There are many ML systems that have been initiated and are currently in use throughout the country. However, never before has a Mission Lifeline System been initiated in a “Rural/Frontier” region with the level funding and commitment that has been generously provided by the Helmsley Charitable Trust. We are creating the Model for Frontier Systems of Care.

4. Why is this so important for Wyoming?
Geographic distance
Only two active PCI centers
Additions soon in Gillette/Sheridan
Flight times are long
Weather impediments
STEMI Mortality is high when compared to other states
Very difficult to reach PCI facility within goal of 120 minutes
Funded Opportunity!

5. A Unique Opportunity for our Citizens
FUNDED GRANT
$5.9M Helmsley Foundation Grant
$1.2M from First Interstate Bank and Wyoming Community Foundation
“Working for Wyoming Fund”
STATEWIDE INITIATIVE
“Four Corners”
Border State involvement desired!!
New “System of Care”

6. Mission: Lifeline “Ideals”
The Ideal Patient
The Ideal EMS
The Ideal STEMI Referral Center
The Ideal STEMI Receiving Center
The Ideal System
-Ideal pt is one that is education on s/s of heart attack and utilizes 911 system
-Ideal EMS is one that has professional/competent care givers that are trained in proper 12 lead acquisition, transmission and if applicable interpretation
-Ideal STEMI Referral Center has a process that stabilizes the pt and arranges for prompt transfer if needed
-Ideal STEMI Receiving Center has processes in place that allow for the best possible care
11/8/2018
©2010, American Heart Association

7. What is a “System of Care?”
An "integrated group of separate entities within a region“1 (such as EMS, ED, cardiologists, PCI receiving centers) focused on providing specialized services for cardiovascular patients, which
"operate in a coordinated fashion through common leadership, goals, standards, data, policies, and quality improvement practices“2 , and
Focus on producing significant changes in patient outcomes (mortality, reducing time to treatment)
This is the definition of System of Care and will provide an overall template for MLWY
References:
Jacobs AK, Antman EM, Faxon DP, Gregory T, Solis P. Development of systems of care for st-elevation myocardial infarction patients. Circulation. 2007;116:
Langabeer, J., Henry, T., et al (2012). A Development Framework for Regionalized Cardiovascular Systems of Care. Forthcoming.

8. The Ideal System of Care
Just a graphic to note the “Ideal System”
11/8/2018
©2010, American Heart Association

9. Regional Challenges: WY, MT, ID,SD, CO
Minimal coordination of STEMI care between EMS and receiving hospitals
Inability for EMS to transmit ECG’s
Complete lack of data accurately reflecting STEMI care in region
Minimal or no QA/QI, or STEMI feedback loops
Overall lack of process understanding transcended EMS, ED and cath lab staff
Lack of STEMI protocol sets between EMS and receiving hospitals
This slide highlights some regional challenges that have been identified from other systems. We will, through our subcommittee structure, identify challenges specific to Wyoming and address as needed. The best way to identify these challenges is through the collection of data. 9

10. Goals of the System
Timely assessment of the patient and acquisition of a 12 lead ECG by EMS providers.
Early transmission of the pre-hospital ECG into the emergency department’s receiving station.
Early diagnosis and start of clinical care and management of the of the acutely ill cardiac patient.
Providing prompt treatment and interventions to prevent ischemic damage to the heart and decrease the overall mortality caused by STEMI events. 10

11. Grant Funding $$$ For:
Two FT AHA staff to travel the state in support x 3yr
12-Lead ECG capability for every ambulance in the State
Transmission capability
AED included (with training)
Public Education
Data gathering in each referring and accepting facility
Includes outreach to border state PCI facilities
Professional Data Analysis
Univ of Wyoming
UTHSC
Professional Education

12. Public Education: Marketing Campaign: We are interested in improving:
2011 Study (Wyoming Dept of Health)
~43% respondents surveyed could identify five major MI symptoms
Only 39% respondents were aware of the signs/symptoms and indicated that they would call first
~85% responded that they would call 9-1-1
We are interested in improving:
“LIVING ROOM TO BALLOON TIME”
And not just D2B

13. Mission: Lifeline Wyoming
Implementation Timeline
Oct st M:LWY Committee Meeting
Establish subcommittees: PQI, CPE, EQU
Dec Hospitals sign up with ACTION
Jan MLWY Committee Meeting (teleconf)
Mar Equipment Assessment Complete
Apr MLWY Committee Meeting – 1st data review
June Educational Assessment Complete
June Equipment placement Begins
This is a brief overview of the timeline our

14. Impact – Data Matters!
Data drives improvement. The only way to focus our efforts as a “System of Care”, is to first identify what is working and apply it to areas that need improvement. The areas that require improvement will see rapid results through this collaborative effort. Data will not only drive our protocol sets, but also our education. Once the major components are honed in our system, we can start the think tanks of our experts (you) on ways to make our system even better! We are making the mold for frontier emergency medicine Systems of Care. No other state / region that is defined as “Frontier” has a system of this magnitude in place.

15. Hospitals to Submit Data via ACTION Registry®-GWTG™
Enroll in ACTION Registry-GWTG
Complete an ACC/AHA Data Release Consent Form and to
Data submission = Quarterly
Submission Deadline = 60 days after end of the quarter
Q1- Jan, Feb, March
Q2- April, May, June
Q3- July, Aug, Sept
Q4- Oct, Nov, Dec

16. EMS Data Options
Certain data elements captured in ACTION-Registry GWTG upcoming v2.3 due out in 2014
EMS agency #
EMS run #
EMS dispatch date/time
EMS leaving scene date/time
Cath lab activation date/time
FMC date/time
With this type of information collected and analyzed, EMS agencies can yield impressive results.

17. D2B Numbers Include
From the time of arrival at the PCI facility to the time of reperfusion
Patients who present by POV to a PCI Facility
From the time of arrival at the PCI facility to the time of perfusion
Patients who present by EMS to a PCI Facility
Patients who are Transferred from a Referral Facility to a PCI Facility
When you hear door to balloon, keep in mind that the clock for the D2B times starts ticking at the door of the PCI facility. No matter where the patient initially presents, whether it is at a referral center, with EMS or directly to the Pci facility, the D2B clock does not start until the patient hits the door of the hospital where the intervention will take place. 17

18. D2B Numbers DO NOT Include
Best Practices Outside Doors of PCI facility
First ECG <10 Minutes
EARLY Notification of STEMI to ED Personnel
EMS to PCI to Reperfusion
Facilitated STEMI Care Plan
Easy Button Transfer System
POV to Referral Facility to Reperfusion
Allow EMS units to transport outside County lines
Implement By-Pass Protocols
Consider and plan for alternative transport to PCI facility
EMS to Referral Facility to Reperfusion
So D2B does not include the time the patient is in the back of the ambulance, it does not include the time at a referral hospital and enroute to the PCI facility. However, the heart’s timer begins at the initial onset of signs and symptoms added to the time in the back of the ambulance added to the time at the referral facility added to the transport time added to the time at the PCI facility. 18

19. 60min 120min 90 minutes The ULTIMATE GOAL
Time of first medical contact
EMS arrival on scene (FMC-PCI)
Patient arrival to hospital (D2B) TO
Balloon Inflation
90 minutes
120min
Remember, the goal is to get the patient to balloon inflation within 90 minutes of 1st medical contact.

20. Examples of System of Care Improvements:
Ottawa Canada had 1,573 cardiac patients between 2004 and 2009.
Their ED-PCI (D2B) times were averaging 122 minutes.
After the implementation of their System they were turning in EMS to Balloon (E2B) times 67 min.
-Keep in mind, EMS to Balloon time includes the time EMS arrived on scene to PCI balloon inflation.
The best way to make these types of improvements is through accurate data collection, education and protocol development.
A rural system that included 19 hospitals in Pennsylvania saw 687 STEMI patients between 2005 and 2007.
Their D2B times dropped from 189 minutes to 88 minutes.

21. STEMI Key Outcome Metrics 1
Q4 2010
Q1 2011
Q2 2011
Q3 2011
Q4 2011
Q1 2012
Q2 2012
Trend Lines
Trend* (+ is good)
SOAR
195
181
173
190
162
180 8%
D2B 74 77 65 70 68 64 67 9%
FMC2B
133
105 83 88 93 82 86
34%
E2B 72 76 69 73 0%
Cath Lab 21 19 20 5%
Total EMS Time -
29.5
30.5 30 29
28.5 2%
D2B Minutes saved with EMS CCL Activation 5 9 10 13 23 16 18
260%
Median EMS Onscene Time 17 15 6% Q4
‘10 Q1
‘11 Q2
‘11
This is the type of information that can be presented with the accurate data capture. An option that will be open for MLWY with this type of information is to have our accomplishments published!!!

22. Common Protocol Sets
We will create common protocol sets which be developed by a subcommittee and then voted, on and approved by the Stakeholder voting body.

23. American Heart Association MLWY Staff Helmsley Charitable Trust
AHA
Volunteer
Co-Chair Board
University of Wyoming
UT Health Science
Center Houston
MLWY Stakeholder Committee
(All EMS & Hospitals)
This is how Mission Lifeline Wyoming is structured. We have partnered with UTHSCH, UW for our data collection. Our Stakeholder Committee represents the voting members from the participating hospitals and EMS agencies that meet to vote on the approved recommendations brought forth from the 3 subcommittees seen at the bottom. We also have a Volunteer Advisory Board that gathers experts from across the country to give feedback and recommendations as to how we can improve our STEMI / SCA care and avoid any roadblocks they have faced in their markets.
Conference Planning
and Education
Subcommittee
(CPE)
Protocols
and Quality Improvement
Subcommittee
(PQI)
Equipment Advisory
Subcommittee
(EQUP) 23

24. Gift Acknowledgment
Mission: Lifeline Wyoming would not be possible without the generous multi-million dollar founding grant from the Leona M. and Harry B. Helmsley Charitable Trust

25. Thank You! 25