1. Landscape of STEMI Care Improvement
Efforts in Texas
H. Vernon Anderson, MD, Jaime McCarthy,MD and
Richard Smalling, MD, PhD
GETAC CCC November 2014
Texas STEMI Care Organizations

2. Texas: Department of State Health Services (DSHS)
11 Health Service Regions
22 Regional Advisory Councils (RACs)

3. What is a RAC? 
each RAC has the same objectives – to reduce the incidence of trauma through education, data collection, data analysis and performance improvement.
Regional Advisory Councils (RACs) are the administrative bodies responsible for trauma system oversight within the bounds of a given Trauma Service Area in Texas.  Each of the 22 RACs is tasked with developing, implementing, and monitoring a regional emergency medical service trauma system plan. Generally, RAC stakeholders are comprised of healthcare entities and other concerned citizens with an interest in improving and organizing trauma care.   As such, not every Regional Advisory Council is structured the same.  However, each RAC has the same objectives – to reduce the incidence of trauma through education, data collection, data analysis and performance improvement. Typically, this is accomplished via the provision of educational programs and performance improvement efforts designed to offer every provider guidance and motive to reduce the incidence of trauma, as well as improve outcomes of trauma patients.

4. Clinically enriched data sources
National registries –
NCDR: ACTION-GWTG
EMS: NEMESIS
Issue: ACTION-GWTG is hospital-based, and lacks many important elements of the pre-hospital care, which could be contained in EMS databases.

5. Elements of both EMS and hospitals
Data flow
Hospital A
Hospital B
Registry • • •
Elements of both EMS and hospitals
EMS A
EMS B
Registry • • •

6. STEMI–Door to Balloon and Door to Needle Times Cumulative 12 Month Data
Note: If patients are not transported to a SEMI receiving center initially, their chances of having timely reperfusion of their infarct related artery are small and their chances of surviving and avoiding heart failure are diminished
DTB = 1st Door to Balloon for Primary PCI
DTN = Door to Needle for Lytics
ACTION Registry-GWTG DATA:
July 01, June 30, 2014

7. Texas STEMI Care Organizations
Impact of Improved Door to Balloon Times on STEMI Patient Mortality in the US
Menees et al, NEJM, 2013
Texas STEMI Care Organizations

8. Clinical Problems in STEMI Care Persist!
Despite significant improvements in STEMI care organization primarily in metropolitan RACs and some less populous regions (Corpus, Waco and El Paso), STEMI mortality and heart failure incidence remain unacceptably high.
Pre-hospital/pre-transfer fibrinolytics are rarely used despite their recommendation in the guidelines for patients who cannot receive primary PCI within 60 minutes of first medical contact.
Texas STEMI Care Organizations

10. NCDR ACTION Registry GWTG Mission: Lifeline Regional STEMI Reports
7 Texas regions utilizing the AHA Mission: Lifeline STEMI System Reports: BorderRAC- El Paso CATRAC- Austin CBRAC- Corpus Christi CTRAC- Temple NCTRAC- DFW SETRAC- Houston STRAC- San Antonio Total of 93 Texas Hospitals included in a regional report
Texas STEMI Care Organizations

19. 11 Years of Hospital & EMS STEMI data collaboration - Houston

21. Summary STEMI Care in Texas: Data Issues
It appears that door to balloon time has been reduced as much as possible and the next major effort should be the reduction of pre-hospital ischemic time.
Pre-hospital and Pre-transfer data capture is not mature or reliable.
A parallel data capture and analysis structure focusing on large, diverse (rural/urban) STEMI systems/RACs affiliated with the CCTS data repositories and communicates with DSHS may provide a key resource
Such a system could provide valuable insight into means for improvement of pre-hospital/pre-transfer STEMI Care
Texas STEMI Care Organizations

22. A Potential New Approach to STEMI Data Management in Texas
DSHS-TCCVDS Activity
Primary focus:
Hospital Phase and
Overall Outcomes
Input: Action and NCDR
Database
“Big Picture” Approach
Texas CCTS – GETAC
Activity
Primary focus:
Pre-Hospital, Pre-
Transfer STEMI Care
Input: RedCap STEMI
Database
“Granular” Approach
NCTTRAC (DFW)
UTSW CCTS
DSHS
Cardiovascular Disease and
Stroke Council
GETAC-CCC
STRAC (San Antonio)
UTSA CCTS
SETRAC (Houston)
UTHealth CCTS
Texas STEMI Care Organizations

23. Texas STEMI Care Organizations

24. Texas Heart Attack Coalition
A volunteer organization has been formed to attempt to bring all STEMI Care stakeholders together in order to craft STEMI Care legislation for the next biennium.
Organizations in the effort include:
THA, TMA, TACC, AHA, TCEP, TETAF
Interventional Cardiologists, STEMI Nurse Coordinators, EMS physicians, EMT/Paramedics
Cardiovascular/EMS Database Experts
Selected volunteer representatives from Texas Cardiovascular councils and committees
Texas STEMI Care Organizations

25. Texas STEMI Care Organizations
Summary
A critical mass of largely volunteer organizations and people are coming together to focus on STEMI care optimization in Texas
The goal will need to be to reduce the time from onset of symptoms to reperfusion therapy in order to reduce the time the heart attack artery is occluded.
It appears that door to balloon time has been reduced as much as possible and the next major effort should be the reduction of pre-hospital ischemic time.
Texas STEMI Care Organizations