1. Can STEMI patients Transferred for Primary PCI Receive Treatment within 90 Minutes in a Rural Setting? C Randolph Hubbard, James C Blankenship, Marie Sledgen, Kimberly A Skelding, Thomas D Scott, Peter B Berger, Michael A Donegan, G Craig Wood, Frank J Menapace

2. “Heart-Attack-on-a-Plate” “Double Heart Attack Fries” “Crispy Crème Heart Attack”

3. Heart Attack Grill www.heartattackgrill.com “Home of the Triple Bypass Burger” and “Flatliner Fries” Arizona

4. Background National Registry for Myocardial Infarction --15% of transferred patients had D2B < 120 minutes -- D2B for transferred patients transferred to rural teaching hospital were 73 minutes slower than their urban counterparts Henry et al and Ting et al: D2B for transferred STEMI patients = 95 – 105 minutes

5. Hypothesis A rapid triage/transfer/ treatment protocol can provide primary PCI in less than 90 minutes for STEMI patients presenting to rural community hospitals.

6. Methods Geisinger Medical Center 437-bed tertiary care hospital in rural central PA. Serves 37 counties, 2.4 million people. Lifeflight: 5 helicopters operated by GHS -- Flies for 98% of all requests for transports. --14 referring hospitals within 25 minutes flight PCI Program -- 4 interventionists, 1000 PCI/year --GMC provided direct PCI for STEMI since 1995 -- 3 of 4 docs lives within 7 minutes

7. Methods January 1, 2005: Level 1 Heart Attack program started -- One call dispatches helicopter -- GMC ED doc pages PCI doc who calls lab staff -- Lab staff meets patient at the helipad doors

8. Database started July 1, 2004 with data to 1/1/04 Prospectively recorded milestones -Presentation to the community hospital -EKG time -Helicopter Dispatch -Helicopter arrival and departure -Arrival at GMC, arrival at Cath Lab -Wire crossing, device activation Visits and protocols to referring hospitals

10. Blue = 30 miles- 15 min flight time (each way) Red= 60 miles- 23 min flight time (each way)

11. Jan 1 2006 Level 1 Nurse Coordinator hired Report cards developed and distributed Quarterly meetings for all members of network

12. Jan 1 2007 ED doc directly activates cath lab Group page broadcast simultaneously

13. Results Patients Presenting Directly to GMC 2004 (n = 36) 2005 (n = 33) 2006 (n = 61) 2007 (n = 34) D2B (Minutes) 110766042

14. Results Patients Transferred to GMC 2004 (n = 110) 2005 (n = 134) 2006 (n = 143) 2007 (n = 63) D2B (Minutes) 18911310596

15. Results Patients Transferred to GMC HospitalD2BFlight Time D2B – Flight Time A83677 B83677 C85778 D941282 E1162591 Others105--

16. Results Jan – March 2007 % transferred patients with D2B < 90: 52% % transferred patients with D2B < 120: 74 %

17. Conclusions D2B < 120 minutes can be frequently achieved D2B < 90 minutes can be frequently achieved by some referring hospitals

18. Limitations GMC experience may not be generalizeable -- GMC owns helicopter service -- Closed cath lab -- Interventionists live close by Used door-to-wire until 2007 Presentation times hard to ascertain from records

19. Future Improvements Pre-hospital 12 lead EKGs

20. One Seamless Network for Pennsylvania