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R eperfusion in A MI in C arolina E mergency Departments

RACE: Reperfusion of acute myocardial infarction in North Carolina emergency departments Christopher Granger, MD Director, Cardiac Care Unit Duke University Medical Center Durham, NC. R eperfusion in A MI in C arolina E mergency Departments.

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R eperfusion in A MI in C arolina E mergency Departments

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  1. RACE: Reperfusion of acute myocardial infarction in North Carolina emergency departmentsChristopher Granger, MDDirector, Cardiac Care Unit Duke University Medical CenterDurham, NC

  2. Reperfusion in AMI in Carolina Emergency Departments A Systems Approach To Improve Survival of Patients with Myocardial Infarction In North Carolina Through Improved Application of Reperfusion Therapy

  3. Importance of TimeMortality reduction versus treatment delay 35 day mortality 1.6 lives per 1000 lost per hour delay to randomization In first hour, up to 40 lives per 1000 lost per hour of delay Absolute benefit per 1000 patients treated Treatment delay (hours) Boersma. Lancet 1996; 348:771-5.

  4. Door-to-Balloon & 30-d Mortality P=0.005 30-day Mortality Door-Balloon Times (minutes) Hudson ACC 2007

  5. Optimizing the System • Understand what the System is: • Begins with the patient • Prehospital environment • Emergency Department (both non-PCI & PCI) • Cardiology interface • Catheterization laboratory for PCI, or fibrinolytic drug administration

  6. What would Trauma do?

  7. Can patients be transferred by helicopter for primary PCI with 1st door to balloon of <100 minutes?

  8. Standardized protocol Zone I (60 miles) Primary PCI Goal of door to balloon < 90 minutes (actual = 96 minutes in first 232 patients) Zone II (60-120 miles) Facilitated PCI(1/2 dose TNK plus PCI) Goal door to balloon times of 90-120 minutes (actual = 116 minutes in first 82 patients)

  9. Can Systems be Developed to Safely Bypass non-PCI centers?

  10. STEMI System BOSTON • In the field ECG • Diversion of STEMI to closest PCI hospital • Hospitals will never be on diversion for ST-elevation MI (similar to trauma center plan) • Each hospital will perform a minimum of 36 primary PCI or rescue PCI procedures / year • PCI will be performed within 120 minutes of hospital arrival (ie, door-to-balloon time of 120 minutes) in 75% of “ideal” patients

  11. The ProblemNRMI-5: North Carolina, July 2003-June 2004 NC Nation Guidelines N 2,738 79,927 % eligible treated 81% 80% Door-balloon 101 min 100 min <90 min 11PM to 7AM 107 min Weekend 105 min Transfer 1st door – balloon 191 min 165 min <90 min 1st d-b <90 min 0.8% 5.5% 100%

  12. Transfer Times and Delay: STEMI Patients Transferred to Another Hospital and Received Primary PCI NRMI 2 NRMI 3 NRMI 4 NRMI 5 4.0 Door to Balloon 2.8 2.6 Hours (Median) Door to Door 1.8 Year of Discharge

  13. 36% Transferred in APEX: 80 minutes 1st to 2nd door “transfer time,” but only 45 minutes longer door-to-balloon No transfer 1.7 0.7 0.5 Transfer 1.6 1.4 0.3 0.4 0 1 2 3 4 Symptom-admission Admission-randomization 1st door - 2nd door Randomization-PCI Widimsky ACC 2007

  14. RACE Objectives Improve the public health of North Carolina residents by: Reducing the eligible STEMI population untreated with reperfusion by 20% (i.e., 20% untreated to 16% untreated). Increasing the speed of reperfusion toward national benchmarks of • 90 minutes door to balloon for Primary PCI and • 30 minutes for fibrinolytic therapy. Establishing regional systems of acute MI care with emergency departments throughout North Carolina.

  15. AMI Guidelines 2004 Guidelines available on the Web site: www.acc.org JACC2004;44:686.

  16. BohleHoekstra/Applegate Maddox/HathawayHunt/Horrine Babb/Shiber Aluko/FletcherValerie/WatlingWilson/Garvey Granger/Jollis/StouferWilson/Pulsipher/Beaton/Mears Reperfusion of AMI in Carolina Emergency Departments (RACE) Winston-Salem Durham/Chapel Hill/Greensboro Asheville Charlotte Greenville 10 PCI Centers 58 non-PCI Centers

  17. Henderson to Durham: 40 mile drive Interventional cardiologist home to Duke 20 minutes 40 mile radius

  18. 11:00 PM Local EMS 1st door to balloon (BMS) 84 min

  19. RACEReperfusion in AMI in North Carolina Emergency Departments OBJECTIVES • Regional approach to overcoming systematic barriers 1) Increase reperfusion rate 2) Increase speed of reperfusion CQI… RACE Phase 3 Organize regions Baseline data Intervention Post data 2 years

  20. Presentation • Only 12% of patients presenting did NOT have CP upon presentation. • Median age 63 yrs; 33% female • Door to ECG Median 11 min (5,25)

  21. Pre-Intervention DataHospital Arrival Mode n=515

  22. RAPID EKG CRITERIADoor to decision 10 minutes 30 YEARS OLD with suspiciousCHEST PAIN (EXCLUDING OBVIOUS TRAUMA) 50 YEARS OLD with: Syncope Weakness Rapid Heart Beat / Palpitations Difficulty Breathing / Shortness of Breath Graff L, Palmer AC, LaMonica P, Wolf S. Annals Emerg Med. December 2000;36:554-560.

  23. Transfer for Consideration of Primary PCI • 192/519 (37%) transferred for consideration for PPCI • Time from non-PCI ED arrival to non-PCI ED departure median 89 minutes • State NRMI 5 2005 First door to balloon inflation in transfer-in Patients n=376 median 156 minutes (2:05,3:40) Only 2.9% of NC transfer-in patients make balloon up in < 90 minutes!

  24. Thrombolytics in Non-PCI Centers in North Carolina • 45% received lytics (n=235/519) • Median Door to Lytic 35 min (25,53) • 34% patients received lytics in < 30 minutes, ACC/AHA Guideline Goal

  25. D2B:An Alliance for QualityA Guidelines Applied in Practice (GAP) Program JACC 2006;48:1911-12.

  26. D2B Goal To achieve a door-to-balloon time of </= 90 minutes for at least 75% of non-transfer primary PCI patients with ST-segment elevation myocardial infarction in all participating hospitals performing primary PCI. As of March 2007, over 800 centers signed up as participants.

  27. Median Door-to-Balloon Times among Study Hospitals (n=365) Mean (of medians) = 100 ± 24 minutes Bradley E et al. N Engl J Med 2006;355:2308-2320

  28. Strategies and Door-to-Balloon Time Saved • ED physicians activate the cath lab (8.2 minutes) • Single call to a central page operator activate the lab (13.8 minutes) • ED activate the cath lab while the patient is en route to the hospital (15.4 minutes) • Expecting staff to arrive in the cath lab within 20 minutes after being paged (vs. >30 minutes) (19.3 minutes) • Attending cardiologist always on site (14.6 minutes) • Having staff in the ED and the cath lab use real-time data feedback (8.6 minutes) Bradley N Engl J Med 2006;355:2308-2320

  29. Door-to-Balloon Time According to the Number of Key Strategies Used Bradley E et al. N Engl J Med 2006;355:2308-2320

  30. Direct Activation of Duke Cath Lab Based on Pre-Hospital ECG by Durham EMS Population n Door-to-balloon Time Historical 15 112 (80, 140) EMS not using hotline 15 92 (78,110) EMS using hotline 20 58 (54,71) Strauss J Electrocard 2007

  31. RACE Reperfusion in Acute myocardial infarction in Carolina Emergency Departments Operations Manual Granger CB, Jollis JG, et al. For the North Carolina RACE steering committee Version 1.2 March 2005 RACE Manualhttp://www.nccacc.org/race.html Optimal system specifications for each component of AMI care • EMS (prehosp ECG, transport) • ED (guideline-based algorithms, training, feedback) • Transfer (single contact, fastest option, streamline,automatic cath lab activation) • Receiving hospital (“hotline” approach) • Cath lab (automatic activation) • Other system issues – communication, feedback, interdisciplinary team, payers, regulations

  32. Top Ten List 10. Use local ambulance to transport pts (within ~50 miles) 9. Keep patient on local ambulance stretcher 8. Give heparin bolus (70 U/kg) and no IV infusion 7. Establish protocol for lytics vs PCI for each ED 6. Establish single call number to PCI centers that "automatically" activates cath lab 5. Provide standardized feedback reports 4. System for rapid triage of walk-ins, rapid ECGs 3. Prehospital ECGs for all CP pts (and ED use them!) 2. "Certify" all EMTs/paramedics to read ST  on ECGs, immediately activate reperfusion (lytics or cath lab) 1. Create EMS, ED, cardiology team with committed leadership

  33. Emergency Cardiovascular Care 2007: Building Regional Integrated STEMI Systems for Reperfusion ACC Sponsored Meeting with goal to teach and enable teams to establish effective regional STEMI reperfusion systems June 1-2, 2007, Washington, DC

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