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Model Heart Attack Systems of Care RACE / North Carolina

James G. Jollis, M.D. Co-Director, RACE. Model Heart Attack Systems of Care RACE / North Carolina. RACE Reperfusion in AMI in Carolina Emergency departments. North Carolina RACE Pilot Design and lessons RACE Design and lessons. North Carolina. Population 8,541,221 11 th

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Model Heart Attack Systems of Care RACE / North Carolina

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  1. James G. Jollis, M.D. Co-Director, RACE Model Heart AttackSystems of CareRACE / North Carolina

  2. RACEReperfusion in AMI in Carolina Emergency departments • North Carolina • RACE Pilot • Design and lessons • RACE • Design and lessons

  3. North Carolina • Population 8,541,221 11th • Size 48,711 square miles 29th • 14 PCI hospitals, ~100 non-PCI hospitals • Relative size • Connecticut and Massachusetts combined • 4 times area, same population • Minnesota • ½ area, 2 times population

  4. North Carolina EMS Milestones 1910 1st air ambulance built in NC 1917 Earliest air ambulance rescue service Outer Banks to Norfolk hospitals

  5. North Carolina EMS Milestones 1968 One of the 1st Paramedic training programs in U.S. Haywood County, North Carolina

  6. North Carolina EMS Milestones 1968 Dr. Ralph Feichter, Waynesville internist • Rescue Squad Volunteers intensive training in cardiac pathophysiology, electrocardiography, arrhythmia recognition, pharmacology (cardio-active drugs) and CPR. • 2 mobile intensive care vehicles

  7. North Carolina EMS Milestones 2003-2006 RACE Reperfusion in AMI in Carolina Emergency Departments

  8. RACEReperfusion in AMI in Carolina Emergency departments • North Carolina • RACE Pilot • Design and lessons • RACE • Design and lessons

  9. RACE pilot 2003 • Improve AMI care at the point of greatest mortality / potential benefit • Increase the rate of reperfusion • Increase the speed of reperfusion

  10. AMI ReperfusionHow are we doing? NRMI 2 NRMI 3 NRMI 4 NRMI 5 47 39% IV Lytic Patients, % 23% PPCI 6.9 Immediate CABG - Range 0.9 % - 1.7 % Year of Discharge

  11. AMI ReperfusionHow are we doing? NRMI 2 NRMI 3 NRMI 4 NRMI 5 None 37% 47 39% IV Lytic Patients, % 23% PPCI 6.9 Immediate CABG - Range 0.9 % - 1.7 % Year of Discharge

  12. AMI ReperfusionHow are we doing? - Age NRMI 2 NRMI 3 NRMI 4 NRMI 5 58.8 53% > 65 Yrs Patients, % 30.9 23% ≤ 65 Yrs Year of Discharge

  13. RACE pilot 2003

  14. 5 local EDs within 40 miles 40 mile radius

  15. Transfer for Primary PCI: Systematic Approach NEW: 100-120 min OLD: >180 min Referring MD Referring MD Fax ECG Fax ECG Call 1-866-MI-2-DUKE Call Duke ED, CCU Fellow, or CAD staff Find best transport CCU Fellow, Attending, Life Flight CCU Attending ICC Fellow ICC Attending ICC Fellow, cath team ICC Attending Cath Team Primary PCI Primary PCI

  16. Direct Activation of Duke Cath Lab based on Pre-hospital ECG by Durham EMS(preliminary data) Population n Door-to-balloon Time Historical 15 104 (75, 131) EMS not using hotline 12 89 (78,100) EMS using hotline 20 58 (54,71) David Strauss 2005

  17. RACE pilot 2003 Lessons from RACE pilot 1) Fix your own primary PCI system first 2) Data are exceedingly difficult to collect without funding or government or payer mandate • Issues include HIPAA, IRB, fear of release, OIG opinion that PRO hospital data are protected, resources

  18. RACEReperfusion in AMI in Carolina Emergency departments • North Carolina • RACE Pilot • Design and lessons • RACE • Design and lessons

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

  20. RACEReperfusion in AMI in North Carolina Emergency Departments • AMI Guideline based • PCI or Lytics • Support “best available therapy” according to resources / local conditions

  21. RACEPartners

  22. RACEOrganization • Funded by BCBS of NC Foundation, Genentech, Participating hospitals • Quality improvement project for state ACC • Independent oversight board • Leaders in ACC (Douglas), acute MI care (O’Neill, Califf, Brodie), emergency medicine (Mears), BC/BS (Harris). • Steering committee • Participating physicians and hospitals • Coordination • Mayme Lou Roettig, Director; 5 Regional Coordinators • ~70 hospitals (10 PCI, 60 no-PCI)

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

  24. RACEData • PCI hospitals – NRMI • Non PCI hospitals • Consecutive chart review • Rate of reperfusion • Time of reperfusion

  25. RACEManual • Optimal system specifications by point of care • EMS • ED • Transfer • Receiving hospital • Cath. Lab • Other system issues – payers, regulations 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 January 2006

  26. RACEInterventions • EMS • In the field ECG • Regional ECG training courses • Securing funding for ECG equipment

  27. RACEInterventions • PCI hospital • - Map out process • - ED physician can make decision about PCI without the need for consultation / confirmation • - Single contact number • - Single interventionalist on call for system • - Accept to cath. lab without bed availability • - Streamline registration process • - NRMI in place

  28. RACEInterventions

  29. RACEAdditional lessons

  30. RACEAdditional lessons • Requires “donated” efforts of 100’s of physicians, nurses, administrators, EMTs, public officials, professional organizations • Chris Granger, Peter Berger, Magnus Ohman, Greg Mears, Sid Smith ….

  31. RACEAdditional lessons • Maintain current referral lines • Physician leadership in ED, Cardiology, and administration

  32. RACEAdditional lessons • Regional structure guides “politics” • - 3 PCI hospitals / 3 Cardiology groups • - 1 PCI hospital / 6 Cardiology groups • - 1 PCI hospital / 1 Cardiology group • - Non-PCI hospital • - Network spoke vs. independent • - Academic hospitals with NIH ranking as primary focus

  33. RACEAdditional lessons • Hospital administration / State legislature buy in • Smaller hospitals • All hospitals should treat AMI • PCI hospitals • All hospitals at the table • Establish single contact number and system for rapid PCI before contacting regional hospitals

  34. RACEAdditional lessons • Data – pre and post intervention • Quality assurance project • No protected health information “there is a reasonable basis to believe the information can be used to identify the individual ” • IRB process potentially one of the greatest systematic barriers to improving care

  35. RACEAdditional lessons • ED physicians “control” much of STEMI care and want asingle regimen.

  36. RACEAdditional lessons What Would Trauma Do?

  37. RACEAdditional lessons Heart disease 700,000 • Myocardial infarction 200,000 Accidents 100,000 • MVA 60,000 3 times as many die from AMI than from trauma National Center for Health Statistics 2005

  38. What Would Trauma Do“Golden hour” • Accept patient regardless of bed availability • Dummy registration • Code trauma • Priority • Everyone knows their role • Single trauma physician on call • Single phone call activation • EMS transport priority • 24/7 hospital capabilities • Regionalized system

  39. 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. Record calls and playback for QI 4. Provide standardized feedback reports to each ED 3. Prehospital ECGs for all CP patients 2. "Certify" all EMTs to read ST elevation on ECGs, call from ambulance to activate cath lab 1. Create EMS, ED, cardiology team with committed leadership

  40. North Carolina • Demographics • EMS history • RACE pilot • Goal – increase reperfusion – save lives • Duke system • Lessons • Fix your own system first • Data exceedingly challenging to collect without funding, legal or payer mandate • RACE • Structure • Timeline • Intervention • Examples • Flow chart • Telephone call • RACE manual • Additional lessons • Top 10 interventions

  41. RACEInterventions • PCI hospital • Single contact number • ED physician makes decision • 2 methods of transport • Reperfuse with fastest / safest approach

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