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Massachusetts STEMI Care. Peter Moyer MD,MPH,FACEP Dallas June 4 ,2011. Who I am. Taught NYC medic classes 5-14 (1977 -84) Chair of BU Emergency Medicine 1984-2000 Medical Director Boston EMS, Fire and Police 2000-2010. Disclosures. NONE. STEMI Statistics.
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Massachusetts STEMI Care Peter Moyer MD,MPH,FACEP Dallas June 4 ,2011
Who I am • Taught NYC medic classes 5-14 (1977 -84) • Chair of BU Emergency Medicine 1984-2000 • Medical Director Boston EMS, Fire and Police 2000-2010
Disclosures NONE
STEMI Statistics Acute Coronary Syndrome (ACS) will strike 935,000 people a year in the United States An estimated 250,000 of those will be STEMIs Heart Disease and Stroke Statistic 2011 Update: A Report From the American Heart Association Statistics Committee and Stroke Statistics Subcommittee. Circulation 2011;123:e18-e209. 1/1/2020 5
Mission: Lifeline & Sudden Cardiac Arrest Statistics • 325,000 suffer from OOHCA • US survival rates are only 8.4% Why include SCA? • Experts estimate that up to 50% of OOHCA are STEMI’s • To develop systems of care to improve survival for OOHCA 7
STEMI Revascularization Strategy Trends MedicallyManaged PCI CABG ACTION Registry-GWTG DATA: July 1, 2009 – June 30, 2010
10 Years of STEMI System of Care in Boston • 1990’s: Paramedic EKG acquisition and interpretation • 2000:Boston EMS criticized in press for by- passing non PCI hospital with STEMI patient • 2001-2002: eventual agreement of medical community to take STEMI’s only to PCI centers (STEMI Point of Entry plan) • 2003: new STEMI POE begun
Boston’s PCI centers • PCI centers agreed to: -perform PCI 24/7/365 -maintain necessary institutional and individual interventionalist volumes -meet performance criteria: PCI rather than lysis >90% D2B < 120 then <90 min 75 % -submit data to a common data coordinating center
Initial Obstacles to STEMI plan -non PCI centers feared loss of revenue -PCI centers feared public airing of performance
Solutions • Shared revenues between PCI and non PCI hospitals • Blinded performance data (blind broken for failure to meet performance criteria)
Boston EMS Third Service Fire First Response .6 -1.2 Million pop 110k calls per year 75k transports per year 6 STEMI PCI Centers
Boston EMS 2 tiers: low paramedic #’s 75 (average intubations/medic/yr : 8.5) bigger BLS tier 275 give albuterol and nasal naloxone ,test sugar, dispatched to stroke
Pre hospital EKG-national EMS transported STEMI’s with and without pre hospital EKG: • D2B with pre hospital EKG: 79 min • D2B without pre hospital EKG: 91 min 5/14/11 AR GWTG
Pre Hospital EKG -Boston • Boston EMS paramedics read 12 leads and radio and transport to PCI hospital bypassing non PCI hospitals if necessary
Boston EMS • Divide 12 leads into: STEMI ,Possible STEMI and non STEMI
Boston EMS • Early: 12 lead Call to hospital Mention of STEMI in radio call
Boston’s STEMI QI • Clinical Care Benchmarks • IV, O2, ASA, 12L EKG • Prehospital Notification • 12L EKG Interpretation • Medical Director Agreement • Hospital Follow up • Agreement with 12L EKG evaluation • Cardiac Cath • Door to Balloon; EKG to Balloon Time
STEMI CARE Benchmarks Prehospital care meets clinical care benchmarks for STEMI patinet
Hospital Data Entry Prehospital Entry note given? If Cardiac Cath, balloon time entered. Able to calculate D2B time or E2B time. 33
EMS Feedback Report Patient outcome available in EMS cQI system immediately after hospital enters data 34
1/1/2020 38 Taken from Quarter 3 2011 ACTION Registry – GWTG 2011
IIa IIa IIa IIa IIb IIb IIb IIb III III III III I I I IIa IIa IIa IIa IIb IIb IIb IIb III III III III I I I IIa IIa IIa IIa IIb IIb IIb IIb III III III III I I I C NEW Recommendation Systems of Care Each community should develop a STEMI system of care following the standards developed for Mission Lifeline (AHA) including: • Ongoing multidisciplinary team meetings with EMS, non-PCI & PCI centers • A process for prehosp identification and activation • Destination protocols for PCI centers • Transfer protocols for non-PCI centers for appropriate patients ACC/AHA 2009 Joint STEMI/PCI Guidelines Focused Update JACC 2009
STEMI Systems of Care • Integration of Patients, EMS and non PCI centers into PCI Systems • Data driven with QI feedback from PCI center to ED’s and EMS • Certificate of Need (CON) and Accreditation
Patients • Increase Use of EMS • Decrease Symptom Onset to Balloon- Dallas/Caruth’s Symptom Onset to Arterial Reperfusion (SOAR) metric • Awareness of PCI centers
1/1/2020 Taken from Quarter 3 2011 ACTION Registry – GWTG 2011 45