Massachusetts STEMI Care by wuzhenguang

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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.
9/28/2012                                                                               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
90%
80%
70%
60%
50%
40%
30%
20%
10%
 0%
      Q3 2009          Q4 2009             Q1 2010             Q2 2010




                PCI               Medically Managed                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)
• Third Service Boston   EMS
• 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
                                        Median Times (in minutes) from
Median number of minutes                       Door to Balloon


                           100     91
                                          83.5
                           80                    73
                                                        66       63   58     54    53.5
                           60
                           40
                           20
                            0
                                   2003 2004 2005 2006 2007 2008 2009 2010
                                 (Q3/Q4) (n=42) (n=54) (n=49) (n=56) (n=35) (n=41) (n=38)
                                  (n=28)
                                                          Year
                                        Trends in elapsed door-to-balloon times,
                                              Post PoE (since July 2003)

                      100%


                                                                      89%               90%      92%
                      80%
% within 90 minutes




                                                         78%                   77%
                                                72%
                      60%
                                       64%

                      40%     46%

                      20%


                       0%
                               2003     2004     2005     2006         2007     2008     2009     2010
                             (Q3+Q4)   (n=42)   (n=54)   (n=49)       (n=56)   (n=35)   (n=41)   (n=38)
                              (n=28)
                                                               Year
                                        Trends in elapsed door-to-balloon times,
                                                stratified by day of week


                      100%



                      80%
% within 90 minutes




                      60%



                      40%
                                                                                       Mon-Fri
                                                                                       Sat/Sun
                      20%



                       0%
                               2003    2004     2005      2006          2007   2008   2009       2010
                             (Q3+Q4)                             Year
                                         Trends in elapsed door-to-balloon times,
                                                 stratified by time of day

                      100%



                      80%
% within 90 minutes




                      60%



                      40%

                                                                                      Night Arrival
                                                                                      Day Arrival
                      20%



                       0%
                               2003    2004     2005      2006          2007   2008   2009       2010
                             (Q3+Q4)
                                                                 Year
E2B
                                           Median Times (in minutes) from
Median number of minutes                      EMS arrival to Balloon


                           140     120
                           120            111
                                                 103
                                                        93      92    90     87
                           100
                                                                                    77
                           80
                           60
                           40
                           20
                            0
                                   2003 2004 2005 2006 2007 2008 2009 2010
                                 (Q3/Q4) (n=42) (n=54) (n=49) (n=56) (n=35) (n=41) (n=38)
                                  (n=28)
                                                             Year
• 2008 Web Based Continuous QI system
  Automated
         Boston’s STEMI QI
1. Clinical Care Benchmarks
 – IV, O2, ASA, 12L EKG
 – Prehospital Notification
2. 12L EKG Interpretation
 – Medical Director Agreement
3. 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
Individual Case review
Hospital Data Entry

               Prehospital
               Entry note
                 given?




                       If Cardiac Cath,
                         balloon time
                       entered. Able to
                        calculate D2B
         33           time or E2B time.
EMS Feedback Report




                Patient outcome
                  available in
               EMS cQI system
               immediately after
         34
              hospital enters data
Mass STEMI care
9/28/2012                                                           38
            Taken from Quarter 3 2011 ACTION Registry – GWTG 2011
Where is STEMI care headed?
                 Systems of Care


     NEW
                           Each community should develop a STEMI
Recommendation
                           system of care following the standards
                           developed for Mission Lifeline (AHA)
 I IIa IIb III             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 Coverage
     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
9/28/2012   Taken from Quarter 3 2011 ACTION Registry – GWTG 2011   45
              EMS
Pre hospital 12 lead EKG’s :
      Equip & train all medics
      Read
      Computer interpretation
      Transmission
Wireless Transmission of 12-Lead ECG's
        From Ambulance to ER

              LifeNet
                   EMS
• Determine hospital destination for STEMI
  and cardiac arrest patients (resuscitation
  centers)
  -may entail bypassing Non PCI hospitals-

• Cath lab activated on EMS call

• Direct to Cath Lab
              EMS


• New field therapies (ex cooling
  for arrest )
              EMS



• More Rapid Interfacility
 transport
                      EMS
Electronic records:

            NEMSIS

            Better QI –systemwide and individual
                       feedack
             PCI centers
• Responsible for:
      -STEMI system integration including
       early return of patient to local
       facility
      -Data management for system
          PCI centers


• Share bundled PCI payment with
  non PCI hospital
PCI Centers-eventually (several
          years)…

   Urban PCI centers’ #’s shrink as volume
 criteria enforced and global health
 budgets adopted-

 fee for service sees STEMI as “revenue”

 global budget-sees STEMI care as “cost”
• PCI centers/population

   Boston         6          1M
   NYC           22           8M
   Dallas County 13        2.2 M
   Vancouver      3          3M
   Nova Scotia     1         1M
PCI centers with wide geographic draw:
      - prehospital as well as non PCI
      hospital lytics
      -air as well as ground ambulances
   Boston MedFlight
• Licensed as a critical care service
      • 501(c)3 public charity
            • CAMTS




                                             CCT
                                           CCT RN,
                                            CCT
                                          paramedic,
                                        plus driver/pilot


                                          ALS Team
                                        2 paramedics




                                         BLS Team
                                           2 EMT’s
           Non PCI centers
• Rapid Interfacility Transport

• Share in STEMI bundled payment
Systems of STEMI care cover all of
              US
      NYS Regs PCI hospitals
         November 2009
• Must have a community outreach program
       NY State Regs –EMS
• EMS should transport all STEMI’s to a PCI
  hospital bypassing non PCI hospitals if
  necessary
                 NYS Regs
• PCI centers must maintain minimal annual
  volumes:

    institution - 150 PCI/yr, at least 36 of
              which are primary

    interventionalist - >3/institution;
      minimum of 75 PCI /yr/interventionalist, at
      least 11 of which must be primary
            NY State Regs
• CON for new PCI hospitals:
     -evidence that existing PCI centers
  cannot meet patient needs due to such
  items as capacity ,geography and or EMS
  limitations
     -meet volume criteria
     -not jeopardize ability of existing PCI
  centers to meet volume criteria
     -plan for community outreach
    NYS Regs - PCI hospitals
• Integrate EMS and hospital QI data

• Collaborate with EMS in their QI to review
  prehospital care including review of
  specific cases

								
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