NEBRASKA – STEMI CONFERENCE 2015 Dr. Matt Johnson …wcm/@mwa/documents/... · NEBRASKA – STEMI...

NEBRASKA – STEMI CONFERENCE 2015Dr. Matt Johnson and Dr. Doug Kosmicki

1©2013, American Heart Association

Dr. Matt Johnson

Putting the State STEMI Guidelines into Practice

Collaboration – Relationships

©2013, American Heart Association

Point Of Entry Protocol : GOAL

3

Less than 90-120 Minutes

Mission: Lifeline Nebraska Statewide STEMI Guideline

Why is a Statewide STEMI Guideline so Important?

-Standardized Guidelines in a System of Care ensure that all of our patients are getting the best possible care. “Where a patient lives should not determine if they live.”

-The next logical step in creating a Rural STEMI System in Nebraska. Bringing all of the resources that were made available under the Helmsley Grant together to ensure these resources work together to improve outcomes.

-A consistent message from all PCI centers in the state helps make the decision making process for the rural providers easier and faster.

Improving the System of Care for STEMI Patients

Why “Rural” Nebraska?

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• Nebraska still has vast rural areas with limited EMS services, and long transports to hospitals with Primary PCI capabilities.

• Mortality is still worse, the farther away you are from a cath lab that performs primary PCI.

• The Metro Areas, and other areas with good ALS EMS presence close to cathlabs, do not have as much need as some other rural areas.

• With limited funding, this project aims to improve care in the rural areas that have traditionally not had as much support or success with STEMI care.


Regional Systems of STEMI Care, Reperfusion Therapy, and Time-to-Treatment Goals

All communities should create and maintain a regional system of STEMI care that includes assessment and continuous quality improvement of EMS and hospital-based activities.

Performance can be facilitated by participating in programs such as Mission: Lifeline and the D2B Alliance.

I IIaIIbIII

Performance of a 12-lead ECG by EMS personnel at the site of FMC is recommended in patients with symptoms consistent with STEMI.

I IIaIIbIII

Publications to Support STEMI SystemDevelopment

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How is STEMI Defined?

• ST elevation at the J point in at least 2 contiguou s

leads of ≥2 mm (0.2 mV) in men or ≥1.5 mm (0.15 mV) in

women in leads V2–V3 and/or of ≥ 1 mm (0.1mV) in other

contiguous chest leads or the limb leads.

• New or presumably new LBBB at

presentation occurs infrequently, may interfere wit h

ST-elevation analysis, and should not be considered

diagnostic of acute myocardial infarction (MI) in i solation.

• ECG demonstrates evidence of ST depression suspect of a Posterior MI8

SYSTEM COMPLEXITY

5/3/2015 ©2010, American Heart Association 9

Walk In

Patients

EMS

Non PCI

Hospital

/ CAH

Interfacility

ALS - EMS

PCI

Center

Walk In

Patients

EMS

Cath

Lab


Reperfusion Therapy for Patients with STEMI

*Patients with cardiogenic shock or severe heart failure initially seen at a non–PCI-capable hospital should be transferred for cardiac catheterization and revascularization as soon as possible, irrespective of time delay from MI onset (Class I, LOE: B). †Angiography and revascularization should not be performed within the first 2 to 3 hours after administration of fibrinolytic therapy.


Barriers to Timely Reperfusion

• The patient– Failure to promptly recognize

symptoms– Hesitation to seek medical attention

• Time to transport– Mandated delivery to the closest

hospital, regardless of PCI capabilities– Long transport in rural areas

• Decision process on arrival– Clot-busting drugs vs. PCI– Off hours– Transfer to PCI facility

• Time to implement treatment strategy– Procedural factors– Team assembly



STEMI Accelerator Program Data…

• Presented at AHA Annual

Meeting

• Chicago, November 2014

12Granger, Jollis; Mission Lifeline STEMI Accelerator Project –Presented at: American Heart Association Scientific Sessions; November 19, 2014; Chicago, IL

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5/3/2015 14


STEMI Goal Times

• FMC to ECG acquisition < 10 minutes

• PCI capable hospital direct presentation, FMC-

PCI time < 90 minutes

• Non-PCI capable hospital presentation, Door In

Door Out <45 minutes

• Transfer for primary PCI only if FMC-PCI time <

120 minutes...

… Otherwise lytics within 30 minutes of arrival

time followed by urgent transfer

STEMI Continuum Relationships

Relationships

Recognition – Reperfusion

Real Time Data Collection

Reassessment – Refine process

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STEMI Recognition – Once identified it MUST trigger a clear response Downstream.

Rapid Recognition of STEMI on ECG will only improve the process “IF”

Recognition leads to a concrete action occurring do wnstream. (system of care)

Recognition allows early Reperfusion

…but it does not guarantee it.

A System of care is needed to

navigate the rapids and have a

Successful outcome for patients.17

Dr. Doug Kosmicki

M:L Guidelines - Utilizing them in your settings.

Disclosure Information


How Much Time do I Have?

First - things - First

Initial ECG within 10 minutes of First Medical Contact

Recommended benchmarks for reperfusion therapy:

� All eligible STEMI patients receiving a Reperfusion (PPCI or fibrinolysis) Therapy

� First Medical Contact (EMS non transfer) to Primary PCI < 90 minutes

� Fibrinolytic eligible STEMI patients with Door-to-Needle time < 30 minutes

� PPCI eligible patients transferred to a PCI receiving center with referring center Door

in- Door out (Length of Stay) < 30 min

� PPCI eligible patients receive a Referring Center ED + Pre-Hospital First Medical

Contact-to-PCI time < 120 minutes (including transport time)

� All STEMI patients without a contraindication receiving Aspirin prior to referring center

ED discharge


• Lack of 24/7 12 Lead ECG capability in the field

• ECG interpretation skills

• False positives

• Lack of protocols to allow rapid identification of a STEMI patient

• Corporate loyalty

• Lack of pre-hospital STEMI activation from the field

• Lack of Multidisciplinary Meetings

• Lack of data collection

• Terrain/Weather

• Interfacility Transport Team response

• ……………………………………..and so on and so on

Identified NE Gaps and Barriers



Mission Lifeline Obstacles you might encounter in im plementing your STEMI System of care

• Building something that did not exist at a state level and or at your local facility

• Misinformed or misunderstanding of the program and how it affects your facility

• Technical issues for EMS and hospitals

• Utilization by EMS of equipment if available

• Availability of ALS services is rural areas

• Limited resources in rural hospital including staffing, time for training and

equipment

• Consistent staffing and knowledge of guidelines and internal protocols

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Acute Coronary Syndrome (ACS) FACTS

• The actions of healthcare providers during the first several hours of

a heart attack determine the magnitude of any benefit from

treatment and intervention

• A system that works together efficiently is paramount in reducing

mortality and optimizing the benefit from any acute cardiac care

strategy


Mission: Lifeline Nebraska Statewide STEMI Guideline• Statewide STEMI Guidelines have been approved.

• The introduction letter signed by members of Interventional Cardiology Steering Committee representing 14 cardiology groups in the state.

• This sends a very powerful message on the need for standardized statewide guidelines and willingness to utilize best practice and evidence based recommendations.

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Signatures:

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Time is Muscle…So Time(s) Are Important!Page 1 – NE STEMI Guideline


NE STEMI Guideline - Page 1 - Continued

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NE STEMI Guideline – Page 2

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NE STEMI Guideline - Page 2 Continued

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NE STEMI Guideline - Page 3

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NE STEMI Guideline – Page 3 continued

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STEMI Recognition – Once identified it MUST trigger a clear response Downstream.

Rapid Recognition of STEMI on ECG will only improve the process “IF”

Recognition leads to a concrete action occurring do wnstream. (system of care)

Recognition allows early Reperfusion

…but it does not guarantee it.

A System of care is needed to

navigate the rapids and have a

Successful outcome for patients.33

NEBRASKA – STEMI CONFERENCE 2015 Dr. Matt Johnson …wcm/@mwa/documents/... · NEBRASKA – STEMI...

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