Anne M Gavic-Ott, MPA Director, Mission: Lifeline Chicago Metro

1. Anne M Gavic-Ott, MPADirector, Mission: Lifeline Chicago Metro

2. Current Landscape • 1.5 Million Myocardial Infarctions Annually • 400,000 STEMI Patients Annually • 80% Live within 1 hour of a PCI capable hospital American Hospital Association 2007.

3. Burden of Heart Disease in SD2007 • #1 Cause of Death • 1623 deaths (23.9%) • 4 of Top 10 Hospital Discharges • Ischemic Heart Disease 2041 • Heart Failure 1888 • Dysrhythmias 1757 • AMI 1654 7340

4. Spectrum of CAD ACUTE CORONARY SYNDROMES No ST elevation ST elevation Stable angina NSTEMI STEMI Unstable angina ~1 Million Discharges Per Year ~0.4 Million Discharges Per Year Figures reproduced with permission from Davies MJ. Heart. 2000;83:361-366. Rosamond W, et al. American Heart Association Statistics Committee and Stroke Statistics Committee. Heart Disease and Stroke Statistics 2008 Update [published online ahead of print December 17, 2007]. Circulation. doi:10.1161/CIRCULATIONAHA.107.187998.

5. Annual Admissions for Acute Coronary Syndromes (ACS) ~ 2.0 MM patients admittedto CCU or telemetry annually 400,000ST-segment elevation MI (STEMI) 1.6 millionNon-ST-segment elevation ACS

6. 2004 AHA/ACC Guidelines for the Management of Patients with ST-Elevation Myocardial Infarction A Report of the American College of Cardiology / American Heart Association Task Force on Practice Guidelines

7. Patient Education for Early Recognition and Response to STEMI Patients should understand their risk of STEMI and how to recognize symptoms of STEMI. Patients should understand the advisability of calling 9-1-1 if symptoms are unimproved or worsening after 5 minutes.

8. 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 B 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 Prehospital Issues Prehospital 12-lead ECG by ACLS Prehospital fibrinolysis Reperfusion “checklist” by ACLS providers that is relayed with the ECG to a predetermined medical control facility and/or receiving hospital

9. 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 B Prehospital Issues Prehospital destination protocols: Patients with STEMI who have contraindications to fibrinolytic therapy should be brought immediately or secondarily transferred promptly (primary-receiving hospital door-to-departure time less than 30 min.) to facilities capable of cardiac catheterization and rapid revascularization

10. I I I I I I IIa IIa IIa IIa IIa IIa IIa IIa IIb IIb IIb IIb IIb IIb IIb IIb III III III III III III III III I I I I I I IIa IIa IIa IIa IIa IIa IIa IIa IIb IIb IIb IIb IIb IIb IIb IIb III III III III III III III III I I I I I I IIa IIa IIa IIa IIa IIa IIa IIa IIb IIb IIb IIb IIb IIb IIb IIb III III III III III III III III B A Primary PCI STEMI patients presenting to a hospital with PCI capability should be treated with primary PCI within 90 min of first medical contact as a systems goal. STEMI patients presenting to a hospital without PCI capability, and who cannot be transferred to a PCI center and undergo PCI within 90 min of first medical contact, should be treated with fibrinolytic therapy within 30 min of hospital presentation as a systems goal, unless fibrinolytic therapy is contraindicated.

11. Reperfusion • Given the current literature, it is not possible to say definitively that a particular reperfusion approach is superior for all pts, in all clinical settings, at all times of day • The main point is that some type of reperfusion therapy should be selected for all appropriate pts with suspected STEMI • The appropriate & timely use of some reperfusion therapy is likely more important than the choice of therapy

12. 4-6 weeks Fibrinolysis vs. angioplasty Meta-analyses P<0.0001 P=0.0002 P=0.0003 P<0.0001 P=0.0004 Ellen C Keeley, Judith A Boura, Cindy L Grines. Lancet 2003; 361:13–20.

13. Fibrinolysis preferred Early presentation < 3 hours from symptom onset Delay to PCI Door to balloon >90 minutes PCI vs. Lysis > 60 minutes PCI not an option PCI preferred PCI available High risk AMI Cardiogenic shock (SBP<=90 mmHg) Rales >1/2 Increased bleeding risk Late presentation >3 hours Unclear diagnosis Early repol., LBBB, pericarditis, dissection Consider time and risk

14. STEMI Chain of Survival

15. Symptom Onset to Balloon Time and Mortality in Primary PCI for STEMI 6 RCTs of Primary PCI by Zwolle Group 1994 – 2001N = 1791 12 10 8 6 4 2 0 P < 0.0001 One-year mortality, % RR = 1.08 [1.01 – 1.16] for each 30 min delay(P = 0.04) 0 60 120 180 240 300 360 Symptoms to balloon inflation (minutes) DeLuca et al. Circulation 2004;109:1223.

16. Barriers to Timely Reperfusion The patient Time to transport Decision process on arrival Time to implement treatment strategy

17. Treatment Gap • 50% of patients do not call 9-1-1 • 90% of EMS do not have 12-lead ECG • 30% Receive no reperfusion therapy • Of the 70% who do - >50% not within recommended guidelines • 70% of patients with contraindications to fibrinolytics do not receive primary PCI. • Door to treatment times are unacceptably long, resulting in larger infarcts and worse outcomes

18. How do we increase the number of patients with timely access to reperfusion therapy?

19. History2004-2006 • May 2004 • Advisory Working Group (AWG) • June 2005 • market research presented • March 2006 • Consensus Statementappears in Circulation • AHA held a conference of multidisciplinary groups Circulation 2006;113:2152-2163. 20

20. Treatment Gap • 50% of patients do not call 9-1-1 • 90% of EMS do not have 12-lead ECG • 30% Receive no reperfusion therapy • Of the 70% who do - >50% not within recommended guidelines • 70% of patients with contraindications to fibrinolytics do not receive primary PCI. • Door to treatment times are unacceptably long, resulting in larger infarcts and worse outcomes

21. Reperfusion goals • Times • Door to needle< 30 minutes • 1st medical contact to balloon < 90 minutes (including transfers) Patient Transport ECG Reperfusion < 10 min 5min < 30 min Methods of Speeding Time to Reperfusion Prehospital ECG Media campaign Patient education MI protocol Critical pathway Quality improvement program Bolus lytics Dedicated PCI team Greater use of 9-1-1 Prehospital Rx

22. History2007-Present • May 2007 • Eleven manuscripts are published in Circulation • Mission: Lifeline was formally launched 23

23. 2007 Update of Guidelines for the Management of Patients With ST-Elevation Myocardial Infarction • This committee continues to endorse the concept that faster times to reperfusion and better systems of care are associated with important reductions in morbidity and mortality rates in patients with STEMI. An underutilized but effective strategy for improving systems of care for STEMI patients is to expand the use of prehospital 12-lead electrocardiography programs by emergency medical systems (EMS) that provide advanced life support. • JACC Vol. 51 No.2, 2008:210-247

24. Who is Mission: Lifeline? 25

25. A Life-Saving Initiative • National, community-based initiative • Goals • Improve quality of care and outcomes in heart attack patients • Improve health care system readiness and response - through the development of STEMI systems of care that improve time to treatment and access to optimal therapy 26

26. The Uniqueness of Mission: Lifeline The initiative is unique in that it: • Addresses the continuum of care for STEMI patients • Preserves a role for the local STEMI-referral hospital • Understands the issues specific to rural communities • Promotes different solutions/protocols for rural vs. urban/suburban areas • Recognizes there is no “one-size-fits-all” solution • Knows the issues of implementing national recommendations on a community level 27

27. Mission: Lifeline’s Guiding Principles • The initiative values: • Patient-centered care as the #1 priority • High-quality care that is safe, effective and timely • Stakeholder consensus • Increased operational efficiencies • Appropriate incentives for quality • Measurable patient outcomes • An evaluation mechanism • A role for local community hospitals • A reduction in disparities of healthcare delivery 28

28. Coordinated Actions Launch Mission: Lifeline awareness campaigns Evaluate existing STEMI system models Explore the possibility of developing a national STEMI-certification program and/or criteria Create system resources Engage strategic alliances Assess and improve the EMS system Establish local initiatives

29. Mission: Lifeline Criteria • Non-PCI Hospitals • PCI Hospitals • EMS Providers • Systems

30. The Ideal Patient • Patients and the public: • Recognize the symptoms of STEMI • Realize the importance of: • Activating emergency medical services (EMS) via 9-1-1 promptly • Getting treatment quickly • Are familiar with their local hospital’s role in STEMI care • Understand the implications of inter-hospital transfer for PCI • The ideal system: • Promotes culturally competent education efforts • Includes patient representatives on community planning coalitions • Provides coordinated and patient-centered care 31

31. The Ideal EMS • In an ideal system: • Ambulances are equipped with 12-lead ECG machines • EMS providers are trained to: • Use and transmit 12-lead ECGs • Care for STEMI patients • Provide feedback on performance and compliance with guidelines • Standardized point-of-entry (POE) protocols define patient transport rules • When there is STEMI, the cath lab is activated promptly • Patients transported to a STEMI-referral hospital remain on the stretcher with EMS present pending a transport decision • When “walk-in” patients present to a STEMI-referral hospital and require primary PCI, activation of EMS occurs • Hospitals close the communication gap with EMS 32

32. The Ideal STEMI-Referral Hospital • In an ideal system: • Standardized POE protocols dictate transport of STEMI patients directly to a STEMI-receiving hospital based on: • Specific criteria for risk • Contraindications to fibrinolysis • The proximity of the nearest PCI service • Patients presenting to a STEMI-referral hospital are treatedaccording to standardized triage and transfer protocols • Incentives are provided to rapidly: • Treat STEMI patients in accordance with ACC/AHA guidelines • Transfer to a STEMI-receiving hospital for primary PCI using: • Reperfusion checklists • Standard pharmacological regimens and order sets • Clinical pathways • There is rapid and efficient data transfer, data collection and feedback • Integrated plans for return of the patient to the community for care are provided 33

33. The Ideal STEMI-Receiving Hospital • In an ideal system: • Pre-hospital ECG diagnosis of STEMI, ED notification and cath lab activation occurs according to standard algorithms • Algorithms facilitate: • A short ED stay for the STEMI patient • Transport directly from the field to the cath lab • Single-call systems from STEMI-referral hospitals immediately activate the cath lab • Primary PCI is provided as routine treatment for STEMI 24, 7 • STEMI-receiving hospital’s administration puts their support in writing • A multidisciplinary team meets regularly to identify and solve problems • A continuing education program is designed and instituted • A mechanism for monitoring performance, process measures and patient outcomes is established 34

34. Strategic Alliances Aetna American Ambulance Association American Association of Critical Care Nurses American College of Cardiology American College of Emergency Physicians Centers for Medicare and Medicaid Services Emergency Nurses Association National Association of Emergency Medical Technicians National Association of EMS Physicians National Association of State EMS Officials National EMS Information System Project National Rural Health Association Society for Cardiovascular Angiography and Interventions Society of Chest Pain Centers Society of Thoracic Surgeons UnitedHealthNetworks 35

35. EMS System Assessment & Improvement • AHA is: • Collaborating with EMS organizations in a needs assessment • Analyzing EMS effectiveness when responding to STEMI patients • Developing a plan to build tailored STEMI systems of care 36

36. EMS System Assessment and Improvement - Nation The most significant findings:  • About 50% of EMS systems have 12-lead electrocardiograms (ECGs), used to detect STEMI, on 75 percent or more of their vehicles. • Of EMS systems with 12-lead ECGs: • Most lacked a standard method for EMS to communicate the 12-Lead ECG results to the hospital. • EMS field personnel remotely activate hospital catheterization ("cath") labs only 40 percent of the time. • Destination protocols are only used a third of the time to enable EMS to take STEMI patients directly to a hospital capable of providing angioplasty/stenting 24 hours a day, seven days a week.

37. EMS System Assessment and Improvement – South Dakota The most significant findings:  • 41% of EMS systems have 12-lead electrocardiograms (ECGs), used to detect STEMI, on 75 percent or more of their vehicles. • Of EMS systems with 12-lead ECGs: • Most lacked a standard method for EMS to communicate the 12-Lead ECG results to the hospital. Although, 32% do interpret and phone/radio • EMS field personnel remotely activate hospital catheterization ("cath") labs <25 percent of the time. • Destination protocols are only used 12%, or less, of the time to enable EMS to take STEMI patients directly to a hospital capable of providing angioplasty/stenting 24 hours a day, seven days a week.

38. Levels of Participation • Registration • Recognition • Certification

39. Local Initiatives • The American Heart Association is: • Convening task forces at state and local levels • Helping identify ways to implement national recommendations for STEMI systems in local communities • Registering STEMI systems with the Mission: Lifeline directory 41

40. STEMI DIRECTORY A "STEMI system" is an integrated group of separate entities focused on reperfusion therapy for STEMI within a region that typically includes emergency medical services (EMS) providers, at least one community (non-PCI) hospital, and at least one tertiary (PCI) center.  Please note: In some systems, there may be a single hospital with PCI capabilities that has established protocols with EMS providers and contains at least one of the components stated above.42

41. STEMI System Evaluation & Registration http://www.ahasurveys.com/se.ashx?s=0B87B7ED6A2911FD • Online questionnaire • Is accessible from the Mission: Lifeline web site • Examines local and regional STEMI system models • Benefits • Input can help Mission: Lifeline target system issues where improvements will yield the greatest results 43

42. Partners for Success Patients and care givers EMS providers Physicians, nurses and other providers STEM-referral (non-PCI) hospitals STEMI-receiving (PCI-capable) hospitals Health systems Departments of health EMS regulatory authority / office of EMS Rural health associations Quality improvement organizations Third-party payers State and local policymakers 44

43. How will wemeasure our impact? 45

45. Implementation Phase 1

46. Implementation Phase 3 48

47. Non-PCI capable PCI capable STEMI System of Care Patient Activate EMS Avoid delay Consider integrated payment No penalty to patients 12-lead ECG 9-1-1 interhospital transport Payer EMSED Activate team No diversion STEMI Referral SYSTEM OF CARE CENTER OF CARE Treatment protocols and clinical pathways Policy Makers STEMI Receiving CENTER OF CARE Protocols and toolkits STEMI Center Certification Quality improvement measures Jacobs. Circulation 2007;116:217-230.

49. For More Information Please visit www.americanheart.org/missionlifeline www.americanheart.org/missionlifelinesouthdakota 51

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