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Rural Healthcare Quality Network WEB CONFERENCE. A Rural-Urban Partnership for Emergency Cardiac Care June 4, 2008. In memory of William F. Stifter, MD January 26 th 1944 to May 17 th 2008. Cardiologist with Heart Clinics Northwest

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Rural Healthcare Quality Network WEB CONFERENCE

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rural healthcare quality network web conference

Rural Healthcare Quality Network WEB CONFERENCE

A Rural-Urban Partnership forEmergency Cardiac Care

June 4, 2008

in memory of william f stifter md january 26 th 1944 to may 17 th 2008
In memory of William F. Stifter, MDJanuary 26th 1944 to May 17th 2008

Cardiologist with Heart Clinics Northwest

Served as liaison between Lincoln Hospital and Sacred Heart to help create the Cardiac Level 1 regional response system

  • Kris Becker, RN, Director, Cardiac Service Line, Sacred Heart Medical Center, Spokane
  • Myron Bloom, MD, Medical Director, Rural Healthcare Quality Network
  • Gerard Fischer, Vice President, Sacred Heart Medical Center, Spokane
  • Tom Martin, CEO, Lincoln Hospital, Davenport
  • Mike Ring, MD, Medical Director Cardiac Service Line and Cardiac Catheterization Laboratory, Sacred Heart Medical Center, Spokane
  • Marilynn Snider, RN, Vice President of Clinical Services, Lincoln Hospital, Davenport
  • Rachel Zamora, RN, Chief Flight Nurse of MedStar, Spokane

“Level One STEMI” Treatment ProtocolMyron E Bloom, MD, MMMMedical DirectorRural Healthcare Quality NetworkTIME COUNTS

  • STEMI – ACS myocardial infarction

with the ST segment of the ECG showing elevation

  • D2N – door to needle time
  • D2B – door to balloon time
  • 10PCI – Primary Percutaneous Coronary Intervention - balloon angioplasty usually with a stent
ACC / AHA 2004 recommendation30 minutes to Thrombolytic if patient can not get PCI within 90 minutes of first Emergency Room Door

Because Time is Muscle


so how are we doing presently
So how are we doing presently?

In the US

  • 37% of all STEMI patients are not reperfused (23% get lytics & 39% get 10PCI)
  • Average D-N time is 33 minutes but only

1/3rd of STEMI 10PCI under 90 minutes and

<5% of transfer in 10PCI under 90 minutes

NRMI 5 database median time of 143 minutes!

Time is muscle, especially first 2-3 hours!

Average time from onset to arrival is 3 hrs like it was 10 years ago

And most downstream heart muscle is dead by 4-5 hr


will show evidence that
Will show evidence that:
  • 10PCI is safer and offers better outcome than lytics
    • 2-3 per 100 STEMI mortality benefit with less

re-thrombosis or bleeding

  • Time delay to thrombolytic &/or PCI deleteriously affects outcome
  • Strategy expedites treatment & optimizes outcome based on
    • Clinical factors: time of Sx onset, age, STEMI location
    • Minimum time of transport
    • Standardized Recipe for STEMI
    • Transfer immediately for 10PCI or after lytics

Long-term Outcome of Primary PercutaneousCoronary Intervention vs Pre-hospital and In-Hospital Thrombolysis for Patients With ST-Elevation Myocardial InfarctionJAMA, October 11, 2006

26,205 consecutive STEMI patients in Sweden 1999 to 2004

10PCI Pre H T In H T

30 day mortality 4.9% 7.6 % 11.4%;

1 year mortality 7.6% 10.3% 15.9%

Primary PCI was also associated with shorter hospital stay and less re-infarction than either PHT or IHT.


Door-to-Balloon Time With Primary Percutaneous Coronary Intervention for Acute Myocardial Infarction Impacts Late Cardiac Mortality in High-Risk Patients and Patients Presenting Early After the Onset of Symptoms J Am Coll CardJanuary 2006

10PCI In-hospital outcomes by Door-to-Balloon Time

<90 90-120 120-180 >180 p Value

Mortality (%) 4.9 6.1 8.0 12.2 0.0001

Reinfarction (%) 2.9 2.4 2.9 2.2 0.84

Stroke (%) 0.8 1.0 1.1 1.9 0.31

(384) (493) (750) (673)

2,322 consecutive patients with STEMI from 1984 through 2003 treated with primary PCI without previous thrombolytic therapy.


EFFECT OF DOOR-TO-BALLOON TIME ON MORTALITY IN PATIENTS WITH ST- SEGMENT ELEVATION MYOCARDIAL INFARCTIONJ Am Coll CardJune 200629,222 patients presenting within 6 hrs of STEMI symptom onset who had PCI at 395 hospitals.

  • Median D2B of 102 min & inpatient mortality of 4.55%.
  • Longer D2B times associated with increasing mortality, regardless of the interval from symptom onset to presentation, or presence of high-risk features.
    • from 3.0% with D2B of 90 minutes or less,
    • to 7.4% with intervals greater than 150 minutes.
  • The odds ratio for inpatient mortality was 1.08 for every 30-minute increase in D2B time.
pci v fibrinolytic therapy in ami 2003 is timing almost everything am j cardiol 2003 92 824 826
PCI v. Fibrinolytic therapy in AMI: 2003Is timing (almost) everything?Am J Cardiol. 2003; 92: 824–826

“No mortality advantage for primary PCI versus fibrinolytic therapy when door-to-balloon time exceeded door-to-needle time by 62 minutes.”

delays in reperfusion for stemi circulation 2006 114 2019 2025
Delays in reperfusion for STEMI… Circulation. 2006; 114: 2019–2025

multivariate analysis of 192,000 STEMI cases by 3 variables:

age, type of STEMI, and time since Sx onset

The survival advantage of PCI is lost when DB-DN time exceeds:

Patients under 65 under 2 hrs after 2 hrs of Sx

Anterior MI @ 40 min. @ 43 min.

Nonanterior MI @ 58 min. @ 103 min

Patients over 65 under 2 hrs after 2 hrs of Sx

Anterior MI @ 107 min @ 148 min.

Nonanterior MI @168 min. @ 179 min.

So what happens when you call?"We found that delays to reperfusion occurred while waiting to talk to the cardiologist,”

"Also, the recommendations for a specific patient often depended on who the cardiologist was, and the time of day and day of the week.“

Quotes by Minneapolis Heart Institute Cardiologists

what to do develop a strategy
What to do? Develop a Strategy

Two Cardiology Centers of Excellence published their strategies in the same issue of Circulation (August 2007)

Mayo Clinic - 10PCIorLytic

Based on time to presentation

AN Minnesota Heart Institute – 10PCI or Lytic & PCI

Based on time to cath lab

the mayo clinic stemi protocol august 2007 issue of circulation
The Mayo Clinic STEMI ProtocolAugust 2007 issue of Circulation

258 presented directly to Mayo for Primary PCI

median D2B 71 min.

236 rural transfers from up to 150 miles

105 Sx >3 hours transferred for Primary PCI median D2B 116 min.

131 Sx <3 hours full-dose fibrinolytic

median D2N 25min (70%<30m)

In-hospital mortality “said to be similar” - ?

Mayo 10PCI 6.6% (95% CI, 3.9 to 10.3) Transfer 10PCI 5.7% (95% CI, 2.1 to 12.0) Thrombolytic 3.1% (95% CI, 0.8 to 7.6)

Minnesota Heart Institute

Protocol based on Predicted minimum expected time to PCI

Clopidogrel 600 mg, UFH, BB, NTG but no IIb/IIIa

Zone One – “within 60 miles 60 minutes” expected arrival

PCI ~ 90 minutes

– no lytic!

Zone Two - “beyond 60 miles 60 minutes” expected arrival

PCI > 90 minutes

– ½ dose lytic facilitated PCI

if no contraindication!

mhi level one program report card 3 03 11 06 1345 consecutive stemi patients
MHI Level One Program Report Card3/03-11/06 1345 consecutive STEMI patients

1048 were transferred Median D2B time

No lytic zone 1 <60 mi 95 min

partial lytic zone 2 <210 mi 120 min



30 Day MORTALITY 4.9%


unselected high-risk patient population with 12.3% in cardiogenic shock, 10.8% cardiac arrest and 14.6% over 80 years age

failure to reperfuse rescue pci
Failure to Reperfuse Rescue PCI

Now defined using the ECG as

Less than 50% reduction in STE at 90 minutes after lytic in the single lead that showed the greatest elevation

ACC/AHA STEMI Guidelines 07 IIa recommendation

and for the others that reperfused

Routine cath by 6 - 24 hours


TRANSFER-AMI: 30 day End Points Both groups got full dose TNK, ASA, LMWH or UFH andIIb IIIa & clopidogrel at the clinician's discretion (American College of Cardiology 2008 Scientific Sessions.)

expedite reperfusion minutes is muscle
Expedite Reperfusion – “Minutes is Muscle”
  • “Symptoms to Test” Time
    • Expedite Transport, Triage and ECG
      • Educate the public
      • Pre-hospital assessment tool, ECG and ED “Cardiac Alert”
      • Expedite ECG – Set standard for door to ECG time
  • “Test to Treatment” Time
    • Empower the emergency room provider to make initial treatment decision for STEMI – your patient until arrives there
      • Standardized Protocols based on
      • Predetermined expected transport times for PCI
  • Then Immediate transfer to cath lab facility
what is a cardiac level 1 response mike ring md and kris becker cardiac service line director
What is a Cardiac Level 1 Response?Mike Ring, MD and Kris Becker, Cardiac Service Line Director
program highlights
Program Highlights
  • Standardized Protocol
  • Rural hospital or field interpretation of ECG
  • One phone call to activate 24/7
  • Individualize transportation
  • Education provided to all players
  • Public education
  • Data collection to promote accountability, process improvement and research
  • Communication!!
protocol development
Protocol development

Based on ACC Guidelines and/but…

  • Cardiology Community consensus
activation of cardiac level 1
Activation of Cardiac Level 1
  • Recognize signs/symptoms of AMI
  • ECG < 10 minutes
  • If STEMI or New/presumed new LBBB
  • Activate
    • MedStar/transport agency
    • Cardiologist
      • And specify “Cardiac Level I”
level 1 activation
Level 1 Activation
  • Cardiologist notifies receiving hospital
  • MedStar also contacts operator at DMC or SHMC
  • Cardiac Level 1 page/notification at DMC or SHMC:
    • Cath Lab Crew and Supervisor
    • ED Charge Nurse
    • CICU and ACU Charge Nurse
    • Chaplaincy
    • Security
    • Hospital Transporter
    • Level 1 Coordinator
    • Administrative/Nursing Supervisor
    • Admitting
cardiac level 1 protocol form
Cardiac Level 1 Protocol Form
  • History & Physical
  • Checklist for medications
  • Data for performance improvement
  • Hand off transfer tool
    • MedStar
    • Cath Lab
    • Admitting
back of level 1 form
Back of Level 1 Form
  • Assistance with ECG interpretation
    • Fax and phone numbers of ED
  • Thrombolytic Indications and Contraindications
  • Post-thrombolytic guidelines













lessons learned
Lessons learned
  • We adopted same nomenclature for STEMI’s originating in our own ED
  • First bed is the cath lab
  • Adapt to your environment
  • ONE protocol for the region
  • Just do it!
names to know
Names to know…
  • Jamie Gant, RN nurse manager for cardiac admit unit and CV nursing, helped establish the program at Sacred Heart
  • Deanna Jones, RN hired into the newly created role of Cardiac Level 1 coordinator
Rural Rapid Response-Marilynn Snider,Vice President of Clinical ServicesLincoln Hospital District #3
best practice in action
Best Practice in Action

Goal: Striving to coordinate and integrate

processes which facilitate delivery of the

best and fastest reperfusion therapy for


establish the team
Establish the team

Senior Leadership:

Successful strategy is motivated by

leadership and commitment to provide

resources and attention to the project.


Lincoln Hospital






Rural Physician

RN leadership

rural hospital strategies
Rural Hospital Strategies
  • Establish partnerships
  • Initiate AMI Rapid Response Team
  • Implement written AMI protocol and educate staff
  • RN 12 lead EKG education and training
  • Quality Improvement Data Collection with feedback mechanism to staff, i.e. dashboard.
  • Communication and feedback staff to staff and hospital to hospital.
  • Continue regional/state/national development of STEMI project
solidifying relationships with urban healthcare systems
Solidifying relationships with urban healthcare systems
  • Continue ongoing relationships by communicating quickly and effectively
  • Sharing goals and meeting challenges
medstar communication center
MedStar Communication Center
  • Request “Cardiac Level 1” transport
  • May assist with contacting cardiologist
  • MedStar team enroute
  • Provide updates:
    • Flight team
    • Referring facility
    • Receiving facility

and cardiologist

medstar flight team
MedStar Flight Team
  • Standardized approach to patient care
  • Heparin and Tridil infusions

prepared enroute

  • Focused physical


  • Minimal verbal report
  • Pilot to remain

with aircraft

referring facility
Referring Facility
  • Accompany flight team to & from helipad
  • Room cleared of obstacles
  • Patient in hospital gown only
  • IV sites with rapid disconnect
  • Assistance with patient transfer
  • Family members - brochure
  • Patient belongings
rural hospital outreach education
Rural Hospital Outreach Education
  • Provide hospital and EMS classes
  • Cardiac Level 1 ECG Class
    • 2 hour class
    • Reviews Cardiac Level 1 protocol
    • 12 Lead ECG interpretation skills
      • STEMI
      • STEMI look-a-likes
      • Case Studies
prior to cath lab arrival
Prior to Cath Lab Arrival
  • Activation Cardiac Level-1
    • CICU bed and cath lab team
  • Communication with referring facility
  • Communication with Medstar
    • In lytic patients: assess for unsuccessful lysis
    • 12 lead ECG ~35 minutes PTA
  • Review medical records and previous cath angios when available
  • Unstable patients
    • IABP
    • Respiratory therapy/mechanical vent
immediately on arrival to cath lab
Immediately on Arrival to Cath Lab
  • Very rapid history and physical
  • Abbreviated consent process
  • Cath lab team is preparing patient simultaneously
  • Arterial access with a 6F sheath
  • ACT (activated clotting time)
  • Decision about anticoagulant and antiplatelet regiment
    • Bivalirudin vs. heparin/glycoprotein IIB/IIIA
stemi coronary intervention
STEMI Coronary Intervention
  • Goal is to establish reperfusion of the infarct vessel ASAP (<25 min from cath lab arrival)
  • Often will inject the non-infarct vessel first
  • Avoid the left ventriculogram until after reperfusion unless issue of MR
  • Establish reperfusion with an undersized balloon to gauge vessel size
  • Thrombectomy if large clot volume
  • Usually will place a stent
    • Literature still unclear if DES better than BMS for STEMI
  • Only treat the infarct vessel acutely
post procedure care
Post-Procedure Care
  • CICU 12-24 hours
  • ECGs, cardiac enzymes, + echocardiogram
  • Lipid profile in AM: factor acute phase reaction
  • Meds: aspirin, beta-blockers, ACE-inhibitors, statin
  • Plavix: 1 year especially for DES
  • Most patients discharged in 48-72 hours
  • Cardiac rehab. (not often an option for rural patients)
false positive stemi activations positive biomarker
“False Positive” STEMI ActivationsPositive Biomarker
  • MHI Level 1 Program: 1345 patients 2003-2006
    • 14% of patients with no apparent culprit vessel
    • 9.5% with no significant CAD

Larson DM et al JAMA 298(23), 19 December 2007, p 2754–2760

false positive stemi activations negative biomarker
“False Positive” STEMI ActivationsNegative Biomarker

Larson DM et al JAMA 298(23), 19 December 2007, p 2754–2760

what are the results
What are the results?

Betty Marsh Story

case presentation
Case Presentation

On 4/8/07 62 year old female

Cardiac Risk Factors: CAD, previous PCI, previous MI, dyslipidemia, HTN, current smoker 1 ppd

12:15 Onset of chest pain

12:51 Arrived at Lincoln Hospital ED

2 min EKG obtained, STEMI recognition, Level 1 protocol initiated

4 min MedStar contacted

12 min Cardiologist called Level 1 activated

level i case presentation
Level I Case Presentation

34 min MedStar landed

Lincoln County Hospital

35 min MedStar arrived bedside

40 min MedStar departed bedside

62 min Arrival at SHMC

65 min Admit to Cath Lab

total time from lincoln county hospital ed in davenport to balloon

Total time from Lincoln County Hospital ED in Davenport, to Balloon…

93 Minutes!

the value to the rural communities tom martin lincoln hospital district 3
The Value to the Rural Communities-Tom Martin, Lincoln Hospital District #3
  • Enhanced Image--a demonstrated competence in World Class Care
  • Major Jump in Staff Morale
  • Enhanced relationships with Regional Specialists and Hospitals
  • New Patients
sacred heart receiving hospital perspective gerard fischer
Sacred Heart/Receiving HospitalPerspective—Gerard Fischer
  • It’s the right thing to do for patient care
  • It respects every individual and organization involved in the care of the patient and provides for mutual accountability of all parties
  • It is a new level of partnership between rural and urban providers that is focused on the right thing – excellent patient care – and should serve as the foundation for further collaboration
  • This is not an expensive program for anybody and the results are tangible!

Thank you