Heart 777

Darrel C. Gumm, MD, FACCHeartCare Midwest

Illinois STEMI ConferenceJune 20, 2008

Background

• Original program at SFMC was informal -started in early 1990’s– NRMI– Crusade– ACC Action

http://jama.ama-assn.org/cgi/content/full/296/14/1749 Stenestrad, et al; JAMA. 2006;296:1749-1756.

5

7

3

7

12

0.05 1

8

14

0

2

4

6

8

10

12

14

16

Death Re MI Total CVA ICH Death+RE-

MI+CVA

Primary PCI vs Lysis for STEMI –Meta-analysis of 23 trials

Short Term Events

PTCA

Thrombolytics

P=0.0003 P=0.0001

P=0.0001P=0.0001

P=0.0001

Keeley, Lancet Jan. 2003

Findings

• Primary PTCA better than thrombolytic therapy at reducing– Short term death (7% vs. 9%) p=0.0002– Non-fatal reinfarction (3% vs. 7%) p=<0.0001– Stroke/ICH (1% vs. 2%) p=<0.0001– 43% relative reduction of combined endpoints

• PTCA superior during long-term follow-up, independent of thrombolytic used and whether or not patient was transferred for primary PTCA.

(Keeley, Boura, & Grines, 2003)

Take away message:

• Primary PCI is superior to fibrinolysis– In high volume PCI centers– If performed in a timely manner:– <120 min, possibly longer

Background

• ACC/AHA guidelines recommend early revascularization for patients with STEMI and cardiogenic shock who are <75 years old (class 1A)

• Patients > 75 years old many benefit as well (class IIaB)

• The guidelines also recommend transfer of STEMI patients with cardiogenic shock to PCI centers for early revascularization despite almost no data

2 Key Ingredients for Success

• Leadership

• Teamwork

AMI Steering Committee• Cardiology Program Coordinator• Cardiology x 4• Director – Emergency Department• Internal Medicine• Director – Cath Lab• Director of Programs and Information• Vice President & COO – Heart Hospital• CEO – Heart Hospital

777 Protocol

• Areas addressed– 12-lead ECG acquisition and interpretation– Cath lab activation generated by ED physician– Data collection– Standard order sets– Prompt feedback to ED/EMS

Admit Date

DC Date

Acct #

Mode of

Arrival

ED Arrival Time

Time Initial EKG

Min to

EKG

Initial Eval

Min to initial exam

777 Called

Total ED

Time

Cath Lab

Ready

3/4/08 5222924 ambulance 5:49 5:53 4 5:54 5 5:54 5 6:09

3/9/08 3/12/08 5244525 ambulance 0:49 0:54 5 0:54 5 1:04 15 1:37

3/21/08 3/24/08 5298746 ambulance 21:18 21:19 1 20:47 0 21:20

3/23/08 3/24/08 5300026 car 3:26 3:31 5 3:45 19 3:36 10 4:01

3/28/08 3/31/08 5324678 car 18:58 19:06 8 19:08 10 19:16 18 19:30

5 5 10<10 min

<5 min

<20 min

OSF Saint Francis Medical Center Door to PCI

Total ED

Time

Cath Lab

Ready

Patient in

Lab

777 to Pt in

Lab

Case Started

PCI Cath lab

time

Door to

PCI TimeMIN

% of cases

w/i 90

min

Day of

Week

Pt. Age

Attending MD

Comments Time saved

5 6:09 6:15 21 6:23 6:38 23 49 Y Thurs M-60 BestPeters

ReoProMetamore 1V23 brought patient

NA

15 1:37 1:53 49 2:03 2:28 35 99 N Sun M-59 SchmidtHauterFarber

No II B IIIA EMS did ECG at 00:33 SQD 3 East Peoria Fire Department

30 min could have been saved

0 21:20 21:31 11 21:37 21:43 10 25 Y Fri M-60 BarzalloCouri

ReoProPre-hospital ECG at 19:46 per Morton FD Para 3Not really called as 777. Dr. Barzallo was paged 30 min PTA. He called the cath lab in a 9 min PTA.

31 min saved

10 4:01 4:08 32 4:13 4:23 15 57 Y Sun M-44 RashidHublerTruong

ReoPro NA

18 19:30 19:46 30 19:53 20:11 25 73 Y Fri M-76 RashidBrownMiller

No IIB IIIA or Angiomax usedTX with underware on it took 16 min to get to lab.16

NA

10 30 23 57 79%

<20 min

<30 min

<25 min

<90 min

100%

PCPFirstName

PCPLast

Name

Group/BusinessName

Address City State Zip

Robert Lizer 5401 N. Knoxville #412 Peoria IL 61614

None

Phillip Rossi Box 267 Hopedale IL 61747

? ?

Timothy LaHood 5401 N. Knoxville # 105 Peoria IL 61614

OSF Saint Francis Medical Center Door to PCI

Door to PCI Time in Minutes

0

25

50

75

100

125

150

175

1Q 04 2Q 04 3Q 04 4Q 04 1Q 05 2Q 05 3Q 05 4Q 05 1Q 06 2Q 06 3Q 06 4Q 06 1Q 07 2Q 07 3Q 07 4Q 07 1Q 08 2Q 08

Min

utes

SFMC Nation

Jan

2006

med

ian

time

star

ted

bein

g us

ed

Apr

il 28

, 200

5 77

7 Pr

ogra

m in

itiat

ed

Apr

il 06

Doo

r to

PCI I

ndic

ator

chan

ged

to <

90

min

Sta

rted

se

ndin

g ou

t spr

eads

heet

Percent of Patients Receiving PCI in < 90 min

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

4Q03

1Q04

2Q04

3Q04

4Q04

1Q05

2Q05

3Q05

4Q05

1Q06

2Q06

3Q06

4Q06

1Q07

2Q07

3Q07

4Q07

1Q08

2Q08

Perc

ent o

f Pat

ient

s

SFMC % <90min Nation

Apr

il 28

, 200

5 77

7 Pr

ogra

m

initi

ated

Apr

il 06

Doo

r to

PCI I

ndic

ator

cha

nged

to

< 90

min

Star

ted

send

ing

out s

prea

d sh

eet

Results of 777

• All have been < 90 min for the last 7/8 quarters• Last 4 Quarters: 53, 65, 49 and 59 min (median)• How have we accomplished this goal

– Developing a collaborative relationship between Cardiologists and ED Physicians

– Discussing cases at quarterly combined meetings– Focus group discusses each outlier individually – Development of a code to activate cath lab staff and

cardiology as soon as we know a patient is arriving (777)

Heart 777• Heart attack

• Emergencies

• And

• Regional

• Transfers

AMI Steering Committee• Cardiology Program Coordinator • Cardiology x 4• Internal Medicine• Director – Emergency Department • Director – Cath Lab• Director of Programs and Information• Vice President & COO – Heart Hospital• CEO – Heart Hospital• Life Flight• Medical Communications

HEART 777• Regional program developed between OSF Saint

Francis Medical Center and HeartCare Midwest• Available for use by all area cardiologists• At present includes 9 hospitals and will be

adding 4 more in near future • Median time currently 105 min • 80% of patients receiving PCI within < 120 min

Participating Hospitals• Graham Hospital – Canton• St. Mary Medical Center – Galesburg• Cottage Hospital – Galesburg• Mason District Hospital – Havana• Kewanee Hospital – Kewanee• St. Margaret’s Hospital – Spring Valley• IVCH – Peru• Perry Memorial Hospital – Princeton• Pekin Hospital - Pekin

Heart 777 Program

• Call PALS, say “HEART 777 and patient weight”

• LifeFlight dispatched or ambulance obtained• Ask for cardiologist on call• MD decision: primary PCI of thrombolytic• Inclusion: STEMI <12 hours or new LBBB• Exclusion: None (including out-of-hospital

cardiac arrest and cardiogenic shock)

Time Required to Transfer

• DANAMI-2 Trial– Transport time from community hospital to PCI center

averaged 32 minutes

• PRAGUE-2 Trial– 48 minutes

• National Registry of Myocardial Infarction in the United States– 180 minutes total (Approx. 120 minutes for decision

making and transfer; 53 minutes between PCI hospital arrival and balloon inflation)

(Jacobs, et al., 2006)

Findings After Implementation

• The median “first” door-to-balloon time for patients <40 miles (zone 1) was 105 minutes

• The median “first” door-to-balloon time of patients <60 miles (zone 2) was 116 minutes

• 60-80 miles (zone 3) not yet implemented

Regional HEART 777Name Admit

DateDC

DateAcct

#Mode

of Arrival

Mode of Transfer

ED Arrival Time

Time Initial EKG

Min to

EKG

Initial Eval

Min to initial exam

MedCom

Receives call

ED to Call to MedCom

Dispatch Enroute Arrived on

scene

Flight Time

1

10/17/07 10/18/07 4695991.0 ? LF 6:40 6:40 1 6:40 1 6:47 7 6:57 7:02 7:22 25

11/13/07 11/16/07 4804638 car LF 13:02 13:14 12 13:02 1 13:21 19 13:21 13:24 13:45 24

1/11/08 1/14/08 5019727 car LF 12:25 12:29 4 12:25 1 12:36 11 12:38 12:44 13:09 33

2/2/08 5103841 car LF 13:58 14:17 19 14:00 2 14:30 32 14:36 14:43 15:07 37

2/20/08 2/22/08 5171756 car LF 11:00 11:04 4 11:00 0 11:13 13 11:25

4 1 13 29<10 min

<5 min

10 min

</= 30 min

Regional HEART 777Rendez-

vousDepart ED with Patient

Ground Time

Depart Scene

ArivedSFMC

Flight Time 2

Facto

FacTime

CathLab

Ready

Patient in

Lab

Arrival to Pt in

Lab

Case Started

PCI Cathlab

time

Door to

PCI TimeMIN

% of cases

w/i90 -120

min

Day of Week

Pt.Age

MD Life Flight

PCP

7:25 7:31 9 7:38 8:00 29 80 7:51 8:10 10 8:18 8:31 21 111 Y Wed 67

13:47 13:54 9 14:01 14:20 26 78 14:29 14:36 16 14:36 #### 10 104 Y Tues F-84

13:15 13:23 14 13:33 13:53 30 88 13:25 14:01 8 14:08 #### 23 119 Y Fri M-69

15:12 15:24 17 15:33 15:53 29 115 16:00 16:11 18 16:18 #### 20 153 N Sat M-51

12:18 12:33 93 12:41 8 12:49 #### 24 125 N Wed M-63

12 29 88 10 21 119 100%<10 </= 60 < 30

min< 90 min

100%

Avedis Donabedian, MD: Father of Quality Assurance

Structure

Process

Outcome

Core Process Measures% Heart Attack Patients:

• Given aspirin on arrival• Given aspirin on discharge• Given ACE inhibitor or ARB for left ventricular

systolic function• % of heart attack patients given smoking cessation

advice• Given β blocker on admission• Given β blocker on discharge• PCI in 90 minutes of arrival

% Given ASA

90919293949596979899

100

US IL SFMC

% Given ASA on Arrival

8788899091929394959697

US IL SFMC

% Given ASA on Discharge

% Given Beta Blocker

8586878889909192939495

US IL SFMC

% Given Beta Blocker on Admission

84

86

88

90

92

94

96

98

100

US IL SFMC

% Given Beta Blocker on Discharge

ACE Inhibitor or ARB for LV Dysfunction

80

82

84

86

88

90

92

US IL SFMC

% Given ACE or ARB for LV Systolic Dysfunction

Smoking Cessation Advice

86

88

90

92

94

96

98

100

102

US IL SFMC

% of Patients Given Smoking Cessation Education

What are the odds?

• Of a coin landing on heads?

• Of a coin landing on heads twice?

• Of a coin landing on heads 4 times in a row?

0.50.5

0.5 x 0.5 = 0.25 0.5 x 0.5 = 0.25

0.5 x 0.5 x 0.5 x 0.5=0.5 x 0.5 x 0.5 x 0.5=0.0625 or 6.25%0.0625 or 6.25%

What are the Odds?

• Of Perfect Acute MI Care?**ASA on admission 0.990.99ASA on discharge X 0.96X 0.96Beta Blocker on admission X 0.94X 0.94Beta Blocker on discharge X 0.99X 0.99ACE inhibitor or ARB X 0.91X 0.91Smoking cessation X X 1.001.00

80.5%80.5%**time to PCI in less than 90 min

not included

Summary

• Primary PCI is superior to thrombolytics• Key strategies can significantly impact D2B

times• Regionalization is feasible• Continue to strive to improve• If it works in Europe it can work in Illinois

Hospital Standardized Mortality Rate (HSMR)

Using Binary Linear Regression:

• A methodology to determine death as a defect versus death as the end of life’s journey THAT

• Adjusts a hospital’s mortality based on case mix characteristics AND

• Adjusts a hospital’s mortality based on community characteristics

Adjustment Factors

Over 25 variables including:• Age• Sex• Length of Stay• Admission category• Excludes palliative care• Emergency care• Hospital volume

Jarman, Brian et al, Explaining differences in English hospital death rates using routinely collected data, BMJ 1999; 318; 1515-1520

HSMR

Facility Observed of Deaths

Total US Expected DeathsX 100

140067 annual (Medicare years Oct-Sep) regression-adjusted HSMR vs USA HSMR

0

20

40

60

80

100

120

1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008

Reg

ress

ion

adju

sted

hos

pita

l HSM

R &

USA

HSM

R

US overall HSMR

REGRESSION ADJUSTED hospital HSMR

Outcome: Mortality

Is It Real?–Coding–Case Mix

Diagnosis Codes410.01 Acute MI anterior/lateral wall initial episode

410.11 Acute MI other anterior wall initial episode

410.21 Acute MI inferolateral wall initial episode

410.31 Acute MI inferoposterior wall initial episode

410.51 Acute MI other lateral wall initial episode

410.81 Acute MI other specific sites initial episode

410.41 Acute MI other inferior wall initial episode

410.71 Acute MI subendcardial infarction initial episode

410.91 Acute MI unspecified site initial episode

SMRs for groups of ICD9 diagnoses (see methodology): 140067 for period covered by current data, compared with USA Medicare 2004

020

4060

80100

120140

160180

200

Infe

ctio

ns 1

4006

7

Infe

ctio

ns U

SA 2

004

Neo

plas

ms

1400

67

Neo

plas

ms

USA

200

4

Dia

bete

s &

met

abol

ic 1

4006

7

Dia

bete

s &

met

abol

ic U

SA 2

004

Acut

e M

I 140

067

Acut

e M

I USA

200

4

Oth

er c

ardi

ac 1

4006

7

Oth

er c

ardi

ac U

SA 2

004

Hyp

erte

nsio

n &

CH

F 14

0067

Hyp

erte

nsio

n &

CH

F U

SA 2

004

Cer

ebro

vasc

ular

dis

ease

140

067

Cer

ebro

vasc

ular

dis

ease

USA

200

4

Perip

hera

l vas

cula

r dis

ease

140

067

Perip

hera

l vas

cula

r dis

ease

USA

200

4

Res

pira

tory

dis

ease

140

067

Res

pira

tory

dis

ease

USA

200

4

Gas

tro-in

test

inal

dis

ease

140

067

Gas

tro-in

test

inal

dis

ease

USA

200

4

Ren

al d

isea

se 1

4006

7

Ren

al d

isea

se U

SA 2

004

Dec

ubitu

s ul

cer &

cel

luliti

s 14

0067

Dec

ubitu

s ul

cer &

cel

luliti

s U

SA 2

004

Frac

ture

d ne

ck o

f fem

ur 1

4006

7

Frac

ture

d ne

ck o

f fem

ur U

SA 2

004

Com

plic

atio

ns 1

4006

7

Com

plic

atio

ns U

SA 2

004

Tota

l 140

067

Tota

l USA

200

4

SMRs (95% CIs)

HSM

R (9

5% C

Is)

Bottom Line

• Higher infarcted-artery patency with primary PTCA• Primary PTCA is more effective than thrombolytic

therapy for the treatment of STEMI when performed expeditiously and expertly

• Data holds out even for PCI transfers• For every 100 patients transferred for PCI, 7 MACE

events prevented

(Nallamothu, et al., 2005)

ACC/AHA

• Recognizes that over 400,000 STEMI patients annually are not having their needs met, 1/3 don’t receive any reperfusion strategy, and in those who do, only 40% < 90’

• Potential benefits of regionalized care• Multidisciplinary group of experts working to

develop recommendations for a strategy to increase the number of STEMI patients with timely access to primary PCI

(Jacobs, et al., 2006)

Issues

• One third of STEMI patients do not receive ANY reperfusion therapy despite availability.– Limited ability to recognize symptoms and contact

medical system in a timely manner– Time to transport to the hospital– Decision process on arrival– Time to actually implement reperfusion strategy

(Jacobs, et al., 2006)

Peoria Region

• As demonstrated by the research at MHI/ANW & Mayo Clinic, it is possible to establish protocols and reduce transfer times from the region

• Our program is currently underway

HEART 777