STEMI ALERT!

Craig M. Hudak, MD, FACC,FACP 24 January 2015

STEMI Overview ST segment Elevated Myocardial Infarction

Patient Outcome Goals: •Save myocardium •Reduce CHF •Reduce arrhythmias •Improve quality of life

The STEMI Network

GHS Hospitals – Greer, Hillcrest, Laurens, North Greenville

Greenville Memorial Hospital –750 bed tertiary referral center Chest Pain Center, Call Center, Referral Center, Cardiac Cath Lab, Coronary Care Unit, STEMI RN, Laboratory, EKG, Emergency Department Physicians, Cardiology Physicians

Baptist Easley Hospital (Easley) Cannon Hospital (Pickens) Oconee Medical Center (Seneca) Wallace Thompson Hospital (Union) PLUS: MD 360, Doctor’s Care, Urgent Care Centers and Doctor’s Offices

Greenville County EMS Mobile Care Pelzer Rescue Squad Pickens County EMS Laurens County EMS Oconee EMS Spartanburg EMS Med-Trans Life Flight

So we are doing this just about every day…practice make perfect?

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STEMI 2010 STEMI 2011 STEMI 2012 STEMI 2013 STEMI 2014 STEMI 2015

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The STEMI Program -Development Began in house at GMH

•Establish Protocols •Train our ED/ CPC staff •Establishment of Call Center and Referral Center •Coordinate with EMS •Monitor times and intervals •Provide ongoing feedback and training •STEMI Nurse position created in 2007 •STEMI Coordinator position created in 2010 •Weekly STEMI meeting for real-time QI •Monthly AMI meeting

Extending the Network

•Relationship building with referring facilities and EMS companies •Case reviews with physicians in referring facilities •Case reviews and training with EMS companies •In-services for staff in referring Emergency Departments •Ongoing feedback and dialogue

With a single call…

STEMI Collaborative Components: • STEMI Activation System • STEMI Work Team (Weekly) • STEMI Tracking Forms • STEMI Feedback (email) • STEMI Monthly Summation Report • AMI Oversight Committee (Monthly) • CMS Publically Reported Submissions • Mission Lifeline Participation (AHA and SCHA)

STEMI Collaborative Work Team • STEMI/CPC Co-Medical Directors: Cardiology and Emergency

Medicine • STEMI/CPC Coordinator: Christina Freeman • Representatives from ER, CCU, Cath Lab,GHS Laboratories,

EMS,Transport, Call/Referral Center, all campuses • Review of EVERY Cath Lab Call Back/STEMI

STEMI Collaborative Work Team Membership • Executive Operations Director, Cardiology Services • Manager, Cardiology Services • Manager, ED Services • Supervisor, CCL • Director and Senior Paramedics, Mobile Care • Practice Liaison, Carolina Cardiology Consultants • Clinical Data Specialist, Quality Management • Manager, GMH Bed Management • Regulatory Affairs Specialist, Cardiac Research • GMH STEMI RN • Nurse Manager, CCU • Lead ECG Tech, ECG Department • Etc.!

THE TAKE HOME MESSAGE!

Mortality Reduction %

Myocardial Salvage %

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Gersh JAMA 2007

Mortality Reduction % Myocardial Salvage %

Impact of Door-to-Balloon Time on One Year Mortality: All Patients in CADILLAC and HORIZONS-AMI Trials

D2B > 90 min

D2B < 90 min

Unadjusted HR 0.72 (0.52–0.99) p = 0.045

4.3%

3.1%

Impact of Door-to-Balloon Time on One Year Mortality: Early (< 1.5 hrs) vs. Late Presenters

DBT < 90 min

DBT > 90 min

Time to Presentation > 1.5 hoursTi

D2B > 90

D2B < 90

4.6%

3.8%

1.9%

HR 0.49 (0.26-0.93) p = 0.029

Time to Presentation < 1.5 hours

D2B > 90

D2B < 90

4.6%

4.0%

HR 0.86 (0.58-1.28) p = 0.47

Time to Presentation > 1.5 hours

Impact of Door-to-Balloon Time on One Year Mortality: High Risk* vs. Low Risk Patients

* TIMI Risk Score > 2

D2B > 90

D2B < 90

D2B > 90

D2B < 90

High Risk Low Risk

7.4%

5.7%

HR 0.75 (0.53-1.08) p = 0.12

HR 0.64 (0.30-1.37) p = 0.25

1.6%

1.1%

Copyright ©2006 American Heart Association

Pinto, D. S. et al. Circulation 2006;114:2019-2025

Multivariable analysis estimating the treatment effect of reperfusion therapy with PCI or fibrinolysis based on increasing PCI-related delay

Patient delay

Symptom onset

Transportation delay

EMS call

Arrival at PCI center

D2B delay

Treatment delay

Health Care System delay

Field-triaged to a PCI center

PPCI

Patient delay Transportation

delay Local hospital

delay

Treatment delay

Health Care System delay

D2B delay

Interhospital delay

Arrival at PCI center

PPCI Arrival at local hospitall

Departure from local hospital

Transferred from local hospitals

THE WHOLE PICTURE

“E2B”

• First Medical Contact (EMS, or ER if patient drives self to hospital) to Balloon Time

• D2B, though heavily emphasized as “Quality” measure, is only part of the story!

• Our goal is E2B less than 90 minutes

PATIENT DELAYS…

• Community Education programs • It’s called “heartburn” because although it could

just be burning from acid reflux…it could also be your heart!

• “Time is Muscle” • Call 911: Do not drive yourself to the ER! EMS

can diagnose and start treatment immediately

EARLY ACTIVATION OF STEMI ALERT BY EMS • Must empower EMS to make this call! • Reduces PCI hospital D2B: Get the team in! • Allows local hospitals to be bypassed • EMS education is crucial, and very effective • 15 lead EKG: Posterior or RV MI • We welcome EMS paramedics in Cath Lab

NON PCI HOSPITALS: DIDO

• Goal: Door In Door Out within 30 minutes • Interchangeable equipment: stretchers • No drips: So no need to change IV

tubing/pumps at transfer points • Recognize potential tension between DIDO and

E2B: ground vs. air transport?

PROTOCOLS: KISS!

• Chew 4 baby aspirins (total about 325 mg) • Plavix 600 mg load • Heparin 5,000 units IV, not weight-adjusted, no

drip! • SL NTG if BP allows, no IV drip! (coronary

spasm) • IV beta blockers only if needed for

HTN/tachycardia! (causes hypotension, bradycardia, and shock!)

D2B Considerations

• STEMI RN: a GMH innovation! Crucial role in coordination, transport, and in Cath Lab

• Be aware of door time! • Address Infarct Related Artery first? • Simultaneous STEMI’S: ? Triage low risk patient

to lysis and PCI--**Communication between ER MD and cardiologists is essential**

• Reversal of cardiogenic shock must take precedence over “achieving” D2B

False positives?

• Inherent tension also between low D2B and potential situations that do not represent STEMI

• Pros and cons of accepting patients directly to Cath Lab: role of non cardiologists…

• Need low threshold for calling STEMI Alert • Constant reassurance of MD’s and EMS about

this new paradigm • Recurring 12 lead EKG training for EMS, ER

MD’s, RN’s, EKG techs

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% False +

% False +

Month

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% Cancel

Month

STEMI Cancel Total % Cancel False + % False + Jan 33 21 54 38.9% 4 7.4% Feb 34 32 66 48.5% 6 9.1% Mar 26 33 59 55.9% 9 15.3% Apr 20 21 41 51.2% 4 9.8% May 27 30 57 52.6% 6 10.5% Jun 22 22 44 50.0% 5 11.4% Jul 23 25 48 52.1% 9 18.8%

Aug 23 29 52 55.8% 5 9.6% Sep 27 19 46 41.3% 4 8.7% Oct 27 26 53 49.1% 9 17.0% Nov 30 30 60 50.0% 9 15.0% Dec 45 18 63 28.6% 5 7.9%

Rates: Cancel and False Positive

SOME CONCLUSIONS…

• The first priority is prompt reperfusion—By any modality!

• D2B--and even E2B times--are only part of the story!

• We (patients, EMS, aircrews, ER MD’s, cardiologists, Cath Lab Techs, nurses—indeed, all GMH physicians) need to be “all in” to work TOGETHER to minimize delays!!

IT’S AMAZING THIS ACTUALLY WORKS!