Bill Koenig, MD Medical Director Los Angeles County EMS Agency.

LA STORY STEMI 2011

Bill Koenig, MDMedical DirectorLos Angeles County EMS Agency

Establishing a Communitywide System of Care

Designated emergency cardiac care centers

Triage to PCI centers

Data driven quality improvement program

Moyer P. Crit Pathways Cardiol 2004;3:53-61

Boston EMS STEMI

Primary Percutaneous Coronary Intervention (PCI) is one of the most complex, multi-disciplinary, and time-sensitive therapeutic intervention medicine. Our process is measured in Minutes Our outcomes are measured in terms of

Mortality Teamwork and smooth Transitions are

essential

PCI for STEMI

October 30,2010

0930Exercising, CP 0935911 Dispatch 0941ALS Arrives

.October 2006: Chest PainDestination: MAR

Interpretive algorithm

Communitywide System of Care

Organized System of Care

Rapid Recognition Public Access

Defibrillation Rapid EMS Response

12 Lead ECG

Hospital Notification PH Cath Lab

Activation V-Fib Cardiac Arrest

Unique aspects of System

“If you have seen one EMS system…..

HOSPITAL CLOSURES:

2002: ST LUKE MEDICAL CENTER2003: GRANADA HILLS COMMUNITY 2004: SANTA TERESITA HOSPITAL CENTURY CITY HOSPITAL COMMUNITY HOSPITAL OF GARDENA ELASTAR COMMUNITY HOSPITAL NORTHRIDGE HOSPITAL ROBERT F. KENNEDY MEDICALCENTER2005: SUBURBAN MEDICAL CENTER2006: CENTINELA FREEMAN HOSPITAL2007: MARTIN LUTHER KING JR

………you have seen one EMS System”

Figure 1. Trends in Emergency Department Operation and Closures in Urban Areas, 1990-2009

Hsia, R. Y. et al. JAMA 2011;305:1978-1985

Copyright restrictions may apply.

Ed Closures

L.A. Fire Department cuts some rescue vehicles, paramedic supervisorsFacing a $56.5-million budget gap, the department will take 15 fire trucks and six ambulances out of service each day…………

The LA Dilemma: Your Money or Your Life -- What to Cut, Who Will Pay?

911 STEMI Focus Data Base includes all pre-hospital

patients taken to an SRC – regardless of whether cath lab is activated or undergoes PCI

Data Collection is Stemi focused

Los Angeles STEMI system: Inclusion criteria into our data base

is all patients transported by 911 to an SRC as a STEMI patient, including those that never encounter a Cardiologist or the cath lab.

Regulatory Framework Standards and Requirements that are County Based

Hospitals participate in other data bases

LAC STEMI Receiving Centers (SRC)

N=30

LAC STEMI Receiving Centers (SRC)

N=30

EMS

North

East

West

West

Tipping Points

Medical Literature Community Leaders - AHA

Conceptual framework presented to system participants

Funding AHA and Annenberg Foundation Los Angeles County Board of Supervisors

EMS Agency Reviews

Stenestrand U. JAMA 2006;296:1749-1756

Mortality reperfusion > 2h from symptom onset

100d 200d 300d 400d0%

5%

10%

15%

20%

In-hospital lysis

Pre-hospital lysis

Primary PCI

“The time is now to reevaluate the optimal approach to treatment of patients with acute MI, with an interventional approach being the optimal strategy. The task for cardiologists and other physicians is to make the best possible therapy available to every patient with acute MI. JAMA April 17,2002

Tipping Points

Medical Literature

Cannon “Primary PCI for all” (2002 JAMA 287:1987)

Topol “Regionalizaton--a call forSpecialized centers” (2003 Circulation 107:1463)

Williams “Treatment delayed is treatment denied” (2004 Circulation 109:1806)

Henry & Larson “Triage to heart attack centers…is it time for a national policy?”

(2005 JACC)

In-hospital deaths/1000 patients treated compared with D2B<90 min.

105 v < 90 120 v < 90 135 v < 90 150 v < 900

5

10

15

20

25

30

Minutes

No.

hosp

death

s/1

00

0 p

ati

en

ts

treate

d

Nallamothu B. NEJM 2007;357:1631-1638

NRMI highlights deficienciesElapsed Time 2003 NRMI

(median)2004 Guidelines

Door-Needle 32 min. 30 min.

Door-Balloon* 100 min. 90 min.

*D-B daytime 90 min. 90 min.

*D-B nights 116 min.** 90 min.

*D-B transfer 180 min.++ 90 min.

Gibson CM, 2004 AHJ 148:S29 **Magid DJ, 2005 JAMA 294:803 ++Nallamothu BK, 2005 Circulation 111:761

Tipping Points

Medical Literature

Circulation June 2007

Antman et al. JACC 2004;44:e19

STEMI System of Care

30 >> 30 >> 30 Rule

EMS >> ED >> Cath lab

Tipping Points

Hospital Best Practices Develop

Hospital-Based Strategies Associated with Shorter Door-to-Balloon Time and Potential Tools

to Implement Them

Nallamothu B et al. N Engl J Med 2007;357:1631-1638

Prehospital ECG Activation Expected interval between page and arrival Single Call from ED to Cath Lab Activation

Single Call Panel Physician

Real time Feedback to EMS, ED Fire Department removes rig from service for cath

Cardiologist in hospital 24/7 Senior Management commitment

CEO Required to attend agency reviews

Hospital-Based Strategies Associated with Shorter Door-to-Balloon Time and Potential Tools

to Implement Them

Nallamothu B et al. N Engl J Med 2007;357:1631-1638

0 1 2 3 40

20

40

60

80

100

120

Average D2B

STEMI: ultra-rapid transport

Rokos et al. JACC: Cardiovascular Interventions 2009;2:4:239

Tipping Points Hospitals Systems change

Placeholder Placeholder Placeholder for data from study Placeholder for data from study Placeholder Placeholder

Implementation of 12 lead studied prior to Stemi Center Designation Reduced D2B

Funded by AHA/Annenberg Foundation

Tipping Point: Funding

American Heart Association and Annenberg Foundation – $3 million

Los Angeles County Board of Supervisors Conceptual Framework was important

Retrospect scope :Uniform EquipmentUniform Transmission Interface

Conceptual Framework

#1 Stemi Patient

#2Prehospital team

#3 ED Team

#4 Interventional team

One patient, seamless treatment

Hospital Ownership

Team Effort

Any One Can Champion

No Turf – time is the Enemy

DATA

Inclusion Criteria

All patients identified as STEMI patients in field and transported to an SRC All Patients Triaged from field – even

when cath lab not activated All 911 inter-facility transfers for

STEMI Independent Base Hospital Data

Base Hospital Bordering LA County

Included

Data Collection Web Based

IFT Transfer Form STEMI RECEIVING CENTER & ROSC PATIENT

ED LOG (Last Revised 10/26/10)

DATE TIME ED

CALLED

PROVIDER AGENCY

& SQUAD/

RESCUE NUMBER

SEQUENCE NUMBER

BASE HOSPITAL NOTIFYING

PATIENT’S CHIEF

COMPLAINT/

ROSC

TIME ON PRE-

HOSPITAL ECG

UNDERLYING RHYTHM

Atrial Fib-(AF)

Atrial Flutter-(FL) Bundle Branch-BBB) S. Vent. Tach-(SVT) Sinus Rhythm-(SR)

HOSPITAL THEY ARE

BYPASSING TO COME

TO US

WAVY BASELINE (WB), MISSED LEADS

(ML), ARTIFACT (A)

OR GOOD QUALITY

(GQ) 12 LEAD

OTHER PERTINENT

INFO/ Time of ROSC

CATH LAB ACTIVATED

PH-Prehospital or ED- Emergency Department Time Activated:/ Canceled Time:

1/10/09 (Example)

0900

RB 61

ZZ999999

LCM

Chest Pain

0852

BBB

None

1ST ECG with WB 2nd GQ

Nrsg Hm On vent Altered

ED- 0921/ 0958

1/11/09 (Example)

2034

ES 31

ZZ888888

LCM

Chest Pain ROSC

2027

SR

Gardena

GQ

Previous Stent 1/09 ROSC @ 2040

PH- 2039/ 2103

median times

Hospital destination: median times

Cath Lab Activations

Interpretive algorithm

12 Lead ECG Quality

Artifact

12 Lead ECG Quality

Wavy Baseline

Evolving role of Medical Control when ***AMI*** doesn’t fit

Paced LBBB Atrial

flutter Artifact

STEMI Interfacility Transfers: Median Times

Journal of Interventional CardologyJanuary

4th Quarter 2010: IFT

JACC CV Interventions, April 2009; 2:339-46

Rokos et al. JACC: Cardiovascular Interventions 2009;2:4:239

STEMI Systems of Care

Door-2-Balloon (D2B)

Rokos et al. JACC: Cardiovascular Interventions 2009;2:4:239

AHA Mission: Lifeline

May 2009 October 2009 April 2010

Established STEMI system of care Working toward STEMI system of care

AHA Mission: Lifeline

May 2009 October 2009 April 2010

Established STEMI system of care Working toward STEMI system of care

Nevada

Utah

End