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Reperfusion of Acute Myocardial Infarction in Carolina Emergency Departments (RACE)

Project

Death from heart attack is 3 times more common than death from motor vehicle crashes.

Rapid reperfusion is the most important way to improve early survival.

rapid PCI (or fibrinolysis if not available)

Before the RACE project, 1st door-to-balloon for patients transferred for PCI from non-PCI center was nearly 3 hours.

Lack of “systems” and coordination to rapidly and effectively treat heart attacks.

The Problem

Background

Transfer for PCI shown to be possible and effective in Europe

While RACE project was ongoing, we collaborated with other programs (Minneapolis, Boston, Maine, Los Angeles, D2B)

None in US had reported a comprehensive approach involving multiple PCI centers and multiple EMS systems in a statewide program

We hypothesized that such an approach could provide an umbrella to manage barriers of competing practices and hospitals and encourage broad participation

RACE Objectives

Establish a state-wide system for reperfusion, as exits for trauma care, to overcome systematic barriers to:

1) Increase speed of reperfusion

2) Increase reperfusion rate

Organizeregions

Baselinedata

Intervention Postdata

2005 Q3 2005 2006 Q1 2007

10 PCI centers16 Transfer for PCI28 Lytics11 Mixed

RACE Centers and Regions65 hospitals (10 PCI, 55 non PCI)

Asheville

Winston-SalemDurham-Chapel Hill-

Greensboro

Charlotte

East Carolina

Each non-PCI center was assessed forreperfusion designation based on resources, transfer ability, and transfer time to PCI center

RACE Participating Hospitals by Region 5 Regions, 65 hospitals

Asheville: Mission Hospitals, Asheville (PCI)Angel Medical Center, FranklinHarris Regional Hospital, SylvaHaywood Regional Medical Center, WaynesvilleHighlands-Cashiers, HighlandsMc Dowell Hospital, MarionMurphy Medical Center, MurphyPardee Hospital, HendersonvillePark Ridge Hospital, FletcherRutherford Hospital, RutherfordtonSpruce Pine Community Hospital, Spruce PineSt. Luke's Hospital, ColumbusTransylvania Community Hospital, Brevard

Charlotte: Carolinas Medical Center (CMC) (PCI)CMC-Mercy (PCI)Presbyterian Hospital (PCI), CharlotteCMC- Lincoln, LincolntonCMC- Pineville, Charlotte CMC-Union, MonroeCMC-University, Charlotte Cleveland Medical Center, ShelbyLake Norman Regional Hospital, MooresvillePresbyterian Hospital, Huntersville Presbyterian Hospital, Matthews Rowan Regional Medical Center, Salisbury

Durham-Greensboro-Chapel-Hill:Duke University Medical Center, Durham (PCI)Moses H. Cone Memorial Hospital, Greensboro (PCI)North Carolina Memorial Hospital, Chapel-Hill (PCI)Alamance Regional Medical Center, BurlingtonAnnie Penn Hospital, Reidsville Chatham Hospital, Siler City Franklin Regional Medical Center, LouisburgMaria Parham Medical Center, Henderson

Durham-Greensboro-Chapel-Hill (continued)Morehead Memorial Hospital, EdenPerson Memorial Hospital, RoxboroRandolph Hospital, AsheboroSampson Regional Medical Center, ClintonWesley Long Community Hospital, Greensboro

East North Carolina:Pitt County Memorial Hospital, Greenville (PCI)Beaufort County Hospital, WashingtonBertie Memorial Hospital, WindsorChowan Hospital, EdentonDuplin General Hospital, KenansvilleHalifax Regional Medical Center, Roanoke RapidsHeritage Hospital, TarboroLenoir Memorial Hospital, KinstonMartin General Hospital, WilliamstonNash General Hospital, Rocky MountOnslow Memorial, JacksonvilleOur Community Hospital, Scotland NeckPungo District Hospital, BelhavenRoanoke-Chowan hospital, AhoskieWashington County Hospital, Plymouth

Winston-Salem: Forsyth Medical Center, Winston-Salem (PCI)Wake Forest University/Baptist Medical Center, Winston-Salem (PCI) Alleghany Memorial Hospital, SpartaAshe Memorial Hospital, JeffersonDavis Regional Medical Center, StatesvilleHugh Chatham Memorial Hospital, ElkinIredell Memorial Hospital, StatesvilleNorthern Hospital of Surry County, Mount AiryLexington Memorial Hospital, LexingtonThomasville Medical Center, ThomasvilleTwin County Regional Hospital, GalaxWilkes Regional Medical Center, N. Wilkesboro

Organization

Supported by grant from Blue Cross Blue Shield of North Carolina

Nurse coordinator and steering committee (EMS, ED, nursing, hospital administration, QI experts, cardiology) for each region

Buy-in from all PCI centers in each region

Co-funded RACE Regional Coordinators

Co-sponsored by NC Chapter of ACC with focus on the patient by promoting ACC/AHA STEMI guidelines

Data systems support from Genentech

Organization

Physician leaders (continued) Joseph Shiber Greg Tarleton F. Scott Valeri Bradley Watling Hadley Wilson

Oversight Board Robert M. Califf Pamela Douglas Robert Harris Greg Mears William O’Neill

Regional Coordinators Marla Jordan, RN Lourdes Lorenz, RN, MSN Lisa Monk, RN, MSN Mary Printz, RN, FNP-C Stephanie Starling-Edwards, RN Jenny Underwood, RN

Central Steering Committee and Statistics

James Jollis, MD Chris Granger, MD Mayme Roettig, RN, MSN Kevin Anstrom, PhD

Physician leaders Akinyele Aluko Robert Applegate Joseph Babb Peter Berger David Bohle Sidney Fletcher J. Lee Garvey Robert Hathaway James Hoekstra Robert Kelly William Maddox

RACEInterventions

OPERATIONS MANUALOptimal system specifications

by point of care– EMS

– Non-PCI and PCI ED

– Transfer

– Catheterization lab

– Other system issues – payers, regulations

– Choice of PCI or lytic reperfusion regimens

available at www.nccacc.org

RACEInterventions

Focus on SYSTEMATIC BARRIERS to care

STEMI team – hospital administration, ED, EMS,

nursing, cardiology

Prespecified reperfusion plan for hospital and region

Prehospital ECGs, interpretation, and earliest

activation

Emergency physician (or paramedic) able to activate

the cath lab

Intense education with focus on EMS and EDs

RACEInterventions

PCI Hospitals

Single number cath lab activation

Accept all STEMI patients regardless of bed

availability

Ongoing QI and data feedback– NRMI database

RACE Regional Coordinator

Responsible for improving process in every

hospital - EMS system in the region

Data CollectionDistinct but overlapping databases

• Non-PCI hospital data – Regional coordinators abstracted data from (10) consecutive

charts from STEMI reperfusion candidates in non-PCI EDs

– Emergency Department data only

– Feedback to all stakeholders

– Not linked to PCI hospital data to satisfy HIPPA restrictions

• PCI hospital data – RACE NRMI 5 system report

Pre-intervention Post-interventionJuly to Sept 2005 Jan to Mar 2007 n= 579 n= 585

10 PCI Centers

presented directly

transferred from non-PCI

61%

presented directly

transferred from non-PCI

39% 53%47%

55 Non-PCI Centers

Pre-intervention Post-interventionJul 05 to Mar 06 Jan to Mar 2007 n= 518 n= 407

lytictreated

transferred for 1° PCI

15%

40%45%

no reperfusion

lytictreated

transferred for 1° PCI

15%

46%39%

no reperfusion

Patient Flow Diagram1164 patients at PCI Centers and 925 at non-PCI centers

RACE resultsPatient features

PCI hospital Non-PCI hospitalPre Post Pre Post

n 579 585 518 407

Age (years, median) 60 61 62 61 ≥ 75 years 20% 19% 22% 20%

Female 33% 28% 33% 30%

Chest pain at presentation 93% 96% 90% 89%

Killip III/IV 4.7% 4.3% 2.7% 5.5%

Initial reperfusion strategy No reperfusion 23% 11% 15% 15% Fibrinolysis 28% 25% 45% 39% Primary PCI 48% 63% 40% 46% CABG 1.7% 1.5% -- --

RACE resultsArrival and transfer features PCI hospital Non-PCI hospital

Pre Post Pre Postn 579 585 518 407

Arrival mode Self-transport 11% 12% 57% 56% Ambulance 71% 63% 42% 44% Helicopter 16% 21% -- --

Pre-hosp ECG 41% 61% 38% 43%

Transferred from another hosp 61% 53% -- --

Transferred to a PCI hosp -- -- 92% 95%

Transfer mode EMS ground 40% 43% Critical care transport 34% 24% Helicopter 25% 43%AMI Hotline used 32% 85%

RACE resultsPCI hospital interventions

8

10

9

10

1

9

4

7

0 2 4 6 8 10

Standardized feedback to EDs

Formal orders for STEMI

Single number activates cathlab

Establish RACE Leadershipteam

Pre

Post

10 total hospitals

RACE resultsPCI hospital interventions

8

8

5

8

4

7

4

1

0 2 4 6 8 10

No requirement for transfers tostop in ED

Eductional program for EMSECG interpretation

Prehosp ECG transmitted tohospital

ECG obtained by EMS used totreat patient

PrePost

10 total hospitals

RACE resultsNon-PCI hospital interventions

11

49

51

51

36

2

11

9

41

14

0 10 20 30 40 50

Stay on strecher for PCI transfer

Single hospital reperfusion plan

Single call to activate cath lab

Give ED MD reperfusionauthority

Establish RACE leadershipteam

PrePost

55 total hospitals

RACE resultsNon-PCI hospital interventions

28

37

45

28

6

25

41

13

0 10 20 30 40 50

Bypass protocol directly to PCIcenter

Eduction program for EMS ECGinterpretation

ECG equipment for prehospitalECG

Local ambulance for transferwithin 50 miles

PrePost

55 total hospitals

RACE resultsNon-reperfusion rates

1523

15 11

0

20

40

60

80

100

Non-PCI hospitals PCI Hospitals

PrePost

% w

ithou

t re

perf

usio

n

P<0.001

RACE resultsPCI hospitals: Door to device times

108

859074

128106149

165

0

30

60

90

120

150

180

All patients Directpresenters

All transfers Transfer forPCI hospitalsPre Post

P<0.001* P<0.001

med

ian

times

in m

inut

es

P<0.001 P=0.01

* Remained significant in analysis accounting for clustering

RACE resultsNon-PCI hospitals: Reperfusion times

120

97

71

452935

0

30

60

90

120

150

180

Door-in door-out,all hospitals

Door-in door-out,transfer hosps

Fibrinolysis, door-to-needle

PrePost

P<0.001* P<0.001

med

ian

times

in m

inut

es P=0.002

* Remained significant in analysis accounting for clustering

RACE resultsReperfusion rates

57%

35%

72%

52%

0%

20%

40%

60%

80%

100%

<90 minutes D2B <30 minutes D2 needle

PrePost

% o

f pa

tient

s

PCI centersDirect presenters

Non-PCI centers

P<0.001 P<0.001

RACE results vs secular trends: PCI hospitals

Pre Post Change

Transfer

National* 150 143 7

RACE 165 128 37

Non transfer

National* 88 81 7

RACE 85 74 11

Median time in minutes *NRMI participating hospitals

Clinical outcomes

Pre

(n=579)

Post

(n=585)

p

Death* (n, (%)) 36 (6.2%) 44 (7.5%) 0.38

Stroke (n, (%)) 6 (1.0%) 1 (0.2%) 0.06

Cardiac arrest (n, (%)) 24 (4.2%) 18 (3.1%) 0.33

Cardiogenic shock (n, (%)) 46 (7.9%) 45 (7.7%) 0.88

*To show a 0.5% reduction (7.0 to 6.5%) with 0.05, 80% power would take 80,000 randomized patients

Summary and Conclusions

RACE represents the largest regional STEMI reperfusion system in the United States.

We focused on moving care forward: enabling EMS to diagnose and ED personnel to initiate treatment, with improved communication, integration, and data feedback.

All times – door-to-balloon at PCI centers, door-in to door out in non-PCI centers, 1st door-to-balloon in transfer patients, and door-to-needle for fibrinolysis – were significantly improved.

Improved application of reperfusion care on a broad scale is possible and should be a high national priority.

Now available online at http://jama.ama-assn.org/