EMS Activation of the Cath Lab in Los

EMS Activation of the Cath Lab in Los Angeles County ACC Webinar D 2 B-Sustain the Gain August 4, 2009

Disclosures • No financial disclosure

Ivan C. Rokos MD, FACEP, (FACC) • • • Emergency Physician Asst. Clinical Professor, UCLA Staff Physician, UCLA - Olive View Staff Physician, Northridge Hospital Member, ACC D 2 B-STG Committee Member, AHA Mission: Lifeline Emergency Cardiac Care and Model Eval Committees

William (Bill) J. French MD, FACC • • • Interventional Cardiologist Harbor-UCLA Medical Center Director, Cardiac Cath Lab Professor, UCLA School of Medicine Member, Los Angeles County STEMI Receiving Center Network Committee

Jonathan Tobis, MD, FACC • • Interventional Cardiologist Ronald Reagan UCLA Medical Center Professor, UCLA School of Medicine Member, American Heart Association California STEMI Task Force

A Quality STEMI Procedure starts with An Efficient STEMI Process Quote source: Dr. Sameer Mehta, MD, FACC Miami, Florida

Webinar Outline • • The Past What started LA county? The Present Current Data The Future Faculty Discussion (20 min. ) Audience Q and A (20 min. )

1970 Cardiology invented EMS Emergency! Gage & De. Soto 2009 EMS transforming Cardiology

Wallis Annenberg Grant 2002 -2004 • In 2003, $3 Million funding to provide 12 -lead PH-ECG for the two largest EMS providers in LA county • 4 Visionary Individuals: – – Dr. Marc Eckstein (LA City Fire Dept. ) Dr. Frank Pratt (LA County Fire Dept. ) Sylvia Beanes (AHA vice president) David Ross (AHA board member) • In 2006, $4 Million approved by LA County Board of Supervisors for complete PH-ECG coverage and creation of STEMI Receiving Center network. – Dr. Bill Koenig (Medical Director, LA County EMS Agency) – Carol Meyer (Administrative Director, LA County EMS Agency)

8 Tectonic Plates Shaped the Formation of Regional STEMI Networks

Tectonic Plates #1 -4 • National Trauma Center Systems – Example of multi-disciplinary collaboration • NRMI Registry – The Status quo for D 2 B was slow • Feds and Core Measures – Mandated Transparency • Institute of Medicine 2006 Report – Emergency Care at the Breaking Point

Tectonic Plates #5 -8 • Two European Studies – Prague-2 and Danami-2 (published in 2003) • Technology – Automated pre-hospital ECGs and Defibrillators • ACC/AHA STEMI Guidelines – 2004 Benchmark of D 2 B ≤ 90 Minutes • ACC D 2 B Alliance (2006) – Improve INTRA-hospital process for PPCI

D 2 B Alliance Tier-I strategies 1. 2. 3. 4. 5. 6. ED physician activates the cath lab One call activates the cath lab Cath lab team ready in 20 -30 minutes Prompt data feedback Senior management commitment Team-based approach Optional = Pre-hospital ECG to activate the cath lab

“Grassroots” Initiative (Rokos IC, 2006 AHJ, 152: 661) • Multi-Disciplinary • Influenced by the 8 prior Tectonic Plates • Inter-hospital transfer & pre-hospital cardiac triage

“Grassroots” intersects with Big Society 11 Papers, Circulation May 30, 2007

Inter-hospital Transfer • • Minneapolis (Henry et al, Circulation 07) Mayo Rochester (Ting et al, Circulation 07) North Carolina RACE (Jollis et al, JAMA 07) Ottawa, Ontario, Canada (Le May, NEJM 08) Challenge: No system has yet achieved an overall >50% rate of D 1//B 2 ≤ 90 Minutes

Pre-hospital Cardiac Triage • Regional diversion protocol allowing EMS to transport STEMI directly to PPCI-capable hospitals • Cardiac cath lab accessible 24/7/365 regardless of ED-diversion status • Parallel processing patient transport and cardiac cath lab activation occurring simultaneously • Plan A = PCI, Plan B = Fibrinolytics • Regional Quality Improvement Database

Map of 58 California Counties Regional STEM Networks • Ventura Co. • Los Angeles Co. • Orange Co. • San Diego Co • Riverside Co. (2008) • San Bernadino Co. (2009)

31 California LEMSAs LA County

45 STEMI Receiving Centers: Ventura, Los Angeles, & Orange Counties (California) 64 in So. Cal: 19 more SRCs San Diego, Riverside, San Bernadino Counties.

Webinar Outline • • The Past What started LA county? The Present Current Data The Future Faculty Discussion Audience Q and A

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

Map of 10 STEMI Networks (Rokos et al, 2009 JACC Intv. , 2: 339) PDF

Demographic Summary for 10 -regions • 20+ million citizens • 5, 000+ paramedics • 166 hospitals Paramedic Receiving Centers – 72 hospitals STEMI Receiving Centers • D 2 B Data spans: – Unique start date for each region – End August 31, 2007 – Includes ALL consecutive patients

Study Population Aggregate 10 -region Data • 2, 712 PH-ECG(+) for presumed STEMI – N= 659 (24%) PH-ECG(+) but PPCI(-) – N=2, 053 (76%) PH-ECG(+) and PPCI(+)

D 2 B Pooled Analysis • N = 2, 053 for 10 SRC networks combined • 86% rate of D 2 B 90 Minutes • Inclusions: – ALL consecutive PH-ECG (+) and PPCI (+) • Exclusions: – No self-transport patients – No inter-hospital transfer patients

Rate of D 2 B ≤ 90 min by Region (Rokos et al, 2009 JACC Intv. , 2: 339) N = 2, 053 Solid Red line represents the Primary Endpoint. Dashed Red line is D 2 B Alliance Benchmark

Secondary Endpoints: N=2, 053 with D 2 B Time • 50% rate of D 2 B ≤ 60 Minutes (N=1, 031) • 25% rate of D 2 B ≤ 45 Minutes (N=517) • 8% rate of D 2 B ≤ 30 Minutes (N=155)

Cath. PCI Registry 2005 -06 (N=43, 801) (Rathore et al, 2009 BMJ 338: b 1807 In-hospital Mortality D 2 B from 90 to 60 minutes associated with 0. 8% Mortality D 2 B from 60 to 30 minutes associated with 0. 5% Mortality

E 2 B EMS-to-Balloon time • EMS = Emergency Medical Services • Time Zero = Date and Time auto-stamped on first PH-ECG diagnostic of STEMI • Builds on 2004 ACC/AHA STEMI guidelines – First medical contact-to-Balloon ≤ 90 min.

Tertiary Endpoint (EMS)-to-Balloon (E 2 B) • 2, 053 were PH-ECG(+) and PPCI(+) • 762 of 2, 053 (37%) had PH-ECG time recorded in a database (5 regions: LAC, MSP, Med, Cha, Ven) – 68% rate of E 2 B ≤ 90 minutes

30 -30 -30 Goal E 2 B≤ 90 Conceptual Framework < 30 minutes for Emergency Med Services (EMS) < 30 minutes for the Emergency Department (ED) < 30 minutes for the Cardiac Cath Lab (CCL)

Limitations • No outcomes data – Donabedian triad: structure-process-outcomes • Experience, Not Experiment (QI vs RCT) – Missing pt characteristics, baseline D 2 B rates, E 2 B for all regions, standardized false(+) CCL activation tracking, variable resources for audits, and incomplete regionalization in areas • Bias issues – Successful SRC networks, adopters/innovators – All consecutive pts.

LA County Rate of D 2 B ≤ 90 min (Rokos et al, 2009 JACC Intv. , 2: 339) N = 476 Pre-SRC is 2005 (Green). Post-SRC is Dec-06 to Aug-07 (Blue) for 30 SRCs

Primary Objective Systems and Networks provide your community with Quality 9 -1 -1 is A 2 Q Access to Quality

Can you see the STEMI solution now? The STEMI Train…A Quality System that is always on Time

EMS Systems and STEMI-care Quality • Mega-Provider of Quality – PH-ECG identification of STEMI consistently provides the fastest D 2 B times • Mega-Consumer of Quality – 50% of all STEMI patients arrive via EMS – EMS drives regional collaboration

Webinar Outline • • The Past What started LA county? The Present Current Data The Future Faculty Discussion Audience Q and A

The Future: Faculty Discussion • • • AHA Mission: Lifeline Inappropriate Cath Lab Activations Paramedics bypassing ED enroute to Cath Lab STEMI Judgment STEMI Etiquette Economic Issues Rural Issues Inter-hospital transfer using 9 -1 -1 responders Cardiac Arrest Centers for Resuscitated Patients ACTION Registry-GWTG and Cath-PCI

Developing Ideal STEMI Systems

Circulation, Sept 2, 2008 3 Pre-hospital ECG Interpretation Strategies – Automated computer algorithm – Direct paramedic interpretation – Wireless transmission & Physician Interpretation (Wi-PI)

The Vision of PH-ECG Transmission On-duty ED Physician Pre-hospital “STEMI Alert” In-hospital “Code STEMI”

The Future: Faculty Discussion • • • AHA Mission: Lifeline Inappropriate Cath Lab Activations Paramedics bypassing ED enroute to Cath Lab STEMI Judgment STEMI Etiquette Economic Issues Rural Issues Inter-hospital transfer using 9 -1 -1 responders Cardiac Arrest Centers for Resuscitated Patients ACTION Registry-GWTG and Cath-PCI

Webinar Outline • The Past What started LA county? • The Present Current Data • The Future Faculty Discussion • Audience Q and A