Interfacility Transfers: The
Joker’s Wild of STEMI Care
Systems
January 19, 2011
Dr. Peter O’Brien, Centra Health, Lynchburg
Dr. Michael Kontos, VCU, Richmond
Dr. David Burt, UVa, Charlottesville
Part I: STEMI Transfers: The
Jokers WILD
Pete O’Brien
VHAC
Part II: STEMI Fireside Chat
Dr. Pete O’Brien
Dr. Mike Kontos
Dr. David R Burt
Drs. Burt, Kontos, and O’Brien:
Nothing to Disclose
The Big Picture
NATIONALLY…
Provider of: STEMI System
Science, Resources,
Collaboration …
5
MISSION: LIFELINE
Mission: Lifeline is the American Heart Association’s national
initiative to advance the systems of care for patients with ST-
segment elevation myocardial infarction (STEMI). The
overarching goal of the initiative is to reduce mortality and
morbidity for STEMI patients to and improve their overall
quality of care
4/13/2015
©2010, American Heart Association
6
….In Virginia …
www.virginiaheartattackcoalition.org
The Virginia Heart Attack Coalition (VHAC) is a volunteer collaboration
dedicated to improving care of heart attack patients throughout
Virginia via the implementation and promotion of Mission: Lifeline
guidelines and by fostering cooperation and coordination among the
Commonwealth's STEMI care providers.
Patient Care….Not Market Share
8
System Delay and Mortality in
STEMI Patients
35
Same old Story!
30
30.8
28.1
25
23.3
20
Mortality, %
15
15.4
10
5
0
0 to 60 min
61 to 120
min
Terkelsen CJ JAMA 2010;304:763-771
121 to 180
min
181 to 360
min
Interhospital Transfer for PCI
Mortality (%)
20
On-site fibrinolysis
Transfer for PCI
14
15
12.1
10
6.7 6.7
7
8.4
10
8.5
6.8
6.5
5
0
LIMI1 PRAGUE-12 AIR-PAMI3 PRAGUE-24 DANAMI5
(n=150)
(n=200)
(n=137)
1. Vermeer F, et al. Heart . 1999;82:426-431.
2. Widimsky P, et al. Eur Heart J. 2000;21:823-831.
3. Grines CL, et al. J Am Coll Cardiol. 2002;39:1713-1719.
4. Widimsky P, et al. Eur Heart J. 2003;24:94-104.
5. Andersen HR, et al. N Engl J Med. 2003;349:733-742.
(n=850)
(n=1129)
10
AHA : System Goals
FIRST MEDICAL CONTACT
DOOR To NEEDLE :
Fibrinolytics OR
DOOR IN 2 DOOR
OUT
DOOR To BALLOON
Primary PCI
EMS To BALLOON
Primary PCI
60
4/13/2015
30
90
90
MINUTES
MINUTES
MINUTES
11
Point Of Entry Protocol : GOAL
Less than 90 Minutes
Improving the System of Care for STEMI
12 Patients
LET’S TAKE A CLOSER
LOOK
4/13/2015
13
JOKER runs Amok!!
Riddle me this Batman!!
• EMS and Self-Driven/Emergent
Triage Decisions, Bypass?
• Referral Facility Recognition, System Activation
• Lytic Administration -OR- Transfer for PCI
– Drip, Ship, or Drip and Ship???
• Interfacility Transport - Ground, Air
• Receiving Facility – “Automatic” Acceptance, One Call
Activation, Direct to Cath lab, Stop in ED
• System Optimization and Feedback, multiple EMS agencies,
providers, institutions, etc
Point of Entry Protocol
Hospital
w/o PCI
PCI center
Hospital
w/o PCI
Improving the System of Care for STEMI Patients
WHY IS THIS AN ISSUE
4/13/2015
©2010, American Heart Association
16
INHERENT CHALLENGES
44
4/13/2015
©2010, American Heart Association
17
ACTION REGISTRY DATA
4/13/2015
National ARG Data and GWTG
18
Recommendations for Triage and
Transfer for PCI (for STEMI)
Each community should develop a
STEMI system of care following the
standards developed for Mission
Lifeline including:
NEW
Recommendation
I IIa IIb III
•
Ongoing multidisciplinary team
meetings with EMS, non-PCIcapable hospitals (STEMI Referral
Centers), & PCI-capable hospitals
(STEMI Receiving Centers)
19
Recommendations for Triage and
Transfer for PCI (for STEMI)
(cont.)
NEW
Recommendation
I IIa IIb III
STEMI system of care standards in
communities should also include:
• Process for prehospital
identification & activation
• Destination protocols to STEMI
Receiving Centers
• Transfer protocols for patients
who arrive at STEMI Referral
Centers and are primary PCI
candidates, and/or are fibrinolytic
ineligible and/or in cardiogenic
shock
20
AHA: STEMI System Blueprints
Mission: Lifeline Recommendations for Criteria
for STEMI Systems of Care
The criteria are divided into:
• EMS
• Non-PCI Hospital/STEMI Referral Center
• PCI Hospital/STEMI Receiving Center
• Systems
Improving the System of Care for STEMI Patients
The Ideal EMS Agency
• EMS equipped with 12 Lead
capability
• EMS educated to recognize
STEMI
• Prearranged transport
destination protocols
– By Pass Non-PCI
– PCI
– Fibrinolytic Checklist
• EMS utilization for
Interfacility Transfers
• Cath Lab Activated on
Paramedic Interpretation
– On paramedic’s
description
/interpretation
– With or Without EKG
Transmission
• EMS actively attends
Multidisciplinary Meetings
• EMS involvement at a state
level
The Ideal STEMI-Referral Hospital
• In an ideal system:
• Standardized POE protocols dictate transport of
STEMI patients directly
to a STEMI-receiving hospital based on:
– Patients presenting to a STEMI-referral hospital are treated
according to standardized triage and transfer protocols
– Incentives are provided to rapidly:
• Treat STEMI patients in accordance with ACC/AHA guidelines
• Transfer to a STEMI-receiving hospital for primary PCI using:
– Reperfusion checklists
– Standard pharmacological regimens and order sets
– Clinical pathways
– There is rapid and efficient data transfer, data collection and
feedback
– Integrated plans for return of the patient to the community for
care are provided
Improving the System of Care for STEMI
23 Patients
CODE STEMI TRANSFER FLOW SHEET
Patient enroute to ED by EMS
Field ECG indicates STEMI
Patient arrived to ED by POV
ED ECG Indicates STEMI
Initiate Interfacility Transport Plan
Treat STEMI per regional protocols
EMS Patient Arrives to Referral ED
Assess Patient
Transfer upon transport arrival
INTERFACILITY TRANSPORT PLAN:
COUNTY 911 SERVICE
(843-911-1111)
PRIVATE GROUND SERVICE
(843-991-2222)
AIR SERVICE
(843-991-3333)
LAST RESORT
(843-991-4444)
4/13/2015
ETA:________________
ETA:________________
ETA:________________
ETA:________________
©2010, American Heart Association
24
Time Savers aka Best Practices
for Referral Facilities
 GOAL : Door In to Door Out =
30 MINUTES
 GOAL : Arrival to ECG < 10 Mins
 Do Not Delay transport team

Do not wait on lab results

FAX Patient Care Record

Call Report after patient
leaves Non-PCI

KNOW the STEMI Protocol
4/13/2015
©2010, American Heart Association
25
TIME SAVERS aka BEST
PRACTICES for Transport
 Turn off all drips
(Administer NTG via SL or NTG Paste)
 NTG and Heparin drips are
not required *
 Minimize time at Bedside
(~10 Minutes – Standard scene time for trauma)
TIME IS NOT ON YOUR SIDE
 Do not delay transport waiting on
patient care records : FAX
* For short distances (not defined)
4/13/2015
©2010, American Heart Association
26
Collaborative Initiatives
• Participate in Drafting of UNIVERSAL interfacility
transport practice standard
–
–
–
–
Pre-Determined Transport Decision Scheme
Patient Care in ED
Patient Care during transport
NO DRIPS
• Early activation of the Code STEMI
– Provides update
– Lytics given or not?
– More prep time allows the
patient to be taken directly to cath lab
Improving the System of Care for STEMI Patients
Ideal STEMI-Receiving Hospital
• STEMI protocols adopted and followed to include single call
activation.
– Criteria for EMS activation.
• 24/7 coverage with expectation that Primary PCI is the standard
reperfusion strategy
• ED activation of cath lab
• Volume/Quality standards
• CCL staff/MD to report in 30 minutes or less
• Universal Acceptance—No Diversion!!
Ideal Receiving Cont’d
• STEMI-receiving hospital’s administration puts their support in
writing (AHA Memorandum of Understanding..MOU)
• Lead multidisciplinary/multiagency team meeting to regularly identify
processes done well and to collaboratively fix those that need
improvement
• A continuing education program is designed and instituted
• A consistent mechanism for monitoring performance, process
measures and patient outcomes is established—ACTION
REGISTRY/GWTG
Improving the System of Care for STEMI Patients
SAMPLE ML Report from Action
Registry
4/13/2015
30
Financial Sensitivities
•
•
•
•
Learn local EMS resources/limitations
Work as a team to address needs
Offer 12 Lead STEMI identification classes
Provide MD level updates on lytic admin
• Feedback assures appropriate Non-PCI Facility Bypass
• Goal is to get the STEMI patient back to their local
community for rehab and follow up
• Involve Non-Invasive Cardiologists on multiple levels
31
Mortality With 1° PCI vs Time
Absolute Risk Difference in Death (%)
For every 10 minutes delay in PCI-> 1% of the advantage is lost
15
Circle sizes = sample size of individual
study
10
Solid line = weighted meta-regression
P=.006
5
62 min
Favors PCI
Favors lysis
0
-5
0
20
40
60
80
100
PCI-Related Time Delay (Door-to-Balloon minus Door-to-Needle)
For every 10-min delay to PCI: 1% reduction in mortality difference vs lytics.
Nallamothu BK, Bates ER. Am J Cardiol. 2003;92:824-826.
32
TRANSFER-AMI: Efficacy
Kaplan Meier Curves for Primary Endpoint
Primary end point: composite of death, reinfarction, recurrent ischemia, new
or worsening CHF, or shock within 30 days
pharmaco-invasive group=11.0% vs. standard treatment group=17.2%
17.2%
Cumulative Incidence
11.0%
p=0.004
Days
RR= 0.64, 95 CI% (0.47-0.87)
Cantor et al. N Engl J Med 2009;360:26
33
Figure 1. The results of the primary outcome from contemporary
randomized trials comparing a pharmacoinvasive strategy with
conservative care after initiating fibrinolytic therapy. In these trials,
conservative care was defined as either an ischemia-guided or a
delayed invasive approach.
Recommendations for Triage and
Transfer for PCI (for STEMI)
(cont.)
NEW
Recommendation
I IIa IIb III
It is reasonable to transfer high
risk patients who receive fibrinolytic
therapy as primary reperfusion
therapy at a non-PCI capable facility
to a PCI-capable facility as soon as
possible where either PCI can be
performed when needed or as a
pharmacoinvasive strategy.
35
Nearest Facility ~vs~ PCI Facility
Improving the System of Care for STEMI Patients
Acute STEMI Protocol for
Halifax Regional
(for acute ST elevation MI or new LBBB)
The Cardiovascular Group of Central Virginia and the Stroobants Heart
Center of Centra Health
1. Notify Transport of need for emergent transfer to LGH.
2. Call 1-434-947-3098 (or 1-434-947-5252) and ask for Cardiologist on call.
Please be prepared to provide via phone:
•
Patient’s name
•
Age
•
Weight, Height
•
EKG interpretation
•
Brief report (i.e., treatment to this point, V, medications)
3. ASA 325 mg chew and swallow
4. Plavix 300 mg
5. Lovenox 30 mg IV.
6. Lovenox 1 mg/kg sub Q (up to 100 mg.)
7. Administer IV Thrombolytic therapy (if no contraindications)
8. IV fluids TKO.
9. If full dose TNK is not given, then give Integrilin 180 mcg ug V bolus.
Repeat bolus in 10 minutes.
If possible, avoid drips such as IV nitroglycerin that may delay transport and
time to treatment.
“Code STEMI…When time equals muscle,
every minute counts!”
Centra Health 1/05/2010
4/13/2015
37
Lessons Learned So Far
• Transfers are more complicated, but just as important to get
right
• EMS involvement and predetermined plans are CRITICAL
• Standardized Referral Center treatment protocols.
Determine Strategy: Lytic Administration vs Transfer forPCI
– Time of s/s onset, patient condition, and time to PCI
• Relationships between nonPCI and PCI hospitals worked out
– And visited frequently
• Interfacility transportation decision scheme
• PCI center commitment to non-diversion and
rapid system activation.
• Continual performance feedback
4/13/2015
©2010, American Heart Association
38
Part II: STEMI Fireside Chat
Dr. Pete O’Brien
Dr. Mike Kontos
Dr. David R Burt