Mission: Lifeline® EMS 2016 Recognition Webinar Transcript
December 2, 2015
Paul:
Welcome and thank you all for standing by. At this time, all of our participants
are in a listen only mode. For the Q&A session of today's call, if you would like
to ask a question, please press * followed by the number 1. This call is also being
recorded. If you have any objections, you may disconnect at this time. Now, I'm
going to go over to your host, Mr. David Travis. Sir, you may now begin.
David Travis:
Well thank you very much Paul, and on behalf of the American Heart
Association and Mission Lifeline, I want to thank you all for joining us on today's
webinar on Mission: Lifeline EMS Recognition Program for 2016.
My name is David Travis and I am the EMS manager for Mission Lifeline and we
have some other panelists who are joining us today, Dr. Lee Garvey, who is a
professor of emergency medicine from the Carolina Medical Center. Alex Kuhn,
who is also with the American Heart Associate, is the Senior Director of Quality
and Systems Improvement. Ben Leonard, also with the American Heart
Association, the EMS Director in Mission Lifeline, Quality and Improvement
Initiatives from Wyoming. And we have Joshua Roberts who is from
Susquehanna Valley, EMS, in Pennsylvania.
Just a few points about EMS recognition. The EMS Recognition Application
period will open on January 1st and remain open through March 31st, 2016. The
EMS Recognition for 2016 will remain focused on STEMI patients. There will
likely be additional measure for stroke and resuscitation in the future, but for
2016, we have just been focusing on STEMI as we did in 2015. And in fact, the
criteria for achievement for 2016 remains the same as for 2015. However, we
have added new optional reporting measures for this year.
So with today's webinar, Dr. Garvey will be discussing the importance of
achieving First Medical Contact to device times of within 90 minutes or less.
Alex Kuhn will be reviewing the EMS Recognition program overall and the
criteria and the new reporting measures. Joshua Roberts will review the process
his agency uses for gathering necessary data. And Ben Leonard will review the
spreadsheet available for all agencies to use. And then we will have a period of
open discussions and questions as time permits.
So without further due, I'll introduce Dr. Lee Garvey. He is a professor of
emergency medicine from Carolina's Medical Center, based out of Charlotte,
North Carolina and a very long time Mission Lifeline volunteer. Thank you Dr.
Garvey.
Dr. Lee Garvey:
Well thanks David. Welcome everyone to this webinar. I am delighted to be a
participant and look forward to all of the good work you are doing and the
recognition that is so well deserved. If we can help facilitate that today and
answer any questions. That's my number one goal.
If we could move to the background slide where the STEMI Point of Entry
Protocol please.
I think I could spend my entire allocated 15 minutes on this slide alone. I think it
is one of the real punch lines and I would call attention to this anytime you're
working on STEMI protocols. I think it really helps define where the important
parts of the process are and how they are integrated together, how they
overlap and our intent is to work in parallel, not sequentially or in serial
processing. If you notice the ambulance is at the key center of of this diagram
and we are going to focus a lot on the ERS role in providing Excellent care to
STEMI patients, focusing on first medical contact and integrating with the
hospital's reprefusion strategy.
Next slide please.
I think it's a very important slide here as well. To call your attention to the
definitions that are used for the Mission Lifeline ERS Recognition strategy.
Highlighted in red is the definition of first medical contact is the time of eye to
eye contact between the STEMI patient and the first caregiver. So, if that
caregiver is the first responder, under EMS, paramedic, physician at clinic and
documented, that is what we use first. We'd like to know if its the first
responder, whether or not, they are able to perform a 12 lead ECG, but that is
the definition that we will be using for this program of ERS recognition.
Next slide please.
I think that just drawing your attention to the fact that these polls, community
initiatives are now part of the guidelines published by the American Heart
Association and the American College of Cardiology. It now acknowledges and it
emphasizes how EMS is central to the community's performance on this critical
measure. Even in the guidelines, it states that it can be. This performance can be
facilitated by participating in programs such as Mission Lifeline and the Door to
Balloon alliance and specifically wants to acknowledge the EMS recognition
portion of this.
Next slide.
Also emphasizes that first medical contact, as we've defined it, until device time
with the system goal of 90 minutes or less. To those patients who are taken
directly from their first site of care to the PCL Center that is different for
transferred patients. We will speak just very briefly about that at the end of this
section if we have some time.
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But I think our country has adopted primarily PCL as a recommended measure
of reperfusion when it can be performed in a timely manner, very very well. And
a lot of hospitals are becoming very expert to the door to balloon portion of that
and a lot of doors systems and community systems are really addressing how
this can be established with destination protocols, integration, EMS services,
and then hospital performance.
Next slide please.
I think that ... I mean, click through this a little bit, through the graphics of the
fly-ins if you will. The doors to balloon, which has been such an emphasis over
the last decades, almost is really solved. The door to balloon is no longer the
measure that we need to watch. We are now much more focused on first
medical contact to device time. How do we facilitate this? Or EMS delivered
patients, just through the use of pre-hospital ECG. You can see over the years
that we've been increasing our performance in these metrics as the systems
have matured, more systems have been brought into the fold.
Next side please.
The slide EMS, the first medical contact to device here just outlines a few bullet
points that I would like to emphasize. For the EMS component of this, it really
begins with call capture, dispatch protocols response. Response times are what
they are. It is a fact that it takes time to process the call, it takes some time to
activate the responding, the first medical responders and or paramedics. We
want to have that operated in a smooth manner as possible. That's work that
you all do, and are familiar with, or not only STEMI, buT all sorts of other acute,
highly acutely patients. But for the STEMI programs, the key piece of
information is the pre-hospital 12 lead ECG. So having the skilled providers,
being able to bring the device to the patient, acquire a 12 lead ECG, interpret
that ECG in some manner, which we can talk about as well, and make a decision
about the destination that is most appropriate for that STEMI patient is really
key. I would say that that element is new to EMS in the last 10 or 15 years and
really critical to the overall performance of STEMI systems of care.
In an effort to maximize efficiency and again use parallel processing, not serial,
sequential processing, the earlier the pre-hospital providers can notify and
activate the receding cath lab, the better. There is some transportation time to
seeing departure until hospital arrival or if you are going directly to cath lab to
cath lab arrival that we need to use. The earliest time point that communication
can occur between the pre-hospital providers who have made that diagnosis
based on the 12 lead ECG and the receiving facility. We want that to be able to
use that time to the best advantage at the receiving facility, to accommodate
the scheduling, if it's a day time event or to recruit staff and to perform the cath
lab procedures if it's a after hours event. Well we do want to minimize the seen
time, we don't have much influence over transportation time. So we want to
maximize the systems use of that transportation time however. As introduced, I
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practiced emergency medicine and I am one of the strongest believers I think
that these patients don't need to come to the emergency department most of
the time. If we can get an accurate appraisal of the patients clinical condition, an
accurate interpretation of the ECG, early activation of the cath lab team, it's
very appropriate for patients to go directly to a cath lab and even bypass the
emergency department.
Next slide please.
Many successful and mature STEMI systems of care have developed such
protocols and are working, and Mission Lifeline is working on this actively to
assist, on developing protocols where EMS patients may go directly to the cath
lab and bypass the emergency department when it's appropriate. We can talk
about that a little bit more in the question and answer if we have the time. Next
slide does outline a little bit of the criteria for ECG acquisition. Most of these
STEMI protocols in the EMS world have criteria that are somewhat similar to
this. This was published actually regarding patients who present to triage and
how to select patients for an immediate ECG upon arrival. I think the same
applies to those patients where EMS personnel encounter them and have to
decide is this a patient who needs an ECG right away. So there are some aged
based criteria. 30 years old with chest pain that is not obviously traumatic or 45
years older with either chest pain or these other potential inguinal equivalents
of synchope weakness, palpitations, rapid heart, difficulty breathing and so
forth. I think that's a useful scheme to use and would advise adopting this in
your systems if you don't already a scheme in place for that.
Next slide please.
Again, the pre-hospital 12 lead ECG is the key piece of information and the
information contained in that is crucial to the timely care of the STEMI patients
presenting through the pre-hospital system. We get into the discussion about
how the information ... Or how the decisions are made and how the diagnosis is
made. There are a lot of options that are used in various programs from
paramedics performing the interpretation and read independently or some
systems use the ECG machine interpretation statement generation and act on
those. Many systems I think use a combination that either uses the algorithm
plus paramedic confirmation or a paramedic screening of appropriate cases and
transmission or either a physician reader at online medical control or at there
receding facility. Some systems are trying to transmit the ECG to all the decision
makers. Through email distribution systems or some other commercial
distribution system so that all the decision makers have access to the ECG
imaging at the first opportunity. My personal opinion is that it's necessary to
institute a system that meets your local requirements and equipment and
expertise but then also to do a quality management program and see how many
of these are being accurately interpreted. Is there any advantage to getting a
different set of eyes on that and so forth.
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Next slide sort of outlines some of the work done across the state in North
Carolina where we wanted to see how well we were performing on STEMI
system activation. So of all those cath lab activations, we deemed about 85% of
them were done appropriately. About 15% we would've considered
inappropriate because the emergency department ECG was interpreted as
STEMI originally and then reinterpreted as not or the EMS ECG was called STEMI
and then later readers and decision makers decided it was not STEMI. Or
something that is also new I think to EMS and emergency departments is
considering how suitable a cath lab candidate is, this particular patient is.
Generally speaking about 5% of the cath lab activations were cancelled or
deemed inappropriate for each of those three red clocks of ED or EMS ECG or
cath lab candidacy issues. What I am adovcating, whenever I get to work with a
system is ...
The next slide please.
Is that, if there is a definite ECG STEMI diagnosis and the paramedics have
confidence in that and the patient is a definite cath lab candidate then the
entire system is activated immediately. If there are questions about either the
ECG diagnosis or the cath lab candidacy, then a core group of individuals,
whether that's the interventionalists and, or emergency physician with the EMS
providers, makes decisions individually and then a decision is made whether to
activate the entire system or not after there is a consultation and individualized
decision making. I think a lot of systems are going to that block to activate the
entire STEMI system when there is good confidence in the ECG diagnosis and
the cath lab candidacy has been worked out. Certain things are in that are
typical cath lab candidacy dis-qualifiers such as advanced directives indicating
hospice or comfort care or non-intervention if there are other comorbidities
that disqualify patients such as active hemorrhage or multiple severe system
comorbidities, some of those things then may be individualized and decisions
made that way.
Will you look at the next slide, which is a stacked bar graph. I wanted to just talk
a little bit about how we are using this information in system use. Each of these
bars represents an individual hospital and the blue bars at the bottom are the
first medical contact until hospital arrival. The tan bars in the middle are from
the hospital arrival until cath lab arrival and then the green bars at the top are
the time intervals for cath lab arrival until device deployment. Our emphasis
today is on this entire stacked bar and our intent is to use the first medical
contact until device, broken down this way, so we can maximize each of those
efforts and minimize the time spent. Some of the most successful programs,
even high volume programs, who are able to coordinate with their EMS
providers and their cath labs, are able to minimize that tan bar in the middle
where patients spend very little time in the emergency department, mainly
because they have been using the time of transport, seen time, and transport
time in the EMS world to prep their cath lab. You'll see most of those green bars
at the top, the cath lab times are pretty close on generally speaking. There's a
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bit more variation in the tans bars so our intent is to use the EMS time to reduce
the time necessary to spend in the emergency department.
Next slide.
I just wanted to mention STEMI transfers because I know a lot of EMS agencies
are evolved in that process and we focus on door in, door out times. There are
lots of issues there's that are outside the EMS responsibility but some of them
have to do with transfer vehicle availability and crew response times. And also
integrating the care from hospital one through the EMS transport agency to
hospital two and limiting barriers such as IV, infused medicines, waiting for xrays and documentation. I think that are EMS colleagues can help a bit there but
most of it is in having a system designed so that the EMS response to that first
hospital is optimized.
Next slide shows again, just a stacked bar graph for individual hospitals in a
system where the blue bars on the bottom are door in, door out of hospital one
time, transport time is the tan bar, and the green bars at the top are the time
spent from arrival at the PCI center until reperfusion or device deployment. So
for transport patients with EMS issues that door in, door out and transport time
are our targets.
With that I will switch to the last slide. My portion of the discussion, which I'll
say is really just the background and hopefully most of it is very familiar to you.
Just to kind of key it up for the rest of the presentations which are focused on
specifics related to the Mission Lifeline EMS Recognition program. Again, its
been my pleasure to participate in this and I look forward to the other
presentations and further discussion. Thank you.
Alex Kuhn:
Thank you Dr. Garvey. This is Alex Kuhn with the American Heart Association. I
know many of the folks on the line have probably from from me, seen emails
from me, actually may have participated the past few years in recognition. I am
certainly happy that you guys continue to explore opportunity and
improvement. I'm going to run through the recognition measures and some
other information related to the recognition program. But I know Dave and
James from the HA will hop on here later and explain that there will be other
opportunities for outreach related to the measures and completing successful
applications and I know that you have local Mission Lifeline or quality directors
in your region that will be eager to help you submit a successful application of
your interest.
Just quickly, it's always good to go a little back in history and this is the third
year that the American Heart Association is doing the Mission Lifeline
Recognition program. Last year in 2015, we had 450 agencies that we
recognized. 123 bronze agencies, 239 silver agencies and 85 Gold agencies. To
achieve recognition at those levels, which will be the same for this year. To
achieve a bronze recognition you would have to have a 75% or higher on each of
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the compliance measures that we will share with you here in just a second, and
at least two STEMI'S at least in one quarter, with the total a four STEMI in the
calendar year for 2015. For agencies that got the silver, or are looking to get a
silver this year, you would have to have again 75% compliance score on your
recognition measures and I think eight STEMI’S in 2015. And for agencies that
are looking to go for gold, or got gold last year, they had 24 month or two
calendar years of meeting the minimum of 75% of each of the required
measures and have at least eight STEMI’S and were silver the year prior.
A couple different things, last year we also opened up really trying to expand,
look at all the different individuals that potentially may be involved in the
STEMI'S care and pre-hospital care and the STEMI'S patients. Really try to
understand systems and the way that they work and accommodate the
recognition to the multiple different systems designed. So again we are doing
that again this year. We have three different categories that agencies can apply
for. Again, we have an individual recognition and that's for a single applicant.
These agencies must do the 12 lead ECG and transport the patient to STEMI
receiving or a STEMI referral facility and meet the volume criteria and
performance criteria. Then we also have a joint application, which is a dual
application, where you may have one or both agencies do a 12 lead ECG and
then transport the patient to a STEMI receiving center within 90 minutes. And
both agencies must meet the performance criteria. Then a team application. A
team application is one that ... You have one agency that may be a first
responding agency or a BLS agency that doesn't have 12 lead ECG capability but
may get dispatched initially to a patient, were the ALS agency is following up
afterwards and doing the 12 lead ECG and then taking those patients to a STEMI
receiving and a STEMI referral facility.
So the three measures, and again the three measures are the ones that we had
for the last 2 years. The first measure is the percentage of patients with nontraumatic chest pain over the age of 35 treated by EMS who get a pre-hospital
12 lead ECG. The second measure as percentage of steady patients with the first
medical contact device within 90 minutes, and those are non-transfer patients.
The third is the percentage of STEMI patients taken to a referral hospital who
are administered fibrinolytic therapy with a door to needle time within 30
minutes.
And again I know Dr. Garvey went over this, that you know we want to make
sure that everybody understands what first medical contact is. We are looking
at from the time that a patient with a STEMI has first contact with any medical
care provider, a physician EMS personnel, they have to be a paramedic or EMT
Basic first responder, anybody that is providing care to that patient initially is
where we're starting the clock for first medical contact.
So a lot of questions usually come up around which measures should I submit,
and it really just kind of depends on where you are regionally and what kind of
hospitals you are taking your patients to. If you are taking your hospital patients
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only to a hospital that is a STEMI receiving center and is going to do primary PCI
then we are asking agencies to report on measures one and two. Again that is
the percentage of patients that have pre-hospital ECG and then the first medical
contact to primary PCI. If you are an agency that may be a little bit more rural
and not have easy access to a hospital that has a primary PCI and you need to go
to a hospital that may either transfer the patient or get fibrinolytic therapy we
are asking those agencies to report on measures 1 and measures 3, which is the
door to needle within 30 minutes. And then if you happen to be in the area
where you have kind of a mix opportunity of taking patients to a semi receiving
or a semi referral facility than you would report on all three measures.
So just going into this a little bit deeper, I'm going to show what the numerators
and the denominators are for each. And give you kind of a screenshot of what
the application will look like online. For measure 1, again this is 12 lead ECG
accusation, your denominator is the number of patients that you have over 35
with non-traumatic chest pain and again I get a lot of questions from folks about
the other signs and symptoms of heart attacks and at this point we're just
looking at those non-traumatic chest pains. The numerator would be the
patient, the number of patients that get a 12 lead ECG. This is what the form
looks like, if folks haven't seen the online form. We're going to ask you to count
up quarter by quarter by quarter, how many patients you had that have had
chest pain and then answer that in the denominator side section and then and
then numerator section it will ask you how many of those patients received a 12
lead ECG.
Measure 2, again this is first medical contact to device within 90 minutes your
denominator, a little bit different than from a age perspective than a ECG
acquisition, were looking at patients 18 and over that had a STEMI noted on the
pre-hospital ECG and were transported to a STEMI receiving center and had
primary PCI. So you'll have to figure out a lot of different information on that
denominator to see who's included in that and then once you figure that out,
then in your numerator how many of your patients had a primary PCI in less
than 90 minutes.
Again, very similar to measure one, we're going to ask you how many patients
had, quarter by quarter by quarter, met that inclusion criteria. And how many
patients, based on the denominator, met the first medical contact primary PCI
within 90 minutes. There are some exclusion on outlier criteria that may come
into play here. If you have a patient that is not giving consent, has cardiac arrest,
can't get access, can't cross the lesion, those patients can be excluded and you'll
want to collect those numbers from your hospitals because we will ask you to
put that information in the form. The good thing here is that it will count
towards your overall number of STEMI's that won't impact your denominator
towards the overall percentage of meeting the first medical contact primary PCI
within 90 minutes.
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Then, the third measure, is similar, is fibrinolytic administration in less than 30
minutes. Again, 18 years or over, transported to a referral center and had
fibrinolytic administered are the denominator and the numerator are the
number of patients that met that within 30 minutes.
Again there are some criteria here for the exclusions and these include patients
who can't get consent for the patient who are in cardiac arrest or needs
intubation.
This year we're adding some optional measures into this. Why we call them
optional, that we highly encourage them. We are beginning to ask that EMS
agencies to report the percentage of 12 lead ECG's for chest pain patients that
are done within ten minutes of FMC. Another optional measure that we are
asking agencies to report on is the time, in minutes, that the 75th percentile of
hospital notifications are performed after the positive 12 lead capture. And then
we're also asking for over triage and under triage or over activation or under
activation the cath lab.
So those were the measures. Fortunately there are good ways that hospitals are
capturing this information that's helping agencies in their applications. Many
hospitals in the US participate in the action [inaudible 00:31:05] the guidelines
on why this data is being captured through that registry. So if you have good
relationships with your hospital and your cath lab, you may be able to get this
data right from them or some of the data from them to help you complete your
application.
A lot of hospitals now are providing some type of feedback form to EMS
agencies with a lot of this critical data and so you should be able to get some of
this information back from your hospitals that help you to complete your
application.
Shamelessly from Lehigh Valley here, they have actually done a lot more
information, provided a lot more information from EMS agencies. They're
providing FMC and pre-hospital ECG and they have a goal of actually having this
done in less than five minutes. You can kind of see how this agency is meeting
that criteria.
Then as we talked about false activation, you can see that they are also
providing out this information to their EMS agencies within their region to really
help them understand the false activation rate is for their agencies.
So just quickly as I'm wrapping up here. Go back to Deming here, without data,
you're just another person with an opinion. The reason I say that is there are
more and more folks looking at EMS data beyond the HA and this recognition
program and I believe it's important for us to really do good data collection, to
advance good quality care.
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We've been doing ECG's for a long time. We've been doing the first ECG's out in
the field were done in 1967. The first time we began to see ECG's in the AHA's
guidelines were in 1999. We saw that it is reasonable for paramedics to do 12
lead ECG's in 2004. Dr. Garvey and the [inaudible 00:33:00] group that wrote a
paper for the federal government that said hey, we really should be having
more ECG's in the field and by 2008, 90% of our cities have 12 lead capabilities.
Then the most recent guidelines really begins to open it up more so not just for
ALS providers but to all EMS providers to do 12 lead ECG's. Why I say that is
again we've been doing advocate [inaudible 00:33:27] 12 lead ECG's since 1967.
Really in about 2004, 2005, 2006 is when it became a standard of care for EMS
providers to do 12 lead ECG's. But we still find that there are gaps in patients
that are having chest pains, getting the 12 lead ECG. This is some data that I
pulled. California's done a great job for measures reporting out and about 80%
of their chest pain patients are getting 12 lead ECG's. Here in Ohio, and it's only
about 60% of patients that are getting 12 lead ECG's. And then Dr. Garvey, I
know that you were co-author on this paper down in North Carolina where you
began to show some variability in patients that are getting ECG's that have chest
pain. I'll let you jump in later on, maybe in the discussion as to what you were
finding there.
If you look at this from Ohio, if you're looking at 65% to California, 80%, that's a
long way from 100. I always ask the question, for any 100%, is 99 good enough?
I sold this from some of the six sigma stuff but looked at 99% being good
enough, if that's the case then there would be 22,000 checks that were
deducted from the wrong back account in the next 60 minutes. There would be
20,000 incorrect drug prescriptions that will be written wrong in the next 12
months and 12 babies that will be given to the wrong parents. While 99% is
something that we should be aiming for, 100% should be really what we're
aiming for. Based on our data, currently, we have a long way to go to get there.
What does that really mean? I think at the end of the day, trying to improve
outcomes of care. This is to me, a real opportunity to look inside the quality of
your organization to identify opportunities to improve quality.
Ben.
Ben Leonard:
Yeah. Thanks Alex. That's a great summation of what quality and improvement
does and just listening to you present on some of those concepts really kind of
tied it all together and it goes back into the concept that you really can't
improve what you do not measure. Which in essence is the quality and
improvement initiative.
My name is Ben Leonard. I worked for the missions lifeline quality and
improvement initiatives for the state of Wyoming. I also spend a little bit of time
with the EMS agencies within the southwest region of the American Heart
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Association. I was asked to present on one of the data collections tools that was
developed within some community work here on the AHA side of things.
Alex, I think you need to switch control over to me. I don't have it quite yet.
Knowing that there's a number of different PCR tools out in the EMS world,
some are electronic, some are still utilizing the paper towels too. It's really hard
to create a one size fits all program or process to in terms of collect this
information. [inaudible 00:36:48] compliance is a great tool and there's some
opportunity for that with the commentated definitions. But really what we want
to be able to do is to assist agents agencies with the capabilities to collect this
stuff if they don't have those other capabilities.
What are group put together here, as my screen pops up. It's really a
spreadsheet that's helped, designed to help track this information. A quick
layout of the sheet is if you see this homepage here, it kind of puts down a
processes to what we're trying to do. A little bit of the descriptors in terms of
what the results what's true or include. But just really kind of an overview. The
sheet itself is broken into three different tabs and those three tabs represent
the three measures that Alex presented upon. If we go to this first tab, percent
of ECG. In all three of these Tabs are outlines and put together in somewhat of
the same fashion. These first three columns really kind of help you track
information regards to patients, obviously the date of incident, the reporting
quarter, it's got to drop down information that you can fill in. I also want to
pressure that this tool is available on the website and by no means is it locked.
What we want to be able to do is provide you with another option to collect this
data. It doesn't have to be used in this fashion, you can take it, use it however
you see fit to make it work for your service.
Column C is patient identifiers and really that's just the way that you can track
your patients when they go through your systems. So you can type in STEMI one
or however you want to do it. The concept is to be able to filter these columns
and so is Alex presented that the way the application tools split up into
quarters, you can start to buy filtering your first quarter patients and be able to
have that information readily available.
Column D, E, and F, really define what the patient population in that
denominator value is. Patient with A chief complaint of non traumatic chest
pain you select yes, patient was transported yes, the patient was 35 years or
older yes. You're going to get a result in this, column G that is true and this
patient is counted in the denominator. I don't know about everybody else on
the call, but in my years of working in EMS, I was lucky if I could put together a
formulation in an Excel spreadsheet to add. Knowing the capabilities of this
program is really great. So conceptually if you filtered on the reporting quarter,
you can just basically highlight this line or this column and you come down in
this count of 7, if you count all of these trues, that gives you that denominator.
You can enter that into your application and go on to your next part.
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If we scroll over here to the side and I'll try to move the scroll bar slowly. I know
having this go through on a webinar can potentially make you dizzy. We go to
the next column here, H, was 12 lead acquired by this agency or department?
You would select yes. What we want to do in this column I is track the date and
time the FMC and a lot of the PCR's, you can get this information from. If you
enter the date and time in the format of month, month, day, day and reported
the year, and in military time, with the colon right there. That format is very
very important. And the reason for that is if there's a formulation in there to do
the time difference and we'll show you how that goes. FMC, you enter that into
column I. In column J, date and time of your 12 lead acquisition. You can kind of
see where these times are starting to track some of those optional reporting
measures that Alex described in terms of FMC to 12 lead and what that
percentage of time is.
Once again, the numerator, based off of this column H. The patient did receive a
12 lead, that's going to change this to yes. Once again, we basically click and
hold, highlight our columns here and you can see our count here is 7. As we
would go as if these are the only patients in quarter one, we would be 7 out of
7. We'd be scoring 100% on that. Our next column over, was the heart team
activated based from this positive STEMI or based from this positive ECG. If you
select yes, the reperfusion strategy, and this really goes for those agencies that
either potentially transport to both referral or PCI. You can start which ones you
went to. As Dr. Garvey pointed out, it's possible PCI is finding the preferred
method as long as it can be done in a timely fashion. If you have that
opportunity, hopefully within your local system, you have those routing
protocols in place, that's a good thing.
Scrolling over again. What we want to do if that patient was activated, if the
heart team was activated from this EKG, let's track the time for that. This might
be one of those pieces of information that you get. Alex presented a very good
example of feedback report that are available, hopefully with those actively
involved systems so you'd be able to see what times the activation actually
happened. Grab that information, put it in this column. Column Q actually starts
to do some of these calculations here so with a time entry that we placed first
medical contact EKG and minutes is basically the difference between the calling
of the first medical contact time and then the 12 lead acquisition. That's the
automatic calculation for that.
Column R has the EKG to EMS request for heart team activation. And that's also
in minutes. So once again that's the difference in time. For those who measures.
Now if we scroll over to column S and column T, it really kind of does break
down into those optional reporting measures. If you look at this little note here
in order to get the 75th percentile. I put a note in there that you have to amend
the second R value, the last field enter the data. So if you see this R value here,
the first is R2 the second is R8. We have obviously 8 cells with data entry, so if
we go through and there's 15 cells in the data entry, go down to R16, you want
to change that number here. The same goes for column T, you want to be able
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to change the second Q value to the last Q cell that has data entered. That will
give you the average time.
It will also give you the 75th percentile for the EKG at cath lab, time activation.
Lots of information this first page. So there is multiple ways for people to track
their 12 lead acquisition rates. If you have something in place, by all means go
for it. If you need ... We really encourage you all to track those additional
measures that's going to help us in the future. That's kind of that first tab. The
second two tabs kind really kind of go hand in hand with the concept of that
first tab.
The third tab I'll highlight really quickly, because it's kind of the same thing.
Everything is laid out, numerator, denominator, you track your hospital and the
time that you had first arrived to the facility because this is the door to needle
time. You can actually get that obviously when you enter that into your PCR. All
you have to do is get the time that the medication was administered. It does an
automatic calculation and it goes through that same process, being an outlier,
tracking if it needs one of the exclusions and then tracking that as an exclusion
criteria. We have this available on the website. Please reach out to us if you
have any further questions on this. I will actually take it back to Dave, I believe
for any other questions.
David Travis:
Well thank you very much Ben and as Ben mentioned, we do have a number of
tools on the Mission Lifeline website available to help you with Mission Lifeline
EMS Recognition. We have a frequently asked questions field guide, this Excel
tool that he just brief you on and also some other materials that will be helpful
regarding the criteria and then you reporting measures and that's what it's
saying.
At this point ... James is Joshua available, as well?
Ben Leonard:
Yes. Dr. Should be online.
Joshua Roberts:
Good afternoon.. my name is Josh Roberts from [inaudible 00:49:33]
Pennsylvania. [inaudible 00:49:35] EMS.
If we can get to the overview page please.
So compiling data for tracking of core clinical cases such as STEMI, cardiac
arrest, CBA, and trauma, there are keys factors in an organizations ability to
identify trends and evaluate areas for improvement. With electronic
documentations software, becoming the norm across the nation, many agencies
are utilizing the back end software components to capture this data. Which
comes as a huge times savings, sparing the user from opening up each case and
manually documenting the data components desired.
Next slide please.
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The first step you have to take is identify what type of data you're looking for.
Planning this out before tinkering with the software reporting system can make
future data pulls quicker. So we need to establish the basics. The first one used
is the date of event. If your software doesn't covert the data into the actual day
you can use an Excel formula to make this happen. With our software, it pulls a
lot of the data for us, but we have to actually key this into another Excel
worksheet to make all of our formulas work. What we found without software,
were using ESO currently, the information is there, but we can't modify it to the
detail level that our organization expects. The thing with event, we use that day
of the week to identify trends. It doesn't really have any effect on patient care
but it certain can be defeminated to EMS providers on duty that a certain day is
generally a higher frequency day of STEMI.
Then we look at our patient demographics, a last name will use suffice, along
with a patients age. We use the patients last name as an easy reference to
obtain the outcome information from our local PCI centers. The age is an
important factor in trend analysis. Municipality, sometimes obtaining this
information can help you identify which areas of your response are a higher risk
or have high rates of STEMI. For example, in Pennsylvania, we are a common
wealth where we have different forms of [inaudible 00:51:38]. We have
Burroughs, we have cities, townships, counties, other areas such as states with
only have county based systems. You can break this down however you want it,
whether it's by zip code or various municipality or incorporated towns and what
now. We use this to do our community outreach programs. We can aim them
more aggressively to certain areas that have higher rates of STEMI's at certain
periods of time. In conjunction with other data, this is also able to assist in
identifying response times and other factors that can lead to a better out come
by better placement of EMS units.
Next slide please.
Here we're identifying event times. These are critical components of tracking
every aspect of the call from start to finish. These include the time of dispatch,
time of response, time of patient contact. The time of transport and receiving
facility and between these various categories, you can identify the minutes to
each component as necessary. I'll show you an example of our layout on the
next slide.
That's the basic layout of our time measurement. We perform calculations of
how long it takes from the time of the 911 dispatch to patient contact. How long
crews are spending on the scene. The time it takes for dispatch to arrive at the
hospital when the time of patient contact when arriving to the hospital. We set
up some very basic parameters to what we expect with the EMS providers. You
can use Excel for a lot of different things with formulas and also conditional
formatting. This is really important for the quality assurance aspect of it. So if
you have certain parameters set up. For example on this screen, you'll see the
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total number of minutes from 911 to the patient, we have that set up. We do
not want that to be any more than 15 minutes.
Next slide please.
Then we get into our STEMI factors and identifying those. What are we actually
looking for as it relates to STEMI care? Here are some of the factors our
organization uses to identify areas for improvement and to benefit the patients
overall. The first one is the EMS STEMI type. This is useful so our QA managers
can verify that the providers are calling the right types of STEMI In the field.
Then we look at our leads and views. Was there a 12, 15, or 18 lead acquired?
At a minimum 12 leads must be performed but then you can also add what
times other 12 leads were obtained if the provider is going serial EKG's. Then we
talk about which hospital was the patient taken to. When was the first 12 lead
obtained and we can measure this to assure that ... Very common that aspirin is
overlooked in the heat of things so we really focus on that, make sure that the
aspirin is done within 5 minutes of patient contact.
Next slide.
This is an example of what type of STEMI the EMS has documented and based
on that type we have conditional formatting to see if a 15 lead or 18 lead was
necessary and if so why was it performed. You can see about 4 lines down, there
was a patient with an infero posterior presentation. In that situation our
provider would have been expected to do a 15 or and an 18 lead EKG which it
was not. When we did the quality assurance on that, that was found to be the
patient was actually one four minutes from the local hospital so it was more
beneficial to get that patient through the doors of the ER.
Next slide.
This is our data table for various STEMI elements that we capture. Again, with
the conditional formatting you can assure that each parameter is met when
ever patient allowed this. You'll see highlighted in grey, where it says total
minutes, that's a formula you can use. I found that Googling a lot of my answers
for Excel formulas has been a great help, especially if you're not familiar. At the
end of this if you have any questions on how we set that up, you can certainly
ask me. This is one of the things that you want to set up well ahead of time and
not be in the middle of tracking your STEMI's and figuring this out.
Next slide.
Now we get into the quality assurance, quality improvement aspect. Again,
planning is always the key to a successful STEMI management system. We need
to identify our goals from the beginning and build that system based on these
goals. Which helps you concentrate the development and implementation effort
without losing focus. Once you have your data build, incorporating quality
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assurance and improvement measures into the STEMI system is rather easy.
Like we showed on the previous slide, with conditional formatting, you can
quickly identify which parameters that were not met. Some of these examples
include the time of 12 lead obtaining and transmissions, the time of aspirin on
seen times, any additional lead views for various presentations and then the
field accuracy of interpret ion by the EMS provider.
Next slide.
We're having some technology issues where I can't show you the QA worksheet.
I'm not sure if it's up, I'm not even seeing the views right now. But we have a
sample QA worksheet that our field training officers use with every single call
that put through the QA and QI process. This ensures that all patients have data
documented in the same ... Reports that come in, they go over the details of the
PCR to ensure compliance to organizational standards and state protocols.
Another piece of information that they have at their disposal is the actual
transmitted EKG. You'll see that this is an example of a 12 lead that comes
through, when its transmitted to the local PCI center that also comes to our
educational managers email account. We save those and they can also be
attached into the PCR software.
When there's a code R that went we notify the organization and give kudos to
the crew involved and then there recognized at the yearly banquet. If there's
issues within the call the FTO will flag this for a medical review. That medical
review goes to a medical advisory board that's made up of a captain, a
lieutenant, the ALS and BLS FTO's, a medical director, and a chief of operations.
So this is where the final determination is made as to remediating by either the
providers platoon captain or a more formal discussion in person with our
medical director. So each case gets 100% review and then that provider has a lot
more feedback coming directly to them.
Next slide.
Obtaining data from the hospitals is rather easy once you have the process set
up and its also part of developing that relationship with your local hospital or
PCI center. We have two hospitals in our local area that do PCI's for us and they
each have their own ways of sending out the information. So this is one of the
data sheets that we receive. This information is mostly visual nature which are
providers can easily see how the various processes measured up to the
standards stat. For this one just happened a few days ago. There was a prehospital EKG and pre-hospital code R called. They got to the hospital at a certain
time. This person actually was only at a total minutes of 70 from door to o,
completed [inaudible 01:01:05] mid RCA.
Next slide.
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Here's another data sheet from another PCI center. This one we really like a lot.
Our providers seem to like this because it shows the before and after
intervention pictures of the vessel. It also gives a lot more information as to the
911 dispatch information when [inaudible 01:01:28] access was made, what
time the wire crossed the lesion when they got the balloon inflated or there was
a [inaudible 01:01:33] performed and then the final outcome.
Next slide.
To wrap this up, studying the STEMI process is not really that difficult. Again, it
all goes back to your appropriate planning and goal identification and that kind
of leads the way as it relates to how were going to proceed. Working with your
PCR software vendor to create custom reports is the key to pulling data and
making sure your software works for you. There's so many different data
systems out there nation wide. Its one of these things that you're going to have
to work with IT people from your software company and see if you can get some
of these customized reports built for you. Again you may have to manually enter
that into your Excel worksheet or however you're going to map your data
through Excel or Access or some other method.
Unfortunately we have not found a tried and true method of simply just pulling
this software data into our current management worksheet. It's very limited
now that we've worked with our vendor to get this down to our level. The
[inaudible 01:02:38] the call is of key importance to measuring your
organizational goals against what is actually happening in the field and the
constant monitoring of the process, ensure that each potential or recognized
STEMI gets the same optimal care. So that concludes my section. I want to thank
you for your time and thanks AJ for working so hard to improve and standardize
STEMI care within the United States.
David Travis:
Well thank you very much Joshua and we have gone just a little bit on time
here. We did make a request to have some additional time. Moderator are
there some questions in queue?
Paul:
Let me just go ahead and inform your participants to ask a question. Please
press star followed by the number one and to record your name clearly and
slowly when prompted. Your name and introduce the question and to cancel
just press star and two. I repeat one and star to ask a question. Thank you.
David Travis:
We did have one question come up about the application window. Again, the
website will be available to accept applications starting January 1st and it will
remain open through March 31st and again that is for calender year 2015 data
to be entered for 2016 EMS recognition.
We have an additional question on a webinar. Will there be any future webinars
on EMS recognition. Yes, we are planning to have a webinar on January 27th,
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which will be a walk through of the applications for those who need some
assistance with that.
Do we have other questions moderator?
Paul:
Yes sir. We do have a couple of questions here so for the first one, this comes
from the line of Steph Roberts and it the line is now open, you may proceed.
Steph Roberts:
I'm just looking for someone to clarify measure number two with the drop down
of the 18 year old for the EKG.
David Travis:
Alex, would you like to handle that question.
Alex Kuhn:
Sure, I'll jump in here for a second and start it off and the other panelists can
jump in here and also, especially Dr. Garvey. The two measures that are in
there, frankly all three measures are based on the ECG, AHA guidelines. The 35
and over for chest pain, getting an ECG that is straight out of the guidelines and
the 18 or over for FMC for primary PCI, again is straight out of the guidelines. I
know there's some ... I know I run into a bunch of agencies where there's finding
younger and younger patients having STEMI's it makes a lot of sense for
probably doing ECG on younger patients but based on the way the guidelines
are written, those are the ages that are in there. That's why there's a difference
in the ages between the two. 18 and over for FMC to primary PCI, 35 and over
for the ECG's.
David Travis:
Thank you Alex.
Alex Kuhn:
Yep.
David Travis:
Do we have another question?
Paul:
Yes sir. We do have the line for Mr. Anthony Cash on the line sir. The line is
open, you may now proceed.
Anthony Cash:
Thank you very much. Regarding FMC, how do we account for when the patient
is picked up at a facility such as a [inaudible 01:06:38]?
David Travis:
A skilled nursing facility is not counted. The time of the FMC is the time of the
physician, the first responder, as such. The arrival time at a skilled nursing
facility would be the time of FMC by EMS. The patient obviously would have
been at the skilled nursing facility and it would be difficult to pinpoint exactly
when the complaint occurred. So were talking about at a physican's office or at
a clinic that first caregiver time when its available or the first responders time if
its EMS.
Anthony Cash:
Okay thank you.
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David Travis:
Sure thank you. Do we have another question?
Paul:
Yes sir. For the next question comes from the line of Jackie Holstrog. The line is
open you may now proceed.
Jackie Holstron:
Hi, thanks for the information and taking my question. We have been
submitting every year and our folks have been doing a great job winning the
award. However, I have a couple small departments, rural departments that
meet all the criteria except for the volume. For example, for the bronze, they
must have at least two STEMI's per reporting quarter. They have a total of four
throughout the year but not two in a quarter. I think what were doing is maybe
limiting or cutting people out from winning awards that are doing a great job
but from no fault of their own, don't have the volume.
David Travis:
And that is absolutely understood and that is a recurring issue on our feedback
surveys when we ask respondents after the survey window, for any comments
about the Mission Lifeline EMS Recognition program. That is probably the single
most common complaint that we get, that we do have the volume
requirements. Those volume requirements were set by our volunteer
committee and they are in effect for 2016, you're absolutely correct, you have
to have a minimum of at least four STEMI patients in a year and two have to be
in a quarter and right now there is no plan to reduce that volume requirement
or eliminate it, however that's something that the steering committee and
cardiac sub-committee of Mission Lifeline will be evaluating in the future. We
appreciate and are sympathetic to that issue.
Paul:
For the next question, this comes from Ms. Michelle Mayor, mam the lines are
open you may not proceed.
Michelle Mayor:
Yes, my question was actually the same of the last individual's. We are first
responders are true first responders not capable of doing a 12 lead EKG and I
thought my understand of first medical contact last year was the provider that
could actually perform a 12 lead EKG and our first responders actually don't
always capture that eye to eye time so I wasn't sure how to go about reporting
it if they don't always capture that information.
David Travis:
Right. The way its laid out, and there was some contradictory information about
that measure last year, about that first medical contact, but the way it is laid out
it's available, that's the time you should use. So if you don't have that time then
you could use your agencies arrival time.
Michelle Mayor:
Okay.
David Travis:
It's preferred to have the FMC be that responders time but its understood that
may not always be available.
Michelle Mayor:
Okay. Thank you.
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David Travis:
Thank you. Moderator any addition questions.
Paul:
Sir right now there are no questions on the queue.
David Travis:
Okay. Well if we don't have any questions, those of you who are remaining on
the line, if you questions that you think about or that you didn't get an
opportunity to ask you can certainly email me directly at david.travis@heart.org
that's david.travis@heart.org and I will follow up with you. Additionally there is
information on the website if you go to heart.org/missionlifeline, you will see
EMS recognition and there a lot of tools available to you there as well. Again on
behalf of the American Heart Associate and Mission Lifeline, I wuld like to thank
all of my panelists for being on today, for all there wonderful presentations and
also thank all of you who participated in this and we look forward to your
participation in Mission Lifeline EMS recognition for 2016. Thank you very much.
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