Smith Mission Lifeline

Rural Nebraska

Julie Smith, RN BSN MHA

Director Mission: Lifeline Nebraska

©2013, American Heart Association 1

WELCOME

2014 NeRHA Conference

Mission: Lifeline

Nebraska STEMI INITIATIVE

4/16/2020 ©2013, American Heart Association 2

OBJECTIVES

1.

Mission: Lifeline

2.

STEMI System of care in Nebraska

3.

Grant funding opportunities for local EMS and Critical Access

Hospitals.

4.

Education

4/16/2020 3

AHA NE MISSION: LIFELINE Support

Julie Smith , RN BSN MHA

Director Mission: Lifeline Nebraska

American Heart Association, Midwest Affiliate

Mobile: (308) 695-6312

Julie.Smith@heart.org

Gary W. Myers, MS

Director Mission: Lifeline South Dakota

EMS Consultant for Midwest Affiliate


Mobile: (605) 215-1551

Gary.Myers@heart.org

Kay Brown CSSBB

Director of Quality & Systems Improvement KC, Kansas and Nebraska


Mobile: (913) 652-1916

Kay.Brown@heart.org


AHA NE MISSION: LIFELINE Support

Brian Krannawitter

Government Relations Director


Office: (952)278-7921

Brian.Krannawitter@heart.org

Kristin Waters

Communications Director


Office: (402) 346-0771

Kristin.Waters@heart.org

4/16/2020

Ngia Mua

Project Specialist


Office: 952-278-7934

Ngia.Mua@heart.org


What is 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) and Out of Hospital Cardiac

Arrest. The overarching goal of the initiative is to reduce mortality and morbidity for STEMI and OOHCA patients to and improve their overall quality of care


What is Mission: Lifeline?

• Mission: Lifeline will:

– Promote ideal STEMI systems of care

– Help STEMI patients get the life-saving care they need in time

–

Bring together healthcare resources into an efficient, synergistic system

–

Improve overall quality of care

• The initiative is unique in that it:

– Addresses the continuum of care for STEMI patients

–

Preserves a role for the local STEMI-referring hospital

–

Understands the issues specific to rural communities

–

Promotes different solutions/protocols for rural vs. urban/suburban areas

– Recognizes there is no “one-size-fits-all” solution

–

Knows the issues of implementing national recommendations on a community level

Improving the System of Care for STEMI Patients

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•

•

•

How is STEMI Defined?

ST elevation at the J point in at least 2 contiguous leads of ≥

2 mm (0.2 mV) in men or ≥ 1.5 mm (0.15 mV) in women in leads V2 –V3, and/or of ≥ 1 mm (0.1 mV) in other contiguous chest leads or the limb leads.

New or presumably new LBBB at presentation occurs infrequently, may interfere with ST-elevation analysis, and should not be considered diagnostic of acute myocardial infarction (MI) in isolation. If doubt persists, immediate referral for invasive angiography may be necessary.

ECG demonstrates evidence of ST depression suspect of a

Posterior MI

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What is a Mission: Lifeline

STEMI System?

At Least one

Receiving Center

At Least One EMS

Agency

At Least One referring

Center

…working together to decrease time to reperfusion and to reduce death and disability by improving patient outcomes.

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Mission: Lifeline – A System of Care


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A System of Care – The Roles

The Patient and Family :

• Recognizing the signs and symptoms of a cardiac emergency

• Participate in community based cardiac education

• Need to use 911 and EMS

• PSA Announcements

STEMI Referring Hospital :

• Receive 12 lead ECG

• Provider notification and interpretation

• Local STEMI Treatment Team activation

• Implement early STEMI treatment

• Forwarding prehospital 12-lead ECG

• Timely arrangements for transfer to interventional care

• Feedback

Community EMS:

• Timely response, assessment, care and deployment of 12-lead ECG technology during a cardiac emergency

• Initiate pre-hospital care and prepare for transport to a receiving facility

• Acquisition and transmit of 12 lead ECG

STEMI Receiving Hospital

(PCI)

• Support referring facilities

• Receive 12 lead ECG from referring facility or EMS

• Provide consultation

• Interventional care

• Capturing STEMI data and reporting

• Feedback


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GRANT

Mission: Lifeline

Nebraska The Grant


Mission: Lifeline Nebraska Grant

5.3 million dollar initiative to enhance systems of care, save lives, and improve outcomes for heart attack patients in rural Nebraska, called Mission: Lifeline.

The lead funder for this investment in Nebraska is The Leona M. and Harry B.

Helmsley Charitable Trust, one of the nation’s largest foundations, providing a grant of $4.1 million to the American Heart Association for the initiative.

Other current funders include the Fund for Omaha through the Omaha

Community Foundation, the Ron and Carol Cope Charitable Fund, Aaron and

Rachel Wagner, Mid – Nebraska Community Foundation, Valmont Foundation,

Pinnacle Bank – Madison Branch and Hamilton County Foundation.

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Mission: Lifeline NE Project Roll-out

1. Three year grant: February 2014 – February 2017

2. Statewide Mission: Lifeline Task Force a. Leadership b. Advisory Committees c. Interventional Cardiology Steering Committee

3. Equipment allocation

4. Protocol Development – Guidelines

5. Provider Education

6. Public Education Campaign

7. Data Collection

8. State STEMI Conference

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Mission: Lifeline Nebraska - Timeline

MAY 2014 – JULY 2014

Mission: Lifeline Director

Hired

–

JULIE SMITH

Contact with all PCI capable facilities -

COMPLETED

Met with DHHS / EMS

Program director and specialists COMPLETED

Task Force Group

CREATED

Task Force leadership selected COMPLETED

Kick Off – Task Force

Meeting – HELD 7.9.2014

4/16/2020

AUG 2014 – DEC 2014 JAN 2015 - MAY 2015

Applications for EMS

Services to be finalized and sent to services -

COMPLETED

EMS Advisory Committee

Meeting and will review and determine eligibility – IN

PROGRESS

Award of first round funding for equipment

MOU and contract work for

PCI capable hospitals begins. Funding to start fall of 2014

Advisory Committees will begin meeting.IN

PROGRESS

I

Interventional Cardiology

Steering Committee

–

IN

PROGRESS

Reporting 1 st quarter data for Action Registry participating hospitals.

Second round funding for

EMS equipment will begin

Development of

Guidelines – NE approved

System of Care IN

PROGRESS

Advisory Committees will continue to meet as needed to review data

Mission: Lifeline

Statewide Conference

2015 AND BEYOND

Data collection continues

Continued EMS equipment funding

Hospital and EMS recognition

Quality Improvement efforts statewide based on registry data

2 nd Annual Mission:

Lifeline Statewide

Conference


Rural NE PCI Capable Hospitals

PCI – 24/7

1. Faith Regional Health Services – Norfolk

2. Saint Francis Medical Center - Grand Island

3.

Good Samaritan Hospital – Kearney

4.

Kearney Regional Medical Center – Kearney

5. Great Plains Regional Medical Center – North Platte

6. Mary Lanning Healthcare – Hastings

PCI – Non 24/7

1. Fremont Area Medical Center – Fremont

2. Regional West Medical Center - Scottsbluff


Nebraska PCI Hospitals


NE CAHS


PCI Referring Hospitals

NE Referring Hospitals 65 CAH hospitals

 12-L receiving equipment funding available starting 2015

 Referring Hospital Education

Plan Development will begin Fall of 2014 with delivery to begin in

Spring of 2015

4/16/2020


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Mission: Lifeline Nebraska Frequently Asked

Questions for Hospitals

1. Who is eligible to participate in the NE Mission: Lifeline statewide Taskforce?

2. Will all Hospitals be eligible to receive grant funding?

3. Are all hospitals required to participate in pre-hospital 12-lead transmission and receiving systems?

4. Will hospitals be required to purchase a particular brand of 12-lead ECG receiving equipment?

5. Will hospitals be eligible for reimbursement for equipment or software already purchased?

6. Will there be education for referring hospitals?

7. Will hospitals be required to participate in any data collection tool?

8. What is the timeline for the grant process?

Ineligible Counties

Cass County

Sarpy County

Lancaster County

Washington County

Douglas County

Saunders County

Seward County

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Mission: Lifeline Nebraska Frequently Asked

Questions for EMS Agencies

1. Will all EMS agencies be eligible to receive grant funding?

2. Will EMS agencies be required to purchase a particular brand of equipment?

3. Will EMS agencies be eligible for reimbursement for equipment already purchased?

4. Will EMS agencies only be able to apply for 12-lead monitors?

5. How much funding (amount) can EMS agencies apply for?

6. What is the timeline for the grant process?

Ineligible Counties

Cass County

Sarpy County

Lancaster County

Washington County

Douglas County

Saunders County

Seward County

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Taskforce & Committees

Mission: Lifeline

Nebraska Task Force


M:L NE Meetings and Conferences

Biannual NE M:L Taskforce in person meetings

• Monthly Teleconferences

• Subcommittee meetings

Annual NE STEMI Summit Conference:

• Highlight NE successes and Lessons learned

• Hear from clinical experts about new science

• Network with peers to advance collaboration

• STEMI Survivor Celebration

• Recognize System excellence and award achievements


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Mission: Lifeline Nebraska

Committee Structure

Nebraska Mission: Lifeline Taskforce

• Composition: All interested volunteers: Nurses/Nursing leaders, EMS Providers, Leadership

& Medical Directors, Rural and Urban health care providers from Emergency medicine and

Cardiology. State Health Department partners. Other medical professionals and leadership interested in improving emergency cardiovascular care in Nebraska.

Nebraska Mission: Lifeline Chairs

• Composition: ED physician, 2 Cardiologists, Maximum 3 members

Interventional Cardiology Steering Committee

• Composition: Cardiologist representation from each PCI Hospital

Nebraska Mission: Lifeline Quality Committee

•

Composition: Quarterly teleconference with Hospital Participants involved in Cardiovascular

Care Quality improvement and/or the ACTION-GWTG Registry tool 10-20 members

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Mission: Lifeline Nebraska

Committee Structure

Nebraska Mission: Lifeline STEMI Hospital Advisory Committee

• Composition: at least 1 nursing and 1 physician representative from each included PCI

Hospital, at least 1 representative from each regional non-PCI Hospital, and at least 2 EMS representatives (40 member maximum)

Nebraska Mission: Lifeline EMS Advisory Committee

•

Composition:

– DHHS EMS regional specialists

– EMS agency representatives from throughout the state

– EMS agency medical directors

– Other EMS representatives (max 18 members)

Nebraska Mission: Lifeline STEMI Conference Planning Committee

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Leadership

Mission: Lifeline


Leadership

4/16/2020 27

Chairs 2014-2015

Dr. Matt Johnson

Matthew Johnson, MD, is an Alma, NE native. Dr. Johnson is an interventional cardiologist withe

Bryan Heart Cardiology group at Bryan Health. He providers outreach clinical services to several communities across NE. We are fortunate to have Matt as one of the task force leads. His knowledge of rural Nebraska will be a great resource.

Dr. Doug Kosmicki

Douglas. Kosmicki M.D. is a St. Paul, NE native. Dr. Kosmicki is an interventional cardiologist form the CHI Nebraska Heart Hospital and provides service to both Grand Island and Hasting PCI cath labs. He also serves rural communities providing outreach clinics. Doug will help provide insight from the central / rural areas of the state.

Dr. David Cornutt

Is the Medical Director for Emergency Services at Regional West Medical Center in Scottsbluff

Nebraska. He and his wife live on a ranch 80 miles from Scottsbluff. He worked in an urban

Emergency department for over 25 years and has in-depth knowledge of STEMI systems of care and is currently the Medical Director for the majority of EMS Services in the Panhandle. David’s rural and ED expertise are an essential part of representation needed.


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LEAD – Cardiology

Interventional Cardiology Steering Committee -

Dr. Steve Martin

Steve Martin, MD is a Nebraska Native. Dr. Martin is an interventional Cardiologist and the medical director for the Cardiovascular Service line for CHI/NHH in Lincoln. He is able to represent the overall CHI system concerning Cardiology here in Nebraska. As the lead for the

Interventional Cardiology Steering Committee he will work with statewide interventionists across the state on the statewide guidelines.

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INTERVENTIONAL

CARDIOLOGIST STEERING

COMMITTEE

Dr. Arshad Ali

Interventional Cardiologist

Great Plains Health Center – North Platte

Dr. John Cimino


Bellevue Medical Center – Bellevue

Dr. Azariah Kirubakaran


Faith Regional Health Services

– Norfolk

Dr. Rick Markiewicz


Kearney Regional Medical Center - Kearney

Dr. Dan McGowan


Central Nebraska Cardiology - Kearney

Dr. Charles Olson


Methodist Hospital – Omaha

Dr. Drew Purdy


Rapid City Regional Hospital

Rapid City South Dakota

Dr. Steve Diamantis


Fremont Area Medical Center - Fremont

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LEAD – Hospital Advisory

Hospital Advisory Committee -

Dr. Ed Mlinek

Dr. Ed Mlinek, is the Medical Director for Bryan Medical Centers Emergency Services. In addition, through Bryan Health, he has participated in outreach efforts in rural areas and is familiar with the differing care models in these areas. He has also hosted EMTALA conferences for the Heartland Health Alliance and has been a CIMRO reviewer which has furthered is understanding of the care provided in the more rural facilities .

The Hospital Advisory Committee has good representation of PCI Capable facilities and CAH across the state.

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Group Decision Making

Mission: Lifeline



Consensus Based Decision Making

• Consensus Decision-Making – Participants make decisions by agreement rather than by majority vote.

• Inclusiveness – To the extent possible, all necessary interests are represented or, at a minimum, approve of the decision.

• Accountability – Participants usually represent stakeholder groups or interests. They are accountable both to their constituents and to the process.

• Facilitation – An impartial facilitator accountable to all participants manages the process, ensures the ground rules are followed, and helps to maintain a productive climate for communication and problem solving.


33


• Flexibility – Participants design a process and address the issues in a manner they determine most suitable to the situation.

• Shared Control/Ground Rules – Participants share with the facilitator responsibility for setting and maintaining the ground rules for a process and for creating outcomes.

• Commitment to Implementation – All stakeholders commit to carrying out their agreement.


34


Elements of a Consensus-Based Decision

• All parties agree with the proposed decision and are willing to carry it out

• No one will block or obstruct the decision or its implementation

• Everyone will support the decision and implement it.

Levels of Consensus

• I can say an unqualified “yes!”

• I can accept the decision.

• I can live with the decision.

• I do not fully agree with the decision, however, I will not block it and will support it.


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Mission: Lifeline South Dakota

Statewide STEMI Guideline

Introduction letter signed by members of Interventional

Cardiology Steering Committee representing all 7 PCI centers in the state sends a very powerful message on the need for standardized statewide guidelines.


Data, Public Awareness

& Guidelines

Mission: Lifeline


4/16/2020


37

Data

How Does the Nebraska Mission: Lifeline Project Support Data

Colletion?

• The PCI Capable Hospitals in the included rural areas will receive funding support to participate in ACTION Registry-GWTG for three years

• 24/7 PCI capable hospitals will also receive FTE support for data abstraction

*** Hospitals must agree to enter patients into ACTION Registry to receive any of these dollars

• All Hospitals will also be eligible for funding support for 12-L receiving software

• Non-funded, Metro PCIs are strongly encouraged to participate in ACTION

Registry to be part of the state system data.


Mission: Lifeline® and

ACTION Registry ® - Get With The Guidelines™

Relationship

ACC

AHA

• Quality Improvement Specialists

• Mission: Lifeline Implementation

• Provide M:L Reports using AR-G data

M:L

Reports

• Keeper of AR-G Data

• Operational Support for data upload

• Executes Data Release Consent

Forms

• Analyze the AR-G data using logic specific to ACTION reports

• Posts AR-G and M:L Reports

DCRI

• Analyze the AR-G data using logic specific to M:L

4/16/2020 2012 AHA Mission: Lifeline 39

Mission: Lifeline Reports are generated through the NCDR Registry called

ACTION Registry-GWTG. This registry collects the data for the entire STEMI system and is the method for reporting outcomes, successes and understanding gaps.

Quarterly, hospitals will receive a Mission: Lifeline report in the Action Registry Dashboard

4/16/2020

4

1


South Dakota Data Examples

4/16/2020

Median time FMC to

Primary PCI Overall % within

90 min

Median time FMC to Primary PCI

Overall % within 90 min

2013 Q1

2013 Q2

2013 Q3

2013 Q4

ML STEMI participating hospitals State Aggregate SD

55.0%

56.0%

61.0%

65.0%

ML STEMI participating hospitals

National Aggregate

59.0%

59.0%

59.0%

60.0%



4/16/2020

REC CTR Mission Lifeline

Composite Score

REC CTR Mission Lifeline

Composite Score

2013 Q1

2013 Q2

2013 Q3

2013 Q4


96.9%

97.9%

98.3%

98.5%

ML STEMI participating hospitals National Aggregate

95.1%

95.3%

96.1%

96.3%



4/16/2020

2013 Q1

2013 Q2

2013 Q3

2013 Q4

SYSTEM Direct Pres

% of patients

Treated for reperfusion

SYSTEM Direct Pres

% of patients


SYSTEM Transfer In

% of patients


SYSTEM Transfer In

% of patients


ML STEMI participating hospitals State

Aggregate SD

95.0%

98.0%

ML STEMI participating hospitals National

Aggregate

90.0%

90.0%

ML STEMI participating hospitals State

Aggregate SD

92.0%

92.0%

ML STEMI participating hospitals National

Aggregate

91.0%

91.0%

96.0%

96.0%

90.0%

90.0%

94.0%

94.0%

91.0%

91.0%



4/16/2020

RC Median time FMC to

Primary PCI (min) Overall

RC Median time FMC to

Primary PCI (min) Overall

2013 Q1

2013 Q2

2013 Q3

2013 Q4


86 min

85 min

80.5 min

77 min

ML STEMI participating hospitals National Aggregate

85 min

85 min

85 min

84 min


Mission: Lifeline Reports will also capture referring hospital metrics for system improvement

STEMI referring Center Achievement Measures:

1. Percentage of STEMI patients with a door-to-first ECG time <10 minutes

2. Percentage of reperfusion – eligible patients receiving any reperfusion (PCI or fibrinolysis) therapy

3. Percentage of reperfusion – eligible patients with door-to-needle time within 30 minutes

4. Percentage of reperfusion – eligible patients transferred to PCI center with door-into door-out time within 45 minutes

* Facility goal to make STEMI referring Center ED FMC

– to device (balloon) within 120 minutes (including transport time)

5. Percentage of STEMI patients receiving aspirin within 24 hours


Hospital and System Improvement

Strategies

• Know your numbers, data sources and benchmarks

• Understand the performance measures and understand who is key to success (FMC is a collaborative measure!)

• Develop plan for Q1 to achieve award Q2 – small tests of change

• Look at your “misses”, Evaluate process change based on trends

• Provide messaging to champions for hospital key partners and use your data!

• Communicate


Mission: Lifeline Statewide STEMI

Guideline

Guidelines Constructed following the 2013 ACC/AHA Guidelines

I IIa IIb III

All communities should create and maintain a regional system of

STEMI care that includes assessment and continuous quality improvement of EMS and hospital-based activities. Performance can be facilitated by participating in programs such as Mission:

Lifeline and the D2B Alliance.

I IIa IIb III

Performance of a 12-lead ECG by EMS personnel at the site of

FMC is recommended in patients with symptoms consistent with

STEMI.


Guideline


I IIa IIb III

Reperfusion therapy should be administered to all eligible patients with STEMI with symptom onset within the prior 12 hours.

I IIa IIb III

Primary PCI is the recommended method of reperfusion when it can be performed in a timely fashion by experienced operators.

I IIa IIb III

EMS transport directly to a PCI-capable hospital for primary PCI is the recommended triage strategy for patients with STEMI with an ideal FMC-to-device time system goal of 90 minutes or less.*

*The proposed time windows are system goals. For any individual patient, every effort should be made to provide reperfusion therapy as rapidly as possible.


Guideline


I IIa IIb III

Immediate transfer to a PCI-capable hospital for primary PCI is the recommended triage strategy for patients with STEMI who initially arrive at or are transported to a non –PCI-capable hospital, with an

FMC-to-device time system goal of 120 minutes or less.*

I IIa IIb III

In the absence of contraindications, fibrinolytic therapy should be administered to patients with STEMI at non –PCI-capable hospitals when the anticipated FMC-to-device time at a PCI-capable hospital exceeds 120 minutes because of unavoidable delays.



Guideline


I IIa IIb III

When fibrinolytic therapy is indicated or chosen as the primary reperfusion strategy, it should be administered within 30 minutes of hospital arrival.

*

I IIa IIb III

Reperfusion therapy is reasonable for patients with STEMI and symptom onset within the prior 12 to 24 hours who have clinical and/or ECG evidence of ongoing ischemia. Primary PCI is the preferred strategy in this population.




South Dakota

Page 1 –

Initial Treatment Guidelines

Definition of STEMI Patient

Blue section: Arrive by EMS

Starts the flowchart process

Follow the “yes” & “no”

Proceed to Page 2 or Page 3

Key items and goal in RED




South Dakota

Page 2 –

Primary PCI Patients

FMC – PCI less than 120 min.





South Dakota

Page 3 –

Fibrinolysis Patients

Greater than 120 min. to PCI

Door to Needle less than 30 min.

Contraindication to fibrinolysis



Mission:

Lifeline

Nebraska

STEMI EMS

Transport

Guideline

Draft


55

Mission:

Lifeline

Nebraska

STEMI EMS

Transport

Guideline

Draft


56

Mission:

Lifeline

Nebraska

STEMI EMS

Transport

Guideline

Draft


57

Mission:

Lifeline

Nebraska

STEMI EMS

Transport

Guideline


58

59

DIDO Goal

45 minutes or less

!

• Observed in-hospital mortality was significantly higher among patients with DIDO times >30 minutes than among those with

DIDO times <30 minutes

STEMI Statistics

• Acute Coronary Syndrome (ACS) will strike 935,000 people a year in the

United States, an estimated 250,000 of those will be STEMIs

• In 2011, 3,267 Nebraska Residents died from heart disease, according to the Nebraska Department of Health and Human Services.

• Heart disease is the #2 leading cause of death in Nebraska.

Heart Disease and Stroke Statistic 2011 Update: A Report From the American Heart Association

Statistics Committee and Stroke Statistics Subcommittee. Circulation 2011;123:e18-e209.

61

Opportunities for Improvement



Are patients not aware of S&S and calling 911, thus causing a delay in treatment/out of hospital death prior to treatment? This supports the need for enhanced public awareness/education.



Access to care? Do we currently have systems in place in which patients are not able to get to the appropriate facility in a timely fashion, thus supporting the need to improve systems of care so that patients are transported to a facility with a plan in place to treat based on guidelines.

4/16/2020 62

Public Awareness

4/16/2020

South Dakota

http:// www.youtube.com/watch?v=QMo07hyqugI http://www.youtube.com/watch?v=Zm5PJUMHPcQ

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Public Awareness

North Dakota

4/16/2020 64

Public Awareness

Minnesota

4/16/2020 65

PCI Referring Hospitals



What does pre-hospital STEMI activation look like at your facility? Do you routinely call for the next leg of transfer pre-arrival?

• What are the greatest barriers in obtaining a door in- door-out of 45 min or less?

• What are the greatest barriers to obtaining a door to lytic administration time of < 30 minutes

• What are the greatest barriers to obtaining a door to ECG time of < 10 minutes?

• How do we break down political barriers and develop a unified voice for

NE?


66

PCI Receiving Hospitals

• What mechanism is your facility currently utilizing for STEMI Data

Collection, Quality Improvement, Outreach and Feedback?

• What is the level of support for ACTION GWTG – ARG Participation at your facility?

• What are the greatest barriers within your network to achieving a:

– 90 FMC to Primary PCI reperfusion in your area? (non-transfers)

– 120 FMC to Primary PCI reperfusion in your area? (transfers)


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Going Forward



Bi-Annual Face to Face Taskforce Meeting



Annual NE STEMI Conference



Local, Regional, and State STEMI system of care development, optimizing the destination plans and protocols and feedback recommendation development.



Referring Hospital Education Curriculum Development and Delivery –

Learn Rapid STEMI ID and STEMI Provider Manual Distribution



Public Awareness Campaign Assessment, Development, and Delivery


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Going Forward



EMS Education Curriculum



Data Analysis and Quality Improvement



Model sharing



Public Media and Awareness campaign



Sustainability Plan Development


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Questions?

4/16/2020

Thank You!

2012 AHA Mission: Lifeline

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