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RACE: Reperfusion of acute myocardial infarction in North Carolina emergency departments Christopher Granger, MD Director, Cardiac Care Unit Duke University Medical Center Durham, NC. R eperfusion in A MI in C arolina E mergency Departments. - PowerPoint PPT Presentation
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RACE: Reperfusion of acute myocardial
infarction in North Carolina emergency
departments
Christopher Granger, MDDirector, Cardiac Care Unit
Duke University Medical CenterDurham, NC
Reperfusion in AMI in Carolina Emergency Departments
A Systems Approach To Improve Survival of Patients with Myocardial Infarction In North Carolina Through
Improved Application of Reperfusion Therapy
Importance of TimeMortality reduction versus treatment delay
Boersma. Lancet 1996; 348:771-5.
Ab
solu
te b
en
efit
pe
r 1
00
0 p
atie
nts
tre
ate
d
Treatment delay (hours)
35 day mortality 1.6 lives per 1000 lost per hour delay to randomization
In first hour, up to 40 lives per 1000 lost per hour of delay
1.6 lives per 1000 lost per hour delay to randomization
In first hour, up to 40 lives per 1000 lost per hour of delay
Door-to-Balloon & 30-d MortalityDoor-to-Balloon & 30-d Mortality
Door-Balloon Times (minutes)Door-Balloon Times (minutes)Door-Balloon Times (minutes)Door-Balloon Times (minutes)
P=0.005P=0.005P=0.005P=0.005
4.44.0
3.5
2.4
0%
2%
4%
6%
<60 60-90 90-120 >120
4.44.0
3.5
2.4
0%
2%
4%
6%
<60 60-90 90-120 >120
Hudson ACC 2007Hudson ACC 2007Hudson ACC 2007Hudson ACC 2007
30-d
ay M
ort
alit
y30
-day
Mo
rtal
ity
30-d
ay M
ort
alit
y30
-day
Mo
rtal
ity
Optimizing the SystemOptimizing the System
Understand what the System is:
Begins with the patient
Prehospital environment
Emergency Department (both non-PCI & PCI)
Cardiology interface
Catheterization laboratory for PCI, or fibrinolytic drug administration
Understand what the System is:
Begins with the patient
Prehospital environment
Emergency Department (both non-PCI & PCI)
Cardiology interface
Catheterization laboratory for PCI, or fibrinolytic drug administration
Can patients be transferred by Can patients be transferred by helicopter for primary PCI with helicopter for primary PCI with
1st door to balloon of <100 1st door to balloon of <100 minutes?minutes?
Can patients be transferred by Can patients be transferred by helicopter for primary PCI with helicopter for primary PCI with
1st door to balloon of <100 1st door to balloon of <100 minutes?minutes?
Zone II (60-120 miles)Zone II (60-120 miles)
Facilitated PCIFacilitated PCI (1/2 dose TNK plus PCI) (1/2 dose TNK plus PCI)
Goal door to balloon times of 90-120 minutesGoal door to balloon times of 90-120 minutes
(actual = 116 minutes in first 82 patients)(actual = 116 minutes in first 82 patients)
Standardized protocolZone I (60 miles)Zone I (60 miles)
Primary PCIPrimary PCI
Goal of door to balloon < 90 minutesGoal of door to balloon < 90 minutes
(actual = 96 minutes in first 232 patients)(actual = 96 minutes in first 232 patients)
Can Systems be Developed to Can Systems be Developed to Safely Bypass non-PCI centers?Safely Bypass non-PCI centers?Can Systems be Developed to Can Systems be Developed to Safely Bypass non-PCI centers?Safely Bypass non-PCI centers?
BOSTONBOSTON In the field ECGIn the field ECG Diversion of STEMI to closest PCI hospitalDiversion of STEMI to closest PCI hospital Hospitals will never be on diversion for ST-Hospitals will never be on diversion for ST-
elevation MI (similar to trauma center plan)elevation MI (similar to trauma center plan) Each hospital will perform a minimum of 36 Each hospital will perform a minimum of 36
primary PCI or rescue PCI procedures / year primary PCI or rescue PCI procedures / year PCI will be performed within 120 minutes of PCI will be performed within 120 minutes of
hospital arrival (ie, door-to-balloon time of hospital arrival (ie, door-to-balloon time of 120 minutes) in 75% of “ideal” patients120 minutes) in 75% of “ideal” patients
STEMI System
The ProblemNRMI-5: North Carolina, July 2003-June 2004
The ProblemNRMI-5: North Carolina, July 2003-June 2004NC Nation
GuidelinesN 2,738 79,927
% eligible treated 81% 80%
Door-balloon 101 min 100 min <90 min
11PM to 7AM 107 min
Weekend 105 min
Transfer
1st door – balloon 191 min 165 min <90 min
1st d-b <90 min 0.8% 5.5%100%
NC NationGuidelinesN 2,738 79,927
% eligible treated 81% 80%
Door-balloon 101 min 100 min <90 min
11PM to 7AM 107 min
Weekend 105 min
Transfer
1st door – balloon 191 min 165 min <90 min
1st d-b <90 min 0.8% 5.5%100%
1
2
3
4
1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005
1
2
3
4
1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005
Ho
urs
(M
ed
ian
)H
ou
rs (
Me
dia
n)
Transfer Times and Delay: Transfer Times and Delay: STEMI Patients Transferred to Another STEMI Patients Transferred to Another Hospital and Received Primary PCIHospital and Received Primary PCI
Transfer Times and Delay: Transfer Times and Delay: STEMI Patients Transferred to Another STEMI Patients Transferred to Another Hospital and Received Primary PCIHospital and Received Primary PCI
Door to Balloon
Door to Door
4.0
2.6
1.8
2.8
Year of DischargeYear of Discharge
NRMI 2NRMI 2 NRMI 3NRMI 3 NRMI 4NRMI 4 NRMI 5NRMI 5
Symptom-admissionSymptom-admission1st door - 2nd door1st door - 2nd door
Admission-randomizationAdmission-randomizationRandomization-PCIRandomization-PCI
1.41.41.41.4 0.30.3
0.70.7
0.40.4
0.50.5
00 11 22 33 44
TransferTransfer
No transferNo transfer
1.61.6
1.71.7
36% Transferred in APEX: 80 minutes 1st to 2nd door “transfer time,” but
only 45 minutes longer door-to-balloon
36% Transferred in APEX: 80 minutes 1st to 2nd door “transfer time,” but
only 45 minutes longer door-to-balloon
Widimsky ACC 2007Widimsky ACC 2007Widimsky ACC 2007Widimsky ACC 2007
RACE Objectives
Improve the public health of North Carolina residents by:
Reducing the eligible STEMI population untreated with reperfusion by 20% (i.e., 20% untreated to 16% untreated).
Increasing the speed of reperfusion toward national benchmarks of
90 minutes door to balloon for Primary PCI and
30 minutes for fibrinolytic therapy.
Establishing regional systems of acute MI care with emergency departments throughout North Carolina.
AMI Guidelines 2004
JACC 2004;44:686.Guidelines available on the Web site: www.acc.org
Asheville
Winston-Salem
Durham/Chapel Hill/Greensboro
GreenvilleCharlotte
Reperfusion of AMI in Carolina Emergency Departments (RACE)
Maddox/HathawayHunt/Horrine
Maddox/HathawayHunt/Horrine
BohleHoekstra/Applegate
BohleHoekstra/Applegate
Babb/ShiberBabb/ShiberAluko/FletcherValerie/WatlingWilson/Garvey
Aluko/FletcherValerie/WatlingWilson/Garvey Granger/Jollis/Stoufer
Wilson/Pulsipher/Beaton/MearsGranger/Jollis/Stoufer
Wilson/Pulsipher/Beaton/Mears10 PCI Centers58 non-PCI Centers
40 mile radius40 mile radius40 mile radius40 mile radius
Henderson to Durham:Henderson to Durham:40 mile drive40 mile driveHenderson to Durham:Henderson to Durham:40 mile drive40 mile drive
Interventional Interventional cardiologist home to cardiologist home to Duke 20 minutesDuke 20 minutes
Interventional Interventional cardiologist home to cardiologist home to Duke 20 minutesDuke 20 minutes
Local EMSLocal EMSLocal EMSLocal EMS
11:00 PM11:00 PM11:00 PM11:00 PM
11stst door to balloon (BMS) door to balloon (BMS) 84 min84 min
11stst door to balloon (BMS) door to balloon (BMS) 84 min84 min
RACEReperfusion in AMI in North
Carolina Emergency Departments
OBJECTIVES
• Regional approach to overcoming systematic barriers
1) Increase reperfusion rate
2) Increase speed of reperfusion
Organizeregions
Baselinedata
Intervention Postdata
CQI…RACEPhase 3
2 years
PresentationPresentation
Only 12% of patients presenting did NOT have CP upon presentation.
Median age 63 yrs; 33% female Door to ECG
Median 11 min (5,25)
Pre-Intervention DataHospital Arrival Mode
42%
57%
EMS Self Transport
n=515
RAPID EKG CRITERIARAPID EKG CRITERIADoor to decision 10 minutesDoor to decision 10 minutes
30 YEARS OLD with suspicious CHEST PAIN(EXCLUDING OBVIOUS TRAUMA)
50 YEARS OLD with:
SyncopeWeakness
Rapid Heart Beat / PalpitationsDifficulty Breathing / Shortness of Breath
Graff L, Palmer AC, LaMonica P, Wolf S.Annals Emerg Med. December 2000;36:554-560.
Transfer for Consideration of Primary PCI
• 192/519 (37%) transferred for consideration for PPCI
• Time from non-PCI ED arrival to non-PCI ED departure median 89 minutes
• State NRMI 5 2005 First door to balloon inflation in transfer-in Patientsn=376 median 156 minutes (2:05,3:40) Only 2.9% of NC transfer-in patients make balloon up
in < 90 minutes!
Thrombolytics in Non-PCI Centers in North Carolina
• 45% received lytics (n=235/519)
• Median Door to Lytic 35 min (25,53)
• 34% patients received lytics in < 30 minutes, ACC/AHA Guideline Goal
D2B:An Alliance for Quality A Guidelines Applied in Practice (GAP) Program
JACC 2006;48:1911-12.
D2B Goal
To achieve a door-to-balloon time of </= 90 minutes for at least 75% of non-transfer primary PCI patients with ST-segment elevation myocardial infarction in all participating hospitals performing primary PCI.
As of March 2007, over 800 centers signed up as participants.
Bradley E et al. N Engl J Med 2006;355:2308-2320
Median Door-to-Balloon Times among Study Hospitals (n=365)
Mean (of medians) = 100 ± 24 minutes Mean (of medians) = 100 ± 24 minutes
Strategies and Door-to-Balloon Time SavedStrategies and Door-to-Balloon Time Saved
ED physicians activate the cath lab (8.2 minutes)
Single call to a central page operator activate the lab (13.8 minutes)
ED activate the cath lab while the patient is en route to the hospital (15.4 minutes)
Expecting staff to arrive in the cath lab within 20 minutes after being paged (vs. >30 minutes) (19.3 minutes)
Attending cardiologist always on site (14.6 minutes)
Having staff in the ED and the cath lab use real-time data feedback (8.6 minutes)
ED physicians activate the cath lab (8.2 minutes)
Single call to a central page operator activate the lab (13.8 minutes)
ED activate the cath lab while the patient is en route to the hospital (15.4 minutes)
Expecting staff to arrive in the cath lab within 20 minutes after being paged (vs. >30 minutes) (19.3 minutes)
Attending cardiologist always on site (14.6 minutes)
Having staff in the ED and the cath lab use real-time data feedback (8.6 minutes)
Bradley N Engl J Med 2006;355:2308-2320
Bradley E et al. N Engl J Med 2006;355:2308-2320
Door-to-Balloon Time According to the Number of Key Strategies Used
Population n Door-to-balloon Time
Historical 15 112 (80, 140)
EMS not using hotline 15 92 (78,110)
EMS using hotline 20 58 (54,71)
Direct Activation of Duke Cath Lab Based on Pre-Hospital ECG by Durham EMS
Strauss J Electrocard 2007
RACE Manual http://www.nccacc.org/race.htmlhttp://www.nccacc.org/race.html
EMS (prehosp ECG, transport)
ED (guideline-based algorithms, training, feedback)
Transfer (single contact, fastest option, streamline,automatic cath lab activation)
Receiving hospital (“hotline” approach)
Cath lab (automatic activation)
Other system issues – communication, feedback, interdisciplinary team, payers, regulations
RACERACEReperfusion in Acute myocardial infarctionReperfusion in Acute myocardial infarctionin Carolina Emergency Departmentsin Carolina Emergency Departments
Operations ManualOperations Manual
Granger CB, Jollis JG, et al.Granger CB, Jollis JG, et al.For the North Carolina For the North Carolina RACE steering committeeRACE steering committeeVersion 1.2Version 1.2March 2005March 2005
Optimal system specifications for each component of AMI care
Top Ten List
10. Use local ambulance to transport pts (within ~50 miles)
9. Keep patient on local ambulance stretcher
8. Give heparin bolus (70 U/kg) and no IV infusion
7. Establish protocol for lytics vs PCI for each ED
6. Establish single call number to PCI centers that "automatically" activates cath lab
5. Provide standardized feedback reports
4. System for rapid triage of walk-ins, rapid ECGs
3. Prehospital ECGs for all CP pts (and ED use them!)
2. "Certify" all EMTs/paramedics to read ST on ECGs, immediately activate reperfusion (lytics or cath lab)
1. Create EMS, ED, cardiology team with committed leadership
Emergency Cardiovascular Care 2007: Building Regional Integrated STEMI
Systems for ReperfusionACC Sponsored Meeting with goal to teach and enable teams to establish effective regional STEMI
reperfusion systems
June 1-2, 2007, Washington, DC