Advancing the One Acute Care Network and Our Strategic Aims

Regional Cardiac ServicesDecember 2009

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Patient Story No local access to PCI results in more extensive heart damage for patients.

A 62 year old man presented to the emergency department by ambulance at 0930 hours. He reported an episode of chest pain at work followed by a loss of consciousness and collapse. His ECG showed ST elevation in the anterior leads. He received TNK (pharmacotherapy) after he had undergone a CT scan of his head to rule out a hemorrhage related to the fall. Following the TNK his chest pain and ECG changes persisted and the patient was transferred at 1250 hours to Kingston General Hospital for rescue PCI. He was found to have an occlusion of his mid left anterior descending coronary artery which was successfully opened and stented, more than 8 hours after the onset of pain. The left ventriculogram done during the procedure showed that the patient had substantial damage to his heart which after 8 hours of ischemia would be very likely permanent. He was discharged home after the usual stay with extensive bruising on his face and on his hip as a result of the fall and TNK administered after admission.

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Objectives

• Obtain CE LHIN Approval to sustain the RVHS STEMI Pilot Project

• Obtain CE LHIN Endorsement of the PRHC Plan to establish a PCI / STEMI service

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Our Shared Vision

‘One Acute Care Network’

Improved and equitable patient access to an integrated hospital system

that provides the highest quality of care across the Central East LHIN

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‘One Acute Care Network’ - Role of Hospitals

• Services needed by the local population, access through the Local facility and utilization of resources and expertise pertinent to the patient needs.

• Ability to provide core, emergency-driven services as they relate to the respective clinical programs.

Role 1: Local Centre

Role 2: District Centre

Role 3: LHIN-wide Centre

• Services are located at one institution for populations with several or many surrounding communities.

• Hospitals will capture a large proportion of residents who may require certain types of subspecialty programs, yet do not need to travel to a LHIN-wide Centre

• Specialized services that will promote access LHIN-wide.• Programs may be located at 1 or 2 sites.• These site(s) will have the critical mass required to sustain quality standards of care and

clinical efficiencies.

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Definitions

Diagnostic Cardiac Catheterization• Procedure in which the cardiologists can view the blood flow in the

arteries and see any blockages.Percutaineous Coronary Intervention (PCI)• Invasive procedure that treats narrowed coronary arteries via the use of

a catheter which could occur using several strategies.STEMI• ST-Elevation Myocardial Infarction.Code STEMI• Strategy of PCI as the first definitive maneuver to achieve reperfusion

of the occluded infarct related artery replacing use of thrombolytics and treatment time within 90 minutes.

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Vascular and Related In Patient Hospital Days 2008-09

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Cardiac Services Recommended Future State Model

Recommendation Timelines

1. Cardiac services across the LHIN should be organized to reflect two clusters – North East/Durham, Scarborough/Durham. Percutaneous Coronary Intervention (PCI) services should be located at PRHC and RVHS-Centenary to serve the Central East LHIN.

Short-Term

2. Inherent in this model is the role that the other sites will continue to play in the overall delivery of care; Local facilities will continue to provide core, emergency-related cardiac services with Local and District sites offering general cardiac consults, and non-interventional diagnostics.

Short-Term

3. This option will also weave in an integrated approach to delivering cardiac rehabilitation services, similar to a hub-and-spoke manner. Medium-Term

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Proposed Cardiac Service Delivery Model

• LHIN residents receive the most appropriate cardiac services as close to home as possible

• Integrated program delivery through effective communication channels and appropriate transfer/repatriation agreements

• Leverage established cardiac expertise, infrastructure, and resources at PRHC and RVHS- Centenary

• Strategic decision-making to minimize service duplication and effectively plan for program expansion

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‘One Acute Care Network’ – Cardiac ServicesCluster Local Centres District Centres LHIN-wide Centre*

North East Cluster

Haliburton HighlandsCampbellford Memorial

Northumberland HillsRoss Memorial

Peterborough Regional

Durham Cluster

Lakeridge BowmanvilleLakeridge Port Perry

Rouge - Ajax/PickeringLakeridge Oshawa

Peterborough RegionalOR Rouge - Centenary

Scarborough Cluster

Scarborough GraceScarborough General

Rouge - Centenary

Basic Diagnostic, Stabilization & Rehabilitation

AdvancedProcedures *

Note: * Patients return to Local and District Centres after receiving advanced procedures,for closer to home care when appropriate

Level of Care Basic Diagnostic, Stabilization & Rehabilitation Specialized Physicians

& Equipment

Basic Diagnostic, Stabilization & Rehabilitation

Specialized Physicians & Equipment

Basic Diagnostic, Stabilization & Rehabilitation

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PCI and STEMI

CSP Cardiac Objective

• For patients with ST-segment Elevation Myocardial Infarctions (STEMI), access to primary angiography and revascularization treatment will be provided within 90 minutes.

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Efforts to Date

CE Cardiac Steering Committee Formed– Rouge Valley Health System: Dr. Joe Ricci, Bryna Rabishaw– Peterborough Regional Health Centre: Dr. Peter McLaughlin,

Jayne White

• Development of Terms of Reference• Principles and Priorities agreed upon

– PCI and STEMI• Assumptions of Integration passed• CE LHIN Cardiac Integration Consultant Posted

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PCI / STEMI Current Status

RVHS• MOHLTC Approved Stand-Alone

PCI Centre• Partnership with St. Mike’s

(Toronto Central)• STEMI Pilot underway• STEMI program requires LHIN

support for sustainability• Meeting/Exceeding Cardiac

Volumes

PRHC• Cath lab support by local and UHN

cardiologists• Seeking MOHLTC approval on

Stand-Alone PCI Centre since 2008– MOHLTC/CNN Evaluation

underway hindering approvals• No PCI / STEMI – Patients

primarily transferred to UHN (Toronto Central)

• Meeting Cardiac Volumes

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PCI and STEMI: Background

• 1997: Cardiac Care Network (CCN)’s Expert Panel on Intracoronary Stents recommended an increase in the number of Percutaneous Coronary Interventions (PCI) performed relative to the number of Coronary Artery Bypass Graft Surgeries (CABG), considered the standard of care at the time.

• 2001: MOHLTC pilots first stand-alone PCI centre at RVHS. Following promising evaluation, MOHLTC funded two additional stand-alone PCI centres at Thunder Bay Regional Health Sciences Centre and Windsor’s Hotel-Dieu Grace Hospital

• 2004: CCN’s Target Setting Consensus Panel recommended provincial targets for diagnostic catheterizations and PCI of 728 per 100,000 and 260 per 100,000 respectively.

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Cardiac Pathway: Emergency Patients

• Patients present to the Emergency Department (ED) exhibiting acute cardiac symptoms such as pain and discomfort, shortness of breath, and/or nausea.

• Patient is triaged as CTAS Level 2 by a nurse. • An ECG and blood work are completed immediately in order to distinguish

among Unstable Angina (UA), Non-ST-segment elevation myocardial infarction (NSTEMI), or a ST-segment elevation myocardial infarction (STEMI).

• Classification of each patient is established by changes on the ECG and by the presence or absence of cardiac markers in the blood. This classification is important as the prognosis and treatment differs for each pathology.

– Both UA and a NSTEMI are similar clinical pathologies and therefore are treated by following the same clinical pathway.

– STEMI is considered to be distinct clinical entity requiring a separate clinical pathway.

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Cardiac Pathway

NSTEMI/UA Pathway• Following diagnosis, medications are administered based on

standardized pre-printed orders as part of an evidence-based clinical pathway.

• Within a day of admission, the patient is sent to the Cath Lab for a semi-urgent catheterization to ascertain the coronary anatomy and the plan for further management if suitable for PCI.

• Patient is transferred to a tertiary cardiac centre for the PCI. Dependent on patient stability, wait times for the PCI proceedure can be up to 7 days.

• Following transfer and procedure, patient is discharged after a 24 hour inpatient stay. The patient is then followed up by his or her cardiologist or family doctor.

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Cardiac PathwaySTEMI Pathway• Once the patient is diagnosed with a STEMI, thrombolytic medications are

administered. If the patient is successfully reperfused (if circulation in the heart is restored), he or she is transferred from the emergency department to the ICU.

• If the reperfused patient is deemed to be medically stable, a transfer to the cath lab is arranged and the patient undergoes an angiogram to determine the need for a PCI or CABG. In the case where the angiogram reveals that a blockage remains, the CCN coordinator makes the appropriate arrangements for a transfer to a tertiary centre for a PCI or CABG.

• If the reperfused patient became unstable in the ICU, or if the thrombolytic medications were ineffective and the patient was not reperfused, an urgent transfer to the tertiary centre via Emergency Medical Services (EMS) for a rescue PCI is quickly arranged.

• The patient is discharged post PCI after a 24 hour inpatient stay, and is then follow-up by a cardiologist or family doctor and referred to a rehabilitation program.

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PCI/STEMI Supports CE LHIN Strategic Aims

• PCI is the treatment of choice as it is less invasive than CABG, reducing the risk of complications, inpatient lengths of stay, overall recovery time, and improving quality of care.

• ED Strategic Aim– PCI as initial treatment of STEMI rather than pharmacotherapy

(i.e., "Primary PCI") results in reduced recurrent myocardial infarction (MI) and reducing re-admissions

• Vascular Strategic Aim– PCI as initial treatment of STEMI rather than pharmacotherapy

(i.e., "Primary PCI") results in reduced stroke and hospital length of stay.

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ED Strategic Aim

RVHS Pilot results show reduced ED visits:

• ED utilization will be more efficient with direct or early transfer to Catheterization laboratory (Cath Lab). For those STEMI cases that are identified in the field, EMS transfers directly to the Cath Lab and therefore bypasses the ED entirely.

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ED Strategic Aim

RVHS Pilot results show reduced ED LOS

• The goal of Code STEMI is 90 minutes D2B as per the Primary PCI protocol. As a result, the length of the stay for a STEMI patient in ED was significantly reduced by 7 hours as compared to Q1, 2008.

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Vascular Aim

RVHS Pilot results show reduced vascular-related hospital days

• Overall ALOS is reduced for STEMI patients through the implementation of Code STEMI as a result of early recognition and immediate access to interventional cardiology and PCI. The ALOS of all STEMI patients is reduced by 0.6 days and the ALOS of STEMI patient whose entry is through Emergency is reduced by 2 days.

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RVHS STEMI Pilot

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CE LHIN Code STEMI Pilot: Volume Distribution

Code STEMI Cases(excluding False Positives, Aborted Cases and Urgent Caths)

February - November 2009

RVHS32%

Scar Gen26%

Field (EMS)21%

Scar Grace21%

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CE LHIN Code STEMI Pilot: Outcomes

RVHSFebruary 2009

RVHSNovember 2009

Total RVHS Pilot

(10 months)

Median Door to Balloon Time (DTBT)

84 minutes 70 minutes 84 minutes

% patients DTBT within 90 minutes

53% 75% 59%

# Day PCI Cases Rescheduled

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Code STEMI Pilot Median Door to Balloon Time by Source

February - November 2009

82.5

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CE LHIN Regional Code STEMI Pilot Successes

• More than half of patients in pilot met 90 minute Door to Balloon Time (DTBT) target

• Significant improvement in DTBT during the course of 10 month pilot period

• Engagement and collaboration between interdisciplinary professionals from all regional partners

• Regular multidisciplinary implementation rounds for case review and continuous process improvement

• Quality improvements implemented to maximize resource utilization for DTBT

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Current Status of CE LHIN Regional Code STEMI Initiative

• 24/7 Primary PCI service implemented with Toronto EMS with significant financial and patient flow impact on current RVHS resources

• 24/7 service not extended to Durham patients– Durham EMS ready to initiate service but requires operational

support

RVHS cannot continue pilot or extend service to Durham without additional resource allocation of at least the highest priority resource requirement

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RVHS Code STEMI Program Resolution

Integration Through Funding• Integration/Letters of Support from

– TSH, LHC• Funding Required:

– 2009-10: $239,000 One Time Start Up; $350 ICU/CCU Bed– 2010-11: $500,000 for additional ICU / CCU Bed

• RVC ICU/CCU:– CCU Occupancy higher than provincial average (84%)– High rates of Inter-LHIN patient transfers (14.5%)– ICU – very high % of Ventilator Patient Day (71%)– Proposal supported by CE LHIN Critical Care Lead

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Peterborough Regional PCI / STEMI

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PRHC PCI / STEMI Program

• CE LHIN Endorsement of PRHC’s intention receive MOHLTC approval to establish a stand-alone PCI service

– Funding requirements and timelines to be negotiated following MOHLTC approval of PRHC’s request

• CE LHIN Endorsement recognizing PRHC PCI/STEMI as the most significant priority for regional cardiac program.

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Benefits of a Stand-Alone PCI Centre (PRHC)

• Improving patient flow by being able to offer treatment to the patient on-site rather than sending them out of the region; reducing wait times by adding PCI capacity to the system; improving the standard of care and outcomes for STEMI patients via the availability of Primary PCI

– Best practice prescribes a door-to-balloon time of 90 minutes or less for Primary PCI. The current distance which must be travelled in order to receive PCI compromises clinical outcomes and prognosis.

– prevent up to 4-5 patients from experiencing death, repeat MI, or stroke per year, and translate into a $228,000 treatment cost savings to the system within the first six months post MI, annually, based on CCN estimates

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Benefits of a Stand-Alone PCI Centre (PRHC) – cont’d

• Reducing Cath Lab utilization by avoiding a second procedure via the availability of ad hoc PCI

• Free up Intensive Care Unit (ICU) and telemetry beds as semi-urgent patients are no longer waiting for a transfer to a tertiary centre for the PCI proceedure.

• Reduce transportation costs on system, patients and families.– Costs of a second admission and patient transfer would also be

incurred. Patient transfer costs for emergency medical services could be as high as $750 for a 150km transfer.

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Support for PRHC PCI / STEMI

• PRHC Underserved for Cath and PCI– potential projected need for 1,062 PCI cases by 2008/09 in the

Peterborough region, which is almost twice the volume currently being offered via referral to other institutions (574 in 2006/07).

• The gap between projected targets and volumes is greater when one factors in the higher AMI rates in PRHC’s four counties, and the accordingly increased specific target procedure rates.

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