Code STEMI at CMMCCode STEMI at CMMC

William J. Phillips, MD, FACC

Director of Cardiology

November 10, 2011

William J. Phillips, MD, FACC

Director of Cardiology

November 10, 2011

Faculty Disclosure Information

FINANCIAL DISCLOSURE:

None

William J. Phillips, MD, FACC, FSCAI

””””

UNLABELED/UNAPPROVED USES DISCLOSURE:UNLABELED/UNAPPROVED USES DISCLOSURE:

None

POTENTIAL CONFLICTS OF INTEREST:

Employed by CMMC as an Interventional Cardiologist

CMHVI: PCI and Heart surgery close to home since May, 2003CMHVI: PCI and Heart surgery close to home since May, 2003

Heart Disease FactsHeart Disease Facts

Cardiovascular disease (CVD) #1 killer since 1900

2,500 Americans die of CVD each dayEstimated Costs: $403.1 billion dollars in 2006

Cardiovascular disease (CVD) #1 killer since 1900

2,500 Americans die of CVD each dayEstimated Costs: $403.1 billion dollars in 2006

Heart Attack is a major form of CVD1.2 million coronary attacks estimated per year

Nearly half of these people will die330,000 coronary heart disease deaths occur out-of-hospital, or in the Emergency Department each year

Heart Attack is a major form of CVD1.2 million coronary attacks estimated per year

Nearly half of these people will die330,000 coronary heart disease deaths occur out-of-hospital, or in the Emergency Department each year

Begin with the end in mind!Begin with the end in mind!

CMHVI began amidst some controversy!

Commitment to evidenced based medicine

Expectation that our earliest patients would likely be emergent or urgent cases, where

CMHVI began amidst some controversy!

Commitment to evidenced based medicine

Expectation that our earliest patients would likely be emergent or urgent cases, where likely be emergent or urgent cases, where travel to a more established center was not an option

Therefore, Primary PCI was an early emphasis. We knew we had to do a great job with our Acute MI patients!

likely be emergent or urgent cases, where travel to a more established center was not an option

Therefore, Primary PCI was an early emphasis. We knew we had to do a great job with our Acute MI patients!

What is Primary PCI?What is Primary PCI?

Primary PCI is when the initial treatment for an Acute MI is the use of balloon angioplasty and/or a stent, to open a

Primary PCI is when the initial treatment for an Acute MI is the use of balloon angioplasty and/or a stent, to open a angioplasty and/or a stent, to open a completely closed coronary artery that is responsible for the heart attack.

angioplasty and/or a stent, to open a completely closed coronary artery that is responsible for the heart attack.

Primary PCIPrimary PCI

Why do it?

How do you do it?

How do you do it faster?

How do you decide between

Why do it?

How do you do it?

How do you do it faster?

How do you decide between How do you decide between thrombolytic or primary PCI, especially at a non-PCI center?

…like most community hospitals in Maine?

How do you decide between thrombolytic or primary PCI, especially at a non-PCI center?

…like most community hospitals in Maine?

Why Do We Do PPCI?Why Do We Do PPCI?

Fibrinolytic Rx for STEMI limited by inadequate reperfusion and/or reocclusion in ~25% of pts.

An occluded infarct-related artery is

Fibrinolytic Rx for STEMI limited by inadequate reperfusion and/or reocclusion in ~25% of pts.

An occluded infarct-related artery is An occluded infarct-related artery is associated with a doubling of long-term mortality.

An occluded infarct-related artery is associated with a doubling of long-term mortality.

0 8 16 24 32 40 480

5

10

15

20

Occluded

Patent

Weeks

Mo

rtali

ty (

%)

Dalen, Gore, Braunwald et al.Am J Cardiol 1988; 62:179.

Evidence for the open

artery hypothesis:

TIMI 1

PPCI vs. ThrombolysisPPCI vs. Thrombolysis

Lower mortality

Lower reinfarction

Fewer complications

Fewer strokes

Lower mortality

Lower reinfarction

Fewer complications

Fewer strokesFewer strokes

But…. Many more variables may be at work in achieving clinical trial-like results.

And it was controversial, because it challenged community practice and referral bias.

Fewer strokes

But…. Many more variables may be at work in achieving clinical trial-like results.

And it was controversial, because it challenged community practice and referral bias.

Nallamothu/Bates: 2003…Nallamothu/Bates: 2003…

93 minutes93 minutes

NRMI 2: Primary PCI DoorNRMI 2: Primary PCI Door--toto--Balloon Time Balloon Time vs. Mortalityvs. Mortality

NRMI 2: Primary PCI DoorNRMI 2: Primary PCI Door--toto--Balloon Time Balloon Time vs. Mortalityvs. Mortality

MV

Ad

jus

ted

Od

ds

of

De

ath

MV

Ad

jus

ted

Od

ds

of

De

ath

P=0.01P=0.01 P=0.0007P=0.0007 P=0.0003P=0.0003

DoorDoor--toto--Balloon Time (minutes)Balloon Time (minutes)

MV

Ad

jus

ted

Od

ds

of

De

ath

MV

Ad

jus

ted

Od

ds

of

De

ath

P=0.01P=0.01 P=0.0007P=0.0007 P=0.0003P=0.0003

n = 2,230n = 2,230 5,7345,734 6,6166,616 4,4614,461 2,6272,627 5,4125,412

PP=0.00=0.0011

PP=0.00=0.0011

Importance of DoorImportance of Door--toto--Balloon Time: Balloon Time: 3030--Day Mortality in the GUSTODay Mortality in the GUSTO--IIb CohortIIb Cohort

Importance of DoorImportance of Door--toto--Balloon Time: Balloon Time: 3030--Day Mortality in the GUSTODay Mortality in the GUSTO--IIb CohortIIb Cohort

Mo

rta

lity

(%

)M

ort

ality

(%

)

TIME DEPENDENT OUTCOME DIFFERENCES ARE MUCH GREATER IN THE FIRST HOUR!

© © CM Gibson 2006CM Gibson 2006

Berger PB, et al. Circulation. 1999;100:14-20.Berger PB, et al. Circulation. 1999;100:14-20.

Door-to-Balloon Time (minutes)Door-to-Balloon Time (minutes)

Mo

rta

lity

(%

)M

ort

ality

(%

)

>< PTCA not performedPTCA not performed

Primary PCI: AHA/ACC Guidelines

STEMI patients presenting to a hospital with PCI

capability should be treated with primary PCI within

90 min of first medical contact as a systems goal.

III IIaIIaIIa IIbIIbIIb IIIIIIIIIIII IIaIIaIIa IIbIIbIIb IIIIIIIIIIII IIaIIaIIa IIbIIbIIb IIIIIIIIIIIaIIaIIa IIbIIbIIb IIIIIIIII

9803mo01, 13

STEMI patients presenting to a hospital without PCI

capability, and who cannotcannotcannotcannot be transferred to a PCI

center and undergo PCI within 90 min of first

medical contact, should be treated with fibrinolytic

therapy within 30 min of hospital presentation as a

systems goal, unless fibrinolytic therapy is

contraindicated.

III IIaIIaIIa IIbIIbIIb IIIIIIIIIIII IIaIIaIIa IIbIIbIIb IIIIIIIIIIII IIaIIaIIa IIbIIbIIb IIIIIIIIIIIaIIaIIa IIbIIbIIb IIIIIIIII

Trends in Prehospital Delay in Patients with AMITrends in Prehospital Delay in Patients with AMI

5967 pts with AMI from 1986 to 2005

Mean and median delays unchanged in 20 years

4.6 and 2.0 hours in 2005 (1/2 patients

5967 pts with AMI from 1986 to 2005

Mean and median delays unchanged in 20 years

4.6 and 2.0 hours in 2005 (1/2 patients 4.6 and 2.0 hours in 2005 (1/2 patients are more than 2 hours)

Longer delays in older patients with DM or prior MI (higher risk patients)

Thrombolysis may be less effective and higher risk in these patients

4.6 and 2.0 hours in 2005 (1/2 patients are more than 2 hours)

Longer delays in older patients with DM or prior MI (higher risk patients)

Thrombolysis may be less effective and higher risk in these patients

AJC, Dec. 15, 2008, p1589ff, Worcester Heart Attack Study

Treatment Delayed is Treatment DeniedTreatment Delayed is Treatment Denied

Symptom Recognition

Call to Medical System

ED Cath LabPreHospital

Delay in Initiation of Reperfusion Therapy

Increasing Loss of Myocytes

Primary Angioplasty was starting to hit the public eye.Primary Angioplasty was starting to hit the public eye.

What was optimal therapy, given the multiple issues?What was optimal therapy, given the multiple issues?given the multiple issues?given the multiple issues?

CHOICE: Selection of the Optimal Reperfusion CHOICE: Selection of the Optimal Reperfusion Options for the STEMI PatientOptions for the STEMI Patient

Full Dose Fibrinolytic Full Dose Fibrinolytic

MonotherapyMonotherapy if…if…

��Door to balloon (DDoor to balloon (D--B) B) > 90 min (?how much > 90 min (?how much greater)greater)

Full Dose Fibrinolytic Full Dose Fibrinolytic

MonotherapyMonotherapy if…if…

��Door to balloon (DDoor to balloon (D--B) B) > 90 min (?how much > 90 min (?how much greater)greater)

Primary PCI Primary PCI if…if…

�� Cardiogenic shock (age < 75)Cardiogenic shock (age < 75)

�� Bleeding riskBleeding risk

�� Diagnosis in doubt Diagnosis in doubt (pericarditis/aneurysm)(pericarditis/aneurysm)

�� Door to balloon < 90 minDoor to balloon < 90 min

Primary PCI Primary PCI if…if…

�� Cardiogenic shock (age < 75)Cardiogenic shock (age < 75)

�� Bleeding riskBleeding risk

�� Diagnosis in doubt Diagnosis in doubt (pericarditis/aneurysm)(pericarditis/aneurysm)

�� Door to balloon < 90 minDoor to balloon < 90 min��Lack of access to skilled Lack of access to skilled PCI centerPCI center

��(D(D--B) B) –– (D(D--N) > 1 hN) > 1 h

��< 3 h from symptom < 3 h from symptom onsetonset

��(TNK(TNK——62% TIMI 3 flow)62% TIMI 3 flow)

��Lack of access to skilled Lack of access to skilled PCI centerPCI center

��(D(D--B) B) –– (D(D--N) > 1 hN) > 1 h

��< 3 h from symptom < 3 h from symptom onsetonset

��(TNK(TNK——62% TIMI 3 flow)62% TIMI 3 flow)

�� Door to balloon < 90 minDoor to balloon < 90 min

�� Symptoms > 2Symptoms > 2--3 h3 h

�� Lytic failure or post lysisLytic failure or post lysis

�� Skilled PCI center available, defined Skilled PCI center available, defined by:by:

•• Operator experience > 75 cases/yrOperator experience > 75 cases/yr

•• Team experience > 36 primary Team experience > 36 primary PCI/yrPCI/yr

�� Age > 75Age > 75

�� (90+% TIMI 3 flow)(90+% TIMI 3 flow)

�� Door to balloon < 90 minDoor to balloon < 90 min

�� Symptoms > 2Symptoms > 2--3 h3 h

�� Lytic failure or post lysisLytic failure or post lysis

�� Skilled PCI center available, defined Skilled PCI center available, defined by:by:

•• Operator experience > 75 cases/yrOperator experience > 75 cases/yr

•• Team experience > 36 primary Team experience > 36 primary PCI/yrPCI/yr

�� Age > 75Age > 75

�� (90+% TIMI 3 flow)(90+% TIMI 3 flow)

Mortality in relation to therapy and delay

Mortality in relation to therapy and delay

7-day mortality

30-day mortality

1-year mortality

Prehospital thrombolysis (PHT)

Primary PCI (PCI)

Any time

Adjusted outcome by Cox regression analysis including 23 variables plus propensity score.

30-day mortality

1-year mortality

30-day mortality

1-year mortality

0,80,60,4 21,2 1,50,1 1 10in-hospital thrombolysis betterPCI or PHT better

Reperfusion started <=2 h

Reperfusion started >2 h

Adjusted outcome by Cox regression analysis including 23 variables plus propensity score.

JAMA 2006;296:1749

1-y

ea

r m

ort

ality

0.1

00

.15

0.2

0

TlysPCI

Primary PCI vs thrombolysisPrimary PCI vs thrombolysisageage--adjusted 1 year mortality in relation to delay timeadjusted 1 year mortality in relation to delay time

Thrombolysis

PCI

Time for reperfusion (h)

1-y

ea

r m

ort

ality

0 -

1

1 -

2

2 -

3

3 -

4

4 -

5

5 -

6

6 -

7

7-1

0

10-1

5

0.0

00

.05

0.1

0

Tlys 122 503 503 332 239 159 121 196 1391248 4375 3659 2199 1438 946 658 1061 703

PCI 7 61 81 50 43 37 17 41 31125 895 1126 776 567 453 282 458 332

Deaths / Patients

JAMA 2006;296:1749

Door to Balloon Time!Door to Balloon Time!

There was convincing evidence that PCI was better, if it could be done promptly

National attention began to focus on achieving the best D2B’s!

There was convincing evidence that PCI was better, if it could be done promptly

National attention began to focus on achieving the best D2B’s!achieving the best D2B’s!

Centers of excellence began to establish protocols that would speed diagnosis and care.

We felt that if we could treat trauma rapidly, we could treat STEMI as well.

achieving the best D2B’s!

Centers of excellence began to establish protocols that would speed diagnosis and care.

We felt that if we could treat trauma rapidly, we could treat STEMI as well.

Recognition of ST elevation by paramedics.

Whitbread, M. Emerg Med J 2002; 19(1):66-7.

Recognition of ST elevation by paramedics.

Whitbread, M. Emerg Med J 2002; 19(1):66-7.

Objective: To define the ability of paramedics to recognize ST-elevation using prehospital 12-lead EKG

Results:

Objective: To define the ability of paramedics to recognize ST-elevation using prehospital 12-lead EKG

Results:Results:

95% accuracy

91% specificity

97% sensitivity

No difference from ER physician results

Results:

95% accuracy

91% specificity

97% sensitivity

No difference from ER physician results

Recognition by paramedicsRecognition by paramedics

Conclusions:

Paramedics can recognize ST elevation using a 12 lead EKG.

Conclusions:

Paramedics can recognize ST elevation using a 12 lead EKG.

Radio transmission of an EKG may not be necessary to pre-alert hospital, is more expensive to implement, and in Maine, may not always be possible.

(what about cell phone photos?)

Radio transmission of an EKG may not be necessary to pre-alert hospital, is more expensive to implement, and in Maine, may not always be possible.

(what about cell phone photos?)

Policy SupportPolicy Support

AHA 2004 Guidelines

ACEP Policy Statement – June 1999

Out-of-hospital 12-lead EKG

AHA 2004 Guidelines

ACEP Policy Statement – June 1999

Out-of-hospital 12-lead EKGOut-of-hospital 12-lead EKG

National Association of EMS Physicians

Position Paper: Prehospital Triage of Chest Pain Patients

Out-of-hospital 12-lead EKG

National Association of EMS Physicians

Position Paper: Prehospital Triage of Chest Pain Patients

The PlanThe Plan

12 lead EKG Course & Repeat every 3 years

All patients with chest pain or possible

12 lead EKG Course & Repeat every 3 years

All patients with chest pain or possible All patients with chest pain or possible cardiac symptoms receive a prehospital 12-lead EKG

100% EKG review from March 1, 2004 –July 1, 2005

All patients with chest pain or possible cardiac symptoms receive a prehospital 12-lead EKG

100% EKG review from March 1, 2004 –July 1, 2005

Prehospital Activation of CMHVI Cath LabPrehospital Activation of CMHVI Cath Lab

United first service in state to activate cath lab

Started 7/05

Improved morale

United first service in state to activate cath lab

Started 7/05

Improved moraleImproved morale

Decreased door to balloon time

Other services immediately wanted to join

Improved morale

Decreased door to balloon time

Other services immediately wanted to join

Activation Inclusion CriteriaActivation Inclusion Criteria

ST elevation > 1mm in 2+ contiguous leads

Ongoing symptoms i.e. chest pain, SOB….

ST elevation > 1mm in 2+ contiguous leads

Ongoing symptoms i.e. chest pain, SOB….SOB….

Palpable lower extremity pulses

Ability to give informed consent (usually)

SOB….

Palpable lower extremity pulses

Ability to give informed consent (usually)

Service AreaService Area

Now there are approx. 17 approx. 17 ambulance services trained

Extending ActivationExtending Activation

Training

All services perform 12 lead EKG’s on potential cardiac patients

Training

All services perform 12 lead EKG’s on potential cardiac patientspotential cardiac patients

100% 12 lead EKG review

All services take a 20 EKG test and have to achieve 90% to pass

potential cardiac patients

100% 12 lead EKG review

All services take a 20 EKG test and have to achieve 90% to pass

Strategies for Reducing the Door-to-Balloon Time in Acute Myocardial InfarctionBradley, E.H., et al. NEJM 2006; 355:2308-20.

Strategies for Reducing the Door-to-Balloon Time in Acute Myocardial InfarctionBradley, E.H., et al. NEJM 2006; 355:2308-20.

Six strategies to a faster door-to-balloon time:

ER physicians activate cath lab (without waiting for cardiology confirmation) – 8.2 min

Single call to central page operator – 13.8 min

Prehospital cath lab activation (depending upon

Six strategies to a faster door-to-balloon time:

ER physicians activate cath lab (without waiting for cardiology confirmation) – 8.2 min

Single call to central page operator – 13.8 min

Prehospital cath lab activation (depending upon Prehospital cath lab activation (depending upon distance to hospital) – 15.4 min

Cath staff arrival < 30 min – 19.3 min

Having a cardiologist on site – 14.6 min

Real time data feedback to ED/Cath Lab – 8.6 min

Prehospital cath lab activation (depending upon distance to hospital) – 15.4 min

Cath staff arrival < 30 min – 19.3 min

Having a cardiologist on site – 14.6 min

Real time data feedback to ED/Cath Lab – 8.6 min

Profile CaseProfile Case

53 yo wm collapses at fire scene – 30 min by ground from CMMC-Vfib arrest

United ambulance – CPR-Defib-IV-O2

53 yo wm collapses at fire scene – 30 min by ground from CMMC-Vfib arrest

United ambulance – CPR-Defib-IV-O2United ambulance – CPR-Defib-IV-O2

12 lead EKG→Ant/Lat MI

United ambulance – CPR-Defib-IV-O2

12 lead EKG→Ant/Lat MI

Profile CaseProfile Case

Cath Lab and LifeFlight activated

3 min flight – 20 min D2B

Cath Lab and LifeFlight activated

3 min flight – 20 min D2B

Patient leaves hospital 3 days laterNeuro intact

Patient leaves hospital 3 days laterNeuro intact

Early Results Prehospital Activation

Early Results Prehospital Activation

Benchmark Times

80 min or less……………………100%

70 min or less……………………89%

60 min or less……………………78%

Benchmark Times

80 min or less……………………100%

70 min or less……………………89%

60 min or less……………………78%60 min or less……………………78%

40 min or less……………………44%

30 min or less……………………15%

60 min or less……………………78%

40 min or less……………………44%

30 min or less……………………15%

““In A HeartbeatIn A Heartbeat””

As many of you are aware, in April 2006, the Dirigo Health Agency's Maine

Quality Forum launched “In a Heartbeat”, a comprehensive initiative that creates an evidence-based treatment map for patients suspected of having a heart attack in Maine.

“In a Heartbeat” seeks to reduce death and disability that result from acute In a Heartbeat seeks to reduce death and disability that result from acute myocardial infarction (AMI) or heart attack, and involves partners from across the state, (Emergency Medical Services, medical providers, Maine Center for Disease Control and Prevention, community outreach groups, and health advocacy organizations, such as the American Heart Association), workingto ensure that Mainers who have heart attacks receive timely, quality care, regardless of where they live or work, and where they are treated.

http://www.mainequalityforum.gov/iahb_tt_invite.pdf

ER admit!

In A Heartbeat programIn A Heartbeat program

Agreed upon need for public education

Ongoing review of emergency services

Could not agree on a statewide priority for transporting STEMI patients to the

Agreed upon need for public education

Ongoing review of emergency services

Could not agree on a statewide priority for transporting STEMI patients to the for transporting STEMI patients to the closest PCI center!!! (unlike the Trauma protocol)

Data collection unfunded

Poster never produced or distributed

for transporting STEMI patients to the closest PCI center!!! (unlike the Trauma protocol)

Data collection unfunded

Poster never produced or distributed

Go in an Ambulance

• Person having a heart attack will be seen more quickly

• EMTs communicate with ER doctors

• ER can prepare for arrival• ER can prepare for arrival

• EMTs can monitor condition andbegin treatment

• Time saved is muscle saved

ACC databaseACC database“As reported in the 2007 Cath/PCI Registry Outcomes Report, the average Door to Balloon time was 118 minutes for the 767 hospitals reporting.

Central Maine Medical Center’s average time

“As reported in the 2007 Cath/PCI Registry Outcomes Report, the average Door to Balloon time was 118 minutes for the 767 hospitals reporting.

Central Maine Medical Center’s average time Central Maine Medical Center’s average time then was 60 minutes which beat the average by 58 minutes!

National D2B Goal is 90 minutes or less.

Most recent data reporting showed CMMC D2B time averaged 51 minutes!

Central Maine Medical Center’s average time then was 60 minutes which beat the average by 58 minutes!

National D2B Goal is 90 minutes or less.

Most recent data reporting showed CMMC D2B time averaged 51 minutes!

What has happened since 2005?What has happened since 2005?

Whereas most PCI centers in 2005 could not reach D2B goals, 90% are now doing so.

We have engaged more community hospitals in our regular D2B meetings to enhance Door In Door Out strategies to facilitate transfers.

Whereas most PCI centers in 2005 could not reach D2B goals, 90% are now doing so.

We have engaged more community hospitals in our regular D2B meetings to enhance Door In Door Out strategies to facilitate transfers. In Door Out strategies to facilitate transfers. Goal is 30 mins or less.

EMS continues to monitor protocols and improve them. For example, we recently found that doing the field ECG in the patient’s house, saved nearly 10 minutes compared to doing it in the vehicle.

In Door Out strategies to facilitate transfers. Goal is 30 mins or less.

EMS continues to monitor protocols and improve them. For example, we recently found that doing the field ECG in the patient’s house, saved nearly 10 minutes compared to doing it in the vehicle.

What next?What next?Engage more regional hospitals to participate.Engage more regional hospitals to participate.Engage more regional hospitals to participate.

Local physician or nurse champions are indispensible.

Protocol development can be collaborative through our D2B team meetings.

Engage more regional hospitals to participate.Local physician or nurse champions are

indispensible.Protocol development can be collaborative

through our D2B team meetings.

Maintaining QualityMaintaining Quality

Monthly D2B meetingsInterventional Cardiology

Nursing

ED physicians

Monthly D2B meetingsInterventional Cardiology

Nursing

ED physiciansED physicians

Cath lab staff

EMS representatives

Transfer hospital representatives from St Mary’s, Rumford, Farmington, Bridgton, Parkview, others invited in person or conference call

ED physicians

Cath lab staff

EMS representatives

Transfer hospital representatives from St Mary’s, Rumford, Farmington, Bridgton, Parkview, others invited in person or conference call

D2B meeting formatD2B meeting format

Review any case outside the 90 minute goal, regardless of transfer status

Review any case outside the 90 minute goal, regardless of transfer status

Cath lab activation time

Depart mode and time

Arrival from transfer site

Cath lab arrival

Cath lab activation time

Depart mode and time

Arrival from transfer site

Cath lab arrivalstatus

Metrics reviewed:

Chest pain onset to 1st med contact

Hospital arrival time

Mode of arrival

Diagnostic EKG time

status

Metrics reviewed:

Chest pain onset to 1st med contact

Hospital arrival time

Mode of arrival

Diagnostic EKG time

Cath lab arrival

Balloon or device deployment time.

Modifiers delaying treatment: VF, respiratory, CPR, etc.

Cath lab arrival

Balloon or device deployment time.

Modifiers delaying treatment: VF, respiratory, CPR, etc.

Ongoing challengesOngoing challengesNew pharmacology

Alternative and competing strategies

Treatment of the post-CPR patient in coma

Hypothermia protocols and training

Additional community hospital support and involvement in QI process

New pharmacology

Alternative and competing strategies

Treatment of the post-CPR patient in coma

Hypothermia protocols and training

Additional community hospital support and involvement in QI processinvolvement in QI process

Cost effectiveness in a changing environment

Drug eluting stents in AMI?

Expensive transfers?

?Declining need? : Incidence of AMI declining and survival improving!

involvement in QI process

Cost effectiveness in a changing environment

Drug eluting stents in AMI?

Expensive transfers?

?Declining need? : Incidence of AMI declining and survival improving!

There is still no general agreement in Maine that every STEMI patient should go to the

There is still no general agreement in Maine that every STEMI patient should go to the STEMI patient should go to the

nearest PCI center!STEMI patient should go to the

nearest PCI center!

Why not? Can EMS play a role here?

Why not? Can EMS play a role here?

Achieving Rapid TreatmentAchieving Rapid Treatment

Diversion to the PCI center?Diversion to the PCI center?

Happening today, though unusual.

Challenges local resources.

Not appropriate for unstable patients or those with a questionable diagnosis.

Happening today, though unusual.

Challenges local resources.

Not appropriate for unstable patients or those with a questionable diagnosis.those with a questionable diagnosis.

May save ½ hour or more!

those with a questionable diagnosis.

May save ½ hour or more!

Think about this…Think about this…

In 2005, the CMMC Heart team recognized the competence, professionalism, and responsibilities of our regions EMS teams and empowered

In 2005, the CMMC Heart team recognized the competence, professionalism, and responsibilities of our regions EMS teams and empowered our regions EMS teams and empowered them to directly activate our cardiac teams while bringing patients rapidly to our PCI center in order to save precious minutes that we call “MINUTES OF MYOCARDIUM”…..

our regions EMS teams and empowered them to directly activate our cardiac teams while bringing patients rapidly to our PCI center in order to save precious minutes that we call “MINUTES OF MYOCARDIUM”…..

Now…Now…

Isn’t it time for our EMS services to extend to our Heart Team, the commensurate rights and responsibilities of displaying emergency flashing lights

Isn’t it time for our EMS services to extend to our Heart Team, the commensurate rights and responsibilities of displaying emergency flashing lights of displaying emergency flashing lights on our vehicles as attempt to get to the hospital promptly in order to definitively treat the patients you are transporting?

of displaying emergency flashing lights on our vehicles as attempt to get to the hospital promptly in order to definitively treat the patients you are transporting?

IS THIS AN EMERGENCYVEHICLE?

Special Thanks to the entire D2B team!Special Thanks to the entire D2B team!

The CMMC Cardiac Cath Lab staff! Their on call duties are incredibly demanding. They are the best!Our ED staff, physicians, nurses (especially!) and all their support staff.CMMC Connect for their invaluable help in facilitating transfers, communication, and quality reviews (everything is recorded!)All the EMS teams who are dedicated to helping their patients get

The CMMC Cardiac Cath Lab staff! Their on call duties are incredibly demanding. They are the best!Our ED staff, physicians, nurses (especially!) and all their support staff.CMMC Connect for their invaluable help in facilitating transfers, communication, and quality reviews (everything is recorded!)All the EMS teams who are dedicated to helping their patients get All the EMS teams who are dedicated to helping their patients get the best care!The Lifeflight crews whose commitment to excellent and rapid care is second to none.Our referring hospitals and their STEMI teams. We have seen them shine!Our Administrators who support the ongoing Quality Assurance.Our Database Team!

All the EMS teams who are dedicated to helping their patients get the best care!The Lifeflight crews whose commitment to excellent and rapid care is second to none.Our referring hospitals and their STEMI teams. We have seen them shine!Our Administrators who support the ongoing Quality Assurance.Our Database Team!

Prehospital Cath Lab ActivationThe Central Maine Experience

Prehospital Cath Lab ActivationThe Central Maine Experience

Kevin M. Kendall, M.D., FACEP

EMS and LifeFlight Director

Kevin M. Kendall, M.D., FACEP

EMS and LifeFlight Director

The End….The End….