model heart attack systems of care race / north carolina james g. jollis, m.d. co-director, race

Model Heart AttackSystems of Care

RACE / North Carolina

James G. Jollis, M.D.

Co-Director, RACE

RACEReperfusion in AMI in Carolina

Emergency departments

• North Carolina

• RACE Pilot

– Design and lessons

• RACE


North Carolina

• Population 8,541,221 11th

• Size 48,711 square miles 29th

• 14 PCI hospitals, ~100 non-PCI hospitals

• Relative size– Connecticut and Massachusetts combined

• 4 times area, same population

– Minnesota

• ½ area, 2 times population

North Carolina EMS Milestones

1910

1st air ambulance built in NC

1917

Earliest air ambulance rescue service

Outer Banks to Norfolk hospitals


1968

One of the 1st Paramedic training programs in U.S.

Haywood County, North Carolina


1968

Dr. Ralph Feichter, Waynesville internist

+Rescue Squad Volunteersintensive training in cardiac pathophysiology,

electrocardiography, arrhythmia recognition, pharmacology (cardio-active drugs) and CPR.

+2 mobile intensive care vehicles


2003-2006 RACEReperfusion in AMI in Carolina Emergency Departments



• North Carolina

• RACE Pilot


• RACE


RACE pilot 2003

• Improve AMI care at the point of greatest mortality / potential benefit

– Increase the rate of reperfusion– Increase the speed of reperfusion

AMI ReperfusionHow are we doing?

0

10

20

30

40

50

60

1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005

IV LyticIV Lytic

PPCIPPCI

Year of DischargeYear of Discharge

NRMI 2NRMI 2 NRMI 3NRMI 3 NRMI 4NRMI 4 NRMI 5NRMI 5

Pat

ien

ts,

%P

atie

nts

, %

Immediate CABG

- Range 0.9 % -

1.7 %

6.96.9

39%39%4747

23%23%

0

10

20

30

40

50

60

1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005

IV LyticIV Lytic

PPCIPPCI



Pat

ien

ts,

%P

atie

nts

, %

Immediate CABG

- Range 0.9 % -

1.7 %

6.96.9

39%39%4747

23%23%

None 37%None 37%

AMI ReperfusionHow are we doing?

15

25

35

45

55

65

1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005


≤ 65 Yrs

> 65 Yrs


Pat

ien

ts,

%P

atie

nts

, %

58.858.853%53%

30.930.923%23%

AMI ReperfusionHow are we doing? - Age

RACE pilot 2003

40 mile radius40 mile radius40 mile radius40 mile radius

5 local EDs within 5 local EDs within 40 miles40 miles5 local EDs within 5 local EDs within 40 miles40 miles

Referring MD Referring MD

Call Duke ED, CCU Fellow, or CAD staffCall Duke ED, CCU Fellow, or CAD staff

OLD: >180 minOLD: >180 min

CCU AttendingCCU Attending

ICC FellowICC Fellow ICC AttendingICC Attending

Cath TeamCath Team

Primary PCIPrimary PCI

Fax ECG

Referring MD Referring MD

Call 1-866-MI-2-DUKECall 1-866-MI-2-DUKE

NEW: 100-120 minNEW: 100-120 min

CCU Fellow, Attending, Life FlightCCU Fellow, Attending, Life Flight

ICC Fellow, cath teamICC Fellow, cath team

ICC Attending

ICC Attending

Primary PCIPrimary PCI

Find best transport

Transfer for Primary PCI: Systematic ApproachTransfer for Primary PCI: Systematic Approach

Fax ECG Fax ECG

Direct Activation of Duke Cath Lab based on Pre-hospital ECG by Durham EMS

(preliminary data)

Population n Door-to-balloon Time

Historical 15 104 (75, 131)

EMS not using hotline 12 89 (78,100)

EMS using hotline 20 58 (54,71)

David Strauss 2005

RACE pilot 2003

Lessons from RACE pilot1) Fix your own primary PCI system

first2) Data are exceedingly difficult to

collect without funding or government or payer mandate– Issues include HIPAA, IRB, fear of

release, OIG opinion that PRO hospital data are protected, resources



• North Carolina

• RACE Pilot


• RACE


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…

2 years

RACEReperfusion in AMI in North

Carolina Emergency Departments

• AMI Guideline based

• PCI or Lytics

– Support “best available therapy”

according to resources / local conditions

RACEPartners

RACEOrganization

• Funded by BCBS of NC Foundation, Genentech, Participating hospitals

• Quality improvement project for state ACC

• Independent oversight board– Leaders in ACC (Douglas), acute MI care (O’Neill, Califf, Brodie), emergency medicine

(Mears), BC/BS (Harris).

• Steering committee– Participating physicians and hospitals

• Coordination– Mayme Lou Roettig, Director; 5 Regional Coordinators

• ~70 hospitals (10 PCI, 60 no-PCI)

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/Berger/Stoufer

Wilson/Pulsipher/BeatonGranger/Jollis/Berger/Stoufer

Wilson/Pulsipher/Beaton

RACEData

• PCI hospitals – NRMI

• Non PCI hospitals– Consecutive chart review

• Rate of reperfusion

• Time of reperfusion

RACEManual

Optimal system specifications by point of care EMS ED Transfer Receiving hospital Cath. Lab Other system issues –

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 1.2January 2006January 2006

RACEInterventions

• EMS– In the field ECG

• Regional ECG training courses• Securing funding for ECG equipment

RACEInterventions

•PCI hospital

- Map out process

- ED physician can make decision about PCI without the need for consultation / confirmation

- Single contact number

- Single interventionalist on call for system

- Accept to cath. lab without bed availability

- Streamline registration process

- NRMI in place

RACEInterventions

RACE Additional lessons


• Requires “donated” efforts of 100’s of

physicians, nurses, administrators, EMTs,

public officials, professional organizations

– Chris Granger, Peter Berger, Magnus Ohman,

Greg Mears, Sid Smith ….


• Maintain current referral lines

• Physician leadership in ED, Cardiology, and

administration


Regional structure guides “politics”

- 3 PCI hospitals / 3 Cardiology groups

- 1 PCI hospital / 6 Cardiology groups

- 1 PCI hospital / 1 Cardiology group

- Non-PCI hospital

- Network spoke vs. independent

- Academic hospitals with NIH ranking as primary focus


• Hospital administration / State legislature buy in

– Smaller hospitals

• All hospitals should treat AMI

– PCI hospitals

• All hospitals at the table

• Establish single contact number and system for

rapid PCI before contacting regional hospitals


• Data – pre and post intervention

• Quality assurance project

– No protected health information

“there is a reasonable basis to believe the

information can be used to identify the

individual ”

– IRB process potentially one of the greatest

systematic barriers to improving care


• ED physicians “control” much of STEMI care

and want a single regimen.


What

Would

Trauma

Do?


Heart disease 700,000

– Myocardial infarction 200,000

Accidents 100,000

– MVA 60,000

National Center for Health Statistics 2005

3 times as many die from AMI than from trauma

What Would Trauma Do“Golden hour”

• Accept patient regardless of bed availability

• Dummy registration

• Code trauma– Priority

– Everyone knows their role

– Single trauma physician on call

– Single phone call activation

• EMS transport priority

• 24/7 hospital capabilities

• Regionalized system

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. Record calls and playback for QI

4. Provide standardized feedback reports to each ED

3. Prehospital ECGs for all CP patients

2. "Certify" all EMTs to read ST elevation on ECGs, call from ambulance to activate cath lab

1. Create EMS, ED, cardiology team with committed leadership

• North Carolina– Demographics– EMS history

• RACE pilot– Goal – increase reperfusion – save lives– Duke system– Lessons

• Fix your own system first• Data exceedingly challenging to collect without funding, legal or payer mandate

• RACE– Structure– Timeline– Intervention– Examples

• Flow chart• Telephone call• RACE manual

• Additional lessons• Top 10 interventions

RACEInterventions

• PCI hospital

– Single contact number

– ED physician makes decision

– 2 methods of transport

– Reperfuse with fastest / safest

approach

model heart attack systems of care race / north carolina james g. jollis, m.d. co-director, race

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