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.

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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

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30-d

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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

What would Trauma do?

What would Trauma do?

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%

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

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

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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