Regional STEMI Transfer Systems: the Mayo and NC RACE

Experiences

Regional STEMI Transfer Systems: Regional STEMI Transfer Systems: the Mayo and NC RACE the Mayo and NC RACE

ExperiencesExperiences

Dr. Henry H. Ting, Mayo Clinic College of MedicineDr. James G. Jollis, Duke University Medical CenterDr. Henry H. Ting, Mayo Clinic College of MedicineDr. Henry H. Ting, Mayo Clinic College of MedicineDr. James G. Dr. James G. JollisJollis, Duke University Medical Center, Duke University Medical Center

Henry H. Ting, MD MBAMayo Clinic

Rochester, MinnesotaJan. 28, 2010

Henry H. Ting, MD MBAHenry H. Ting, MD MBAMayo ClinicMayo Clinic

Rochester, MinnesotaRochester, MinnesotaJan. 28, 2010Jan. 28, 2010

Mayo Clinic STEMI SystemMayo Clinic STEMI Systemfor Transferred Patientsfor Transferred Patients

““FAST TRACKFAST TRACK””

DisclosuresDisclosuresDisclosures

•

No financial disclosures•

No conflicts of interest

•

No off-label use

••

No financial disclosuresNo financial disclosures••

No conflicts of interestNo conflicts of interest

••

No offNo off--label uselabel use

D2B –

“Sustain The Gain”D2B D2B ––

““Sustain The GainSustain The Gain””

Nestler DM. Circ Cardiovasc Qual Outcomes. 2009;2:508-513.

64 min30 min

PH ECG and Door-to-BalloonPH ECG and DoorPH ECG and Door--toto--BalloonBalloon

Ting HH. Presented at AHA November 2009

Patients Transferred for Primary PCIPatients Transferred for Primary PCIPatients Transferred for Primary PCI

1.3

8.6

26.4

36.3

17.6

8.24.3 2.2 3.7

0

20

40

60

<1 <90min

1 to <2 2 to <3 3 to <4 4 to <5 5 to <6 6 to <7 7 to<12

PatientsPatients (%)(%)

Total doorTotal door--toto--balloon time (hours)balloon time (hours)

Chakrabarti A, J Am Coll Cardiol 2008;51:2442-2443.

Reperfusion Strategies for Transferred STEMI Patients

Reperfusion Strategies for Reperfusion Strategies for Transferred STEMI PatientsTransferred STEMI Patients

1.

Interhospital

transfer for primary PCI2.

Pharmaco-invasive approach with lytics and early PCI

3.

Lytic facilitated PCI4.

Prehospital triage for primary PCI

1.1.

InterhospitalInterhospital

transfer for primary PCItransfer for primary PCI2.2.

PharmacoPharmaco--invasive approach with lytics and early PCIinvasive approach with lytics and early PCI

3.3.

Lytic facilitated PCILytic facilitated PCI4.4.

Prehospital triage for primary PCIPrehospital triage for primary PCI

Reperfusion Strategies for Transferred STEMI Patients

Reperfusion Strategies for Reperfusion Strategies for Transferred STEMI PatientsTransferred STEMI Patients

1.

Interhospital

transfer for primary PCI2.

Pharmaco-invasive approach with lytics and early PCI

3.

Lytic facilitated PCI4.

Prehospital triage for primary PCI

1.1.

InterhospitalInterhospital

transfer for primary PCItransfer for primary PCI2.2.

PharmacoPharmaco--invasive approach with lytics and early PCIinvasive approach with lytics and early PCI

3.3.

Lytic facilitated PCILytic facilitated PCI4.4.

Prehospital triage for primary PCIPrehospital triage for primary PCI

Minnesota

Wisconsin

Iowa

Rochester

0 100 200

Duluth

St. Cloud

Minneapolis/ St. Paul

Ting HH, et al. Circulation 2007;116:729-736

Cum

ulat

ive

prob

abili

tyC

umul

ativ

e pr

obab

ility

Door-to-balloon/door-to-needle time (minutes)Door-to-balloon/door-to-needle time (minutes)

0.00

0.25

0.50

0.75

1.00

0 60 120 180 240

Regional Hospital Primary PCIRegional Hospital FibrinolysisRegional Hospital Primary PCIRegional Hospital Fibrinolysis

Regional STEMI Patients Treated with Primary PCI or Fibrinolytic Therapy

Regional STEMI Patients Treated with Primary Regional STEMI Patients Treated with Primary PCI or Fibrinolytic Therapy PCI or Fibrinolytic Therapy

25 min 110 min

Ting HH, et al. Circulation 2007;116:729-736

Mortality and Door-to-Needle / Door-to-Balloon

Mortality and Mortality and DoorDoor--toto--Needle / DoorNeedle / Door--toto--BalloonBalloon

3.5

5.66.6

11.513.5

1.1

0

4

8

12

16

20

<30 30-60 60-90 90-120 120-180 >180

In-h

ospi

tal M

orta

lity

(%)

In-h

ospi

tal M

orta

lity

(%)

Door-to-balloon / Door-to-needle time (minutes)Door-to-balloon / Door-to-needle time (minutes)

P=0.01P=0.01

Door-in Door-out (DIDO) at 1st Hospital and 1st Door-to-balloon Time

143

87

0

50

100

150

200

250

DIDO >30 min DIDO <=30 min Med

ian

1st D

oor-

to-b

allo

on (m

in)

P < 0.0001

Ting HH, et al. AHA November 2009

Pharmaco-Invasive StrategyPharmacoPharmaco--Invasive StrategyInvasive Strategy

•

Definition:

Broad use of rescue PCI after failed fibrinolysis, as well as an early PCI within 3-24 hours of successful fibrinolysis

••

Definition:Definition:

Broad use of rescue PCI after failed Broad use of rescue PCI after failed fibrinolysis, as well as an early PCI within 3fibrinolysis, as well as an early PCI within 3--24 hours 24 hours of successful fibrinolysisof successful fibrinolysis

30-day 1°

Endpoint and Components3030--day 1day 1°°

Endpoint and ComponentsEndpoint and Components

EndpointEndpointStandard Standard N=498 (%)N=498 (%)

PharmacoPharmaco--Invasive Invasive N=512 (%)N=512 (%) P valueP value

11

end pointend point 16.616.6 10.610.6 0.00130.0013

DeathDeath 3.63.6 3.73.7 0.940.94

ReRe--infarctioninfarction 6.06.0 3.33.3 0.0440.044

Recurrent ischemiaRecurrent ischemia 2.22.2 0.20.2 0.0190.019

Death/MI/ischemiaDeath/MI/ischemia 11.711.7 6.56.5 0.0040.004

New/worsening CHFNew/worsening CHF 5.25.2 2.92.9 0.0690.069

Cardiogenic shockCardiogenic shock 2.62.6 4.54.5 0.110.11

Cantor WJ. N Engl J Med 2009;360:2705

30-day 1°

Endpoint and Components3030--day 1day 1°°

Endpoint and ComponentsEndpoint and Components

EndpointEndpointStandard Standard N=498 (%)N=498 (%)

PharmacoPharmaco--Invasive Invasive N=512 (%)N=512 (%) P valueP value

11

end pointend point 16.616.6 10.610.6 0.00130.0013

DeathDeath 3.63.6 3.73.7 0.940.94

ReRe--infarctioninfarction 6.06.0 3.33.3 0.0440.044

Recurrent ischemiaRecurrent ischemia 2.22.2 0.20.2 0.0190.019

Death/MI/ischemiaDeath/MI/ischemia 11.711.7 6.56.5 0.0040.004

New/worsening CHFNew/worsening CHF 5.25.2 2.92.9 0.0690.069

Cardiogenic shockCardiogenic shock 2.62.6 4.54.5 0.110.11

Cantor WJ. N Engl J Med 2009;360:2705

Median time from lytics to PCI was 3.9 hours

Pharmaco-Invasive Strategy: NORDISTEMI

PharmacoPharmaco--Invasive Strategy: Invasive Strategy: NORDISTEMINORDISTEMI

Bohmer E. JACC 2010; 55:102-110

Pharmaco-Invasive Strategy: NORDISTEMI

PharmacoPharmaco--Invasive Strategy: Invasive Strategy: NORDISTEMINORDISTEMI

Bohmer E. JACC 2010; 55:102-110

Median time from lytics to PCI was 2.7 hours

3

0 0

6

1.81

0

2

4

6

8

In-hospitalDeath

Total Stroke HemorrhagicStroke

%

Primary PCI Facilitated PCI

3

0 0

6

1.81

0

2

4

6

8

In-hospitalDeath

Total Stroke HemorrhagicStroke

%

Primary PCI Facilitated PCI

ASSENT-4 TrialPrimary vs. Full-dose TNK Fibrinolytic-Facilitated PCI

ASSENT-4 TrialPrimary vs. Full-dose TNK Fibrinolytic-Facilitated PCI

P =0.01

P <0.0001 P =0.0037

DSMB terminated

study after 1667 / 4000 enrolled because of higher in-hospital mortality observed for facilitated PCI

Van de Verf, Lancet 2006;367:569-578

3

0 0

6

1.81

0

2

4

6

8

In-hospitalDeath

Total Stroke HemorrhagicStroke

%

Primary PCI Facilitated PCI

3

0 0

6

1.81

0

2

4

6

8

In-hospitalDeath

Total Stroke HemorrhagicStroke

%

Primary PCI Facilitated PCI

ASSENT-4 TrialPrimary vs. Full-dose TNK Fibrinolytic-Facilitated PCI

ASSENT-4 TrialPrimary vs. Full-dose TNK Fibrinolytic-Facilitated PCI

P =0.01

P <0.0001 P =0.0037

DSMB terminated

study after 1667 / 4000 enrolled because of higher in-hospital mortality observed for facilitated PCI

Van de Verf, Lancet 2006;367:569-578

Median time from lytics to PCI was 1.9 hours

Prehospital Triage ModelPrehospital Triage ModelPrehospital Triage Model

Proximal LAD

Prehospital Triage ModelPrehospital Triage ModelPrehospital Triage Model

1.

Paramedics acquire and interpret PH ECG2.

If “Definite STEMI”, then 1-call activation of cath lab and helicopter auto-launch to intercept patient at regional hospital (or intercept enroute)

3.

Bypass ED evaluation at regional hospital & PCI hospital4.

Patient transported directly to cath lab

5.

Explicit diversion criteria to deviate from #2-4

1.1.

Paramedics acquire and interpret PH ECGParamedics acquire and interpret PH ECG2.2.

If If ““Definite STEMIDefinite STEMI””, then 1, then 1--call activation of cath lab call activation of cath lab and helicopter autoand helicopter auto--launch to intercept patient at launch to intercept patient at regional hospital (or intercept regional hospital (or intercept enrouteenroute))

3.3.

Bypass ED evaluation at regional hospital & PCI hospitalBypass ED evaluation at regional hospital & PCI hospital4.4.

Patient transported directly to cath labPatient transported directly to cath lab

5.5.

Explicit diversion criteria to deviate from #2Explicit diversion criteria to deviate from #2--44

Description Time Time Interval (minutes)

Symptom Onset 05:30 0

9-1-1 Call 06:05 35

EMS On-Scene 06:09 4

PH ECG Acquired 06:16 7

STEMI Protocol Activation 06:17 1

Transport to Local Community Hospital 06:22 5

Arrival at Door 1 06:26 4

Departure from Door 1 06:37 11

Arrival at Door2 07:10 33

First PCI Device 07:27 17

Time Intervals Duration (minutes)

*Door 1 In-to-Door 1 Out 11

*Door 2-to-First PCI Device 17

*Door 1-to-First PCI Device 61

*First EMS Contact-to-First PCI Device 82

*Symptom Onset-to-First PCI Device 117

Pitta SR. Circ Cardiovasc Qual Outcomes. 2010;3:93-97

North Carolina's Statewide STEMI System

James G. Jollis, MD, FACCDuke University

RACERACE Reperfusion in AMI in Carolina Emergency Departments

How patients present

• Call 911 EMS

• (~50%)

• Walk-in

• (~50%)

• Hospital transfer

• - Walk in or EMS to 1st

hospital

• (~60% of PCI hospital)

How patients present

EMS Walk-inHosp.

transfer

Current 90 90 180

Potential <60 <90 <120

121 emergencydepartments

500 EMS systems

5,240 paramedics

18,000EMTs

21 primary PCI labs

Integrated, Systematic

Integrated, Systematic

AMI CareAMI Care

RACE Process

2) Establish REGIONAL PCI CENTERS(primary, lytic ineligible, rescue)

Measurement& Feedback

3a) HOSPITAL by hospitalestablishment of STEMI plan(review, consensus, training)

3b) EMS by EMSestablishment of STEMI plan(review, consensus, training)

4) Improve system

1) Develop leadership, funding, data structure

Establish a plan

Regional coordinatorsRegional coordinators

RACE Interventions

• OPERATIONS MANUAL

• Optimal system specifications by point of care

– EMS

– ED

– Transfer

– Receiving hospital

– Cath. Lab

– Other system issues – payers, regulations

Available at www.race-er.org

RACE Interventions

RACE Interventions

• Emergency Department

Coordination and training of entire staff

Registration (nurse first)

Designated area for immediate

Standing STEMI protocol agreed upon by entire

emergency and cardiology staff

Emergency physician leads team

PCI Hospitals

Single number cath lab activation

Accept all STEMI patients regardless of bed availability

Ongoing QI and data feedback– NRMI database

RACE Regional CoordinatorResponsible for improving process in every hospital - EMS system in the region

RACE Interventions

EMS

1) In the field ECG for all chest pain patients

2) 15 minute scene time

3) Hospital pre-notification

4) Standing STEMI plan / destination protocols

RACE Interventions

JAMAJAMA Nov. 2007Nov. 2007

1088590

74

106

149

0

30

60

90

120

150

180

All patients Direct presenters Transfer for PCIhospitals

Pre Post

P<0.001* P<0.001

med

ian

times

in m

inut

es P=0.01

RACE results PCI hospitals: Door to device

12097

7145

2935

0

30

60

90

120

150

180

Door-in door-out,all hospitals

Door-in door-out,transfer hosps

Fibrinolysis, door-to-needle

PrePost

P<0.001* P<0.001

med

ian

times

in m

inut

es P=0.002

* Remained significant in analysis accounting for clustering

RACE results Non-PCI hospitals: Reperfusion times

10 PCI centers16 Transfer for PCI28 Lytics11 Mixed

Asheville

Winston-SalemDurham-Chapel Hill-

Greensboro

Charlotte

East Carolina

Each non-PCI center was assessed forreperfusion designation based on resources, transfer ability, and transfer time to PCI center

RACE Centers and Regions 65 hospitals (10 PCI, 55 non PCI)