STEMI Systems of Care in New Jersey:

An interview with Bil Rosen of Capital Health EMS and Chair of the NJ Association of Paramedic

Program's Education Committee

By David B. Hiltz

There are nearly 250,000 cases of ST-Elevation Myocardial Infarction (STEMI) each year in the

United States. Tragically, a significant number don't receive prompt reperfusion therapy, which

is critical in restoring blood flow. Additionally, 30 percent of STEMI victims don't receive

reperfusion treatment at all.

In the ideal STEMI system of care, stakeholders (parties with a vested interest in the treatment

of STEMI patients) including EMS providers, cardiologists, emergency physicians, hospital

administrators to policymakers and from third-party payers to the public - share a common belief

that quality and timely patient care is the top priority. There is a mutual respect for the critical

role of each player in the STEMI system. Individual parties are not out to promote their own self-

serving interests. Rather, everyone works together to build a consensus on what the ideal

STEMI system looks like for their region, considering its unique challenges.

In this interview, Bil Rosen and I will discuss STEMI systems of care, Mission: Lifeline and

efforts to improve recognition, care and outcomes for Acute Coronary Syndrome (ACS) patients

in New Jersey.

HILTZ-

Bil, tell me about yourself, New Jersey Association of Paramedic Programs (NJAPP) and their collective goals in NJ.

ROSEN-

I have been involved in NJ EMS and EMS education since the mid 80's. I became a paramedic in 1995 and aside from per diem jobs, have been with Capital Health EMS in the Capital City of Trenton since paramedic school. I became the NJ Association of Paramedic Program's Education Committee chair in 2001.

HILTZ-

The State of New Jersey conducted a study http://www.nj.gov/health/ems/emsreport.shtml to assess its Emergency Medical Services (EMS) system back in 2006. This study was mandated by the New Jersey State Legislature to evaluate the current EMS system and determine short and long term needs. The study outlined over 50 recommendations for New Jersey to consider. Could you tell us a little about how the study is driving systems change and NJAPPs role in that process?

ROSEN-

As an ALS system, we received a pretty decent review. As quoted from the study report "New Jersey’s ALS system provides excellent clinical care by well-trained paramedics and an active cadre of physicians who provide medical oversight." However, the fiscal, dispatch and BLS issues affect us every day.

NJAPP was identified as a major player in the focus groups and evaluations. As an association, we lobby the government to consider and act on our recommendations. We represent all MICU agencies in the state and although some disagreements may occur, our recommendations and association opinions represent the consensus of the state's MICU programs. Having a seat on legislative committees makes our voice heard.

As an association, we represent all of the NJ Mobile Intensive Care Units (MICU), we have seats, voices and votes on the NJ EMS Council and the MICU

Advisory Committee, as well as on two NJ legislative committees. We lobby for EMS Legislation and recommend actions that affect MICUs across the

state. We promote, develop and maintain standards of operation, practice, education and ethics for the paramedic profession.

NJAPP's position is that improvement of the overall system is needed and based on the years of experience and knowledge of our members and constituents, and we truly believe that we have some sound recommendations. They originate from research and best practices from across the state and nation. We want the entire system to work well and believe the citizens and visitors of our great state deserve the best prehospital care there is to offer.

The NJAPP education committee works closely with the New Jersey Department of Health and Office of Emergency Medical Services to identify needs of the paramedic colleges, assess evaluators and students, and look for opportunities and methods to improve results.

PREHOSPITAL ECG PROGRAMS

From the AHA Scientific Statement: Implementation and Integration of Prehospital ECGs into Systems of Care for Acute Coronary Syndrome Circulation 2008; 118: 1066-1079

“Prehospital ECG programs have the potential to improve the way care is delivered to patients with STEMI in the United States. Current American Heart Association guidelines recommend that paramedics perform and evaluate a prehospital ECG routinely on patients with chest pain suspected of having STEMI (Class IIa, Level of Evidence B).1,3 The central challenge for healthcare providers is not to simply perform a prehospital ECG, but to use and integrate the diagnostic information from a prehospital ECG with systems of care. The potential savings in time from first medical contact to reperfusion therapy by integrating prehospital ECGs with hospital systems of care are considerable and clinically relevant. However, the gaps between use under ideal circumstances and in routine practice remain substantial (Table 3). There are many logistic barriers, including the need for increased patient use of EMS; increased EMS capacity; improved education and quality assurance for EMS providers; improved collaboration among EMS, emergency departments, and cardiology; improved organization of hospital systems and providers; and improved coordination of regional hospital networks to provide the ideal patient care rather than optimize market share. It also is apparent that several financial barriers, including reimbursement and cost-effectiveness of this diagnostic technology, will need to be overcome for prehospital ECGs to gain widespread support across payors, providers, and healthcare systems. But these barriers are not insurmountable and can be overcome with dedicated efforts to improving systems of care. Future investigations and policy measures are needed to encourage EMS, hospitals, and healthcare systems to adopt and maximize the full potential of this technology, as well as monitor unintended consequences.”

HILTZ-

Bil, it sounds like NJAPP is playing a significant role in statewide efforts aimed at improving the system of care. As we know, out-of-hospital cardiac arrest and ST elevation MI continue to be significant public health issues. Furthermore, given that regional performance and outcomes are so variable, coordinated efforts are needed to optimize available resources and improve outcomes. Many areas of the U.S. are lacking well-coordinated approaches to cardiac arrest and STEMI care. I, along with the American Heart Association share your belief that citizens and our families deserve the best prehospital care there is to offer.

Figure 2. Reperfusion time goals for patients with ST-segment–elevation myocardial infarction.

Ting H H et al. Circulation 2008;118:1066-1079

Copyright © American Heart Association

SEE ALSO: Part 10: Acute Coronary Syndromes: 2010 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care

Could you describe a typical response to a “chest pain” or related cardiac emergency in your system?

ROSEN-

Sure, NJ MICU regulations have standing orders that paramedics and MICNs may follow prior to contacting medical command.

At this time, all of the revisions to the NJ Standing Orders have been approved and rolled out. The orders include: Administering Acetylsalicylic Acid (ASA, Aspirin), obtaining 12-lead ECG, administering Nitroglycerine, establishing vascular access and reviewing patient’s eligibility for thrombolytic therapy. One of the additions to this revision is to follow the 2009 New Jersey Department of Health and Senior Services’ STEMI Triage Guidelines.

The NJDHSS STEMI Guidelines for MICUs provide for determining which patients may benefit from transportation directly to a Primary Percutaneous Coronary Intervention (PCI) hospital licensed to perform primary percutaneous coronary intervention. Many systems are bypassing EDs for direct admission to the cath lab. We are able to send 12-lead ECGs from the field right to the ED, Base Command and, at times, directly to the cath lab. This helps activate the CCL in an expedient manner.

HILTZ-

As I understand, NJ uses a tiered response model. Assuming this is correct, could you tell us a little bit about how that works and what your MICU program is doing to maximize performance when it comes to working with area BLS agencies and responders to improve interactions, response and care?

ROSEN-

Most MICU Programs have a robust education division. These Training Centers and instructors hold open classes to the BLS and first response agencies as well as their own staff. Most also offer an instructor or instructors to go to an agency to provide a course. When new policies or protocols are developed and released, these agencies often have additional training sessions as well. So when the STEMI protocols were approved and disseminated, many training centers brought it out to the local BLS agencies as a training and information session. We also attend local and county EMS group meetings to advise EMS providers of new practices.

The NJEMS Council and MICU Advisory Council, the 2 legislative committees I mentioned, have a BLS Subcommittee in which NJAPP participates. We are working on a BLS protocol for Aspirin administration.

NJ Emergency Medical Dispatch Guide cards allow for the dispatcher to advise the person experiencing chest pain to self administer aspirin.

The Centers for Medicare and Medicaid Services (CMS) measures are pretty

strict with regards to aspirin administration in cardiac patients. The guidelines for AMI patients dictate that the patient should receive ASA within the last 24 hours. This can be accomplished by dispatcher instruction, EMS

administration or documentation of daily home meds. So we are tackling improved response and care on all levels of emergency response and provision of care.

In New Jersey, EMS is essentially a two-tiered system. First tier is Basic

Life Support (BLS) and next is Advanced Life Support (ALS). There are a few other first responders in some areas such as Fire Department or Police Department. Anyone who calls 9-1-1 for a medical complaint will

get a BLS ambulance. There is a special group of more critical complaints or reported incidents that would get ALS response for example, Stroke, Chest Pain, Respiratory Distress or Significant Traumatic

injury. In theory, there is a simultaneous dispatch of ALS and BLS when certain criterion is met. Other times BLS may request ALS due to assessment findings.

HILTZ-

Education certainly seems to be a critical aspect of system improvement and overall performance. But, before we talk about that, give us a sense for how STEMI alerts are called in NJ and what criteria is used?

ROSEN-

In New Jersey, there are some differences from MICU program to MICU program.

Most of the programs carry Lifepak 12's with a few planning to the purchase the Lifepak 15’s soon. There are a few Phillips monitors our there as well. The machine's interpretive algorithms are pretty accurate but we also incorporate the paramedic’s analysis as well. Occasionally the interpretive algorithms don’t work due to the nature of the business (variables such as moving ambulance, etc). In these cases, the interpretation is determined by the paramedic.

12-lead ECGs remarkable for STEMI are usually transmitted to base command and/or receiving ED and in some programs directly to the cath lab.

While only a few MICU systems take patients directly to the cath lab, the time saved with prehospital 12-lead transmission and notification can shave critical minutes off of the Door to Therapy time.

In 2009, the NJ Department of Health and Senior Services, Office of EMS, our regulatory body published the NJ STEMI Triage guidelines. These guidelines assist all EMS Providers with transport decision making.

Additionally, there is a NJ Conference on EMS annually. Since the STEMI protocol came out, it has been a session topic for

ALS and BLS personnel. This year's conference will be held on November 2nd -5th.

HILTZ-

Bil, through the efforts of many, improvements in STEMI

care, reperfusion times and outcomes have been made

both in New Jersey and across the U.S. Regretfully, many

patients still do not heed early warning signs, delay seeking

medical care and often drive themselves to the hospital

rather than calling 9-1-1. Additionally, delays continue to

occur, particularly in transferring patients from non-PCI

capable hospitals to those that perform artery-opening

angioplasty.

In a recent study, published in Circulation, researchers examined data from 2,034 STEMI

patients transferred from 31 local non-PCI hospitals in Minnesota and Wisconsin from March

2003 to December 2009. In this study, they found that 34.2 percent of patients experienced a

delay in total treatment time, and the study found delays most frequently occurred at the referral

hospital (64 percent), followed by the PCI center (15.7 percent) and during transport (12.6

percent).

The issue around symptom recognition and 9-1-1 activation are beyond the scope of our

discussion today but could you describe how transfers from referral hospitals to those with PCI

capability are handled in the NJ system and what measures are being taken, if any to improve

time to reperfusion for these patients?

ROSEN-

That is a great question, David. Transfers from non PCI centers to more appropriate facilities occur through Specialty Care Transport Units (SCTU). Hospitals have agreements and/or contracts with SCTUs either hospital owned and operated commercial or MICU run. SCTUs have a separate set of regulations (NJAC 8:41 subchapter 10-A sending health care facility may request a patient to be transferred according to N.J.A.C. 8:43G-12.2(c) and the Federal regulations at 42 C.F.R. 489.24.).

The SCTUs are usually pretty close and ready to move at a moment's notice with a dedicated unit. This is the easy part and typically keeps times to a minimum.

The tougher part is getting the patient directly to the PCI center without going elsewhere first. Many citizens do not recognize or even deny having ACS symptoms and either delay arrival to the hospital or go to the wrong one. IF EMS is involved, the 12-lead assists with STEMI recognition as we have discussed and the destination is more appropriate.

What we need to do is educate the public. They need to have early recognition and activate EMS. AS EMS and Hospital Agencies, we need to promote prevention and recognition and the entire lay person chain of survival. The Fire Service has done a great job of this with fire prevention (This month is Fire Prevention Month!). This is probably the best way to improve time to reperfusion. The Hospital transfer/transport system is pretty well designed. The issue is everything leading up to this.

HILTZ-

Knowing that EMS education plays a strong role in supporting early reperfusion, what do you look for as an ideal educational program for preparing MICPs and MICNs to evaluate and assess ACS patients, acquire and interpret 12 lead ECGs, and determine an appropriate point of entry, potentially diverting from nearby hospitals to those who are recognized as being capable of emergent PCI? ROSEN-

Education needs to be a blend of delivery models. EMS professionals all learn differently and time is always a factor.

I do see a real benefit to having some classroom time. Face- to- Face interaction is important as is the ability to ask questions in real-time and to discuss and clarify issues in person. Additionally, protocols are easier to explain and discuss in a classroom or round-table, peer review type of session. Some providers will have a real hard time accepting the fact of bypassing the closest hospital. We saw this when trauma centers first popped up. But with the right education, this is second nature now. Conferences are great opportunities to not only learn but to also network with peers from all over the country or world. Mass gatherings of EMS providers also afford us the opportunity to compare and contrast protocols.

Bil, it certainly appears that NJ is

actively implementing the current

AHA recommendations for an ideal

system for EMS and EDs including:

“standardized point of entry protocols

(created by state-based coalitions of

EMS personnel, emergency physicians

and cardiologists, and supported by

payers and administrators) would

establish which patients are

transported to the nearest hospital

and which patients are transported to

the nearest STEMI-Receiving hospital.

This will be based in part on the

acquisition, interpretation and

transmission of a pre-hospital 12-lead

electrocardiogram (ECG).” NJ HOSPITAL MAP

However, I think there is a huge value in distance and distributive education such as web based or video/DVD based programs. With the schedules we all keep, it is often difficult to find enough downtime or "spare" time to attend a classroom for every educational opportunity.

What I liked about the AHA Rapid STEMI ID was the opportunity to have a self paced program that could be stopped and started at will. This program also afforded the learner some practical applications with the interpretation of 12-lead ECGs. This gave an online course a practical application. All NJ Paramedics, MICNs and Paramedic students were afforded this course for free based on an anonymous contributor to the system.

HILTZ-

For the benefit of others, Learn:™ Rapid STEMI ID is a self-paced course intended to prepare individuals like paramedics to evaluate and assess victims with potential symptoms of myocardial infarction, interpret their ECG for signs of STEMI, as well as activate a system of

care for rapid reperfusion of an occluded coronary artery.

This course is web-based and supports the American Heart Association’s Mission: Lifeline™, a national initiative to advance the systems of care for patients with STEMI and features narrated lessons, animated graphics, interactive mini-games, and self-study cards. Those who successfully pass the cognitive and ECG recognition post-course tests can receive a completion certificate and are eligible for CE credits.

In addition to offering a convenient, flexible means to improving STEMI identification and training, Learn: Rapid STEMI ID also provides learners with access to course for 12 months following initial activation, allowing for at-will and as needed refresher options.

Based on your experience and what you have heard from your peers at other programs, how

was Learn:™ Rapid STEMI ID received by MICPs and MICNs in NJ?

ROSEN-

As a group, we have found this education program very valuable and well put together. Many of the paramedics with whom I spoke felt that the courseware was effective, was a great class and presented very useful information. For some, it was a true learning experience, others a great refresher. Together with the new NJ Statewide STEMI Guidelines, I think there will be, or already has been a huge improvement in total STEMI recognition and care.

HILTZ-

Well, I am pleased to hear how well the program was received by the paramedics and mobile intensive care nurses in the NJ system. Given the large number of MICPs and MICNs in New Jersey, there must have been some big challenges in delivering the program. Could you describe how course delivery was accomplished?

ROSEN-

That’s an understatement! From a regulatory stand point, even though the Department of health co sponsored this, they weren't able to mandate it. Therefore, it was up to the MICU program Educators to administer, track and assure completion of the course. Some programs paid their employees and others didn’t. There really was no way to standardize this.

We can all teach 12-lead courses in house and our staff can attend different courses around the conference circuit. But to have a standardized process where all ALS folks can take the identical class is a great way to accomplish continuity and standardization. I think the Rapid STEMI ID program was a great way to get all ALS providers on the same page with STEMI care.

HILTZ-

Well, based on your remarks, it sounds like the Online Key Manager made your life and work easier, and I am not at all surprised. When we set up the effort, I felt that providing the OKM would be instrumental to streamlining and improving record keeping, facilitate ongoing communication with your MICPs/MICNs, and enable better overall training management. Again, for the benefit of our readers, the OKM was used by yours and other MICU programs to assign and distribute keys, send e-mail reminders, reassign lost or unused keys, monitor completion status, as well as create and print reports.

The Online Key Manager (OKM) was a fantastic tool. It tracks all those who were assigned to the course and broke down into who started,

completed and passed or failed. I was able to print certificates to an adobe PDF file and save in my employee’s electronic folders.

Another challenge was tracking those who work for

multiple MICU programs. It was up to us as educators to assist each other and reduce duplicate course assignments. We partially relied

upon the paramedics to let us know that they were given a key code by someone else.

Still, there are a few who have not started or completed this course. There really is no way

to force them to do so. But I think a majority have successfully completed the course and are happy with both the program and the results.

We extended the training out to all paramedic

students as well. These students were added to and tracked by the MICU program that sponsored them. This lessened the burden on a

single school and alleviated the need to have them sign up as a site on OKM.

It has been my pleasure to have worked with you on this effort and article, as well as the many productive discussions we have had on this subject.

Do you have any closing remarks or thoughts you would like to share, Bil?

ROSEN-

David, it has been a pleasure working with you. Thanks go to the American Heart Association and Foundation who afforded this program to NJs Paramedics and MICNs. Also, to the Clinical folks of NJs MICU programs for sticking together and managing their programs' use of this course. Part of the reason NJ MICUs have been so highly rated and recognized is the cohesiveness of the program administrators and educators. As chairman of the education committee, I commend all of the educators who make up the group and who do all of the work not just for their program but for the education and enrichment of NJs entire EMS community. I would also commend the NJ Department of Health and Senior Services Office of Emergency Medical Services for working with NJAPP and the Mobile Intensive Care Advisory Council (MAC), facilitating our recommendations and assisting with the continuous improvement in New Jersey's Emergency Medical Service System. Lastly, but most importantly, I thank all of the New Jersey Paramedics, MICNs and Paramedic Students who dedicated the time to completing this program. Without them, the system would not exist. The ALS providers of the Great Garden State are truly committed to caring for their patients in the best possible way.

SUMMARY-

Hats off to the New Jersey Association of Paramedic Programs (NJAPP) and their support of Mission: Lifeline, a national initiative by the American Heart Association that recognizes leaders who are helping improve the response and treatment of ST-elevation myocardial infarction (STEMI), the most serious and deadly type of heart attack.

By joining Mission Lifeline, NJAPP and their member agencies are committing to facilitate a system of evidence-based care, and helping to save the lives and preserve the quality of life of STEMI patients.

Every year, countless citizens suffer a STEMI, caused by the sudden, total blockage of a coronary artery and we know that unless reperfusion is quickly restored, a victim’s health and life are at serious risk. With the proper equipment, strategies and actions, healthcare providers can quickly recognize and treat a STEMI to reduce heart damage, but it calls for a fast and systematic response on many fronts.

Through partnerships, we can develop systems of care and strategies aimed at quickly activating the appropriate chain of events critical to treating STEMI victims and achieving the very best outcomes possible. It is recommended that STEMI patients receive PCI procedures within 90 minutes of having STEMI. Regretfully, a significant number don’t receive prompt, recommended therapy to restore blood flow and 30 percent of STEMI victims don't receive reperfusion treatment at all.

The entire NJ healthcare system should be recognized and commended for their collective efforts to improve STEMI care. Additionally, NJAPP and their agencies are to be congratulated for successfully and efficiently delivering standardized STEMI education to nearly all of the practicing MICPs and MICNs across the entire state of New Jersey.

Many thanks to Bil Rosen and all countless others who endeavor, every day, to improve response, care, systems, and outcomes for patients. I, along with the American Heart Association continue to acknowledge and share in the EMS community’s goal of improving patient outcomes through the development and delivery of the highest quality prehospital care available.

CONNECTING WITH BIL ROSEN

Bil Rosen, BA, NREMT-P Clinical Coordinator at Capital Health EMS 609-815-7498 wrosen@chsnj.org http://www.chsems.org ABOUT DAVE HILTZ

David has over 25 years experience in the healthcare industry with a special interest in emergency medicine and resuscitation. His current full time occupation is with the American Heart Association’s Emergency Cardiovascular Care Program-Public Safety Team. David is a member of the Massachusetts Department of Public Health’s Emergency Medical Care Advisory Board and Vice Chair of the Board’s EMS Education and Public Education and Information Resource Committees.

David is also known for his work with the HEARTSafe Community concept and was recognized by JEMS and Physio-Control as an Innovator in EMS. Visit David on Facebook or email him at david.hiltz@heart.org .

We are grateful for the EMS community’s steadfast dedication to

compassionate and competent care for people in need, anywhere, and under any conditions. You make the world a safer and better place every day.

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