Post on 01-Feb-2020
transcript
Heart 777
Darrel C. Gumm, MD, FACCHeartCare Midwest
Illinois STEMI ConferenceJune 20, 2008
Background
• Original program at SFMC was informal -started in early 1990’s– NRMI– Crusade– ACC Action
http://jama.ama-assn.org/cgi/content/full/296/14/1749 Stenestrad, et al; JAMA. 2006;296:1749-1756.
5
7
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7
12
0.05 1
8
14
0
2
4
6
8
10
12
14
16
Death Re MI Total CVA ICH Death+RE-
MI+CVA
Primary PCI vs Lysis for STEMI –Meta-analysis of 23 trials
Short Term Events
PTCA
Thrombolytics
P=0.0003 P=0.0001
P=0.0001P=0.0001
P=0.0001
Keeley, Lancet Jan. 2003
Findings
• Primary PTCA better than thrombolytic therapy at reducing– Short term death (7% vs. 9%) p=0.0002– Non-fatal reinfarction (3% vs. 7%) p=<0.0001– Stroke/ICH (1% vs. 2%) p=<0.0001– 43% relative reduction of combined endpoints
• PTCA superior during long-term follow-up, independent of thrombolytic used and whether or not patient was transferred for primary PTCA.
(Keeley, Boura, & Grines, 2003)
Take away message:
• Primary PCI is superior to fibrinolysis– In high volume PCI centers– If performed in a timely manner:– <120 min, possibly longer
Background
• ACC/AHA guidelines recommend early revascularization for patients with STEMI and cardiogenic shock who are <75 years old (class 1A)
• Patients > 75 years old many benefit as well (class IIaB)
• The guidelines also recommend transfer of STEMI patients with cardiogenic shock to PCI centers for early revascularization despite almost no data
2 Key Ingredients for Success
• Leadership
• Teamwork
AMI Steering Committee• Cardiology Program Coordinator• Cardiology x 4• Director – Emergency Department• Internal Medicine• Director – Cath Lab• Director of Programs and Information• Vice President & COO – Heart Hospital• CEO – Heart Hospital
777 Protocol
• Areas addressed– 12-lead ECG acquisition and interpretation– Cath lab activation generated by ED physician– Data collection– Standard order sets– Prompt feedback to ED/EMS
Admit Date
DC Date
Acct #
Mode of
Arrival
ED Arrival Time
Time Initial EKG
Min to
EKG
Initial Eval
Min to initial exam
777 Called
Total ED
Time
Cath Lab
Ready
3/4/08 5222924 ambulance 5:49 5:53 4 5:54 5 5:54 5 6:09
3/9/08 3/12/08 5244525 ambulance 0:49 0:54 5 0:54 5 1:04 15 1:37
3/21/08 3/24/08 5298746 ambulance 21:18 21:19 1 20:47 0 21:20
3/23/08 3/24/08 5300026 car 3:26 3:31 5 3:45 19 3:36 10 4:01
3/28/08 3/31/08 5324678 car 18:58 19:06 8 19:08 10 19:16 18 19:30
5 5 10<10 min
<5 min
<20 min
OSF Saint Francis Medical Center Door to PCI
Total ED
Time
Cath Lab
Ready
Patient in
Lab
777 to Pt in
Lab
Case Started
PCI Cath lab
time
Door to
PCI TimeMIN
% of cases
w/i 90
min
Day of
Week
Pt. Age
Attending MD
Comments Time saved
5 6:09 6:15 21 6:23 6:38 23 49 Y Thurs M-60 BestPeters
ReoProMetamore 1V23 brought patient
NA
15 1:37 1:53 49 2:03 2:28 35 99 N Sun M-59 SchmidtHauterFarber
No II B IIIA EMS did ECG at 00:33 SQD 3 East Peoria Fire Department
30 min could have been saved
0 21:20 21:31 11 21:37 21:43 10 25 Y Fri M-60 BarzalloCouri
ReoProPre-hospital ECG at 19:46 per Morton FD Para 3Not really called as 777. Dr. Barzallo was paged 30 min PTA. He called the cath lab in a 9 min PTA.
31 min saved
10 4:01 4:08 32 4:13 4:23 15 57 Y Sun M-44 RashidHublerTruong
ReoPro NA
18 19:30 19:46 30 19:53 20:11 25 73 Y Fri M-76 RashidBrownMiller
No IIB IIIA or Angiomax usedTX with underware on it took 16 min to get to lab.16
NA
10 30 23 57 79%
<20 min
<30 min
<25 min
<90 min
100%
PCPFirstName
PCPLast
Name
Group/BusinessName
Address City State Zip
Robert Lizer 5401 N. Knoxville #412 Peoria IL 61614
None
Phillip Rossi Box 267 Hopedale IL 61747
? ?
Timothy LaHood 5401 N. Knoxville # 105 Peoria IL 61614
OSF Saint Francis Medical Center Door to PCI
Door to PCI Time in Minutes
0
25
50
75
100
125
150
175
1Q 04 2Q 04 3Q 04 4Q 04 1Q 05 2Q 05 3Q 05 4Q 05 1Q 06 2Q 06 3Q 06 4Q 06 1Q 07 2Q 07 3Q 07 4Q 07 1Q 08 2Q 08
Min
utes
SFMC Nation
Jan
2006
med
ian
time
star
ted
bein
g us
ed
Apr
il 28
, 200
5 77
7 Pr
ogra
m in
itiat
ed
Apr
il 06
Doo
r to
PCI I
ndic
ator
chan
ged
to <
90
min
Sta
rted
se
ndin
g ou
t spr
eads
heet
Percent of Patients Receiving PCI in < 90 min
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
4Q03
1Q04
2Q04
3Q04
4Q04
1Q05
2Q05
3Q05
4Q05
1Q06
2Q06
3Q06
4Q06
1Q07
2Q07
3Q07
4Q07
1Q08
2Q08
Perc
ent o
f Pat
ient
s
SFMC % <90min Nation
Apr
il 28
, 200
5 77
7 Pr
ogra
m
initi
ated
Apr
il 06
Doo
r to
PCI I
ndic
ator
cha
nged
to
< 90
min
Star
ted
send
ing
out s
prea
d sh
eet
Results of 777
• All have been < 90 min for the last 7/8 quarters• Last 4 Quarters: 53, 65, 49 and 59 min (median)• How have we accomplished this goal
– Developing a collaborative relationship between Cardiologists and ED Physicians
– Discussing cases at quarterly combined meetings– Focus group discusses each outlier individually – Development of a code to activate cath lab staff and
cardiology as soon as we know a patient is arriving (777)
Heart 777• Heart attack
• Emergencies
• And
• Regional
• Transfers
AMI Steering Committee• Cardiology Program Coordinator • Cardiology x 4• Internal Medicine• Director – Emergency Department • Director – Cath Lab• Director of Programs and Information• Vice President & COO – Heart Hospital• CEO – Heart Hospital• Life Flight• Medical Communications
HEART 777• Regional program developed between OSF Saint
Francis Medical Center and HeartCare Midwest• Available for use by all area cardiologists• At present includes 9 hospitals and will be
adding 4 more in near future • Median time currently 105 min • 80% of patients receiving PCI within < 120 min
Participating Hospitals• Graham Hospital – Canton• St. Mary Medical Center – Galesburg• Cottage Hospital – Galesburg• Mason District Hospital – Havana• Kewanee Hospital – Kewanee• St. Margaret’s Hospital – Spring Valley• IVCH – Peru• Perry Memorial Hospital – Princeton• Pekin Hospital - Pekin
Heart 777 Program
• Call PALS, say “HEART 777 and patient weight”
• LifeFlight dispatched or ambulance obtained• Ask for cardiologist on call• MD decision: primary PCI of thrombolytic• Inclusion: STEMI <12 hours or new LBBB• Exclusion: None (including out-of-hospital
cardiac arrest and cardiogenic shock)
Time Required to Transfer
• DANAMI-2 Trial– Transport time from community hospital to PCI center
averaged 32 minutes
• PRAGUE-2 Trial– 48 minutes
• National Registry of Myocardial Infarction in the United States– 180 minutes total (Approx. 120 minutes for decision
making and transfer; 53 minutes between PCI hospital arrival and balloon inflation)
(Jacobs, et al., 2006)
Findings After Implementation
• The median “first” door-to-balloon time for patients <40 miles (zone 1) was 105 minutes
• The median “first” door-to-balloon time of patients <60 miles (zone 2) was 116 minutes
• 60-80 miles (zone 3) not yet implemented
Regional HEART 777Name Admit
DateDC
DateAcct
#Mode
of Arrival
Mode of Transfer
ED Arrival Time
Time Initial EKG
Min to
EKG
Initial Eval
Min to initial exam
MedCom
Receives call
ED to Call to MedCom
Dispatch Enroute Arrived on
scene
Flight Time
1
10/17/07 10/18/07 4695991.0 ? LF 6:40 6:40 1 6:40 1 6:47 7 6:57 7:02 7:22 25
11/13/07 11/16/07 4804638 car LF 13:02 13:14 12 13:02 1 13:21 19 13:21 13:24 13:45 24
1/11/08 1/14/08 5019727 car LF 12:25 12:29 4 12:25 1 12:36 11 12:38 12:44 13:09 33
2/2/08 5103841 car LF 13:58 14:17 19 14:00 2 14:30 32 14:36 14:43 15:07 37
2/20/08 2/22/08 5171756 car LF 11:00 11:04 4 11:00 0 11:13 13 11:25
4 1 13 29<10 min
<5 min
10 min
</= 30 min
Regional HEART 777Rendez-
vousDepart ED with Patient
Ground Time
Depart Scene
ArivedSFMC
Flight Time 2
Facto
FacTime
CathLab
Ready
Patient in
Lab
Arrival to Pt in
Lab
Case Started
PCI Cathlab
time
Door to
PCI TimeMIN
% of cases
w/i90 -120
min
Day of Week
Pt.Age
MD Life Flight
PCP
7:25 7:31 9 7:38 8:00 29 80 7:51 8:10 10 8:18 8:31 21 111 Y Wed 67
13:47 13:54 9 14:01 14:20 26 78 14:29 14:36 16 14:36 #### 10 104 Y Tues F-84
13:15 13:23 14 13:33 13:53 30 88 13:25 14:01 8 14:08 #### 23 119 Y Fri M-69
15:12 15:24 17 15:33 15:53 29 115 16:00 16:11 18 16:18 #### 20 153 N Sat M-51
12:18 12:33 93 12:41 8 12:49 #### 24 125 N Wed M-63
12 29 88 10 21 119 100%<10 </= 60 < 30
min< 90 min
100%
Avedis Donabedian, MD: Father of Quality Assurance
Structure
Process
Outcome
Core Process Measures% Heart Attack Patients:
• Given aspirin on arrival• Given aspirin on discharge• Given ACE inhibitor or ARB for left ventricular
systolic function• % of heart attack patients given smoking cessation
advice• Given β blocker on admission• Given β blocker on discharge• PCI in 90 minutes of arrival
% Given ASA
90919293949596979899
100
US IL SFMC
% Given ASA on Arrival
8788899091929394959697
US IL SFMC
% Given ASA on Discharge
% Given Beta Blocker
8586878889909192939495
US IL SFMC
% Given Beta Blocker on Admission
84
86
88
90
92
94
96
98
100
US IL SFMC
% Given Beta Blocker on Discharge
ACE Inhibitor or ARB for LV Dysfunction
80
82
84
86
88
90
92
US IL SFMC
% Given ACE or ARB for LV Systolic Dysfunction
Smoking Cessation Advice
86
88
90
92
94
96
98
100
102
US IL SFMC
% of Patients Given Smoking Cessation Education
What are the odds?
• Of a coin landing on heads?
• Of a coin landing on heads twice?
• Of a coin landing on heads 4 times in a row?
0.50.5
0.5 x 0.5 = 0.25 0.5 x 0.5 = 0.25
0.5 x 0.5 x 0.5 x 0.5=0.5 x 0.5 x 0.5 x 0.5=0.0625 or 6.25%0.0625 or 6.25%
What are the Odds?
• Of Perfect Acute MI Care?**ASA on admission 0.990.99ASA on discharge X 0.96X 0.96Beta Blocker on admission X 0.94X 0.94Beta Blocker on discharge X 0.99X 0.99ACE inhibitor or ARB X 0.91X 0.91Smoking cessation X X 1.001.00
80.5%80.5%**time to PCI in less than 90 min
not included
Summary
• Primary PCI is superior to thrombolytics• Key strategies can significantly impact D2B
times• Regionalization is feasible• Continue to strive to improve• If it works in Europe it can work in Illinois
Hospital Standardized Mortality Rate (HSMR)
Using Binary Linear Regression:
• A methodology to determine death as a defect versus death as the end of life’s journey THAT
• Adjusts a hospital’s mortality based on case mix characteristics AND
• Adjusts a hospital’s mortality based on community characteristics
Adjustment Factors
Over 25 variables including:• Age• Sex• Length of Stay• Admission category• Excludes palliative care• Emergency care• Hospital volume
Jarman, Brian et al, Explaining differences in English hospital death rates using routinely collected data, BMJ 1999; 318; 1515-1520
HSMR
Facility Observed of Deaths
Total US Expected DeathsX 100
140067 annual (Medicare years Oct-Sep) regression-adjusted HSMR vs USA HSMR
0
20
40
60
80
100
120
1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008
Reg
ress
ion
adju
sted
hos
pita
l HSM
R &
USA
HSM
R
US overall HSMR
REGRESSION ADJUSTED hospital HSMR
Outcome: Mortality
Is It Real?–Coding–Case Mix
Diagnosis Codes410.01 Acute MI anterior/lateral wall initial episode
410.11 Acute MI other anterior wall initial episode
410.21 Acute MI inferolateral wall initial episode
410.31 Acute MI inferoposterior wall initial episode
410.51 Acute MI other lateral wall initial episode
410.81 Acute MI other specific sites initial episode
410.41 Acute MI other inferior wall initial episode
410.71 Acute MI subendcardial infarction initial episode
410.91 Acute MI unspecified site initial episode
SMRs for groups of ICD9 diagnoses (see methodology): 140067 for period covered by current data, compared with USA Medicare 2004
020
4060
80100
120140
160180
200
Infe
ctio
ns 1
4006
7
Infe
ctio
ns U
SA 2
004
Neo
plas
ms
1400
67
Neo
plas
ms
USA
200
4
Dia
bete
s &
met
abol
ic 1
4006
7
Dia
bete
s &
met
abol
ic U
SA 2
004
Acut
e M
I 140
067
Acut
e M
I USA
200
4
Oth
er c
ardi
ac 1
4006
7
Oth
er c
ardi
ac U
SA 2
004
Hyp
erte
nsio
n &
CH
F 14
0067
Hyp
erte
nsio
n &
CH
F U
SA 2
004
Cer
ebro
vasc
ular
dis
ease
140
067
Cer
ebro
vasc
ular
dis
ease
USA
200
4
Perip
hera
l vas
cula
r dis
ease
140
067
Perip
hera
l vas
cula
r dis
ease
USA
200
4
Res
pira
tory
dis
ease
140
067
Res
pira
tory
dis
ease
USA
200
4
Gas
tro-in
test
inal
dis
ease
140
067
Gas
tro-in
test
inal
dis
ease
USA
200
4
Ren
al d
isea
se 1
4006
7
Ren
al d
isea
se U
SA 2
004
Dec
ubitu
s ul
cer &
cel
luliti
s 14
0067
Dec
ubitu
s ul
cer &
cel
luliti
s U
SA 2
004
Frac
ture
d ne
ck o
f fem
ur 1
4006
7
Frac
ture
d ne
ck o
f fem
ur U
SA 2
004
Com
plic
atio
ns 1
4006
7
Com
plic
atio
ns U
SA 2
004
Tota
l 140
067
Tota
l USA
200
4
SMRs (95% CIs)
HSM
R (9
5% C
Is)
Bottom Line
• Higher infarcted-artery patency with primary PTCA• Primary PTCA is more effective than thrombolytic
therapy for the treatment of STEMI when performed expeditiously and expertly
• Data holds out even for PCI transfers• For every 100 patients transferred for PCI, 7 MACE
events prevented
(Nallamothu, et al., 2005)
ACC/AHA
• Recognizes that over 400,000 STEMI patients annually are not having their needs met, 1/3 don’t receive any reperfusion strategy, and in those who do, only 40% < 90’
• Potential benefits of regionalized care• Multidisciplinary group of experts working to
develop recommendations for a strategy to increase the number of STEMI patients with timely access to primary PCI
(Jacobs, et al., 2006)
Issues
• One third of STEMI patients do not receive ANY reperfusion therapy despite availability.– Limited ability to recognize symptoms and contact
medical system in a timely manner– Time to transport to the hospital– Decision process on arrival– Time to actually implement reperfusion strategy
(Jacobs, et al., 2006)
Peoria Region
• As demonstrated by the research at MHI/ANW & Mayo Clinic, it is possible to establish protocols and reduce transfer times from the region
• Our program is currently underway
HEART 777