Ambulance Victoria and MonashHEART Acute Myocardial Infarction (Mon-AMI) 12 lead ECG project. An update. On behalf of the MonAMI Team A Hutchison, Y Malaiapan , B Barger, I Jarvie , E Watkins, G Braitberg , T Kambourakis , JD Cameron, IT Meredith. - PowerPoint PPT Presentation
Ambulance Victoria and MonashHEART Ambulance Victoria and MonashHEART Acute Myocardial Infarction (Mon- Acute Myocardial Infarction (Mon- AMI) AMI) 12 lead ECG project. 12 lead ECG project. An update An update On behalf of the MonAMI Team On behalf of the MonAMI Team A Hutchison, Y Malaiapan, B Barger, I Jarvie, E A Hutchison, Y Malaiapan, B Barger, I Jarvie, E Watkins, G Braitberg, T Kambourakis, JD Cameron, IT Watkins, G Braitberg, T Kambourakis, JD Cameron, IT Meredith. Meredith. Monash Cardiovascular Research Centre, MonashHEART, Southern Health & Monash Cardiovascular Research Centre, MonashHEART, Southern Health & Department of Medicine Department of Medicine (MMC), Monash University, Melbourne, Australia. (MMC), Monash University, Melbourne, Australia. Metropolitan Ambulance Service, Melbourne Australia. Metropolitan Ambulance Service, Melbourne Australia. Southern Health Emergency, Southern Health, Melbourne Australia. Southern Health Emergency, Southern Health, Melbourne Australia.
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Ambulance Victoria and MonashHEART Ambulance Victoria and MonashHEART Acute Myocardial Infarction (Mon-AMI) Acute Myocardial Infarction (Mon-AMI)
12 lead ECG project.12 lead ECG project.
An updateAn update
Ambulance Victoria and MonashHEART Ambulance Victoria and MonashHEART Acute Myocardial Infarction (Mon-AMI) Acute Myocardial Infarction (Mon-AMI)
12 lead ECG project.12 lead ECG project.
An updateAn update
On behalf of the MonAMI TeamOn behalf of the MonAMI Team
A Hutchison, Y Malaiapan, B Barger, I Jarvie, E Watkins, G Braitberg, A Hutchison, Y Malaiapan, B Barger, I Jarvie, E Watkins, G Braitberg, T Kambourakis, JD Cameron, IT Meredith.T Kambourakis, JD Cameron, IT Meredith.
Monash Cardiovascular Research Centre, MonashHEART, Southern Health & Department of Medicine Monash Cardiovascular Research Centre, MonashHEART, Southern Health & Department of Medicine (MMC), Monash University, Melbourne, Australia.(MMC), Monash University, Melbourne, Australia.
On behalf of the MonAMI TeamOn behalf of the MonAMI Team
A Hutchison, Y Malaiapan, B Barger, I Jarvie, E Watkins, G Braitberg, A Hutchison, Y Malaiapan, B Barger, I Jarvie, E Watkins, G Braitberg, T Kambourakis, JD Cameron, IT Meredith.T Kambourakis, JD Cameron, IT Meredith.
Monash Cardiovascular Research Centre, MonashHEART, Southern Health & Department of Medicine Monash Cardiovascular Research Centre, MonashHEART, Southern Health & Department of Medicine (MMC), Monash University, Melbourne, Australia.(MMC), Monash University, Melbourne, Australia.
Early recognition, rapid transport and treatment is absolutely vital
Early recognition, rapid transport and treatment is absolutely vital
Door to Balloon time affects Door to Balloon time affects in hospital mortalityin hospital mortality
Door to Balloon time affects Door to Balloon time affects in hospital mortalityin hospital mortality
US National registry of myocardial infarctionJ Am Coll Cardiol, 2006 47:2180-2186
In p
atie
nt
Mo
rtal
ity
%
Symptom onset < 1 hourbefore presentation
PCI available within 1 hour†
YES NO
PCI Fibrinolysis‡
Symptom onset 1–3 hoursbefore presentation
PCI available within 90 minutes†
YES NO
PCI Fibrinolysis‡
Symptom onset 3–12 hours before presentation
PCI available within 90 minutes(onsite) or 2 hours
(offsite, including transport)†
YES NO
PCI Fibrinolysis‡
* Assuming no contraindications to fibrinolytic therapy; † Time delay refers to time from first medical contact to balloon; ‡ Patients with ongoing symptoms or instability should be transferred for PCI.PCI = percutaneous coronary intervention
Acute Coronary Syndrome Guidelines Working Group Med J Aust 2006;184(8 Suppl):S9-29.
Hospital Management of STEMI*Hospital Management of STEMI*
Time to presentation Time to presentation MonashHEART experience MonashHEART experience
Time to presentation Time to presentation MonashHEART experience MonashHEART experience
Aims of MonAMIAims of MonAMIAims of MonAMIAims of MonAMI
To determine if paramedic performed field 12 To determine if paramedic performed field 12 lead ECG and activation of the infarct team, via lead ECG and activation of the infarct team, via the emergency physician, reduced D2BT in the emergency physician, reduced D2BT in patients undergoing primary PCI (PPCI)patients undergoing primary PCI (PPCI)
To determine if paramedic performed field 12 To determine if paramedic performed field 12 lead ECG and activation of the infarct team, via lead ECG and activation of the infarct team, via the emergency physician, reduced D2BT in the emergency physician, reduced D2BT in patients undergoing primary PCI (PPCI)patients undergoing primary PCI (PPCI)
MethodsMethodsMethodsMethods Prospective interventional study in a single Australian Prospective interventional study in a single Australian
metropolitan health care network.metropolitan health care network. 560 patients 560 patients
MonAMI groupMonAMI group All patients (n=186) who underwent PPCI following All patients (n=186) who underwent PPCI following
field ECGfield ECG
Non-MonAMI groupNon-MonAMI group Patients (n=254) who underwent PPCI following Patients (n=254) who underwent PPCI following
standard triage during the time of field ECG capabilitystandard triage during the time of field ECG capability
Pre-MonAMI groupPre-MonAMI group.. The D2BT of 120 consecutive patients who underwent The D2BT of 120 consecutive patients who underwent
PPCI prior to initiation of field triagePPCI prior to initiation of field triage
Prospective interventional study in a single Australian Prospective interventional study in a single Australian metropolitan health care network.metropolitan health care network.
560 patients 560 patients
MonAMI groupMonAMI group All patients (n=186) who underwent PPCI following All patients (n=186) who underwent PPCI following
field ECGfield ECG
Non-MonAMI groupNon-MonAMI group Patients (n=254) who underwent PPCI following Patients (n=254) who underwent PPCI following
standard triage during the time of field ECG capabilitystandard triage during the time of field ECG capability
Pre-MonAMI groupPre-MonAMI group.. The D2BT of 120 consecutive patients who underwent The D2BT of 120 consecutive patients who underwent
PPCI prior to initiation of field triagePPCI prior to initiation of field triage
12 Lead ECG Project12 Lead ECG Project
Patient with CPPatient with CP MICAMICA
Traditional AMI Communication Strategy:Traditional AMI Communication Strategy:
MICA Transports Patient to ED
MICA Transports Patient to ED
Patient Triaged in ED
Patient Triaged in ED
12 Lead ECG Performed by ED
Staff
12 Lead ECG Performed by ED
StaffDiagnosis MadeDiagnosis Made
ED Resident/Registrar
or Consultant
ED Resident/Registrar
or Consultant
Calls Cardiology Registrar
Calls Cardiology Registrar
Cardiology Registrar sights ECG & calls
Cardiology Registrar sights ECG & calls
CCU Ward Service Consultant
CCU Ward Service Consultant
Interventional Cardiologist
Contact
Interventional Cardiologist
Contact
Infarct Team Activated
Infarct Team Activated
12 Lead ECG Project12 Lead ECG Project
Patient with CPPatient with CPMICA Attends &
Performs 12 Lead ECG On Site
MICA Attends & Performs 12 Lead
ECG On Site
New lines of Communication:New lines of Communication:MICA Transports
Patient to Monash Heart Cath Labs
MICA Transports Patient to Monash Heart Cath Labs
12 Lead ECG Electronically
Transmitted to ED
12 Lead ECG Electronically
Transmitted to ED
Diagnosis Made by ED Consultant
Diagnosis Made by ED Consultant
Interventional Cardiologist
Contact
Interventional Cardiologist
Contact
Infarct Team Ready & Waiting in Cath LabsInfarct Team Ready & Waiting in Cath Labs
PagePage
Pre Mon-AMI Non Mon-AMI Mon-AMI P value
Male 81% 74% 81% 0.20
Age (Years) 58.5 61.2 63.5 0.003
Hypertension 38% 47% 40% 0.22
Diabetes 16% 19% 14% 0.20
Hyperlipidaemia 32% 37% 41% 0.16
Smoker (current) 42% 40% 37% 0.42
Family History 19% 23% 24% 0.52
Out of hours 54% 63% 53% 0.08
Patient DemographicsPatient Demographics
MonAMI Pilot StudyDecember 2007 – July 2008
MonAMI Pilot StudyDecember 2007 – July 2008
ED stand downN = 85 (41%)
STEMIN = 0
ACS(excluding STEMI)
N = 35
Field ECG faxed to MMCField ECG faxed to MMC204204
Field ECG faxed to MMCField ECG faxed to MMC204204
No ACSN = 52
Primary PCIN = 107
Taken to Cath LabN = 119 (59%)
CAD no PCIN = 3*
No overt CADN = 9
* Severe Triple Vessel Disease (CABG)* Severe Triple Vessel Disease (CABG)
Median D2B TimesMedian D2B Times
P < 0.001 P < 0.001
December 2007 – July 2009December 2007 – July 2009
Median TimesMedian Times
Pre MonAMI Non MonAMI MonAMI P value
D2BT 102 102.5 56.5 <0.001
Door-to-cath lab time
69 70 26 <0.001
Cath lab-to-Balloon time
28 28 27 0.44
Ambulance times (minutes)Ambulance times (minutes)
P = 0.31
Proportion of cases achieving D2B time under 90 minutes
Proportion of cases achieving D2B time under 90 minutes
75%*75%*
*AHA /ACC/SCAI guidelines
ConclusionConclusionConclusionConclusion
The performance of field 12 lead ECG to triage The performance of field 12 lead ECG to triage
and pre hospital activation of the infarct team and pre hospital activation of the infarct team significantly improves door to balloon times significantly improves door to balloon times and results in a greater proportion of patients and results in a greater proportion of patients achieving guideline recommendations.achieving guideline recommendations.
The performance of field 12 lead ECG to triage The performance of field 12 lead ECG to triage
and pre hospital activation of the infarct team and pre hospital activation of the infarct team significantly improves door to balloon times significantly improves door to balloon times and results in a greater proportion of patients and results in a greater proportion of patients achieving guideline recommendations.achieving guideline recommendations.
MonAMI Pilot StudyMonAMI Pilot StudyMonAMI Pilot StudyMonAMI Pilot StudyAmbulance VictoriaGreg Cooper Ambulance Victoria Group Manager
Danny McGennisken Operations Manager Paramedic Education & Training
Eddy Watkins Clinical support Officer
Bill Barger Manager Clinical Standards & Audits
Ian Jarvie Ambulance Victoria Clinical Support Officer
Monash HeartProf Ian Meredith Director MonashHeart
Dr Yuvi Malaiapan Head Interventional Services
SH Emergency DeptProf George Braitberg Professor and Director SH Emergency Medicine
Dr Tony Kambourakis Director Emergency Monash Clayton
Mr Damien Gibney NUM Emergency Monash Clayton
Strategy Planning & PerformanceMs Fiona Webster Executive Director SPP
Ms Ruth Smith Director Access, Innovation & Service Improvement
Ms Karen Barker Project Officer
Southern Health Information Technology
Mr Charles Burgess Executive Director IT
Mr Peter Kinsman Director IT
Monash Sector ExecutiveMr Adam Horsburgh Director Monash sector
Ambulance VictoriaGreg Cooper Ambulance Victoria Group Manager
Danny McGennisken Operations Manager Paramedic Education & Training
Eddy Watkins Clinical support Officer
Bill Barger Manager Clinical Standards & Audits
Ian Jarvie Ambulance Victoria Clinical Support Officer
Monash HeartProf Ian Meredith Director MonashHeart
Dr Yuvi Malaiapan Head Interventional Services
SH Emergency DeptProf George Braitberg Professor and Director SH Emergency Medicine
Dr Tony Kambourakis Director Emergency Monash Clayton
Mr Damien Gibney NUM Emergency Monash Clayton
Strategy Planning & PerformanceMs Fiona Webster Executive Director SPP
Ms Ruth Smith Director Access, Innovation & Service Improvement
Ms Karen Barker Project Officer
Southern Health Information Technology
Mr Charles Burgess Executive Director IT
Mr Peter Kinsman Director IT
Monash Sector ExecutiveMr Adam Horsburgh Director Monash sector
