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Toronto STEMI Project

Toronto STEMI Project. 24/7 Primary PCI in the GTA. GENERAL BACKGROUND.

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Toronto STEMI Project

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  1. Toronto STEMI Project 24/7 Primary PCI in the GTA

  2. GENERAL BACKGROUND • Centres offering PCI 24/7 (St. Michael’s Hospital, Sunnybrook and UHN), Toronto EMSand hospitals across the GTA have agreed to improve and optimize existing emergent interventional services by joining forces to provide a ‘guaranteed accept’ 24/7 service within the city of Toronto boundaries for heart attack patients who will benefit most from an emergency angioplasty • Other hospitals in Toronto EMS catchment area may also take part by either referring patients to PCI centres and repatriating patients or by providing angioplasty where available • Heart Attack Committee formed January 2007 - focused on developing a model and generating buy-in from participating organizations and other stakeholders • EMS advanced life support paramedics will use 12-lead ECGs to identify STEMI patients in pre-hospital setting, and will bring those patients directly to a PCI centre to enable a 90-minute door-to-balloon time. These patients will go directly to the Cath Lab, seen in the PCI centre's ER only if  unstable despite pre-hospital treatment • Where applicable, following PCI, stable patients will be transferred back to their local hospital within 24 hours of procedure

  3. GEOGRAPHICAL AREA • Steeles to the North • Etobicoke Creek/Hwy 427 to the West • East to Rouge Valley; and South to the Lake • Anticipated total STEMIs within boundary: 1,200 a year based on data extrapolated from the Ottawa experience and population data from City of Toronto

  4. CLINICAL BACKGROUND • Timely reperfusion of STEMI patients improves short and long-term survival and has become the mainstay of therapy in this setting • As an alternative to primary PCI, patients are given thrombolytic pharmacotherapy • numerous studies and analysesshow that PCI achieves better outcomes, with much lower risk of intracerebral hemorrhaqe • Primary PCI to be of benefit when the door to balloon time in the range of 60 to 90 minutes. Subsequent data from large registries have indicated, the actual door-to-balloon time is considerably longer than these optimal clinical trial times • Recent analysis of a large US National Registry of Myocardial Infarction (NRMI) indicates that the benefit of primary PCI relative to thrombolysis is not related just to PCI-related delay, but also by patient characteristics

  5. CLINICAL BACKGROUNDcontinued • Figure 1 • relationship between patient age, infarct location and the time from symptom onset to presentation • apparent that mode of reperfusion therapy needs to be taylored to individual patient, based on all parameters, not just door-to-balloon time.

  6. TORONTO’S SITUATION • Majority of emergeny cath lab procedures for STEMIs occur when thrombolytic therapy fails • Provision of emergent interventional cardiology care in Toronto has three major challenges: • frequent shortage of critical care beds at all institutions with interventional cardiology programs • lack of an efficient and timely transport system to transfer patients to PCI centres • current lack of an organized and efficient 24/7 primary PCI service in the region

  7. Toronto STEMI Project: The Challenges

  8. TRANSPORATION SYSTEM • Current EMS is equipped with very few critical care trained paramedic units needed to handle possible emergencies during transport • Majority of units not available to transport patients with STEMI from community hospitals unless a physician provides advanced care during transport • rarely occurs in Toronto - on-call cardiologist in the community hospital is responsible for many other patients

  9. CARDIAC INTENSIVE CARE BED CAPACITY • Shortage of critical care beds to accept a patient with a STEMI • Shortage of nurses to care adequately and safely for extra patient(s) • Result: physicians in community hospitals must commonly contact as many as four tertiary centres and still may not find a bed and thus timely care

  10. Toronto STEMI Project: The Benefits

  11. COLLABORTATION • the STEMI program is a coordinated effort, which will improve the integration of care with EMS, referring hospitals and PCI facilities • Need to ensure efficient flow of patients from hospitals without PCI capability to PCI centres and vice versa

  12. SAVING LIVES • The STEMI initiative optimizes door to balloon time, which may decrease: • co-morbidities • reduce complications • limit the need for prolonged hospital stays and readmissions

  13. SUCCESS STORIES • Well-studied and recommended process of care that benefits patients and practitioners • Most recently, an article about Ottawa Heart Institute’s usage of the protocol was published in the January 2008 issue of the New England Journal of Medicine

  14. HOSPITAL LEADS

  15. FOR MORE INFORMATION www.stemitoronto.ca • Project Overview • List of Partners • Resources - detailed PowerPoint - models of reference (Ottawa Heart; Mayo Clinic) • Upcoming Events / News • Tools - canned ppt - Q&A - Community Consultation Plan • Contact Information for questions/feedback

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