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Massachusetts STEMI Care

Massachusetts STEMI Care. Peter Moyer MD,MPH,FACEP Dallas June 4 ,2011. Who I am. Taught NYC medic classes 5-14 (1977 -84) Chair of BU Emergency Medicine 1984-2000 Medical Director Boston EMS, Fire and Police 2000-2010. Disclosures. NONE. STEMI Statistics.

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Massachusetts STEMI Care

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  1. Massachusetts STEMI Care Peter Moyer MD,MPH,FACEP Dallas June 4 ,2011

  2. Who I am • Taught NYC medic classes 5-14 (1977 -84) • Chair of BU Emergency Medicine 1984-2000 • Medical Director Boston EMS, Fire and Police 2000-2010

  3. Disclosures NONE

  4. STEMI Statistics Acute Coronary Syndrome (ACS) will strike 935,000 people a year in the United States An estimated 250,000 of those will be STEMIs Heart Disease and Stroke Statistic 2011 Update: A Report From the American Heart Association Statistics Committee and Stroke Statistics Subcommittee. Circulation 2011;123:e18-e209. 1/1/2020 5

  5. Mission: Lifeline & Sudden Cardiac Arrest Statistics • 325,000 suffer from OOHCA • US survival rates are only 8.4% Why include SCA? • Experts estimate that up to 50% of OOHCA are STEMI’s • To develop systems of care to improve survival for OOHCA 7

  6. STEMI Revascularization Strategy Trends MedicallyManaged PCI CABG ACTION Registry-GWTG DATA: July 1, 2009 – June 30, 2010

  7. 10 Years of STEMI System of Care in Boston • 1990’s: Paramedic EKG acquisition and interpretation • 2000:Boston EMS criticized in press for by- passing non PCI hospital with STEMI patient • 2001-2002: eventual agreement of medical community to take STEMI’s only to PCI centers (STEMI Point of Entry plan) • 2003: new STEMI POE begun

  8. Boston’s PCI centers • PCI centers agreed to: -perform PCI 24/7/365 -maintain necessary institutional and individual interventionalist volumes -meet performance criteria: PCI rather than lysis >90% D2B < 120 then <90 min 75 % -submit data to a common data coordinating center

  9. Initial Obstacles to STEMI plan -non PCI centers feared loss of revenue -PCI centers feared public airing of performance

  10. Solutions • Shared revenues between PCI and non PCI hospitals • Blinded performance data (blind broken for failure to meet performance criteria)

  11. Boston EMS Third Service Fire First Response .6 -1.2 Million pop 110k calls per year 75k transports per year 6 STEMI PCI Centers

  12. Boston EMS 2 tiers: low paramedic #’s 75 (average intubations/medic/yr : 8.5) bigger BLS tier 275 give albuterol and nasal naloxone ,test sugar, dispatched to stroke

  13. Pre hospital EKG-national EMS transported STEMI’s with and without pre hospital EKG: • D2B with pre hospital EKG: 79 min • D2B without pre hospital EKG: 91 min 5/14/11 AR GWTG

  14. Pre Hospital EKG -Boston • Boston EMS paramedics read 12 leads and radio and transport to PCI hospital bypassing non PCI hospitals if necessary

  15. Boston EMS • Divide 12 leads into: STEMI ,Possible STEMI and non STEMI

  16. Boston EMS • Early: 12 lead Call to hospital Mention of STEMI in radio call

  17. E2B

  18. 2008 Web Based Continuous QI system Automated

  19. Boston’s STEMI QI • Clinical Care Benchmarks • IV, O2, ASA, 12L EKG • Prehospital Notification • 12L EKG Interpretation • Medical Director Agreement • Hospital Follow up • Agreement with 12L EKG evaluation • Cardiac Cath • Door to Balloon; EKG to Balloon Time

  20. STEMI CARE Benchmarks Prehospital care meets clinical care benchmarks for STEMI patinet

  21. Individual Case review

  22. Hospital Data Entry Prehospital Entry note given? If Cardiac Cath, balloon time entered. Able to calculate D2B time or E2B time. 33

  23. EMS Feedback Report Patient outcome available in EMS cQI system immediately after hospital enters data 34

  24. Mass STEMI care

  25. 1/1/2020 38 Taken from Quarter 3 2011 ACTION Registry – GWTG 2011

  26. Where is STEMI care headed?

  27. IIa IIa IIa IIa IIb IIb IIb IIb III III III III I I I IIa IIa IIa IIa IIb IIb IIb IIb III III III III I I I IIa IIa IIa IIa IIb IIb IIb IIb III III III III I I I C NEW Recommendation Systems of Care Each community should develop a STEMI system of care following the standards developed for Mission Lifeline (AHA) including: • Ongoing multidisciplinary team meetings with EMS, non-PCI & PCI centers • A process for prehosp identification and activation • Destination protocols for PCI centers • Transfer protocols for non-PCI centers for appropriate patients ACC/AHA 2009 Joint STEMI/PCI Guidelines Focused Update JACC 2009

  28. STEMI Systems Coverage

  29. STEMI Systems of Care • Integration of Patients, EMS and non PCI centers into PCI Systems • Data driven with QI feedback from PCI center to ED’s and EMS • Certificate of Need (CON) and Accreditation

  30. Patients • Increase Use of EMS • Decrease Symptom Onset to Balloon- Dallas/Caruth’s Symptom Onset to Arterial Reperfusion (SOAR) metric • Awareness of PCI centers

  31. 1/1/2020 Taken from Quarter 3 2011 ACTION Registry – GWTG 2011 45

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