12 tectonic plates shaping the formation of regional stemi networks ivan c. rokos, md, facep, (facc)...
TRANSCRIPT
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12 Tectonic Plates Shaping the Formation of
Regional STEMI Networks
Ivan C. Rokos, MD, FACEP, (FACC)
Emergency Physician
Asst. Clinical Professor, UCLA
Staff Physician, Olive View-UCLA
Staff Physician, Northridge Hospital
Los Angeles, CA
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Disclosures• No financial disclosure• Member
– ACC D2B Alliance Steering Committee– AHA Mission: Lifeline
• Emergency Cardiac Care Committee• Model Evaluation Committee
– AHA California STEMI Task Force– LA County STEMI Receiving Center Network planning– Volunteer consultant to the E2B Coalition
• www.E2Bchallenge.com
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Primary Objective
• ACC vision Quality and Value– Guidelines, Registries, Appropriate Use Criteria
– Dr. Weaver, President’s Page, JACC, March 10, 2009
• Systems and Networks allow frontline clinicians to consistently achieve Quality
• In an organized system….– Good clinicians excel
– Average providers still do the right thing
– Fix “bad systems,” not “bad clinicians”
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Large and Powerful Tectonic Plates shape our planet’s geography
12 Tectonic Plates are shaping the formation
of STEMI Networks
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Tectonic Plates #1-4
• National Trauma Center Systems– Example of multi-disciplinary collaboration
• NRMI Registry– The Status quo for D2B was slow
• Feds and Core Measures– Mandated Transparency
• Institute of Medicine 2006 Report– Emergency Care at the Breaking Point
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Tectonic Plates #5-8
• ACC/AHA STEMI Guidelines– 2004 Benchmark of D2B ≤90 Minutes
• ACC D2B Alliance– Improve INTRA-hospital process for PPCI
• Two European Studies– Prague-2 and Danami-2
• Technology– Automated pre-hospital ECGs and Defibrillators
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#9) “Grassroots” Initiative(Rokos IC, 2006 AHJ,152:661)
• Multi-Disciplinary• Influenced by the 8 prior Tectonic Plates• Inter-hospital transfer & pre-hospital cardiac triage
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“Grassroots” intersects with Big Society
11 Papers, Circulation May 30, 2007
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Inter-hospital Transfer in 2007
• Minneapolis (Henry et al, Circulation 07)
• Mayo Rochester (Ting et al, Circulation 07)
• North Carolina RACE (Jollis et al, JAMA 07)
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Pre-hospital Cardiac Triage
• Regional diversion protocol allowing EMS to transport STEMI directly to PPCI-capable hospitals
• Cardiac cath lab accessible 24/7/365 regardless of ED-diversion status
• Parallel processing patient transport and cardiac cath lab activation occurring simultaneously
• Plan A = PCI, Plan B = Fibrinolytics• Regional Quality Improvement Database
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“Clever” Devices need Networks & Systems
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45 STEMI Receiving Centers: Ventura, Los Angeles, & Orange Counties (California)
64 in So. Cal: 19 more SRCs San Diego, Riverside, San Bernadino Counties.
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The DATA
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JACC CV Interventions, April 2009, in press
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Map of 10 STEMI Networks(Rokos et al, 2009 JACC Intv., in press)
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Demographic Summary for 10-regions
• 20+ million citizens• 5,000+ paramedics• 166 hospitals Paramedic Receiving Centers
– 72 hospitals STEMI Receiving Centers
• D2B Data spans:– Unique start date for each region– End August 31, 2007– Includes ALL consecutive patients
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Study PopulationAggregate 10-region Data
• 2,712 PH-ECG(+) for presumed STEMI– N= 659 (24%) PH-ECG(+) but PPCI(-)– N=2,053 (76%) PH-ECG(+) and PPCI(+)
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D2B Pooled Analysis
• N = 2,053 for 10 SRC networks combined
• 86% rate of D2B 90 Minutes• Inclusions:
– ALL consecutive PH-ECG (+) and PPCI (+)
• Exclusions:– No self-transport patients– No inter-hospital transfer patients
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Rate of D2B ≤ 90min by Region(Rokos et al, 2009 JACC Intv., in press)Figure 2
0%
20%
40%
60%
80%
100%
120%
OC(563)
LAC(476)
Mar(231)
SDC(210)
MSP(168)
Roy(112)
Cha(89)
Med(85)
Ven(67)
Atl(52)
Rate (%) of D2B 90 Min.
86%
Solid Red line represents the Primary Endpoint. Dashed Red line is D2B Alliance Benchmark
N = 2,053
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Secondary Endpoints:N=2,053 with D2B Time
• 50% rate of D2B ≤ 60 Minutes (N=1,031)
• 25% rate of D2B ≤ 45 Minutes (N=517)
• 8% rate of D2B ≤ 30 Minutes (N=155)
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CathPCI Registry 2005-06 (N=43,801)(Rathore et al, Circulation, AHA08 abstract #6174)
Fractional Polynomial - Adjusted
Overall mortality 4.6%
Best fit from 3rd degree polynomial
P<0.001 for comparison with linear term
03
69
1215
Mor
talit
y (%
)
15 30 45 60 75 90 105 120 135 150 165 180 195 210 225 240Door-to-Balloon Time
Adjusted Mortality Rate95% CI: Low er Limit
95% CI: Upper Limit
D2B from 90 to 60 minutes associated with 0.8% Mortality
D2B from 60 to 30 minutes associated with 0.5% Mortality
In-hospital
Mortality
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E2B EMS-to-Balloon time
• EMS = Emergency Medical Services
• Time Zero = Date and Time auto-stamped on first PH-ECG diagnostic of STEMI
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Tertiary Endpoint(EMS)-to-Balloon (E2B)
• 2,053 were PH-ECG(+) and PPCI(+)• 762 of 2,053 (37%) had PH-ECG time recorded
in a database (5 regions: LAC, MSP, Med, Cha, Ven)
–68% rate of E2B ≤ 90 minutes
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Primary ObjectiveSystems and Networks
provide your community with Quality
9-1-1 is A2QAccess to Quality
(Tectonic Plate #9)
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#10) National Registries
ACC/AHA Collaboration
NCDR created and empowered a large, enthusiastic workforce
of QI personnel across most PPCI hospitals
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#11) AHA Mission: Lifeline• National community-based initiative• The “ideal” becomes the “routine”• Goals:
– Improve quality of care & outcomes in STEMI– Improve health care system readiness and
response
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Developing Ideal STEMI Systems
27
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Secondary Objective: How do ACC-D2B and AHA-MLL
interact?
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Developing Ideal STEMI Systems
29
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STEMI Systems Synergy
Collaborating
Societies & Organizations
AHA Mission: Lifeline Inter-Hospital, Pre-hospital,
Patient Education pre/post (N=5,000)
ACC D2B Alliance Intra-hospital (N=1200)
Registries
Guideline-based Performance Measures and Quality Metrics
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Tectonic Plate #12
Bigger than
ACC, AHA, NCDR, TJC, etc.
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#12) Change ….You Can Believe In
• Obama Campaign website– “I am asking you to Believe…not just in my
ability to bring about real change in Washington…I’m asking you to Believe in yours
• “STEMI Activist”– Ordinary healthcare professionals trying to optimize the
STEMI system in their region using best evidence
– Empowerment & Engagement Sustainability
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SummaryThree Objectives
• To achieve Quality and Value…– Organize Systems and Networks– Patient-centered care is Priority #1 (ACC/AHA)
• Synergy clearly exists between…– ACC D2B Alliance– AHA Mission: Lifeline
• Spread the spirit of STEMI Activism– State STEMI Contact List
Email: [email protected]