Mark C. Bieniarz, MD

Andrew Harrell, MD

Peter Berger, MD

� Should PCI center activate the cath lab off EMS field interpretation of ECG? Is this happening consistently in New Mexico?

� What is acceptable rate of activation without intervention?

� How far is too far? Lytic vs. PCI and distance/time

� Fly or drive- distance, base locations and weather.

� Monitoring inappropriate activations and data feedback loops between EMS and hospital

� HIPPA rules around data sharing

� In rural state, transfer for STEMI care is necessary

ST-segment–elevation myocardial infarction reperfus ion pathways for non–percutaneous coronary intervention (PCI) centers.

Daniel Muñoz, and Christopher B. Granger Circulation . 2011;124:2477-2479

Copyright © American Heart Association, Inc. All rights reserved.

� The Way We’ve Always Done It…� Previous STEMI transfer mish mosh

� Prehospital ECG not available and chest pain patient taken to local hospital

� ECG there documented STEMI and transfer arranged calling the cardiologist or ER at PCI center

� Prior to acceptance, the ER doc assessed the patient for appropriateness of PCI, checked for CCU bed availability, then requested helicopter transfer

� On arrival, patient taken to ER where assessed by ER doc, general cardiologist on call and then interventional cardiologist consulted

� If appropriate, interventional card called in cath lab who were to arrive in 30 minutes to begin case

� Standard care at beginning of the STEMI network protocol 2004

� STEMI receives same priority as bleeding trauma� Transfer plans in place with backup� Patient stays on EMS stretcher for eval� Transport directly to cath lab� When possible exclude IV infusions of Heparin and

nitroglycerin� Transfer protocol goal should be speed NOT pain

relief. Don’t get distracted from goal.� Hospital records faxed to receiving facility. Should not

delay transfer. � No facility bias. Transfer should ALWAYS be to

closest PCI facility. Advanced life support units serving a specific hospital should always be willing to transfer to closest PCI facility

� STEMI receives same priority as trauma and 911 call

� 10 minute pickup time. Hot load. Standard across systems (Duke, Mayo)

� Helicopter capable of transferring with 10 minutes notice

� Avoid IV nitro, heparin when possible

� Transfer directly to cath lab

� Guidelines state aim for 90 minutes and transfer if possible for primary PCI in 120 minutes

Pinto, DS, et al. Circulation. 2011; 124: 2512-2521

� Multiple agencies involved

� Lack of cooperation between hospitals for the benefit of the community

� Failure to rapidly diagnose STEMI at referring hospital

� EMS not regarding STEMI with same priority as trauma

� Early identifcation of STEMI based on symptoms and prompt ECG

� Eyeballs to beltbuckles campaign

� Door to ECG standard of 5 minutes

� Early initiation of transfer

� Prehospital notification or rerouting of EMS to PCI center

High-risk ST elevation MI patients (>4 mm elevation), Sx < 12 hrs5 PCI centers (n=443) and 22 referring hospitals (n=1,129), transfer in < 3 hrs

High-risk ST elevation MI patients (>4 mm elevation), Sx < 12 hrs5 PCI centers (n=443) and 22 referring hospitals (n=1,129), transfer in < 3 hrs

Lytic therapyFront-loaded tPA 100

mg

(n=782)

Lytic therapyFront-loaded tPA 100

mg

(n=782)

Death / MI / Stroke at 30 DaysDeath / MI / Stroke at 30 Days

Primary PCIwith transfer

(n=567)

Primary PCIwith transfer

(n=567)

Primary PCIwithout transfer

(n=223)

Primary PCIwithout transfer

(n=223)

Stopped early by safety and efficacy committeeStopped early by safety and efficacy committee

N Engl J Med 2003; 349: 733-42N Engl J Med 2003; 349: 733-42

13.7%

8.0%

0%

4%

8%

12%

16%13.7%

8.0%

0%

4%

8%

12%

16%

30

Da

y D

ea

th /

MI

/ S

tro

ke

(%

)3

0 D

ay

De

ath

/ M

I /

Str

ok

e (

%)

LyticLytic Primary PCIPrimary PCI

P<0.001P<0.001 P=0.002P=0.002

CombinedCombined Transfer SitesTransfer SitesP=0.05P=0.05

Non-Transfer SitesNon-Transfer Sites

LyticLytic Primary PCIPrimary PCI LyticLytic Primary PCIPrimary PCI

14.2%

8.5%

0%

4%

8%

12%

16%14.2%

8.5%

0%

4%

8%

12%

16%

12.3%

6.7%

0%

4%

8%

12%

16%

12.3%

6.7%

0%

4%

8%

12%

16%

N=27N=27 N=15N=15N=80N=80 N=48N=48

N Engl J Med 2003; 349: 733-42N Engl J Med 2003; 349: 733-42

N=107N=107 N=63N=63

2.0%

1.1%

0%

2%

4%

6%

8%

2.0%

1.1%

0%

2%

4%

6%

8%

6.3%

1.6%

0%

2%

4%

6%

8%

6.3%

1.6%

0%

2%

4%

6%

8%

7.8%

6.6%

0%

2%

4%

6%

8%

10%

7.8%

6.6%

0%

2%

4%

6%

8%

10%

LyticLytic Primary PCIPrimary PCI

P=0.35P=0.35

DeathDeath

LyticLytic Primary PCIPrimary PCI

P=0.15P=0.15

StrokeStroke

LyticLytic Primary PCIPrimary PCI

P<0.001P<0.001

Recurrent MIRecurrent MI

N Engl J Med 2003; 349: 733-42N Engl J Med 2003; 349: 733-42

Pinto D, et al. Cardiovascular Reviews and Report. 2003;24:267-276.

0

Med

ian

Tim

e (

min

)M

ed

ian

Tim

e (

min

)

DANAMIOn-Site Primary PCI

DANAMIOn-Site Primary PCI

DANAMITransfer Primary PCI

DANAMITransfer Primary PCI

US AMITransfer Primary PCI

US AMITransfer Primary PCI

90

110

185

50

100

150

200

225

25

75

125

175

http://www.mmclc.org/

Coordination across care systems

STEMI Receiving HospitalSTEMI Referring Hospital

� Each hospital and EMS system should have contingency plan for STEMI care

� Transfer protocols

� STEMI medical protocols

� STEMI consortium development for shared protocols and data. Mission:lifeline facilitating this.