Saving lives from heart attack ‘Mission DELHI’

Delhi Emergency Life Heart-Attack Initiative

‘A scientific project to develop, test and implement a

comprehensive, information technology-aided, 24-hour

emergency response system for a pre-hospital

thrombolysis service, using bolus-dose thrombolytic agent

followed by Primary PCI for the treatment of acute

myocardial infarction in a defined geographic area of Delhi’

Mission statement

• Director, AIIMS• Deputy Director, AIIMS• Chief Cardiothoracic Centre• Principal Nursing College, AIIMS

Mission DELHI: Institutional support

• AIIMS: Emergency Medicine; Cardiology; Nursing College, Community Medicine

• Professor Praveen Agarwal• Dr G Karthikeyan• Dr Sandeep Seth• Dr Nitish Naik• Dr Sandeep Singh• Dr Rakesh Yadav• Dr S Ramakrishnan• Dr Ambuj Roy• Dr Manju Vatsa• Dr K Anand• Dr D Prabhakaran (PHFI)

Mission DELHI: The team

Mission DELHI : Aims• Decrease response times of suspected heart attack patients

• Rapid triage, identification and transfer of suspected heart attack patients

• Timely and consistent provision of pre-hospital thrombolysis and subsequent care to heart attack patients

• Advanced Heartcare Ambulance service

• Education and upgrading skills of healthcare providers

• Estabilishing systems for evaluation of the project

• Primary angioplasty considered superior to thrombolysis (not universally feasible)

• Newer bolus thrombolytics (prehospital) comparable to primary angioplasty (also less expensive). Non inferior to primary PCI: STREAM NEJM 2013

• Can we establish a model for delivery of prehospital thrombolysis for India?

Key question? Prehospital thromolysis or primary angioplasty for all?

ChennaiHyderabad

MumbaiBangalore

Delhi

Health care mismatch

PCI Hospitals 400

Fixed labs 700 Mobile labs 70

150,000 Procedures200,000 Stents<10% Acute MI<6% reach by ambulance

4,000 Km

Parameter USA India Ratio

Population 314 million 1241 million 4 times

Cath labs sites 2000 400 One fifth

Total Cath Labs 4000 800 One fifth

Doctors 569/Lakh 59/Lakh One tenth

Lysis availability 100% 73% Nearly three quarters

PAMI 28% 8% One fourth

Reality check

Pilot StudyFootprint: 3kM radius

Heart attacks: Rough estimates

• 12,00,000 heart attacks per year

• 40,000 heart attacks per year per crore

(Data for USA, AHA 2007 statistics)

• 60,000 heart attacks per year per crore in men

• 20,000 heart attacks per year per crore in women (British Heart Foundation data 2007)

• In Delhi about 100 heart attacks occur per day

• Every 15 minutes one person suffers heart attack

• 3 km radius covers 30 sq km• Data from 1298 and 108 ambulances (predominantly rural)• 60% trauma; 30% maternal/pediatric• 10% heart attack• 20 sq km approx 1 lakh population (double in Delhi)• Footprint approximately 3 lakh population

• Only 6% AMI reach hospital by ambulance• 6 STEMI; 4 NSTEMI; 100 chest pain; 150 calls/day

Rough estimates

Components

1. Dispatch Centre and Training of Nurses in ACLS (Advanced Cardiac Life Support)

2. Motorcycle ‘First Responders’

3. ‘HEART’ Ambulances Prehospital thrombolysis

4. Angioplasty capability

Component 1:Dispatch centre

• 24 hour helpline: 33544 (DELHI)

• Will dispatch EMS personnel to the site of patient with chest pain on motorcycle

• Ambulance to follow if high suspicion of heart attack

• Every ambulance to be manned by 2 nurses

• ECG machine, defibrillator with external pacing (Lifepak 15) will be available in each motorcycle and ambulance

Dispatch Centre

Dispatch Centre

Dispatch centre

Component 2: First responder: Motorcycle Staff

• Assess vitals: BP, pulse

• 12- lead ECG to identify heart attack

• Transmits ECG consults cardiologist

• Aspirin, clopidogrel and atorvastatin

• Nitroglycerine (NTG) tablet/spray

• Troponin T (Bedside kit); IV access

• Oxygen

Motorcycle ‘First responder’

• Basic emergency equipment

• Mobile connection with dispatch

• Lifepak 15

Motorcycle: Lifepak 15

• EKG transmission• Monitoring• Defibrillation• External pacing

Component 3: Prehospital thrombolysis in ambulance

Ambulance: Transportation

• Every ambulance to be manned by 2 nursing staff fully trained in Advanced Cardiac Life Support

• Oxygen, ECG machine and defibrillator will be available in each ambulance (Lifepak 15)

• AIIMS to have 3 such ambulances

• Goal : dispatch -to- thrombolysis time 30 minutes

Ambulance: Tenectaplase

Ambulance: Tenectaplase

Component 4: Angioplasty capability

• AIIMS has 4 cardiac catheterization laboratories

• Fulfils all requirements of operators for angioplasty

• Primary angioplasty currently free of cost

• On-site cardiac surgery back up available

• Information technology backbone of the project will be created and commissioned

• An ambulance and a motorcycle will be procured at this stage and dry runs will be performed

• Lacunae in the proposed mode of operation and logistics will be identified and rectified

• Nursing personnel will be trained in ECG recognition of STEMI, advanced cardiac life support and administration of pre-hospital thrombolysis with tenecteplase

Phase I: Establishing infrastructure

• The protocols for triage and treatment of acute STEMI will be implemented

• Increasing awareness among the residents surrounding AIIMS: symptoms of STEMI and need for timely treatment

• Setting up of an efficient telephone helpline and reducing patient response times

• Augmentation of nursing staff (both in number and level of expertise) and addition of ancillary staff (administrative and data management) for the project

• Establishment of a comprehensive EMS system with trained nurses and required infrastructure

Phase II: SOPs Awareness

• Establishment of processes to optimize work flow for prompt pre-hospital thrombolysis and transfer

• Regular data collection and feedback system

• Establishment of objective parameters for ongoing evaluation of different processes

• Engagement with government agencies and policymakers in order to expand this model to other areas of the city 

• Regular training system for healthcare providers

• Establishment of regular dialogues to ensure policy level changes

Phase III: Implementation

Work flow

Patient with chest pain calls helpline number “33544” DELHI

Performs and transmits ECG

Nurse administers IV tenecteplase in ambulance (transfers to AIIMS )

Stabilisation and discharge

Nurse calls ambulance

Motorcycle nurse dispatched

PTCA if no reperfusion or recurrent ischemia

STEMI diagnosed: In consultation with cardiologist at dispatch centre

Confirms STEMI to following ambulance: aspirin, IV access

1. STEMI• Aspirin and atorvastatin• ECG transmission• Check list and consent• Thrombolysis

2. Non-STEMI• Aspirin and atorvastatin• Call for ambulance• Refer to nearby hospital/AIIMS emergency on our ambulance

3. Chest pain with Non-diagnostic or Normal ECG• History typical or known CAD – Aspirin 325mg• A repeat ECG after 10 min• Still normal – refer to nearby hospital/AIIMS emergency on CATS

Clinical scenarios I

4. Cardiac pain but stable angina• Aspirin and atorvastatin• Features of unstable angina• Repeat ECG – 10 min• No USA or ECG changes refer to OPD

5. Atypical or non-cardiac chest pain• History typical or known CAD – Aspirin 325mg• A repeat ECG after 10 min• Still normal – refer to nearby hospital/AIIMS emergency on CATS

6. Non-cardiac emergencies• First aid and hemodynamic assessment• Refer to nearby hospital/AIIMS emergency on CATS ambulance

Clinical scenarios II

7. Death of the patient before arrival of motorcycle• Confirm death• No BLS/ACLS• If suspicious death – inform police• Refer to nearby hospital

8. Death of the patient after arrival of motorcycle, but before ambulance arrival• BLS/ACLS• Confirm death• Refer to AIIMS emergency/nearby hospital

9. Death of a patient with STEMI after signing consent• BLS/ACLS• Confirm death• Refer to AIIMS emergency in our ambulance

Clinical scenarios III: Deaths

10. STEMI Special situations (all patients with STEMI will be shifted using our ambulances even to other hospitals)

11. STEMI in shock

• Aspirin and atorvastatin

• ECG transmission

• Check list and consent

• Supportive measures and monitoring

• Shift to AIIMS for primary PCI

12. STEMI Late presentation

• Aspirin and atorvastatin

• ECG transmission

• Check list and consent

• Supportive measures and monitoring

• Shift to AIIMS for further management

Clinical scenarios IV

13. STEMI wants to go to another hospital for treatment

• Aspirin and atorvastatin

• ECG transmission

• Shift to other hospital for treatment if within 5 km in our ambulance

14. STEMI wants to go to another hospital after thrombolysis

• Aspirin and atorvastatin

• ECG transmission

• Check list and consent

• Thrombolysis

• Supportive measures and monitoring

• Shift to other hospital for further therapy

• Contact with patient and doctor/hospital for in-hospital and 30-day outcomes

Clinical scenarios V: Another hospital

Structure and Curriculum of EMS education – Proposed plan

EMS Staff training

Initial training:EMT-P -10 weeksEMT - 6 weeksACA - 2 weeksDriver – 1 week

Ongoing Training and CME

Train the trainersKnowledge transfer

Certification

Remediation and gap specific assessment

Formal assessment

CME modules through Newsletters and audio visual aids

ERC physician’s role 60:30:10

Ongoing evaluation by team leaders, supervisors and ERC Physicians

Annual Formal assessment and skill training

Career progression plan for EMS staffBased on performance and training

EMT (BLS) EMT (ALS)EMT-P (ALS)EMT-P Instructors

Pre hospital Medical Protocols for quality assurance

1. Standardized medical protocols and SOP’s.

Pre-hospital Medical Protocols for quality assurance

2. Initial training, assessment and remediation Training curriculum designed by Falcks

international team and based on internationally accepted pre-hospital medical emergency and trauma stabilization principles.

This method will be consistent will all trainings

Duration of training will be based on specific role, eg. EMT-P, EMT, ACA, DriverMost advanced training aids eg. Feedback enabled manikins, audio visual aids etc

3. Ongoing case by case evaluation through interactive feed back mechanism to ensure we capture vital cases

4. Annual formal assessments and remediation's

5. Periodic field visit and onsite training by ERC physicians

Pre-hospital Medical Protocols for quality assurance

Pre hospital Medical Protocols for quality assurance

Architecture of 24 hour ERC – IT Solution

Call Screening & Taking

Medical Triage

Dispatch

Supervision

Medical recording

Police case handling

Workforce Planning

Fleet Mgmt

Mobile

Simple solutions in a complete package

Reporting

...

• Average symptom-to-needle time and total ischemic time

• Proportion of all STEMI patients receiving reperfusion• Proportion of all patients receiving pre-hospital thrombolysis• Proportion of thrombolysed patients needing rescue PTCA or urgent

PTCA in-hospital

• Mortality and morbidity of STEMI- both in-hospital and 6 month for all patients irrespective of reperfusion strategy

• We will determine the cost-effectiveness of our approach in the context of the Indian healthcare system

Outcome measures

• Funding approved and sanctioned by DBT

• Funding application to ICMR (DHR) approved

• Funding of nursing staff payroll by AIIMS

• Tenectaplase to be given free

Financial commitments

• Space / bed commitment from Emergency medicine

• Training of nurses commitment by Principal Nursing College, and Emergency Medicine

• Director AIIMS has provided green signal

• AIIMS to provide space for Dispatch Centre

• Ethics clearance obtained

AIIMS commitments

Monitoring operations I

Reducing ‘symptom onset-seek help’ time Goal: within 30 minutes

Increase awareness

of symptoms

Campaigns to increase recognition

Media-print and AV

Resident welfare bodies

Government health clinics

Qualitative and semi-

quantitative surveys

Time taken from symptom

onset to seeking help

Establishing 24 hr

helpline

(DELHI:33544)

Promote use of 33544 systems (to be

set up or use existing) by all suspected

ACS patients. Provides

Initial counseling/therapy

Alerts EMS

Time taken to respond and

dispatch EMS

% of time EMS/lab alerts

done within specified time

% of callers satisfied with

helpline service

Monitoring operations II

Rapid Triage (pre-hospital thrombolysis) and transport of ACS patients

Goal: within 30 minutes

Ambulance

transport

Rapid transport with motorcycles

Transfer patient to advanced care

center from home or other hospital

by ambulance

Median response time/

time taken for transport to

hospital

Prehospital ECG Motorcycle/ambulance equipped

with 12 lead ECG

Proportion of ECG correctly

recorded/ transmitted

Pre-hospital

thrombolysis

Intravenous bolus of Tenecteplase

at 0.5 mg/kg

Audit by treating

cardiologist at hospital

Advanced cardiac

life support

Ambulance equipped with

defibrillator/ other equipment

Proportion of cardiac arrest

successfully defibrillated

Monitoring operations III

Emergency

Services

Rapid acquisition and

interpretation of ECG within 10

min of arrival

Enable rapid transfer to advance

care center in case referral

required

Proportion of suspected

ACS undergoing

ECG<10 min

Proportion of STEMI

undergoing rescue

interventions

Cost-

effectiveness

Relative cost of a strategy of pre-

hospital thrombolysis and

transfer compared to existing

standards of care

Incremental costs of

pre-hospital

thrombolysis and

incremental effects

(clinical outcomes)

Events avoided per unit

of additional cost

Proposed model for STEMI

For INDIA practically the best situation is early thrombolysis preferably prehospital with early routine angiography within 3-24 hours

( Pharmaco-invasive approach )

Thank You Mission DELHI!

STREAM