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Regional STEMI Transfer Systems: the Mayo and NC RACE
Experiences
Regional STEMI Transfer Systems: Regional STEMI Transfer Systems: the Mayo and NC RACE the Mayo and NC RACE
ExperiencesExperiences
Dr. Henry H. Ting, Mayo Clinic College of MedicineDr. James G. Jollis, Duke University Medical CenterDr. Henry H. Ting, Mayo Clinic College of MedicineDr. Henry H. Ting, Mayo Clinic College of MedicineDr. James G. Dr. James G. JollisJollis, Duke University Medical Center, Duke University Medical Center
Henry H. Ting, MD MBAMayo Clinic
Rochester, MinnesotaJan. 28, 2010
Henry H. Ting, MD MBAHenry H. Ting, MD MBAMayo ClinicMayo Clinic
Rochester, MinnesotaRochester, MinnesotaJan. 28, 2010Jan. 28, 2010
Mayo Clinic STEMI SystemMayo Clinic STEMI Systemfor Transferred Patientsfor Transferred Patients
““FAST TRACKFAST TRACK””
DisclosuresDisclosuresDisclosures
•
No financial disclosures•
No conflicts of interest
•
No off-label use
••
No financial disclosuresNo financial disclosures••
No conflicts of interestNo conflicts of interest
••
No offNo off--label uselabel use
D2B –
“Sustain The Gain”D2B D2B ––
““Sustain The GainSustain The Gain””
Nestler DM. Circ Cardiovasc Qual Outcomes. 2009;2:508-513.
64 min30 min
PH ECG and Door-to-BalloonPH ECG and DoorPH ECG and Door--toto--BalloonBalloon
Ting HH. Presented at AHA November 2009
Patients Transferred for Primary PCIPatients Transferred for Primary PCIPatients Transferred for Primary PCI
1.3
8.6
26.4
36.3
17.6
8.24.3 2.2 3.7
0
20
40
60
<1 <90min
1 to <2 2 to <3 3 to <4 4 to <5 5 to <6 6 to <7 7 to<12
PatientsPatients (%)(%)
Total doorTotal door--toto--balloon time (hours)balloon time (hours)
Chakrabarti A, J Am Coll Cardiol 2008;51:2442-2443.
Reperfusion Strategies for Transferred STEMI Patients
Reperfusion Strategies for Reperfusion Strategies for Transferred STEMI PatientsTransferred STEMI Patients
1.
Interhospital
transfer for primary PCI2.
Pharmaco-invasive approach with lytics and early PCI
3.
Lytic facilitated PCI4.
Prehospital triage for primary PCI
1.1.
InterhospitalInterhospital
transfer for primary PCItransfer for primary PCI2.2.
PharmacoPharmaco--invasive approach with lytics and early PCIinvasive approach with lytics and early PCI
3.3.
Lytic facilitated PCILytic facilitated PCI4.4.
Prehospital triage for primary PCIPrehospital triage for primary PCI
Reperfusion Strategies for Transferred STEMI Patients
Reperfusion Strategies for Reperfusion Strategies for Transferred STEMI PatientsTransferred STEMI Patients
1.
Interhospital
transfer for primary PCI2.
Pharmaco-invasive approach with lytics and early PCI
3.
Lytic facilitated PCI4.
Prehospital triage for primary PCI
1.1.
InterhospitalInterhospital
transfer for primary PCItransfer for primary PCI2.2.
PharmacoPharmaco--invasive approach with lytics and early PCIinvasive approach with lytics and early PCI
3.3.
Lytic facilitated PCILytic facilitated PCI4.4.
Prehospital triage for primary PCIPrehospital triage for primary PCI
Minnesota
Wisconsin
Iowa
Rochester
0 100 200
Duluth
St. Cloud
Minneapolis/ St. Paul
Ting HH, et al. Circulation 2007;116:729-736
Cum
ulat
ive
prob
abili
tyC
umul
ativ
e pr
obab
ility
Door-to-balloon/door-to-needle time (minutes)Door-to-balloon/door-to-needle time (minutes)
0.00
0.25
0.50
0.75
1.00
0 60 120 180 240
Regional Hospital Primary PCIRegional Hospital FibrinolysisRegional Hospital Primary PCIRegional Hospital Fibrinolysis
Regional STEMI Patients Treated with Primary PCI or Fibrinolytic Therapy
Regional STEMI Patients Treated with Primary Regional STEMI Patients Treated with Primary PCI or Fibrinolytic Therapy PCI or Fibrinolytic Therapy
25 min 110 min
Ting HH, et al. Circulation 2007;116:729-736
Mortality and Door-to-Needle / Door-to-Balloon
Mortality and Mortality and DoorDoor--toto--Needle / DoorNeedle / Door--toto--BalloonBalloon
3.5
5.66.6
11.513.5
1.1
0
4
8
12
16
20
<30 30-60 60-90 90-120 120-180 >180
In-h
ospi
tal M
orta
lity
(%)
In-h
ospi
tal M
orta
lity
(%)
Door-to-balloon / Door-to-needle time (minutes)Door-to-balloon / Door-to-needle time (minutes)
P=0.01P=0.01
Door-in Door-out (DIDO) at 1st Hospital and 1st Door-to-balloon Time
143
87
0
50
100
150
200
250
DIDO >30 min DIDO <=30 min Med
ian
1st D
oor-
to-b
allo
on (m
in)
P < 0.0001
Ting HH, et al. AHA November 2009
Pharmaco-Invasive StrategyPharmacoPharmaco--Invasive StrategyInvasive Strategy
•
Definition:
Broad use of rescue PCI after failed fibrinolysis, as well as an early PCI within 3-24 hours of successful fibrinolysis
••
Definition:Definition:
Broad use of rescue PCI after failed Broad use of rescue PCI after failed fibrinolysis, as well as an early PCI within 3fibrinolysis, as well as an early PCI within 3--24 hours 24 hours of successful fibrinolysisof successful fibrinolysis
30-day 1°
Endpoint and Components3030--day 1day 1°°
Endpoint and ComponentsEndpoint and Components
EndpointEndpointStandard Standard N=498 (%)N=498 (%)
PharmacoPharmaco--Invasive Invasive N=512 (%)N=512 (%) P valueP value
11
end pointend point 16.616.6 10.610.6 0.00130.0013
DeathDeath 3.63.6 3.73.7 0.940.94
ReRe--infarctioninfarction 6.06.0 3.33.3 0.0440.044
Recurrent ischemiaRecurrent ischemia 2.22.2 0.20.2 0.0190.019
Death/MI/ischemiaDeath/MI/ischemia 11.711.7 6.56.5 0.0040.004
New/worsening CHFNew/worsening CHF 5.25.2 2.92.9 0.0690.069
Cardiogenic shockCardiogenic shock 2.62.6 4.54.5 0.110.11
Cantor WJ. N Engl J Med 2009;360:2705
30-day 1°
Endpoint and Components3030--day 1day 1°°
Endpoint and ComponentsEndpoint and Components
EndpointEndpointStandard Standard N=498 (%)N=498 (%)
PharmacoPharmaco--Invasive Invasive N=512 (%)N=512 (%) P valueP value
11
end pointend point 16.616.6 10.610.6 0.00130.0013
DeathDeath 3.63.6 3.73.7 0.940.94
ReRe--infarctioninfarction 6.06.0 3.33.3 0.0440.044
Recurrent ischemiaRecurrent ischemia 2.22.2 0.20.2 0.0190.019
Death/MI/ischemiaDeath/MI/ischemia 11.711.7 6.56.5 0.0040.004
New/worsening CHFNew/worsening CHF 5.25.2 2.92.9 0.0690.069
Cardiogenic shockCardiogenic shock 2.62.6 4.54.5 0.110.11
Cantor WJ. N Engl J Med 2009;360:2705
Median time from lytics to PCI was 3.9 hours
Pharmaco-Invasive Strategy: NORDISTEMI
PharmacoPharmaco--Invasive Strategy: Invasive Strategy: NORDISTEMINORDISTEMI
Bohmer E. JACC 2010; 55:102-110
Pharmaco-Invasive Strategy: NORDISTEMI
PharmacoPharmaco--Invasive Strategy: Invasive Strategy: NORDISTEMINORDISTEMI
Bohmer E. JACC 2010; 55:102-110
Median time from lytics to PCI was 2.7 hours
3
0 0
6
1.81
0
2
4
6
8
In-hospitalDeath
Total Stroke HemorrhagicStroke
%
Primary PCI Facilitated PCI
3
0 0
6
1.81
0
2
4
6
8
In-hospitalDeath
Total Stroke HemorrhagicStroke
%
Primary PCI Facilitated PCI
ASSENT-4 TrialPrimary vs. Full-dose TNK Fibrinolytic-Facilitated PCI
ASSENT-4 TrialPrimary vs. Full-dose TNK Fibrinolytic-Facilitated PCI
P =0.01
P <0.0001 P =0.0037
DSMB terminated
study after 1667 / 4000 enrolled because of higher in-hospital mortality observed for facilitated PCI
Van de Verf, Lancet 2006;367:569-578
3
0 0
6
1.81
0
2
4
6
8
In-hospitalDeath
Total Stroke HemorrhagicStroke
%
Primary PCI Facilitated PCI
3
0 0
6
1.81
0
2
4
6
8
In-hospitalDeath
Total Stroke HemorrhagicStroke
%
Primary PCI Facilitated PCI
ASSENT-4 TrialPrimary vs. Full-dose TNK Fibrinolytic-Facilitated PCI
ASSENT-4 TrialPrimary vs. Full-dose TNK Fibrinolytic-Facilitated PCI
P =0.01
P <0.0001 P =0.0037
DSMB terminated
study after 1667 / 4000 enrolled because of higher in-hospital mortality observed for facilitated PCI
Van de Verf, Lancet 2006;367:569-578
Median time from lytics to PCI was 1.9 hours
Prehospital Triage ModelPrehospital Triage ModelPrehospital Triage Model
Proximal LAD
Prehospital Triage ModelPrehospital Triage ModelPrehospital Triage Model
1.
Paramedics acquire and interpret PH ECG2.
If “Definite STEMI”, then 1-call activation of cath lab and helicopter auto-launch to intercept patient at regional hospital (or intercept enroute)
3.
Bypass ED evaluation at regional hospital & PCI hospital4.
Patient transported directly to cath lab
5.
Explicit diversion criteria to deviate from #2-4
1.1.
Paramedics acquire and interpret PH ECGParamedics acquire and interpret PH ECG2.2.
If If ““Definite STEMIDefinite STEMI””, then 1, then 1--call activation of cath lab call activation of cath lab and helicopter autoand helicopter auto--launch to intercept patient at launch to intercept patient at regional hospital (or intercept regional hospital (or intercept enrouteenroute))
3.3.
Bypass ED evaluation at regional hospital & PCI hospitalBypass ED evaluation at regional hospital & PCI hospital4.4.
Patient transported directly to cath labPatient transported directly to cath lab
5.5.
Explicit diversion criteria to deviate from #2Explicit diversion criteria to deviate from #2--44
Description Time Time Interval (minutes)
Symptom Onset 05:30 0
9-1-1 Call 06:05 35
EMS On-Scene 06:09 4
PH ECG Acquired 06:16 7
STEMI Protocol Activation 06:17 1
Transport to Local Community Hospital 06:22 5
Arrival at Door 1 06:26 4
Departure from Door 1 06:37 11
Arrival at Door2 07:10 33
First PCI Device 07:27 17
Time Intervals Duration (minutes)
*Door 1 In-to-Door 1 Out 11
*Door 2-to-First PCI Device 17
*Door 1-to-First PCI Device 61
*First EMS Contact-to-First PCI Device 82
*Symptom Onset-to-First PCI Device 117
Pitta SR. Circ Cardiovasc Qual Outcomes. 2010;3:93-97
North Carolina's Statewide STEMI System
James G. Jollis, MD, FACCDuke University
RACERACE Reperfusion in AMI in Carolina Emergency Departments
How patients present
• Call 911 EMS
• (~50%)
• Walk-in
• (~50%)
• Hospital transfer
• - Walk in or EMS to 1st
hospital
• (~60% of PCI hospital)
How patients present
EMS Walk-inHosp.
transfer
Current 90 90 180
Potential <60 <90 <120
121 emergencydepartments
500 EMS systems
5,240 paramedics
18,000EMTs
21 primary PCI labs
Integrated, Systematic
Integrated, Systematic
AMI CareAMI Care
RACE Process
2) Establish REGIONAL PCI CENTERS(primary, lytic ineligible, rescue)
Measurement& Feedback
3a) HOSPITAL by hospitalestablishment of STEMI plan(review, consensus, training)
3b) EMS by EMSestablishment of STEMI plan(review, consensus, training)
4) Improve system
1) Develop leadership, funding, data structure
Establish a plan
Regional coordinatorsRegional coordinators
RACE Interventions
• OPERATIONS MANUAL
• Optimal system specifications by point of care
– EMS
– ED
– Transfer
– Receiving hospital
– Cath. Lab
– Other system issues – payers, regulations
Available at www.race-er.org
RACE Interventions
RACE Interventions
• Emergency Department
Coordination and training of entire staff
Registration (nurse first)
Designated area for immediate
Standing STEMI protocol agreed upon by entire
emergency and cardiology staff
Emergency physician leads team
PCI Hospitals
Single number cath lab activation
Accept all STEMI patients regardless of bed availability
Ongoing QI and data feedback– NRMI database
RACE Regional CoordinatorResponsible for improving process in every hospital - EMS system in the region
RACE Interventions
EMS
1) In the field ECG for all chest pain patients
2) 15 minute scene time
3) Hospital pre-notification
4) Standing STEMI plan / destination protocols
RACE Interventions
JAMAJAMA Nov. 2007Nov. 2007
1088590
74
106
149
0
30
60
90
120
150
180
All patients Direct presenters Transfer for PCIhospitals
Pre Post
P<0.001* P<0.001
med
ian
times
in m
inut
es P=0.01
RACE results PCI hospitals: Door to device
12097
7145
2935
0
30
60
90
120
150
180
Door-in door-out,all hospitals
Door-in door-out,transfer hosps
Fibrinolysis, door-to-needle
PrePost
P<0.001* P<0.001
med
ian
times
in m
inut
es P=0.002
* Remained significant in analysis accounting for clustering
RACE results Non-PCI hospitals: Reperfusion times
10 PCI centers16 Transfer for PCI28 Lytics11 Mixed
Asheville
Winston-SalemDurham-Chapel Hill-
Greensboro
Charlotte
East Carolina
Each non-PCI center was assessed forreperfusion designation based on resources, transfer ability, and transfer time to PCI center
RACE Centers and Regions 65 hospitals (10 PCI, 55 non PCI)