systems of care for st-segment−elevation myocardial ... of a hospital.8–12 by implementing...

Alice K. JacobsPeter H. Moyer, Franklin D. Pratt, Ivan C. Rokos, Anna R. Acuña, Mayme Lou Roettig and

James G. Jollis, Christopher B. Granger, Timothy D. Henry, Elliott M. Antman, Peter B. Berger,Mission: LifelineAmerican Heart Association's

Elevation Myocardial Infarction: A Report From the−Systems of Care for ST-Segment

Print ISSN: 1941-7705. Online ISSN: 1941-7713 Copyright © 2012 American Heart Association, Inc. All rights reserved.

Greenville Avenue, Dallas, TX 75231is published by the American Heart Association, 7272Circulation: Cardiovascular Quality and Outcomes

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Original Article

423

For more than 2 decades, medical evidence has shown rapid coronary reperfusion reduces mortality in patients

with ST-segment–elevation myocardial infarction (STEMI).1–3 Moreover, it has been increasingly clear that percutaneous cor-onary intervention (PCI) is the preferred method of reperfusion if it can be performed in a timely manner.4,5 Yet, reperfusion therapy continues to be administered too slowly, particularly in patients undergoing hospital transfer for primary PCI.6,7

In order to provide primary PCI more rapidly, many medical centers have begun to coordinate care beyond the traditional boundaries of a hospital.8–12 By implementing reperfusion strategies that incorporate the patient with STEMI’s first and subsequent medical contacts, including emergency medical service (EMS) transport between hospitals, delays in achiev-ing reperfusion have been greatly reduced, and enthusiasm for developing systems of care has emerged.13–15 Based on

© 2012 American Heart Association, Inc.

Circ Cardiovasc Qual Outcomes is available at http://circoutcomes.ahajournals.org DOI: 10.1161/CIRCOUTCOMES.111.964668

10.1161/CIRCOUTCOMES.111.964668

2012

July

Received July 12, 2011; accepted April 12, 2012.From Duke University Medical Center, Durham, NC (J.G.J., C.B.G.); Minneapolis Heart Institute Foundation, Minneapolis, MN (T.D.H.); Brigham

and Women’s Hospital, Boston, MA (E.M.A.); Geisinger Health System, Danville, PA (P.B.B.); Boston Emergency Medical Services, Boston, MA (P.H.M.); Los Angeles County Fire Department, Los Angeles, CA (F.D.P.); University of California, Los Angeles (UCLA)-Olive View Medical Center, David Geffen School of Medicine at UCLA (I.C.R.); American Heart Association, Dallas, TX (A.R.A.); Duke Clinical Research Institute, Durham, NC (M.L.R.); Boston Medical Center, Boston, MA (A.K.J.).

This article was handled independently by Guest Editor Brahmajee K. Nallamothu, MD. The Editors had no role in the evaluation of the article or the decision about its acceptance.

The online-only Data Supplement is available at http://circoutcomes.ahajournals.org/lookup/suppl/doi:10.1161/CIRCOUTCOMES.111.965111/-/DC1.Correspondence to James G. Jollis, MD, Professor of Medicine and Radiology, Room 3347 Duke South Hospital, Box 3254 DUMC, Durham, NC 27710.

E-mail [email protected]

Systems of Care for STEMI

Jollis et al

Systems of Care for ST-Segment–Elevation Myocardial Infarction: A Report From the American Heart

Association’s Mission: LifelineJames G. Jollis, MD; Christopher B. Granger, MD; Timothy D. Henry, MD; Elliott M. Antman, MD;

Peter B. Berger, MD; Peter H. Moyer, MD, MPH; Franklin D. Pratt, MD; Ivan C. Rokos, MD; Anna R. Acuña; Mayme Lou Roettig, RN, MSN; Alice K. Jacobs, MD

Background—National guidelines call for participation in systems to rapidly diagnose and treat ST-segment–elevation myocardial infarction (STEMI). In order to characterize currently implemented STEMI reperfusion systems and identify practices common to system organization, the American Heart Association surveyed existing systems throughout the United States.

Methods and Results—A STEMI system was defined as an integrated group of separate entities focused on reperfusion therapy for STEMI within a geographic region that included at least 1 hospital that performs percutaneous coronary intervention and at least 1 emergency medical service agency. Systems meeting this definition were invited to participate in a survey of 42 questions based on expert panel opinion and knowledge of existing systems. Data were collected through the American Heart Association Mission: Lifeline website.

Between April 2008 and January 2010, 381 unique systems involving 899 percutaneous coronary intervention hospitals in 47 states responded to the survey, of which 255 systems (67%) involved urban regions. The predominant funding sources for STEMI systems were percutaneous coronary intervention hospitals (n = 320, 84%) and /or cardiology practices (n = 88, 23%). Predominant system characteristics identified by the survey included: STEMI patient acceptance at percutaneous coronary intervention hospital regardless of bed availability (N = 346, 97%); single phone call activation of catheteriza-tion laboratory (N = 335, 92%); emergency department physician activation of laboratory without cardiology consultation (N = 318, 87%); data registry participation (N = 311, 84%); and prehospital activation of the laboratory through emergency department notification without cardiology notification (N = 297, 78%). The most common barriers to system implementa-tion were hospital (n = 139, 37%) and cardiology group competition (n = 81, 21%) and emergency medical services transport and finances (n = 99, 26%).

Conclusions—This survey broadly describes the organizational characteristics of collaborative efforts by hospitals and emergency medical services to provide timely reperfusion in the United States. These findings serve as a benchmark for existing systems and should help guide healthcare teams in the process of organizing care for patients with STEMI. (Circ Cardiovasc Qual Outcomes. 2012;5:423-428.)

Key Words: delivery of health care ◼ multi-institutional systems ◼ myocardial infarction ◼ myocardial reperfusion

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424 Circ Cardiovasc Qual Outcomes July 2012

the existing delays to reperfusion, the barriers to timely treat-ment, and the success of early model STEMI systems,16 the American Heart Association (AHA) embarked on Mission: Lifeline, an initiative to improve the quality of care and out-comes for patients with STEMI and to improve the healthcare system readiness and response to STEMI. An important focus of Mission: Lifeline is to increase the number of patients with timely access to primary PCI.17–18

Editorial see p 420In order to characterize currently implemented STEMI

reperfusion systems and identify practices common to system organization and potential best practices, the AHA surveyed existing systems throughout the United States.

MethodsWe developed a 42-question survey based on expert panel opinion and knowledge of existing systems (online-only Supplemental Data Appendix A). Survey questions focused on processes of care for the

diagnosis, system activation, and treatment of STEMI. The survey also examined resource allocation, financial considerations, and the most significant barriers to implementing systematic care. Survey data were collected through the AHA website (Register Your System) (online-only Supplemental Data Appendix A). In addition to posting the survey on the website, registration of existing STEMI networks was encouraged at local, regional, and national meetings involving the treatment of STEMI and by the AHA staff of 8 regional affili-ates covering all 50 states. The survey was initially made available in April 2008, and responses through January 2010 were analyzed. The survey took approximately 60 minutes to complete and was deployed using online survey software (Vovici Corporation). For the majority of questions, multiple responses were allowed. For the purposes of this survey, a STEMI system was defined as an integrated group of separate entities focused on reperfusion therapy for STEMI within a geographic region that included at least 1 hospital that performs PCI and at least 1 EMS agency.

In order to avoid double counting, all new system submissions were reviewed on a monthly basis. Any system that did not meet the system definition based on their responses was not included in the data. Duplicate responses were identified using 1 of 2 methods: 1) the regional AHA office reported a duplicate; or 2) the response was from the same individual, agency, and address. Systems that had mul-tiple submissions were contacted by an AHA staff member to verify which submission should be kept in the systems database. To con-sider the representativeness of the survey, responses were categorized by state and as a function of the number of PCI hospitals.

ResultsA total of 381 unique systems involving 899 PCI hospitals from 47 states responded to the survey (Figure 1A and 1B and online-only Supplemental Data Appendix B). Of these sys-tems, 202 involved a single PCI hospital, 150 encompassed 2 to 5 PCI hospitals, and 29 included >5 PCI hospitals (online-only Supplemental Data Appendix C). The systems identi-fied affiliations with 3539 non-PCI hospitals, some of which may have been counted by more than 1 system. From a geo-graphic perspective, 279 (74%) involved rural regions, and 255 (67%) involved urban regions; 228 (60%) were county-based; 190 (50%), city-based; 620 (16%), state-based, and 87 (23%) crossed state lines. The predominant funding sources for STEMI systems are shown in Figure 2. A broad array of groups provided STEMI system oversight, including cardiology, emergency medicine, emergency departments (ED), hospital and catheterization laboratory administration,

WHAT IS KNOWN

•Coronary reperfusion can be greatly accelerated by coordinated care between hospitals and emergency medical services in a region.

WHAT THE STUDY ADDS

• In a large national survey, several processes were commonly implemented, including accepting pa-tients at a PCI hospital regardless of bed availabil-ity, single phone call activation of catheterization laboratory, emergency department physician activa-tion of a laboratory without cardiology consultation, national data registry participation, and prehospital activation of the catheterization laboratory by para-medics and transferring physicians.

• The most commonly reported barriers to system implementation were hospital and cardiology group competition and EMS transport and finances.

Figure 1. A, Mission: Lifeline: Registered STEMI systems by state. B, Mission Lifeline: STEMI systems coverage.




Jollis et al Systems of Care for STEMI 425

nursing, EMS, and cardiology quality improvement person-nel (Figure 3).

EMS OrganizationA number of survey questions involved EMS organization and protocols. Most systems responded to potential STEMI calls using a combination of paramedic and lower level emergency medical technician-staffed ambulances (N = 237, 62%), while 115 systems (30%) had only basic or intermedi-ate-level emergency medical technician-staffed vehicles, and 249 systems (66%) included helicopter transport. More than one half of systems (N = 209, 55%) reported the availability of 12-lead electrocardiograms (ECGs) in their vehicles, and it was available in some but not all for an additional 155 (41%) systems. The ability to transmit ECGs to the receiv-ing hospitals for all ambulances was available in 132 (35%) of systems, and an additional 135 systems (36%) could transmit ECGs in some ambulances. The most commonly reported methods of ECG interpretation were transmis-sion to a hospital (N = 184, 68%), paramedic interpretation (N = 170, 63%), and computer interpretation (N = 92, 34%). When a prehospital ECG revealed a STEMI, the catheteriza-tion laboratory was activated through ED notification with-out the involvement of cardiology for 297 systems (78%); 72 systems (19%) involved a cardiologist for activation; and 58 systems (15%) enabled an emergency medical technician to directly activate the laboratory. The EMS performance mea-sures routinely tracked and reviewed are shown in Figure 4. The most commonly reported frequencies of laboratory can-cellation were <10% (N = 202, 54%), 10% to 24% (N = 79, 21%), and >25% (N = 14, 4%). Two hundred and twenty

seven (61%) systems reported that protocols were in place to allow for diversion to a PCI hospital for patients diagnosed with a STEMI by a prehospital ECG. Most of these protocols were implemented independent of legislation (N = 186, 82%); while 41 systems (18%) indicated that destination protocols were supported by legislation. Seventy seven systems (21%) reported the use of prehospital fibrinolysis (sometimes, 52 systems; routinely, 25 systems).

PCI HospitalsRegarding PCI hospitals involved in the STEMI systems, 346 (97%) accepted STEMI patients regardless of bed availabil-ity, 335 (92%) could activate the catheterization laboratory with a single call, 318 (87%) permitted emergency physi-cians to activate the laboratory without cardiology consulta-tion, and 311 (84%) participated in a data registry. The most frequently reported registries were National Cardiovascular Data Registry (NCDR) Cath PCI (N = 201, 61%), NCDR Acute Coronary Treatment and Intervention Outcomes Net-work (ACTION) (N = 114, 35%), Get With The Guidelines (N = 89, 27%), and local or program-specific registries (N = 72, 22%). Common performance measures at the PCI hospital are shown in Figure 5. Most systems provided feedback on performance to the ED at the PCI hospital (N = 318, 84%) and to emergency medical personnel (N = 285, 75%), and 175 sys-tems (46%) provided feedback to the referring hospital ED. The most common time frame for feedback was 24 hours to 1 week (N = 173, 46%), with 135 systems (36%) providing

Figure 2. Predominate funding sources.

Figure 3. Organizations that provide oversight.

Figure 4. EMS performance measures routinely tracked.

Figure 5. Hospital performance measures routinely tracked.





monthly feedback and 133 systems (35%) providing feed-back within 24 hours.

Reperfusion StrategyThe most frequent reperfusion strategy employed by non-PCI hospitals involved a mixed strategy employing both fibrinoly-sis and PCI (N = 198, 52%); 135 systems (36%) predominantly referred for a PCI strategy, and 69 systems (18%) involved a fibrinolysis strategy. Among patients treated with fibrinolysis, 256 systems (81%) transferred these patients on an emergency basis to PCI hospitals, 35 systems (11%) routinely transferred patients on a nonurgent basis, and 24 systems (8%) did not routinely transfer fibrinolysis patients unless their clinical condition necessitated it later. For patients requiring transport to PCI hospitals, local EMS was used by 241 systems (63%), air transport by 168 systems (44%), and mobile intensive care unit sent by the PCI hospital for 48 systems (13%). Reper-fusion protocols for non-PCI hospitals included standard-ized protocols specifying adjunctive anticoagulation (N = 244, 78%), transfer by the same EMS unit that brought the patient to the non-PCI hospital (N = 136, 36%), avoidance of intrave-nous infusions (N = 73, 19%), and reduced-dose fibrinolysis before transfer for PCI (N = 25, 7%).

Barriers to System ImplementationThe final question about barriers to the optimal functioning of the STEMI system allowed respondents to choose >1 response and to identify additional barriers not listed among the possible responses provided. The most common barriers were hospi-tal competition (N = 139, 37%), EMS transport and finances (N = 99, 26%), competition between cardiology groups (N = 81, 21%), lack of data collection and feedback (N = 68, 18%), lack of infrastructure support and funding (N = 59, 16%), and lack of bed availability (N = 59, 16%). Additional responses, many of which included free text, are listed in the online-only Supple-mental Data Appendix.

DiscussionRecognizing the importance of regional coordination of EMS and hospitals for the rapid diagnosis and treatment of STEMI, the 2009 update of the American College of Cardiology/AHA STEMI Guidelines added a new Class I recommendation that “each community should develop a STEMI system of care.”14 This report presents the first national survey of STEMI sys-tems, examining implementation from multiple perspectives, including funding, data, and specific EMS and hospital pro-tocols. Respondents identified the widespread application of a number of interventions likely to improve treatment times, including direct activation of the catheterization laboratory by paramedics and emergency physicians, destination or hospital bypass protocols, interhospital transfer protocols, data collec-tion using national data instruments, and timely feedback to healthcare providers involved in STEMI care. The survey also revealed common barriers to regional STEMI care with com-petition, EMS finances, and data collection being the predom-inant challenges. These findings should assist ongoing efforts to organize regional care by identifying common approaches to systematic problems and by defining those challenges

most frequently shared by systems that warrant the greatest investment of additional resources. Moreover, those systems registered with Mission: Lifeline are now part of a STEMI sys-tem community that may share new information, resources, and best practices through the AHA’s social network (http://mlcommunity.heart.org).

A number of interesting themes emerged from the inquiry. By far, the most frequent source of funding for STEMI systems was the PCI hospitals. Additional funding was derived from a broad array of industry, government, and foundation sources. As PCI hospitals have a mandate from the Center for Medicare & Medicaid Services to provide timely reperfusion and report their results publicly, these hospitals have additional incen-tive to improve the speed of coronary reperfusion19,20; how-ever, the Center for Medicare & Medicaid Services mandate does not entirely explain the finding, as patients transferred from other hospitals to PCI hospitals are excluded from the measures. PCI hospitals have incentives to support the devel-opment of STEMI systems above and beyond improving the quality of care, which include increasing catheterization labo-ratory volume and to be recognized as an exceptional regional facility in the provision of cardiac care. It is interesting that so few systems identified payers as a source of support. The financial interests of health insurers are not limited to a single hospital or physicians group. Potentially, payers have much to gain from more coordinated and rapid treatment of patients with STEMI, including better outcomes for their beneficiaries manifested as fewer complications, shorter hospitalizations and lower use of medical care after discharge.21 Greater payer support for STEMI systems will likely require additional evi-dence to build a business case for coordinated rapid coronary reperfusion.

More than half of the STEMI systems reported the availability of ECGs in emergency medical vehicles, with approximately two-thirds having the capability to transmit ECGs in some or all of their ambulances. The predominant method for EMS to activate the catheterization laboratory involved communication with the receiving ED, while some systems permitted emergency medical technicians to directly activate the laboratory team. Most importantly, the survey identified continued opportunities to improve STEMI care, particularly by establishing protocols for early laboratory activation for all patients with the prehospital diagnosis of STEMI, as well as by expanding the 12-lead ECG capability on ambulances. According to this survey, STEMI protocols can be established without the need for legislation for the majority of systems.

For hospitals lacking PCI facilities, ~one half reported the use of a mixed strategy of fibrinolysis and PCI while an additional third relied on a transfer for a PCI strategy. Patients treated with fibrinolysis were urgently transferred to PCI-capable hospitals for most STEMI systems, indicat-ing that provisions for rapid transfer represent an important component for STEMI treatment, even in the systems ini-tially relying on fibrinolysis. This approach is consistent with randomized trials and current guidelines supporting transfer of higher-risk patients treated with fibrinolysis.14,22,23 Local EMS transfer was more commonly reported than air transport, likely a function of distances between facilities




Jollis et al Systems of Care for STEMI 427

among the systems surveyed. The fact that only 8% of non-PCI capable hospitals do not routinely transfer patients after fibrinolytic therapy provides important insight into the role of the PCI center for the vast majority of patients with STEMI, even those presenting to non-PCI centers.

Commonly reported barriers to STEMI systems included competition between hospitals and physician groups, funding, and data collection. Medical care in the United States is tradi-tionally organized by hospitals, physician practices, and EMS. These reported barriers reflect deficiencies of our healthcare system in providing adequate support to allow for coordinated patient care among these entities. In particular, fiscal horizons that end at the hospital or ambulance door may not allocate ade-quate funds for STEMI systems. Furthermore, in this traditional model, competition between hospitals and physician groups discourages collaboration in a joint and systematic fashion.

The lack of support for the development of STEMI systems may be remedied through a number of approaches. As above, public reporting of performance measures that extend beyond traditional borders, such as first medical contact to reperfu-sion, will provide an incentive to hospitals and EMS to collab-orate. Support for STEMI systems may also be encouraged by involving entities with medical and fiscal responsibilities that span multiple hospitals, physician groups, and EMS such as large payers and government agencies. It has been suggested that the most attractive proposition for payment reform would be to create a single prospective payment that covers care from first medical contact to interhospital transfer, if appropri-ate, that would allow EMS and both hospitals to share gains resulting from the coordination of patient care and that would remove the inefficiencies inherent in the payment system.24 Finally, collaborative systems may be fostered by private or public foundations wishing to have a measurable effect on one of the leading causes of death.

LimitationsThe most significant limitation of this survey is likely related to our definition of a system requiring at least 2 hospitals and 1 EMS agency. By giving equal weight to responses regard-less of system size, the responses of larger systems involving larger numbers of EMS and hospitals are underrepresented in our cumulative approach. If larger systems substantially dif-fered from smaller systems according to processes of care, resources, and barriers, our survey responses may not ade-quately reflect issues in these larger systems. A second limita-tion of our methods involves the framing of survey questions. Although our questions were derived from an expert panel familiar with STEMI system issues and we included some open-ended queries, it is possible that significant issues in implementation were not identified owing to a lack of ques-tions pertaining to such issues. A third limitation of our tech-nique involves our reliance on voluntary participation and self reporting. Biases may have been introduced by selecting respondents more likely to participate in a system survey and by the provision of answers that were not fully reflective of the corresponding system. The 381 responding systems, including 899 hospitals with PCI facilities, representing approximately 66% of the 1355 hospitals identified as having PCI facilities according to the American Hospital Association.25 A final

limitation involves our question concerning systematic use of prehospital fibrinolysis. The 21% rate appears high compared with practical experience, and we believe that some respon-dents possibly misinterpreted this question to include fibrino-lysis administered at a transferring hospital.

In conclusion, this survey of 381 STEMI systems broadly describes the organizational characteristics of collaborative efforts by hospitals and EMS to provide timely reperfusion in the United States. We identified a number of common approaches to STEMI diagnosis and coronary reperfusion, and we identified major barriers that must be overcome in order to implement systematic care. These findings serve as a benchmark to existing systems and to regions in the process of organizing care for STEMI patients and provide a foundation for the ongoing implementation of Mission: Lifeline across the country.

DisclosuresThe following authors report conflicts of interest: James G. Jollis, MD: Medtronic Foundation, Sanofi-aventis, and Philips; Christopher B. Granger, MD: AstraZeneca, Boehringer Ingelheim, Bristol-Myers Squibb, GlaxoSmithKline, Novartis, Otsuka, Roche, Sanofi-aventis, The Medicines Company, and Astellas Pharma; and Elliott M. Antman, MD: Merck & Co., Bristol-Myers Squibb Pharmaceutical Research Institute, Sanofi-aventis, Millennium Pharmaceuticals, AstraZenaca Pharmaceuticals, CV Therapeutics, Inotek Pharmaceuticals Corporation, Eli Lilly and Company, Schering-Plough Research Institute, Bayer Healthcare LLC, Sanofi-Synthelabo Recherche, GlaxoSmithKline, Beckman Coulter, Inc., Biosite Incorporated, Roche Diagnostics Corporation, Pfizer, Accumetrics, and Novartis Pharmaceuticals. The other authors report no conflicts.

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16. Rokos IC, Larson DM, Henry TD, Koenig WJ, Eckstein M, French WJ, Granger CB, Roe MT. Rationale for establishing regional ST-elevation myocardial infarction receiving center (SRC) networks. Am Heart J. 2006;152:661– 667.

17. Jacobs AK, Antman EM, Faxon DP, Gregory T, Solis P. Development of systems of care for ST-elevation myocardial infarction patients: execu-tive summary. Circulation. 2007;116:217 – 230.

18. American Heart Association. Mission: Lifeline. http://www.heart.org/HEARTORG/HealthcareResearch/MissionLifelineHomePage/Mission-Lifeline-Home-Page_UCM_305495_SubHomePage.jsp. Accessed February 22, 2010.

19. Centers for Medicare & Medicaid Services and the Joint Commission, Specification Manual for National Inpatient Hospital Quality Measures. Version 3.0, March 31, 2009.

20. Hibbard JH, Stockard J, Tusler M. Hospital performance reports: impact on quality, market share, and reputation. Health Affairs. 2005;24:1150 –1160.

21. Concannon TW, Kent DM, Normand SL, Newhouse JP, Griffith JL, Cohen, Beshansky JR, Wong JB, Aversano T, Selker HP. Comparative effectiveness of STEMI regionalization strategies. Circ Cardiovasc Qual Outcomes. 2010;3:506 – 513.

22. Cantor WJ, Fitchett D, Borgundvaag B, Ducas J, Heffernan M, Cohen EA, Morrison LJ, Langer A, Dzavik V, Mehta SR, Lazzam C, Schwartz B, Casanova A, Goodman SG. Routine early angioplasty after fibri-nolysis for acute myocardial infarction. N Engl J Med. 2009;360: 2705 – 2718.

23. Di Mario C, Dudek D, Piscione F, Mielecki W, Savonitto S, Murena E, Dimopoulos K, Manari A, Gaspardone A, Ochala A, Zmudka K, Bolog-nese L, Steg PG, Flather M; CARESS-in-AMI (Combined Abciximab RE-teplase Stent Study in Acute Myocardial Infarction) Investigators. Immediate angioplasty versus standard therapy with rescue angio-plasty after thrombolysis in the Combined Abciximab REteplase Stent Study in Acute Myocardial Infarction (CARESS-in-AMI). Lancet. 2008;371:559 – 568.

24. Solis P, Amsterdam EA, Bufalino V, Drew BJ, Jacobs AK. Development of systems of care for ST-elevation myocardial infarction patients: policy recommendations. Circulation. 2007;116:e73 – e76.

25. American Hospital Association. Hospital statistics. 2010 ed. Chicago.




Appendix A. STEMI System On-line Questionnaire

STEMI SYSTEM OF CARE QUESTIONNAIRE

Are you already a part of a STEMI System of Care? Or, are you involved in an effort considering implementing a STEMI System of Care? If so, please take the time to fill out the STEMI System assessment questionnaire and let the AHA know about your initiative. This questionnaire should be filled out on behalf of your overall STEMI system, not just your individual institution. Don’t forget to search the Mission: Lifeline STEMI Systems Directory to see if your system is already registered with Mission: Lifeline. Part A: Contact Information 1. Describe the current status of your STEMI System.

System in place System being planned (The system oversight group is in place and planning has begun) System being considered (The development of the system is currently being debated)

2. Are you willing to have your STEMI System listed in the Mission: Lifeline STEMI Systems Directory?

Yes No

3. Name of STEMI System (Please indicate how you would want it to be listed in the Mission: Lifeline STEMI Systems Directory): 4. Name and contact information (Name, Address, City, State, Zip, Phone, e-mail) of individual completing the questionnaire: 5a. Are you also the system Champion?

Yes No

5b. Name and contact info for STEMI System Champion. Click here if this person is the same as person completing the questionnaire. 2a. Name, Address, City, State, Zip, Phone, e-mail

6a. Is the System Champion willing to be the contact person listed in the Mission: Lifeline STEMI Systems Directory?

Yes No

6b. Occupation of System Champion(s): (Check all that apply) Cardiologist ED physician Other physician Nurse EMT/paramedic Hospital/health care administrator Other: 6c. What organization is the System Champion(s) affiliated with? (Check all that apply): PCI hospital Non-PCI hospital EMS Other: 7. Enter the zip codes that are covered in your STEMI system of care. 8. Is there a website for your system that you want listed in the Mission: Lifeline STEMI Systems Directory? If so, please provide the website url.

Yes, the website is: ____________________________________ No

Part B: STEMI Initiative General Information (The next three questions are formatted as a grid in the survey) Indicate how the following organizations are involved, if at all, in the STEMI initiative: 9a. Partnered in the STEMI initiative. (Check all that apply) Local or state government Local American Heart Association American College of Cardiology Chapter Hospital// cardiology QI personnel Hospital administration Cath lab administration Emergency medicine Emergency Medical Services Nursing Air transport system Third party payers Other:

9b. Work with, sponsor or endorse the lead and/or governing organizations. (Check all that apply) Local or state government Local American Heart Association American College of Cardiology Chapter Hospital/ cardiology QI personnel Hospital administration Cath lab administration Emergency medicine Emergency Medical Services Nursing Air transport system Third party payers Other: 9c. Represented on the governing body that provides oversight. (Check all that apply) Local or state government Local American Heart Association American College of Cardiology Chapter Hospital/ ED/ cardiology QI personnel Hospital administration Cath lab administration Emergency medicine Emergency Medical Services Nursing Air transport system Third party payers Other: 10. Describe the system coverage, specifically EMS transport range. (Check all that apply) Rural Suburban Urban 11. Which of the following would best describe your STEMI System? (Check all that apply) Multiple hospital system Cardiology practice (academic or private) City-wide County State Cross-state regional 12. What are the specific funding sources for the STEMI System operations, including but not limited to: administration, performance feedback, training, equipment and supplies? (Select all that apply) PCI hospital

Cardiology practice Foundation State QI organization Professional society Pharmaceutical industry Third party payers Medical device industry State government agency Federal government agency Other (specify) Part C: EMS Assessment 13. Describe the specific EMS/Ambulance transport vehicles involved in your STEMI System. (Check all that apply) EMT or BLS only ambulance Paramedic or other ALS only ambulance EMT/Paramedic combination Helicopter transport 14. How many EMS programs work with your STEMI System? Ground: N= Air: N= 15. Does your STEMI System have pre-hospital 12-lead ECGs available in EMS vehicles? Yes Yes, but not in all ambulances No (skip to Q20)

16. Does your STEMI System transmit pre-hospital 12-lead information to the receiving hospital? Yes No In some ambulances yes and in some no. 17. How is the pre-hospital 12-lead ECG information transmitted and/or interpreted ? (Check all that apply) ECG read by paramedic and interpretation called by phone

ECG read by computer algorithm and called by phone

ECG transmitted to hospital by wireless or satellite phone

ECG transmitted to hospital by other device (i.e. fax)

18. Does your EMS system track and review any of the following performance measures? Check all that apply.

12-lead ECG interpretation accuracy (including false-positive rate)

Complications (including death) during transport Symptom onset to 911 call time. 911 call time to 12-lead ECG Pre-hospital positive ECG for STEMI to balloon time

EMS arrival to on scene time to hospital door arrival None

19. Is the EMS data review performed in partnership with: (Check all that apply) Non- PCI hospital PCI hospital ED Cardiologists EMS State Health Department 20. What is your estimate of the false positive (ie, cath lab activated but ECG did not really show ST elevation) of 12-Lead ECG readings in your STEMI System? Check the answer that best applies. >50% 25-50% 10-25% <= 10% Don’t know/not applicable 21. Are there destination protocols (i.e. bypass non-PCI centers to go directly to PCI centers) for patients that have had a pre-hospital identification of a STEMI? Yes No 22. Was legislation/regulation needed to implement the EMS destination protocols? Yes No 23. Please specify if the legislation/regulation was implemented at the (Check all that apply): City level County level State level 24. Is an inclusion/exclusion to thrombolysis criteria checklist completed on suspected AMI patients prior to ED arrival? Yes No

25. Is pre-hospital fibrinolysis used in your STEMI System? Yes

No Sometimes

26a. What type of inter-facility ambulance service is used to transport STEMI patients between non-PCI and PCI hospitals? (Check all that apply) Ground Air 911 activation is used None 26b. If ground, is a private ambulance service used? Yes No Not Applicable

26c. Is there an expected response time for the private service? Yes No 26d. If 911 is used: is 911 used as a primary protocol is 911 used as a back up if a private service cannot meet response times

Not applicable Part D: Participating Hospital System Assessment 27. What is the total number of hospitals in your system? Hospitals perform primary PCI? N= Hospitals are not PCI-capable? N=

28. Do you have a single call activation number to activate the STEMI Team/Cath Lab in your STEMI System? Yes No Not Sure

29. Please describe the pre-hospital and hospital department interaction when a patient either calls 911 or presents to a hospital. (Check all that apply) Pre-hospital/EMS Activation: EMS identifies STEMI and: Activates STEMI Team/Cath Lab Alerts ED & ED activates STEMI Team/Cath Lab (without consulting cardiologist or determining if patient has cardiologist)

Alerts ED & Cardiologist activates STEMI Team/Cath Lab

Other: 30. Hospital / ED Activation

Emergency Department staff:

Activates STEMI Team/Cath Lab (without cardiologist Consultation)

Calls Cardiologists prior to activation of STEMI team

Other: 31a. Do the hospitals in the system participate in a data registry program? Yes No 31b. In which data registry programs do the hospitals utilize? Check all that apply. ACTION Registry- GWTG Local/program specific NCDR Cath PCI Other: Other: 31c. Do hospitals in your system track and review any of the following performance measures? (Check all that apply) Hospital times:

Median arrival time for interventional cardiologist and staff at lab

Time to reperfusion: Door to balloon or door to needle

Time to reperfusion for transfer patients: 1st door to balloon

Time from door-in to door-out for transfer

Time from 1st medical contact (i.e. 1st ECG and/or EMS arrival) to reperfusion

Time from patient EMS summons to EMS arrival

% of patients eligible for reperfusion who receive it

Incidence of vascular complications Angiographic Success: % of stented lesions with angiographic success

Procedure Success: % of procedures with angiographic success and no death, MI or emergent/salvage CBG during admission

In hospital mortality 30-day risk adjusted mortality Major Adverse Cardiac Events (MACE)

32. Please categorize data feedback of performance and patient outcomes, including door to balloon times. (Check all that apply)

None To cardiology/cath lab To PCI hospital emergency department To non-PCI hospital emergency department To EMS 33. How frequently is feedback provided to members of the STEMI Team?. Check all that apply. Within 24 hours 24 hours to one week Monthly Quarterly or less N/A 34. Are there protocols for inter-facility transfer between non-PCI hospitals and PCI hospitals? Yes No

35. Do your non-PCI centers, (Check all that apply) Have a PCI strategy Fibrinolytic based strategy Have a mixed strategy (PCI and fibrinolytic) 36. When patients are treated with fibrinolysis in a non-PCI capable hospital are they routinely transferred to a PCI capable hospital? Yes, not urgently Yes, treated as emergency No

37. Please check which of the following strategies are used for patient transferred from a non- -PCI capable hospital to a PCI-capable hospital for PCI. Check all that apply. Non-PCI center directly activates cath lab Transportation generally by helicopter Transportation generally by local EMS Patients brought to non-PCI center by EMS taken to PCI center by same EMS

Transportation generally by EMS/mobile ICU sent from PCI center

Reduced dose fibrinolytic part of protocol Intravenous infusions generally avoided

38. Does the patient return to the hospital of origin prior to discharge to home? Yes No

38a. If “Yes” are they transferred

between 24 hrs. to 48 hrs. >48 hrs when the patient is stable 39. Do your PCI capable hospitals accept STEMI transfers regardless of hospital bed availability? Yes No 40a. Do your PCI capable hospitals include a standardized protocol for adjunctive therapy (antiplatelet, antithrombin, etc)? Yes No 40b. Do your non-PCI capable hospitals include a standardized protocol for adjunctive therapy (antiplatelet, antithrombin, etc)? Yes No

41. Does your system use the following six (6) ACC’s D2B Alliance evidence-based strategies?

1. ED physician activates the cath lab

2. One call activates the cath lab

3. Cath lab team ready in 20 – 30 minutes

4. Prompt data feedback

5. Senior management commitment

6. Team-based approach

42. Which of the following barriers has your STEMI system encountered? (Check all that apply) Bed availability Infrastructure support/funding Non-PCI hospital finances EMS/transport finances Cardiology group competition Hospital competition Lack of data collection/ feedback to systems EMS organization EMTALA regulations Receiving hospital on diversion Lack of leadership/identified champion Limited availability of interventional cardiologists Other Other Any additional comments or suggestions would be greatly appreciated.

Appendix B. Responses (Hospital identifiers removed)

STEMI System of Care Questionnaire

Date: 1/13/2010

Number of Responses Analyzed: 381

1: STEMI status: Describe the current status of your STEMI System. (Respondents could only choose a single response)

Response Chart Frequency Count

System in place 100.0% 381

System being planned (The system oversight group is in place and planning has begun)

0.0% 0

System being considered (The development of the system is currently being debated)

0.0% 0

Valid Responses 381

9a: Indicate how the following organizations are involved, if at all, in the STEMI initiative. (Partnered in the STEMI Initiative)

Yes No Total

Cardiology Count 349 8 357

Emergency medicine

Count 356 5 361

Emergency Medical Services

Count 356 4 360

Nursing Count 344 13 357

Primary care Count 153 156 309

EMS Count 353 8 361

Hospital/ED/ Count 356 4 360

Cardiology QI personnel

Count 319 24 343

Hospital administration

Count 340 11 351

Cath lab administration

Count 348 5 353

Air transport system

Count 218 108 326

Local or state government

Count 106 185 291

Local American Heart Association

Count 157 152 309

American College of Cardiology Chapter

Count 120 176 296

Third party payers Count 51 222 273

Total Count 3926 1081 5007

9b: Indicate how the following organizations are involved, if at all, in the STEMI initiative. (Work with/sponsor/endorse the lead/governing organizations)

Yes No Total


Emergency medicine

Count 231 30 261


Count 232 29 261



EMS Count 221 37 258



Count 210 40 250


Count 229 31 260


Count 224 34 258


Count 146 106 252


Count 91 152 243


Count 118 126 244


Count 86 158 244


Total Count 2599 1181 3780

9c: Indicate how the following organizations are involved, if at all, in the STEMI initiative. (Represented on the governing body that provides oversight)

Yes No Total


Emergency medicine

Count 241 31 272


Count 214 44 258



EMS Count 201 54 255



Count 204 52 256


Count 223 44 267


Count 223 40 263


Count 95 141 236


Count 48 175 223


Count 45 182 227


Count 34 189 223


Total Count 2317 1407 3724

10: Describe the system coverage, specifically EMS transport range. (Select all that apply.) (Respondents were allowed to choose multiple responses)


Rural 73.4% 279

Suburban 72.9% 277

Urban 67.1% 255

Valid Responses 380

11: Which of the following would best describe your STEMI system of care? (Select all that apply.) (Respondents were allowed to choose multiple responses)


Multiple hospital system or network

71.3% 271

Cardiology practice (academic or private)

41.1% 156

City-wide 50.0% 190

County 60.0% 228

State 16.3% 62

Cross-state regional 22.9% 87

Valid Responses 380

12: What are the specific funding sources for STEMI System operations, including but not limited to: administration, performance feedback, training, equipment and supplies? (Select all that apply.) (Respondents were allowed to choose multiple responses)


PCI hospital 84.2% 320

Cardiology practice 23.2% 88

Foundation 18.2% 69

State QI organization 2.6% 10

Professional society 6.1% 23

Pharmaceutical industry 3.4% 13

Third party payers 11.1% 42

Medical device industry 4.2% 16

State government agency 8.7% 33

Federal government agency 5.3% 20

Other (specify) 16.6% 63

Valid Responses 380

13: Describe the specific EMS/Ambulance transport vehicles involved in your STEMI System. (Select all that apply.) (Respondents were allowed to choose multiple responses)


EMT only or BLS only ambulance

30.3% 115

Paramedic or other ALS only ambulance combination

62.4% 237

EMT/Paramedic combination 82.6% 314

Helicopter transport 65.5% 249

Valid Responses 380

15: Does your STEMI System have pre-hospital 12-lead ECGs available in EMS vehicles? (Respondents could only choose a single response)


Yes 55.1% 209

Yes, but not in all ambulances 40.9% 155

No 4.0% 15

Not Answered 1

Valid Responses 379

16: Does your STEMI System transmit pre-hospital 12-lead information to the receiving hospital? (Respondents could only choose a single response)


Yes 35.0% 132

No 29.2% 110

In some ambulances yes and in some no

35.8% 135

Not Answered 3

Valid Responses 377

17: How is the pre-hospital 12-lead ECG information transmitted and/or interpreted? (Select all that apply.) (Respondents were allowed to choose multiple responses)


ECG read by paramedic and interpretation called by phone

62.5% 170

ECG read by computer algorithm and called by phone

33.8% 92

ECG transmitted to hospital by wireless or satellite phone

67.6% 184

ECG transmitted to hospital by other device (i.e. fax)

48.2% 131

Valid Responses 272

Total Responses 272

18: Does your EMS system track and review any of the following performance measures? (Select all that apply.) (Respondents were allowed to choose multiple responses)


12-lead ECG interpretation accuracy (including false-positive rate)

64.2% 244

Complications (including death) during transport

64.5% 245

Symptom onset to 911 call time 45.3% 172

911 call time to 12-lead ECG 48.2% 183

Pre-hospital positive ECG for STEMI to balloon time

65.0% 247

EMS arrival to on scene time to hospital door arrival

71.8% 273

Valid Responses 380

19: Is the EMS data review performed in partnership with: (Select all that apply.) (Respondents were allowed to choose multiple responses)


Non-PCI hospital 29.7% 113

PCI hospital 77.1% 293

ED 67.4% 256

Cardiologists 55.0% 209

EMS 73.9% 281

State Health Department 5.5% 21

Valid Responses 380

20: What is your estimate of the false positive (i.e. cath lab activated but ECG did not really show ST elevation) of 12-lead ECG readings in your STEMI System? (Select the answer that best applies.) (Respondents could only choose a single response)


Greater than 50% 0.8% 3

25-50% 3.8% 14

10-24% 21.2% 79

Less than 10% 54.3% 202

Don't know/not applicable 19.9% 74

Not Answered 8

Valid Responses 372

21: Are there destination protocols (i.e. bypass non-PCI centers to go directly to PCI centers) for patients that have had a pre-hospital identification of a STEMI? (Respondents could only choose a single response)


Yes 60.9% 227

No 39.1% 146

Not Answered 7

Valid Responses 373

22: Was legislation/regulation needed to implement the EMS destination protocols? (Respondents could only choose a single response)


Yes 18.1% 41

No 81.9% 186

Not Answered 19

Valid Responses 227

23: Please specify if the legislation/regulation was implemented at the: (select all that apply) (Respondents were allowed to choose multiple responses)


City level 18.2% 10

County level 40.0% 22

State level 40.0% 22

Valid Responses 55

24: Is an inclusion/exclusion criteria checklist completed on suspected AMI patients prior to ED arrival? (Respondents could only choose a single response)


Yes 37.9% 141

No 62.1% 231

Not Answered 8

Valid Responses 372

25: Is pre-hospital fibrinolysis used in your STEMI System? (Respondents could only choose a single response)


Yes 6.6% 25

No 79.6% 301

Sometimes 13.8% 52

Not Answered 2

Valid Responses 378

26a: What type of inter-facility ambulance service is used to transport STEMI patients between non-PCI and PCI hospitals? (Check all that apply) (Respondents were allowed to choose multiple responses)


Ground 92.1% 350

Air 67.9% 258

911 activation is used 33.4% 127

Valid Responses 380

26b: If ground, is a private ambulance service used? (Respondents could only choose a single response)


Yes 54.1% 196

No 37.3% 135

Not Applicable 8.6% 31

Not Answered 18

Valid Responses 362

26c: Is there an expected response time for the private service? (Respondents could only choose a single response)


Yes 73.7% 146

No 26.3% 52

Not Answered 29

Valid Responses 198

26d: If 911 is used: (Respondents could only choose a single response)


is 911 used as a primary protocol 39.4% 143

is 911 used as a back up if a private service cannot meet response times

17.1% 62

Not applicable 43.5% 158

Not Answered 17

Valid Responses 363

28: Do you have a single call activation number to activate the STEMI Team/Cath Lab in your STEMI System? (Respondents could only choose a single response)


Yes 85.3% 320

No 14.7% 55

Not Answered 5

Valid Responses 375

29: Pre-hospital/EMS Activation. EMS identifies STEMI and: (Select all that apply.) (Respondents were allowed to choose multiple responses)


Activates STEMI Team/Cath Lab

15.3% 58

Alerts ED & ED activates STEMI Team/Cath Lab (without consulting Cardiologist or determining if patient has Cardiologist)

78.2% 297

Alerts ED & Cardiologist activates STEMI Team/Cath Lab

18.9% 72


Valid Responses 380

30: Hospital/ED Activation: Emergency Department staff: (Select all that apply.) (Respondents were allowed to choose multiple responses)


Activates STEMI Team/Cath Lab (without Cardiologist consultation)

83.2% 316

Calls Cardiologist prior to activation of STEMI team

21.3% 81


Valid Responses 380

31a: Do your hospitals in the system participate in a data registry program? (Respondents could only choose a single response)


Yes 83.8% 311

No 16.2% 60

Not Answered 9

Valid Responses 371

31b: Which data registry programs do the hospitals utilize? (Select all that apply.) (Respondents were allowed to choose multiple responses)


ACTION 34.8% 114

GWTG-CAD 27.1% 89

Local/program specific 22.0% 72

NCDR Cath PCI 61.3% 201



Valid Responses 328

31c: Do hospitals in your system track and review any of the following performance measures? (Select all that apply.) (Respondents were allowed to choose multiple responses)


(Hospital time) Median arrival time for interventional cardiologist and staff at lab

77.6% 295

(Hospital time) Time to reperfusion: door to balloon or door to needle

94.5% 359

(Hospital time) Time to reperfusion for transfer patients: 1st door to balloon

76.6% 291

(Hospital time) Time from door-in to door-out for transfer

56.1% 213

Time from 1st medical contact (i.e. 1st ECG and/or EMS arrival) to reperfusion

67.6% 257

Time from patient EMS summons to EMS arrival

39.5% 150

% of patients eligible for reperfusion who receive it

47.9% 182

Incidence of vascular complications

74.7% 284

Angiographic success: % of stented lesions with angiographic success

70.3% 267

Valid Responses 380

32: Please categorize data feedback of performance and patient outcomes, including door to balloon times. (Select all that apply.) (Respondents were allowed to choose multiple responses)


None 2.6% 10

To cardiology/cath lab 86.3% 328

To PCI hospital emergency department

83.7% 318

To non-PCI hospital emergency department

46.1% 175

To EMS 75.0% 285

Valid Responses 380

33: How frequently is feedback provided to members of the STEMI Team? (Select all that apply.) (Respondents were allowed to choose multiple responses)


Within 24 hours 35.0% 133

24 hours to one week 45.5% 173

Monthly 35.5% 135

Quarterly or less 21.6% 82

Not applicable 2.9% 11

Valid Responses 380

34: Are there protocols for inter-facility transfer between non-PCI hospitals and PCI hospitals? (Respondents could only choose a single response)


Yes 71.8% 255

No 28.2% 100

Not Answered 25

Valid Responses 355

35: Do your non-PCI centers: (Select all that apply.) (Respondents were allowed to choose multiple responses)


Have a PCI strategy 35.5% 135

Fibrinolytic based strategy 18.2% 69

Have a mixed strategy (PCI and fibrinolytic)

52.1% 198

Valid Responses 380

36: When patients are treated with fibrinolysis in a non-PCI capable hospital, are they routinely transferred to a PCI-capable hospital? (Respondents could only choose a single response)


Yes, not urgently 11.1% 35

Yes, treated as emergency 81.3% 256

No 7.6% 24

Not Answered 65

Valid Responses 315

37: Please check which of the following strategies are used for patients transferred from a non-PCI capable hospital to a PCI-capable hospital for PCI. (Select all that apply.) (Respondents were allowed to choose multiple responses)


Non-PCI center directly activates cath lab

31.8% 121

Transportation generally by helicopter

44.2% 168

Transportation generally by local EMS

63.4% 241

Patients brought to non-PCI center by EMS taken to PCI center by same EMS

35.8% 136

Transportation generally by EMS/mobile ICU sent from PCI center

12.6% 48

Reduced dose fibrinolytic part of protocol

6.6% 25

Intravenous infusions generally avoided

19.2% 73

Valid Responses 380

38: Does the patient return to the hospital of origin prior to discharge to home? (Respondents could only choose a single response)


Yes 2.1% 7

No 97.9% 326

Not Answered 47

Valid Responses 333

38a: Are they transferred: (Respondents could only choose a single response)


Between 24 hours to 48 hours 36.4% 4

More than 48 hours 9.1% 1

When the patient is stable 54.5% 6

Not Answered 46

Valid Responses 11

39: Do your PCI-capable hospitals accept STEMI transfers regardless of hospital bed availability? (Respondents could only choose a single response)


Yes 96.9% 346

No 3.1% 11

Not Answered 23

Valid Responses 357

40a: Do your PCI-capable hospitals include a standardized protocol for adjunctive therapy (antiplatelet, antithrombin, etc.)? (Respondents could only choose a single response)


Yes 92.4% 326

No 7.6% 27

Not Answered 27

Valid Responses 353

40b: Do your non-PCI capable hospitals include a standardized protocol for adjunctive therapy (antiplatelet, antithrombin, etc.)? (Respondents could only choose a single response)


Yes 77.5% 244

No 22.5% 71

Not Answered 65

Valid Responses 315

41: Does your system use the following six (6) ACC's D2B Alliance evidence-based strategies?

Yes No Partially Total

ED physician activates the cath lab

Count 318 18 30 366

One call activates the cath lab

Count 335 11 18 364

Cath lab team ready in 20-30 minutes

Count 352 4 10 366

Prompt data feedback

Count 322 5 33 360

Senior management commitment

Count 354 2 6 362

Team-based approach

Count 360 2 1 363

Total Count 2041 42 98 2181

42: Which of the following barriers has your STEMI system encountered? (Select all that apply.) (Respondents were allowed to choose multiple responses)


Bed availability 15.5% 59

Infrastructure support/funding 15.5% 59

Non-PCI hospital finances 10.3% 39

EMS/transport finances 26.1% 99

Cardiology group competition 21.3% 81

Hospital competition 36.6% 139

Lack of data collection/feedback to systems

17.9% 68

EMS organization 13.9% 53

EMTALA regulations 6.6% 25

Receiving hospital on diversion 5.8% 22

Lack of leadership/identified champion

2.9% 11

Limited availability of interventional cardiologists

6.3% 24



Valid Responses 380

Other responses: 7: What are the specific funding sources for STEMI System operations, including but not limited to: administration, performance feedback, training, equipment and supplies? (Select all that apply.) Response County government County government agency public parish hospital Local (County) Gov. Agency data coordinating center pro bono County government donations, operating expenses Cardiac PHO Grant, initially Fire Based EMS City and County Taxes Not sure how to answer, as there is no funding for the System per se County EMS; EMS providers local government agency Local Government

County, Private ambulance EMS County Health Services, EMS Agency County EMS Municipality and Grants non-PCI hospital County EMS Agency, local fire departments and private ambulance providers (see above) EMS Municipality of Anchorage County Government Local Government Fire / EMS Departments City govt None city government EMS System, Fire Department Our EMS ESD local government Local Government RACE Cooperative agreement RACE grant Hospital Hospital District County Government, AHA EMS Agency Individual Hospitals JCAHO (core measures), Society of Chest Pain Centers none grants donations, operating expenses Hospital EMS Agency County EMS, Berkshire Medical Center PCI referral center non-PCI facilities, regional EMS providers EMS private donations county budget grant funded EMS 25: Pre-hospital/EMS Activation. EMS identifies STEMI and: (Select all that apply.) Response Hospital determines policy alert ED only notification is in house ED varies between PCI facilities

One phone call to a centralized # activates the Cardiologist on call, the Interventional Cardiologist, the Cath lab Team, Bed control staff at the Hospital, Chaplaincy, Managers of the ED, CCU and the Cath Lab, Security and The STEMI Coordinator.

interventional cardiologist called same time If we suspect MI we call in the field it is up to the recieving hospitalt to activate the

Cardiologist/Cath Lab transports via airmedical to PCI facility alerts ED, PT arrives, EKG, Labs done, Cath Lab MD notified, consulted, then team

activation ED Cardiologist activates STEMI TEAM/Cath Lab Cardiologist receives EKG via phone and activates STEMI.

calls AMI hotline and discusses with CCU fellow for activation of lab

Brings patient to the ED EMS notifies ED, ED notifies PCI hospital ED to notify Cath Lab/STEMI Notifies Medcomm who activates Cath Lab ED evaluates the calls one of two other facilities in the area that perform PCI None 26: Hospital/ED Activation: Emergency Department staff: (Select all that apply.) Response Different protocols at different hospitals Hospital determines policy varies between PCI facilities One phone call to a centralized # activates the Cardiologist on call, the Interventional

Cardiologist, the Cath lab Team, Bed control staff at the Hospital, Chaplaincy, Managers of the ED, CCU and the Cath Lab, Security and The STEMI Coordinator.

Don't know facility's internal protocol interventional cardiologist called same time unsure unsure Transmit 12 lead to PCI Hospital notifies PCI hospital ED, notifies Cath LAB/STEMI Notifies medcomm who activates Cath lab EMS calls hosptal enroute None 28: Which data registry programs do the hospitals utilize? (Select all that apply.) Response Web Data Collected by EMS IHI Initiative: Operational and Clinical Improvement in the Emergency Room 6th Sigma ACC

NRMI BMC2 Michigan CMS (I'm not sure of the name) CMS TJC, CMS, HQA. Leapfrog, NQF, BSC Level 1 Heart Attack Procotol, ACC unk Leapfrog ACC-D2B Initiative ACC STS CABG Hospital Quality Alliance initiative ACC CMS ACHA Core Measures I don't know local BMC2 PCI Registry ACC NYS DOH reporting guidelines Unknown D2B Alliance ACTION-GWTG clar trauma Trauma Registry Solucient D2B Alliance STS Database unkown ICD AMI ACC D2B; MQIP; RACE/CLAR; CMS core measures Society of Thoracic Surgeons soon to be Action ACC database not sure Core Measures ACC only for stroke and trauma sts EMS - Macrologic (Code Red) - NEMSIS Compliant Lumedex Maryland Healthcare Commission-Sextant database IHI Initiative: AMI Mentor Hospital JACHO D2B JCAHO

Pinpoint Compliance for Quality Measures Centers for Medicare and Medicaid/Joint Commission data reporting JCAHO HQI - AMI (CMS) STS WCHQ – state CMS 42: Which of the following barriers has your STEMI system encountered? (Select all that apply.) Response False Positive Rate non-interventional cardiologist assessment EKG transmission We encountered many barriers and worked through them at a local level Cardiologist are not interested in doing primary PCI for patients at non PCI center If adverse weather conditions preclude flying, ground transport is arranged time and availability of staff at non PCI centers technology linkage between many independent organizations physician protocol compliance some reluctance from one cardiology group to standardize one-call activation Multiple

STEMI's at the same time Just getting started working wit the local PCI hospital, the previous cardiologist did not want to work with EMS. Consistency in data collection/feedback to systems Enough people dedicated to data collection ED staff buy in vendor ability to provide equipment for transmissions Labor individual cardiologist and group practice patterns EMS availability throughout area difficulty finding transport, Lack of EMS education to recognize STEMI State regulations regarding EMS hospital destinations Need for Atomic Clocks patients with cardiologists at different centers Education of EMS, local hospitals Lack of resources to provide consistent feedback and loop closure Weather delays Non-PCI Hospital bypasses the closest PCI hospital to stay within their system. This

results in delays for the patient EMS transportatin from non PCI facilities lenghty call backs by receiving PCI capable Hospital none of the above EKG transmission Rural area

Emergency physicians functioning separately and hesitant to allow interaction within/as STEMI team

weather/distance none Not all EMS have 12 Lead ablilty on current equipment medical education of the patients lack of administrative support prehospital transmission of 12 lead pre-hospital EKG technology Lack of EMS capability to transmit EKGs Time and Distance cath lab availability EMS has 40% accurancy rate in identifying STEMI the mentality of the chief cardiologist

Appendix C. System representation by hospital ranges

202 Systems with 1 PCI center 55 systems with 1 PCI center and no referral centers 33 systems with 1 PCI and 1 referral center 63 systems with 1 PCI center and 2-5 referral centers 50 systems with 1 PCI center and > 5 referral centers 150 Systems with 2-5 PCI centers 30 systems with 2-5 PCI centers and no referral centers 22 systems with 2-5 PCI centers and 1 referral center 73 systems with 2-5 PCI centers and 2-5 referral centers 25 systems with 2-5 PCI centers and > 5 referral centers 29 systems with greater than 5 PCI centers 7 systems with >5 PCI centers and no referral centers 2 systems with >5 PCI centers and 1 referral centers 10 systems with >5 PCI centers and 2-5 referral centers 10 systems with >5 PCI centers and >5 referral centers

systems of care for st-segment−elevation myocardial ... of a hospital.8–12 by implementing...

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