The Role of DHMC as an ST Elevation Myocardial Infarction Receiving Center in a Regional STEMI Care Network:

Size: px

Start display at page:

Download "The Role of DHMC as an ST Elevation Myocardial Infarction Receiving Center in a Regional STEMI Care Network:"

Jayson Austen Hines
5 years ago
Views:

1 The Role of DHMC as an ST Elevation Myocardial Infarction Receiving Center in a Regional STEMI Care Network: Nathaniel Niles, MD CREST Symposium November 7th, 28

2 STEMI = Acute Coronary Thrombosis

3 STEMI (ST elevation Myocardial Infarction) Relatively common Multiple treatment strategy options Requires coordination Multidisciplinary EMS Emergency Medicine Cardiology Interhospital Must be managed quickly Time ~ Muscle

4 Pre-Hospital Delay The Golden early hours: Meta-analysis analysis on 5,246 patients in thrombolytic trials Boersma E. et al. Lancet. 1996:348:771

5 Thrombolytic Therapy is Inferior to PCI for Treating STEMI 23 study systematic review: short-term term outcomes 3 Frequency (%) 2 1 p= Death Primary PCI Thrombolytic Therapy p= Non-fatal reinfarction p= Total stroke p= Recurrent ischemia p= Death, reinfarction, stroke Lancet 23;361:13-2

6 Transfer for PCI vs On-site Thrombolytic 5 study systematic review: Frequency (%) Death o 1 PCI (n=1466) TTx (n=1443) Average Transfer Time 39 minutes p=.57 p= Non-fatal reinfarction p= p= p=.1 15 Total stroke ICH Death, reinfarction, stroke 8 Lancet 23;361:13-2

7 Absolute Risk Difference in Death (%) 1 o PCI Benefit also time dependent Mortality benefit with primary PCI as function of PCI-related time delay Circle sizes = P = sample size of the individual study. Solid line = weighted meta-regression. 62 min Benefit Favors PCI PCI-Related Time Delay (door-to-balloon - door-to-needle) Harm Favors Lysis Nallamothu BK, Bates ER. Am J Cardiol. 23;92:824-6

8 I IIa IIb III STEMI Guidelines (27) STEMI patients presenting to a hospital with PCI capability should be treated with primary PCI within 9 minutes of first medical contact as a systems goal (Level of Evidence: A) STEMI patients presenting to a hospital without PCI capability and who cannot be transferred to a PCI center and undergo PCI within 9 minutes of first medical contact should be treated with fibrinolytic therapy within 3 minutes of hospital presentation as a systems goal unless contraindicated. (Level of Evidence: B)

9 Regional STEMI Care Network Rationale PCI is > thrombolytic therapy Transfer for PCI > on-site fibrinolytic therapy Death during transfer rare US Guidelines: D2B 9 minutes Only ~ 25% acute care hospitals in the US are PCI capable and even en fewer have 24/7 cath labs Hospital specialization on primary PCI faster treatment and lower mortality So What once could be treated locally (Ttx( can be given at any hospital) now requires a regional network around a PCI Center to diagnose STEMI get the patient rapidly to PCI Moreover Trauma center systems have been successful Formalization of regional networks will better enable payers to track quality (treatment times) and structure incentives

10 DHMC Position in the System STEMI Patient ED 16% STEMI Patient EMS Primary PCI-Capable Capable Hospital DHMC ~4% 8% Zone 1 Zone 2 Local Non PCI-Capable Capable Hospital STEMI Referral Hospital Remote Non PCI-Capable Capable Hospital STEMI Referral Hospital STEMI Patient STEMI Patient

11 Reperfusion Strategy DHMC ED Primary PCI-Capable Capable Hospital 1 o PCI STEMI Patient Zone 1 Non PCI-Capable Capable Hospital (STEMI Referral Hospital) PCI avail within 9 Trf 1 o PCI Pharmaco-invasive Zone 2 Non PCI-Capable Capable Hospital (STEMI Referral Hospital) PCI not avail within 9 1 o Lytic Tx or ½ dose Lytic plus GP 2b3a Inh Trf for immediate PCI

12 CARESS Trial Outcome Death/re-MI/ refractory ischemia at 3 days Pharmaco invasive strategy (½ dose Lytic +Abciximab +PCI for all) (%) Thrombolysis alone (½ dose Lytic +Abciximab +rescue PCI only) (%) p Di Mario C. European Society of Cardiology Congress 27; September 3, 27; Vienna, Austria.

13 How has DHMC really performed as a STEMI Receiving Center?

14 The Region Upper CT Valley, ~6 m N and 45 m S on I91 and 3-4 m NW or SE on I89. 2 Referral Hospitals Zone 1 = the local area, APD and VAMC Zone 2 = everything else ~4 Ambulance services 2 Helicopters based at DHMC

15 DHMC STEMI Registry 94 total registry patients from 21 mid STEMI patients 13 NSTEMI patients 742 Presented to regional referral hospitals 149 Presented to DHMC 145 admitted with STEMI from DHMC ER 4 DHMC inpatients 34 Zone 1 (VAMC or APD) 33 transferred emergently to DHMC with STEMI 1 Admitted to initial hospital or initially tfxd elsewhere 78 Zone 2 (Other referral hospitals) 53 Admitted to 655 initial hospital transferred or initially tfxd emergently to elsewhere DHMC with STEMI 9 Managed conservatively 1 Managed conservatively 12 Managed conservatively 136 to cath lab emergently 5 post lytic 131 no lytic to cath lab late post lytic 32 to cath lab emergently 3 post lytic 29 no lytic to cath lab late post lytic 596 to cath lab emergently 47 post lytic 124 no lytic 47 to cath lab late post lytic

16 Median Times Over Time DHMC ED STEMI Patients minutes Door-to-tabletop Tabletop-to-balloon Door-to-balloon % of patients 9 minutes

17 Bradley E et al. N Engl J Med 26;355: MEDIAN DOOR-TO TO-BALLOON TIMES Distribution among 365 hospitals studied Median 1.4 SD April to September 25

18 DHMC ED STEMI Patients n= Actual 3 day mortality (%) ns TIMI score predicted 3 day mortality (%) 15 ns Years

19 DHMC ED & Zone 1 STEMI Patients n= Actual 3 day mortality (%) ns TIMI score predicted 3 day mortality (%) 15 ns Years

20 Zone 2 Patients (STEMI Patients Transferred from Remote Referral Hospitals)

21 Median Times Over Time Zone 2 STEMI Patients Ideal (Weekdays 7 AM to 5 PM) Door-to-tabletop Tabletop-to-balloon Door-to-balloon Suboptimal (After hours and Weekends) Door-to-tabletop Tabletop-to-balloon Door-to-balloon)

22 Circulation. 25;111: Initial Door-to-balloon times in Transfer Patients Undergoing 1 PCI in the US NRMI-3/4 Analysis ( ) n= % >24 minutes 4% < 9 minutes 12% 9-12 minutes 56% minutes 5% had door-to to-balloon time > 3 hours

23 Zone 2 STEMI Emergent Transfers: Zone 2 STEMI Emergent Transfers: Median Door-to to-table table time Q1(1)-Q2(7) Q2(7) Door-to-table table time (min) APD WRJVA Mt Ascutney New London VRH Gifford Springfield Cottage Grace Cottage NVRH Rutland CVH Speare Brattleboro Littleton Cheshire Weeks NCH Androscoggin UCVH Hospital

24 UCVH Zone 2 Transfers: Helicopter vs Ground Transport Median Door-to to-table table time Q1(1)-Q2(7) Q2(7) Helicopter (44%) Ground (56%) Mean of Median differences = 69 min Door-to-table table time (min) APD WRJVA Mt Ascutney New London VRH Gifford Springfield Cottage Grace Cottage NVRH Rutland CVH Speare Brattleboro Littleton Cheshire Weeks NCH Androscoggin Hospital

25 Q4(6) Q1(7) Q2(7) STEMI Emergent Transfer Volumes Q1(1)-Q2(7) Q2(7) Half Dose Full Dose No Lytic Given Ukn Percent of STEMI Patients Percent of STEMI Patients Q1(1) Q2(1) Q3(1) Q4(1) Q1(2) Q2(2) Q3(2) Q4(2) Q1(3) Q2(3) Q3(3) Q4(3) Q1(4) Q2(4) Q3(4) Q4(4) Q1(5) Q2(5) Q3(5) Q4(5) Q1(6) Q2(6) Q3(6)

26 Zone 2 STEMI Emergent Transfer Patients: By Intended Dose 3 Day Mortality % Mortality ns p< None Given Full Dose Half Dose Lytic Dose Strategy p=.8 N=136 N=171 N=339

27 Zone 2 STEMI Emergent Transfer Patients: By Intended Dose Neuro Complications (ICH, Total Stroke) 4 ns 3.5 ns ns % ICH Total Stroke None Given Full Dose Half Dose Lytic Dose Strategy

28 Zone 2 Transfer Patients n= Actual 3 day mortality (%) ns TIMI Score predicted 3 day mortality (%) 15 ns Years

29 Door-to to-balloon Times Non- transfers (PPCI) (min) Transfers Zone 1 Zone 2 No lytic (PPCI) (min) No Lytic (PPCI) (min) ½ Dose Lytic (min) Full Dose Lytic (min) DHMC ANW Not reported 12 - Mayo Not reported

30 3 day Mortality DHMC n=395 ANW N=1345 Mayo N=597 Non- transfers (PPCI) No lytic (PPCI) Transfers ½ Dose Lytic Full Dose Lytic Overall * * *Facilitated PCI Primary Ttx with rescue PCI if necessary Late presenters only Early presenters only

31 DHMC ED & Zone 1-1 PCI Patients Early and Late Door-to to-balloon Times vs : 3 Day Mortality (%) TIMI Risk Predicted 3 Day Mortality (%) Pre-Cath Shock or Intubation 2 ns ns hours >2 hours -2 hours >2 hours Door-to-Balloon Time -2 hours >2 hours

32 Zone 2 PCI Patients Door-to to-balloon Time 3 Day Mortality (%) TIMI Risk Predicted 3 Day Mortality (%) Pre-Cath Shock or Intubation ns hours hours >4 hours -2 hours 2-4 hours >4 hours Door-to-Balloon Time -2 hours 2-4 hours > 4 hours

33 Can we be satisfied No! In- house D2B times are too slow We can see a relationship between D2B time and 3 day outcome in our overall data Less than 2% of our patients are offered 1º 1 PCI ICH risk of ½ dose lytic protocol (1.5%- in our hands too high?) A STEMI Center Certification Program is in the works (Criteria for eligibility will likely be based on treatment times and volumes as well as quality outcomes) Pay-for for-performance reimbursement strategies are here or coming

34 STEP 1 - Get Organized ST Elevation MI Process Upgrade STEP UP Project Obtain commitment of DHMC Senior management Form a multidisciplinary group with members from Cardiology, Emergency medicine, EMS, Communications, CCU, Cardiac Cath Lab, DHMC administration and Quality management Identify/develop and implement strategies which improve the process of care, treatment times and outcomes of STEMI patients within our hospital and within our region

35 STEP UP Project: Goals 1. Implement proven strategies for reducing Doorto-balloon time to < 9 min in > 75% of STEMI patients 2. Design a STEMI pre-hospital triage network for the purpose of providing timely primary angioplasty to STEMI patients from an enlarged geographic area around DHMC 3. Critically assess our current inter-hospital transfer system including the current facilitated PCI program in order to identify process/protocol improvements

36 STEP 2 - Improve In-house D2B D2B: An Alliance for Quality Evidence-based Strategies for reducing Doorto-balloon time to < 9 min in > 75% of STEMI patients 1. ED physician activates the cath lab 2. One call activates the cath lab 3. Cath lab team ready in 2-3 minutes 4. Prompt data feedback 5. Team-based approach 6. Pre-hospital ECG to activate the cath lab*

37 STEMI Patients Presenting to DHMC ED QC Chart D2B Individual Measurements 21-28(Q3) 28(Q3) May 1 st

38 STEMI Patients Presenting to DHMC ED % D2B 9 min by Quarter 1 >75% 9 min Target! % 75 5 On line with D2B Strategies May 1 st st '1 2nd '1 3rd '1 4th '1 1st '2 2nd '2 3rd '2 4th '2 1st '3 2nd '3 3rd '3 4th '3 1st '4 2nd '4 3rd '4 4th '4 1st '5 2nd '5 3rd '5 4th '5 1st '6 2nd '6 3rd '6 4th '6 1st '7 2nd '7 3rd '7 4th '7 1st '8 2nd '8 3rd '8

39 STEP 3 Expanding EMS DHMC system Strategies EMS 12 lead ECG capability (Medtronic grant) EMS checklist to establish candidacy for 1º PCI and collect QI data Cath Lab activation based on ECG in the field (automated reading) Destination protocols for local ED bypass and transport directly to DHMC Cath Lab Goal = 35 miles up and down I91 and I89

STEP 4 Expanding Zone 1 Strategy Shorten in-door-out-door time at

Suspected STEMI patients EMS transported patients remain on

Checklists to allow parallel workflow and QI data feedback system

40 STEP 4 Expanding Zone 1 Strategy Shorten in-door-out-door time at presenting hospital ECG within 1 minutes of arrival for all Suspected STEMI patients EMS transported patients remain on stretcher for ECG and transfer decision Doc, Nurse, Scribe Checklists to allow parallel workflow and QI data feedback system Zone 1 ED Physician activates cath lab if transport is immediately available. Response to interhospital STEMI transfer based on system rather than next available ambulance Goal = min. Zone 1 Option Zone 1

44 STEP 5 Rethink the Zone 2 Strategy Continue the Facilitated PCI option? Selected patients only? Change lytic regimen? Yes No Yes

45 The Pharmaco-invasive Option for Zone 2 Patients Alternative Regimens ½ dose Lytic plus GP 2b3a inhibitor plus low dose heparin infusion followed by PCI ASAP Pros Superior to Stand-alone lytic Tx in CARESS Trial Benefits early presenters We have good mortality track record Cons Increased bleeding/ich in our hands Not guideline compliant Complex and time consuming Full dose lytic and clopidogrel plus low dose heparin bolus followed by PCI ASAP Pros Superior to Stand-alone lytic Tx in TRANSFER AMI and CAPITAL AMI Trials Benefits early presenters Simpler / Quicker Cons More Bleeding / ICH risk

46 Questions?

The Window for Fibrinolysis. Frans Van de Werf, MD, PhD Leuven, Belgium

The Window for Fibrinolysis. Frans Van de Werf, MD, PhD Leuven, Belgium The Window for Fibrinolysis Frans Van de Werf, MD, PhD Leuven, Belgium ESC STEMI Guidelines : December 2008 Reperfusion Therapy: Fibrinolytic Therapy Recommendations Class LOE In the absence of contraindications