Regional STEMI Transfer Systems: the Mayo and NC RACE Experiences

Transcription

1 Regional STEMI Transfer Systems: the Mayo and NC RACE Experiences Dr. Henry H. Ting, Mayo Clinic College of Medicine Dr. James G. Jollis,, Duke University Medical Center

2 Mayo Clinic STEMI System for Transferred Patients FAST TRACK Henry H. Ting, MD MBA Mayo Clinic Rochester, Minnesota Jan. 28, 2010

3 No financial disclosures No conflicts of interest No off-label use Disclosures

4 D2B Sustain The Gain Nestler DM. Circ Cardiovasc Qual Outcomes. 2009;2:

5 PH ECG and Door-to-Balloon 30 min 64 min Ting HH. Presented at AHA November 2009

6 Patients Transferred for Primary PCI 60 Patients (%) <1 <90 min to <2 2 to <3 3 to <4 4 to <5 5 to <6 6 to <7 7 to < Total door-to to-balloon time (hours) Chakrabarti A, J Am Coll Cardiol 2008;51:

7 Reperfusion Strategies for Transferred STEMI Patients 1. Interhospital transfer for primary PCI 2. Pharmaco-invasive approach with lytics and early PCI 3. Lytic facilitated PCI 4. Prehospital triage for primary PCI

8 Reperfusion Strategies for Transferred STEMI Patients 1. Interhospital transfer for primary PCI 2. Pharmaco-invasive approach with lytics and early PCI 3. Lytic facilitated PCI 4. Prehospital triage for primary PCI

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10 Minnesota Duluth St. Cloud Minneapolis/ St. Paul Wisconsin Rochester Iowa Ting HH, et al. Circulation 2007;116:

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12 Regional STEMI Patients Treated with Primary PCI or Fibrinolytic Therapy 1.00 Cumulative probability min 110 min Regional Hospital Primary PCI Regional Hospital Fibrinolysis Door-to-balloon/door-to-needle time (minutes) Ting HH, et al. Circulation 2007;116:

13 Mortality and Door-to-Needle / Door-to-Balloon 20 In-hospital Mortality (%) P= < >180 Door-to-balloon / Door-to-needle time (minutes)

14 Door-in Door-out (DIDO) at 1 st Hospital and 1 st Door-to-balloon Time Median 1st Door-to-balloon (min) DIDO >30 min P < DIDO <=30 min Ting HH, et al. AHA November 2009

15 Pharmaco-Invasive Strategy Definition: Broad use of rescue PCI after failed fibrinolysis, as well as an early PCI within hours of successful fibrinolysis

16 30-day 1 1 Endpoint and Components Endpoint Standard N=498 (%) Pharmaco-Invasive N=512 (%) P value 1 end point Death Re-infarction Recurrent ischemia Death/MI/ischemia New/worsening CHF Cardiogenic shock Cantor WJ. N Engl J Med 2009;360:2705

17 30-day 1 1 Endpoint and Components Endpoint Standard N=498 (%) Pharmaco-Invasive N=512 (%) P value 1 end point Median time from lytics to PCI was 3.9 hours Death Re-infarction Recurrent ischemia Death/MI/ischemia New/worsening CHF Cardiogenic shock Cantor WJ. N Engl J Med 2009;360:2705

18 Pharmaco-Invasive Strategy: NORDISTEMI Bohmer E. JACC 2010; 55:

19 Pharmaco-Invasive Strategy: NORDISTEMI Median time from lytics to PCI was 2.7 hours Bohmer E. JACC 2010; 55:

20 ASSENT-4 Trial Primary vs. Full-dose TNK Fibrinolytic-Facilitated PCI 8 6 % P = In-hospital Death DSMB terminated study after 1667 / 4000 enrolled because of higher in-hospital mortality observed for facilitated PCI Primary PCI P < P = Total Stroke 1 Hemorrhagic Stroke Facilitated PCI Van de Verf, Lancet 2006;367:

21 ASSENT-4 Trial Primary vs. Full-dose TNK Fibrinolytic-Facilitated PCI 8 6 Median time from lytics to PCI was 1.9 hours P = DSMB terminated study after 1667 / 4000 enrolled because of higher in-hospital mortality observed for facilitated PCI Primary PCI Facilitated PCI % In-hospital Death P < P = Total Stroke Hemorrhagic Stroke Van de Verf, Lancet 2006;367:

22 Prehospital Triage Model

23 Proximal LAD

24 Prehospital Triage Model 1. Paramedics acquire and interpret PH ECG 2. If Definite STEMI,, then 1-call 1 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 hospital 4. Patient transported directly to cath lab 5. Explicit diversion criteria to deviate from #2-4

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26 Description Time Time Interval (minutes) Symptom Onset 05: 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

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28 North Carolina's Statewide STEMI System James G. Jollis, MD, FACC Duke University

29 RACE Reperfusion in AMI in Carolina Emergency Departments

30 How patients present Call 911 EMS (~50%) Walk-in (~50%) Hospital transfer - Walk in or EMS to 1 st hospital (~60% of PCI hospital)

31 How patients present EMS Walk-in Hosp. transfer Current Potential <60 <90 <120

32 21 primary PCI labs 500 EMS systems 5,240 paramedics 18,000 EMTs 121 emergency departments

33 Integrated, Integrated, Systematic Systematic AMI AMI Care Care

34 RACE Process 1) Develop leadership, funding, data structure 2) Establish REGIONAL PCI CENTERS (primary, lytic ineligible, rescue) 4) Improve system Measurement & Feedback 3b) EMS by EMS establishment of STEMI plan (review, consensus, training) 3a) HOSPITAL by hospital establishment of STEMI plan (review, consensus, training)

35 Establish a plan

36 RACE Interventions Regional coordinators

37 RACE Interventions Available at OPERATIONS MANUAL Optimal system specifications by point of care EMS ED Transfer Receiving hospital Cath. Lab Other system issues payers, regulations

38 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

39 RACE Interventions PCI Hospitals Single number cath lab activation Accept all STEMI patients regardless of bed availability Ongoing QI and data feedback NRMI database RACE Regional Coordinator Responsible for improving process in every hospital - EMS system in the region

40 EMS RACE Interventions 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

41 JAMA Nov. 2007

42 RACE results PCI hospitals: Door to device median times in minutes P<0.001* P<0.001 Pre 85 Post P= All patients Direct presenters Transfer for PCI hospitals

43 RACE results Non-PCI hospitals: Reperfusion times median times in minutes P<0.001* Door-in door-out, all hospitals P< Door-in door-out, transfer hosps P= Pre Post 29 Fibrinolysis, doorto-needle * Remained significant in analysis accounting for clustering

44 RACE Centers and Regions 65 hospitals (10 PCI, 55 non PCI) Winston-Salem Durham-Chapel Hill- Greensboro Asheville 10 PCI centers 16 Transfer for PCI 28 Lytics 11 Mixed Charlotte East Carolina Each non-pci center was assessed for reperfusion designation based on resources, transfer ability, and transfer time to PCI center