Mark C. Bieniarz, MD Andrew Harrell, MD Peter Berger, MD

Mark C. Bieniarz, MD Andrew Harrell, MD Peter Berger, MD

Should PCI center activate the cathlab off EMS field interpretation of ECG? Is this happening consistently in New Mexico? What is acceptable rate of activation without intervention? How far is too far? Lytic vs. PCI and distance/time Fly or drive-distance, base locations and weather. Monitoring inappropriate activations and data feedback loops between EMS and hospital HIPPA rules around data sharing

In rural state, transfer for STEMI care is necessary

ST-segment elevation myocardial infarction reperfusion pathways for non percutaneous coronary intervention (PCI) centers. Daniel Muñoz, and Christopher B. Granger Circulation. 2011;124:2477-2479 Copyright American Heart Association, Inc. All rights reserved.

The Way We ve Always Done It Previous STEMI transfer mish mosh PrehospitalECG not available and chest pain patient taken to local hospital ECG there documented STEMI and transfer arranged calling the cardiologist or ER at PCI center Prior to acceptance, the ER doc assessed the patient for appropriateness of PCI, checked for CCU bed availability, then requested helicopter transfer On arrival, patient taken to ER where assessed by ER doc, general cardiologist on call and then interventional cardiologist consulted If appropriate, interventional card called in cathlab who were to arrive in 30 minutes to begin case Standard care at beginning of the STEMI network protocol 2004

STEMI receives same priority as bleeding trauma Transfer plans in place with backup Patient stays on EMS stretcher for eval Transport directly to cath lab When possible exclude IV infusions of Heparin and nitroglycerin Transfer protocol goal should be speed NOT pain relief. Don t get distracted from goal. Hospital records faxed to receiving facility. Should not delay transfer. No facility bias. Transfer should ALWAYS be to closest PCI facility. Advanced life support units serving a specific hospital should always be willing to transfer to closest PCI facility

STEMI receives same priority as trauma and 911 call 10 minute pickup time. Hot load. Standard across systems (Duke, Mayo) Helicopter capable of transferring with 10 minutes notice Avoid IV nitro, heparin when possible Transfer directly to cath lab

Guidelines state aim for 90 minutes and transfer if possible for primary PCI in 120 minutes Pinto, DS, et al. Circulation. 2011; 124: 2512-2521

Multiple agencies involved Lack of cooperation between hospitals for the benefit of the community Failure to rapidly diagnose STEMI at referring hospital EMS not regarding STEMI with same priority as trauma

Early identifcationof STEMI based on symptoms and prompt ECG Eyeballs to beltbuckles campaign Door to ECG standard of 5 minutes Early initiation of transfer Prehospitalnotification or rerouting of EMS to PCI center

High-risk ST elevation MI patients (>4 mm elevation), Sx < 12 hrs 5 PCI centers (n=443) and 22 referring hospitals (n=1,129), transfer in < 3 hrs Lytic therapy Front-loaded tpa 100 mg (n=782) Primary PCI with transfer (n=567) Primary PCI without transfer (n=223) Death / MI / Stroke at 30 Days Stopped early by safety and efficacy committee N Engl J Med 2003; 349: 733-42

16% 13.7% Combined P<0.001 16% Transfer Sites 14.2% P=0.002 16% Non-Transfer Sites P=0.05 30 Day Death / MI / Stroke (%) 12% 8% 4% 0% 8.0% N=107 N=63 12% 8% 4% 0% Lytic Primary PCI 8.5% N=80 N=48 12% 8% 4% 0% Lytic Primary PCI 12.3% 6.7% N=27 N=15 Lytic Primary PCI N Engl J Med 2003; 349: 733-42

Death Recurrent MI Stroke P=0.35 P<0.001 P=0.15 10% 8% 8% 8% 7.8% 6.6% 6% 6.3% 6% 6% 4% 4% 4% 2% 2% 1.6% 2% 2.0% 1.1% 0% Lytic Primary PCI 0% Lytic Primary PCI 0% Lytic Primary PCI N Engl J Med 2003; 349: 733-42

225 200 185 Median Time (min) 175 150 125 100 75 50 90 110 25 0 DANAMI On-Site Primary PCI DANAMI Transfer Primary PCI US AMI Transfer Primary PCI Pinto D, et al. Cardiovascular Reviews and Report.2003;24:267-276.

Coordination across care systems http://www.mmclc.org/

STEMI Receiving Hospital STEMI Referring Hospital

Each hospital and EMS system should have contingency plan for STEMI care Transfer protocols STEMI medical protocols STEMI consortium development for shared protocols and data. Mission:lifelinefacilitating this.