Timothy A. Mixon MD FACC FSCAI
Interventional Cardiology, Scott & White Heart & Vascular Institute
Associate Professor of Medicine, Texas A&M College of Medicine
Course Director, STEMI Texas
Hospital C & D
Hospital A & B
20-30 miles away
Ground transport for PPCI
5 miles away
Ground transport for PCI
In Town EMS
5-20 miles away
Diversion to PCI Center
Out of Town EMS
20-60 miles away
Diversion ground transport to
PCI center or intercepted for
air transport
Hospital E
30-60 miles away
Reperfusion based on
clinical factors, air or
ground transport
Hospital F
> 60 miles away
Fibrinolytics, air transport
1. Penetration—how many systems?
involved?
“low hanging fruit”
fruit”
how
2. Outcomes
oPublicly reported data
oACTION-GWTG® data
“If you don’t
don t measure it,
you can’t
can t improve it.”
it.”
*Number of PCI hospitals
*PCI hospitals in ACTION-GWTG
*Non PCI hospitals (5 in ACTION)
*EMS agencies (48,000 personnel)
*First responder organizations
138
76
(55%)
445 (1%)
485
475
Information courtesy of Loni Denne, RN American Heart Association, April 2012
5
0
Variation in STEMI System Coverage
Variation in STEMI mortality
37%
42%
60 %
53%
32%
30%
60%
53%
36%
45%
Data from ACTIONGWTG™, Q4 2011
52 min
50 min
118 min
118 min
38 min
41 min
62 min
61 min
35 min
30 min
Data from ACTIONGWTG™, Q4 2011
Circ Cardiovasc Qual Outcomes, 2011
84 min
Median, FMC-2b, non
transfer
84 min
137 min
Median, FMC-2b, transfer
115 min
0
US
Data from ACTIONGWTG™, Q4 2011
20
40
Texas
60
80
100
120
140
160
Risk
adjusted
mortality
6.5%
6.6%
3 days
Length of
Stay
3 days
0
Data from ACTIONGWTG™, Q4 2011
US
Texas
5.9%
Unadjusted
mortality
2
4
6
8
Keys to Success within Regional
Cooperation
Strong, committed leadership
High stakeholder buy-in
Multiple hospital & EMS systems “at the table”
Common protocols/order sets
http://www.catrac.org/Mission_Lifeline/CATRAC_ML_Field_Guide_F
inal_newlogo7.26.2011.pdf
RAC wide data sheet (see example
)
Data sharing plans
ECG transmission
STEMI drills: especially among EMS and
non-PCI hospitals (where volume is lower)
Educational offerings
Areas Requiring Intense Focus
Transfer patients
• Accounts for 1/3 of STEMIs
• Treatment times significantly fall short of goal metrics
Potential Solutions:
1. Focus on DIDO at outlying facility (proven strategies to minimize)
2. Increase/encourage diversion destination protocols (i.e. avoid non3.
PCI hospital)
Think outside the box in terms of most rapid way to transfer
patients:
Ground over air ?
Mock transfer drills
EMS that brings to non-PCI hospital, also transport to PCI
Areas Requiring Intense Focus
Patient Factors
• 40% still present by private vehicle
• Median presentation time by POV is 118 minutes!
Potential Solutions:
1. Public education and awareness
2. ????
3. Think outside the box !!
Areas Requiring Intense Focus
ED of PCI Centers
• Median length of stay 38-41 minutes
Potential Solutions:
1. Greater penetration/usage of PH ECG
2. Increase effective communication of findings
3. Streamlined processes and therapies
Areas Requiring Intense Focus
Time to Reperfusion Therapy
•
•
1/3 patients present to non-PCI centers
Only 25% of US hospital have 24/7 PCI capabilities
•
•
(31% in TX)
Patient delay in presentation
Potential Solutions:
1.
2.
3.
Patient education
Effective and rapid networks of PCI and non-PCI hospitals
Desperately need adequately powered/well designed trial of
pharmaco-invasive strategy vs transfer for PCI !!!
The Good
*Regional cooperation is happening
*Metrics tracking with national trends
*Overall treatment times improving
The Bad
*Many pockets of “immature” systems
*Wide variation in outcomes
*Lack strong, central leadership/oversight
www.stemitexas2012.com