Welcome
Mission: Lifeline – Rural Minnesota
Taskforce Committee Meeting
Tuesday, April 22, 2014: 5:30 pm – 8:30 pm Itasca Room
Arrowwood Resort Alexandria, MN
Improving the System of Care for STEMI Patients
For those unable to attend in person:
Audio Portion:
Teleconference 877-985-5153
Passcode 7543907
Net Meeting Access:
Meeting number: SW474610
Meeting passcode:
SW474561
Participant Join:
URL:http://www.mymeetings.com/nc/join.php?i=SW474610&p=SW474561&t=c
Improving the System of Care for STEMI Patients
Agenda
Facilitator’s – Mindy Cook, Gary Myers, Katie Sahajpal, Rural MN M:L Co-Chairs
Dr. Scott Mikesell, Richard Mullvain RPH
Orientation Reminders
Consensus Based Decision Making
Meeting Goals:
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To gather in a spirit of collegiality and cooperation
To receive a report about Mission: Lifeline progress and the AHA’s role in convening decision makers and
providing resources to encourage STEMI System Development, Streamlining, and Standardization.
To receive an update from the EMS advisory committee
To review proposed Rural Minnesota Mission: Lifeline EMS STEMI Transport Guideline, and gain consensus
towards a taskforce recommendation
To receive an update from the hospital advisory committee
To review proposed MN STEMI Inter-facility Hospital Destination based Pathway, Adjunctive Tools, and gain
consensus towards a taskforce recommendation.
To receive an update from the Time Critical Care Committee and review plans sustainability of State level
STEMI systems of care
To receive an update on the MN M:L public awareness campaign and delivery plan
To define committee next steps and scope of work moving forward for the upcoming year
Improving the System of Care for STEMI Patients
Consensus Based Decision Making
•
A consensus based decision-making process is an effort in which affected parties
(taskforce members) seek to reach agreement on a course of action to address an
issue or set of related issues. In a consensus process, the stakeholders work together to
find a mutually acceptable solution.
•
Each consensus process is unique because the parties design their agreement to fit
their circumstances. However, successful consensus processes follow several guiding
principles
Elements of a Consensus-Based Decision
•
•
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All parties agree with the proposed decision and are willing to carry it out;
No one will block or obstruct the decision or its implementation; and
Everyone will support the decision and implement it.
Levels of Consensus
1.
2.
3.
4.
4
I can say an unqualified “yes!”
I can accept the decision.
I can live with the decision.
I do not fully agree with the decision, however, I will not block it and will support it.
Improving the System of Care for STEMI Patients
Consensus Based Decision Making
Consensus Decision-Making– Participants make decisions by agreement rather than
by majority vote.
Inclusiveness– To the extent possible, all necessary interests are represented or, at a
minimum, approve of the decision.
Accountability– Participants usually represent stakeholder groups or interests. They
are accountable both to their constituents and to the process.
Facilitation– An impartial facilitator accountable to all participants manages the
process, ensures the ground rules are followed, and helps to maintain a productive
climate for communication and problem solving.
Flexibility– Participants design a process and address the issues in a manner they
determine most suitable to the situation.
Shared Control/Ground Rules– Participants share with the facilitator responsibility for
setting and maintaining the ground rules for a process and for creating outcomes.
Commitment to Implementation – All stakeholders commit to carrying out their
agreement
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Improving the System of Care for STEMI Patients
Consensus Based Decision Making
Sample Ground Rules
1. It’s Your Show: We understand that this is our process. The facilitators are resources to take us
where we agree to go. We determine the agenda, ground rules, issues and process. We agree to attend
and fully participate in all meetings.
2. Everyone is Equal: We agree that all participants in the process are equal.
3. No Relevant Topic is Excluded: We agree that no relevant topics are excluded from
consideration unless we agree they are. This is our opportunity to bring up and thoroughly discuss
issues that concern us.
4. No Discussion is Ended: We agree that no discussion is ended, including process discussion,
ground rules and rule of decision. Agreements reached at prior meetings, unless implemented, are
always open for further consideration.
5. Respect Opinions: We agree to respect each other’s opinions. We will use gentle candor in
comments to each other and will not interrupt.
6. Respect the Time: We all understand the time constraints we face and agree to respect the time.
No one will dominate the discussions, and all participants will have an opportunity to express their
opinions.
6
Improving the System of Care for STEMI Patients
Consensus Based Decision Making
7. Silence Is Agreement: We agree that silence on decisions is agreement. The facilitators and other
participants cannot read our minds. If it appears that the group is reaching a consensus on an issue, if
no one voices disagreement, it is assumed that all are in agreement.
8. Keep the Facilitator Accurate: We agree to make certain that the facilitators capture what we
meant to say. We will keep the facilitators accurate.
9. Non-attribution: We agree that we will not attribute ideas or comments made by participants to
others outside of this process.
10. Rule of Decision: We agree that the rule of decision is Consensus, a described above. We agree
to strive for consensus. If agreement by all participants on an issue is not possible, we will seek to
develop a clear and balanced statement of the areas of disagreement. Neutrality by any participant
does not constitute a lack of consensus.
11. Media: We agree that all of our meetings are open to the media and to the public unless we close
all or a portion of them by consensus.
12. Substitutes/Proxies: We agree that we will not send substitutes or proxies. We may send
observers to meetings, but they will not have participant status.
13. Have Fun: We agree to do our best to enjoy the process and to help other participants do so as
well.
Improving the System of Care for STEMI Patients
7
Agenda
Welcome
Rural MN M:L Co-Chairs
M:L Rural MN Mission: Lifeline Implementation Update
EMS Implementation and Education update
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MN M:L EMS Transport Guideline
Gary Myers
Richard Mullvain
Mindy Cook
6:15
Contracts and Education
Hospital Advisory Committee Update
Dr. Scott Mikesell
Minnesota Statewide Inter-Hospital STEMI Transfer Pathway
M:L MN Reference Maps
Swim-Lane Process Flow chart
Richard Mullvain
Excel chart with each destination hospitals and protocols
Quality and System Improvement Update
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5:45
EMS Advisory committee update
Hospital Implementation and Education Update
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5:30
Katie Sahajpal
7:00
ACTION GWTG and Mission: Lifeline Reporting
Mission: Lifeline Recognition
EMS Recognition Tools
8
Agenda Cont.
TCCC and AHA Advocacy Update
Justin Bell
7:20
Public Awareness
Joan Enderle
7:35
Rural MN M:L Co-Chairs
8:00
Mindy Cook
8:20
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Delivery Plan and Materials available
STEMI Survivor Stories Submission
Website: www.heart.org/mn
STEMI Vision for the Future
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Annual Chair & Committee Structure Review
Closing Remarks and Future Meeting Dates
9
Mission: Lifeline History 2004 - Present
2012 AND BEYOND
2010 - 2011
2008 - 2009
MAY 2004 – JUNE 2007
AHA recruited Advisory
Working Group
Price Waterhouse
Coopers presents its
market research to AWG
AWG Consensus
Statement
appears in Circulation
Affiliate Staff Kick-Off
was held
Completion of a national
EMS Assessment for
STEMI Systems
represents 91% of US
population
Hospital recognition
program and reports are
released
AHA collaborates with
SCPC and hospital
accreditation program
released
Mission: Lifeline
Cardiac resuscitation
Program was
launched
Plans to add a
Mission: Lifeline PreHospital Recognition
Program
2014 – Add Mission:
Lifeline EMS
Recognition Program
Eleven manuscripts are
published in Circulation
Mission: Lifeline was
formally launched
AWG develops a set of
guiding principles
7/31/2014
©2013, American Heart Association
10
What is Mission: Lifeline?
Mission: Lifeline is the American Heart
Association’s national initiative to advance the
systems of care for patients with ST-segment
elevation myocardial infarction (STEMI) and Out of
Hospital Cardiac Arrest. The overarching goal of
the initiative is to reduce mortality and morbidity
for STEMI and OOHCA patients to and improve
their overall quality of care
7/31/2014
©2013, American Heart Association
11
Mission: Lifeline will:
• Promote ideal STEMI systems of care
• Help STEMI patients get the life-saving care they need in time
• Bring together healthcare resources into an efficient, synergistic system
• Improve overall quality of care
The initiative is unique in that it:
• Addresses the continuum of care for STEMI patients
• Preserves a role for the local STEMI-referring hospital
• Understands the issues specific to rural communities
• Promotes different solutions/protocols for rural vs. urban/suburban areas
• Recognizes there is no “one-size-fits-all” solution
• Knows the issues of implementing national recommendations on a community level
Improving the System of Care for STEMI
12 Patients
What is a Mission: Lifeline
STEMI System ?
At Least one
Receiving Center
At Least One
EMS Agency
At Least One
Referral Center
…working together to decrease time to
reperfusion and to reduce death and
disability by improving patient outcomes.
13
Rural MN M :L Funding
Rural MN 6.5 Million Grant 2013 – 2016
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The Leona M. and Harry B. Helmsley Charitable Trust
Medtronic Foundation/Philanthropy
Otto Bremer Foundation
Shakopee Mdewakanton Sioux Community
Karla and Tim O’Donnell
Fred C. and Katherine B. Andersen Foundation
Thom Family Foundation
Foundation
St. Luke’s Hospital and its Foundation
Dave Bernhard
Dakota Medical Foundation
John F. Rooney Family Charitable
Mayo Clinic Health System Mankato
Additional in-kind gifts from the American Heart Association and many additional partners will
total over $1 million
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Improving the System of Care for STEMI Patients
EMS Advisory Committee Update
Gary W. Myers, MS, NREMT
Sr. Mission: Lifeline Director
EMS Consultant for Midwest Affiliate
American Heart Association, Midwest Affiliate
P.O. 90545
Sioux Falls, SD 57109-0545
(605) 215-1551
[email protected]
15
Mission: Lifeline Minnesota EMS Equipment Grant
Awarded Agencies
Round 1, Northwest and West Central EMS Regions
Ambulance Service, Inc.
Ashby Fire Dept. Ambulance Service
Barnesville Ambulance
Browns Valley Ambulance Service
F-M Ambulance Service
Glacial Ridge Ambulance (Glenwood)
Hoffmann Volunteer Ambulance Service
Perham Area EMS
Prairie Ridge Hospital & Health Services Ambulance Service
Blackduck Ambulance Association Inc.
County Emergency Medical Services
Kittson County Volunteer Ambulance
Lake of the Woods Ambulance Service
Red Lake Comprehensive Health Services
Red Lake Falls Volunteer Ambulance
Roseau EMS
Sanford Bagley Ambulance
Thief River Falls Area Ambulance
Number or Services: 38
Warren Volunteer Ambulance Service
Number of Applications: 35
Number of Awards to date: 19
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Mission: Lifeline Minnesota EMS Equipment Grant
Awarded Agencies
Round 2, Northeast and EMS Central Regions
Tower Area Volunteer Ambulance Service
Deer River Ambulance Service
CentraCare Paynesville
Cook County Ambulance
Floodwood Ambulance Service
Cook Area Ambulance Service
Bigfork Ambulance Service Association
Chisholm Ambulance Association, DBA Longyear Inc.
Tri-County Hospital Emergency Medical Service
Eveleth Ambulance Service
Lakewood Health System
First Light Health System Ambulance
Orr Ambulance
Bertha Ambulance Service
Littlefork Ambulance Service
Nashwauk Ambulance Service
Gunflint Trail Volunteer Fire Department Ambulance
Lake County Ambulance Service
Number or Services: 50
International Falls Ambulance
Number of Applications: 33
City of Babbitt Ambulance Service
Number of Awards to date: 21
Biwabik Ambulance Service
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Mission: Lifeline Minnesota EMS Equipment Grant
Awarded Agencies
Round 3, Southwest EMS Region (As of 4/21/14. List not finally as
not all have confirmed)
Cottonwood Ambulance Service
Ortonville Ambulance Service
Lamberton Ambulance
Adrian Ambulance Service
Graceville Ambulance Service
Madison Ambulance Service
Morgan Ambulance Service
Pipestone County Ambulance
Westbrook Ambulance Service
Swift County Benson Hospital Ambulance
Hendricks Community Hospital Association
Hector Ambulance Service
Sanford Canby Ambulance
Rock County Ambulance
Atwater Fire Department Ambulance
Buffalo Lake Ambulance
Number or Services: 59
Number of Applications: 30
Number of Awards to date: 16
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Mission: Lifeline Minnesota EMS Equipment Grant
Awarded Agencies
Round 4, South Central and Southeast EMS Regions
Open: May 5th 2014
Close: May 30th, 2014 – 5:00pm
Excluded Counties:
Anoka County
Carver County
Chisago County Dakota County
Hennepin County
Isanti County
Ramsey County
Scott County
Sherburne County
Washington County
Wright County
Number or Services: 48
Number of Applications:
Number of Awards to date:
Dodge County
Olmsted County
Wabasha County
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Mission: Lifeline Minnesota EMS Education
Plan
Instructors to date:
Northwest: Narrowing down
West Central: Narrowing down
Northeast:
Sue Bengtson
Amy Saylor
Ken Klatt
Central:
Julie Jenson
Shawna Fuhrer
Southwest: Narrowing down
Southeast:
Brady Cather Dustin Meyer Tom Mork
Joan Hankins Meghan Lamp Todd Emanuel
South Central:
Josh More
Brad Zinniel
Shane Stevens
Carrie Lager
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21
2013 ACCF/AHA STEMI Guidelines:
Regional Systems of STEMI Care, Reperfusion Therapy, and Time-toTreatment Goals
I IIa IIb III
Reperfusion therapy should be administered to all eligible
patients with STEMI with symptom onset within the prior 12
hours.
I IIa IIb III
I IIa IIb III
Primary PCI is the recommended method of reperfusion when it
can be performed in a timely fashion by experienced operators.
EMS transport directly to a PCI-capable hospital for primary PCI is
the recommended triage strategy for patients with STEMI with an
ideal FMC-to-device time system goal of 90 minutes or less.*
*The proposed time windows are system goals. For any individual patient, every effort should be
made to provide reperfusion therapy as rapidly as possible.
Improving the System of Care for STEMI Patients
http://www.heart.org/idc/groups/heart-public/@wcm/@global/documents/downloadable/ucm_311142.pdf
Improving the System of Care for STEMI Patients
http://www.heart.org/idc/groups/heart-public/@wcm/@global/documents/downloadable/ucm_311142.pdf
Improving the System of Care for STEMI Patients
MN M:L EMS Transport Guideline
Rural Minnesota Mission: Lifeline EMS STEMI Transport Guideline
Obtain 12 L ECG with Initial Vital Signs
Goal: First Medical contact to ECG < 10 min, Scene time: < 15 minutes *to provide early identification and pre-hospital
arrival notification for suspected myocardial infarction or STEMI.
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Chest pain, pressure, tightness or persistent discomfort above the waist in pts. > 35 yrs. of age
"Heartburn" or epigastric pain
Complaints of “heart racing” (HR >150 or irregular and >120) or “heart too slow” (HR < 50 and symptomatic)
A syncopal episode, severe weakness, or unexplained fatigue
New onset stroke symptoms (< 24 hours old)
Difficulty breathing or shortness of breath (with no obvious non-cardiac cause)
ROSC (return of spontaneous circulation) post cardiac arrest
Recent Cocaine, stimulant and/or other Illicit drug use (pts. of any age)
PH (Pre- Hospital) STEMI ALERT Activation Criteria:
**Goal: Identify STEMI, Alert receiving facility- do not delay transport. Activate STEMI Alert when any one of the
following criteria met & signs & symptoms suspect of (AMI) acute myocardial infarction including chest discomfort as
described below are demonstrated with a duration of >15 minutes <24 hours
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12 L ECG trained ALS EMS recognize ST segment elevation of ≥ 1 mm in 2 contiguous leads
Confirmed Interpretation of STEMI transmitted and reviewed by a Practitioner (Physician, NP, PA)
ECG Monitor interpretative statement infers: “Acute Myocardial Infarction” with signs & symptoms suspect of
acute myocardial infarction including chest discomfort and symptoms listed above
**Reminder: For persistent symptoms obtain serial 12 L ECG’s every 10 minutes during transport
Determine Transport Destination
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Transport time < 60 minutes and total
time from first medical contact (EMS at
patient’s side) to PCI (Percutaneous
Coronary Intervention) FMC to PCI < 120
minutes. Notify medical control and
consider transport directly to PCI Capable
Receiving Hospital for Primary PCI.
Activate STEMI Alert, transmit 12 L ECG
as able, provide report to receiving hospital
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Transport time > 60 minutes and estimated time
from first medical contact (EMS at patient’s side)
FMC to PCI >120 minutes. Notify medical control
and consider transport to the closest appropriate
non-PCI capable referring hospital for possible
fibrinolytic therapy and urgent transfer to a PCI
Capable Receiving Facility for reperfusion.
Initiate fibrinolytic checklist per protocol
Activate STEMI Alert, transmit 12 L ECG as able,
provide report to receiving hospital
Consider Air Transport.
Richard Mullvain
RPH BCPS (AQC) CCCC
MN Mission: Lifeline Co-Chair
Cardiovascular Clinical
Pharmacist; STEMI Program
Manager; Chest Pain Center
Coordinator, Essentia Health
Heart & Vascular Center
Duluth, MN
Diversion Criteria: If patient demonstrates instability and/or has any one of the following Diversion Criteria requiring
ED evaluation by a practitioner proceed to closest appropriate hospital:
 Possible need of head CT or neurological intervention / Confusion
 Emergent intubation Immediate circulatory stabilization
 Chest trauma or MVC victims
 Consider DNR Status
 Consider Left Bundle Branch Block
Confidential Statement Here
(revised 3/2014)
Revised 4-2014
Improving the System of Care for STEMI Patients
25
MN M:L EMS Transport Guideline
Rural Minnesota Mission: Lifeline EMS STEMI Transport Guideline
BLS & ALSPPCI after confirmation by PCI Receiving Facility
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ALS
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Administer O2 starting at 2 L/Min per nasal cannula, titrate as needed to maintain SpO2 > 92%
Obtain Systolic/Diastolic blood pressure (BP) in both arms
Administer Chewable Aspirin 324 mg by mouth or rectally
Administer Nitroglycerin Sublingual 0.4 mg every 5 minutes up to 3 doses if chest discomfort present and
SBP > 100. Check BP prior to each administering dose. Hold if SBP < 100 mm HG.
 Evaluate if Erectile Dysfunction or Pulmonary hypertension medications taken:
 Hold nitrates for 24 hours following last dose of Sildenafil (Viagra, Revatio), Vardenafil (Levitra, Staxyn),
or Avanafil (Stendra). Hold nitrates for 48 hours following last dose of Tadalafil (Cialis, Adcirca)
BLS only: Request ALS Intercept per local protocol
Establish large bore IV (L) upper extremity preferred) access per protocol – Normal Saline 500ml KVO
Establish a 2nd IV line as time allows.
Clopidogrel (Plavix) 600 mg by mouth if transferring for PPCI after confirmation by PCI Receiving Facility
Heparin IV Bolus 70 Units/kg IV, max 5,000 Units if transferring for PPCI after confirmation by PCI Receiving
Facility
Establish a Nitroglycerine IV Drip if chest discomfort is unrelieved. Initiate @ 5 mcg/min & titrate in increments
of 5mcg/min to maintain a systolic BP of 100 mm/Hg or greater.
Administer Analgesia as needed for discomfort per protocol
Documentation Reminders:
 Provide Copy of EMS Run Sheet with Report to RN or MD
 If STEMI/AMI alert is requested of the receiving hospital, document the time.
 Provide a Printed Copy of Pre-Hospital 12 L ECG with Report to RN or MD
Patient Care Goals:
 Provide early identification of patients and early notification of the hospital for suspected AMI or STEMI.
 Utilize an assessment tool that may reduce the time from onset of symptoms to receiving definitive cardiac
interventions at the receiving hospital.
 Prepare patient for immediate transport with indicated medications administered en route to hospital. Attempt
to limit the scene time to the shortest time possible.

AHA Mission: Lifeline EMS Best Practice Goals
1. All patients with non-traumatic chest pain, ≥ 35 yrs. of age, treated and transported by EMS who receive a prehospital 12-lead electrocardiogram
2. All STEMI patients transported directly to a STEMI receiving center, with first (pre-hospital) medical contact to
PCI time < 90 minutes directly or <120 minutes for transfers
3. All lytic eligible STEMI patients treated and transported to a referring hospital for fibrinolytic therapy with a door
to needle time < 30 minutes
AHA Mission: Lifeline EMS Reporting Measures:
1. Time from symptom onset to EMS dispatch
2. Time from EMS dispatch to vehicle arrival at hospital door
3. All STEMI patients treated and transported to a referring hospital for fibrinolytics therapy should have a
Fibrinolytic Checklist completed to identify contraindications to lytic therapy.
4. All suspected AMI/STEMI patients treated and transported by EMS should receive a 12-lead ECG
5. All STEMI patients with a pre-hospital identified STEMI call for field activation of a STEMI Alert at receiving
Confidential hospital
Statement Here
Revised 4-2014
Improving the System of Care for STEMI Patients
26
M:L Rural MN Hospital Implementation
Update
•
PCI Receiving Hospitals
•
•
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ACTION GWTG Participation
12 L Software Receiving Capabilities
PCI Referring Hospitals
•
•
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Hospital FAQ
Funding Availability – Referring hospital Available now
Contract Review
Mindy Cook, RN BSN
Director Mission: Lifeline North Dakota, Minnesota
American Heart Association, Midwest Affiliate
4701 W. 77th St.
Minneapolis, MN 55435
Mobile: 218-770-3305
[email protected]
Improving the System of Care for STEMI Patients
27
Referring Hospital Funding
MEMORANDUM OF UNDERSTANDING
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•
•
•
MOU
Mission: Lifeline Minnesota System Participant (Select One below for each EMS or Hospital):
W9

M:L MN Grant Contract
EMS Organization Name: _______________________________________________________
20 Referring Hospitals
Participating
•
Acknowledged and agreed to this ___ day of _________, _____.
100 eligible
EMS Agency
EMS Agency Representative Signature: ___________________________________________
Title: ____________________________Printed Name: _______________________________
Physician Medical Director Signature: ____________________________________________
Credentials: _____________________ Printed Name: ________________________________

Non-PCI (Percutaneous Coronary Intervention-) Capable Hospital
Organization Name: ___________________________________________________________________
Administrative Representative Signature: ________________________________________________
Title: _______________________________________________________________________________
Printed Name: _______________________________________________________________________
Physician Champion Signature: __________________________________________________
Credentials: ______________________ Printed Name: _______________________________
AMERICAN HEART ASSOCIATION
Signature: ________________________Printed Name: _______________________________
Title: ________________________________________________________________________
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Rural MN M:L Hospital Funding
COMPANY will be paid $xxxxx.xx (based on actual invoices submitted) within 14 business days of
receipt of the signed grant agreement. These funds are to be utilized as follows:
∙
Up to $12,000.00 for the purchase of 5 year license of software program that will allow for
the wireless reception of 12 lead ECGs from ambulances to the hospital;
or
∙
If the COMPANY secures free 12-lead receiving monitoring service or chooses not to
receive 12- lead ECG’s for the life of the Agreement – up to $12,000 to be used for the purchase of a
12-lead ECG monitor with wireless transmission capabilities.
COMPANY agrees to purchase, install and begin utilizing the equipment or software within 6 (six)
months of receiving this payment and will continue throughout the period covered by this
agreement.
COMPANY agrees that it will develop a secondary STEMI field activation plan that allows for
EMS (both EMT and paramedic based) unable to transmit to activate STEMI’s from the field
based on computer algorithm analysis or paramedic interpretation.
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Referring Hospital Education
Curriculum and Training Plan
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Review ND and SD Curriculum and Training Plan
MN Training Hospital Education Plan
Referring Hospital Survey Results
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In person education for 100 referring hospitals
Learn Rapid STEMI ID Course (# 500)
STEMI Provider Manuals 10 per hospital
Adjunctive Training materials – Orderable
•
12 L placement guides
•
Protocol pathways
•
Training Curriculums
30
31
ND Referring Hospital Ed Summary
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Diagnostic Criteria for STEMI, 12 L ECG Interpretation
Role of Pre-Hospital Providers in ideal STEMI Systems of care
State Demographics and MI Statistics
M:L Grant Scope of Project and Role in System Development and Support
Current Literature Review including ACC/AHA Guidelines
ACTION Registry Data Collection, system achievement measures for EMS,
Referring, and Receiving Hospitals
Pt. Signs and Symptoms and ECG Acquisition
Pt. Triage and Transfer: Local Implementation of Referring Hospital STEMI
Protocol and EMS STEMI Transport Guidelines
Process Improvement and how to stay engaged in your regional network
32
33
34
35
MN Referring Hospital Survey (N=43)
Do you utilize a STEMI inter-facility transfer protocol? If so, please identify the
number of regional protocols you may possibly use within your facility.
Yes - 1 Protocol
69.77%
30
Yes - 2 Protocols
23.26%
10
Yes - 3 or more Protocols
4.65%
2
No Protocol
6.98%
3
Comments:
DASH(Duluth Area STEMI Hospitals)
Utilize Abbott North Western, St. Mary's, Fairview STEMI Protocol
I would prefer that we only have one so as to not cause a decision point at the beginning of care
which hospital will be the destination.
36
What is your Primary STEMI patient triage and treatment strategy?
Transfer for Primary PCI utilizing
established protocol
60.47%
26
Lytic Administration and urgent transfer
for PCI utilizing established protocol
23.26%
10
Mixed Reperfusion strategy depending on
25.58%
estimated time to treatment utilizing
11
established protocols
Referral Reperfusion strategy varies
depending on PCI receiving facility
discretion
13.95%
6
No established plan or protocol in placed 0%
for STEMI patient triage
0
Non-Transfer and Non-PCI hospital
0
37
Identify your principle mode of transfer for STEMI patients.
Air Transport by Helicopter
47.62%
20
ALS Ground transport
26.19%
11
Mixed Strategy depending on conditions
45.24%
19
0%
0
30% transport by ground; 2 local services have pre-hospital 12 lead capability.
85-90% Helicopter
we use whatever is available
Primarily Air unless weather does not permit
15% ground 50% Prehospital 12 lead capable
No EMS capable pre-hospital ECG at this time. Depending on capability of Sanford Bemidji, we
try to transfer there by ground, otherwise mostly by air- so 30-40% ground the rest air
40% by ground but no EMS capable of pre-hospital 12 L ECG at this time.
We have used all of the options above depending on availability and weather.
38
Air Transport by Fixed Wing
What is your estimated transfer time to the closest PCI receiving facility or the
PCI receiving facility you have an established transport plan with?
< 30 minutes by Air
34.88%
15
< 30 minutes by Ground
6.98%
3
30-60 minutes by Air
41.86%
18
30-60 minutes by Ground
30.23%
13
60-90minutes by Air
4.65%
2
60-90 minutes by Ground
25.58%
11
>90 minutes by Ground or Air
2.33%
1
39
Please indicate which of the topics below providers within your facility would
find most valuable as the focus of the first wave of Rural MN Mission: Lifeline
STEMI Education:
STEMI Mock Scenarios
50%
21
Fibrinolytic Administration
42.86%
18
Regional STEMI Case Reviews
64.29%
27
12 L ECG Interpretation
35.71%
15
STEMI Patient Triage & Protocol
Utilization
54.76%
23
ACC/AHA STEMI Guidelines
38.10%
16
40
What delivery method of education that works best for physicians within your facility?
In-Person Facilitated Training with AHA
M:L Educators at your facility
69.77%
30
Facilitated Webinar Series
30.23%
13
Regionalized Mini-Conferences
23.26%
10
Responses
Other (please specify)
9.30%
4
Comments:
• materials for review.
• Lunch and learns over the noon hour at the clinic setting
• Our physicians rarely ever attend education that is planned specifically for them onsite. Again, I can't speak for physicians.
• Send guidelines and protocols by email. Our ED physicians only meet quarterly as a
group.
41
What delivery method of education that works best for Nurses, Ancillary Staff and EMS
within your facility?
In-Person Facilitated Training with AHA
M:L Educators at your facility
86.05%
37
Facilitated Webinar Series
48.84%
21
Regionalized Mini-Conferences
23.26%
10
Comments:
In person training is the best, hands on training if at all possible although difficult to get all staff to attend
due to limited staffing available.
Sanford Bagley Medical Center and EMS
We are open to whatever is available - we have 12 hour shifts with 6 week block schedules -so we try to
plan events that all can get to either in person or webinars
Case studies to read followed by a quiz, with CEU's offered.
Red Lake Hospital
42
Do you receive regular feedback regarding STEMI patients from your regional PCI
receiving facility?
•
•
•
•
•
•
•
•
•
Yes
92.86% (39)
No
7.14% (3)
door to reperfusion times; total time spent in regional ED
All of it.
For data collection, getting a periodic report is helpful as to seeing our treatment and intervention times.
It would be helpful to receive more immediate feedback on immediate cases as to what we did well or
what we can learn from the case, as well as learning outcome.
Door to vessel open time.
The times at each level
EKG to transfer time.
Sometimes- and it is great to see areas where we can improve our care here and better "package" our
patient
Each portion of the STEMI is tracked by minutes with a goal time, (Ex. EKG time 5 min, call to transport,
Meds given, our package time In Rural Hospital to Out Rural Hosp within 30 minutes is helpful to assure
out times are good, and where we need to work on. And then total in Rural Hosp to Open vessel time
within 90minutes.
Timeframes
43
Please describe a specific barriers or challenges that you have identified within
your local STEMI system of care.
Pre-Hospital Identification and
Recognition of STEMI
38.46%
15
EMS Transport
33.33%
13
Hospital or EMS Communication
17.95%
7
Feedback and Process Improvement
12.82%
5
Inter-facility Provider to Provider
Communication
17.95%
7
Responses
Other Barriers or Suggested Solutions
33.33%
13
44
Responses:
•
•
•
Distance of helicopters and dispatch sending the closest most appropriate one.
•
•
Our providers (ED physicians) don't always recognize STEMI's via EKGs.
•
•
Contracted providers in the ED
•
All our local ambulances are basic, if air ambulance not flying ground must be dispatched and
could be a 2 hour transfer (one hour here and back to transfer hospital)
•
Location/availability of air ambulance
Feedback is often done several weeks after the fact.
In our rural area- we have BLS services that provide ambulance services which is a barrier to
getting anything reported or started on some of our patients
We have EMT-basic here- no paramedic and no pre-hospital ECG which delays care especially if we
plan to fly the patient.
Geographically LaCrosse is closer to our facility and we are part of the SW Wisconsin region.
However, we are hesitant to send patients to Skemp because all of the Cardiology out reach
providers are from Rochester.
45
Would your STEMI System be interested in forming a regional task force to meet
quarterly to support system improvement.
Yes
70.73% (29)
No
29.27% (12)
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
Northeast MN
Meetings are difficult. Webinars and teleconferences would be best.
South central/south west
Northwest MN
Fargo regionI'm not in favor of this.
West Central Minnesota
Northeast Minnesota. Itasca county
Could
Northeast region, we already have one with Essentia & St Lukes
Pipestone County Medical Center, Southwest MN
South west Wisconsin.
SE MN
Southwest
We belong to the West region of Essentia Health Fargo.
46
Hospital Advisory Committee Update
Historical MN STEMI Statewide collaboration
ACC/AHA 2013 Guidelines
Committee Member and Meeting Minute Review
Minnesota Statewide Inter-Hospital STEMI Transfer Pathway
M:L MN Reference Maps
Scott Mikesell DO, FACC, FSCAI
Minnesota Mission: Lifeline
Co-Chair
Cardiac Catheterization
Laboratory Director
St. Luke's Hospital, Duluth, MN
Improving the System of Care for STEMI Patients
47
History:
Minnesota STEMI Steering Committee – 2009-2010
Wendy Shear: North Memorial Hospital
Nancy Hassinger: St Mary’s Hospital, Duluth
Ken Baran: United Hospital
Stephen Batista: Southdale Hospital
Richard Aplin: St Cloud Hospital
MN Protocol Committee 2009-2010
Jeff Chambers: Mercy Hospital
Tim Henry: Abbott Northwestern Hospital
Carmelo Panetta: Methodist Hospital
Vish Nadig: St. Joseph’s Hospital
Stefan Bertog: VA
Robert Wilson: University of Minnesota
Michael Thurmes: Regions Hospital
Arashk Motiei: ISJ, Mankato
Jeff Chambers
Richard Aplin
Stephen Batista
Richard Mullvain
Ganesh Raveendran
Henry Ting: Mayo Clinic
Tim Henry
Fouad Bachour: HCMC
Henry Ting
Lee Giorgi: St Like’s Hospital, Duluth
Improving the System of Care for STEMI Patients
History: 12 of 16 MN STEMI Systems Registered
Back in 2010
•Code 31 system
Saint Louis
Park
•Fairview Health Services
Edina
•Fast Track for STEMI
Rochester
•Hennepin County Medical Center
Minneapolis
•North Memorial Heart & Vascular Institute
Robbinsdale
•Regions Hospital Level 1 Cardiac Program
Saint Paul
•St. Luke’s Regional Heart Center
Duluth
•United Hospital Level One Cardiac Program
Saint Paul
•University of Minnesota Medical Center
Fairview STEMI Program
Minneapolis
•Minneapolis Heart Institute at Abbott
Northwestern Hospital
Minneapolis
•Central Minnesota Heart Center STEMISC
Saint Cloud
•SMDC STEP (ST-Elevation Myocardial
Infarction Program)
Duluth
Improving the System of Care for STEMI Patients
History: Minnesota Proposed Models
2009-2010
Less than 90 minutes door to balloon time : PCI
A
B
C
Full Dose Lytics &
Transfer
½ Dose Lytics and
Transfer
Transfer all
Cath Next day
Cath ASAP
Cath ASAP
Heparin
Heparin
Heparin
Bivalirudin
Bivalirudin
Bivalirudin
No GP IIb IIIa receptor
antagonist
No GP IIb IIIa receptor
antagonist
GP IIb IIIa receptor
antagonist
Prasugrel
Prasugrel
Prasugrel
Clopidogrel
Clopidogrel
Clopidogrel
Improving the System of Care for STEMI Patients
2013 ACCF/AHA STEMI Guidelines:
I IIa IIb III
All communities should create and maintain a
regional system of STEMI care that includes
assessment and continuous quality improvement
of EMS and hospital-based activities.
Performance can be facilitated by participating in
programs such as Mission: Lifeline and the D2B
Alliance.
2013 ACCF/AHA Guideline for the Management of ST-Elevation Myocardial Infarction http://circ.ahajournals.org/lookup/doi/10.1161/CIR.0b013e3182742cf6
Improving the System of Care for STEMI Patients
2013 ACCF/AHA STEMI Guidelines:
Regional Systems of STEMI Care, Reperfusion Therapy, and Time-to-Treatment Goals
I IIa IIb III
I IIa IIb III
Immediate transfer to a PCI-capable hospital for primary PCI is
the recommended triage strategy for patients with STEMI who
initially arrive at or are transported to a non–PCI-capable
hospital, with an FMC-to-device time system goal of 120 minutes
or less.*
In the absence of contraindications, fibrinolytic therapy should be
administered to patients with STEMI at non–PCI-capable hospitals
when the anticipated FMC-to-device time at a PCI-capable
hospital exceeds 120 minutes because of unavoidable delays.
*The proposed time windows are system goals. For any individual patient, every effort should be
made to provide reperfusion therapy as rapidly as possible.
Improving the System of Care for STEMI Patients
2013 ACCF/AHA STEMI Guidelines:
Regional Systems of STEMI Care, Reperfusion Therapy, and Time-to-Treatment Goals
I IIa IIb III
When fibrinolytic therapy is indicated or chosen as the primary
reperfusion strategy, it should be administered within 30 minutes
of hospital arrival.*
I IIa IIb III
Reperfusion therapy is reasonable for patients with STEMI and
symptom onset within the prior 12 to 24 hours who have clinical
and/or ECG evidence of ongoing ischemia. Primary PCI is the
preferred strategy in this population.
*The proposed time windows are system goals. For any individual patient, every effort should be
made to provide reperfusion therapy as rapidly as possible.
Improving the System of Care for STEMI Patients
Antiplatelet Therapy to Support Primary PCI for STEMI
I IIa IIb III
Aspirin 162 to 325 mg should be given before primary PCI.
I IIa IIb III
After PCI, aspirin should be continued indefinitely.
Improving the System of Care for STEMI Patients
Antiplatelet Therapy to Support Primary PCI for STEMI
I IIa IIb III
A loading dose of a P2Y12 receptor inhibitor should be given as
early as possible or at time of primary PCI to patients with
STEMI. Options include:
• Clopidogrel 600 mg; or
• Prasugrel 60 mg; or
• Ticagrelor 180 mg
Improving the System of Care for STEMI Patients
Fibrinolytic Therapy When There Is an Anticipated Delay to
Performing Primary PCI Within 120 Minutes of FMC
I IIa IIb III
I IIa IIb III
I IIa IIb III
Harm
In the absence of contraindications, fibrinolytic therapy should
be given to patients with STEMI and onset of ischemic
symptoms within the previous 12 hours when it is anticipated
that primary PCI cannot be performed within 120 minutes of
FMC.
In the absence of contraindications and when PCI is not
available, fibrinolytic therapy is reasonable for patients with
STEMI if there is clinical and/or ECG evidence of ongoing
ischemia within 12 to 24 hours of symptom onset and a large
area of myocardium at risk or hemodynamic instability.
Fibrinolytic therapy should not be administered to patients with
ST depression except when a true posterior (inferobasal) MI is
suspected or when associated with ST elevation in lead aVR.
Improving the System of Care for STEMI Patients
Adjunctive Antiplatelet Therapy With Fibrinolysis
I IIa IIb III
Aspirin (162- to 325-mg loading dose) and clopidogrel (300-mg
loading dose for patients ≤75 years of age, 75-mg dose for
patients >75 years of age) should be administered to patients
with STEMI who receive fibrinolytic therapy.
Improving the System of Care for STEMI Patients
Minnesota Protocols & Pathways for Inter-Hospital Transfer Goals
Minnesota has well established STEMI systems of care
• Served by over 20 PPCI hospitals, including ND, SD, and WI
Each STEMI receiving hospital / Primary PCI center will follow the same
Minnesota Statewide Inter-Hospital STEMI Transfer Pathway
Each STEMI receiving hospital will keep and maintain their own STEMI InterHospital Transfer (Destination) Protocol
Improving the System of Care for STEMI Patients
Hospital Advisory Committee 2013-2014
MN Hospital Protocol Advisory Meeting Agenda
October 30 2013 12:00 pm – 1:00 pm
To join Audio:
Teleconference 877-985-5153 Passcode 7543907
To join Net Meeting slide show:
Meeting number: SW474610
Meeting passcode: SW474561
MN Hospital Protocol Advisory Meeting Minutes
Participant Join URL: http://www.mymeetings.com/nc/join.php?i=SW474610&p=SW474561&t=c
Date: Tuesday, January 21, 2014
Composition: at least 1 nursing and 1 physician representative from each included PCI Hospital,10:00am
at least - 2:00pm
1represenative from each regional non-PCI Hospital are, and at least 2 EMS representatives (Lunch provided)
(40 member maximum)
Location: CentraCare Heart & Vascular
Center Conference Room Main Campus
Time commitment: Quarterly conference calls with bi annual face to face meetings
1406 Sixth Ave N
St. Cloud, MN 56303
rd
Meeting Schedule: Quarterly Teleconference or Net Meeting as needed the 3 Wednesday quarterly from
Mission:
12:00 pm to 1:00 pm beginning October 16 2013, JanTo
15-2014,
April 16 2014, July 16 2014, October 15
join Audio:
Teleconference 877-985-5153 Passcode 7543907
2014…
Date: Thursday, February 20, 2014
12:00 pm - 1:00pm
If inclement
Facilitated by: Mindy Cook, Katie Watkins, and MN M:
L Chair (s)weather:
10-30-2013
1-21-2014
2-20-14
To join Net Meeting slide show:
Task Assignment:
To join Audio:
Meeting number: SW474610
 Create a Rural MN Hospital Education Plan and Curriculum
Meeting passcode: SW474561
Teleconference 877-985-5153 Passcode 7543907
 Identification and cultivation of hospital education providers
Participant
Join
URL:
http://www.mymeetings.com/nc/join.php?i=SW474610&p=SW474561&t=c
 Guidance of Regional STEMI System quality improvement and performance
To join Net Meeting slide show:
measurement
Composition: at least 1 nursing and 1 physician representativehttp://www.mymeetings.com/nc/join.php?i=SW474610&p=SW474561&t=c
from each included PCI Hospital, at least
 Facilitation of Regional and Local STEMI System Champion support and engagement
1represenative from each regional non-PCI Hospital are, and at least 2 EMS representatives
 Create recommendations for Rural MN STEMI Protocols and Transport Guidelines
Mission: Lifeline Rural MN Hospital Advisory Meeting Summary
(40 member maximum)
Facilitated by: Mindy Cook, Katie Watkins, and MN M: L Chair (s) Richard Mullvain RPH, Dr. Scott
Mikesell, Dr. Ganesh Raveedran
Time
commitment:
Quarterly
conference
calls
with
bi
annual
face
to
face
meetings
1. MN M:L STEMI System Development
Date: Thursday, March 20, 2014
Task Assignment:
Meeting Schedule: Quarterly Teleconference or Net Meeting as needed the 3rd Wednesday quarterly from
10:00 am - 2:00pm
Meeting Goals:
 Create a Rural MN Hospital Education Plan and Curriculum
12:00 pm to 1:00 pm beginning October 16 2013, Jan 15-2014, April 16 2014, July 16 2014, October 15
 Identification and cultivation of hospital education providers
2014…
 To gather in a spirit of collegiality and cooperation
To join Audio:
 Guidance of Regional STEMI System quality improvement and performance
 To receive a report about Mission: Lifeline and the AHA’s role in convening decision makers and
Teleconference 877-985-5153 Passcode 7543907
Facilitated
by: Mindy
Cook, Katieand
Sahajpal, and MN M: L Chair (s):
measurement
providing resources to encourage STEMI System
Development,
Streamlining,
Ganesh Raveendran, M.D., M.S.Director, Section of Interventional Cardiology
and Cardiovascular
To join Net Meeting slide show:
of Regional and Local STEMI System Champion support and
 Facilitation
Standardization.
 To assess and share regional MN STEMI Referring Hospital
and Program
EMS Protocols
in place Division | University of Minnesota
Fellowship
Cardiovascular
Medical School,
engagement
http://www.mymeetings.com/nc/join.php?i=SW474610&p=SW474561&t=c
 To assess and share processes in place for STEMI
Hospital,
Referring
Scott feedback
Mikesell, for
DO,PCI
FACC,
FSCAI
CardiacHospital,
Catheterization Laboratory Director
St. Luke’s
Hospital,
for Rural MN STEMI Protocols and Transport
recommendations
 Create
and EMS
Duluth, MNMN
Guidelines
Facilitated
by: Mindy Cook, Katie Sahajpal, and MN M: L Chairs Richard Mullvain RPH, Dr. Scott
 To build consensus towards a committee recommendation for 12 L ECG acquisition thresholds
Richard Mullvain RPH BCPS (AQC) CCCC Cardiovascular Clinical Pharmacist STEMI Program
Mikesell, Dr. Ganesh Raveedran
and STEMI diagnostic criteria to present to the MN M:L taskforce
Manager Chest Pain Center Coordinator Essentia Health Heart & Vascular Center Duluth, MN
1. MN M:L STEMI System Development
Task Assignment:
Task Assignment:
Meeting Goals:
 Create a Rural MN Hospital Education Plan and Curriculum
 Create a Rural MN Hospital Education Plan and Curriculum
 Identification and cultivation of hospital education providers
 Identification and cultivation of hospital education
providers
 To gather in a spirit of collegiality and cooperation
 Guidance
Regional
 Guidance of Regional STEMI System quality improvement
and performance
and STEMI System quality improvement and performance
makers
decision of
a report about Mission: Lifeline and the AHA’s role in convening
 To receive
and
Streamlining,
Development,
System
STEMI
encourage
to
resources
providing
measurement
measurement
Standardization.
 Facilitation of Regional and Local STEMI System Champion
support and engagement
 Facilitation of Regional and Local STEMI System Champion support and engagement
 To assess and share regional MN STEMI Referring Hospital and EMS Protocols in place
 Create recommendations for Rural MN STEMI Protocols and Transport Guidelines
 Create
recommendations
for Rural MN STEMI Protocols and Transport Guidelines
Hospital,
Referring
 To assess and share processes in place for STEMI feedback for PCI Hospital,
and EMS
1. L MN
STEMI
System Development
thresholds
acquisition
ECGM:L
 To gain consensus towards a committee recommendation for 12
and STEMI diagnostic criteria to present to the MN M:L taskforce
Protocol
EMS STEMI
 To gain consensus towards a Rural MN M:L Referring Hospital and
Meeting
Goals:
recommendation utilizing the existing regional protocols in place throughout rural MN to present
to the MN M:L taskforce
 To gather in a spirit of collegiality and cooperation
 To gain consensus towards a recommendation for ALS and BLS EMS Transport Guideline for
 To receive a report about Mission: Lifeline and the AHA’s role in convening decision makers and
the Rural MN EMS Advisory committee.

3-20-14
Lifeline Rural MN Hospital Advisory Meeting Agenda
resources
to encourage STEMI System Development, Streamlining, and
hospital
MN Referring
To gain consensus towards a curriculum and training plan for Ruralproviding
Standardization.
education
 To receive an update on a sustainability plan for State level MN STEMI systems of care
 To review regional MN STEMI Referring Hospital and EMS Protocols in place To gain





consensus towards a committee recommendation for 12 L ECG acquisition thresholds and
STEMI diagnostic criteria to present to the MN M:L taskforce in April 2014 for confirmation
To gain consensus towards a Rural MN M:L Referring Hospital and EMS STEMI Pathway and
Destination based protocol recommendation that builds upon existing regional protocols
throughout rural MN to present to the MN M:L taskforce for confirmation April 2014
To gain consensus towards a recommendation for a Rural MN EMS Transport Guideline for the
Rural MN EMS Advisory committee review and MN M:L Taskforce confirmation April 2014.
To gain consensus towards a curriculum and training plan for Rural MN Referring hospital
education
To receive an update on the MN M:L public awareness campaign and delivery plan
To define committee next steps and scope of work moving forward
Improving the System of Care for STEMI Patients
59
First Name
Alicia
Dr. Arashk
Last Name
Muller
Motiei
Carie
Carrie
Weller
Lager
Danielle
David A.
Devra
Dr. Lisa A.
Dr. Nancy L
Dr. Scott
Strandlien
Hildebrandt
Carlson
Abrahams
Hassinger
Mikesell
Dr. Thomas
Haldis
Geoffrey
Dr. Ismail
Galaski
Bekdash
Janna
Pietrzak
Jen Sather
JoAnn
Julie
Olson
Foltz
Clark
Kim
Brunmeier
Lynell
Grieser
Michael
Paul
Paula
Phil
Schultz
Schoenberg
Meskan
Martin
Sandy
Kovar
Mindy
Ngia
Cook
Mua
Katie
Sahajpal
Michelle
Gardner
Gary
Myers
Richard
Mullvain
Title
MD, Mayo Clinic Interventional
Cardiologist
NREMT-P, Manager, EMS &
Ambulance Services
RN Cath Lab
Manager CV Program
Director of Hospital Patient Care
Interventional Cardiologist
Interventional Cardiologist
MN M:L Co-Chair, Interventional
Cardiologist
ND M:L Co-Chair, Interventional
Cardiologist
EMTP, Executive Director
Cardiologist
RN, BSN, STEMI Network
Coordinator- Heart Services
EMT, LPN, Exercise Physiologist
CEO
RN, CCRN, Nurse Manager
Cardiac Services
RN, Cardiology Clinician
Director of Cardiovascular
Services
Base Supervisor
MBA, RN, CEN Director ETC
RN, DON
CentraCare Heart and Vascular
Director
STEMI/Stroke Coordinator
Director M:L MN, ND
Administrative Associate MWA
M:L
Director Quality Improvement
MN, WI
VP Quality and System
Improvement MWA
Director M:L MWA, EMS
Consultant
RPH STEMI Coordinator
Organization
Sanford Bemidji
Mayo Clinic Health System,
Mankato
Mayo Clinic Health System
River's Edge Hospital
Rural MN Hospital
Advisory Committee
2013-2014
51 members
Sanford Health Bemidji
Minneapolis Heart Institute
Essentia Health, Fosston
St. Mary's Essentia, Duluth
St. Mary’s Essentia, Duluth
St. Luke's Hospital, Duluth
Sanford Health Fargo
Ely Area Ambulance Service
Altru Health System, Grand
Forks, ND
Sanford Health- Fargo
Montevideo, MN
Sanford Wheaton
St. Luke's Hospital, Duluth
Mayo Clinic Health System,
Mankato
Fairview Southdale Hospital
Sanford AirMed
River's Edge Hospital
CentraCare, St Cloud
Altru Health System, Grand
Forks
AHA
AHA
Dr. Ganesh
Jennifer
Raveedran
Erdmann
MD, Interventional Cardiology
Dr. Yassar
Ashlee
Curtis
Barry
Jody
Dr. Richard
Julie
Chad
Dr. Nick
Dr. Guy
Dr. Mohammad
Julie
Dr. Rabeea
Almanaseer
Rostvedt
Crist
Royce
Holmen
Aplin
Tryon
Macheel
Burke
Reeder
Jameel
Beevor
Aboufakher
Medical Director of Cardiology
RN, BSN, STEMI Coordinator
Cath Lab Director
RN, BSN, CCRN
STEMI Program Coordinator
Interventional Cardiologist
Annette
Scott
Dr. Henry
Al
Persak
Scepaniak
Ting
Tsai
STEMI Coordinator
Cardiac Cath Lab
Interventional Cardiology
PHD MPH Principal Investigator,
Minnesota Stroke Registry
Patient Care Manager
Cami
Linke
Interventional Cardiologist
Interventional Cardiologist
Interventional Cardiologist
Interventional Cardiologist
U of MN
Johnson Memorial Health
Services
Essentia Health Fargo, ND
Essentia Health Fargo, ND
Sanford Health Bemidji
Sanford Health Bemidji
Mayo Clinic, Rochester
CentraCare, St Cloud
Minneapolis Heart Institute
Mayo Clinic, Rochester
Sanford Health Bemidji
Sanford Health System
Altru Health System, Grand
Forks ND
Sanford Health Bemidji
CentraCare, St Cloud
Mayo Clinic, Rochester
MN DOH
Fairview University of M
AHA
AHA
AHA
St. Mary’s Essentia Duluth
Improving the System of Care for STEMI Patients
60
Proposed DRAFT ONLY – (4-2014)
Minnesota Statewide Inter-Hospital STEMI Transfer Pathway




Diagnostic Criteria for STEMI (ST Elevation Myocardial Infarction) Alert Activation
Signs & Symptoms of discomfort suspect for AMI (Acute Myocardial Infarction) or STEMI with a duration >15 minutes <12 hours
ST elevation at the J point in at least 2 contiguous leads of ≥ 2 mm (0.2 mV) in men or ≥ 1.5 mm (0.15 mV) in women in leads V2–V3,
and/or of ≥ 1 mm (0.1 mV) in other contiguous chest leads or the limb leads.
New or presumably new LBBB at presentation occurs infrequently, may interfere with ST-elevation analysis, and should not be
considered diagnostic of acute myocardial infarction (MI) in isolation. If doubt persists, immediate referral for invasive angiography may
be necessary.
If initial ECG is not diagnostic but suspicion is high for STEMI, obtain serial ECG’s at 5-10 minute intervals
NO
YES
O
ACTIVATE Emergent Transport and STEMI Alert at Receiving Hospital
STANDARD MEDICATIONS






Aspirin 324 mg chewable PO
Ticagrelor (Brilinta) 180 mg PO OR Clopidogrel (Plavix) 600 mg PO
if transferring for PPCI (Choose Brilinta or Plavix, but not both!)
Clopidogrel (Plavix) 300 mg PO if administering Lytic **If patient > 75 years old,
consult with cardiologist before giving Plavix
Heparin IV Bolus 70 Units/kg IV, max 5,000 Units if transferring for PPCI
Heparin IV Bolus 60 Units/kg IV, max 4,000 Units if administering Lytic
Oxygen as needed to maintain SpO2 > 92%
STANDARD ORDERS & LABS
- PT/INR - (Standard) Panel
Refer to local chest pain protocol

OPTIONAL MEDICATIONS
Heparin IV Drip if transferring for Primary PCI
15 Units/kg/hr., max 1,000 Units/hr.
 Heparin IV Drip if administering Lytic
12 Units/kg/hr., max 1,000 Units/hr.
 Metoprolol 25 mg PO Hold if signs of Heart Failure,
low output state or risk of Cardiogenic Shock, Age
over 70 years, Heart Rate <60 or over 110, Systolic
Blood Pressure <120 mmHg
 Nitrates & Analgesia as needed per local protocol
**Do not delay transfer if not immediately available
- Apply Continuous Cardiac Monitor - Insert (2) peripheral IV’’s - CK, CK-MB - Glucose
- aPTT - CBC - Troponin - Serum HCG women of childbearing age
- Magnesium
Proceed to the chosen pathway on page 2:
Pathway 1 - TRANSFER - Primary PCI (Percutaneous Coronary Intervention)
Pathway 2 - TRANSFER- Full Dose Lytic
Pathway 3 - TRANSFER - Half Dose Lytic
2013 AHA Mission: Lifeline STEMI Best Practice Guidelines:
 FMC (First Medical Contact)-to-First ECG time <10 minutes unless pre-hospital ECG obtained
 All eligible STEMI patients receiving a Reperfusion (PPCI or fibrinolysis) Therapy
 Fibrinolytic eligible STEMI patients with Door-to-Needle time < 30 minutes
 PPCI eligible patients transferred to a PCI receiving center with referring center Door in- Door out (Length of Stay) < 45 minutes
 Referring Center ED or Pre-Hospital First Medical Contact-to-PCI time < 120 minutes (including transport time)
 All STEMI patients without a contraindication receiving Aspirin prior to referring center ED discharge
Choose Pathway
Patients with a contraindication to transfer or PCI:
 Aspirin within 24 hours of hospital arrival, and aspirin at discharge
 Beta blocker at discharge
 LDL >100 who receive statins or lipid lowering drugs
 STEMI patients with left ventricular systolic dysfunction on ACEI/ARB at discharge
 STEMI patients that smoke with smoking cessation counseling at discharge
Improving the System of Care for STEMI Patients
61
Proposed DRAFT ONLY – (4-2014)
PATHWAY 1 - DIRECT TRANSFER - Primary PCI (Percutaneous Coronary Intervention) PATHWAY
Goal: FMC (First Medical Contact) to PCI time < 120 minutes (transport time included), Referring Center Door- inDoor out: < 45 minutes
Transport to PCI Hospital: Direct admit to Cardiac Catheterization Lab for PCI




Preferred strategy of PCI Receiving Hospitals in MN, ND Statewide STEMI Guideline, SD Statewide STEMI Guideline,
and when anticipated FMC (First Medical Contact) to PCI time <120 minutes
Preferred strategy of CentraCare St. Cloud
Preferred strategy of Mayo Clinic Rochester and Mankato when time from symptom onset to presentation > 2 hours
Please refer to individual PCI Receiving Hospital Protocol
PATHWAY 2 – TRANSFER- FULL DOSE LYTIC PATHWAY
Goal: 1st Door- to- Needle (Lytic Administration) <30 minutes, Referring Center Door- in- Door out: < 45 minutes
Transport to PCI Hospital: Admit to CCU if symptom and ST elevation free, or Cath lab is symptoms or ST elevation persist



Preferred strategy of St Luke’s Hospital and Essentia Health -Duluth, and Sanford Medical Bemidji, ND Statewide STEMI
Guideline, SD Statewide STEMI Guideline when anticipated First Medical contact to PCI time > 120 minutes
Preferred strategy of Mayo Clinic Rochester and Mayo Clinic Mankato when symptom onset to presentation < 2 hours
Please refer to individual PCI Receiving Hospital Protocol
PATHWAY 3 – TRANSFER - HALF DOSE LYTIC PATHWAY
Goal: 1st Door- to- Needle (Lytic Administration: <30 minutes, Referring Center Door- in- Door out: < 45 minutes
Transport to PCI Hospital: Direct to Cath Lab for PCI or Admit to CCU if symptom and ST elevation free, or Cath lab is
symptoms or ST elevation persist



Preferred strategy of Minneapolis Heart Institute Abbott Northwestern Hospital when anticipated First Medical contact to
PCI time > 120 minutes
Preferred strategy of Mayo Clinic Rochester and Mankato when symptom onset to presentation < 2 hours and pt. age >
75 years
Please refer to individual PCI Receiving Hospital Protocol
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M:L MN Reference Maps
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M:L MN Adjunctive Tools


Swim-Lane Process Flow chart
Excel Destination Protocol Grid
Richard Mullvain
D.Ph., BCPS (AQC) CCPC
MN Mission: Lifeline Co-Chair
Cardiovascular Clinical Pharmacist;
STEMI Program Manager; Chest Pain
Center Coordinator, Essentia Health
Heart & Vascular Center Duluth, MN
Confidential Statement Here
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MN STEMI Receiving Centers Inter-Hospital Transfer Protocol
- Key Treatments and Contact Info
Not Ready for Use Yet!!!!
Concept of document to be
housed on our MN
Mission:Lifeline Website
…with links to receiving center
transfer protocols
Draft Only Concept…
Minnesota Statewide Inter-Hospital STEMI Transfer Pathway ** DRAFT ONLY ** Created by the AHA MN Mission Lifeline Workgroup (current 2/20/14)
(STEMI Referral Facility)
Regional Hospital
STEMI Identified
by 12-Lead ECG
Activate
Transport
Is
Prompt Air
Transport An
Option?
Yes
Dispatch Air
Transport
No
Dispatch Ground
ALS Transport
Is
PCI Possible
Within 120
min?
Yes
PCI Hospital
EMS Transport
(Air or Ground)
Call Destination
PCI Hospital
Activate for
STEMI
Transfer
Patient to PCI
Hospital
Call Nursing
Report & Fax
Paperwork to
PCI Hospital
No
Use AHA
Mission
Lifeline
Reperfusion
Checklist
(STEMI Receiving Center)
Use the Specific
Destination PCI Hospital
STEMI Protocol
for drugs and treatments
Choose
Destination PCI
Hospital
Dispatch to
Regional Hospital
Arrive at
Patient
EMS
Departs with
Patient
Is patient
Lytic
Elligible?
Yes
Administer Fibrinolytic
(Dose Per Destination
PCI Hospital Protocol)
Arrive at
PCI Hospital
Receive Nursing
Report &
Paperwork
Cardiologist
Accepts STEMI
Transfer
CCU
CCU
Cath Lab
Receive Patient
from EMS
Cath Lab or
CCU?
Cath Lab
Perform Urgent
Angiography &
PCI if / when
appropriate
M:L Rural MN Quality Committee
Update
•
•
•
ACTION GWTG and Mission: Lifeline Reporting
Mission: Lifeline Recognition
Mission: Lifeline EMS Recognition Tools
Katie Sahajpal BSN, MSN
Director of Quality & Systems
Improvement Minnesota and Wisconsin
American Heart Association, Midwest
Affiliate Office: (414)227-1416
[email protected]
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Mission Lifeline Quality Updates
• Q4 Mission Lifeline Reports are available
• Q1 Data Deadline May
• Rural MN System Report:
•
Preliminary Report ran for Q4
•
Will start to examine regional system report with Q1 data
•
System Report Includes:
• 5 Rural MN PCIs
• 4 SD PCIs
• 3 ND PCIs
7/31/2014
©2010, American Heart Association
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Mission Lifeline Award Recognition 2014
• CURRENTLY REVIEWING REPORTS/DATA
• AWARD NOTICES EARLY MAY
•
Available to do award presentations
• USNWR IN JULY
• SCIENTIFIC SESSIONS AWARD EVENT MONDAY, NOV 18TH
7/31/2014
7/31/2014
7/31/2014
7/31/2014
EMS Mission Lifeline Recognition
•
New Recognition for EMS agencies this past year
•
Goals:
•
Help facilitate the communication/engagement between EMS and hospitals
•
Help EMS start to understand how QI and data can help enhance the services they provide and how they impact the
overall continuum of patient care
•
Promote teamwork and recognition EMS looks for
•
Help break down the barriers of data/communication
•
Improve pre-hospital data accessibility
7/31/2014
What are the Achievement Measures?
1. Percentage of patients with non-traumatic chest pain > 35 years treated
by EMS who get a pre-hospital 12-lead electrocardiogram
2. Percentage of STEMI patients with first (pre-hospital) medical contact to
device time within 90 minutes (non-transfer)
3. Percentage of STEMI patients taken to a referral hospital who
administers fibrinolytic therapy with a door to needle time within 30
minutes.
7/31/2014
©2013, American Heart Association
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Must all 3 measures be reported?
Transport Destination Protocols determine achievement measures required to complete:
Agencies with STEMI patients transported to
STEMI Receiving Centers only
Reporting Measures #1 and #2 required
Agencies with STEMI patients transported to
STEMI Referring Centers only
Reporting Measures #1 and #3 required
Agencies with STEMI patients transported to
both STEMI Receiving Centers and STEMI
Referring Centers
Reporting Measures #1, #2, and #3 required
7/31/2014
©2013, American Heart Association
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Congratulations!!!!
Gold Cross Rochester
Silver Recognition
7/31/2014
2012 AHA Mission: Lifeline
86
Working with EMS/Data
7/31/2014
2012 AHA Mission: Lifeline
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TCCC and AHA Advocacy Update
Justin Bell - J.D.
Government Relations Director
American Heart Association
Midwest Affiliate
4701 W. 77th St.
Minneapolis, MN 55435
(952)278-7921
[email protected]
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M:L Rural MN Public Awareness Campaign
•
•
•
Your Life is on the Line Media Campaign
Materials Availability and Orders
STEMI Survivor Stories
Joan Enderle, MBA, RD, LRD
Communications Director, Mission: Lifeline Public
Education – ND/MN
American Heart Association, Midwest Affiliate
1005 12th Ave SE
Jamestown, ND 58401
Tel: 701.252.5122
1-800-437-9710
Cell: 701.320.5950
[email protected]
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Public Education Campaign
Your Life is on the Line: Dial 9-1-1
Public Website: heart.org/MN
Public Website: heart.org/MN
Survivor Stories
Signs and Symptoms of a Heart Attack – links to
national site
American Heart Association Events – Rural MN
News / Media Clips
Your Life is on the Line: Dial 9-1-1 materials
Live April 1, 2014
Earned Media
Radio Public Service Announcements
 Professionally produced radio spots
 Pitched by communication staff in May
Local Media – Newspaper, Magazines, TV,
Radio
Work in collaboration with EMS, hospitals
 Pitch local survivor stories
 Public Education Campaign
 New advances
Paid Media
Facebook campaign
 Reach rural MN residents Adults 35-75
 Start date May
Radio News Stories
 Start with April Campaign Launch
 Series of 6 over 12 months
Print ads in the county seat newspapers
 50 mile radius of the PCI hospitals funded
 Series of 6 print ads
 Start in late August
Campaign Materials
Pull up banner - PCI hospitals
Panels for Display Boards (set of 3)
Collateral Materials
 Bookmarks
 Posters
 Magnets
Materials available:
 Order Form – www.heart.org/missionlifelinemn
 Exhibit booth at conference
STEMI Survivor Story Submission
 Story Submission Form
 Signed Authorization & Media Release
M:L MN Vision for the Future
2014-2015 Rural Minnesota Mission: Lifeline Chair Description
Length of Involvement:
May 1, 2014 – April 31, 2015
Time Commitment:
30 hours for the calendar year
Important Dates:

Monthly Chair Update Calls 1st Monday of each month from 7:00 – 8:00 am

Participation in Quarterly Committee teleconferences, in-person meetings, and Taskforce
teleconferences at least 50% of the time, as schedules allow.

Host and provide leadership at the Bi-Annual Face to Face Rural MN M:L Taskforce Meeting
October 2014, April 2015

Host and present at the Annual Rural Minnesota Mission: Lifeline STEMI Conference in 2014-2015
Annual Chair &
Committee
Structure
Review
Rural MN M:L
Co-Chair Term
My signature confirms my understanding of the above expectations to ensure a successful program.
Through this commitment, I will be helping the American Heart Association realize its 2020 goal to
improve the cardiovascular health of all Americans by 20 percent and to reduce deaths from
cardiovascular disease and stroke by 20 percent by the year 2020.
_____________________________________________
Rural MN M:L Chair Signature
__________________________
Date
_____________________________________________
AHA Mission: Lifeline Representative Signature
__________________________
Date
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Mission: Lifeline Committee Structure
Consensus Based Decision Making
Mission: Lifeline Taskforce Co-Chairs
Richard Mullvain, Dr. Scott Mikesell, Dr. Ganesh Raveedran
Mission: Lifeline Taskforce Quality Committee 2013-2014
• Katie Sahajpal
Mission: Lifeline Taskforce EMS Advisory Committee 2013-2014
• Gary Myers
Mission: Lifeline Taskforce STEMI Hospital Advisory Committee
• Mindy Cook, Katie Sahajpal, Richard Mullvain, Dr. Scott Mikesell, Dr. Ganesh Raveedran
Mission: Lifeline Taskforce STEMI Conference Planning Committee
• Mindy Cook, Katie Sahajpal
MN Time Critical Care Committee TCCC
• Justin Bell
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Improving the System of Care for STEMI Patients
Next Meeting Date
Discuss future meeting schedule and feasibility of video conferencing
(determine sites) for future meetings, arrive at consensus
Adjournment – Enjoy the Rural MN M:L STEMI Conference!
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