Brief History on Mission: Lifeline Each year, hundreds of thousands of Americans have a type of heart attack known as STEMI, in which blood flow is completely blocked to a portion of the heart. Unless the blockage is eliminated quickly, the patient’s health and life are at serious risk. Currently, around two-thirds of STEMI patients fail to receive the best available treatments to restore blood flow. The American Heart Association created MISSION:LIFELINE as a response to missed opportunities caused by gaps in the system of care. Every day, new systems from all areas of the United States register with Mission: Lifeline. Because our organizations share similar missions, the AHA entered into a business agreement with the Society of Chest Pain Centers (in May of 2011) to provide Mission: Lifeline accreditation for STEMI Referring and Receiving Centers.  The goal of the combined effort is to improve the consistency of cardiac care by providing a standard approach to the treatment of STEMI patients.  The official launch of the ML accreditation program was September 2, 2011

WI STEMI/Mission Lifeline Projects Eastern WI Mission Lifeline Initiative South Central Regional STEMI Event Potential Grant for Mission Lifeline In Western WI 11/13/2018 ©2010, American Heart Association

Data Definitions 11/13/2018 ©2010, American Heart Association

STEMI Definition STEMI is a clinical syndrome defined by characteristic symptoms of myocardial ischemia in association with persistent electrocardiographic (ECG) ST elevation and subsequent release of biomarkers of myocardial necrosis. 11/13/2018 ©2010, American Heart Association

Time Points For STEMI Patients 11/13/2018 ©2010, American Heart Association

First Medical Contact 11/13/2018 ©2010, American Heart Association

Mission: Lifeline FMC to PCI AR-G DATA Definition: FMC – What exactly is FMC ? Means of Transport = AMBULANCE Pre-Arrival 1st Med Contact Date/Time = Eye to Eye contact between the STEMI patient and the 1st Medical provider to deliver (ACS) Acute Coronary Syndrome care – 12 Lead ECG Aspirin Administration Nitroglycerine Administration PRINT THIS SLIDE Moving onto the FMC measure and line items. This is a measure where the data definition is defined by ACTION and the reported measure is defined by AHA M:L. FMC is entered into ARG and the data definition according to ARG is the Pre-Arrival 1st medical contact date and time for patients that arrive directly to the PCI Center by AMBULANCE. This is the time EMS lays eyes on the patient. However, if a patient presents to an Urgent Care Center or any other office where ACS care is initiated prior to the ambulance’s arrival, and then EMS is called for transport directly to the STEMI Receiving Center, the FMC time, based on the ARG data definition, is now the time the urgent care providers laid eyes on the patient. In ARG, there is currently no way to differentiate between EMS 1st medical contact and Urgent Care 1st medical contact. The key here is that treatment for chest pain is started at the urgent care center or physician office. This is important to keep in mind when reviewing these patients with your customers. If the chest pain patient reports to any office where ACS care is not initiated, such as from a dental office, and ems is summoned, then the time that is entered for Seq 3105, is when EMS makes that eye to eye contact with the patient. 11/13/2018 2012 AHA Mission: Lifeline

Opportunities for Process Improvement: FMC looks beyond Door to Balloon FMC applies a SYSTEM perspective to Quality and Process Improvements The Patient, The EMS Agencies and the PCI Centers EMS – FMC to Pre-Hospital ECG Pre-Hospital ECG to ED Arrival EARLY IDENTIFICATION of the STEMI patient EARLY ACQUISITION of the 12 Lead ECG EARLY NOTIFICATION of the STEMI to the Receiving ED PCI Centers - PCI Arrival to Cath Lab EARLY ACTIVATION of the Cath Lab Team EARLY REPERFUSION The FMC to PCI measure is the sum of its three main parts. When working with EMS and with each other to improve this measure, it may be beneficial to look at this measure in its parts. FMC to Pre-Hospital ECG Pre-Hospital ECG to ED Arrival and ED Arrival to Cath Lab. Nationally once a patient arrives in the cath lab, the time from cath lab arrival to PCI is fairly consistent. 11/13/2018 2012 AHA Mission: Lifeline

AR-G and M:L Recognition Measure Comparison ACTION Registry-GWTG performance achievement award requirements Mission: lifeline receiving center recognition measures for stemi systems of care Mission: lifeline referral center recognition measures for stemi systems of care ASA at Arrival DTN < 30 Minutes DTB < 90 Minutes ASA on Discharge Discharge beta-blocker Discharge ACE-I/ARB (ideal patients) Discharge statin Smoking Cessation Cardiac Rehabilitation Door to first device < 90 Minutes, non-transfer patients FMC to first device < 90 Minutes, non-transfer patients Eligible patients receiving any reperfusion (PCI or Lytics) ASA within 24 hours ASA at Discharge Beta-blocker at Discharge Statins or lipid lowering drugs ACEI/ARB at discharge Smoking Cessation Door to first ECG time <10 Minutes Eligible patients receiving any reperfusion (PCI or Lytics) Door to Needle < 30 Minutes Door In – Door Out < 45 Minutes ASA within 24 hours ASA at Discharge Beta-blocker at Discharge Statins or lipid lowering drugs ACEI/ARB at discharge Smoking Cessation Now in looking in depth at the % Reperfusion measure and the FMC to PCI Measure, our hopes is that all of our Mission: Lifeline hospitals achieve Mission: Lifeline Recognition. Here in column 2 and 3 are the Mission Lifeline recognition criteria for both Receiving and Referral Centers. Every referral center that missed achieving ML recognition did not achieve at least a 75% in the Arrival to ECG < 10 minutes measure. Mission Lifeline Achievement is offered to STEMI receiving Centers and STEMI Referral Centers using either Limited or Premier Forms. Each measure must have at least 75% adherence. And the overall composite score must be at least 85%. 11/13/2018 2012 AHA Mission: Lifeline

Referring Hospital Education/Tools 11/13/2018 ©2010, American Heart Association

11/13/2018 2012 AHA Mission: Lifeline

11/13/2018 2012 AHA Mission: Lifeline

Group Discussion How do you interact with your referring hospitals currently? Education? Protocols? Data Feedback 11/13/2018 ©2010, American Heart Association

Education Current Education Practices What are the gaps in Education from the referring hospital side? Can we collaborate state-wide to address education/barriers? State-wide STEMI Conference State-wide CME Webinar Series 11/13/2018 ©2010, American Heart Association

Protocols Does everyone have a STEMI and lytic protocol for their referring hospitals? If a referring hospital sends patients to more than 1 facility, is there regional collaboration? Sample Protocols 11/13/2018 ©2010, American Heart Association

11/13/2018 2012 AHA Mission: Lifeline

11/13/2018 2012 AHA Mission: Lifeline

11/13/2018 2012 AHA Mission: Lifeline

Data Feedback 3.4.1. Regional Systems of STEMI Care, Reperfusion How do we create an effective data feedback system between care providers? 3.4.1. Regional Systems of STEMI Care, Reperfusion Therapy, and Time-to-Treatment Goals: Recommendations See Figure 2. Class I 1. All communities should create and maintain a regional system of STEMI care that includes assessment and continuous quality improvement of EMS and hospitalbased activities. Performance can be facilitated by participating in programs such as Mission: Lifeline and the D2B Alliance.71,76–78 (Level of Evidence: B) 11/13/2018 ©2010, American Heart Association

11/13/2018 2012 AHA Mission: Lifeline

Next Meeting??? 11/13/2018 ©2010, American Heart Association