Landscape of STEMI Care Improvement Efforts in Texas H. Vernon Anderson, MD, Jaime McCarthy,MD and Richard Smalling, MD, PhD GETAC CCC November 2014 Texas STEMI Care Organizations

Texas: Department of State Health Services (DSHS) 11 Health Service Regions 22 Regional Advisory Councils (RACs)

What is a RAC?  each RAC has the same objectives – to reduce the incidence of trauma through education, data collection, data analysis and performance improvement. Regional Advisory Councils (RACs) are the administrative bodies responsible for trauma system oversight within the bounds of a given Trauma Service Area in Texas.  Each of the 22 RACs is tasked with developing, implementing, and monitoring a regional emergency medical service trauma system plan. Generally, RAC stakeholders are comprised of healthcare entities and other concerned citizens with an interest in improving and organizing trauma care.   As such, not every Regional Advisory Council is structured the same.  However, each RAC has the same objectives – to reduce the incidence of trauma through education, data collection, data analysis and performance improvement. Typically, this is accomplished via the provision of educational programs and performance improvement efforts designed to offer every provider guidance and motive to reduce the incidence of trauma, as well as improve outcomes of trauma patients.

Clinically enriched data sources National registries – NCDR: ACTION-GWTG EMS: NEMESIS Issue: ACTION-GWTG is hospital-based, and lacks many important elements of the pre-hospital care, which could be contained in EMS databases.

Elements of both EMS and hospitals Data flow Hospital A Hospital B Registry • • • Elements of both EMS and hospitals EMS A EMS B Registry • • •

STEMI–Door to Balloon and Door to Needle Times Cumulative 12 Month Data Note: If patients are not transported to a SEMI receiving center initially, their chances of having timely reperfusion of their infarct related artery are small and their chances of surviving and avoiding heart failure are diminished DTB = 1st Door to Balloon for Primary PCI DTN = Door to Needle for Lytics ACTION Registry-GWTG DATA: July 01, 2013 - June 30, 2014

Texas STEMI Care Organizations Impact of Improved Door to Balloon Times on STEMI Patient Mortality in the US Menees et al, NEJM, 2013 Texas STEMI Care Organizations

Clinical Problems in STEMI Care Persist! Despite significant improvements in STEMI care organization primarily in metropolitan RACs and some less populous regions (Corpus, Waco and El Paso), STEMI mortality and heart failure incidence remain unacceptably high. Pre-hospital/pre-transfer fibrinolytics are rarely used despite their recommendation in the guidelines for patients who cannot receive primary PCI within 60 minutes of first medical contact. Texas STEMI Care Organizations

NCDR ACTION Registry GWTG Mission: Lifeline Regional STEMI Reports 7 Texas regions utilizing the AHA Mission: Lifeline STEMI System Reports: BorderRAC- El Paso CATRAC- Austin CBRAC- Corpus Christi CTRAC- Temple NCTRAC- DFW SETRAC- Houston STRAC- San Antonio Total of 93 Texas Hospitals included in a regional report Texas STEMI Care Organizations

11 Years of Hospital & EMS STEMI data collaboration - Houston

Summary STEMI Care in Texas: Data Issues It appears that door to balloon time has been reduced as much as possible and the next major effort should be the reduction of pre-hospital ischemic time. Pre-hospital and Pre-transfer data capture is not mature or reliable. A parallel data capture and analysis structure focusing on large, diverse (rural/urban) STEMI systems/RACs affiliated with the CCTS data repositories and communicates with DSHS may provide a key resource Such a system could provide valuable insight into means for improvement of pre-hospital/pre-transfer STEMI Care Texas STEMI Care Organizations

A Potential New Approach to STEMI Data Management in Texas DSHS-TCCVDS Activity Primary focus: Hospital Phase and Overall Outcomes Input: Action and NCDR Database “Big Picture” Approach Texas CCTS – GETAC Activity Primary focus: Pre-Hospital, Pre- Transfer STEMI Care Input: RedCap STEMI Database “Granular” Approach NCTTRAC (DFW) UTSW CCTS DSHS Cardiovascular Disease and Stroke Council GETAC-CCC STRAC (San Antonio) UTSA CCTS SETRAC (Houston) UTHealth CCTS Texas STEMI Care Organizations

Texas STEMI Care Organizations

Texas Heart Attack Coalition A volunteer organization has been formed to attempt to bring all STEMI Care stakeholders together in order to craft STEMI Care legislation for the next biennium. Organizations in the effort include: THA, TMA, TACC, AHA, TCEP, TETAF Interventional Cardiologists, STEMI Nurse Coordinators, EMS physicians, EMT/Paramedics Cardiovascular/EMS Database Experts Selected volunteer representatives from Texas Cardiovascular councils and committees Texas STEMI Care Organizations

Texas STEMI Care Organizations Summary A critical mass of largely volunteer organizations and people are coming together to focus on STEMI care optimization in Texas The goal will need to be to reduce the time from onset of symptoms to reperfusion therapy in order to reduce the time the heart attack artery is occluded. It appears that door to balloon time has been reduced as much as possible and the next major effort should be the reduction of pre-hospital ischemic time. Texas STEMI Care Organizations