Interfacility Transfers: The Joker’s Wild of STEMI Care Systems January 19, 2011 Dr. Peter O’Brien, Centra Health, Lynchburg Dr. Michael Kontos, VCU, Richmond Dr. David Burt, UVa, Charlottesville 1

Part I: STEMI Transfers: The Jokers WILD Pete O’Brien VHAC

Part II: STEMI Fireside Chat Dr. Pete O’Brien Dr. Mike Kontos Dr. David R Burt

Drs. Burt, Kontos, and O’Brien: Nothing to Disclose

Provider of: STEMI System Science, Resources, Collaboration … The Big Picture NATIONALLY… Mission: Lifeline is a national, community-based initiative designed to meet the needs of the STEMI patient throughout the continuum of care, beginning with the patient’s entry into the system (from symptom onset) through each component of the system, and return to the local community and physician for rehabilitative care. Mission: Lifeline uses a community-based, multidisciplinary, patient-centric approach. Mission: Lifeline is addressing systems of care for STEMI on multiple levels and through many collaborating organizations, starting with the STEMI patient and continuing through EMS, ED, STEMI Referral, and STEMI Receiving hospitals; implications for policy makers and third party payers are also being addressed within Mission: Lifeline.   To meet the overarching goal, Mission: Lifeline will bring together the necessary partnerships between: Patients and care givers EMS Physicians, nurses and other providers Non-PCI capable (STEMI-referral) hospitals PCI capable (STEMI-receiving) hospitals Departments of health EMS regulatory authority/Office of EMS Rural health associations Quality improvement organizations State and local policymakers Third-party payers Health systems Provider of: STEMI System Science, Resources, Collaboration … 5 5

PATIENT CENTERED COLLABORATION COMMUNICATION 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). The overarching goal of the initiative is to reduce mortality and morbidity for STEMI patients to and improve their overall quality of care COLLABORATION PATIENT CENTERED COMMUNICATION 4/13/2017 ©2010, American Heart Association

….In Virginia … www.virginiaheartattackcoalition.org The Virginia Heart Attack Coalition (VHAC) is a volunteer collaboration dedicated to improving care of heart attack patients throughout Virginia via the implementation and promotion of Mission: Lifeline guidelines and by fostering cooperation and coordination among the Commonwealth's STEMI care providers.

Patient Care….Not Market Share

System Delay and Mortality in STEMI Patients Same old Story! Terkelsen CJ JAMA 2010;304:763-771

Interhospital Transfer for PCI 20 On-site fibrinolysis Transfer for PCI 15 14 12.1 10 Mortality (%) 10 8.4 8.5 7 6.7 6.7 6.8 6.5 5 A major issue that many community hospitals face is how to meet the tight timeframes for transferring patients to PCI-capable centers. The data from the five trials listed on this slide suggest that establishing rapid transfer protocols for PCI is worth the effort, as the PCI groups had lower mortality rates in 4 out of 5 of the trials. LIMI1 PRAGUE-12 AIR-PAMI3 PRAGUE-24 DANAMI5 (n=150) (n=200) (n=137) (n=850) (n=1129) 1. Vermeer F, et al. Heart . 1999;82:426-431. 2. Widimsky P, et al. Eur Heart J. 2000;21:823-831. 3. Grines CL, et al. J Am Coll Cardiol. 2002;39:1713-1719. 4. Widimsky P, et al. Eur Heart J. 2003;24:94-104. 5. Andersen HR, et al. N Engl J Med. 2003;349:733-742. 10 Vermeer F, Oude Ophuis AJM, vd Berg EJ, et al. Prospective randomised comparison between thrombolysis, rescue PTCA, and primary PTCA in patients with extensive myocardial infarction admitted to a hospital without PTCA facilities: a safety and feasibility study. Heart.1999;82:426-431. Widimsky P, Groch L, Zelizko M, et al. Multicentre randomized trial comparing transport to primary angioplasty vs immediate thrombolysis vs combined strategy for patients with acute myocardial infarction presenting to a community hospital without a catheterization laboratory. The PRAGUE Study. Eur Heart J. 2000;21:823-831. Grines CL. Westerhausen DR Jr, Grines LL, et al. A randomized trial of transfer for primary angioplasty versus on-site thrombolysis in patients with high-risk myocardial infarction. The Air Primary Angioplasty in Myocardial Infarction Study. J Am Coll Cardiol. 2002;39:1713-1719. Widimsky P, Budesinsky T, Vorac D, et al. Long distance transport for primary angioplasty vs immediate thrombolysis in acute myocardial infarction. Final results of the randomized national multicentre trial – PRAGUE-2. Eur Heart J. 2003;24:94-104. Andersen HR, Nielsen TT, Rasmussen K, et al. A comparison of coronary angioplasty with fibrinolytic therapy in acute myocardial infarction. N Engl J Med. 2003;349:733-742.

60 AHA : System Goals 90 MINUTES 90 FIRST MEDICAL CONTACT MINUTES DOOR To NEEDLE : Fibrinolytics OR DOOR IN 2 DOOR OUT DOOR To BALLOON Primary PCI EMS To BALLOON Primary PCI 60 30 MINUTES 90 MINUTES 90 MINUTES 4/13/2017

Point Of Entry Protocol : GOAL Considerations EMS has to make when deciding to transport to the nearest facility or to the farther away PCI facility….Patient condition (hypotension w s/s of acute coronary syndrome = PCI facility), Patient preference (utilize informed consent), Fibrinolytic Checklist (If patient is ineligible to receive fibrinolytics, then transport to PCI facility), EMS resources, Highest level of certification, Subtle EKG findings, Medical Control support for by pass of nearest non-PCI facility, Local facility support of by-pass protocols….. And the list goes on. Less than 90 Minutes

LET’S TAKE A CLOSER LOOK 4/13/2017

Riddle me this Batman!! JOKER runs Amok!! EMS and Self-Driven/Emergent Triage Decisions, Bypass? Referral Facility Recognition, System Activation Lytic Administration -OR- Transfer for PCI Drip, Ship, or Drip and Ship??? Interfacility Transport - Ground, Air Receiving Facility – “Automatic” Acceptance, One Call Activation, Direct to Cath lab, Stop in ED System Optimization and Feedback, multiple EMS agencies, providers, institutions, etc 14

Point of Entry Protocol Hospital w/o PCI Nationally 50% of patients use EMS and that leaves the other 50% not utilizing EMS to access care. PCI center Hospital w/o PCI

WHY IS THIS AN ISSUE 25 % of hospitals perform primary PCI. 75% Do not. 4/13/2017 ©2010, American Heart Association

INHERENT CHALLENGES Most are located in rural areas Transport Distance to PCI Shift to >50% Walk in patients Centers Financial Challenges Non-PCI Center Available EMS Resources Local Non-Invasive Cardiologists 44 Rural areas = Transport distance, difficult terrain (mountains, islands, deserts, wide open spaces) EMS bypass to PCI = longer time out of local service areas, longer transport distances with sicker patients, may require an ALS supervisor to rendezvous with a BLS unit or preplan and coordinate transport with Air Medical providers….. As EMS unit is driving to non-PCI center with a STEMI patient, the Air Medical provider is also enroute to the Non-PCI facility to meet EMS and the patient. 4/13/2017 ©2010, American Heart Association

ACTION REGISTRY DATA This slide is a combination of the 2 D2B slides. Although there are improvements nationally, these numbers only reflect those programs participating in ARG ~ 425 facilities nationwide. 82 or 20% of these facilities are from the Mid Atlantic Affiliate. A median of 112 minutes still demonstrates that more than 50% of the Transfer STEMI patients receive PCI in over 112 minutes (1.9 hours), 32 minutes over the recommended 90 minutes. The current Non-Transfer STEMI patient goal of 90 has been and is being met. 4/13/2017 National ARG Data and GWTG

Recommendations for Triage and Transfer for PCI (for STEMI) Each community should develop a STEMI system of care following the standards developed for Mission Lifeline including: Ongoing multidisciplinary team meetings with EMS, non-PCI-capable hospitals (STEMI Referral Centers), & PCI-capable hospitals (STEMI Receiving Centers) NEW Recommendation I IIa IIb III C 19 19

Recommendations for Triage and Transfer for PCI (for STEMI) (cont.) STEMI system of care standards in communities should also include: Process for prehospital identification & activation Destination protocols to STEMI Receiving Centers Transfer protocols for patients who arrive at STEMI Referral Centers and are primary PCI candidates, and/or are fibrinolytic ineligible and/or in cardiogenic shock NEW Recommendation I IIa IIb III C 20 20

AHA: STEMI System Blueprints Mission: Lifeline Recommendations for Criteria for STEMI Systems of Care The criteria are divided into: EMS Non-PCI Hospital/STEMI Referral Center  PCI Hospital/STEMI Receiving Center Systems

The Ideal EMS Agency EMS equipped with 12 Lead capability EMS educated to recognize STEMI Prearranged transport destination protocols By Pass Non-PCI PCI Fibrinolytic Checklist EMS utilization for Interfacility Transfers Cath Lab Activated on Paramedic Interpretation On paramedic’s description /interpretation With or Without EKG Transmission EMS actively attends Multidisciplinary Meetings EMS involvement at a state level Guidelines for EMS.

The Ideal STEMI-Referral Hospital In an ideal system: Standardized POE protocols dictate transport of STEMI patients directly to a STEMI-receiving hospital based on: Patients presenting to a STEMI-referral hospital are treated according to standardized triage and transfer protocols Incentives are provided to rapidly: Treat STEMI patients in accordance with ACC/AHA guidelines Transfer to a STEMI-receiving hospital for primary PCI using: Reperfusion checklists Standard pharmacological regimens and order sets Clinical pathways There is rapid and efficient data transfer, data collection and feedback Integrated plans for return of the patient to the community for care are provided In the ideal system, standardized point-of-entry (POE) protocols would dictate those STEMI patients to be transported directly to a STEMI-receiving hospital based on specific criteria for risk, contraindications to fibrinolysis, and the proximity of the nearest PCI service. Standardized triage and transfer protocols are in place for patients presenting to a STEMI-referral hospital. Alignment of patient outcome and financial incentives are provided to: Rapidly treat STEMI in accordance with ACC/AHA guidelines; Transfer to a STEMI-receiving hospital for primary PCI using reperfusion checklist in regions that do not readily have access to STEMI-receiving hospitals, standardized pharmacological regimens, order sets and clinical pathways; There is rapid and efficient data transfer, data collection and feedback; and Integrated plans for return to the community for care are provided.

CODE STEMI TRANSFER FLOW SHEET Patient enroute to ED by EMS Patient arrived to ED by POV Field ECG indicates STEMI ED ECG Indicates STEMI   Initiate Interfacility Transport Plan Treat STEMI per regional protocols EMS Patient Arrives to Referral ED Assess Patient Transfer upon transport arrival Referral facility must establish a collaborative plan along with the EMS providers as well as the PCI STEMI Receiving facility. Designate the top 3 or 4 options for agencies to perform interfacility transports. Adhere to strict time expectations for those agencies to arrive. Due to EMS systems implementing bypass protocols, there is a shift in presentation to referral facilities…. More than 50% are now walk in STEMI patients. INTERFACILITY TRANSPORT PLAN: COUNTY 911 SERVICE (843-911-1111) ETA:________________ PRIVATE GROUND SERVICE (843-991-2222) ETA:________________ AIR SERVICE (843-991-3333) ETA:________________ LAST RESORT (843-991-4444) ETA:________________ 4/13/2017 ©2010, American Heart Association

Time Savers aka Best Practices for Referral Facilities GOAL : Door In to Door Out = 30 MINUTES GOAL : Arrival to ECG < 10 Mins Do Not Delay transport team Do not wait on lab results FAX Patient Care Record Call Report after patient leaves Non-PCI KNOW the STEMI Protocol 4/13/2017 ©2010, American Heart Association

TIME SAVERS aka BEST PRACTICES for Transport Turn off all drips (Administer NTG via SL or NTG Paste) NTG and Heparin drips are not required * Minimize time at Bedside (~10 Minutes – Standard scene time for trauma) Do not delay transport waiting on patient care records : FAX * For short distances (not defined) TIME IS NOT ON YOUR SIDE 4/13/2017 ©2010, American Heart Association

Collaborative Initiatives Participate in Drafting of UNIVERSAL interfacility transport practice standard Pre-Determined Transport Decision Scheme Patient Care in ED Patient Care during transport NO DRIPS Early activation of the Code STEMI Provides update Lytics given or not? More prep time allows the patient to be taken directly to cath lab

Ideal STEMI-Receiving Hospital STEMI protocols adopted and followed to include single call activation. Criteria for EMS activation. 24/7 coverage with expectation that Primary PCI is the standard reperfusion strategy ED activation of cath lab Volume/Quality standards CCL staff/MD to report in 30 minutes or less Universal Acceptance—No Diversion!!

Ideal Receiving Cont’d STEMI-receiving hospital’s administration puts their support in writing (AHA Memorandum of Understanding..MOU) Lead multidisciplinary/multiagency team meeting to regularly identify processes done well and to collaboratively fix those that need improvement A continuing education program is designed and instituted A consistent mechanism for monitoring performance, process measures and patient outcomes is established—ACTION REGISTRY/GWTG

SAMPLE ML Report from Action Registry Facilities who participate in Action Registry and are registered with Mission: Lifeline will receive quarterly Mission:Lifeline reports and be eligible for Mission: Lifeline recognition 4/13/2017 30 30

Financial Sensitivities Learn local EMS resources/limitations Work as a team to address needs Offer 12 Lead STEMI identification classes Provide MD level updates on lytic admin Feedback assures appropriate Non-PCI Facility Bypass Goal is to get the STEMI patient back to their local community for rehab and follow up Involve Non-Invasive Cardiologists on multiple levels

Mortality With 1° PCI vs Time For every 10 minutes delay in PCI-> 1% of the advantage is lost 15 Circle sizes = sample size of individual study Solid line = weighted meta-regression 10 P=.006 Absolute Risk Difference in Death (%) 5 62 min Favors PCI Favors lysis Timing is everything when it comes to reperfusion strategies for acute MI. According to Nallamothu and Bates: “The mortality benefit associated with primary percutaneous coronary intervention in ST-segment elevation myocardial infarction may be lost if door-to-balloon time is delayed by >1 hour as compared with fibrinolytic therapy door-to-needle time. Interventional cardiology laboratories endeavoring to achieve the benefits of primary percutaneous coronary intervention seen in randomized clinical trials should aim to match their short door-to-balloon times.” This slide shows the absolute risk reduction in 4- to 6-week mortality rates with primary PCI as a function of PCI-related time delay. Circle sizes reflect the relative sample size of the individual study (the larger the circle, the larger the study). Values of absolute risk that exceed 0 represent benefit and values that are less than 0 represent harm. The solid line represents a weighted meta-regression. As time delays in PCI increase past 62 minutes, the lines separate, indicating that absolute mortality reduction in favor of primary PCI decrease significantly until its benefit relative to fibrinolysis is lost. Every 10-minute delay in PCI delivery is associated with a one percent reduction in mortality difference in favor of fibrinolytics. After a 62-minute time delay in PCI delivery, the two reperfusion strategies appear to become equivalent in terms of mortality rates and then diverge in favor of fibrinolytics. The survival advantage of PCI may be negated if door-to-balloon time is delayed by more than one hour, compared with fibrinolysis door-to-needle time. These findings support the recommendations of the European Society of Cardiology and the ACC/AHA, which suggest that delivery of primary PCI should not delay time to treatment for STEMI by more than 60 minutes. -5 20 40 60 80 100 PCI-Related Time Delay (Door-to-Balloon minus Door-to-Needle) For every 10-min delay to PCI: 1% reduction in mortality difference vs lytics. Nallamothu BK, Bates ER. Am J Cardiol. 2003;92:824-826. 32 Antman EM, Anbe DT, Armstrong PW, et al, American College of Cardiology, American Heart Association, Canadian Cardiovascular Society. ACC/AHA guidelines for the management of patients with ST-elevation myocardial infarction—executive summary. A report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Writing Committee to revise the 1999 guidelines for the management of patients with acute myocardial infarction). J Am Coll Cardiol. 2004;44:671-719. Nallamothu BK, Bates ER. Percutaneous coronary intervention versus fibrinolytic therapy in acute myocardial infarction: is timing (almost) everything? Am J Cardiol. 2003;92:824-826.

TRANSFER-AMI: Efficacy Kaplan Meier Curves for Primary Endpoint Primary end point: composite of death, reinfarction, recurrent ischemia, new or worsening CHF, or shock within 30 days pharmaco-invasive group=11.0% vs. standard treatment group=17.2% 17.2% Cumulative Incidence 11.0% p=0.004 Death & reinfarction not different between groups at 6 months Days RR= 0.64, 95 CI% (0.47-0.87) Cantor et al. N Engl J Med 2009;360:26 33 33

Figure 1. The results of the primary outcome from contemporary randomized trials comparing a pharmacoinvasive strategy with conservative care after initiating fibrinolytic therapy. In these trials, conservative care was defined as either an ischemia-guided or a delayed invasive approach.

Recommendations for Triage and Transfer for PCI (for STEMI) (cont.) NEW Recommendation It is reasonable to transfer high risk patients who receive fibrinolytic therapy as primary reperfusion therapy at a non-PCI capable facility to a PCI-capable facility as soon as possible where either PCI can be performed when needed or as a pharmacoinvasive strategy. I IIa IIb III B High risk based on definitions used in CARESS-IN-AMI and TRANSFER-AMI 35 35

Nearest Facility ~vs~ PCI Facility If any of the contraindications are met, then TRANSPORT TO A PCI FACILITY. If a relative contraindication is met, discuss and decide what is in the patient’s best interest.

Acute STEMI Protocol for Halifax Regional (for acute ST elevation MI or new LBBB) The Cardiovascular Group of Central Virginia and the Stroobants Heart Center of Centra Health 1. Notify Transport of need for emergent transfer to LGH. 2. Call 1-434-947-3098 (or 1-434-947-5252) and ask for Cardiologist on call. Please be prepared to provide via phone: Patient’s name Age Weight, Height EKG interpretation Brief report (i.e., treatment to this point, V, medications) 3. ASA 325 mg chew and swallow 4. Plavix 300 mg 5. Lovenox 30 mg IV. 6. Lovenox 1 mg/kg sub Q (up to 100 mg.) 7. Administer IV Thrombolytic therapy (if no contraindications) 8. IV fluids TKO. 9. If full dose TNK is not given, then give Integrilin 180 mcg ug V bolus. Repeat bolus in 10 minutes. If possible, avoid drips such as IV nitroglycerin that may delay transport and time to treatment. “Code STEMI…When time equals muscle, every minute counts!” Centra Health 1/05/2010 4/13/2017 37 37

Lessons Learned So Far Transfers are more complicated, but just as important to get right EMS involvement and predetermined plans are CRITICAL Standardized Referral Center treatment protocols. Determine Strategy: Lytic Administration vs Transfer forPCI Time of s/s onset, patient condition, and time to PCI Relationships between nonPCI and PCI hospitals worked out And visited frequently Interfacility transportation decision scheme PCI center commitment to non-diversion and rapid system activation. Continual performance feedback 4/13/2017 ©2010, American Heart Association

Part II: STEMI Fireside Chat Dr. Pete O’Brien Dr. Mike Kontos Dr. David R Burt