Bill Koenig, MD Medical Director Los Angeles County EMS Agency

Establishing a Communitywide System of Care

 Designated emergency cardiac care centers  Triage to PCI centers  Data driven quality improvement program Moyer P. Crit Pathways Cardiol 2004;3:53-61 Boston EMS STEMI

 Primary Percutaneous Coronary Intervention (PCI) is one of the most complex, multi- disciplinary, and time-sensitive therapeutic intervention medicine.  Our process is measured in Minutes  Our outcomes are measured in terms of Mortality  Teamwork and smooth Transitions are essential PCI for STEMI

October 30,2010  0930Exercising, CP  Dispatch  0941ALS Arrives.October 2006: Chest Pain Destination: MAR

Interpretive algorithm

Communitywide System of Care Organized System of Care  Rapid Recognition  Public Access Defibrillation  Rapid EMS Response  12 Lead ECG  Hospital Notification  PH Cath Lab Activation  V-Fib Cardiac Arrest

Unique aspects of System  “If you have seen one EMS system…..

………you have seen one EMS System”

Figure 1. Trends in Emergency Department Operation and Closures in Urban Areas, Hsia, R. Y. et al. JAMA 2011;305: Copyright restrictions may apply. Ed Closures

L.A. Fire Department cuts some rescue vehicles, paramedic supervisors Facing a $56.5-million budget gap, the department will take 15 fire trucks and six ambulances out of service each day…………  The LA Dilemma: Your Money or Your Life -- What to Cut, Who Will Pay?  911 STEMI Focus  Data Base includes all pre-hospital patients taken to an SRC – regardless of whether cath lab is activated or undergoes PCI

Data Collection is Stemi focused  Los Angeles STEMI system:  Inclusion criteria into our data base is all patients transported by 911 to an SRC as a STEMI patient, including those that never encounter a Cardiologist or the cath lab.  Regulatory Framework  Standards and Requirements that are County Based  Hospitals participate in other data bases

LAC STEMI Receiving Centers (SRC) N=3 0

LAC STEMI Receiving Centers (SRC) N=3 0 EMS NorthEastWest

Tipping Points  Medical Literature  Community Leaders - AHA  Conceptual framework presented to system participants  Funding  AHA and Annenberg Foundation  Los Angeles County Board of Supervisors  EMS Agency Reviews

Stenestrand U. JAMA 2006;296: Mortality reperfusion > 2h from symptom onset In-hospital lysis Pre-hospital lysis Primary PCI

 “ The time is now to reevaluate the optimal approach to treatment of patients with acute MI, with an interventional approach being the optimal strategy. The task for cardiologists and other physicians is to make the best possible therapy available to every patient with acute MI. JAMA April 17,2002 Tipping Points

Medical Literature  Cannon “Primary PCI for all” (2002 JAMA 287:1987)  Topol “Regionalizaton--a call forSpecialized centers” (2003 Circulation 107:1463)  Williams “Treatment delayed is treatment denied” (2004 Circulation 109:1806)  Henry & Larson “Triage to heart attack centers…is it time for a national policy?” (2005 JACC)

In-hospital deaths/1000 patients treated compared with D2B<90 min. Nallamothu B. NEJM 2007;357:

NRMI highlights deficiencies Elapsed Time2003 NRMI (median) 2004 Guidelines Door-Needle32 min.  30 min. Door-Balloon*100 min.  90 min. *D-B daytime90 min.  90 min. *D-B nights116 min.**  90 min. *D-B transfer180 min.++  90 min. Gibson CM, 2004 AHJ 148:S29**Magid DJ, 2005 JAMA 294:803 ++Nallamothu BK, 2005 Circulation 111:761

Tipping Points  Medical Literature  Circulation June 2007

Antman et al. JACC 2004;44:e19 STEMI System of Care

30 >> 30 >> 30 Rule EMS >> ED >> Cath lab

Tipping Points  Hospital Best Practices Develop

Hospital-Based Strategies Associated with Shorter Door-to-Balloon Time and Potential Tools to Implement Them Nallamothu B et al. N Engl J Med 2007;357:  Prehospital ECG Activation  Expected interval between page and arrival  Single Call from ED to Cath Lab Activation  Single Call Panel Physician  Real time Feedback to EMS, ED  Fire Department removes rig from service for cath  Cardiologist in hospital 24/7  Senior Management commitment  CEO Required to attend agency reviews

Hospital-Based Strategies Associated with Shorter Door-to-Balloon Time and Potential Tools to Implement Them Nallamothu B et al. N Engl J Med 2007;357:

STEMI: ultra-rapid transport Rokos et al. JACC: Cardiovascular Interventions 2009;2:4:239

Tipping Points  Hospitals Systems change  Placeholder  Placeholder for data from study  Placeholder  Implementation of 12 lead studied prior to Stemi Center Designation Reduced D2B  Funded by AHA/Annenberg Foundation

Tipping Point: Funding  American Heart Association and Annenberg Foundation – $3 million  Los Angeles County Board of Supervisors  Conceptual Framework was important  Retrospect scope :  Uniform Equipment  Uniform Transmission Interface

Conceptual Framework #1 Stemi Patient #2Prehospital team #3 ED Team #4 Interventional team One patient, seamless treatment Hospital Ownership Team Effort Any One Can Champion No Turf – time is the Enemy

Inclusion Criteria  All patients identified as STEMI patients in field and transported to an SRC  All Patients Triaged from field – even when cath lab not activated  All 911 inter-facility transfers for STEMI  Independent Base Hospital Data Base  Hospital Bordering LA County Included

Data Collection Web Based

IFT Transfer Form

Demographics  Q1Q2Q3Q4Q1Q2Q3Q4 PH ECG Positive Age Male Female

median times

Hospital destination: median times

Cath Lab Activations

Interpretive algorithm

12 Lead ECG Quality Artifact

12 Lead ECG Quality Wavy Baseline

Evolving role of Medical Control when ***AMI*** doesn’t fit  Paced  LBBB  Atrial flutter  Artifact

STEMI Interfacility Transfers: Median Times

Journal of Interventional Cardology January

4 th Quarter 2010: IFT

JACC CV Interventions, April 2009; 2:339-46

Rokos et al. JACC: Cardiovascular Interventions 2009;2:4:239 STEMI Systems of Care

Door-2-Balloon (D2B) Rokos et al. JACC: Cardiovascular Interventions 2009;2:4:239

AHA Mission: Lifeline May 2009 October 2009 April 2010 Established STEMI system of care Working toward STEMI system of care

AHA Mission: Lifeline May 2009 October 2009 April 2010 Established STEMI system of care Working toward STEMI system of care Nevada Utah

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