Toronto STEMI Project 24/7 Primary PCI in the GTA

GENERAL BACKGROUND Centres offering PCI 24/7 (St. Michael’s Hospital, Sunnybrook and UHN), and hospitals across the GTA have agreed to improve and optimize existing emergent interventional services by joining forces to provide a ‘guaranteed accept’ 24/7 service within the city of Toronto boundaries for heart attack patients who will benefit most from an emergency angioplasty Centres offering PCI 24/7 (St. Michael’s Hospital, Sunnybrook and UHN), Toronto EMS and hospitals across the GTA have agreed to improve and optimize existing emergent interventional services by joining forces to provide a ‘guaranteed accept’ 24/7 service within the city of Toronto boundaries for heart attack patients who will benefit most from an emergency angioplasty Other hospitals in Toronto EMS catchment area may also take part by either referring patients to PCI centres and repatriating patients or by providing angioplasty where available Other hospitals in Toronto EMS catchment area may also take part by either referring patients to PCI centres and repatriating patients or by providing angioplasty where available Heart Attack Committee formed January focused on developing a model and generating buy-in from participating organizations and other stakeholders Heart Attack Committee formed January focused on developing a model and generating buy-in from participating organizations and other stakeholders EMS advanced life support paramedics will use 12-lead ECGs to identify STEMI patients in pre-hospital setting, and will bring those patients directly to a PCI centre to enable a 90-minute door-to-balloon time. These patients will go directly to the Cath Lab, seen in the PCI centre's ER only if unstable despite pre-hospital treatment EMS advanced life support paramedics will use 12-lead ECGs to identify STEMI patients in pre-hospital setting, and will bring those patients directly to a PCI centre to enable a 90-minute door-to-balloon time. These patients will go directly to the Cath Lab, seen in the PCI centre's ER only if unstable despite pre-hospital treatment Where applicable, following PCI, stable patients will be transferred back to their local hospital within 24 hours of procedure Where applicable, following PCI, stable patients will be transferred back to their local hospital within 24 hours of procedure

GEOGRAPHICAL AREA Steeles to the North Steeles to the North Etobicoke Creek/Hwy 427 to the West Etobicoke Creek/Hwy 427 to the West East to Rouge Valley; and South to the Lake East to Rouge Valley; and South to the Lake Anticipated total STEMIs within boundary: 1,200 a year based on data extrapolated from the Ottawa experience and population data from City of Toronto Anticipated total STEMIs within boundary: 1,200 a year based on data extrapolated from the Ottawa experience and population data from City of Toronto

CLINICAL BACKGROUND Timely reperfusion of STEMI patients improves short and long-term survival and has become the mainstay of therapy in this setting As an alternative to primary PCI, patients are given thrombolytic pharmacotherapy numerous studies and analyses show that PCI achieves better outcomes, with much lower risk of intracerebral hemorrhaqe Primary PCI to be of benefit when the door to balloon time in the range of 60 to 90 minutes. Subsequent data from large registries have indicated, the actual door-to-balloon time is considerably longer than these optimal clinical trial times Recent analysis of a large US National Registry of Myocardial Infarction (NRMI) indicates that the benefit of primary PCI relative to thrombolysis is not related just to PCI-related delay, but also by patient characteristics

CLINICAL BACKGROUND continued Figure 1 Figure 1 relationship between patient age, infarct location and the time from symptom onset to presentation apparent that mode of reperfusion therapy needs to be taylored to individual patient, based on all parameters, not just door- to-balloon time.

TORONTO’S SITUATION Majority of emergeny cath lab procedures for STEMIs occur when thrombolytic therapy fails Provision of emergent interventional cardiology care in Toronto has three major challenges: frequent shortage of critical care beds at all institutions with interventional cardiology programs lack of an efficient and timely transport system to transfer patients to PCI centres current lack of an organized and efficient 24/7 primary PCI service in the region

Toronto STEMI Project: The Challenges

TRANSPORATION SYSTEM Current EMS is equipped with very few critical care trained paramedic units needed to handle possible emergencies during transport Majority of units not available to transport patients with STEMI from community hospitals unless a physician provides advanced care during transport rarely occurs in Toronto - on-call cardiologist in the community hospital is responsible for many other patients

CARDIAC INTENSIVE CARE BED CAPACITY Shortage of critical care beds to accept a patient with a STEMI Shortage of critical care beds to accept a patient with a STEMI Shortage of nurses to care adequately and safely for extra patient(s) Shortage of nurses to care adequately and safely for extra patient(s) Result: physicians in community hospitals must commonly contact as many as four tertiary centres and still may not find a bed and thus timely care Result: physicians in community hospitals must commonly contact as many as four tertiary centres and still may not find a bed and thus timely care

Toronto STEMI Project: The Benefits

COLLABORTATION the STEMI program is a coordinated effort, which will improve the integration of care with EMS, referring hospitals and PCI facilities Need to ensure efficient flow of patients from hospitals without PCI capability to PCI centres and vice versa

SAVING LIVES The STEMI initiative optimizes door to balloon time, which may decrease: The STEMI initiative optimizes door to balloon time, which may decrease: co-morbidities co-morbidities reduce complications reduce complications limit the need for prolonged hospital stays and readmissions limit the need for prolonged hospital stays and readmissions

SUCCESS STORIES Well-studied and recommended process of care that benefits patients and practitioners Most recently, an article about Ottawa Heart Institute’s usage of the protocol was published in the January 2008 issue of the New England Journal of Medicine

HOSPITAL LEADS Hospital NameER LeadCardiology Lead CEO LHINDan Cass Toronto Central: Matthew Anderson Central – Hy Eliasoph Central East – Deborah Hammons North York GeneralKuldip Sidhu / Tim RutledgePhilip MyronBonnie Adamson St. Joseph ’ s Marco Duic Mark FisherCarolyn Baker Scarborough General/GraceTom Chan Chris Li (Grace) / Sharon Roth (General) Lewis Hooper (CIO) Etobicoke GeneralNaveed MohammadDavid BortsJudy Middleton (CIO) Humber RiverRakesh KumarRobert BauerRueben Devlin St. Mike ’ sSimon KingsleyJeff Lozon UHNAnil ChopraBob Bell Mount Sinai Howard Ovens N/AJoseph Mapa Toronto East General Paul Hannum Charles LefkowitzRob Devitt Sunnybrook Jeff Tyberg Barry McLellan Women ’ s College Doug Beattie N/AMarilyn Emery Rouge Valley / CentenaryTom StavroJoe Ricci / Saleem KassamRik Ganderton

FOR MORE INFORMATION Project Overview List of Partners Resources - detailed PowerPoint - models of reference (Ottawa Heart; Mayo Clinic) Upcoming Events / News Tools - canned ppt - Q&A - Community Consultation Plan Contact Information for questions/feedback