RACE: Reperfusion of acute myocardial infarction in North Carolina emergency departments Christopher Granger, MD Director, Cardiac Care Unit Duke University Medical Center Durham, NC

Reperfusion in AMI in Carolina Emergency Departments A Systems Approach To Improve Survival of Patients with Myocardial Infarction In North Carolina Through Improved Application of Reperfusion Therapy

Importance of Time Mortality reduction versus treatment delay Boersma. Lancet 1996; 348: Absolute benefit per 1000 patients treated Treatment delay (hours) 35 day mortality 1.6 lives per 1000 lost per hour delay to randomization In first hour, up to 40 lives per 1000 lost per hour of delay 1.6 lives per 1000 lost per hour delay to randomization In first hour, up to 40 lives per 1000 lost per hour of delay

Door-to-Balloon & 30-d Mortality Door-Balloon Times (minutes) P=0.005P=0.005 Hudson ACC day Mortality

Optimizing the System n Understand what the System is: l Begins with the patient l Prehospital environment l Emergency Department (both non-PCI & PCI) l Cardiology interface l Catheterization laboratory for PCI, or fibrinolytic drug administration n Understand what the System is: l Begins with the patient l Prehospital environment l Emergency Department (both non-PCI & PCI) l Cardiology interface l Catheterization laboratory for PCI, or fibrinolytic drug administration

What would Trauma do?

Can patients be transferred by helicopter for primary PCI with 1st door to balloon of <100 minutes?

Zone II ( miles) Facilitated PCI (1/2 dose TNK plus PCI) Goal door to balloon times of minutes (actual = 116 minutes in first 82 patients) Standardized protocol Zone I (60 miles) Primary PCI Goal of door to balloon < 90 minutes (actual = 96 minutes in first 232 patients)

Can Systems be Developed to Safely Bypass non-PCI centers?

BOSTON In the field ECG In the field ECG Diversion of STEMI to closest PCI hospital Diversion of STEMI to closest PCI hospital Hospitals will never be on diversion for ST- elevation MI (similar to trauma center plan) Hospitals will never be on diversion for ST- elevation MI (similar to trauma center plan) Each hospital will perform a minimum of 36 primary PCI or rescue PCI procedures / year Each hospital will perform a minimum of 36 primary PCI or rescue PCI procedures / year PCI will be performed within 120 minutes of hospital arrival (ie, door-to-balloon time of 120 minutes) in 75% of “ideal” patients PCI will be performed within 120 minutes of hospital arrival (ie, door-to-balloon time of 120 minutes) in 75% of “ideal” patients STEMI System

The Problem NRMI-5: North Carolina, July 2003-June 2004 NCNationGuidelines N2,73879,927 % eligible treated81%80% Door-balloon101 min100 min<90 min 11PM to 7AM107 min Weekend105 min Transfer 1 st door – balloon191 min165 min<90 min 1 st d-b <90 min0.8%5.5%100% NCNationGuidelines N2,73879,927 % eligible treated81%80% Door-balloon101 min100 min<90 min 11PM to 7AM107 min Weekend105 min Transfer 1 st door – balloon191 min165 min<90 min 1 st d-b <90 min0.8%5.5%100%

Hours (Median) Transfer Times and Delay: STEMI Patients Transferred to Another Hospital and Received Primary PCI Door to Balloon Door to Door Year of Discharge NRMI 2 NRMI 3 NRMI 4 NRMI 5

Symptom-admission 1st door - 2nd door Admission-randomization Randomization-PCI Transfer No transfer % Transferred in APEX: 80 minutes 1 st to 2 nd door “transfer time,” but only 45 minutes longer door-to-balloon Widimsky ACC 2007

RACE Objectives Improve the public health of North Carolina residents by: Reducing the eligible STEMI population untreated with reperfusion by 20% (i.e., 20% untreated to 16% untreated). Increasing the speed of reperfusion toward national benchmarks of   90 minutes door to balloon for Primary PCI and   30 minutes for fibrinolytic therapy. Establishing regional systems of acute MI care with emergency departments throughout North Carolina.

AMI Guidelines 2004 JACC 2004;44:686. Guidelines available on the Web site:

Asheville Winston-Salem Durham/Chapel Hill/Greensboro Greenville Charlotte Reperfusion of AMI in Carolina Emergency Departments (RACE) Maddox/Hathaway Hunt/Horrine Bohle Hoekstra/Applegate Babb/Shiber Aluko/Fletcher Valerie/Watling Wilson/Garvey Granger/Jollis/Stoufer Wilson/Pulsipher/Beaton/Mears 10 PCI Centers 58 non-PCI Centers

40 mile radius Henderson to Durham: 40 mile drive Henderson to Durham: 40 mile drive Interventional cardiologist home to Duke 20 minutes

Local EMS 11:00 PM 1 st door to balloon (BMS) 84 min

RACE Reperfusion in AMI in North Carolina Emergency Departments OBJECTIVES Regional approach to overcoming systematic barriers 1) Increase reperfusion rate 2) Increase speed of reperfusion Organize regions Baseline data InterventionPost data CQI… RACE Phase 3 2 years

Presentation  Only 12% of patients presenting did NOT have CP upon presentation.  Median age 63 yrs; 33% female  Door to ECG Median 11 min (5,25)

Pre-Intervention Data Hospital Arrival Mode n=515

RAPID EKG CRITERIA Door to decision 10 minutes  30 YEARS OLD with suspicious CHEST PAIN (EXCLUDING OBVIOUS TRAUMA)  50 YEARS OLD with: Syncope Weakness Rapid Heart Beat / Palpitations Difficulty Breathing / Shortness of Breath Graff L, Palmer AC, LaMonica P, Wolf S. Annals Emerg Med. December 2000;36:

Transfer for Consideration of Primary PCI 192/519 (37%) transferred for consideration for PPCI Time from non-PCI ED arrival to non-PCI ED departure median 89 minutes State NRMI First door to balloon inflation in transfer-in Patients n=376 median 156 minutes (2:05,3:40) Only 2.9% of NC transfer-in patients make balloon up in < 90 minutes!

Thrombolytics in Non-PCI Centers in North Carolina 45% received lytics (n=235/519) Median Door to Lytic 35 min (25,53) 34% patients received lytics in < 30 minutes, ACC/AHA Guideline Goal

D2B: An Alliance for Quality A Guidelines Applied in Practice (GAP) Program JACC 2006;48:

D2B Goal To achieve a door-to-balloon time of </= 90 minutes for at least 75% of non-transfer primary PCI patients with ST-segment elevation myocardial infarction in all participating hospitals performing primary PCI. As of March 2007, over 800 centers signed up as participants.

Bradley E et al. N Engl J Med 2006;355: Median Door-to-Balloon Times among Study Hospitals (n=365) Mean (of medians) = 100 ± 24 minutes

Strategies and Door-to-Balloon Time Saved n ED physicians activate the cath lab (8.2 minutes) n Single call to a central page operator activate the lab (13.8 minutes) n ED activate the cath lab while the patient is en route to the hospital (15.4 minutes) n Expecting staff to arrive in the cath lab within 20 minutes after being paged (vs. >30 minutes) (19.3 minutes) n Attending cardiologist always on site (14.6 minutes) n Having staff in the ED and the cath lab use real-time data feedback (8.6 minutes) n ED physicians activate the cath lab (8.2 minutes) n Single call to a central page operator activate the lab (13.8 minutes) n ED activate the cath lab while the patient is en route to the hospital (15.4 minutes) n Expecting staff to arrive in the cath lab within 20 minutes after being paged (vs. >30 minutes) (19.3 minutes) n Attending cardiologist always on site (14.6 minutes) n Having staff in the ED and the cath lab use real-time data feedback (8.6 minutes) Bradley N Engl J Med 2006;355:

Bradley E et al. N Engl J Med 2006;355: Door-to-Balloon Time According to the Number of Key Strategies Used

PopulationnDoor-to-balloon Time Historical15112 (80, 140) EMS not using hotline1592 (78,110) EMS using hotline2058 (54,71) PopulationnDoor-to-balloon Time Historical15112 (80, 140) EMS not using hotline1592 (78,110) EMS using hotline2058 (54,71) Direct Activation of Duke Cath Lab Based on Pre-Hospital ECG by Durham EMS Strauss J Electrocard 2007

RACE Manual  EMS (prehosp ECG, transport)  ED (guideline-based algorithms, training, feedback)  Transfer (single contact, fastest option, streamline,automatic cath lab activation)  Receiving hospital (“hotline” approach)  Cath lab (automatic activation)  Other system issues – communication, feedback, interdisciplinary team, payers, regulations RACE Reperfusion in Acute myocardial infarction in Carolina Emergency Departments Operations Manual Granger CB, Jollis JG, et al. For the North Carolina RACE steering committee Version 1.2 March 2005 Optimal system specifications for each component of AMI care

Top Ten List 10. Use local ambulance to transport pts (within ~50 miles) 9. Keep patient on local ambulance stretcher 8. Give heparin bolus (70 U/kg) and no IV infusion 7. Establish protocol for lytics vs PCI for each ED 6. Establish single call number to PCI centers that "automatically" activates cath lab 5. Provide standardized feedback reports 4.System for rapid triage of walk-ins, rapid ECGs 3. Prehospital ECGs for all CP pts (and ED use them!) 2. "Certify" all EMTs/paramedics to read ST  on ECGs, immediately activate reperfusion (lytics or cath lab) 1. Create EMS, ED, cardiology team with committed leadership

Emergency Cardiovascular Care 2007: Building Regional Integrated STEMI Systems for Reperfusion ACC Sponsored Meeting with goal to teach and enable teams to establish effective regional STEMI reperfusion systems June 1-2, 2007, Washington, DC

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