1. Status of Washington State Emergency Cardiac and Stroke System Kathleen Jobe, MD FACEP Chair, Emergency Cardiac and Stroke Technical Advisory Committee

2. Centers for Disease Control and Prevention NAEMSP Minneapolis Level One Heart Attack Program WA State Department of Health EMS and Trauma System Heart Disease and Stroke Prevention Program

4. In Washington 1999-2001: EMS/T recognized MI and stroke as time- critical conditions similar to trauma. Conducted assessment of emergency cardiac and stroke care – no funding to address findings 2005: DOH gets CDC funding for Heart Disease and Stroke Prevention Program. Top priority:  Improve emergency response for cardiac and stroke care  HDSP and EMS/T resurrect project and convene Emergency Cardiac and Stroke Work Group 2007-8: Findings and recommendations reported, Emergency Cardiac and Stroke TAC formed to implement recommendations, objectives in EMS/T Strategic Plan

5. Assessment of Emergency Cardiac and Stroke Care - Findings Effective treatments are available-many appropriate patients are not treated Variation across the state in: Level and timeliness of emergency response Protocols, patient care procedures, and resources to diagnose and treat Access to optimal treatment Patient outcomes

6. Assessment of Emergency Cardiac and Stroke Care in WA. PCI performed in only 39% of cases t-PA given in only 2.4% of ischemic strokes

7. PCI Hospital 30 minute Drive Time

8. Recommendations Establish statewide emergency cardiac and stroke system similar to trauma (right pt/right place/right time) Create Emergency Cardiac and Stroke Technical Advisory Committee to implement system

9. Emergency Cardiac (Stroke) System Dispatch Protocols training EMS Protocols Training pre arrival notification 15 minutes on-scene time Triage & destination plan PCPs COPs Hospital Verification/ Categorization; training Data, Evaluation, Quality Improvement Website ECS TAC Patient Outcomes Feedback Community Education & Outreach

10. ECS TAC Membership Hospitals Dispatch and EMS Clinicians (ED MDs, Cardiologists, Neurologists, RNs, EMS Directors) DOH, AHA, WSHA, COAP, ACC(???)

11. Recommendations continued… Patient early recognition and call 911 Standardized prehospital EMS protocols and triage Uniform training Hospital capability verification program Quality improvement based on standard data collection and reporting

12. State of Washington Prehospital Stroke Triage (Destination) Procedures Effective - Dispatch: Nearest available EMS response capable of transport. Rapid transport is priority. Assess vital signs, LOC, glucose  Unconscious  Airway unmanageable  Hemodynamically unstable (  BP, HR)  Hypoglycemic  Unable to perform FAST assessment YES Transport per regional patient care procedures NO Assess for stroke (F.A.S.T.)  Face (unilateral facial droop)  Arms (unilateral drift/weakness)  Speech (abnormal/slurred) Yes to one or more indicates stroke NO Transport per regional patient care procedures YES Time last normal  Determine time last normal  Estimate time last normal to destination arrival <3.5 hrs Emergent transport to nearest highest level 1, 2, or 3 stroke center per regional patient care procedures BLS: if stroke center >30 mins, or patient deteriorates, consider rendezvous with ALS <3.5 hrs to < 6 Emergent transport to nearest level 1 stroke center per regional patient care procedures BLS: if stroke center >30 mins, or patient deteriorates, consider rendezvous with ALS >6 hrs or unknown Non-emergent transport to level 1 or 2 stroke center per regional patient care procedures Alert destination hospital en route State of Washington Prehospital Stroke Triage (Destination) Procedures Effective - Dispatch: Nearest available EMS response capable of transport. Rapid transport is priority. Assess vital signs, LOC, glucose  Unconscious  Airway unmanageable  Hemodynamically unstable (  BP, HR)  Hypoglycemic  Unable to perform FAST assessment YES Transport per regional patient care procedures NO Assess for stroke (F.A.S.T.)  Face (unilateral facial droop)  Arms (unilateral drift/weakness)  Speech (abnormal/slurred) Yes to one or more indicates stroke NO Transport per regional patient care procedures YES Time last normal  Determine time last normal  Estimate time last normal to destination arrival <3.5 hrs Emergent transport to nearest highest level 1, 2, or 3 stroke center per regional patient care procedures BLS: if stroke center >30 mins, or patient deteriorates, consider rendezvous with ALS <3.5 hrs to < 6 Emergent transport to nearest level 1 stroke center per regional patient care procedures BLS: if stroke center >30 mins, or patient deteriorates, consider rendezvous with ALS >6 hrs or unknown Non-emergent transport to level 1 or 2 stroke center per regional patient care procedures Alert destination hospital en route Where we are now… Prehospital ACS and Stroke Protocol Guidelines ACS and Stroke Triage and Destination Plans Hospital Criteria Key data measures Public education strategies 4 Regional STEMI systems forums Assisting with regional STEMI systems development

16. The goal in WA… Total ischemic time of 120 minutes E2B 90 minutes + or – 30 minutes Hospital door to balloon 90 minutes

17. What’s next… Final comments coming in Present to EMS/T November 18 Train EMS and categorize hospitals in 2010 Collect data (ACTION/GWTG, COAP) Public education Full implementation by 2011 Evaluate and revise as indicated by the data

18. Regulatory and Legislative Options for a Statewide system Designation The highest level of state regulation and oversight Verification State oversight to assure compliance with verification requirements Categorization Hospitals voluntarily comply with system requirement No regulatory or oversight authority

19. Legislative possibilities A hospital verification program is unlikely due to the state deficit but we can do prehospital triage to participating hospitals AHA legislation to support development of the ECS System. Sponsor for bill. Awaiting legislative session to drop bill

20. Future goals Would ACC join as major partner to push for a statewide system of STEMI care ??

21. Thank you Kathleen Jobe, MD, FACEP 206-508-4220 kaj@u.washington.edu