1. Model Heart Attack Systems of Care RACE / North Carolina James G. Jollis, M.D. Co-Director, RACE

2. RACE Reperfusion in AMI in Carolina Emergency departments North Carolina RACE Pilot –Design and lessons RACE –Design and lessons

3. North Carolina Population 8,541,22111 th Size 48,711 square miles 29 th 14 PCI hospitals, ~100 non-PCI hospitals Relative size –Connecticut and Massachusetts combined 4 times area, same population –Minnesota ½ area, 2 times population

4. North Carolina EMS Milestones 1910 1 st air ambulance built in NC 1917 Earliest air ambulance rescue service Outer Banks to Norfolk hospitals

5. North Carolina EMS Milestones 1968 One of the 1 st Paramedic training programs in U.S. Haywood County, North Carolina

6. North Carolina EMS Milestones 1968 Dr. Ralph Feichter, Waynesville internist + Rescue Squad Volunteers intensive training in cardiac pathophysiology, electrocardiography, arrhythmia recognition, pharmacology (cardio-active drugs) and CPR. + 2 mobile intensive care vehicles

7. North Carolina EMS Milestones 2003-2006 RACE Reperfusion in AMI in Carolina Emergency Departments

8. RACE Reperfusion in AMI in Carolina Emergency departments North Carolina RACE Pilot –Design and lessons RACE –Design and lessons

9. RACE pilot 2003 Improve AMI care at the point of greatest mortality / potential benefit –Increase the rate of reperfusion –Increase the speed of reperfusion

10. AMI Reperfusion How are we doing? IV Lytic PPCI Year of Discharge NRMI 2 NRMI 3 NRMI 4 NRMI 5 Patients, % Immediate CABG - Range 0.9 % - 1.7 % 6.9 39% 47 23%

11. IV Lytic PPCI Year of Discharge NRMI 2 NRMI 3 NRMI 4 NRMI 5 Patients, % Immediate CABG - Range 0.9 % - 1.7 % 6.9 39% 47 23% None 37% AMI Reperfusion How are we doing?

12. Year of Discharge ≤ 65 Yrs > 65 Yrs NRMI 2 NRMI 3 NRMI 4 NRMI 5 Patients, % 58.8 53% 30.9 23% AMI Reperfusion How are we doing? - Age

13. RACE pilot 2003

14. 40 mile radius 5 local EDs within 40 miles

15. Referring MD Call Duke ED, CCU Fellow, or CAD staff OLD: >180 min CCU Attending ICC Fellow ICC Attending Cath Team Primary PCI Fax ECG Referring MD Call 1-866-MI-2-DUKE NEW: 100-120 min CCU Fellow, Attending, Life Flight ICC Fellow, cath team ICC Attending Primary PCI Find best transport Transfer for Primary PCI: Systematic Approach Fax ECG

16. Direct Activation of Duke Cath Lab based on Pre- hospital ECG by Durham EMS (preliminary data) PopulationnDoor-to-balloon Time Historical15104 (75, 131) EMS not using hotline1289 (78,100) EMS using hotline2058 (54,71) David Strauss 2005

17. RACE pilot 2003 Lessons from RACE pilot 1) Fix your own primary PCI system first 2) Data are exceedingly difficult to collect without funding or government or payer mandate –Issues include HIPAA, IRB, fear of release, OIG opinion that PRO hospital data are protected, resources

18. RACE Reperfusion in AMI in Carolina Emergency departments North Carolina RACE Pilot –Design and lessons RACE –Design and lessons

19. 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… 2 years

20. RACE Reperfusion in AMI in North Carolina Emergency Departments AMI Guideline based PCI or Lytics –Support “best available therapy” according to resources / local conditions

21. RACE Partners

22. RACE Organization Funded by BCBS of NC Foundation, Genentech, Participating hospitals Quality improvement project for state ACC Independent oversight board –Leaders in ACC (Douglas), acute MI care (O’Neill, Califf, Brodie), emergency medicine (Mears), BC/BS (Harris). Steering committee –Participating physicians and hospitals Coordination –Mayme Lou Roettig, Director; 5 Regional Coordinators ~70 hospitals (10 PCI, 60 no-PCI)

23. 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/Berger/Stoufer Wilson/Pulsipher/Beaton

24. RACE Data PCI hospitals – NRMI Non PCI hospitals –Consecutive chart review Rate of reperfusion Time of reperfusion

25. RACE Manual  Optimal system specifications by point of care  EMS  ED  Transfer  Receiving hospital  Cath. Lab  Other system issues – 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 January 2006

26. RACE Interventions EMS –In the field ECG Regional ECG training courses Securing funding for ECG equipment

27. RACE Interventions PCI hospital - Map out process - ED physician can make decision about PCI without the need for consultation / confirmation - Single contact number - Single interventionalist on call for system - Accept to cath. lab without bed availability - Streamline registration process - NRMI in place

28. RACE Interventions

29. RACE Additional lessons

30. Requires “donated” efforts of 100’s of physicians, nurses, administrators, EMTs, public officials, professional organizations –Chris Granger, Peter Berger, Magnus Ohman, Greg Mears, Sid Smith ….

31. RACE Additional lessons Maintain current referral lines Physician leadership in ED, Cardiology, and administration

32. RACE Additional lessons Regional structure guides “politics” - 3 PCI hospitals / 3 Cardiology groups - 1 PCI hospital / 6 Cardiology groups - 1 PCI hospital / 1 Cardiology group - Non-PCI hospital - Network spoke vs. independent - Academic hospitals with NIH ranking as primary focus

33. RACE Additional lessons Hospital administration / State legislature buy in –Smaller hospitals All hospitals should treat AMI –PCI hospitals All hospitals at the table Establish single contact number and system for rapid PCI before contacting regional hospitals

34. RACE Additional lessons Data – pre and post intervention Quality assurance project –No protected health information “there is a reasonable basis to believe the information can be used to identify the individual ” –IRB process potentially one of the greatest systematic barriers to improving care

35. RACE Additional lessons ED physicians “control” much of STEMI care and want a single regimen.

36. RACE Additional lessons What Would Trauma Do?

37. RACE Additional lessons Heart disease700,000 –Myocardial infarction200,000 Accidents100,000 –MVA 60,000 National Center for Health Statistics 2005 3 times as many die from AMI than from trauma

38. What Would Trauma Do “Golden hour” Accept patient regardless of bed availability Dummy registration Code trauma –Priority –Everyone knows their role –Single trauma physician on call –Single phone call activation EMS transport priority 24/7 hospital capabilities Regionalized system

39. 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. Record calls and playback for QI 4. Provide standardized feedback reports to each ED 3. Prehospital ECGs for all CP patients 2. "Certify" all EMTs to read ST elevation on ECGs, call from ambulance to activate cath lab 1. Create EMS, ED, cardiology team with committed leadership

41. North Carolina –Demographics –EMS history RACE pilot –Goal – increase reperfusion – save lives –Duke system –Lessons Fix your own system first Data exceedingly challenging to collect without funding, legal or payer mandate RACE –Structure –Timeline –Intervention –Examples Flow chart Telephone call RACE manual Additional lessons Top 10 interventions

42. RACE Interventions PCI hospital –Single contact number –ED physician makes decision –2 methods of transport –Reperfuse with fastest / safest approach