1. Bill Koenig, MD Medical Director Los Angeles County EMS Agency

2. Establishing a Communitywide System of Care

3.  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

5.  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

6. October 30,2010  0930Exercising, CP  0935911 Dispatch  0941ALS Arrives.October 2006: Chest Pain Destination: MAR

7. Interpretive algorithm

8. 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

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

10. ………you have seen one EMS System”

11. Figure 1. Trends in Emergency Department Operation and Closures in Urban Areas, 1990- 2009 Hsia, R. Y. et al. JAMA 2011;305:1978-1985 Copyright restrictions may apply. Ed Closures

12. 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

13. 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

14. LAC STEMI Receiving Centers (SRC) N=3 0

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

16. 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

17. Stenestrand U. JAMA 2006;296:1749-1756 Mortality reperfusion > 2h from symptom onset In-hospital lysis Pre-hospital lysis Primary PCI

18.  “ 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

19. 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)

20. In-hospital deaths/1000 patients treated compared with D2B<90 min. Nallamothu B. NEJM 2007;357:1631-1638

21. 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

22. Tipping Points  Medical Literature  Circulation June 2007

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

24. 30 >> 30 >> 30 Rule EMS >> ED >> Cath lab

25. Tipping Points  Hospital Best Practices Develop

26. 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;357:1631-1638  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

27. 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;357:1631-1638

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

29. 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

30. 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

31. 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

33. 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

34. Data Collection Web Based

36. IFT Transfer Form

38. Demographics  2009 2010 Q1Q2Q3Q4Q1Q2Q3Q4 PH ECG Positive 493487447486494468515524 Age65.764.764.865.766.465.16562 Male342312310 329320353362 Female151175137176165148162

39. median times

41. Hospital destination: median times

42. Cath Lab Activations

43. Interpretive algorithm

44. 12 Lead ECG Quality Artifact

45. 12 Lead ECG Quality Wavy Baseline

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

50. STEMI Interfacility Transfers: Median Times

51. Journal of Interventional Cardology January

52. 4 th Quarter 2010: IFT

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

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

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

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

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

59. End