1. Improved Care for Acute Myocardial Infarction Linking Referral and Receiving Centres – How can We Communicate Better? Dr. James McMeekin AMI Faculty Cardiologist, Foothills Medical Centre, Calgary Health Region

2. Improved Care for Acute Myocardial Infarction- Outline 1. History of the Calgary Health Region STEMI Project - a system approach 2. Changing reperfusion management in the STEMI Population 3. New directions- STEMI project in the Rural Calgary Health Region

3. History of the CHR STEMI Project 2003 –STEMI project (STrategic Evaluation and Management of ST Elevation MI) initiated by Cardiology Interventional group –willing to be on call 24/7 for Direct PCI for STEMI population –Approached QI Council to make it a QI project

4. Calgary’s STEMI initiative Goals 1. Develop a comprehensive management model for ST Elevation MI 2. Optimize the use of timely reperfusion therapy and use PCI as the primary reperfusion therapy whenever possible (60-90 minutes) 3. Initiate an early discharge program for low risk patients 4. Improve and coordinate discharge and access to out patient care/community care

5. 1. Develop a comprehensive management model for ST Elevation MI Many players- EMS, ED, Cardiac Cath Lab, CCU Many meetings Many lessons

6. P = 0.02P < 0.001 2. Optimize the use of timely reperfusion therapy

7. 3. Initiate an early discharge program for low risk patients Develop criteria for a low risk post STEMI group for discharge on day 2 - 3 Ensure all discharge planning is covered whether in hospital or in community Track this low risk group in AMI data base

8. Objectives 1. To use the Cadillac trial Risk Score to determine risk groups in our STEMI population. 2. To monitor length of stay (LOS) and complication rates in each risk group. 3. To understand reasons (clinical and operational) why patients were not discharged within the target.

9. The Cadillac (Controlled Abciximab Device Investigation to Lower Late Angioplasty Complications) Risk Stratification Score (J Am Coll Cardiol 2005; 45: 1397-1405). Risk Factor Baseline LVEF < 40% Renal Insufficiency Killip Class ≥2 Final TIMI Flow ≤2 Age > 65 years Anemia 3 Vessel Disease Score Range: Score433222_2_0-18

10. Cadillac Risk Score Characteristics Risk Low Intermediate High Risk Score 0-2 3-5 ≥6 1 yr mortality 12% D/C Target 2-3 4-5 Clinical (Days) judgment JACC 2005;45: 1397-1405

11. Patient Characteristics 297 consecutive STEMI patients were assigned risk scores between Jan. 25, 2006 and Jan 31, 2007. Risk Low (0-2) Interm (3-5) High (>5) n 148 78 71 Mean Age 58* 63** 68* ** Male 77% 74% 64% * **p<.05

12. Patient Characteristics RISK Group LOW Intermediate HIGH DM15% 22% 25% HTN39% 50% 46% Smoker41% 38% 30% Prev MI11% 9% 22% Prev PCI10% 10% 16% Prev CABG 1% 0% 3% Stroke 3% 6% 7% Killip Class ≥2 0%* 13%** 26%* ** * **p<.05

13. Length of Stay * ** * ** p <.05 *

14. In Hospital Complications excluding Death * * * p<.05

15. In Hospital Death * * * p <.05

16. 30 Day Complications Including Death * * *p<.05

17. Percent Discharged by Target Risk Group: Low (≤3 d) Interm (≤5d) High (≥6d) 28% 50% N/A 28% 50% N/A

18. Low Risk Group 104/148 low risk patients were not discharged by the target of 3 days ( 72%) Of the 104 patients, the reason for delay in discharge was analyzed: clinical (65 pts) and operational issues (39 pts) were identified (system issues with potential for improvement)

19. Clinical Delays to Discharge n=65

20. Operational Delays to Discharge n=39/104 Operational Delays to Discharge n=39/104

21. Conclusions 1. The CRS predicts complications in the risk groups well and ability to discharge a low risk population, early after STEMI, only modestly well. 2. There are operational factors that may contribute to prolonged hospital stays. 3. Targeting these factors with improvement strategies may shorten the length of stay.

22. 4. Improve and coordinate discharge and access to out patient care/community care –Nurse clinicians in CCU identify low risk patients through the risk score –Patient referred for follow-up and medical assessment in a Nurse run STEMI clinic 1 week after discharge –Automatic referral to Cardiac Rehabilitation program

23. History of the CHR STEMI Project 2005-6- moved STEMI ‘Project’ into day to day operation Bimonthly meetings –review of results, outliers, review the flow diagram when changes needed Results still awesome- 80% receive 1 st flow within 90 min of presentation

24. Changing reperfusion management in the STEMI Population Who receives fibrinolytic therapy? Who receives rescue PCI? What adjuvant therapy is appropriate?

25. Time is Muscle The longer the clot has matured in the coronary artery, the more difficult it is for a fibrinolytic agent to work. Optimal window - first 3 hours after symptom onset. During this 3-hour window, fibrinolytic therapy and primary PCI have about the same efficacy in terms of limiting mortality.

26. Time is Muscle Beyond the first 3 hours, primary PCI becomes the preferred strategy because it can salvage myocardium more effectively than fibrinolytic therapy. The goal is to get the patient quickly to where pharmacologic reperfusion is available or to create a situation (system) where the patient can be transported rapidly to a primary PCI center.

27. Reperfusion Options for STEMI Pts Step One: Assess Time and Risk Time Since Symptoms Time Required to Initiate Invasive Strategy Risk of STEMI Risk of Lysis

28. PCI FOR AMI STRATEGIES Primary PCI Preferred strategy Rescue PCI Clinical benefit in moderate to large MI Facilitated PCI No proven benefit Likely harmful Immediate PCI Superior to watchful waiting

29. 3. New directions- STEMI project in the Rural Calgary Health Region

30. Southern Alberta STEMI initiative Early diagnosis of STEMI with field ECG Timely communication between field EMS and local hub /emergency dept Use of technology to transmit ECG Treatment pathway is initiated in the field or local centre Early risk stratification with expedited access to tertiary care for high risk patients Streamline referral process to expedite access to angiography/CV service Rapid patient repatriation

31. High River STEMI Emergency Department January 15, 2008 (revision due date 3, 6 and 12 months post implementation) MUSE

32. MUSE (Marquette Universal System for ECG’s) Calgary Health Region’s Electronic ECG Repository

33. HOW ECG’S ARE TRANSMITTED TO CALGARY HEALTH REGION’S MUSE DATABASE MUSE ECG User with remote access to MUSE WEB can view the ECG “online” ECG’s TRANSMITTED DIRECTLY FROM EMS PROVIDERS IN THE FIELD - URBAN AND RURAL – TOTAL OF 14 EMS PROVIDERS MUSE ECG’s TRANSMITTED FROM CHR RURAL HEALTH CARE FACILITIES (VIA ECG CART OR BEDSIDE MONITOR) – TOTAL OF 14 SITES

34. Timeliness: ECG acquisition and ability to view it online 01:22 01:27

35. BENEFITS OF THE HEART ALERT MUSE INITIATIVE Heart Alert’s MUSE initiative affords the Region’s Rural patients Early consultation Improved access to care Access to historical and real time clinical information (ECG transmission)

36. Pathway Principles Primary Percutaneous Coronary Intervention Eligibility Criteria Onset less than 12 Hours Onset defined as beginning of symptoms leading to patient seeking medical attention

37. Pathway Principles Onset between 1-3 Hours Primary Percutaneous Coronary Intervention if transport to Catheterization Lab guaranteed within 60 minutes from EDMD Assessment

38. Pathway Principles Onset 3 – 6 Hours Primary Percutaneous Coronary Intervention Preferred Fibrinolytic Therapy may be recommended by Cardiac Interventionalist if no contraindications or PPCI is delayed

39. Pathway Principles Onset 6 - 12 Hours Primary Percutaneous Coronary Intervention Preferred

40. Pathway Principles Onset Greater than 12 Hours, continued symptoms, ST Elevation and/or Hemodynamic Instability Contact Cardiac Interventionalist via SARCC regarding plan of care Angiogram with or without Angioplasty

41. Conclusions System models for Coronary reperfusion are necessary for optimal care in our STEMI population Should we consider the ‘System Approach for STEMI Patients’ as a risk indicator for assessment of AMI programs? Spreading this system model to the rural population is our next challenge. Should it be considered elsewhere?