1. The New Washington State Emergency Cardiac and Stroke System: Developing a Best Practice Plan for Your Community Bev McCullough Quality Improvement Manager, RHQN Kim Kelley, MSW Planning Coordinator, WA State DOH

2. The Washington State Emergency Cardiac and Stroke System: Creating Opportunities Together Kim Kelley, MSW Cardiac/Stroke Systems Coordinator WA State Department of Health Kim.kelley@doh.wa.gov

3. The Continuum of Care Prevention PrehospitalHospitalSecondary Prevention/ Rehabilitation System Evaluation

4. Working together across the continuum we can coordinate care and find efficiencies in the system to reduce time to treatment and improve outcomes for our patients. Creating Opportunities Together…

5. Washington’s Population is Aging Annual Change in Population Ages 65 and Over

6. Risk Factors Are Increasing

7. The Chain of Events Emergency Cardiac and Stroke System Physical Inactivity Poor Diet Tobacco Use Chronic Stress (Risk Factors) Diabetes Hypertension High Cholesterol Obesity (Diseases & Conditions) (Events/Deaths) Medical/Health Homes Healthy Communities

8. The Bottom Line A rapidly aging population and increasing rates of obesity, diabetes, and high blood pressure mean more people at risk for heart attack, cardiac arrest and stroke.

9. Emergency Cardiac and Stroke Care in Washington Problem: effective treatments are available--but too many people don’t get them at all or in time Only 4% strokes get t-PA Only 35 of 95 hospital administered t- PA Estimated 39% of heart attacks get PCI Only 55% of hospitals give lytics under 30 min OHCA survival rates very low

10. The Solution An organized system to get the right patient to the right place in the right time, just like we do for trauma.

12. D2B Time and Mortality

14. SSHB 2396 Passed 2010

15. System Components EMS protocols for the identification, treatment, and triage of ACS and stroke patients Hospital categorization Commitment to implement best practices to improve outcomes Data driven quality improvement across the system

17. Hospital Categorization Program 65 of 95 hospitals applied by 1/31/11 12 more applied by 5/31/11 Notice of categorization sent to all hospitals. List sent to Regional Councils, EMS Councils Lists will be on ECS website soon

18. STROKE CENTERS AND COVERAGE AREA 2007 I

19. STROKE CENTERS AND COVERAGE AREA 2011

20. CARDIAC CENTERS AND COVERAGE AREA 2007

21. CARDIAC CENTERS AND COVEREAGE AREA 2011

23. Quality Improvement SHB 2396: Requires QI of participating hospitals Allows the trauma QI programs to evaluate emergency cardiac and stroke care delivery

24. ECS System Measures and Goals 15 minutes on-scene time for EMS 30 minutes in transfer hospital (AMI) 30 minutes door-to-needle (lytics, AMI) 60 minutes door-to-t-PA (stroke) 90 minutes first medical contact (EMS or transfer hospital) to definitive treatment 120 minutes symptom onset to definitive treatment Participating hospital within 1 hour from every citizen Cardiac arrest goals - to be determined

25. Outcomes Discharge status Length of stay 30-day readmission/30-day mortality Immediate and one-year mortality Function at 3 months Quality of life Ejection fraction Neurologic status

26. What You Can Do… Make your hospital part of the prevention cycle. Educate your communities: CPR, signs and symptoms of heart attack and stroke, and to call 9-1-1 immediately. Become cardiac and stroke centers and implement best practices.

27. What You Can Do… Work with your EMS partners and fellow hospitals to create comprehensive regional systems. Collect data and use it to figure out what works and what doesn’t. Participate in the statewide ECS TAC.

28. Kim Kelley Cardiac/Stroke Systems Coordinator 360-236-3613 Kim.kelley@doh.wa.gov Thank you!

32. Kittitas Valley Community Hospital (KVCH) to Door to Balloon at Yakima Regional Medical & Coronary Center (YRMCC) > 2.5 HoursGoal < 90 minutes KVCH Throughput> 60 MinutesGoal < 30 minutes KVCH Door to EKG> 15 MinutesGoal < 5 minutes

33. Every patient taken to Kittitas Valley for initial assessment and stabilization EKG’s done by Respiratory Therapy only Chest X-Ray obtained “per protocol” EMS left the hospital, then were called back to transport patient to YRMCC Lab No partnerships established and varying “trust” of the assessment of our EMS providers Patients from KVCH taken to Yakima Reg. ED, reassessed & then cardiac cath team called

34. A focus on “what is right for the patient” All partners at the table to develop standardized protocols and training of EMS providers EKG performed in the field- if obvious STEMI and stable, EMS bypasses KVCH EMS notifies YRMCC directly - cath lab notified EMS bypasses Yakima ED - go directly to cath lab

35. Only unstable STEMI patients transported to KVCH Implemented a STEMI Alert Eliminated “wasteful” steps- Chest X-Ray Multiple staff trained to perform EKG EMS remains on scene when possible, ready to transport to YRMCC Cath Lab One call to YRMCC- single line for referrals

37. The call is dispatched for a patient experiencing chest pain. Volunteers from Cle Elum Fire Department respond, along with two off duty Medic One paramedics. Paramedics are on scene at 12:51 (<8 minutes from time of initial call). Patient diaphoretic and short of breath; reporting 10/10 substernal pain radiating to both arms. Transport from scene at 13:08.

39. At 13:10 12-Lead ECG transmitted to YRMCC STEMI protocol initiated. By 13:28, Cheryl received x3 NTG SL, 25mcg Fentanyl IVP 324 ASA PO, 600mg Plavix IVP and 5000 units Heparin IVP Patient reports being pain free by 13:30. 1336 Cath Team Called in to YRMCC 1415 Medic Unit arrived at YRMCC 1418 entered cath lab with team waiting for her

40. Upon arrival at cath lab: Reperfusion at 15:15

43. Transfer success of the STEMI Program to our Stroke Program EMS performs a FAST exam in the field and notifies KVCH of a “Stroke Alert” Developed a joint NIHSS- EMS initiates the NIHSS in the ambulance, ED staff utilize the same form to assess patient on arrival Patients taken directly to our CT, EMS reports to ED provider and RN cares for patient in CT “Door to CT” time <25 min in 75% of patients Average Door to CT Read = 30 minutes

45. Cheryl and attending paramedic Beth Williams; Winter, 2011.

46. Upper Kittitas County Medic One- HD #2 Cle Elum Fire Department Kittitas Valley Community Hospital Kittitas County EMS (KITTCOM Dispatch) Kittitas Valley Fire & Rescue Yakima Regional Medical & Cardiac Center Virginia Mason Medical Center (Stroke)

48. Rural “Best Practice”: Community Education Tom Martin, Administrator Lincoln Hospital Davenport, WA

49. Initial Level One Newspaper Ad

50. Cardiac Level One Brochure

51. Stroke Billboard/Poster

52. Lincoln’s Stroke Program Developing a program for the future Lincoln Hospital bridges the gap in rural healthcare with robotic doctor (Davenport, Wash. )— Lincoln Hospital has announced the placement of a remote physician presence robot that will expand the delivery of specialized health care to patients in their service area. On September 20 the robot will be active at Lincoln

53. Co-Managing Complex Patients The Accountable Health Home RHC & CAH Tertiary and Specialty Services Optimizing Quality Outcomes, Cost and Access

54. Lincoln’s Robot: Part of the Team

56. Washington Rural Emergency Cardiac and Stroke Systems……

57. Working together across the continuum we can coordinate care and find efficiencies in the system to reduce time to treatment and improve outcomes for our patients. Creating Opportunities Together…

58. Questions? Thank you to Kim, Paul, Rhonda and Tom!