1. Improving the System of Care for STEMI Patients
Mission: Lifeline is the American Heart Association’s national community based multidisciplinary initiative to advance the systems of care for patients with ST-segment elevation myocardial infarction (STEMI).
The overarching goal of the initiative is to reduce mortality and morbidity for STEMI patients to and improve their overall quality of care.

2. List of Commonly Used Terms
Electrocardiogram (ECG) A recorded tracing of the electrical activity of the heart
Percutaneous Coronary Intervention (PCI) A procedure used to open or widen narrowed or blocked blood vessels supplying the heart
ST-Elevation Myocardial Infarction (STEMI) A myocardial infarction for which the ECG shows ST-segment elevation, usually associated with a recently closed coronary artery
Fibrinolytic An agent used to facilitate fibrin breakdown
PCI Hospital/STEMI- Receiving Center Hospital that can perform primary PCI
Non-PCI Hospital/STEMI- Referral Center Hospital that cannot perform primary PCI and may transfer to a center for primary PCI or use fibrinolytics
Reperfusion The restoration of blood flow to an organ or tissue. PCI and fibrinolytics are two types of reperfusion strategies.
[NOTE TO PRESENTER: This slide should be used when presenting to non-clinical audiences.]
Here is a list of commonly used terms found throughout the presentation.

3. Partially blocked artery Completely blocked artery
Types of Heart Attack
Partially blocked artery
Non-STEMI
Non ST-elevation myocardial infarction
Partially blocked artery
Decreased blood flow to a portion of the heart
STEMI
ST-elevation myocardial infarction
Completely blocked artery
No blood flow to a portion of the heart
Substantial risk of death and disability
Critical need for quick reperfusion
Restoration of blood flow by reopening the blocked artery
Completely blocked artery
Coronary artery disease (CAD) and its most severe sequel -- acute myocardial infarction (AMI) or “heart attack” -- is the number one cause of mortality in western civilization. Risk factors for CAD are well described as modifiable- smoking, hypertension, hypercholesterolemia, and diabetes mellitus and those one can not modify -- genetics, increasing age, and male gender. STEMI accounts for approximately one third of patients presenting with acute coronary syndromes with an incidence of approximately 400,000/year in the Unites States. In this syndrome, an acute thrombosis adjacent to a ruptured atherosclerotic plaque completely occludes the coronary artery, resulting in ST-segment elevation in electrocardiogram leads overlying the involved myocardium. As muscle infarction and necrosis ensues, the treatment for STEMI involves rapid reestablishment of coronary flow by either primary percutaneous coronary intervention (PCI) (balloon angioplasty, usually accompanied by stenting) or by fibrinolysis- “clot-busting” drugs.
Myocardial infarction may be divided into two types based on the presenting 12-lead electrocardiogram (ECG) – non-STEMI or STEMI. To summarize and differentiate between the two entities of non-STEMI and STEMI:
In non-STEMI the pathogenesis is generally caused by a partially occlusive, platelet-rich thrombus in the coronary artery resulting in decreased blood flow to a portion of the heart.
In STEMI the pathogenesis is generally caused by a completely occlusive thrombus in a coronary artery. It results from stabilization of a platelet aggregate at the site of plaque rupture by a fibrin mesh network. There is no blood flow to a potion of the heart. In this type of heart attack there is a critical need for quick reperfusion- restoration of blood flow by reopening the blocked artery. 3 3

4. Reperfusion Strategies for STEMI
Plan A: percutaneous coronary intervention (primary PCI)
Mechanical means of restoring blood flow
Balloon angioplasty
Stents
More effective
Lower bleeding risk
Available at only 25% of U.S. hospitals
Treatment delays
Plan B: thrombolytics (fibrinolytics)
Pharmacologic means of restoring blood flow
“Clot-busting” drugs
Less effective
Greater bleeding risk
Widely available at U.S. hospitals
The ACC/AHA STEMI guidelines support two forms of reperfusion:
Plan A
The preferred reperfusion strategy for STEMI is the mechanical means of restoring blood flow to the coronary artery by primary percutaneous coronary intervention (PCI) including balloon angioplasty and, in most cases, the placement of intracoronary stents. This requires specialized invasive cardiac catheterization labs, interventional cardiologists, and trained cardiac catheterization staff. Primary PCI is preferred because it is more effective than pharmacological reperfusion and has a lower bleeding risk. In the United States, approximately 25% of acute care facilities can perform primary PCI but may not have the capability of providing the service at all hours of the day. Currently, there are considerable treatment delays for patients presenting to centers that do not have primary PCI capability.
Plan B
When patients cannot get to primary PCI within guideline goal times by EMS or transfer, pharmacological reperfusion with “clot-busting” drugs (fibrinolytics or thromobolytics) remains a strategy for restoring blood flow. It is less effective and has a greater bleeding risk. Use of fibrinolysis is widely available in U.S. hospitals as it is given intravenously.

5. Reperfusion Recommendations
III
IIa
IIb A
STEMI patients presenting to a hospital with PCI capability should be treated with primary PCI within 90 minutes of first medical contact.
STEMI patients presenting to a hospital without PCI capability and who cannot be transferred to a PCI center for intervention within 90 minutes of first medical contact should be treated with fibrinolytic therapy within 30 minutes of hospital presentation, unless contraindicated. I
III
IIa
IIb B
This slide lists the new updated ACC/AHA 2007 STEMI Reperfusion Recommendations.
ACC/AHA 2007 STEMI Focused Update
Circulation 2007; on line, December 10.

6. Barriers to Timely Reperfusion
The patient
Failure to promptly recognize symptoms
Hesitation to seek medical attention
Time to transport
Mandated delivery to the closest hospital, regardless of PCI capabilities
Long transport in rural areas
Decision process on arrival
Clot-busting drugs vs. PCI
Off hours
Transfer to PCI facility
Time to implement treatment strategy
Procedural factors
Team assembly
There are many barriers to timely reperfusion that require careful consideration and practical solutions by multidisciplinary system teams.
There are four main barriers to patients getting to the appropriate care.
1. The patient often fails to promptly recognize heart attack symptoms and call Despite many public awareness trials and public health initiatives, there is hesitation to seek medical attention -- STEMI patients have, on average, 2 hours of symptoms before arriving to a hospital. 50% of STEMI patients call for their symptoms. The other 50% self transport or have someone else drive them to the emergency department.
Time to transport – Local policies often mandate that ambulances must be routed to the nearest hospital – regardless if the hospital has the capability to perform PCI AND/OR patients in rural areas cannot get to a hospital with PCI in the recommended timeframe.
Decision on reperfusion strategy – If a STEMI patient arrives at a primary PCI center, the decision regarding the reperfusion strategy is an easy one – primary PCI. Only the issue of timeliness in off hours or simultaneous STEMIs with one team available remains problematic. Commitment to primary PCI at interventional capable hospitals is paramount. However, the decision process on arrival of the STEMI patient for reperfusion in a hospital without PCI needs to be predetermined. The hospital staff must decide if the STEMI patient will have timely transfer to a facility that provides primary PCI or be given fibrinolytics. In addition, in rural situations, STEMI patients that are fibrinolytic ineligible need urgent transfer, and use of medical air rescue should be considered.
Time to implement treatment strategy – Cardiac catheterization lab teams time for assembly and procedural issues can also pose additional issues for the STEMI patient.

7. The Reality of Today’s Patients
Not all STEMI patients call 9-1-1
50% of STEMI patients present to their local emergency department (ED)
“Walk-in” patients hinder:
Registration
Quick triage to electrocardiograms (ECG) for diagnosis
ECG privacy
Advance warning to activate hospital staff to prepare for reperfusion
Only 50% of STEMI patients call when they have heart attack symptoms. The other half present to their local emergency department (ED). When entering the ED by EMS, a heightened awareness of the heart attack is present and helps move the patient to rapid reperfusion.
A “walk-in” patient can be problematic in several arenas:
Registration clerks must understand the chest pain and chest pain equivalent symptoms and expedite these patients to triage.
Obtaining a 12-lead ECG on chest pain patients in heart attack is paramount. The guidelines recommend a 12-lead ECG within 10 minutes of arrival to the ED. In a space-limited ED, providing a private space in triage for obtaining a 12-lead can be challenging.
The importance of the EMS advance warning to activate hospital staff to prepare for reperfusion should be emphasized.

8. STEMI – Door-to-Balloon and Door-to-Needle Times Cumulative 12-Month Data from ACTION Registry
Please note the time to treatment goals in the most recent cumulative report from the ACTION-GWTG database leave us short of our guideline goals. Most concerning are patients presenting to non-PCI centers and transferring for primary PCI. Only 7% made first door-to-balloon time (DTB) in less than 90 minutes.
ACTION DATA: January 1, 2007 – December (n=19,523)
DTB = 1st door to balloon for primary PCI
DTN = Door to needle for lytics

9. ACTION Median Door-to-Balloon Times For Transfer In & Non-Transfer In Patients
250
240
236
230
220
223
215
212
210
200
190
180
170
169
160
158
150
151
156
Time (min)
140
130
123
120
120
116
110
103
102
113
100 96 95 90
This graphic depicts that while we are watching a decline in primary PCI D2B times, the transfer-in patient 1st DTB times are fairly static. 79 80 78 75 70 74 62 60 60 57 57 50 40 30 20 10
Q1 07
Q2 07
Q3 07
Q4 07
Transfer in DTB Times
Non-Transfer in DTB Times

10. How do we increase the number of patients with timely access
to reperfusion therapy?
Mission: Lifeline seeks to solve the question, “ How do we increase the number of patients with timely access to reperfusion therapy?”

11. A Life-Saving Initiative
National, community-based initiative
Goals
Improve quality of care and outcomes in heart attack patients
Improve health care system readiness and response
Mission: Lifeline is a national, community-based initiative designed to meet the needs of the STEMI patient throughout the continuum of care, beginning with the patient’s entry into the system (from symptom onset) through each component of the system, and return to the local community and physician for rehabilitative care.
Mission: Lifeline uses a community-based, multidisciplinary, patient-centric approach.
Mission: Lifeline is addressing systems of care for STEMI on multiple levels and through many collaborating organizations, starting with the STEMI patient and continuing through EMS, ED, STEMI Referral, and STEMI Receiving hospitals; implications for policy makers and third party payers are also being addressed within Mission: Lifeline.  
To meet the overarching goal, Mission: Lifeline will bring together the necessary partnerships between:
Patients and care givers
EMS
Physicians, nurses and other providers
Non-PCI capable (STEMI-referral) hospitals
PCI capable (STEMI-receiving) hospitals
Departments of health
EMS regulatory authority/Office of EMS
Rural health associations
Quality improvement organizations
State and local policymakers
Third-party payers
Health systems

12. Mission: Lifeline’s Guiding Principles
The initiative values:
Patient-centered care as the #1 priority
High-quality care that is safe, effective and timely
Stakeholder consensus
Increased operational efficiencies
Appropriate incentives for quality
Measureable patient outcomes
An evaluation mechanism
A role for local community hospitals
A reduction in disparities of healthcare delivery
Mission: Lifeline’s guiding principles will be upheld. Listed are the initiative values for review.

13. The Uniqueness of Mission: Lifeline
Mission: Lifeline will:
Promote the ideal STEMI systems of care
Help STEMI patients get the life-saving care they need in time
Bring together healthcare resources into an efficient, synergistic system
Improve overall quality of care
The initiative is unique in that it:
Addresses the continuum of care for STEMI patients
Preserves a role for the local STEMI-referral hospital
Understands the issues specific to rural communities
Promotes different solutions/protocols for rural vs. urban/suburban areas
Recognizes there is no “one-size-fits-all” solution
Knows the issues of implementing national recommendations on a community level
What Makes Mission: Lifeline Unique?
Mission: Lifeline:
Addresses continuum of care for STEMI patients from entry into the system, through the system, and back to local community and provider for secondary prevention.
Preserves a role for the community STEMI Referral hospital (non-PCI capable) -- one of Mission: Lifeline’s guiding principles
Understands the issues specific to rural communities and importance of promoting different solutions/protocols for rural versus urban/suburban areas
Understand the issues of implementing national recommendations on a community level (no “one size all” solution), considering local geography, resources, legislation, and regulation

14. STEMI Chain of Survival
Mission: Lifeline ultimately hopes to fix the broken chain of STEMI systems.
[NOTE TO PRESENTER: The below is taken from the 2008 AHA STEMI Provider Manual]
Reducing the time from onset of symptoms to establishment of coronary artery patency in STEMI is critical and embodies the concept “time is muscle.” The links in the STEMI chain of survival can be divided into four components:
Time from symptom onset until patient recognition and decision to seek medical help;
EMS activation, evaluation, treatment and transport;
ED evaluation and initiation of a reperfusion strategy; and
Pharmacologic or mechanical reperfusion therapy.

15. History 2004-2006 May 2004 June 2005 March 2006
AHA recruited an Advisory Working Group (AWG)
June 2005
Price Waterhouse Coopers presents its market research to AWG
March 2006
AWG Consensus Statement appears in Circulation
Stakeholders called to action
AWG develops a set of guiding principles
AHA held a conference of multidisciplinary groups involved in STEMI patient care
Here is a look at Mission: Lifeline’s history in brief.
In May 2004, the American Heart Association (AHA) recruited an Advisory Working Group (AWG) to evaluate the quality of care for all acute myocardial infarction patients and to explore the issue of increasing the number of STEMI patients with timely access to primary percutaneous intervention (PCI).
In June 2005, a market research study was conducted by Price Waterhouse Coopers in order to understand cardiac services for STEMI patients. The market research suggested that there was a recognized need to improve the systems of care for STEMI patients and that the American Heart Association should play a leading role in bringing together all of the constituents involved in the care of these patients. This research resulted in an AHA AWG Consensus Statement published in Circulation in 2006 and a stakeholder “Call to Action”.
In late March 2006, the American Heart Association convened a three-day conference with multidisciplinary groups of physicians (noninvasive and interventional cardiologists, cardiac surgeons, emergency care and critical care practitioners, internists), nurses, EMS personnel, community and tertiary hospital administrators (including representation from rural areas), payers, quality and outcomes experts, and government officials involved in the care of STEMI patients.
Circulation 2006;113:

16. History 2007-Present Early 2007 April 2007 May 2007 July 2008
Drafts of STEMI Systems of Care manuscripts are finalized
Action items for the AHA begin to take shape
April 2007
A cross-functional team was recruited to spearhead Mission: Lifeline
May 2007
Eleven manuscripts are published in Circulation
Mission: Lifeline was formally launched
July 2008
Affiliate Staff Kick-Off was held
The findings and recommendations of the March 2006 conference were published in Circulation: Journal of the American Heart Association in May These conference proceedings form the basis for Mission: Lifeline. The focus of the initiative is to increase the number of patients with timely access to primary PCI.
In July 2008, Mission: Lifeline held a staff kick-off that introduced close to 300 AHA staff to the Mission: Lifeline initiative. The staff represented almost all of the 50 states and all of the health strategies division of the organization.

17. The Ideal STEMI System of Care
Mission: Lifeline seeks to promote the ideal STEMI system of care in the United States. Public awareness and the patient factors of recognition of symptoms and calling will always be considered as important to the AHA and Mission: Lifeline. However, in the first phases of the initiative, the primary focus will be on:
Creating an ideal system of response of the healthcare team in all components of the system; and
Emergency Medical Services (EMS) and implementation of destination protocols for improving access to primary PCI by either EMS bypass of non-PCI hospitals for primary PCI hospitals or timely transfer from non-PCI hospitals to primary PCI hospitals.
Each hospital in the United States should have a plan in place for reperfusion and a back-up plan. Involvement of payers; health agencies; and local, state, and national policy makers will be critical to this initiative.
[OPTIONAL NOTE TO PRESENTER: Use Chain of Survival Picture?]

18. The Ideal Patient Patients and the public: The ideal system:
Recognize the symptoms of STEMI
Realize the importance of:
Activating emergency medical services (EMS) via promptly
Getting treatment quickly
Are familiar with their local hospital’s role in STEMI care
Understand the implications of inter-hospital transfer for PCI
The ideal system:
Promotes culturally competent education efforts
Includes patient representatives on community planning coalitions
Provides coordinated and patient-centered care
In the ideal system, patients and the public would recognize the symptoms of STEMI and the importance of time to treatment, activate EMS promptly, be familiar with their community hospital’s role in the delivery of STEMI care, and understand the implications involved in inter-hospital (rapid) transfer for PCI.
The ideal system promotes culturally competent education efforts, includes patient representatives on community planning coalitions, and provides coordinated and patient-centered care.

19. The Ideal EMS In an ideal system:
Ambulances are equipped with 12-lead ECG machines
EMS providers are trained to:
Use and transmit 12-lead ECGs
Care for STEMI patients
Provide feedback on performance and compliance with guidelines
Standardized point-of-entry (POE) protocols define patient transport rules
When there is STEMI, the cath lab is activated promptly
Patients transported to a STEMI-referral hospital remain on the stretcher with EMS present pending a transport decision
When “walk-in” patients present to a STEMI-referral hospital and require primary PCI, activation of EMS occurs
Hospitals close the communication gap with EMS
In the ideal system for EMS, standardized point-of-entry (POE) protocols (created by regional or state-based coalitions of EMS personnel, emergency physicians and nurses, and cardiologists and supported by payers and administrators) would advocate which patients are transported to the nearest hospital and which patients are transported to the nearest primary PCI/STEMI-receiving hospital based in part on the acquisition, interpretation, and transmission of a pre-hospital 12-lead ECG. EMS plays a role in activating the primary PCI staff when proper equipment, training in 12-leads ECG interpretation and relaying the 12-lead information with adequate medical control is in place to STEMI-receiving hospital.
If EMS takes patient to a non-PCI or STEMI-referral hospital, a strategy of leaving the patient on the EMS stretcher with EMS present for potential STEMI transfer to STEMI-receiving hospital would be time saving.
In addition, when walk-in patients present to STEMI-referral hospital in need of primary PCI, activation of EMS, as in a call to 9-1-1, to transport should occur.

20. The Ideal STEMI-Referral Hospital
In an ideal system:
Standardized POE protocols dictate transport of STEMI patients directly to a STEMI-receiving hospital based on:
Specific criteria for risk
Contraindications to fibrinolysis
The proximity of the nearest PCI service
Patients presenting to a STEMI-referral hospital are treated according to standardized triage and transfer protocols
Incentives are provided to rapidly:
Treat STEMI patients in accordance with ACC/AHA guidelines
Transfer to a STEMI-receiving hospital for primary PCI using:
Reperfusion checklists
Standard pharmacological regimens and order sets
Clinical pathways
There is rapid and efficient data transfer, data collection and feedback
Integrated plans for return of the patient to the community for care are provided
In the ideal system, standardized point-of-entry (POE) protocols would dictate those STEMI patients to be transported directly to a STEMI-receiving hospital based on specific criteria for risk, contraindications to fibrinolysis, and the proximity of the nearest PCI service.
Standardized triage and transfer protocols are in place for patients presenting to a STEMI-referral hospital.
Alignment of patient outcome and financial incentives are provided to:
Rapidly treat STEMI in accordance with ACC/AHA guidelines;
Transfer to a STEMI-receiving hospital for primary PCI using reperfusion checklist in regions that do not readily have access to STEMI-receiving hospitals, standardized pharmacological regimens, order sets and clinical pathways;
There is rapid and efficient data transfer, data collection and feedback; and
Integrated plans for return to the community for care are provided.

21. The Ideal STEMI-Receiving Hospital
In an ideal system:
Pre-hospital ECG diagnosis of STEMI, ED notification and cath lab activation occurs according to standard algorithms
Algorithms facilitate:
A short ED stay for the STEMI patient
Transport directly from the field to the cath lab
Single-call systems from STEMI-referral hospitals immediately activate the cath lab
Primary PCI is provided as routine treatment for STEMI 24, 7
STEMI-receiving hospital’s administration puts their support in writing
A multidisciplinary team meets regularly to identify and solve problems
A continuing education program is designed and instituted
A mechanism for monitoring performance, process measures and patient outcomes is established
In the ideal system, pre-hospital ECG diagnosis of STEMI, ED notification and catheterization laboratory activation would occur according to standard algorithms that would facilitate a brief ED stay or transport directly from the field to the catheterization laboratory. Single-call in systems from STEMI-referral hospitals (and potentially progressive EMS) would allow “one-call” to put in motion the staff at the STEMI-receiving center to be ready to accept the outside STEMI ASAP.
In addition:
The STEMI-receiving center should ensure that primary PCI is provided as routine treatment for STEMI 24 hours, 7 days a week;
The hospital’s administration puts their support in writing;
A multidisciplinary team meets regularly to identify and solve problems;
There is a continuing education program designed and instituted for staff; and
There is an established mechanism for monitoring performance, process measures and patient outcomes.

22. POE Protocol
Patient point-of-entry (POE) protocols should be developed with the understanding that a patient may call and be in an EMS zone that transports to a STEMI-referral or STEMI-receiving hospital. Also, patients may directly present to a non-PCI center and be in need of inter-hospital transfer or present to a primary PCI center.
The ACC/AHA guidelines encourage EMS on scene be equipped with 12-Lead ECG technology. Advanced systems may consider pre-hospital fibrinolysis, but the majority in the U.S. EMS should have a destination protocol in place.
[Note to Presenter: Following text from the 2004 Full Text STEMI ACC/AHA Guidelines caption (pg 19).]
Patient transported by EMS after calling
1: Reperfusion in patients with STEMI can be accomplished by the pharmacologic (fibrinolysis) or catheter-based (primary PCI) approaches. Implementation of these strategies varies based on the mode of transportation of the patient and capabilities at the receiving hospital. Transport time to the hospital is variable from case to case, but the goal is to keep total ischemic time within 120 minutes. There are three possibilities:
a) If EMS has fibrinolytic capability and the patient qualifies for therapy, pre-hospital fibrinolysis should be started within 30 minutes of EMS arrival on scene;
b) If EMS is not capable of administering pre-hospital fibrinolysis and the patient is transported to a non-PCI-capable hospital, the hospital door-to-needle time should be within 30 minutes for patients in whom fibrinolysis is indicated;
c) If EMS is not capable of administering pre-hospital fibrinolysis and the patient is transported to a PCI-capable hospital, the hospital door-to-balloon time should be within 90 minutes.
Inter-hospital transfer:
It is also appropriate to consider emergency inter-hospital transfer of the patient to a PCI-capable hospital for mechanical revascularization if:
1: There is a contraindication to fibrinolysis;
2: PCI can be initiated promptly (within 90 minutes after the patient presented to the initial receiving hospital or within 60 minutes compared to when fibrinolysis with a fibrin-specific agent could be initiated at the initial receiving hospital); fibrinolysis is administered and is unsuccessful (i.e.,"rescue PCI").
Secondary non-emergency inter-hospital transfer can be considered for recurrent ischemia.
Patient self transport:
Patient self-transportation is discouraged. If the patient arrives at a non-PCI capable hospital, the door-to-needle time should within 30 minutes. If the patient arrives at a PCI-capable hospital, the door-to-balloon time should be within 90 minutes. The treatment options and time recommended after first hospital arrival are the same.

23. Coordinated Actions Assess and improve the EMS system
Evaluate existing STEMI system models
Establish local initiatives
Explore the possibility of developing a national STEMI-certification program and/or criteria
Launch Mission: Lifeline awareness campaigns
Create system resources
Engage strategic alliances
Listed here are action items that Mission: Lifeline is currently promoting.

24. Partners for Success Patients and care givers EMS providers
Physicians, nurses and other providers
STEM-referral (non-PCI) hospitals
STEMI-receiving (PCI-capable) hospitals
Health systems
Departments of health
EMS regulatory authority / office of EMS
Rural health associations
Quality improvement organizations
Third-party payers
State and local policymakers
All partners listed are suggested. For your region, additional partners may be necessary for the promotion of regional systems.

25. EMS System Assessment & Improvement
AHA is:
Collaborating with EMS organizations in a needs assessment
Analyzing EMS effectiveness when responding to STEMI patients
Developing a plan to build tailored STEMI systems of care
Affiliate AHA staff will be engaging along with EMS agency representatives from across the United States in an EMS survey assessment. The EMS Assessment strives to understand the current barriers and gaps that must be addressed in order to create an ideal system of care for STEMI and stroke patients. All responses will provide valuable information to help the American Heart Association assess EMS needs for all areas of the United States. The results of this national survey should be available after the first of the year (2009).
Based on the outcomes of the assessment responses, Mission: Lifeline will facilitate the development of a plan to build a system to serve STEMI patients that can be tailored, when necessary, to the appropriate region or state.

26. STEMI System Evaluation & Registration
Online questionnaire
Is accessible from the Mission: Lifeline web site
Examines local and regional STEMI system models
Locale
Processes of care
Financial considerations
Resource allocation
Benefits
Input can help Mission: Lifeline target system issues where improvements will yield the greatest results
STEMI Systems across the United States are asked to participate in a STEMI System Assessment. The survey is designed to understand the types of system that currently exist. The survey is geared toward STEMI systems.
A "STEMI system" is an integrated group of separate entities focused on reperfusion therapy for STEMI within a region that typically includes emergency medical services (EMS) providers, at least one community (non-PCI) hospital and at least one tertiary (PCI) center.  
The system may include one or more of the following elements:
Leadership teams of EMS, emergency medicine, cardiology, nursing and administration;
Standardized communication (i.e. STEMI alert system);
Standardized transportation; and
Data collection and feedback.  
Please note: In some systems, there may be a single hospital with PCI capabilities that has established protocols with EMS providers and contains the elements stated above.
If you have not registered your STEMI System with Mission: Lifeline, please access the web site and submit your system’s information. This will provide you with benefits of the Mission: Lifeline newsletter, AHA’s social networking platform, and other STEMI information.

27. Local Initiatives The American Heart Association is:
Convening a task force at state and local levels
Helping identify ways to implement national recommendations for STEMI systems in local communities
Registering STEMI systems with the Mission: Lifeline directory
This slide provides a listing of local activities that will help professionals become engaged at the local level.

28. STEMI Certification & Recognition
The American Heart Association will:
Develop recommendations for a certification program
Generate and publish criteria to define a:
STEMI system of care
EMS
Non-PCI hospital
PCI hospital
Support policy approaches that advance the development of STEMI systems
Develop a recognition program to:
Salute health care teams who comply with guidelines
Commend STEMI systems for raising quality of care
Help compliant hospitals differentiate themselves
Motivate more health care providers to embrace the Mission: Lifeline standards
The Mission: Lifeline leadership team is committed to the development of a certification and recognition program for STEMI systems of care and each component of the system (EMS, non-PCI, PCI).
The American Heart Association will:
Develop recommendations for a certification program;
Generate and publish criteria to define a STEMI system of care, EMS, Non-PCI hospital, PCI hospital;
Support policy approaches that advance the development of STEMI systems;
Develop a recognition program to:
-Salute health care teams who comply with guidelines;
-Commend STEMI systems for raising quality of care;
-Help compliant hospitals differentiate themselves; and
-Motivate more health care providers to embrace the Mission: Lifeline standards.

29. Implementation Plan Please visit www.americanheart.org/missionlifeline
For each component of the system, Mission: Lifeline will:
Define the ideal practice
Recommend strategies to achieve the ideal practice
Provide resources/tools to achieve the ideal practice
Recommend metrics for structure, process and outcomes
Recommend criteria for recognition and certification
The implementation phase will include:
Defining the ideal practice;
Recommending strategies to achieve the ideal practice;
Providing resources/tools to achieve the ideal practice;
Recommending metrics for structure, process and outcomes; and
Recommending criteria for recognition and certification.
The new “What is Mission: Lifeline” tool is available for your review via worldwide web.

30. Implementation Phase 1
Based on your Mission: Lifeline implementation plans, this map depicts the first phase of full Mission: Lifeline implementation. The red states and metro area dots indicate that the AHA will attempt to place actual Mission: Lifeline dedicated staff/resources. These areas were evaluated and identified through an extensive readiness tool (existence of STEMI component champions, regional support, local-state advocacy, some STEMI system work in place, etc.).
If your area is not in red, that does not mean Mission: Lifeline activities are not present. The AHA has state health alliance, quality, advocacy, emergency cardiovascular care staff and development staff in place that will have Mission: Lifeline integrated activities as part of their job this year. Reach out to an AHA staff member in your state to find out what is going on in Mission: Lifeline in your area of the country.

31. Implementation Phase 2
The next two slides depict the vision for what the next two implementation phases will look like. It is important to note that while the majority of the first phase will be funded with our internal AHA commitment, the majority of phase 2 and 3 will not be possible without fundraising for external dollars.
If we do this right -- if the first phase is executed with the right resources and measured impact -- that will become our case for support to raise the significant additional dollars that will be needed to cover the rest of the country.

32. Implementation Phase 3
At the end of a 3- to 5-year implementation, we believe that we can cover the entire country – so no matter where you live, the system is there to support you.
This accomplishment will be quite impressive, and no other organization is positioned to make this happen.
The resources you have dedicated today will make this dream become a reality and we will literally save lives.

33. How will we measure our impact?
ACTION Registry–GWTG will be the largest and most comprehensive national AMI patient database ever developed by the medical profession. It will establish a national standard for understanding and improving the quality, safety and outcomes of care provided for patients with coronary artery disease, specifically, high-risk STEMI and non-STEMI patients.

34. Mission: Lifeline Metrics Data Sources
EMS
EMS assessment (NAEMSO and local assessments)
ACTION/Get With The Guidelines (GWTG)
NEMSIS
Emergency department
ACTION/GWTG “Non-PCI Version”
STEMI-receiving (PCI-capable) hospitals
ACTION/GWTG
NCDR CATH/PCI registry
Mission: Lifeline metrics will be evaluated predominantly though the ACC/AHA tool ACTION Registry-GWTG. There is a new version 2 available, and you may review it on the NCDR web site.
A non-PCI version of STEMI-only data will be available in the new year to evaluate STEMI care in the emergency department and at discharge for institutions just getting started in integrating QI into their STEMI population.
STEMI-receiving centers have been encouraged to participate in both NCDR Cath/PCI registry and ACTION-GTWG.
EMS data needs to be integrated into the system assessment. Tools are being evaluated and piloted so that this area of Mission: Lifeline metrics will be highlighted.

35. Who is Mission: Lifeline?
Mission: Lifeline leadership involves strong volunteer direction. The volunteer structure includes volunteer AWG. Model Evaluation and the ECC Task Force headed by Robert O’Connor. 35

36. Administrative Structure
Advisory
Working Group
Chair: Alice Jacobs, MD
ECC
Task Force
Chair: Robert O'Conner, MD
Model Evaluation
Task Force
Chair: Elliott Antman, MD
The three volunteer committees that steer the Mission: Lifeline initiative include the Advisory Working Group (AWG), the ECC Task Force and the Model Evaluation Task Force. 36

37. Administrative Structure
Elliott Antman, MD
Bob O’Connor, MD
Gray Ellrodt, MD
Chris Granger, MD (VC)
Mary Hand, RN
Tim Henry, MD
Neil Meltzer
Bob Harrington, MD
George Mensah, MD
Jean McSweeny, pHD, RN
Eric Peterson, MD
David Williams, MD
Advisory
Working Group
Chair: Alice Jacobs, MD
Advisory Working Group team members are shown here. [VC = vice chair]"

38. Administrative Structure
David Burt, MD
Graham Nichol, MD (VC)
Lee Garvey, MD
Louis Gonzalas, EMT-P
David Larson, MD
Peter Moyer, MD
Ivan Rokos, MD
Michael Sayer, MD
Robert Solomon, MD
Gary Windgrove, EMT-P
ECC
Task Force
Chair: Robert O'Conner, MD
These volunteers make up the ECC Task Force.

39. Administrative Structure
Peter Berger, MD
Chris Granger, MD
Tim Henry, MD
James Jollis, MD (VC)
Peter Moyer, MD
Frank Pratt, MD
Ivan Rokos, MD
John Rumsfeld, MD
Model Evaluation
Task Force
Chair: Elliott Antman, MD
The Model Evaluation Task Force includes these members.

40. State Health Alliances Cultural Health Initiatives
AHA Staff
State Advocacy
State Health Alliances
Communications
Mission: Lifeline
Quality Improvement
Development
This slide identifies all of the AHA business units that are necessary to further Mission: Lifeline
Cultural Health Initiatives
ECC

41. Organizational Commitment
Current model = Partial staff dedication
State-level and hospital clinical quality improvement (QI) support
State Health Alliance staff
State Advocacy staff
Quality Improvement staff
Emergency Cardiovascular Care (ECC) Community Strategies managers
Training of existing resources
Initiative fundraising
Current model = State-level and hospital clinical QI support
Programmatic support
Stakeholder meetings and/or planning in all 50 states
ACTION/GWTG regional workshops
Reactive advocacy agendas
The AHA has committed extensive financial and staff resources to the Mission: Lifeline initiative.
This slide outlines this commitment.

42. Increased Organizational Commitment
State-level and hospital clinical quality improvement support
PLUS
Affiliate-level and market-level dedicated Mission: Lifeline resources
As an organization, AHA is committed to Mission: Lifeline. We will provide state-level and hospital clinical quality improvement support plus affiliate- and market-level dedicated Mission: Lifeline resources.

43. Strategic Alliances Aetna American Ambulance Association
American Association of Critical Care Nurses
American College of Cardiology
American College of Emergency Physicians
Centers for Medicare and Medicaid Services
Emergency Nurses Association
National Association of Emergency Medical Technicians
National Association of EMS Physicians
National Association of State EMS Officials
National EMS Information System Project
National Rural Health Association
Society for Cardiovascular Angiography and Interventions
Society of Chest Pain Centers
Society of Thoracic Surgeons
UnitedHealthNetworks
These organizations have endorsed the 2007 “11 Development of Systems of Care Conference Proceedings.”
Currently, Mission: Lifeline seeks to increase the professional strategic alliances on a national level. Regional support for Mission: Lifeline may vary.

44. Registered STEMI Systems
Every day, new systems from all areas of the United States register with Mission: Lifeline.
STEMI systems will improve the quality of care for all myocardial infarction patients.
Any healthcare professional wanting to improve the quality of care of all myocardial infarction patients can be a part of Mission: Lifeline.
For healthcare professionals, if you:
are already a part of a STEMI System*
and
attend regular quality improvement meetings with your STEMI system
have a system champion** who can represent your STEMI system
then you are already part of Mission: Lifeline.
Your system is encouraged to register with Mission: Lifeline so you can help the AHA gain a more thorough understanding of system issues.
For those that are not part of a STEMI System, Mission: Lifeline encourages you to cooperate with your hospitals, health agencies, professional organizations, EMS entities – and most of all your local AHA office – to help build a regional system to reduce the barriers to timely care. Mission: Lifeline has the tools to help you get started.

45. [Closing/questions slide]