1. Presenter Disclosure Information Kevin Daniel, RN, CEN Clinical Data Supervisor Northside Hospital System Metro Atlanta Mission Lifeline Quality & Data Co-Chair Atlanta, Georgia 1 FINANCIAL DISCLOSURE: No relevant financial relationship exists

2. 2 Objectives Demonstrate how participating in the ACTION registry improves ED/Hospital performance and patient outcomes by adhering to the AHA/ACC GWTG guidelines. Identify the inclusion and exclusion criteria of the ACTION registry and Mission: Lifeline using data abstraction guidelines.

4. 542 STEMI patients 66% were Direct Presenters 34% were Transfers STEMI Referral to STEMI Receiving center. 5%  Q2 2013

5. 18 Hospitals TN Region 22 Hospitals TN Region

8. 7 min  Q2 2013

11. Pre-Hospital Activation is key in reducing ED times & Achieving FMC to Device in < 90 min

13. Longest PCI Time Shortest PCI Time 75 th Percentile Median PCI Time Average PCI Time 25 th Percentile Box and Whisker Plots

14. System Median Time 83mins

16. heart.org/missionlifeline

17. Click Regional Report Glossary

19. Critical Process Timelines: First Medical Contact to Device for Non-Transfers Arriving via Ambulance (pages 5-6) VariableDefinitionInclusion/Exclusion Criteria First Medical Contact to Device Activation (Direct Presentation EMS Only)  Transferred from Outside Facility = No  Means of Transport to First Facility = Ambulance  Median Time in Minutes (current quarter) o First Medical Contact to Door (Arrival date/time) – (Pre-arrival 1st Medical Contact date/time) o Door to Arrival at Cath Lab (Cath Lab Arrival date/time) – (Arrival date/time) o Arrival at Cath Lab to Device Activation (First Device Activation date/time) – (Cath Lab Arrival date/time) o First Medical Contact to Device Activation (National Median) (First Device Activation date/time) – (Pre-arrival 1st Medical Contact date/time)  All STEMI patients indicated for immediate primary PCI, excluding transfers in, patients with STEMI diagnosed on subsequent ECG, patients administered thrombolytics, documented non-system reason for delay in PCI, and FMC to PCI > 12 hours.  Patients may have missing or negative values for specific time intervals, which excludes them from ONLY the affected intervals. All other intervals with valid date/time data are included in the graph  Includes all direct presenters arriving via Ambulance only; Mobile ICU and Air transport are not included. First Medical Contact to Device Activation Transferred from Outside Facility = No Means of Transport to First Facility = Ambulance  Distribution of Times in Minutes (current quarter)  First Medical Contact to Device Activation (First Device Activation date/time) – (Pre-arrival 1st Medical Contact date/time)  All STEMI patients indicated for immediate primary PCI, and had a reported first device activation date/time after first medical contact, excluding transfers-in, patients with STEMI diagnosed on subsequent ECG, patients administered thrombolytics, documented non- system reason for delay in PCI, and FMC to PCI time > 12 hours.  Includes all direct presenters arriving via Ambulance only; Mobile ICU and Air transport are not included. Graph on Page 5 Regional Report Graph on Page 6 Regional Report EMS = Ambulance only, does not include Mobile ICU or Air transport POV = Personally Operated Vehicle (i.e., self/family transport) FMC = First Medical Contact - 7 - Confidential Information (ver 09/24/2013) 3110 3100 32013105 & 3106 4030 7101 & 71023201 7103 & 71047101 & 7102 7103 & 7104 3105 & 3106 7100 & 7109 & 80003110 4041 8020 7110 3100 3110 3100 7103 & 7104 4030 7100 & 7109 & 8000 3110 4041 8020 7110 3100

22. Pre-Hosp ECG obtained on 72% of STEMI pts arriving by EMS

24. 26% of STEMI pts who walk in to ED’s are waiting for more than 10 minutes for their first ECG

27.  Recommended DIDO 30 min  If expected delays D2B >120 mins give Lytics

28. Median Time 125 mins

31. Median Time

32. Prehospital activation is the most important thing that EMS can do to increase the chance that a STEMI patient will achieve FMC to device in < 90 mins. EMS must work to increase the rate of obtaining field ECGs in patients with suspected STEMI. Successful prehospital activation depends on calling the ED as soon as STEMI is recognized on the field ECG. Transmission of the field ECG is secondary and should not delay a phone call to alert the ED of a “code STEMI”. Take home points: Direct presentation by EMS

33. If there is a nearby STEMI receiving center (24/7 PCI center), EMS should bypass referral centers and go directly to receiving centers. Centers that transfer STEMI patients and/or receive these transfer patients must work together to reduce Door-in-door-out time and reduce patient transport times to the STEMI receiving facility. If anticipated Door-to-Door-to-Device time > 120 minutes, give fibrinolytic at the first hospital. Take home points: Transfers