1. Chattanooga/TriState Regional Update 2015 Robert L. Huang, MD MPH UT Erlanger Health System

2. Disclosures None relevant to this lecture

3. 2015

5. PCI Hospital Non-PCI Hospital

9. Challenges in Creating a Regional Network As seen from the maps, we cover a very large region and up to 5 states (KY, TN, GA, AL, NC). Weather, topography, limited resources Patient Delay and Recognition Regional Variation in EMS protocols Regional Variation in STEMI receiving centers Regional Variation in STEMI transferring centers

10. Barriers to Timely Reperfusion The Patient –Hesitation to seek medical attention –Transported to E.D. by private vehicle Time to transport/EMS –Delivery to the closest hospital by EMS, regardless of PCI capabilities –Long transport in rural areas –Limited Resources STEMI Referral Hospitals –Reticence to use Thrombolytics –Delay in Transfer to PCI facility STEMI Receiving Hospitals –Multiple Thrombolytic and transport protocols

11. Tri-State Regional STEMI Taskforce Charter Mission Statement: The mission of the Tri-State Regional STEMI Taskforce is to improve the quality of care and outcomes in acute coronary syndrome patients through a uniform readiness and response to ST-Elevated Myocardial Infarction (STEMI) patients. Purpose: The Tri-State Regional STEMI Taskforce is a multi- disciplinary, multi-organizational group of healthcare providers focused on decreasing the time to reperfusion therapy, reducing inefficiencies, optimizing resources for patients with ST-Elevated Myocardial Infarctions, and caring for the patent with acute coronary syndrome.

12. EMS/Helicopter Services Provide Educational Resources to EMS providers –Use and transmission of 12-lead ECGs –12 Lead STEMI interpretation Empower EMS/Lifeforce to diagnose STEMI in the field Develop Standardized EMS STEMI protocols Develop Alternative options for Counties without automated 12 Lead transmission capabilities. Create Feedback documents for EMS

14. STEMI-Referral Hospitals Provide Educational support to ED’s Create Standardized STEMI Medical Treatment Protocols Create Standardized Thrombolytic Protocols Create Standardized Transport Protocols (EMS protocols) Rapid feedback with phone follow-up to ED and Feedback document

18. Conclusions from Data Review EMS activated STEMI patients usually have best times. Direct presentation STEMI patients to ED usually will get timely primary PCI. Opportunities to improve STEMI care still exist w/ the transfer patients. –DIDO <30 min –Thrombolytics when appropriate

19. Questions???

20. ED/EMS Protocol ECG within 10 min Oxygen, morphine, nitrates, 2 working IVs, defibrillation pads on Notify PCI center to arrange transport –EMS may be able to transfer once stabilized ASA 325 mg Heparin bolus 60 Units/kg up to 4000 Units IV Metoprolol 25 mg po if hemodynamically stable Plavix/Prasugrel/Ticagrelor load* depends on culture Send/fax labs to PCI center Pants off, gown on, shaved preferably Even patients who have gotten lytics should go to PCI- capable center