How to Establish a MultiHow to Establish a Multi‐‐ Hospital STEMI Transfer SystemHospital STEMI Transfer System

Dr. Greg Mishkel for the Doctors of Prairie Cardiovascular

and in collaboration with ourCommunity & Springfield Hospitals

Barriers to PPCI STEMI Care in Central Illinois•Limited facilities•Long inter-hospital travel distances•Limited ACLS EMS accessibility•Variability in ED services (locum tenens)

Barriers to PPCI STEMI Care in Central Illinois•Limited facilities•Long inter-hospital travel distances•Limited ACLS EMS accessibility•Variability in ED services (locum tenens)

MI: Evolution of care in Central Illinois•1990’s early adoption/promotion of iv thrombolyis = “drip & ship”•2000 adoption of mechanical reperfusion • 2002: Establish Institutional processes for acute MI care• 2005: DANAMI/PRAGUE/MHI model: Inter-hospital transfer to TWO Springfield hospitals (St. John’s Hospital, Memorial Medical Center) = PRAIRIE STAT HEART PROGRAM

2005: 6 Referral CentersMean Transfer Distance: 46 miles

(range:28-88)4: Helicopter, 2: Ambulance

20092009

So how was this done?

Physician leadership, physician buy in

Full time co‐ordinator/facilitator (communications, logistics, 

deal with “SNAFU’s”, educational events)

Hospital commitment (funding, quality, cath

lab personnel)

Establish effective high quality ER STEMI program

Establish lines of communication (ERswitchboardcath

lab)

Treatment guidelines

Monitor outcomes, modify procedures

Reduce readmissions

Build on success of local program to entice outside programs to 

be “part of the team”

Regular (annual?) of all

participants (we include the switchboard 

operators) in educational forums/updates to share 

results/successes/challenges

What do all of these first 3  requirements have in common

PEOPLE NOT STRUCTURES

Dofasco Steel my first summer job in Hamilton, 

Ontario

“Our product is Steel…Our Strength is People”

So how was this done?

Physician leadership, physician buy in

Full time co‐ordinator/facilitator (communications, logistics, deal 

with “SNAFU’s”, educational events)

Hospital commitment (funding, quality, cath

lab personnel)

Establish effective high quality ER STEMI program (St. John’s 

* 90)

Establish lines of communication (ERswitchboardcath

lab)

Treatment guidelines

Monitor outcomes, modify procedures

Reduce readmissions

Build on success of local program to entice outside programs to 

be “part of the team”

Regular (annual?) of all

participants (we include the switchboard 

operators) in educational forums/updates to share 

results/successes/challenges

STEMI: Where We Started at our  hospital

Doing well: performing above the average hospital for STEMI care

in Crusade 

and NRMI registries, but wanted to be exceptional

Formation of AMI Team in 2003 to target performance above the top 10% of 

Crusade/Action registry hospitals

Formal Intervention started late 2003/early 2004

Obstacles to performance improvement included distance of new ED

from 

cath

lab, lack of standardized protocols and medical record documentation.

AMI Team Strategic Goals

Achieve D2B time of <90 minutes for 100% of STEMI patients

Implement standardized, evidence based and guideline driven 

pathways of care to improve quality

Achieve 100% compliance with admission and discharge 

medications for all AMI patients

Achieve results above the top 10% of Action registry hospitals for 

STEMI care

EKG done within 5 minutes for patients with chest pain

ED Door to cath

lab arrival of < 30 minutes

Cath

Lab arrival to balloon dilatation of < 25 minutes

Implement pre‐hospital ECG 

Methods 

Formation of a multidisciplinary AMI team with quarterly meetings in Fall of 

2003

ED meds bundled‐ASA, Beta Blocker, Heparin, and Nitroglycerin

ED physician empowered to concurrently activate cardiologist and

cath

lab 

team upon diagnosis of STEMI with STAR 90 page

Cardiologist meets and evaluates patient in cath

lab, not ED 

Accountability and tracking form following patient through process allowing 

evaluation of performance of various phases of the D2B process

Implementation of guideline driven treatment protocol and procedural 

protocol

Weekday night team resides in hospital

Benchmarking of performance with other centers using Action and MIDAS 

registries.

AMI Team

Dr. Charles Lucore, Chairman, Department of Cardiology

Dr. Linda Nordeman, Chairman, Department of Emergency Medicine

Dr. Greg Mishkel

and Frank Mikell, PCCL

Dr. John Nester, Springfield Clinic

Dr. John Byrnes, Emergency Room

Cardiac Catheterization Lab Representatives: Sheryl Friedrich et

al

Emergency Department Representatives: Amy Jones et al

Cardiac Nursing Representatives: Jennifer Cullen et al

Quality Resource Management Representatives: Diane Tebrugge

et al

Health Information Management Representatives: Heather Shankland

et al

AMI Door to Cath

Lab Tracking Sheet

To be completed only for ST elevation and/or LBBB on 1st

12‐lead EKG patients

Arrival Time__________

EKG Time___________

Tech__________

Time Cardiologist paged__________

ED Physician________

Time Cardiologist returns page_______

Cardiologist_________

Cath

Lab notified__________

Cath

lab responds_____

Pt prepared for cath

lab_________

ED Nurse__________

Time Cath

Lab calls for patient________

Pt leaves ED___________

Cath

lab arrival time________

Balloon inflation time________

Complications that may delay process (pt requires intubation, pt

arrests, or requires 

additional stabilization, atypical presentation)

_________________________________________________________

_________________________________________________________

Acute Myocardial Infarction

Discharge Medications

2003 – May 2009

(Data from NRMI 4, Action, MIDAS Comparative Performance System (CPMS))

65

70

75

80

85

90

95

100

2003 2004 2005 2006 2007 2008 2009

AspirinBeta BlockerAce InhibitorStatin/lipid

Top 10% (Action STEMI rpt)ASA 100%Beta Blocker 99%Ace/ARB 95%Statin 97%

ACE #s do not always screen for LVEF < 40% from NRMI report

ASA 99%Beta Blocker 98%Ace/ARB 97%Statin 99%

STEMI Myocardial InfarctionIn-Hospital Events (last 12 months)

St. John’s National Avg. Top 10%

Death Rate (%) 2.8% 5.9% 5.8%

Door to Balloon Time (minutes) 54 71 59Bleeding Requiring Transfusion (%) 2.3% 6.3% 7.4%Stroke 0.60% 0.80% 0.60%Length of Stay (days) 3.6 4.4 4.6

Source: 2nd Qtr 08 - 1st Qtr 2009 ACTION Registry(Get With the Guidelines) Gold Performance Achievement Award for 2009

So how was this done?

Physician leadership, physician buy in

Full time co‐ordinator

(communications, logistics, deal with “SNAFU’s”, 

educational events)

Hospital commitment (funding, quality, cath

lab personnel)

Establish effective high quality ER STEMI program

Establish lines of communication (ERswitchboardcath

lab)

Treatment guidelines

Monitor outcomes, modify procedures

Reduce readmissions

Build on success of local program to entice outside programs to be 

“part of the team”

Devise (based on local needs) an integrated/consistent one call,

one 

protocol 

Regular (annual?) of all

participants (we include the switchboard 

operators) in educational forums/updates to share 

results/successes/challenges

Door In-Door Out

ECGDecision

TreatmentInitiate STAT HeartArrange Transfer

IdealGoal: <30 minutes

Departure-Door 2

TransferAir

Ambulance

<30 minutes <30 minutes

Door 2-Balloon

Cath Lab ArrivalDiagnostic Cath

PCI

Goal: Door-Balloon: ≤

90 min.

Global Components of Process of Transfer STEMI CareCommunity Facility Transport Tertiary Facility

3- 5 min•Suspected MI (Step1)

•12 Lead ECG/STEMI Identified (Step 2)•Determine Bleeding Risk (Step 3)

5-10 minActivate Stat Heart

Team

Call for quickest availabletransport (Step 4)

Ambulance/Helicopter

Call Springfield HospitalActivate

Stat Heart Team

15-20 min

CommunityStat Heart

Team

ED MD2-RN

Ancillary staff

SpringfieldStat Heart

Team

CardiologistCoordinator

Cath LabSecurity

AdmittingAdministrative

RepER contact

Contraindication ProtocolAir/Ground Transport

30 minute Transporttime NOT Available

Low Bleeding Risk

Thrombolytic ProtocolAir/Ground Transport

High Bleeding Risk

PCI ProtocolAir/GroundTransport

30 minute Transporttime Available

Goal: Out the Door in < 30 minutes

Prairie Stat Heart Protocols

Lisa Page, RN

Goal out the door in 30 minutes or less

5-12 minutes

Activate STAT Heart team at community hospital (staff pre-assigned duties) First call -staff calls quickest transport air or ground

(base on mileage between hospitals) Second call – Springfield Hospital receiving pt. Stat Heart team

activated in Springfield. Automatic - accepting Prairie cardiologist and bed assigned.

0-3 minutes Patient presents with chest pain or associated symptoms TREAT ALL patients as potential Stat Heart until deemed otherwise

3-5 minutes ECG done ECG to ED physician for quick diagnosis. ED physician determines if STAT Heart criteria is met.

12-20 minutes

Nurses start IV’s & give standard meds (ASA, Lopressor, NTG)

Physician determines if patient is high bleeding risk (contraindication questions)

Transport time < 30 min. helicopter/ambulance - PCI protocol

Transport time > 30 min. helicopter/ambulance - Thrombolytic protocol

Helicopter or ambulance transfer - Contraindication protocol if pt. is high risk for bleeding (80 yrs or older, on Coumadin etc.)

Give protocol meds

20-30 minutes

EMS transport arrives, packages pt., brief report(transport team is educated on process)

Departure Call receiving Springfield Hospital with departure page

So how was this done?

Physician leadership, physician buy in

Full time co‐ordinator

(communications, logistics, deal with “SNAFU’s”, 

educational events)

Hospital commitment (funding, quality, cath

lab personnel)

Establish effective high quality ER STEMI program

Establish lines of communication (ERswitchboardcath

lab)

Treatment guidelines

Monitor outcomes, modify procedures

Reduce readmissions

Build on success of local program to entice outside programs to be “part 

of the team”

Devise (based on local needs) an integrated/consistent one call,

one 

protocol 

Regular (annual?) of all

participants (we include the switchboard 

operators) in educational forums/updates to share 

results/successes/challenges

SO HOW ARE WE DOING? STAT Heart Population: 2005‐2009

N approx. 600

Comparison Of STEMI Process of Care For 

Inter‐hospital Transfer: Door‐Balloon Times

4.2

16.28.6

26.4

13

5964

89

20

64

0102030405060708090

NRMI 3/4 NCDR 2005-2006

Stat Heart-Spr.2008

Stat Heart-Carb.2008

Total StatHeart

< 90 min. < 120 min.% PTS

(n=4278)(n=15,049) (n=338) (n=382)(n=44)

In‐Hospital Clinical  Outcomes

Length of hospitalization (mean ± SD days): 3.6 ± 2.5 vs. 5 ± 6.3; p=0.0001

7

3.7

2.62.1

1.2

3

1.10.3 0.05

1.1 0.9

8

5.9

3.7

0

2

4

6

8

10

Death Non-ShockDeath

Re-infarction Stroke Composite

Meta-analysis Stat Heart/07 Stat Heart 8/08% PTS

Comparison Of 30‐day Clinical Outcomes NRMI vs. Stat Heart: Springfield Hub 

(n=1472) (n=188)

PROCEDURAL KEYS PROCEDURAL KEYS toto SuccessSuccess1. EARLY RECOGNITION OF MI starts the “interventional cascade”

beginning with QUICK call to helicopter or ambulance for transport

2. A SINGLE call to activate Stat Heart Process in Springfield3. Standardized Protocol/ Orders (PCC and ED physician agree to adhere to standard orders as

written)4. Standardized communications via pager identifies MI, patient departure, 15 minute arrival 5. Cath lab nurse calls after receiving departure page for brief report-cath lab nurse calls community

hospital nurse. Cardiologist and team awaits arrival in cath lab.6. Communication ON-GOING throughout the process from beginning to end7. Rapid transportation via ground or air is mandatory. Regular meetings with these providers8. Education provided to all Stat Heart team members9. Data collection to promote process improvement and quality10. Feedback and reports given promptly (immediately after each case)11. Public education (regarding Sx of MI, program in their area)12. Debrief with Stat Heart team members at regular intervals and especially after failures

(problems compound with out intervention)13. No Blame Environment!14. Continue to innovate. Don’t tolerate failure, don’t rest on success (EKG’s in the field, paramedic

education, earlier initiation of Rx)15. D2B time is important, but it’s LIVES SAVED THAT REALLY COUNTS. Mortality reflects the proof in

the pudding

Conclusions Stat Heart (Rural Inter-Hospital Transfer)

Regional STEMI Program: feasible/safe with reproducible, favorable and comparable process measure outcomes to U.S. Registry, despite program growth among broad range of hospital systems.

Between 2005-2009, the utilization of this coordinated, rural inter-hospital STEMI transfer program, appears to associated with shorter hospitalization

and improved in-

hospital clinical outcomes, as compared to non- standardized pre-STAT Heart STEMI care.

Regional STEMI Program: feasible/safe with reproducible, favorable and comparable process measure outcomes to U.S. Registry, despite program growth among broad range of hospital systems.

Between 2005-2009, the utilization of this coordinated, rural inter-hospital STEMI transfer program, appears to associated with shorter hospitalization

and improved in-

hospital clinical outcomes, as compared to non- standardized pre-STAT Heart STEMI care.

Conclusions Stat Heart (Rural Inter-Hospital Transfer)

Improvements- Procedural Time (wide inter-procedural/inter-operator variability)

- “Standardization” of cardiac cath lab process- Implementation of pre-hospital ECG: Reduce door-in/door-out time

Emphasis on program maintenance and improvement - Avoid complacency (delays): meetings, updates, teamwork (transport, ED’s, ancillary staff, cath lab, administration, etc)- Program-wide commitment to collection, interpretation and dissemination of data- Nimble program: modifiable process/treatment changes

RN Coordinator: Education, education, education!!

Improvements- Procedural Time (wide inter-procedural/inter-operator variability)

- “Standardization” of cardiac cath lab process- Implementation of pre-hospital ECG: Reduce door-in/door-out time

Emphasis on program maintenance and improvement - Avoid complacency (delays): meetings, updates, teamwork (transport, ED’s, ancillary staff, cath lab, administration, etc)- Program-wide commitment to collection, interpretation and dissemination of data- Nimble program: modifiable process/treatment changes

RN Coordinator: Education, education, education!!

Minneapolis Heart Institute

Timothy D. Henry, MD, FACC

EMS COMPONENTS OF A SYSTEM

Non PCI Capable

PCI Capable

Only 50% of STEMI use EMS in the US

10% Pre-hosp ECG

1. PREHOSPITAL2. TRIAGE3. TRANSFER

42.0% PCI hospital is closest facility 

79.0% within 60 minute prehospital

time

Primary PCI: Access

Nallamothu et al. Circulation 2006;113:1189

Red– Zone II (90-120 mins)

Blue– Zone I (< 90 mins)

Zone1 ProtocolAspirin 325 mgAspirin 325 mgClopidogrel 600mgClopidogrel 600mgUFHUFHBetaBeta--blockerblockerPCIPCI

Red– Zone II (90-120 mins)

Blue– Zone I (< 90 mins)

Zone 2 ProtocolAspirin 325 mgAspirin 325 mgClopidogrel 600mgClopidogrel 600mgUFHUFHTNK TNK ½½ dosedoseBetaBeta--blockerblockerPCIPCI

Protocol focus:

Simple

Fast

Reduce variability

MHI Level 1 MI: Door – Balloon Times

0102030405060708090

100

ANW Zone 1 Zone 2 NRMI 3/4

< 90 mins<120mins

% o

f pat

ient

s

Kaplan-Meier Survival CurveKaplan-Meier Survival Curve

0 50 100 150 200 250 300 350

0.0

0.2

0.4

0.6

0.8

1.0

Days

Sur

viva

l Pro

babi

lity

ANWZone 1Zone 2

p = 0.31

“Level 1” Heart Attack System

Sioux Falls

A national quality improvement effort led by the ACC and IHI A national quality improvement effort led by the ACC and IHI 

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