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Reperfusion of Acute Myocardial Infarction in Carolina Emergency Departments Emergency Response (RACE-ER) Project

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(1)

R

eperfusion of

A

cute Myocardial

Infarction in

C

arolina

E

mergency

Departments –

E

mergency

R

esponse

(

RACE-ER

) Project

on behalf of RACE Coordinators, Nurses, Physicians,

Paramedics, and Administrators

(2)

• Research grants/contracts from

– Sanofi Aventis, AstraZeneca, Novartis, Boehringer

Ingelheim, Genentech, GlaxoSmithKline, BMS,

Medicines Company, Astellas, Roche

• Consulting fees/honoraria from

– Sanofi Aventis, AstraZeneca, Genentech,

GlaxoSmithKline, Medicines Company, Roche

COI Disclosure Related

to This Presentation:

Complete listing available at:

(3)

Regional approach to overcoming systematic

barriers

1) Increase reperfusion rate

2) Increase speed of reperfusion

RACE

Pilot

RACE

65 hospitals

RACE - ER

119 hospitals

2003

2005

2006

2007

2008

2009

Objectives

(4)

Methods

Hospitals

21 Primary PCI Hospitals (with surgery on-site)

98 Non PCI Hospitals

Data

Used Action Registry– Get With The Guidelines (ARG)

from the 21 primary PCI centers

Followed ARG data definitions for RACE metrics

Timeline

Pre:

Q3 2008

During:

Q4 2008 – Q3 2009

Post:

Q4 2009

(5)

Organization

Nurse-EMT-RT RACE

Coordinators

21 Primary PCI Centers

Central Organizing Committee

and Statistics

Dr. James Jollis, MD

Dr. Chris Granger, MD

Mayme Lou Roettig, RN, MSN

Lisa Monk, RN, MSN, CPHQ

Claire Corbett, MMS, NREMT-P

Hussein Al-Khalidi, PhD

Physician leadership

21 Primary PCI Centers

EMS Medical Director

Leadership in all NC Counties

Hospital Administration

Support

21 Primary PCI Centers

98 non-PCI Centers

Hospital Quality Improvement

Support

(6)

Organization

RACE Regional &System Coordinators

Nurse System Coordinators

 Joanne Cary, BS, RN, CN, RHIA IV

 Frank Castleblanco, RN, ADN, BA

 Bridget Harding, RN, MSN

 Cheryl Henderson, RN,BSN

 Michelle Keasling, RN, MSN

 Robyn Keller, RN, BSN, CEN

 Jan Matthews, RN,

 Jeannie Moore, RN, BSN, CCRN, NE-BC

 Heather Norman, MHA, RN, BSN

 Gloria Paul, RN, MSN

 Mary Printz, RN, MSN, FNC

 Susan Rouse, RN, BSN,CPHQ

 Betsy Russell, RN

 Stephanie Starling, MHA, BSN, RN

 Jennifer Sarafin, RN, MSN

 Amanda Thompson, RN, BSN, MHA

 April Traxler, RN, BSN

State Project Leader

Lisa Monk, RN, MSN, CPHQ

EMS Regional Coordinators

Claire Corbett, MMS, NREMT-P

Scott Starnes, NREMT-P

Nurse Regional Coordinator

*

Harriet Buss, RN, BSN, MSHA

Other Systems Coordinators

Keith Pendergrass, RRT, RCP

Cathy Rabb, RRT, RCP

David Reich RCIS, BS

*

AHA Mission: Lifeline Director
(7)

Organization

Physician Leadership

Cardiology Leaders

 Yele Aluko, MD  Robert Applegate, MD  Joseph Babb, MD  Chris Barber, MD  Robert Preli, MD  William Hathaway, MD  Bryan Hearon, MD  Lee Job, MD  Kevin Kruse, MD  Mike Komada, MD  William Maddox, MD  Steve Rohrbeck, MD  John Sinden,MD  Pat Simpson, MD  Mark Thompson, MD  Scott Valeri, MD

 John Williams, III, MD

 Hadley Wilson, MD  Joseph Rossi, MD

ED Medicine Leaders

Robert Beaton, MD Sidney Fletcher, MD Lee Garvey, MD Matthew Harmondy, MD James Hoekstra, MD Brad Watling, MD Scott Miekley, MD P.J. Hamilton, MD Paul Horton, MD Josh Cochrane, MD Randall Willard, MD

EMS State Leaders

Greg Mears, MD
(8)
(9)

RACE QI Process

2) Establish Regional PCI Centers

(primary PCI, lytic ineligible, rescue)

Measurement

& Feedback

3a) Hospital by hospital

establishment of STEMI plan

(review, consensus, training)

3b) EMS by EMS

establishment of STEMI plan

(review, consensus, training)

4) Improve the system

1) Develop leadership,

(10)

RACE

Interventions

OPERATIONS MANUAL

Optimal system specifications by

point of care

EMS

Non-PCI and PCI ED

Transfer

Catheterization lab

Other system issues –

payers, regulations

Choice of PCI or lytic

reperfusion regimens

(11)

Primary PCI (21)

Transfer for Primary PCI (52)

Lytics (31)

Mixed (15)

RACE Hospitals by PCI and

Reperfusion Designation

(12)

Primary PCI (21)

Transfer for Primary PCI (52)

Lytics (31)

Mixed (15)

RACE Hospitals by PCI and

Reperfusion Designation

(13)

Primary PCI (21)

Transfer for Primary PCI (52)

Lytics (31)

Mixed (15)

RACE Hospitals by PCI and

Reperfusion Designation

(14)

Primary PCI (21)

Transfer for Primary PCI (52)

Lytics (31)

Mixed (15)

(primary PCI if transport readily available

RACE Hospitals by PCI and

Reperfusion Designation

(15)

Baseline Characteristics

All

Direct

Transfer

N

6841

3907 (57%)

2933 (43%)

Age (yrs)

59 (51,69)

60 (51,70)

59 (51,69)

Female

30%

30%

29%

Race (Black)

14%

14%

14%

Prior MI

20%

22%

18%

Prior HF

4.7%

5.3%

4.0%

Shock presentation

9.2%

9.6%

8.6%

HF presentation

8.1%

7.9%

8.3%

Diabetes

22%

22%

23%

Sx duration (min)

91 (49, 190) 83 (42, 181) 100 (58, 205)

(sx onset to 1st ECG)
(16)

Reperfusion Strategy

Overall population, Eligible Patients

(17)

Reperfusion Strategy

Transfer Population, Eligible Patients

(18)

Patient Presentation by Hospital Type

PCI centers

Non-PCI

centers

P=0.05
(19)

Patients Presenting Directly

to PCI Centers

(20)

Use of Pre-hospital 12-lead ECG

(21)

Direct to PCI Centers

Door to Device Times

(minutes, median)

(22)

Direct to PCI Centers

Door to Device Times

(minutes, median)

(23)

Direct to PCI Centers

Door to Device Times

(minutes, median)

P = 0.01 for walk-in, p=<0.0001 for all direct, and p= 0.02 for EMS for trends

Door to device for patients via EMS: 91% < 90 minutes

(24)

Direct to PCI Centers

EMS 1st Medical Contact to Device Times

p<0.0001

(74, 112)

(25)

Direct Presenters:

% Reaching Goal of Door to Device

or 1

st

Medical Contact to Device < 90 minutes

Pre Post Pre Post

Door to Device P=0.03

First Medical Contact to Device P=0.0002

(26)

Patients Presenting to

Non-PCI Centers, Transferred to

(27)

Transfer, Door-in-door-out Times

(minutes, median (Interquartile range))

(31,71)

(28,57)

p= 0.02

(28)

Transfer Patients: Time to lytic or to device by

designation strategy

(29)

Transfer Patients: Time to lytic or to device by

designation strategy

(30)

Transfer Patients: Time to lytic or to device by

designation strategy

(31)

Transfer: First Door to Device Times

(For hospitals with designated transfer strategy)

(85, 127) (93, 155) (91, 153) (93, 155) (94, 145) (89, 134) p=0.0008 (85, 127) (93, 155) (91, 153) (93, 155) (94, 145) (89, 134)

(32)

Outcomes, In-hospital

Pre

Post

n 1067 1179

Death

5.8%

5.7%

Death, no shock

#

3.4%

2.6%

Death, shock

#

29.3%

34.8%

Bleeding

6.8%

5.1%

Shock after admission

6.3%

5.9%

CHF

6.5%

8.1%

Stroke

1.7%

1.2%

Re-infarction

0.9%

0.9%

(33)
(34)

Limitations

No data audit

No contemporaneous control group

(35)

Summary

RACE represents the first program to incorporate all

hospitals in a state to develop STEMI systems of care

Very low proportion of eligible patients were untreated (4.0%)

There was a shift in pattern of care to more EMS transport to

PCI centers and more transfer for primary PCI, yet over 30%

of patients at non-PCI centers were still treated with

fibrinolysis

There were substantial improvements in guideline-based

times to treatment, yet over one quarter of transfer patients

were over 120 minutes first D2B

Improved application of reperfusion care on a state-wide

basis is possible and should be a high national priority, as

addressed by Mission: Lifeline.

References

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