CATRAC Mission: Lifeline Regional STEMI Field Guide

Transcription

1 CATRAC Mission: Lifeline Regional STEMI Field Guide CATRAC Mission: Lifeline Cardiac Care Workgroup Updated December 2013

2 Table of Contents Introduction... 3 CATRAC M:L... 3 Regional geography defined Workgroup organizational structure Regional Assessments and key findings... 7 Regional STEMI plan and guidelines... 8 Pre-hospital ECGs 12 Lead ECG Screening Guidelines 12 Lead ECG criteria for field activation of the cath lab 12 Lead ECG communication of findings Regional destination plan Regional STEMI treatment plans Regional double hit strategy Levels of involvement in AHA Mission: Lifeline Participation Recognition Accreditation Mission: Lifeline Recommended Ideal EMS, strategies, barriers and solutions Ideal Non-PCI hospital, strategies, barriers and solutions Ideal PCI hospital, strategies, barriers and solutions Ideal Public, strategies, barriers and solutions Public and Professional Education QI Subgroup Best practice PCI hospital multi-disciplinary team meeting NCDR Action Registry GWTG Regional 12 Lead ECG accuracy project References Appendix

3 Introduction The CATRAC Mission: Lifeline Regional STEMI System of Care is a partnership between the American Heart Association Mission: Lifeline initiative, Capital Area Trauma and Regional Advisory Council and volunteer stakeholders from PCI hospitals, Non-PCI hospitals, EMS Agencies and Inter-facility Transport Agencies. The workgroup was established in June of 2009 in order to collaborate to decrease death and disability from ST-Elevation Myocardial Infarction in the 11 county Austin, Texas region. CATRAC Mission: Lifeline Cardiac Care Workgroup mission statement: Optimize the outcome of cardiovascular emergencies through multi-disciplinary collaboration in CATRAC. We wish to thank those who have provided resources, tools, guidance and support: Dr. David Burt/Project Upstart, SETRAC (SouthEast Texas Regional Advisory Council) Mission: Lifeline Cardiac Care Committee members, STRAC (SOUTHWEST Texas Regional Advisory Council) Heart Alert Program members, Scott and White Temple Central Texas Regional STEMI Network, North Carolina RACE STEMI System staff and AHA Mission: Lifeline National Center staff/task force members. CATRAC Mission: Lifeline defined geography: The work of the CATRAC Mission: Lifeline Cardiac Care Workgroup encompasses the counties included in region O, as defined by the Office of EMS/Trauma Systems Coordination. The eleven counties included in the region are Bastrop, Blanco, Burnet, Caldwell, Fayette, Hays, Llano, Lee, San Saba, Travis and Williamson. 3

4 In the fall of 2009 the CATRAC Mission: Lifeline Cardiac Care Workgroup took under advisement, the recommendations included in the ACC/AHA Joint STEMI/PCI Guidelines Focused Update: Each community should develop a STEMI system of care following the standards developed for Mission: Lifeline including: Ongoing multidisciplinary team meetings with EMS, non-pci capable hospitals (STEMI Referral Centers), & PCI-capable hospitals (STEMI Receiving Centers) STEMI system of care standards in communities should also include: Process for pre-hospital identification & activation Destination protocols to STEMI Receiving Centers Transfer protocols for patients who arrive at STEMI Referral Centers and are primary PCI candidates, and/or are fibrinolytic ineligible and/or in cardiogenic shock 4

5 CATRAC Mission: Lifeline Cardiac Care Workgroup The CATRAC Mission: Lifeline Cardiac Care Workgroup functions in an advisory capacity. The CATRAC Mission: Lifeline subgroups were developed for the purpose of focusing on specific identified regional needs and goals. See organizational chart below. 5

6 CATRAC QI Subgroup The first QI Subgroup goal was to develop an inventory and key contact list for the hospitals and EMS agencies in the region and conduct baseline assessments of all Non-PCI hospitals, PCI hospitals, 911 Transporting EMS Agencies and Inter-hospital transport agencies in the 11 county CATRAC area. The regional baseline assessments and letters that accompanied the assessments are located in the appendix. PCI (13) NON-PCI (10) Cedar Park Regional Medical Center Heart Hospital of Austin Lakeway Regional Medical Center St. David s Medical Center St. David s North Austin Medical Center St. David s Round Rock Medical Center St. David s South Austin Medical Center Baylor Scott & White Hospital Round Rock Seton Medical Center Austin Seton Medical Center Hays Central TX Medical Center San Marcos Llano Memorial Hospital St. David s Georgetown Hospital St. Marks Medical Center La Grange Baylor Scott and White Hospital Taylor Seton Edgar B. Davis Hospital Luling Seton Highland Lakes Hospital Burnet Seton Northwest Hospital Seton Southwest Hospital Smithville Regional Hospital Seton Medical Center Williamson The Hospital at Westlake University Medical Center Brackenridge Pre-hospital Providers (25) Air Evac Lifeteam Guardian EMS Travis CO STAR Flight Acadian EMS Lexington Vol EMS Williamson CO EMS American Medical Response Llano CO EMS Wimberley EMS Austin Travis County EMS Luling EMS *Inter-facility Transport Only B & M Ambulance Blanco Vol FD/EMS Buda Fire Dept. Burnet Fire and EMS Lexington City of Lockhart EMS San Saba Fayette CO EMS First Medical Response * Marble Falls Area EMS North Blanco EMS PHI Air Medical San Marcos-Hays CO EMS San Saba CO EMS Spicewood FD/EMS Thorndale Vol. FD 6

7 The regional baseline assessment revealed the following key findings for EMS: A small number of EMS agencies/counties had no 12 lead ECG capability. Annual 12 lead ECG education/training was variable & some EMS staff had no training. A 12 lead ECG triage protocol was needed. For those performing 12 lead ECGs, all appear to have a PCI destination protocol. Most EMS agencies were not able to activate the cath lab. Participation in STEMI Receiving Center QI meetings was uncommon. The regional baseline assessment revealed the following key findings for Non-PCI hospitals: A small number repeated the EMS ECG at the ED. Reperfusion using transfer to PPCI is consistent. Routine review of STEMI data with EMS is uncommon. There is a need for a transfer plan for fibrinolytic ineligible and shock patients. Transfer distances to STEMI Receiving Hospitals: Average Distance Median Distance Distance Range 65.5 Miles 40 Miles Minimum: 5 Miles Maximum: 78 Miles The regional baseline assessments revealed the following key findings for PCI hospitals: There was a need for development and posting of a 12 lead ECG triage protocol. Hospital protocols required improvements. 40% of hospitals did not participate in on-going multidisciplinary team meetings that included EMS, non-pci hospitals/stemi Referral Centers, and PCI hospitals/stemi-receiving Centers to evaluate outcomes and quality improvement data, review operational issues, identify problems and implement solutions. There was variation in STEMI/AMI data collection tools. Not all hospitals were using the NCDR Action Registry-GWTG. 20% were not routinely activating the Cath Lab based on the EMS finding. 40% repeated the EMS ECG to confirm the diagnosis. Feedback to EMS & Referral Hospitals was inconsistent. EMS responses regarding ability to activate the cardiac cath lab prior to the patients arrival was inconsistent with the PCI hospital response to the same question. 7

8 The regional baseline assessments revealed the following key findings for inter-facility transport services: Written STEMI Care Plans need to include inter-facility transport service Inter-facility transport services need a goal for the maximum total hospital time for STEMI patient Need a better feedback loop from receiving hospitals Participation in STEMI Receiving Center QI meetings is uncommon Annual 12 lead ECG education/training is variable & some have no training A small number have no12 lead ECG capabilities Key finding for the regional system: In general, System aspects were not being addressed. A regional plan was developed to address/reflect key findings and specific committee goals were established. Visit the CATRAC website to view complete plan, committee goals, workgroup and subgroup meeting agendas and minutes. Full regional plan to be posted at 8

9 A regional 12 Lead ECG who gets a 12 Lead guideline was needed in order to provide consistency in 12 Lead triage and screening protocols being used by hospitals and EMS and regional assessments revealed that some hospitals and agencies did not have a screening protocol in place. A review of the body of knowledge around heart attack warning signs revealed the following: Heart Attack Warning Signs. Some heart attacks are sudden and intense the "movie heart attack," where no one doubts what's happening. But most heart attacks start slowly, with mild pain or discomfort. Often people affected aren't sure what's wrong and wait too long before getting help. Here are signs that can mean a heart attack is happening: Chest discomfort. Most heart attacks involve discomfort in the center of the chest that lasts more than a few minutes, or that goes away and comes back. It can feel like uncomfortable pressure, squeezing, fullness or pain. Discomfort in other areas of the upper body. Symptoms can include pain or discomfort in one or both arms, the back, neck, jaw or stomach. Shortness of breath with or without chest discomfort. Other signs may include breaking out in a cold sweat, nausea or lightheadedness. The most common heart attack symptom for both men and women is chest pain or discomfort. But women are somewhat more likely than men to experience some of the other common symptoms, particularly shortness of breath, nausea/vomiting, and back or jaw pain. Additionally, diabetic and elderly patients are more likely to present with atypical heart attack symptoms. Elderly patients may have symptoms such as generalized weakness, altered mental status, nausea/vomiting, shortness of breath, diaphoresis, or syncope as their only sign of acute heart attack. Patients over the age of 75 are more likely to experience shortness of breath at the time of their heart attack than they are to present with chest pain. A printable version of the ECG Screening Guideline is located in Appendix. Typical heart attack warning signs were weighed along with atypical heart attack warning signs in an effort to ensure the least possible number of missed STEMI patients or STEMI patients with delayed STEMI treatment in the region. The Project Upstart ECG Screening Guideline was used as a template. After lengthy Protocol Subgroup member discussions, there was agreement on the modifications seen on the CATRAC M:L ECG Screening Guideline. 9

10 A consistent process for regional activation of the STEMI response was needed. Regional criteria for field activation of the cath lab was discussed and the committee came to consensus: Signs / Symptoms of Acute Coronary Syndrome (ACS) AND ST segment elevation of 1mm or more in two contiguous leads If both criteria are met then recommend field activation of PCI-Hospital If ST elevation inconclusive, isolated to V1 V2, or LBBB identified then recommend consultation with physician and PCI-Hospital prior to activation. Terms that EMS providers in the region currently use to activate the cath lab are either Code STEMI or STEMI Alert. The committee determined that as long as the word STEMI is used at the time of activation, there was no preference for either term. Use of the term Non-STEMI was discouraged during pre-hospital field staff contact with the PCI hospital in order to decrease confusion. The process for activating the STEMI response in the region is dependent on the point of entry and method of 12 Lead ECG interpretation. The committee advocates for activation in en route whenever possible when defined criteria are met. The committee defined a good, better, best tiered recommendation: Good- Computer Algorithm Interpretation alone Better- Computer Algorithm Interpretation in combination with EMS Provider Interpretation Best- EMS Provider Interpretation in combination with Wireless Transmission All other scenarios would involve activation by the STEMI receiving center after consultation, ideally while patient is still en route. See catrac.org for most updated key contact lists for EMS Agencies and Hospitals and one call activation numbers for each facililty. The CATRAC QI Subgroup recently completed a regional 12 Lead ECG Accuracy project to determine accuracy of 12 Lead ECG interpretation by EMS providers. See project tool, explanations and poster at appendix. 10

11 Triage and Transfer for Percutaneous Coronary Intervention for Patients with STEMI have been updated to reflect the most current ACC/AHA 2013 STEMI Guideline recommendations: It is an ACC/AHA class I recommendation that every community have a written protocol that guides EMS system personnel where to take patients with possible STEMI: Based on the 2013 ACC/AHA STEMI treatment guidelines: Regional EMS and Non-PCI hospital STEMI treatment guidelines were developed and approved by the CATRAC Mission: Lifeline Cardiac Care Workgroup. All PCI hospitals have STEMI treatment protocols in place and shared their ACC/AHA guidelines based protocols with the committee. Full page printable versions of the CATRAC M:L regional EMS and Non-PCI hospital STEMI treatment guidelines are available in the appendix. CATRAC M:L Non-PCI hospital STEMI treatment guidelines were updated in

12 CATRAC M:L EMS STEMI Guideline CATRAC M:L Non-PCI Hospital STEMI GL Page 1 Full printable versions are located in the appendix. 12

13 Recommendations for Simultaneous Presentation AHA Mission: Lifeline includes criteria for the PCI/STEMI Receiving hospital to provide universal acceptance of STEMI patients (no diversion). There should be a plan for triage and treatment for simultaneous presentation of STEMI patients. The CATRAC M:L Cardiac Care Workgroup made the following recommendation for simultaneous presentation of STEMI patients at a PCI Capable Hospital in the region: Regional Double Hit Strategy 3 Scenarios: 1 st STEMI in the cardiac cath lab and 2 nd STEMI with: Scenario #1 ED Presentation Scenario #2 EMS Presentation Scenario #3 Transfer Presentation Scenario #1, ED Presentation of Second STEMI - ED MD calls special line (STEMI line, one-call) - Transfer RN calls Interventionalist cell phone. If scrubbed in, phone answered by Cardiac Cath Lab staff. - Interventionalist to triage: accept the 2nd case (if 1st STEMI almost complete; most uncomplicated STEMIs can be complete within 20 minutes) for PPCI If > 30 minutes; ED MD to give lytics Transfer to another facility with open cath lab Scenario #2, EMS Presentation - EMS calls designated number with STEMI alert resulting in PCI hospital notification. - ED MD calls Special line (One-call, STEMI line) (if not already done through EMS call) - If destination PCI hospital unavailable EMS informed but not diverted PCI Hospital implements internal plan for 2 nd STEMI EMS leaves patient on stretcher in ED until Patient transferred to other PCI hospital Patient moved to ED bed or to Cath Lab Scenario #3, Transfer Presentation -Transferring facility call special line. -Staff determines Cardiac Cath Lab availability and will accept to available PCI Center. 13

14 Mission: Lifeline Participation Requirements The levels of involvement in AHA Mission: Lifeline are outlined in the updated documented located in the appendix. There are three levels of involvement with Mission: Lifeline: Participation, Recognition and Accreditation. For every program, all system components (EMS, Non-PCI/STEMI Referral Centers and PCI/STEMI Receiving Centers) requirements must be met in order for the system to qualify for each level of involvement. AHA National Center Mission: Lifeline developed strategies to achieve ideal STEMI System of Care and suggestions for overcoming barriers for EMS, Referral Hospitals, Receiving Hospitals, STEMI System and Public which are included below: EMS Strategies to Achieve Ideal Initial Contact by an EMT Basic or Intermediate Provider 911 operator trained to recognize potential acute cardiac symptoms and dispatch appropriate EMS resources to potential STEMI patient ECG equipment and personnel dispatched to allow for 12 lead ECG within a total scene time of less than or equal to 15 minutes ECG acquisition to be extended to basic providers including EMT basic and first responders ECG obtained on all patients with chest discomfort suspected to be of ischemic origin In the field ECG (to be interpreted by receiving physician on arrival or by transmission) Documentation of symptom onset Scene time of less than 15 minutes Patient stays on ambulance stretcher for STEMI evaluation for hospitals that routinely transfer all or some patients by same ambulance Initial contact by an EMT-Paramedic In addition to above: Training to diagnose STEMI by symptoms and ECG In the field ECG with a goal scene time of 15 minutes (An ECG machine should be dispatched to all potential STEMI calls to meet this 15 minute window) Administer reperfusion checklist (See tools) If patient is fibrinolytic ineligible, EMS notifies STEMI-Receiving hospital staff and transports to a STEMI- Receiving hospital, as long as transportation time < 90 minutes by ground or by utilizing air medical transport Early notification of the receiving hospital on all STEMI patients prior to arrival that includes direct communication with the physician capable of activating a reperfusion plan regarding symptom onset, ECG findings, and reperfusion checklist in addition to: o Patient age, gender, and DNR status o Time of onset of symptoms o Primary physician/cardiologist 14

15 o Whether patient taking Warfarin (Coumadin) or Dabigatran (Pradaxa) o Past hx of MI, PCI/stent/CABG, renal failure, contrast allergy Administer aspirin (162 to 325 mg chewed) to chest pain patients suspected of having STEMI unless contraindicated or an adequate dose of immediate-release aspirin can be verified as taken EMS data elements collected, made available to receiving hospitals via run event sheet, and reviewed on a regular basis regarding symptom onset, time of 1st medical contact, ECG performance and findings, and transportation complications including arrest and death Patient Transfer Inter-hospital Transfer STEMI patient for reperfusion has same priority as 911 call and trauma. Focus should be on rapid response, short scene time (10 minutes), and rapid transport. Patient stays on EMS stretcher for STEMI evaluation for inter-hospital transfer. Transfer plan including preferred transport modality and backup transport modality is established. Transport directly to catheterization laboratory when laboratory is staffed and available for PCI without reevaluation in the ED. When possible, minimize or avoid continuous IV infusions such as nitroglycerin or heparin. Transfer protocol should focus on rapid transport to catheterization laboratory rather than pain relief with medications. Transfer patients to STEMI-Receiving hospital with similar consideration to patient registration, bed availability, and accepting physician as trauma patients (use of dummy registration numbers, acceptance of all STEMI patients regardless of bed availability, and reliance on a single accepting physician that is on call 24 hours per day / 7 days per week). When transporting a patient treated with fibrinolysis who has continued chest pain and < 50% ST resolution (in the lead showing the worst initial elevation) after 90 minutes following the initiation of fibrinolysis, notify the receiving hospital about the potential need for rescue angioplasty. Hospital records should be faxed to the receiving catheterization laboratory so as not to delay patient pickup. EMTALA/COBRA/medical necessity of transfer form should be completed as soon as possible after the decision to transfer. Helicopter Transfer In addition to above: Focus should be on rapid response, short scene time (10 minutes), and rapid transport. Local EMS should generally be used if available and 30 minutes transportation time to destination hospital. Whenever possible, helipad adjacent to emergency department. Helicopter capable of transporting patients on ten minutes notice 24/7. When not available, alternate transport options identified. Immediately activate helicopter transport during initial communication between referral hospital ED and receiving hospital regarding the need for reperfusion. Establish a system whereby all patient transfers of any type can be specified as time critical within one hour versus diversion possible Bring only essential equipment into hospital with crew: stretcher, portable oxygen and ear protection. 15

16 Temporarily discontinue any infusions until the patient is loaded into the aircraft (unless infusion absolutely cannot by stopped momentarily). Perform a rapid focused patient assessment that does not delay transport. If the patient develops cardiac arrest between the sending facility ED and the helipad, return to the sending facility ED to work the code. If the patient develops cardiac arrest after the patient is loaded into the helicopter, lift off and proceed to the STEMI receiving hospital Attach all monitoring cables to the patient either prior to lift off (if it doesn t slow the lift off) or once the transport has begun If necessary, continue/start any infusions. Otherwise, use SL nitro along with a narcotic for pain management. Provide other comfort medications as necessary (nausea, anxiety, etc.) During the flight to the STEMI receiving center, provide a radio report at the earliest opportunity to confirm that the receiving hospital personnel are aware of a Code STEMI and that the Cath Lab has been alerted. Once at the STEMI receiving center, proceed with the patient to the Cath Lab instead of to the ED. For ED: Establish reperfusion checklists, standard pharmacological regimens and order sets Establish clinical pathways Use of single call activation systems 16

17 EMS Barriers & Solutions EMS systems face a variety of barriers to achieving the ideal STEMI care practice. However, there are solutions, as depicted in the chart below. BARRIERS SOLUTIONS Lack resources: Electrocardiogram (ECG) equipment Appropriate level of EMS provider Medical leadership Funding, particularly in rural or impoverished areas "Creative funding" Multiple source grant writing County board of education Lack training to obtain 12-lead ECG and recognize STEMI STEMI training courses Case review Advocacy-change laws Lack of destination protocols Stakeholder STEMI steering agreement Buy-in from all entities Plan to implement Advocacy No protocol for: Pre-hospital diagnosis Advance notification Cath. Lab activation False activation Meet with EMS director, hospital and/or medical leadership to establish protocol Monitor "appropriate activation" Transfer patients are second to calls Change policy for transfer patients with STEMI to be viewed as Local, city, county and state advocacy Lack training on STEMI guidelines STEMI training course New STEMI chapter No existing link between EMS and PCI-capable hospital for data feedback Establish data feedback for entire STEMI team 17

18 The Ideal STEMI-Referral Hospital In the ideal STEMI system of care, standardized point of entry protocols dictate the STEMI patients to be transported directly to a STEMI-receiving (PCI-capable) hospital based on: Specific criteria for risk Contraindications to fibrinolysis The proximity of the nearest PCI service Those patients transported by EMS or who arrive via self-transport (or via family or friends) at a STEMI Referral hospital would be treated according to standardized triage and (potential) transfer protocols. Incentives are provided to rapidly: Treat STEMI patients in accordance with American Heart Association and American College of Cardiology guidelines Transfer to the STEMI-Receiving hospital for primary PCI using reperfusion checklists, standard pharmacological regimens and order sets, clinical pathways with attention to details such as eliminating continuous intravenous infusions and tubing Promote efficient data transfer to the STEMI-Receiving hospital as well as integrate data collection and feedback into the system of care Integrate plans for return of the patient to the local community for follow-up care following discharge from the STEMI-Receiving hospital on a routine basis The Ideal STEMI-Referral Hospital Strategies Overall system goal of first medical contact to balloon within 90 minutes Senior leadership commitment to best STEMI care and demonstration of this commitment through the provision of adequate resources to establish an optimal system Establish a predetermined, institution-specific, written protocol for rapid reperfusion agreed upon by all cardiology and emergency department physicians and staff that includes criteria for rapid transfer to STEMI-Receiving Hospital for PCI Emergency physician on duty activates the reperfusion plan according to established local guidelines / care pathways. Prompt identification of patients requiring ECG through nurse interview prior to registration or registration personnel training All patients presenting to ED meeting criteria for 12 lead acquisition to undergo ECG within 10 minutes regardless of room or nurse availability For continued symptoms of STEMI, repeat the 12 lead ECG and/or continuous ST-segment monitoring. Specify system for rapidly acquiring ECG including having ECG equipment in the ED and specifying a location that affords prompt access and adequate patient privacy 18

19 Reperfusion checklist for hospitals with a predetermined plan for fibrinolysis Door in-door out time goal within 30 minutes for hospitals with a predetermined plan for transfer for PCI, and for patients ineligible for fibrinolysis or in cardiogenic shock The Ideal STEMI-Referral Hospital Strategies cont. Establish compatible intravenous tubing and pumps for potential transfer patients. May be changed to established hospital system if admitted. Standard pharmacologic regimen for all STEMI patients agreed upon by all cardiology and emergency department physicians Patient registration should be treated in a fashion similar to trauma patients with the ability to fast-track critical labs, such as creatinine and PT/INR. Establish initial and backup plan for transfer / transport to a STEMI-Receiving hospital. Establish compatible intravenous tubing and pumps for potential transfer patients. Data collection and rapid feedback to representatives from all involved groups In rural geography when rapid transport to STEMI-Receiving hospital unavailable for medical contact to balloon inflation within guideline goal or in urban/suburban areas where regular and backup plan for rapid transport is unavailable: o Door to needle time within 30 minutes for hospitals with a predetermined plan for fibrinolysis o Fibrinolytic agent stored in the ED and the intensive care unit. o Ability to reconstitute and administer fibrinolytic in ED. o If contraindication to fibrinolysis or uncertain diagnosis, expedited transfer plan to STEMI-Receiving hospital. o Ongoing training and assessment program 19

20 STEMI-Referral Hospitals Barriers & Solutions BARRIERS Multiple interests regarding STEMI plan Hospital administration: Keep patient, build volume ED physician: Rapid disposition, litigation EMS: Avoid delay in non-pci hospital Cardiology local hospital: Keep patient Cardiology at PCI hospital: Transfer patient SOLUTIONS Build consensus around what is best for the patient according to: Data Guidelines Resources, leave patient on stretcher Local leadership Multiple STEMI plans Waiting room delays Registration Educate registration staff about chest pain presentation Nurse first Lack of electrocardiogram (ECG) space Whose patient is it anyway? ED physician not empowered to make a reperfusion call Provide privacy for an ECG in triage (convert a closet or curtain area) Change policy for ED medicine empowered to make reperfusion decision EMTALA and transfer issues Ensure protocol is in place for community Accelerate EMTALA forms Fax additional paperwork Rural issues: Lytic ineligible, shock patients Have a transfer plan in place and a back-up plan for rural areas 20

21 The Ideal STEMI-Receiving Hospital 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 short ED stay or transport directly from the field to the catheterization laboratory. Similarly, single call systems from STEMI Referral hospitals with universal patient acceptance by STEMI-Receiving hospitals would result in immediate activation of the catheterization laboratory team without the need for additional review or determination of bed availability. Primary PCI would be provided as routine treatment for appropriate STEMI patients 24 hours per day and seven days per week and STEMI-Receiving hospitals would never be on diversion. Each STEMI-Receiving hospital would have a written commitment from the hospital's administration to support the program. A multidisciplinary group with representation for the ED, EMS, the cardiac catheterization laboratory, the quality improvement team, and the coronary care unit that includes both physicians and nurses would meet regularly to identify problems and implement solutions. A formal continuing education program that includes practical implementation training for staff would be designed and instituted. A mechanism for monitoring program performance, process measures, and patient outcomes would be established. STEMI-Receiving Hospital Strategies: Refer to the Mission: Lifeline recommendations above for outcomes and measurements for quality improvement recognition. The Mission: Lifeline Recognition Program will acknowledge PCI/STEMI-Receiving Centers for their efforts to improve quality of care for STEMI patients. This is the second level of involvement. Receiving Centers should participate in the approved Mission: Lifeline national registry program, ACTION Registry-GWTG. All achievement measures will be considered in the composite score. All reporting measures will be reviewed and collected but will not be used in the composite score. 21

22 STEMI-Receiving Hospital Barriers & Solutions While STEMI-receiving hospitals have the expertise, facilities and equipment to deliver percutaneous coronary intervention (PCI) to STEMI patients, they still have barriers to overcome as part of a STEMI system of care. The chart below examines these barriers and provides a list of solutions. BARRIERS Multiple interests regarding STEMI plan Hospital administration: Build program and maintain PCI volume standards, great quality improvement (QI) numbers and payer contracts Emergency department physician: Rapid disposition, litigation EMS: Avoid delay in non-pci hospital Cardiology: Multiple private groups vs. academic or single cardiology group, provider volume SOLUTIONS Build consensus around what is best for the patient according to: Data Guidelines Resources Local leadership 30-minute activation Monitoring of team members and post times At least one team member within a 15-minute call CCU or house supervisor No diversion: 24 hours a day, 7 days a week, 365 days a year On-site sleeping facilities for staff Policy changes Advocacy State/national level criteria Simultaneous STEMIs Plan in place with second call team member, back up plan or nearby PCI center to cover False activation and resource allocation Definition Monitor and feedback loop Education and training 22

23 Ideal STEMI-System In the ideal STEMI system of care, all parties with a vested interest in the treatment of STEMI patients - from EMS providers to cardiologists, from hospital administrators to policymakers and from third-party payers to the public - share a common belief that quality and timely patient care is the top priority. There is a mutual respect for the critical role of each player in the STEMI system. Individual parties are not out to promote their own self-serving interests. Rather, everyone works together to build a consensus on what the ideal STEMI system looks like for their region, considering its unique challenges. Mission: Lifeline Ideal Public: Within the ideal STEMI system of care, patients and the public would: Recognize the symptoms of a heart attack Realize the importance of activating emergency medical services (EMS) via promptly and getting treatment quickly Be familiar with their local hospital's role in the delivery of STEMI care Understand the implications involved in inter-hospital (rapid) transfer for the purpose of getting the patient percutaneous coronary intervention (PCI), the preferred method of treatment for a STEMI attack The ideal system would: Promote culturally competent educational efforts with clear and consistent messages Include patient representatives on community planning coalitions Provide highly coordinated and patient-centered care 23

24 Public and Professional Education: The CATRAC M:L Professional Education Subgroup work has centered around STEMI and 12 Lead ECG Education for the counties in the region with newly acquired 12 Lead ECG equipment and mock STEMI drills at regional hospitals. The CATRAC M:L Public Awareness and Education Subgroup members have researched regional data related to public awareness and education gaps in addition to work on a heart attack public awareness campaign. See regional data fact sheet from the Texas Department of State Health Services and Zero to Hero Campaign information and resources in the appendix. CATRAC Mission: Lifeline QI Subgroup: One of the resources developed by this subgroup is a STEMI Receiving Center best practice document which outlines best practices for multidisciplinary STEMI team meetings, located in the appendix. All STEMI receiving hospitals in CATRAC are voluntarily participating in the national ACC/AHA Acute MI Data Registry titled NCDR Action Registry GWTG. The data collection tool is located in the appendix. The AR-G data elements that are collected from EMS and the STEMI referral hospital and included in the data collection tool are listed below. Means of Transport TO First Facility O Self/Family O Ambulance O Mobile ICU O Air If Ambulance or Mobile ICU or Air, Pre-Arrival 1 st Medical Contact (Pre-hospital provider at patients side) Date/Time Transferred FROM Outside Facility? If yes, Means of Transfer O Ambulance O Mobile ICU O Air If yes, Arrival at Outside Facility Date/Time If yes, Transfer from Outside Facility Date/Time If yes, Name of Transferring Facility/American Hospital Association number 24

25 Cardiac Status On First Medical Contact (Pre-hospital provider or first hospital): Symptom Onset Date/Time (time that patient experienced symptoms that prompted patient to activate the system or take action) First ECG obtained (date/time) O Pre-Hospital (e.g. ambulance) O After 1 st hospital arrival STEMI or STEMI Equivalent O Yes O No If Yes, ECG Findings: O ST elevation O LBBB (new or presumed new) O Isolated posterior MI If Yes, STEMI or STEMI Equivalent First Noted O First ECG O Subsequent ECG If No, Other ECG Finding If Subsequent ECG, Subsequent ECG with STEMI or STEMI Equivalent Date/Time O New or presumed new ST depression O Transient ST elevation lasting < 20 minutes O New or Presumed new T-Wave inversion O None Continued Cardiac Status on First Medical Contact Heart Failure O No O Yes Cardiogenic Shock O No O Yes Cocaine Use O No O Yes Heart Rate (bpm) Systolic BP (mmhg) Cardiac Arrest O No O Yes If Yes, Pre-hospital O No O Yes If Yes, Outside Facility O No O Yes Any Medications Administered up to 24 hours before or after first medical contact 25

26 References AHA Mission: Lifeline. Antman EM, Anbe DT, Armstrong PW, Bates ER, Green LA, Hand M, Hochman JS, Krumholz HM, Kushner FG, Lamas GA, Mullany CJ, Ornato JP, Pearle DL, Sloan MA, Smith SC Jr. ACC/AHA guidelines for the management of patients with ST-elevation myocardial infarction: executive summary. A report of the American College of Cardiology/American Heart Associaiton Task Force on Practice Guidelines (Writing Committee to Revise the 1999 Guidelines on the Management of Patients With Acute Myocardial Infarction). Circulation. 2004;110: Antman EM, Hand M, Armstrong PW, Bates ER, Green LA, Halasyamani, LK, Hochman J S, Krumholz HM, Lamas GA, Mullany C J, Pearle DL, Sloan M A, Smith, SC focused update of the ACC/AHA 2004 Guidelines for the Management of Patients With ST-Elevation Myocardial Infarction: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Writing Group to Review New Evidence and Update the ACC/AHA 2004 Guidelines for the Management of Patients With ST-Elevation Myocardial Infarction). Circulation. 2008;117: Graff L, Palmer AC, LaMonica P, Wolf S. Rule of rapid ECG Triage of Patients for a Rapid (5-Minute) Electrocardiogram: A Rule Based on Presenting Chief Complaints. Annals of Emergency Medicine 2000; 36: Jacobs AK, Antman EM, Faxon DP, Gregory T, Solis P. Development of systems of care for ST-elevation myocardial infarction patients; executive summary. Circulation. 2007; Jain S, Ting HT, Bell M, et al.utility of Left Bundle Branch Block as a Diagnostic Criterion for Acute Myocardial Infarction. Am J Cardiol 2011;107: King III SB, Smith Jr. SC, Hirshfeld Jr. JW, et al Focused Update of the ACC/AHA/SCAI 2005 Guideline Update for Percutaneous Coronary Intervention: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (2007 Writing Group to Review New Evidence and Update the ACC/AHA/SCAI 2005 Guideline Update for Percutaneous Coronary Intervention) J Am Coll Cardiol. 2008;51: Kontos MC, Hammad AA, Vinh QC, et al. Outcomes in patients with chronicity of left bundle branch block with possible acute myocardial infarction. Am Heart J 2011;161: Kushner FG, Hand M, Smith SC, et al. Focused update: ACC/AHA guidelines for the management of patients with ST-elevation myocardial infarction (updating 2004 guidelines and 2007 focused update). JACC 2009;54: Project Upstart. RACE Optimal STEMI System Specification By Point Of Care Operations Manual. Rokos IC, French WJ, Mattu A, et al. Appropriate Cardiac Cath Lab activation: Optimizing electrocardiogram interpretation and clinical decision making for acute ST-elevation myocardial infarction. Am Heart J 2010; 160: e8. Ting HH, Krumholz HM, Bradley EH, et al. Implementation and integration of prehospital ECGs into systems of care for acute coronary syndrome: a scientific statement from the American Heart Association. Circulation 2008;118:

27 Appendix Regional Assessment Cover Letter PCI Hospital Assessment tool Non-PCI Hospital Assessment tool EMS Assessment tool Inter-hospital Transport Agency Assessment tool 12 Lead ECG Who gets a 12 Lead Regional Guideline Updated Lead ECG Accuracy Project Overview 12 Lead ECG Accuracy Project Start Up Instructions 12 Lead ECG Accuracy Project Data Sheet 12 Lead ECG Accuracy Project Poster Regional EMS STEMI Guideline EMS Reperfusion Checklist Non-PCI Hospital STEMI Treatment Guideline Updated 2013 AHA Mission: Lifeline Levels of Involvement CATRAC STEMI Fact Sheet Texas DSHS CATRAC Mission: Lifeline Public Awareness Campaign CATRAC M:L Best Practices PCI Hospital Multidisciplinary STEMI Meeting Action Registry GWTG Data Collection Tool v2.3

28 September 10, 2009 To: Re: Capital Area Trauma Region STEMI Systems of Care Baseline Assessment As a partner in the Systems of Care for ST Elevation MI patients, you recognize the importance of providing timely, effective and quality care. Recently, the American Heart Association s Mission Lifeline Initiative joined with the Capital Area Trauma Regional Advisory Council to form a Cardiac Care Workgroup for our region. The primary purpose of the Workgroup is to work with PCI Hospitals, Non-PCI Hospitals and EMS Organizations to improve the STEMI Systems of Care within the entire region. The first step in this process requires that we gain a more detailed understanding of our current Systems. To do this, the Cardiac Care Workgroup is asking for your assistance in performing a baseline assessment of our Region s STEMI Systems of Care. Each Hospital and EMS Organization (911 response agencies only at this time) is asked to complete the appropriate baseline assessment using one of the three baseline assessment tools provided (only one assessment per Hospital or EMS Agency). The purpose of the assessment is to assess our baseline rather than to actually evaluate or measure each hospital or EMS organization. By knowing our baseline, the Workgroup can more effectively address improvements from a Regional perspective. The assessment also allows us to identify regional examples that may benefit others. Additionally, the Quality Improvement Sub-Workgroup is assessing the data measures currently collected or calculated by each Hospital and EMS Organization. Because some Hospitals may collect data for EMS Organizations or some EMS Organizations collect data for local Hospitals, the assessment tools include many data elements group by PCI Hospital, Non-PCI Hospital, EMS Organization and System (regional). We ask that the person completing the assessment simply review each data measure and indicate whether the measure is currently being captured by your Organization. Non-applicable data measures require no response. There also is no need to enter any of your actual performance data at this time. We sincerely appreciate the time and attention given to completion of this baseline assessment. We would like to have all assessments completed and returned by October 12, Questions regarding the assessment tool may be addressed to Louis Gonzales, louis.gonzales2@ci.austin.tx.us or Ronda Mackey, ronda.mackey@stdavids.com (co-facilitators of the QI/PI SubWorkgroup). Robert Wozniak, MD, FACC Cardiac Care Workgroup Co-Facilitator Frank Zidar, MD, FACC Cardiac Care Workgroup Co-Facilitator

29 CATRAC Mission: Lifeline Baseline Assessment Primary PCI Hospital Please return completed Assessments by or fax to: Hospital Name: City, State: Healthcare System Key Contact (s): Position Held: 1. Are you Society of Chest Pain Center accredited? a. Yes b. No 2. Does your hospital have a 12 lead ECG triage protocol, who gets a 12 lead, and is it posted? a. Yes, we have one and it is posted. b. Yes, we have one; but it is not posted. c. No, but we are working to obtain one. d. No, we do not have one. 3. Who performs the 12 lead ECG on patients with suspected acute cardiac patients in your ED? Circle all that apply. a. ECG Tech b. ED Nurse c. ED Tech d. Other 4. Is this person located within your emergency department? a. Yes b. No 5. Does your hospital ED have an AMI/STEMI order set/treatment protocols? a. Yes b. No Ver 1 - Sept

30 6. Does your hospital have an AMI/STEMI point of entry (triage) and patient pathway plan (diagnosis) including cardiac cath lab activation policies and procedures documentation? a. Yes, we have documented plan. b. Yes, we have an understood plan; but it is not documented at this time. c. No, we do not have documentation. 7. Does your hospital have a plan for triage and treatment for simultaneous presentation of STEMI patients? a. Yes b. No 8. Who is the first person a patient sees when arriving at your ED (by personally owned vehicle)? a. Greeter. b. Triage Nurse. c. Registration Staff. d. Other 9. Are you a STEMI receiving center available 24 hours/7 days a week to perform primary PCI? a. Yes, we are resources and staff 24/7. b. No, we have resources and staff during our regular business hours. c. No, we are working to obtain resources d. No, not at this time. 10. Does a single phone call/page alert the cardiac catheterization lab team including the interventional cardiologist? a. Yes b. No 11. Does your cardiac catheterization laboratory staff including the interventional cardiologist arrive at the hospital within 30 minutes of the activation call/page? a. Yes b. No 12. Does your hospital STEMI system staff have support from your administration/upper level management? a. Yes b. No Ver 1 - Sept

31 13. What is your STEMI data collection tool? a. NCDR Action Registry GWTG b. GWTG-CAD (this program will sunset at the end of 2009) c. NCDR Cath PCI Registry d. Other (please specify) 14. Does your hospital provide immediate feedback on D2B time within 24 hours to your inhouse STEMI team? a. Yes b. No 15. Does your hospital have a formal continuing education program for staff (ED, Cath lab, house supervisors, clinical educators, etc) around STEMI care? a. Yes b. No 16. If EMS Agency staff communicate that they have identified a STEMI, do you activate your Cath Lab team and interventional cardiologist ahead of the patient s arrival to your emergency department? a. Yes b. No Why Not? c. Yes, for some EMS Agencies 17. If a patient is brought to your ED by EMS with a pre-hospital ECG identifying STEMI, do you repeat the ECG? Circle all that apply. a. Yes, we need to confirm the diagnosis. b. Yes, we need our own ECG for medical records. c. No, we treat the patient based on the EMS d. Other. ECG. 18. If the patient has confirmed STEMI diagnosis in the field by EMS, do they have to be formally re-evaluated by an emergency physician (> 5 minute check) prior to admission to the Cath Lab? a. Yes b. No Ver 1 - Sept

32 19. Within what time period does your hospital provide regular outcome feedback to EMS providers? a. Within 48 hours b. Within 2-7 days c. Greater than 7 days d. We do not provide regular outcome feedback 20. If you communicate outcome feedback to EMS providers, what do you provide? Circle all that apply. a. Door to balloon time b. Discharge outcome c. Cath lab findings d. Other (please describe) 21. Do you offer your referral hospitals some type of Hotline for STEMI patients and uncertain STEMI when cardiology consultation is needed? a. Yes b. No 22. If the patient has confirmed STEMI diagnosis at Non-PCI center with plan to transfer for primary PCI, do they bypass your ED and go straight to the Cath Lab when the Cath Lab team is available? a. Yes b. No 23. Within what time period does your hospital provide regular outcome feedback to the referring hospital/non-pci center? a. Within 48 hours b. Within 2-7 days c. More than 7 days d. We do not provide regular outcome feedback Ver 1 - Sept

33 24. If you communicate outcome feedback to the referring hospital, what do you provide? Circle all that apply. a. Door to balloon time b. Discharge outcome c. Cath lab findings d. Other (please describe) 25. Does your hospital have an in-house STEMI team, representing all disciplines, that routinely, at least monthly, meets to evaluate your STEMI performance and make improvement recommendations? a. Yes b. No 26. Are EMS agencies and the non-pci hospitals within and outside of your healthcare system represented and included in those monthly meetings? a. Yes b. No 27. Does your hospital participate in on-going multidisciplinary team meetings that include EMS, non-pci hospitals/stemi Referral Centers, and PCI hospitals/stemi-receiving Centers to evaluate outcomes and quality improvement data, review operational issues, identify problems and implement solutions? a. Yes b. No 28. How many cardiology groups provide primary PCI at your hospital? a. 1 b. 2-3 c. 4-5 d. >5 29. If more than one group, is there a mutual agreement to a shared system for treating unassigned STEMI patients? a. Yes b. No Ver 1 - Sept

34 30. When EMS leaves a copy of the run report/patient care record, where does that documentation go? a. On the chart b. In a bin to be collected later by medical records c. Discarded/Not used d. Other-please explain 31. Do you have a recognized STEMI Receiving Center liaison/system coordinator and a recognized physician champion? a. Yes b. No 32. Who serves in these capacities? Please list names below Liaison/System Coordinator: Physician Champion: 33. Do each of your interventional cardiologists meet ACC/AHA criteria requiring the performance of at least 11 primary PCI procedures per year and 75 total PCI procedures per year? a. Yes b. No c. Don t know 34. Does your hospital meet ACC/AHA criteria requiring the performance of at least 36 primary PCI procedures per year and 200 total PCI procedures per year? a. Yes b. No c. Don t know Ver 1 - Sept

35 The following question lists several data measures. Although the data measures are grouped by EMS, PCI Hospital, Non- PCI Hospital and System, please read each measure to determine whether it is applicable to your group. If you do not capture or record a measure, please leave the column blank for that measure. 35. Which of the following STEMI related data measures does your Agency / Hospital currently capture/record? Please refer to the following example. No specific data is requested. E - Electronic, only capture electronically M - Manual, only capture manually B - Both, use both electronic & manual methods EXAMPLEs Data Measure Capture / Method Comment Record? Arrival at ED Y B Manual then transferred to electronic record EMS Transport Data Measure Capture / Record Method Time interval from EMS dispatch to vehicle arrival at hospital door Patient Contact to First 12 Lead ECG Time interval from symptom onset to EMS dispatch Time from prehospital 12 Lead ECG to balloon inflation (first device used) Time from first medical contact to balloon inflation (first device used) Percentage of patients confirmed by the Hospital to be STEMI who also had an EMS acquired 12 lead ECG Comment Ver 1 - Sept

36 PCI / STEMI Receiving Hospital Data Measure Capture / Record? Method Door to first 12 lead ECG (if no EMS ECG) Cardiac cath lab staff & interventionalist time interval from notification to arrival Interventionalist procedure volume of primary PCI and total PCI Facility procedure volume of primary PCI and total PCI Track compliance with ACC/AHA Class I therapies (Core Measures) In hospital mortality of STEMI patients Time from prehospital 12 Lead ECG to balloon inflation (first device used) Percentage of reperfusion eligible patients who receive any reperfusion therapy (PCI or Fibrinolysis). Percentage of STEMI patients with a door to balloon inflation (first device used) < 90 mins (non-transfer) Percentage of STEMI patients with first medical contact to balloon inflation (first device used) < 90 mins (non-transfer) Percentage of STEMI patients with first medical contact to balloon inflation (first device used) < 90 mins (transfer) Percentage of STEMI patients receiving aspirin within 24 hours Percentage of STEMI patients on aspirin at discharge Percentage of STEMI patients on beta blocker at discharge Percentage of STEMI patients with LDL > 100 who receive statins or lipid lowering drugs Percentage of STEMI patients with LVSD on ACEI/ARB at discharge Percentage of STEMI patients that smoke with smoking cessation counseling at discharge Comment Ver 1 - Sept

37 PCI / STEMI Receiving Hospital (continued) Data Measure Capture / Method Comment Record? Percentage of STEMI patients with a door-toballoon (first device used) < 90 mins Percentage of STEMI patients with a door (referring hospital)-to-balloon (first device used) < 90 mins, transfer Percentage of STEMI patients with a referral to cardiac rehabilitation at discharge Non- PCI / STEMI Referral Hospital Data Measure Capture / Record? Method Percentage of STEMI patients with a door to first ECG time < 10 minutes STEMI patient time interval from ED arrival (Non-PCI Center) to ED discharge (Non-PCI Center) STEMI patient time interval from ED arrival (Non-PCI Center) to balloon (first device) Percentage of PCI eligible STEMI patients with time interval from ED arrival (Non-PCI Center) to balloon (first device) in less than 90 minutes In Hospital mortality of STEMI patients Percentage of reperfusion eligible patients who receive any reperfusion therapy (PCI or Fibrinolysis) Percentage of reperfusion eligible patients with door to needle time within 30 minutes Percentage of STEMI patients with LVSD on ACEI/ARB at discharge Percentage of STEMI patients that smoke with smoking cessation counseling at discharge Comment Ver 1 - Sept

38 Data Measure Proportion of STEMI patients who receive reperfusion therapy Proportion of patients with field diagnosis of STEMI who receive field activation of cardiac cath lab for intended 1 PCI Proportion of patients with field diagnosis of STEMI who do not undergo acute cath due to misdiagnosis Proportion of patients with field diagnosis of STEMI who do not undergo acute cath and have no cardiac marker elevation or revascularization in first 24 hrs Proportion of suspected cardiac patients > 35 years treated by EMS for whom a 12 Lead ECG was obtained Proportion of STEMI patients treated by EMS for whom a 12 Lead ECG was obtained Proportion of patients with presumed STEMI and EMS treated VF who are taken to the cardiac cath lab for intended primary PCI Survival to hospital discharge for all STEMI patients Survival to hospital discharge for all STEMI patients with prehospital VF Proportion of transferred STEMI patients with an initial door to balloon (first device used) time within 90 mins SYSTEM Calculate & Record Method Comment Notes and Additional Comments Ver 1 - Sept

39 CATRAC Mission: Lifeline Baseline Assessment Non- PCI Hospital Please return completed Assessments by or fax to: Hospital Name: City, State: Healthcare System Key Contact (s): Position Held: 1. Who is the first person a patient sees when arriving at your ED (by personally owned vehicle)? a. Greeter b. Triage Nurse c. Registration Staff d. Other 2. If a suspected STEMI patient is brought in by EMS (with possibility of transfer), is the patient left on the EMS stretcher to be evaluated? a. Yes b. Yes, sometimes c. No 3. If a patient is brought to your ED by EMS with a pre-hospital ECG identifying STEMI, do you repeat the ECG? Circle all that apply. a. Yes, we need to confirm the diagnosis b. No, we treat the patient based on the EMS ECG c. Yes, we need our own ECG for medical d. Other records Ver 1 - Sept

40 4. Does your hospital have a 12 lead ECG triage protocol, who gets a 12 lead, and is it posted? a. Yes, we have one and it is posted. b. Yes, we have one; but it is not posted. c. No, but we are working to obtain one. d. No, we do not have one. 5. Who performs the 12 lead ECG on patients with suspected acute cardiac patients in your ED? Circle all that apply. a. ECG Tech b. ED Nurse c. ED Tech d. Other 6. Is this person located within your emergency department? a. Yes b. No 7. Do you have appropriate protocols and standing orders in place for the identification of STEMI? a. Yes b. No 8. If you have such protocols, do you have them present for the Intensive Care Unit/Coronary Care Unit and Emergency Department? a. Yes b. No 9. Does your ED maintain a standardized reperfusion STEMI care pathway that designates primary PCI as the preferred reperfusion strategy if transfer of the patient to a primary PCI hospital/stemi receiving center can be achieved within time consistent with ACC/AHA guidelines? a. Yes b. No 10. Does your ED maintain a standardized reperfusion STEMI care pathway that designates fibrinolysis in the ED (for eligible patients) when the system cannot achieve times consistent with ACC/AHA guidelines for primary PCI? a. Yes b. No Ver 1 - Sept

41 11. Do you have a program in place to track and improve treatment (acutely and at discharge) with ACC/AHA guideline based Class I therapies? a. Yes b. No 12. Do you have a multidisciplinary STEMI team that includes EMS that reviews hospital specific STEMI data on a quarterly basis? a. Yes b. No 13. What is the most commonly used reperfusion strategy in your ED? a. Fibrinolytics and admit b. Fibrinolytics and immediate transfer c. Transfer for primary PCI d. Other (please describe) 14. Do you have a back up reperfusion strategy/plan depending on availability of transport, weather, traffic, etc? a. Yes b. No 15. Do you have and routinely use a fibrinolytic exclusion checklist? a. Yes b. No 16. If your ED uses fibrinolytics, are they stored in the ED? a. Yes b. No 17. If your ED uses fibrinolytics, does the ED physician consult another physician or a cardiologist before administration? a. Yes, calls a Cardiologist b. Yes, Calls patient s primary doctor c. Only on uncertain dx d. ED doc makes reperfusion decisions 18. Does your ED have a relationship with primary PCI Hospitals, whereby you can call a Hotline for patient transfer acceptance and cath lab activation? a. Yes. b. No. Ver 1 - Sept

42 19. If you transfer for primary PCI, what is the most frequently used mode of transport? a. Local EMS or other ground ambulance b. Air medical helicopter c. Critical Care Ground d. Other 20. Do you have a pre-determined transfer for PCI plan for fibrinolytic ineligible & shock patients? a. Yes. b. No. 21. If EMS leaves a copy of their run record/patient care report, where does that documentation go? a. On the chart b. In a bin to be collected later by medical records c. Not used or discarded d. Other (please explain) 22. How far is your hospital from a primary PCI center (can use mapquest if necessary)? Please list all primary PCI Hospitals that you refer to below. Hospital Ground Air Hospital Ground Air Hospital Ground Air miles minutes miles minutes miles minutes miles minutes miles minutes miles minutes Ver 1 - Sept

43 CATRAC Mission: Lifeline Baseline Assessment EMS Agency Please return completed Assessments by or fax to: *For the typical or most likely agency to respond to 911 calls in your city/county. EMS Agency Name: County/Counties Served: Key Contact: Key Contact Address: Position Held (eg-ems Director, Med Director): 1. Describe the staffing of the EMS transport vehicles that immediately respond to treat patients with chest pain. Circle all that apply. a. All EMT Basic b. All EMT Intermediate c. All EMT Paramedic d. Combination with at least one Intermediate e. Combination with at least one Paramedic f. Other, please describe 2. Approximately what percentage of active (first out) EMS transport vehicles have 12 lead ECG devices? a. 100% d. 26%-50% b. 76%-99% e. 1%-25% c. 51%-75% f. 0% 3. How many hours of 12 lead ECG interpretation training/education do your staff typically receive per year? a. 0 b. 1-4 c. 5-8 d. > 8 Ver 1 - Sept

44 4. Who provides this training/education? a. EMS Training Officer/Staff b. PCI Hospital Staff (ED, cardiology) c. EMS Medical Director d. Web based or Distributive education e. Combination or Other f. Not Applicable 5. Does your EMS Agency have written AMI/STEMI/chest pain protocols that include "who gets a 12 lead", 12 lead ECG acquisition, criteria for cardiac cath lab activation, and appropriate communication of ECG findings to receiving hospital and treatments? a. Yes. b. No. c. Our protocol has some of these items but not all 6. For patients experiencing chest pain, how is the 12-Lead ECG information interpreted and communicated? Circle all that apply. a. ECG read by EMS personnel and interpretation called by phone/radio. b. ECG read by computer algorithm and called by phone/radio to receiving hospital. c. ECG read by EMS personnel and transmitted (electronically) to hospital. d. Receiving hospital not notified of ECG results prior to arrival. e. ECG acquired by EMS personnel and transmitted (electronically) to hospital for ED interpretation f. ECG read by computer algorithm and interpreted by EMS personnel and communicated to receiving hospital g. Other, please describe: 7. If a STEMI patient is identified by your EMS Agency, is there a plan/protocol in place recommending or requiring that these patients be transported to a hospital that has a cardiac cath lab ( destination or bypass protocol )? a. Yes. b. No. 8, Does your EMS Agency plan/protocol designate primary PCI as the preferred reperfusion strategy if first medical contact to balloon (first device) is achievable within 90 minutes? a. Yes. b. No. 9. Does your EMS Agency have a protocol in place to transport STEMI patients to the closest Non-PCI hospital for fibrinolysis if first medical contact to balloon (first device) within 90 minutes is not possible? a. Yes. b. No. 10. For patients transported to hospitals that use fibrinolytics, is a fibrinolytic or reperfusion check sheet completed on all suspected STEMI patients prior to arrival at the ED? a. Yes. b. No. c. Not applicable. Ver 1 - Sept

45 11. In your EMS Agency, can EMS personnel activate the cardiac catheterization lab prior to the patient s arrival at the hospital by communicating the EMS findings? a. Yes, for all hospitals. b. Yes, for some hospitals. c. No. 12. Does your EMS Agency have an EMS total scene time goal that includes obtaining a 12 lead ECG for patients with STEMI? a. Yes. b. No. 13. Does your EMS crew leave a copy of the run report/patient care report in the ED within a specified period of time? a. Yes b. No. c. Yes, sometimes 14. If yes to #13, what method is routinely used to provide the patient care record to the ED? a. Paper/Carbon copy b. Fax copy c. Electronic file 15. If yes to #13, within what time period are the patient care records routinely provided to the ED? a. Before the crew leaves the ED b. < 8 hours c. < 24 hours d. 24 hours 16. Does your EMS crew leave a copy of the 12 lead ECG in the ED? a. Yes b. No c. Yes, sometimes 17. If no to question 16, please explain. Circle all that apply. a. Technology deficiency (there is not a b. We don t have time to leave it (e.g. have compatible or accessible printer in the ED) another call) c. The ED does not review/use our records d. Other, please explain: 18. Do you consistently receive feedback from the receiving hospital regarding the STEMI patient outcome? a. Yes b. No 19. Does a representative from your Agency regularly participate in the STEMI Receiving Hospital's Quality Improvement review of STEMI cases and outcomes? a. Yes, with all STEMI receiving hospitals b. Yes, with some STEMI receiving hospitals c. Yes, but is variable d. No Ver 1 - Sept

46 CATRAC Mission: Lifeline Baseline Assessment Inter-facility Transport Provider Please return completed Assessments by or fax to: *This assessment is for ambulance and air medical organizations who transport/transfer STEMI patients from one hospital to another (typically a non-pci hospital to a PCI hospital). Transport Provider Name: Cities & Hospitals to which you provide transfer service Key Contact Name: Contact Address: Contact Position/Title: 1. Describe the staffing of the vehicles/aircraft that are designated to transport/transfer suspected STEMI patients from one facility to another. Select all that apply. a. All EMT Basic b. All EMT Intermediate c. All EMT Paramedic d. Paramedic and RN e. Combination with at least one Paramedic f. Other, please describe 2. Approximately what percentage of active inter-facility transport capable vehicles/aircraft have 12 lead ECG devices? a. 100% d. 26%-50% b. 76%-99% e. 1%-25% c. 51%-75% f. 0% 3. How many hours of 12 lead ECG interpretation training/education does your interfacility transport staff typically receive each year? a. 0 b. 1-4 c. 5-8 d. > 8 4. Who provides this training/education? a. EMS Training Officer/Staff b. PCI Hospital Staff (ED, cardiology) c. EMS Medical Director d. Web based or Distributive education e. Combination or Other f. Not Applicable Ver 1 - Jan

47 5. Is your inter-facility transport service included in the written STEMI Care plans developed by non-pci hospitals in your transport area? a. Yes, for some hospital STEMI plans b. Yes, for all hospital STEMI plans c. No d. Not sure 6. Does your inter-facility transport service routinely measure and record the interval from the time a request for transfer of a STEMI patient is received to the time the STEMI patient is delivered to the receiving ED staff? a. Yes b. No 7. Does your inter-facility transport service have a goal for the maximum total time at hospital for STEMI patients being transferred from a non-pci hospital to a PCI hospital? a. Yes. b. No. 8. If your inter-facility transport crew acquires an additional 12 lead ECG during transport, does the crew leave a copy of the 12 lead ECG in the ED? a. Yes, every time b. No/Never c. Yes, sometimes d. Don't have 12 lead ECG capability 9. If no to question 8, please explain. Select all that apply. a. Technology deficiency (there is not a b. We don t have time to leave it (e.g. have compatible or accessible printer in the ED) another call) c. The ED does not review/use our records d. Other, please explain: 10. Does your service have the capability to provide fibrinolytic therapy and/or continue fibrinolytic therapy during transport? a. Yes, we can initiate and maintain fibrinolytic therapy prior to or during transport b. Yes, we can only maintain fibrinolytic therapy initiated by the transferring hospital c. Yes, we can only initiate our own fibrinolytic d. No, we can not initiate or maintain fibrinolytic therapy prior to or during transport therapy 11. Does your service s transport destination decision consider high/low risk patient, time from symptom onset, or other factors? a. Yes, our protocol/guideline allows us to b. Yes, but only in consultation with the alter the destination based on such factors transferring physician c. Yes, but only in consultation with the d. No, we always use the hospital's destination receiving physician decision 12. Does your service participate in multidisciplinary QI team meetings with all non-pci and PCI hospitals to which you transport STEMI patients? a. Yes, with all non-pci hospitals b. Yes, with all PCI hospitals c. Yes, with some non-pci & PCI hospitals d. No, not with any hospitals 13. Does your service routinely receive feedback and patient outcome information from all transferring and receiving hospitals? a. Yes, all transferring hospitals b. Yes, all receiving hospitals c. Yes, both transferring & receiving hospitals d. No, not with any hospitals Ver 1 - Jan

48 Instructions for Completing the Baseline Assessment 1. We would like to have the contact information for the person responsible for coordinating clinical aspects of your Organization's STEMI care. 2. For each question, provide an answer consistent with how your Organization ROUTINELY practices. Exceptions or rare practices should generally not be included. 3. If more than one selection applies for a specific question, you may select more than one response choice. 4. If you would like to provide clarification for any response, please feel free to make a note on the question or in a separate document. 5. For the purposes of this baseline assessment, STEMI only includes those patients diagnosed with an acute ST segment elevation MI based on at least one diagnostic ECG. 6. For question #5, we are interested in knowing whether your Organization is specifically included (by name) in a non-pci hospital's written plan for STEMI Care. This plan would address how the Hospital will transfer the STEMI patient from their hospital to a PCI capable hospital. 7. Question #7 is seeking to learn whether your Organization seeks to minimize the time at the transferring hospital by limiting the total time to less than an established target/goal. 8. Question #11 is simply clarifying how your Organization decides on the destination PCI hospital. In some Organizations, protocols may allow consideration of other factors. In others, the referring or receiving hospitals make the destination decision and transferring Organizations do not alter the decision. There is no right or wrong answer; we simply want to know your current practice. Ver 1 - Jan

49 ECG Screening Guidelines When in doubt, do the ECG! Patients > 30 years old & experiencing any of the following: Chest pain (any pain between the navel and jaw) Chest pressure, discomfort, or tightness "Heartburn" or epigastric pain Complaints of heart racing or heart too slow Syncope Severe weakness New onset stroke symptoms Difficulty breathing (with no obvious non-cardiac cause) Above patients require ECG in 5 minutes! Patients (regardless of age) with any of the above symptoms & history of: Remember: Prior cardiac disease such as heart attack A family history of early heart disease Diabetes mellitus Severe obesity Recent cocaine use These patients also require an ECG within 5 minutes! Present ECG for immediate interpretation! Women & diabetic patients are more likely to present with atypical symptoms Elderly patients may have symptoms such as generalized weakness, altered mental status, nausea/vomiting, shortness of breath, diaphoresis, or syncope as their only sign of acute heart attack Atypical pain can be in jaw, neck, arm, or upper back. Minimize patient exertion 12 Lead on any post resuscitation cardiac arrest to evaluate for AMI When in doubt, do the ECG!

50 Process Improvement Initiative Prospectively measure the accuracy of EMS 12 Lead ECG Interpretation for STEMI Alert Patients Hypothesis/Concern Anecdotal information suggests that the EMS ECG interpretation accuracy for patients identified as STEMI Alert is low. If this concern is confirmed, the incidence of incorrect cardiac catheterization lab activations may be unnecessarily increased Objective The project s primary objective is to prospectively measure the EMS ECG STEMI interpretation accuracy to determine whether improvements may be identified. If the concern is confirmed, a secondary objective is to determine potential reasons for the low accuracy in order to identify and implement educational improvements. It is anticipated that this initiative will continue for a minimum of 6 months. Hospital and EMS System participation is voluntary. However, increased Hospital and EMS System participation will improve the reliability of the results. At the onset of this project in February 2010, all 11 PPCI Hospitals within the Region have agreed to participate along with Austin/Travis County EMS, San Marcos/Hays County EMS, and Williamson County EMS. Process 1. The Office of the Medical Director for the Austin/Travis County EMS System in concert with the Clinical Leadership for Williamson County EMS and San Marcos/Hays Co EMS will define the minimum required data fields, data definitions and data choices and formatting. These will be incorporated into a standardized Excel spreadsheet. (See below for defined data fields) 2. Each EMS System through its defined Clinical or Performance Management group will send (via an attachment) each defined hospital representative the Project s standardized Excel spreadsheet on a monthly basis. This will generally occur at the beginning of each month starting with March The spreadsheet will contain a listing of all EMS patients deemed as STEMI Alerts (Code STEMI) and transported to the specific hospital. The spreadsheet will identify the EMS agency, EMS incident number and receiving Hospital. 4. In addition to the spreadsheet, each STEMI Alert case will also have the EMS 12 lead ECG used to activate the STEMI Alert. The ECG may be provided in an electronic (preferred) or paper format. February 7, 2011 Page 1 of 4

51 5. The participating STEMI Receiving Hospital will complete the Blank fields labeled ECG Confirmed, Potential Confounder and Comments & Outcome Feedback using the provided Excel Spreadsheet. No other changes to the spreadsheet should be made in order to ease the process of data aggregation. 6. In order to complete the data fields, the STEMI Receiving Hospital will identify a cardiologist who will review the EMS ECG. The cardiologist will reach two decisions. a. First, the cardiologist will determine whether the ECG meets the regional Mission Lifeline diagnostic criteria for ST segment elevation indicating a STEMI (Yes/No). b. Second, the cardiologist will determine whether other ECG findings may have contributed to an incorrect STEMI interpretation (choices from a standardized drop down menu). c. Ideally, the cardiologist will not be one involved with the cardiac catheterization decisions for the STEMI Alert patient. It is also preferred that the number of cardiologists involved in this process be limited to 1 or 2 in order to minimize inter-rater reliability concerns. 7. If the cardiologist determines the ECG does NOT meet the Mission Lifeline STEMI ECG Criteria (listed on the spreadsheet), the cardiologist should identify any potential confounders and include sufficient comments to assist in determining reasons for the EMS interpretation error. 8. The participating STEMI Receiving Hospital will then send the completed spreadsheet to the designated person within the EMS System. Designated persons for each EMS System are: a. Austin/Travis County EMS: Send to Jeff Brockman AND Louis Gonzales b. Williamson County EMS: Send to Terri King c. San Marcos/Hays County EMS: Send to John Moseley 9. To the extent possible, each hospital should send completed spreadsheets within 10 business days of receipt. 10. Completed spreadsheet data will then be aggregated into a single spreadsheet. This task will be overseen by Jeff Brockman and Louis Gonzales. 11. Louis Gonzales will prepare reports of the data for the purpose of reporting key measures (see below for key measures and definitions). Reports will be distributed to the Mission Lifeline QI group and each participating Hospital and EMS System. 12. Additionally, each participating EMS System and Hospital will receive (if requested) raw data in the form of an Excel Spreadsheet. 13. At the end of the 6-month initiative, this process will be discussed with the Mission Lifeline QI group and the participating Hospitals and EMS Systems to determine whether it should continue and/or be revised. February 7, 2011 Page 2 of 4

52 Data Points & Definitions STEMI Alert (Code STEMI) A response in which the paramedic crew acquires a 12 lead ECG and interprets the ECG as meeting the diagnostic criteria for an ST segment elevation myocardial infarction. A STEMI Alert (Code STEMI) is only activated when the patient also has a clinical presentation consistent with a possible acute coronary syndrome. EMS Incident Number The EMS System s unique incident number for each case defined as a STEMI Alert (Code STEMI). Receiving Hospital The Hospital who initially received the STEMI Alert (Code STEMI) patient from the EMS System. Alert Declared Time The clock time and date at which the paramedic crew notifies EMS Communications of a STEMI Alert (MM:DD:YYYY HH:MM:SS). This is an optional field for the EMS System. ECG Confirmed The decision made by the STEMI Receiving Hospital s over-reading cardiologist regarding whether the ECG met the diagnostic criteria for an ST segment elevation myocardial infarction. (Yes, No) Potential ECG Confounders a listing of ECG findings commonly associated with erroneous interpretations of ECGs as STEMI. This field allows the over-reading cardiologist to list the primary reason why the ECG may have been difficult to interpret and which may have contributed to an incorrect ECG interpretation. (LBBB, RBBB, LVH, Early Repolarization, Pericarditis, Ventricular paced, Non-specific ST changes, Other) Comments a limited text field for entry of feedback information for the treating EMS providers. This field may contain information related to the location and extent of coronary artery lesions identified as well as any available patient outcome information. (Free Text; Field Size Limit to be determined). It is also very useful for comments explaining why the ECG did not meet the regional ECG criteria for STEMI. STEMI For the purposes of this project, STEMI refers only to the evaluation of the 12 lead ECG to determine if it meets the agreed upon definition. The CATRAC Regional Mission Lifeline group has agreed upon the following definition for STEMI: Signs / Symptoms of Acute Coronary Syndrome AND ST segment elevation of 1 mm or more in two continuous leads Excluded are inconclusive ST elevation, elevation isolated to V1 V2 only, and LBBB February 7, 2011 Page 3 of 4

53 Measures The key measure for this initiative is the EMS ECG Accuracy Rate calculated as follows: n = number of STEMI Alerts with an affirmative ECG Confirmed data field N = number of STEMI Alerts EMS ECG Accuracy Rate (reported as a percentage) = ( n / N ) x 100% The EMS ECG Accuracy Rate indicates the frequency of correct ECG STEMI identification (Sensitivity). This measure may be reported using aggregate data and/or sorted by EMS System or destination hospital. Initiative Endpoints After approximately 6 months of data collection, the initiative will be reevaluated. The reevaluation will include both the Mission Lifeline QI group and the participating Hospitals and EMS Systems Additionally, any identified improvement opportunities related to increasing the frequency of EMS ECG STEMI Interpretation accuracy will be addressed by the Clinical Leadership of the participating EMS Systems. Questions or Additional Information Please direct all questions and requests for additional information regarding this project to one of the CATRAC Region Mission Lifeline QI group Co-Chairs: Louis Gonzales Louis.gonzales2@ci.austin.tx.us Anne Robinson Ext arobinson@seton.org February 7, 2011 Page 4 of 4

54 Process Improvement Initiative Prospectively measure the accuracy of EMS 12 Lead ECG Interpretation for STEMI Alert Patients Start up Instructions Below are a few things to keep in mind as we begin the start up of this Process Improvement Initiative. Please feel free to contact Louis Gonzales or Anne Robinson with any questions that arise. Hospital Coordinators for this Project 1. The project will start with STEMI patients identified by EMS during the month of February. This means you will receive the first spreadsheet and batch of ECGs in early March. 2. Please ensure the reviewing cardiologists are familiar with the STEMI ECG criteria adopted by our regional Mission Lifeline. It is highlighted on the left hand side of the spreadsheet. This is a critically important point. 3. It will prove to be extremely beneficial if the cardiologist notes the confounder and/or other reasons that the ECG did not meet the STEMI definition (if applicable). 4. Please do not modify the spreadsheet or enter choices other than those provided in the drop down menus. Changes to the spreadsheet format will make it difficult to aggregate data. Changes to field contents will make it difficult to correctly analyze the data. 5. Please submit the completed spreadsheets to the appropriate EMS System contact person(s) within about 10 days of receipt if at all possible. EMS System Coordinators for this Project 1. The process will start with STEMI patients identified by your EMS System during the month of February. This means you should compile at list of February STEMI cases using the provided spreadsheet. 2. Divide the list of STEMI cases and ECGs by Hospital and send a spreadsheet and accompanying ECGs to each appropriate Hospital. 3. Please ensure the name of your EMS Agency, your EMS incident number and the name of the receiving hospital are entered for every STEMI case listed on the spreadsheet (drop down menus are provided for two of these fields). 4. Once you receive the completed spreadsheets from each Hospital to which your STEMI patients were transported, forward the spreadsheets to both Louis Gonzales and Jeff Brockman via This project assumes your Organization is using the Mission Lifeline definition agreed upon by our Region (see the definitions and spreadsheet notation). Thank you all for participating in this improvement initiative and thus helping us improve our Region s STEMI System of Care February 7, 2011 Page 1 of 1

55 CATRAC Mission: Lifeline STEMI ECG Accuracy Project Data Sheet

56 Cardiologist Interpretation of Prehospital EKG Impacts Accuracy of EMS STEMI Activations Louis Gonzales BS LP, Kayla Riggs, Osvaldo S Gigliotti MD, Robert J Wozniak MD, Frank J Zidar MD, Jose G Cabanas MD, Paul R Hinchey MD MBA Capital Area Trauma Regional Advisory Council Cardiac Care Workgroup BACKGROUND Prehospital ST-Segment Elevation Myocardial Infarction (STEMI) identification is essential for an effective STEMI System of Care. Accurate EMS interpretation of STEMI is critical to appropriate activation of the catheterization team, maintaining cardiology process commitment and improving the performance of EMS STEMI care. Interventional cardiologist agreement with the EMS interpretation of the EKG remains the gold standard for accuracy and the decision to proceed to the catheterization lab. OBJECTIVES To define EMS EKG interpretation accuracy and describe the interventional cardiologist s interpretation of paramedic STEMI activations utilizing a regional STEMI definition. METHODS From 2/1/2011 to 6/30/2011 we performed a prospective study using EKGs from all paramedic STEMI activations in an urban/suburban EMS System. (population 1.1 million) Paramedics used STEMI criteria agreed upon by the AHA regional Mission Lifeline workgroup. Three interventional cardiologists blinded to the decision to proceed to the catheterization lab and the catheterization results were selected to form a review panel. For each EKG, the cardiologists were asked to determine whether the activation met defined regional STEMI criteria. Data were collected for descriptive analysis and level of agreement among the 3 reviewers. RESULTS A total of 106 STEMI activations were included in the analysis. All 3 cardiologists agreed the EKG met STEMI criteria in 51 of 106 cases (48%). 2 or more cardiologists agreed that STEMI criteria were met for 71 of 106 EKGs (67%). 1 or more cardiologists agreed the EKG met STEMI criteria in 88 of 106 cases (83%). Overall agreement among the 3 cardiologists was low k= % CI ( ). Table 1 - Regional STEMI Criteria Inclusions S/S of ACS ST elevation 1 mm Paramedic interpretation of STEMI Table 2 Cardiologist Agreement Cardiologist Agreement Exclusions Isolated V1-V2 ST elevation LBBB Absence of other STEMI mimics 1 or more 2 or more All 3 88/106 71/106 51/106 % of Total 83% 67% 48% Table 3 Identified EKG Confounders 2 or more Agree = STEMI 2 or more Agree NOT STEMI V1-V2 STE only 0 9 Poor tracing 0 5 LBBB 0 4 Early Repol 5 3 LVH 4 7 LIMITATIONS This study did not include cases not identified by paramedics as a STEMI. Cardiologists were asked to use criteria that did not take into account other factors used by experienced cardiologists to identify STEMI. CONCLUSIONS We found low agreement between cardiologists when determining the accuracy of paramedic STEMI activations. Paramedic accuracy is dependent on the specific cardiologist who reviews the EKG. Difficulty in defining a standard for EMS performance measurement remains. Further studies are needed to define an accuracy standard for EMS Systems and to understand the reasons for cardiologist variation.

57 12 Lead ECG criteria Chest Pain, Suspected Acute Coronary Syndrome Signs & Symptoms STEMI Criteria Patients >20 years old experiencing any signs and symptoms listed Or any age patient with signs and symptoms and history of: Cardiac disease Family history of early heart disease Diabetes mellitus Severe obesity Recent cocaine use WHEN IN DOUBT, DO THE ECG! Chest pain (any pain between the navel and jaw) Chest pressure, discomfort or tightness Complaints of heart racing or too slow Syncope Severe weakness in patients > 45 years old New onset stroke symptoms Difficulty breathing (with no obvious cause) Signs / Symptoms of Acute Coronary Syndrome (ACS) AND ST segment elevation of 1mm or more in two contiguous leads * If ST elevation inconclusive, isolated to V1-V2, or LBBB then consult with physician If STEMI criteria is met: declare a STEMI Alert and expedite transport to appropriate STEMI Center OR If transport time will be greater than 60 min s consider transport to the closest Non-PCI facility STEMI S S B I If O2 Sat <94% apply Oxygen at 4L/min and titrate to maintain O2 sat between 94-99% Aspirin 324 mg PO chewed X1 12 Lead ECG < 5 mins NTG SL q 5min if SBP 90 until patient is pain free Hold if SBP<90 NTG paste 1" Hold if SBP <90 S S B I S B I P M Legend System Responder EMT - B EMT- I EMT- P Medical Control S B I P M Complete fibrinolytic checklist P Analgesia (Morphine or Fentanyl) PRN for pain P With local Medical Direction P Consider: Metoprolol 5 mg IV x 1 if patient hypertensive (>160/90). May repeat x 1 if indicated. Hold if SBP < 120, O2 sat< 92%, HR < 60 or active CHF or Asthma P STEMI? Yes No P Clopidogrel (Plavix) 600mg PO P P Heparin 70 units/kg IV P M Contact Destination or Medical Control M Pearls: Do not administer Nitroglycerin in any patient who has used Sildenafil (Viagra, Revatio) or Vardenafil (Levitra) in the past 24 hours or Tadalafil (Cialis) in the past 36 hours due to potential severe hypotension. Target: Contact to Balloon time is less than 90 minutes. If geography or hazards exists that would cause transport times to exceed 60 minutes Consider Air Transport. If patient has ECG changes, or is going directly to cardiac cath lab, establish a second IV if possible. Monitor for hypotension and respiratory depression after administration of Nitroglycerin, Metoprolol,Morphine and Fentanyl. Females, diabetics and geriatric patients often have atypical pain, or only generalized complaints. Hypersympathetic state from amphetamine, cocaine or PCP use usually presents with sustained HR >120 bpm and HTN Contraindications to Heparin or Plavix is allergy to the medication or Thrombocytopenia / history of HIT (Heparin Induced Thrombocytopenia)

58 Agency: Patient ID: DOB: REPERFUSION CHECKLIST for Evaluation of the Patient with STEMI STEP 1 Has patient experienced chest discomfort for greater than 15 minutes and less than 12 hours? YES NO STEP 2 Are there contraindications to fibrinolysis? If ANY of the below are checked Yes, fibrinolysis is contraindicated Consider direct transport to PPCI capable facility where feasible STOP YES NO ABSOLUTE CONTRAINDICATIONS: YES NO ABSOLUTE CONTRAINDICATIONS: Any prior intracerebral hemorrhage Known structural cerebral vascular lesion (eg, arteriovenous malformation) Known malignant intracranial neoplasm (primary or metastatic) Ischemic Stroke within 3 months EXCEPT acute ischemic stroke within 4.5 hours Suspected aortic dissection Active bleeding or bleeding diathesis (excluding menses) Significant closed-head or facial trauma within 3 months Intracranial or intraspinal surgery within 2 months Severe uncontrolled hypertension (unresponsive to emergency therapy) For streptokinase, prior treatment within the previous 6 months O Gara PT, et al ACCF/AHA guideline for the management of ST-elevation myocardial infarction: a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines. Circulation. 2013;127

59 Non-PCI Hospital STEMI Guidelines (v 04.13) Page 1 STEMI Criteria: Signs / Symptoms of Acute Coronary Syndrome (ACS) AND ST segment elevation of 1 mm or more in two contiguous leads If both criteria are met then recommend activating the PCI Hospital If ST-elevation inconclusive, isolated to V1-V2, or LBBB identified, then recommend consultation with physician and PCI Hospital prior to activation Goal: Patient in the door and out the door < 30 minutes 1st Medical Contact/EMS Time: Pt. ED Arrival Time: Pt. ED DischargeTime: Signs / Symptoms of Acute Coronary Syndrome (ACS) YES NO Refer to hospital s non-acs guidelines Acquire 12 lead ECG Physician reads 12 lead within 10 minutes STEMI / ST elevation conclusive? YES NO Consult PCI Receiving Physician Activate Code STEMI / STEMI Alert Contact Transport (EMS or Air Medical) and Obtain ETA: Call for transfer to PCI Hospital with Code STEMI / STEMI Alert Estimated time from 1st Medical Contact* to Device < 120 minutes? If no, consider Fibrinolytics** * EMS Scene Arrival or ED Arrival YES NO **See Page 2 - Fibrinolysis Therapy or Consult PCI receiving physician Patient Care Priorities Prior to Transport or During Transport DO NOT DELAY TRANSPORT If O2 Sat < 94% apply Oxygen at 4L/min and titrate to maintain O2 Sat between 94-99% Aspirin 324 mg PO chewable Apply Cardiac Monitor & have hands-free defibrillator pads available at bedside Obtain vital signs and pain scale Establish Saline Lock #1 large bore needle Administer Heparin IV loading dose 70 units/kg Administer Ticagrelor (Brilinta) 180 mg PO (preferred). If unavailable, Clopidogrel (Plavix) 600 mg PO or Prasugrel (Effient) 60 mg PO. Precautions with Prasugrel: Do not use in patients with active bleeding, history of TIA or stroke, age > 75 years, body weight less than 60 kg or 132 lbs. Patient Care when time allows DO NOT DELAY TRANSPORT Fax ECG to PCI Hospital Establish Saline Lock #2 large bore needle Obtain Lab: cardiac markers (CKMB, Trop I), CBC, BMP, PT/INR, PTT, and pregnancy serum if childbearing age Administer NTG 1/150 gr.sl every 5 min x3 doses or Nitropaste PRN for chest pain (hold for SBP < 90); caution with inferior MI Administer Analgesia (Morphine sulfate or Fentanyl) IV PRN for chest pain unrelieved by NTG Consider Metoprolol (Lopressor) 5 mg IV x 1 if patient hypertensive (>160/90). May consider additional doses if clinically indicated. Hold if SBP < 120, Pulse ox < 92%, HR < 60 or active CHF or Asthma, or cocaine use.

60 Non-PCI Hospital STEMI Guidelines (v 04.13) Page 2 Fibrinolytic Therapy Goal: Patient in Door to Needle Time < 30 minutes Is Estimated Time from First Medical Contact (EMS or Door) to Device/Reperfusion > 120 minutes? NO Return to Page 1 YES Reperfusion Checklist MUST BE COMPLETED Prior to Administration of Fibrinolytic Therapy ABSOLUTE contraindications to Fibrinolytic Therapy RELATIVE contraindications to Fibrinolytic Therapy Active internal bleeding or bleeding diathesis Yes No Active internal bleeding in past 2-4 weeks Yes No Any prior Intracranial Hemorrhage Yes No Prior exposure to Fibrinolytics Yes No Allergy to Fibrinolytics Yes No Severe hepatic and renal dysfunction Yes No Ischemic stroke < 3 months (exception: acute ischemic stroke within 4.5 hours) Yes No Recent GI bleed or active Ulcer disease Yes No Known malignant intracranial neoplasm Yes No Traumatic or prolonged CPR > 10 minutes Yes No Known/suspected aortic dissection or aneurysm Yes No Current use of anticoagulants Yes No Cerebral aneurysm or AVM Yes No History of prior ischemic stroke > 3 months Yes No Trauma / Surgery (Intra-cranial Or Intra-spinal) < 3 months Significant closed-head or facial trauma within < 3 months Yes No Major surgery or trauma within 3 weeks Yes No Yes No Pregnancy or early postpartum Yes No Severe hypertension unresponsive to emergency therapy (SBP > 180 mmhg or DBP > 110 mmhg) Yes No Significant Hypertension on presentation (SBP < 180 mmhg or DBP < 110 mmhg) Yes No Known structural cerebral vascular lesion (e.g. Arterlovenous malformation) Yes No History of chronic, severe, poorly controlled hypertension Yes No Dementia Yes No Known intracranial pathology not covered in Absolute Contraindications Yes No Non-compressible vascular punctures Yes No

61 Non-PCI Hospital STEMI Guidelines (v 04.13) Page 3 Fibrinolytic Administration Guidelines Goal: Patient in Door to Needle Time < 30 minutes Has patient experienced chest discomfort for greater than 12 hours? NO YES Consult PCI receiving physician Are there contraindications to Fibrinolytic? (see Page 2) NO YES Primary Drug Treatment Plan Consult PCI receiving physician Fibrinolytic should be given in a dedicated IV line. Flush line before and after administration of medication Tenecteplase (TNKase) IV over 5 seconds: ***(If unable to give TNKase, give Reteplase (Retavase) per Alternative Drug Treatment Plan on page 4)*** Patient Weight TNKase Reconstituted kg lbs mg ml <60 < to < to < to < to < to < to < >90 > Enoxaparin (Lovenox): (If unable to give Enoxaparin, give Heparin per alternative drug plan below) Patient Age Dose <75 30 mg IV plus 1 mg/kg SC (maximum dose 100 mg) 75 No bolus mg/kg SC (maximum dose 75 mg) Clopidogrel (Plavix): Patient Age 75 Dose 300 mg PO loading dose >75 75 mg PO dose If O2 Sat <94% apply Oxygen at 4L/min and titrate to maintain O2 Sat between 94-99% Aspirin 324 mg PO chewable times 1 dose (if not already given) Repeat EKG 30 minutes after fibrinolytics administration if possible Ensure transport agency will accept Fibrinolytic Drip during patient transport to PCI hospital If Goal is missed talk to PCI Hospital

62 Non-PCI Hospital STEMI Guidelines (v 04.13) Page 4 Fibrinolytic Administration Guidelines Goal: Patient in Door to Needle Time < 30 minutes Has patient experienced chest discomfort for greater than 12 hours? NO YES Consult PCI receiving physician Are there contraindications to Fibrinolytic? (see Page 2) NO YES Consult PCI receiving physician ***Alternative Drug Treatment Plan*** Reteplase (Retavase) 10 Units IV over 2 minutes x 2 at 30-minute intervals 1st dose given at: 2nd dose given at: Unfractionated Heparin bolus 60 IU/kg IV (maximum 4,000 IU) If O2 Sat <94% apply Oxygen at 4L/min and titrate to maintain O2 Sat between 94-99% Aspirin 324 mg PO chewable times 1 dose (if not already given) Repeat EKG 30 minutes after fibrinolytics administration if possible OR Alteplase (tpa) 90 min weight-based infusion Unfractionated Heparin bolus 60 IU/kg IV (maximum 4,000 IU) If O2 Sat <94% apply Oxygen at 4L/min and titrate to maintain O2 Sat between 94-99% Aspirin 324 mg PO chewable times 1 dose (if not already given) Repeat EKG 30 minutes after fibrinolytics administration if possible Ensure transport agency will accept Fibrinolytic Drip during patient transport to PCI hospital If Goal is missed talk to PCI Hospital

63 There are three levels of involvement with Mission: Lifeline: Participation, Recognition and Accreditation (not available for EMS). For every program, all system components (EMS, Non-PCI/STEMI Referring Centers and PCI/STEMI Receiving Centers) requirements must be met in order for the system to qualify for each level of involvement. Mission: Lifeline PARTICIPATION Requirements for STEMI Systems of Care The Mission: Lifeline Participation Program will acknowledge STEMI Systems, EMS, Non-PCI/STEMI Referring Centers and PCI/STEMI Receiving Centers for their efforts to improve quality of care for STEMI patients. This is a basic first level of involvement. The bar for participation is set at a basic level to encourage entry into Mission: Lifeline. Furthermore, there are no monetary requirements to participate other than the systems and system component s internal administrative costs. Systems and their components can start immediately participating with Mission: Lifeline by adhering to the following component criteria: EMS 1. Identify an EMS system champion. 2. There must be on-going multidisciplinary team meetings to evaluate outcomes and quality improvement data. Operational issues should be reviewed, problems identified, and solutions implemented. 3. Commitment to develop a plan for allocating resources for equipment and training of EMS personnel dispatched to suspected cardiac patients to facilitate early identification of STEMI. 4. Commitment to develop and/or refine EMS triage and transfer protocol to be in compliance with the regional STEMI systems of care plan. (Could include, but not limited to Reperfusion Checklists, STEMI diagnosis communication and most appropriate hospital destination.) 5. Participate in data collection, continuous quality improvement efforts and feedback loops to ensure optimal STEMI patient care. STEMI Referring Center 1. Identify a hospital champion. 2. There must be on-going multidisciplinary team meetings to evaluate outcomes and quality improvement data. Operational issues should be reviewed, problems identified, and solutions implemented. 3. Participate on the regional Mission: Lifeline Stakeholder group (if available) to contribute to the development of the regional STEMI System of Care plan. 4. Commitment to the Emergency Department (ED) having adequate staff, equipment, and training to perform rapid evaluation, triage, transport and treatment for STEMI patients. 5. Commitment to develop and/or refine ED triage for rapid reperfusion, either transfer protocol or fibrinolytic, to be in compliance with the regional STEMI systems of care plan. 6. Commitment to develop a plan with local EMS to ensure inter-hospital STEMI transfers receive priority response. 7. Participate in data collection, continuous quality improvement efforts and feedback loops to ensure optimal STEMI patient care. STEMI Receiving Center 1. Identify a hospital champion. 2. There should be on-going multidisciplinary team meetings to evaluate outcomes and quality improvement data. Operational issues should be reviewed, problems identified, and solutions implemented. 3. Participate on the regional Mission: Lifeline Stakeholder group (if available) to contribute to the development of the regional STEMI System of Care plan. 4. Commitment to accept STEMI patients regardless of ED diversion status 5. Commitment to the Emergency Department (ED) and Cardiac Catheterization Lab having adequate staff, equipment, and training to perform rapid evaluation, triage, and treatment for STEMI patients. 6. Commitment to developing and/or refining ED and cath lab triage and transfer receiving protocol to be in compliance with the regional STEMI systems of care plan. 7. Commitment to develop a plan with EMS to ensure inter-hospital transfers and fibrinolytic ineligible patients receive priority response and en-route communication to bypass Non-PCI Capable ED when appropriate. 8. Participate in data collection, continuous quality improvement efforts and feedback loops to ensure optimal STEMI patient care. System 1. The System should be registered with Mission: Lifeline. 2. There should be on-going multidisciplinary team meetings that include EMS, non-pci hospitals/stemi Referring Centers, and PCI hospitals/stemi-receiving Centers to evaluate outcomes and quality improvement data. Operational issues should be reviewed, problems identified, and solutions implemented. 3. Each system should have a recognized system coordinator, receiving and referring hospital champions, and an EMS medical director/champion. 4. At least one of each system components (EMS, STEMI Referring Centers and STEMI Receiving Centers) should meet the appropriate participating criteria. Updated: August 14, 2013 ***Subject to update***

64 Mission: Lifeline RECOGNITION for STEMI Systems of Care The Mission: Lifeline Recognition Program will acknowledge STEMI Systems, EMS, Referring Centers (Non-PCI/STEMI) and Receiving Centers (Non-PCI/STEMI) for their efforts to improve quality of care for STEMI patients. Systems and their components must participate in the approved Mission: Lifeline national data registry program, ACTION Registry -GWTG with the exception of EMS measures which will be self-reported and collected. All achievement measures will be considered in the composite score that is used to determine recognition status. Reporting measures may be reviewed and collected but will not be used in the composite score or to determine recognition status. It should be noted that at this time, only data from STEMI Referring Centers, STEMI Receiving Centers and EMS programs may be submitted. HOSPITAL Measures for STEMI Systems of Care Recognition Achievement Criteria: Must meet 85% or greater composite score with no single measure below 75% for specified periods of time Award duration: May 31 - May 31 of the following year when new awards are announced Annual award period: includes data submitted from January December of the previous year Volume requirements: o Receiving Center- 9 or more STEMI patients in the award quarter or an average of 9 per quarter for the year to equal a minimum of 36 per year o Referring Center- 4 or more STEMI patients in the award quarter or an average of 10 minimum for the year Award Levels: BRONZE 90 calendar days (1 calendar quarter) of Mission: Lifeline compliance criteria. NEW Beginning 2014 (2013 Data) Hospitals previously recognized as achieving the Mission: Lifeline BRONZE award, must achieve SILVER to maintain Mission: Lifeline recognition status. SILVER One calendar year achieving overall composite scores of Mission: Lifeline compliance criteria. Sites achieving 2012 Silver Award level must maintain a second calendar year of Mission: Lifeline data compliance for 2013, advancing to Gold level. GOLD 2 consecutive calendar years achieving overall composite scores of Mission: Lifeline compliance criteria. Sites achieving Gold level recognition must maintain this level in order to keep Mission: Lifeline recognition status. Receiving Center Plus Award - an additional award provided to Receiving Centers that meet Bronze, Silver or Gold criteria and in addition are able to achieve 1 st door to device time of 120 minutes or less (for transfers). Must have an achievement score of 75% or greater for this plus measure. The PLUS measure is an independent measure that is not scored in combination with the other achievement measures. This measure will not disqualify sites from obtaining Mission: Lifeline bronze, silver or gold recognition if they do not achieve 75% First Door to Device in transfer patients. Those sites that can achieve this measure will be recognized as earning a bronze plus, silver plus, or gold plus award. *The above criteria apply to each type of hospital recognition program described in the following sections. Updated: August 14, 2013 ***Subject to update***

65 REFERRING CENTER RECOGNITION MEASURES Achievement Measures: 1. Percentage of STEMI patients with a door-to-first ECG time 10 minutes 2. Percentage of reperfusion eligible patients receiving any reperfusion (PCI or fibrinolysis) therapy 3. Percentage of fibrinolytic eligible patients with door-to-needle time 30 minutes 4. Percentage of reperfusion eligible patients transferred to a PCI center with referring center Door in- Door out time (Length of Stay) 45 minutes 5. Percentage of transferred STEMI patients receiving aspirin before ED discharge The remaining measures are for patients that are not transferred: 6. Percentage of STEMI patients who receive aspirin within 24 hours of hospital arrival 7. Percentage of STEMI patients on aspirin at discharge 8. Percentage of STEMI patients on beta blocker at discharge 9. Percentage of STEMI patients with LDL >100 who receive statins or lipid lowering drugs 10. Percentage of STEMI patients with left ventricular systolic dysfunction on ACEI/ARB at discharge 11. Percentage of STEMI patients that smoke with smoking cessation counseling at discharge Reporting Measures 1. STEMI Referring Center ED door-to- device time 120 minutes (includes transport time) RECEIVING CENTER RECOGNITION MEASURES Achievement Measures: 1. Percentage of direct admit STEMI patients (Non EMS Arrival) with Door-to-device time 90 minutes, non-transfer 2. Percentage of direct admit STEMI patients (arrival via EMS Ambulance Only) with FMC-to-device time 90 minutes 3. Percentage of reperfusion eligible patients receiving any reperfusion therapy (PCI or fibrinolysis) 4. Percentage of STEMI patients receiving aspirin within 24 hours of hospital arrival 5. Percentage of STEMI patients on aspirin at discharge 6. Percentage of STEMI patients on beta blocker at discharge 7. Percentage of STEMI patients with LDL>100 who receive statins or lipid lowering drugs 8. Percentage of STEMI patients with left ventricular systolic dysfunction on ACEI/ARB at discharge 9. Percentage of STEMI patients that smoke with smoking cessation counseling at discharge Receiving Center Plus Award - an additional award provided to Receiving Centers that meet Bronze, Silver or Gold criteria and in addition are able to achieve 1 st door to device time of 120 minutes or less (for transfers). Must have an achievement score of 75% or greater for this plus measure. The PLUS measure is an independent measure that is not scored in combination with the other achievement measures. This measure will not disqualify sites from obtaining Mission: Lifeline bronze, silver or gold recognition if they do not achieve 75% First Door to Device in transfer patients. Those sites that can achieve this measure will be recognized as earning a bronze plus, silver plus, or gold plus award. Reporting Measures: 1. In-hospital mortality 2. Percentage of STEMI patients with referring Hospital door-to-device time 120 minutes (transfer) Updated: August 14, 2013 ***Subject to update***

66 EMS Measures for STEMI Systems of Care Recognition Mission: Lifeline EMS will accept applications for this new program January 1, 2014 February 28, 2014 based on self-reported quarterly summary data for the 2013 calendar year. The listed achievement measures will be used to determine recognition eligibility. Any issued award will be in effect from May 31, May 31, Achievement CRITERIA: Each measure must achieve at least 75% compliance for the number of specified quarters per award level to be eligible for recognized status. The 2014 award period includes data for patients treated from January 1, 2013 December 31, Patient volume requirements pertain to achievement measures #2 and/or #3 below*. It is assumed when volume requirements are met for measure #2 and/or #3, volume requirements will also be met for measure #1. Data is to be submitted in quarterly intervals as stated below: o o o o Quarter 1 January, February, March Quarter 2 April, May, June Quarter 3 July, August, September Quarter 4 October, November, December Achievement MEASURES: 1. Percentage of patients with non-traumatic chest pain, 35 years, treated and transported by EMS who receive a pre-hospital 12-lead electrocardiogram 2. Percentage of STEMI patients treated and transported directly to a STEMI receiving center, with prehospital first medical contact to device time 90 minutes 3. Percentage of lytic eligible STEMI patients treated and transported to a STEMI referring hospital for fibrinolytic therapy with a door to needle time 30 minutes *All agencies must submit data for Achievement Measure #1 (Percentage of patients with non-traumatic chest pain, 35 years, treated and transported by EMS who get a pre-hospital 12-lead electrocardiogram). Submission of data for Measure #2 AND/OR Measure #3 is dependent on current transport protocols. Agencies that transport to both PCI capable and Non-PCI capable hospitals will report measures #1, 2, and 3. Agencies that only transport to PCI capable hospitals will report measures #1 and #2. Agencies that only transport to non-pci capable hospitals will report measures #1 and #3. Award LEVELS and VOLUME Requirements: BRONZE: At least 1 calendar quarter achieving a minimum of 75% compliance for each required measure. o Volume: at least 2 patients per reporting quarter with at least 4 patients in the calendar year. SILVER: 1 calendar year achieving a minimum of 75% compliance for each required measure in all 4 quarters. o Volume: at least 2 patients in each of the 4 calendar quarters and at least 8 patients in the calendar year. GOLD (Not available for 2014 award cycle): 2 calendar years achieving a minimum of 75% for each required measure compliance in all 4 reporting quarters of each year (8 consecutive quarters total). Updated: August 14, 2013 ***Subject to update***

67 Mission: Lifeline ACCREDITATION of Referring and Receiving Hospitals The Mission: Lifeline Accreditation Program will acknowledge STEMI (Heart Attack) Referring Hospitals and STEMI (Heart Attack) Receiving Hospitals for their efforts to improve quality of care for STEMI patients. This program is a joint effort in conjunction with the Society of Cardiovascular Patient Care. **A current Mission: Lifeline Achievement Award must be attained prior to application for Accreditation. STEMI Referring Center / Non-PCI Hospital 1. Appropriate protocols and standing orders should be in place for the identification of STEMI. At a minimum, these protocols should be present in the Intensive Care Unit/Coronary Care Unit and Emergency Department (ED). Each ED should maintain a standardized reperfusion STEMI care pathway that designates primary PCI as the preferred reperfusion strategy if transfer of patients to a primary PCI hospital/stemi-receiving Center can be achieved within times consistent with ACC/AHA guidelines. If hospital s primary reperfusion strategy is Lytics-- Item 2 does not apply, item 3 is required to support. Each ED should maintain a standardized reperfusion STEMI care pathway that designates fibrinolysis in the ED (for eligible patients) when the system cannot achieve times consistent with ACC/AHA guidelines for primary PCI. If hospital s primary reperfusion strategy is Primary PCI accomplished by transfer to a Receiving Center-- Item 3 does not apply, item 2 is required to support. If reperfusion strategy is for primary PCI transfer, a streamlined, standardized protocol for rapid transfer and transport to a STEMI-Receiving Center should be operational. If reperfusion strategy is for primary PCI transfer, all patients should be transported to the most appropriate STEMI-Receiving Center where the expected first door-to-balloon (first device used) time should be within 90 minutes (considering ground versus air transport, weather, traffic).the STEMI Referring Center should have an ongoing quality improvement process, including data measurement and feedback, for the STEMI population and collect and submit Mission: Lifeline required data elements (using the ACTION Registry GWTG Limited Form*).A program should be in place to track and improve treatment (acutely and at discharge) with ACC/AHA guideline based Class I therapies. A multidisciplinary STEMI team, including EMS, should review hospital specific STEMI data on a quarterly basis. a. Door-to-first ECG time (goal <10 minutes) b. Proportion of STEMI-eligible patients receiving any reperfusion (PCI or fibrinolysis) therapy. c. STEMI Referring Center ED door-to-balloon (first device used) time for patients transferred to PCI center i. STEMI Referring Center ED door to ED discharges ii. STEMI Referring Center ED door-to-balloon (first device used) time within 90 minutes (including transport time) 2. The ACTION Registry GWTG Limited Form is for the use of STEMI Referring Hospitals and will focus on abbreviated STEMI emergency treatment, process times, and discharge data. STEMI-Receiving Center / Primary PCI Hospital Updated: August 14, 2013 ***Subject to update***

68 1. Protocols for triage, diagnosis and Cardiac Catheterization Laboratory activation should be established within the primary PCI hospital/stemi-receiving Center. A single activation phone call should alert the STEMI team. Criteria for EMS activation of the Cardiac Catheterization Laboratory should be established in conjunction with EMS offices. 2. The STEMI-Receiving Center should be available 24 hours/7 days a week to perform primary PCI. 3. The Cardiac Catheterization Laboratory staff including interventional cardiologist should arrive within 30 minutes of activation call. 4. There should be universal acceptance of STEMI patients (no diversion). There should be a plan for triage & treatment for simultaneous presentation of STEMI patients. 5. Interventional cardiologists should meet ACC/AHA criteria for competence. Interventional cardiologists should perform at least 75 total PCI procedures per year. The volume requirement per interventional cardiologist may include primary PCI procedures performed at other facilities. 6. The STEMI-Receiving Center should meet ACC/AHA criteria for volume and perform a minimum of 36 primary PCI procedures and 200 total PCI procedures annually. 7. The STEMI-Receiving Center should participate in the Mission: Lifeline-approved data collection tool, ACTION Registry GWTG. 8. A program should be in place to track and improve treatment (acutely & at discharge) with ACC/AHA guideline based Class I therapies. 9. There should be a recognized STEMI-Receiving Center liaison/system coordinator to the system and a recognized physician champion. 10. There should be monthly multidisciplinary team meetings to evaluate outcomes and quality improvement data. Operational issues should be reviewed, problems identified, and solutions implemented. The following measurements should be evaluated on an ongoing basis: i. Door to ECG time within 10 minutes Activation and arrival of (STEMI) cardiac cath team to cardiac cath lab within 30 minutes ii. First medical contact to device time within 90 minutes iii. Transfer of STEMI patient from STEMI Referring Center to STEMI Receiving Center within 120 minutes (door to balloon within 120 minutes) iv. Transfer of STEMI patient from STEMI Referring Center to STEMI Receiving Center within 30 minutes (door in/door out) v. STEMI Referring Hospital first medical contact to device time transfer within 120 minutes vi. Proportion of eligible patients receiving reperfusion therapy vii. Proportion of eligible patients administered guideline-based Class I therapies viii. Proportion of patients with a positive ECG for STEMI and activation of the cardiac cath lab for intended primary PCI that: 1. did not undergo acute catheterization because of misdiagnosis 2. did undergo acute catheterization and found to have no elevation in cardiac biomarkers and no revascularization in the first 24 hours ix. In-hospital mortality Updated: August 14, 2013 ***Subject to update***

69 Texas Cardiovascular Health & Wellness Program Texas Department of State Health Services ST Elevation Myocardial Infarction (STEMI) Facts Texas Trauma Service Area (TSA) O Updated March 2010 Hispanic 30.6% Other 4.5% Demography of TSA O in 2008 (Estimated Texas Population) White 57.2% Age Total Male Female Percent , , , , , , , , , , , , ,203 62,163 82, African American 7.6% Total 1,732, , , Prevalence 1 (%) of Heart Attack, Adults (18+ years), Heart Attack Age-Adjusted Mortality Rates 2 (per 100,000) TSA O Texas TSA O Texas TSA O Ages <65 TSA O Ages 65+ Total Male Female White African American Hispanic Number of Discharges Hospital Discharge Data 3 for STEMI, Texas, 2008 Total Age <65 Age 65+ TSA O Texas TSA O Texas TSA O Texas , , ,707 Total Charges $55,239,941 $926,981,129 $35,328,302 $544,602,262 $19,911,639 $382,378,867 Texas EMS/Trauma Registry Data 4 for TSA O by Time (Min), 2007 Response Time = (Time Call Received - Time EMS Arrived on Scene) Scene Time = (Time EMS Arrived on Scene Time EMS Departed Scene) TSA O Texas Transport Time = (Time EMS Departed Scene Time EMS Arrived at Destination) Delivery Time = (Time Call Received Time EMS Arrived at Destination) , 2006, 2007, and 2008 Texas Behavioral Risk Factor Surveillance System, Statewide BRFSS Survey, for Respondents 18 years and older who report that they have been diagnosed as having had a Heart Attack, Myocardial Infarction Texas Department of State Health Services Vital Statistics. Mortality due to Heart Attack (ICD-10 Code I21-I22); Age adjusted to the US 2000 census population Texas Health Care Information Council, Inpatient Hospital Discharge Public Use File, for persons all ages. STEMI (ICD-9 Code; through and ); 4 Texas EMS/Trauma Registry Data Selected in The selection criteria are: Calls received during 2007 Suspected Illness types defined as cardiac arrest, cardiac rhythm disturbance, and chest pain/discomfort Medical-related calls only (i.e. calls exclusively related to trauma were excluded) 911 calls only (no inter-facility transfers) Texas residents only * Unable to calculate due to small sample size (< 50 respondents).

70 Texas Cardiovascular Health & Wellness Program Texas Department of State Health Services Heart Attack Facts Texas Trauma Service Area (TSA) O Heart Attack Risk Factors 1, Texas, 2005, 2006, 2007, 2008 High Blood Cholesterol Diabetes TSA O Texas TSA O Texas (2005 & 2007) Total Total Male Male Female White Female 8.0 White African American African American Hispanic Hispanic Current Smoker TSA O Texas High Blood Pressure (2005 & 2007) TSA O Total Total Male Male Female Female White White African American African American Hispanic Hispanic Obesity 2 (BMI 30) TSA O Texas No Leisure Time 3 Physical Activity TSA O Texas Total Total Male Female White Male 27.3 Female 24.7 White African American African American Hispanic Hispanic Heart Attack Symptoms Recognition of Heart Attack Symptoms 1 (2005) Texas % Of Respondents Recognizing Symptoms TSA O Pain or discomfort in jaw, neck or back Feeling weak, lightheaded, or faint Chest pain or discomfort Pain or discomfort in the arms or shoulders Shortness of breath Recognizes all heart attack symptoms Would call 911 as a first response if Heart Attack OR Stroke is suspected , 2006, 2007 and 2008 Texas Behavioral Risk Factor Surveillance System, Statewide BRFSS Survey, for Respondents 18 years and older who report that they have been diagnosed with high Blood Pressure, but not during pregnancy; Respondents 18 years and older who report that they have been diagnosed with high Blood Cholesterol; Respondents 18 years and older who report that they have been diagnosed with Diabetes. Does not include gestational diabetes 2 Obese > 95th Percentile for BMI by Age/Sex 3. Recommendation: Physical Activity -Percentage of students who were physically active doing any kind of physical activity that increased their heart rate and made them breathe hard some of the time for a total of at least 60 minutes per day on five or more of the 7 days before the survey The '*' indicates that the sample size was not a statistically valid sample size (< 50 respondents). Texas

71 Mission: Lifeline Austin Public Awareness Campaign From Zero to Hero in Seconds Final Report October 2013 Whitney Presley Senior Director of Digital Communications and New Media American Heart Association, SouthWest Affiliate

72 From Zero to Hero in Seconds Advertising: Four billboards placed in demographically Hispanic areas of East and South Austin Four weeks 8/26-9/22 Estimated impressions: 1,535,408

73 Advertising: 200 interior bus signs One month 8/26-9/26 Demographics: Average age: 32 years old Nearly half of Capital Metro riders are white (46%), 25% are Hispanic/ Latino, 22% African-American and 7% identify as another race or ethnicity Estimated impressions: 1,663,500 From Zero to Hero in Seconds

74 Advertising: 23 on-air PSAs on The Beat streaming PSAs and web banner presence on Weeks of 8/26 & 9/2 Additional: Appeared on public affairs show for 30 min. interview to discuss warning signs and use of system with volunteer Austin/Travis EMS Chief Rodriguez Aired on: KISS 96.7, KASE 101, The BEAT 102.3, KVET FM 98.1 and KVET-AM Estimated Impressions: 4.3 Million From Zero to Hero in Seconds

75 Advertising: 52 on-air PSAs on Latino streaming PSAs and web banner presence on Weeks of 8/26 & 9/2 (web banner presence 1 month 8/26-9/26). Additional: Appeared on public affairs show to discuss warning signs and use of system with volunteer, Dr. Angel Caldera. Interviewed aired on KLZT/107.1 La Z & LATINO ( Estimated Impressions: 5 Million From Zero to Hero in Seconds

76 From Zero to Hero in Seconds Created a Facebook tab on the Austin Market page ( that contained FAQ about warning signs, what the EMS/hospitals do and the Mission: Lifeline program. Total 28 day reach of Austin Facebook page: 6,847 users

77 From Zero to Hero in Seconds Total Impressions for Public Awareness Program: 12.5 Million Impressions Impact: Campaign pushed out in four channel approach to target market Hit the target market during the back to school period, which is an elevated period for media consumption This combination should result in a high impact/high reach overall campaign