Rural Minnesota: Hospital Advisory Committee

Transcription

1 Rural Minnesota: Hospital Advisory Committee To join Audio: Teleconference Passcode To join Net Meeting slide show: Meeting number: SW Meeting passcode: SW Participant Join URL: , American Heart Association 1

2 Agenda 1. Welcome Katie Sahajpal 10:00-10:15 2. M:L Rural MN Mission: Lifeline Project Overview Mindy Cook 10:15 10:30 3. M:L Rural MN STEMI Protocol Recommendations All 10:30 12:00 Historical Insight on STEMI System Development in MN Dr. Ganesh Raveedran MN STEMI State of the State: Regional MN STEMI Referring Hospital Protocol EMS STEMI Protocol and Transport Guidelines Quality Improvement / STEMI Feedback Katie Sahajpal Lunch 12:00 12:30 4. Referring Hospital Education Curriculum and Training Plan 12:30 1:00 5. Public Awareness Campaign Proposal Joan Enderle 1:00 1:30 Campaign goals, overview and proposed plan Tara Olson Flint Communications 6. Sustainability and Advocacy in STEMI Systems of Care Justin Bell 1:30 2:00 7. Closing Remarks and Future Meeting Dates 2013, American Heart Association 2

3 Rural MN Hospital Advisory Committee Composition: at least 1 nursing and 1 physician representative from each included PCI Hospital, at least 1represenative from each regional non-pci Hospital are, and at least 2 EMS representatives (40 member maximum) Current 38 members Time commitment: Quarterly conference calls with bi annual face to face meetings Meeting Schedule: Quarterly Teleconference or Net Meeting as needed the 3 rd Wednesday quarterly from 12:00 pm to 1:00 pm beginning October , Jan , April , July , October Facilitated by: Mindy Cook, Katie Watkins, and MN M: L Chair (s) Dr. Scott Mikesell, Dr. Ganesh Raveedran, Richard Mullvain Task Assignment: Create a Rural MN Hospital Education Plan and Curriculum Identification and cultivation of hospital education providers Guidance of Regional STEMI System quality improvement and performance measurement Facilitation of Regional and Local STEMI System Champion support and engagement Create recommendations for Rural MN STEMI Protocols and Transport Guidelines 2013, American Heart Association 3

4 Rural MN Hospital Advisory Overview Composition: at least 1 nursing and 1 physician representative from each included PCI Hospital, at least 1represenative from each regional non-pci Hospital are, and at least 2 EMS representatives (40 member maximum) Current 38 members Time commitment: Quarterly conference calls with bi annual face to face meetings Meeting Schedule: Quarterly Teleconference or Net Meeting as needed the 3rd Wednesday quarterly from 12:00 pm to 1:00 pm beginning October , Jan , April , July , October Facilitated by: Mindy Cook, Katie Watkins, and MN M: L Chair (s) Dr. Scott Mikesell, Dr. Ganesh Raveedran, Richard Mullvain 1/22/ , American Heart Association 4

5 Rural MN Hospital Advisory Goals Create a Rural MN Hospital Education Plan and Curriculum Identification and cultivation of hospital education providers Guidance of Regional STEMI System quality improvement and performance measurement Facilitation of Regional and Local STEMI System Champion support and engagement Create recommendations for Rural MN STEMI Protocols and Transport Guidelines 2014 American College of Emergency Medicine 1/22/ , American Heart Association 5

6 Minnesota should work to further enhance its safeguards for Quality and Patient Safety in its emergency care system by exploring destination policies to ensure that stroke and STEMI patients are triaged to the most appropriate medical facilities. Adopting other state-level standards, such as field triage protocols and uniform systems for providing pre-arrival instructions, would also improve the overall environment. 1/22/ , American Heart Association 6

7 Mission Lifeline MN Hospital Advisory Committee PAST MEETING REVIEW 10/30/2013: 1hr. Teleconference. Reviewed Rural MN Mission Lifeline Grant Timeline & Deliverables Reviewed current STEMI guidelines and recommendations for Mission Lifeline Ideal Systems of Care Open discussion on existing STEMI protocols for referring hospitals Colorado, SD, ND Duluth, Mayo, St. Cloud, Sanford Bemidji, Fairview University, Abbott Northwestern EMS Protocols for ECG acquisition/pre-hospital care STEMI Feedback

8 Committee Meeting Goals To gather in a spirit of collegiality and cooperation To receive a report about Mission: Lifeline and the AHA s role in convening decision makers and providing resources to encourage STEMI System Development, Streamlining, and Standardization. To assess and share regional MN STEMI Referring Hospital and EMS Protocols in place To assess and share processes in place for STEMI feedback for PCI Hospital, Referring Hospital, and EMS To gain consensus towards a committee recommendation for 12 L ECG acquisition thresholds and STEMI diagnostic criteria to present to the MN M:L taskforce 1/22/ , American Heart Association 8

9 To gain consensus towards a Rural MN M:L Referring Hospital and EMS STEMI Protocol recommendation utilizing the existing regional protocols in place throughout rural MN to present to the MN M:L taskforce To gain consensus towards a recommendation for ALS and BLS EMS Transport Guideline for the Rural MN EMS Advisory committee. To create training plan and curriculum model for Rural MN Referring hospital education. To gain consensus on a public awareness campaign and delivery plan To gain consensus on a sustainability plan for State level MN STEMI systems of care 1/22/ , American Heart Association 9

10 Consensus Based Decision Making Elements of a Consensus-Based Decision All parties agree with the proposed decision and are willing to carry it out; No one will block or obstruct the decision or its implementation; and Everyone will support the decision and implement it. Levels of Consensus 1. I can say an unqualified yes! 2. I can accept the decision. 3. I can live with the decision. 4. I do not fully agree with the decision, however, I will not block it and will support it. Improving the System of Care for STEMI Patients 10

11 Consensus Based Decision Making Consensus Decision-Making Participants make decisions by agreement rather than by majority vote. Inclusiveness To the extent possible, all necessary interests are represented or, at a minimum, approve of the decision. Accountability Participants usually represent stakeholder groups or interests. They are accountable both to their constituents and to the process. Facilitation An impartial facilitator accountable to all participants manages the process, ensures the ground rules are followed, and helps to maintain a productive climate for communication and problem solving. Flexibility Participants design a process and address the issues in a manner they determine most suitable to the situation. Shared Control/Ground Rules Participants share with the facilitator responsibility for setting and maintaining the ground rules for a process and for creating outcomes. Commitment to Implementation All stakeholders commit to carrying out their agreement. Improving the System of Care for STEMI Patients 11

12 Consensus Based Decision Making Sample Ground Rules 1. It s Your Show: We understand that this is our process. The facilitators are resources to take us where we agree to go. We determine the agenda, ground rules, issues and process. We agree to attend and fully participate in all meetings. 2. Everyone is Equal: We agree that all participants in the process are equal. 3. No Relevant Topic is Excluded: We agree that no relevant topics are excluded from consideration unless we agree they are. This is our opportunity to bring up and thoroughly discuss issues that concern us. 4. No Discussion is Ended: We agree that no discussion is ended, including process discussion, ground rules and rule of decision. Agreements reached at prior meetings, unless implemented, are always open for further consideration. 5. Respect Opinions: We agree to respect each other s opinions. We will use gentle candor in comments to each other and will not interrupt. 6. Respect the Time: We all understand the time constraints we face and agree to respect the time. No one will dominate the discussions, and all participants will have an opportunity to express their opinions. Improving the System of Care for STEMI Patients 12

13 Consensus Based Decision Making 7. Silence Is Agreement: We agree that silence on decisions is agreement. The facilitators and other participants cannot read our minds. If it appears that the group is reaching a consensus on an issue, if no one voices disagreement, it is assumed that all are in agreement. 8. Keep the Facilitator Accurate: We agree to make certain that the facilitators capture what we meant to say. We will keep the facilitators accurate. 9. Non-attribution: We agree that we will not attribute ideas or comments made by participants to others outside of this process. 10. Rule of Decision: We agree that the rule of decision is Consensus, a described above. We agree to strive for consensus. If agreement by all participants on an issue is not possible, we will seek to develop a clear and balanced statement of the areas of disagreement. Neutrality by any participant does not constitute a lack of consensus. 11. Media: We agree that all of our meetings are open to the media and to the public unless we close all or a portion of them by consensus. 12. Substitutes/Proxies: We agree that we will not send substitutes or proxies. We may send observers to meetings, but they will not have participant status. 13. Have Fun: We agree to do our best to enjoy the process and to help other participants do so as well. Improving the System of Care for STEMI Patients 13

14 Organization Chart Mission: Lifeline MN Taskforce MN M:L Executive Leadership Committee TCCC MN M:L Quality Committee MN M:L Hospital Advisory Committee MN M:L EMS Advisory Committee MN M:L Conference Planning Committee 1/22/ , American Heart Association 14

15 Mission: Lifeline will: Promote ideal STEMI systems of care Help STEMI patients get the life-saving care they need in time Bring together healthcare resources into an efficient, synergistic system Improve overall quality of care The initiative is unique in that it: Addresses the continuum of care for STEMI patients Preserves a role for the local STEMI-referral hospital Understands the issues specific to rural communities Promotes different solutions/protocols for rural vs. urban/suburban areas Recognizes there is no one-size-fits-all solution Knows the issues of implementing national recommendations on a community level 15 Improving the System of Care for STEMI Patients

16 What is Mission :Lifeline? Mission: Lifeline is the American Heart Association s national initiative to advance the systems of care for patients with ST-segment elevation myocardial infarction (STEMI) and those resuscitated after experiencing an Out-of-Hospital Cardiac Arrest. The overarching goal of the initiative is to reduce mortality and morbidity for STEMI and Out of Hospital Cardiac Arrest patients and to improve their overall quality of care 1/22/ , American Heart Association 16

17 Point Of Entry Protocol : GOAL Less than 90 Minutes Improving the System of Care for STEMI Patients 17

18 Identified MN Gaps and Barriers EMS protocols do not allow transport outside a certain area/county Lack of 24/7 12 Lead ECG capability in the field ECG interpretation skills False positives Lack of protocols to allow rapid identification of a STEMI patient Corporate loyalty Lack of pre-hospital STEMI activation from the field Lack of Multidisciplinary Meetings Lack of data collection Terrain/Weather Interfacility Transport Team response..and so on and so on 1/22/ , American Heart Association 18

19 Barriers to Timely Reperfusion The patient Failure to promptly recognize symptoms Hesitation to seek medical attention Time to transport Mandated delivery to the closest hospital, regardless of PCI capabilities Long transport in rural areas Decision process on arrival Clot-busting drugs vs. PCI Off hours Transfer to PCI facility Time to implement treatment strategy Procedural factors Team assembly 1/22/ , American Heart Association 19

20 The Ideal EMS In an ideal system: Ambulances are equipped with 12-lead ECG machines EMS providers are trained to: Use and transmit 12-lead ECGs Care for STEMI patients Provide feedback on performance and compliance with guidelines Standardized point-of-entry (POE) protocols define patient transport rules When there is STEMI, the cath lab is activated promptly Patients transported to a STEMI-referral hospital remain on the stretcher with EMS present pending a transport decision When walk-in patients present to a STEMI-referral hospital and require primary PCI, activation of EMS occurs Hospitals close the communication gap with EMS 20 Improving the System of Care for STEMI Patients

21 The Ideal STEMI-Referral Hospital In an ideal system: Standardized POE protocols dictate transport of STEMI patients directly to a STEMI-receiving hospital based on: Specific criteria for risk Contraindications to fibrinolysis The proximity of the nearest PCI service Patients presenting to a STEMI-referral hospital are treated according to standardized triage and transfer protocols Incentives are provided to rapidly: Treat STEMI patients in accordance with ACC/AHA guidelines Transfer to a STEMI-receiving hospital for primary PCI using: Reperfusion checklists Standard pharmacological regimens and order sets Clinical pathways There is rapid and efficient data transfer, data collection and feedback Integrated plans for return of the patient to the community for care are provided 21 Improving the System of Care for STEMI Patients

22 The Ideal STEMI-Receiving Hospital In an ideal system: Pre-hospital ECG diagnosis of STEMI, ED notification and cath lab activation occurs according to standard algorithms Algorithms facilitate: A short ED stay for the STEMI patient Transport directly from the field to the cath lab Single-call systems from STEMI-referral hospitals immediately activate the cath lab Primary PCI is provided as routine treatment for STEMI 24, 7 STEMI-receiving hospital s administration puts their support in writing A multidisciplinary team meets regularly to identify and solve problems A continuing education program is designed and instituted A mechanism for monitoring performance, process measures and patient outcomes is established Improving the System of Care for STEMI Patients

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24 COLLABORATION

25 Rural MN M: L Grant Committments Swift diagnosis -- accomplished by equipping ambulances with 12-lead ECGs EMS training -- to ensure the ability of ambulance personnel to transmit pre-hospital Improved EMS and hospital transport protocols-- to guide EMS and referring hospitals to the most appropriate facility Hospitals equipped with 12-lead ECG receiving station software -- to enable activation of the cardiac catheterization lab prior to arrival at the hospital and to facilitate rapid treatment; Stakeholder education -- including ongoing updates of new science Data collection and use -- to ensure adherence to guidelines, to achieve consistency in care, to enhance quality improvement methods and to give rapid feedback to EMS and referral hospitals Public education -- to inform the public about the importance of using emergency response systems (911) and how to recognize signs and symptoms. 25

26 Scope of Project: Year 1 Taskforce engagement and committee structure development Bi-Annual Face to Face Taskforce Meeting Annual MN STEMI Conference April 2014 EMS Equipment Allocation and placement, 12 L ECG curriculum and training plan development PCI Capable Hospital Pre-hospital activation plan support through 12 L ECG Transmission receiving system, computer interpretation or paramedic recognition PCI Receiving Hospital ACTION-GWTG registry participation Improving the System of Care for STEMI Patients 1/ 22 /

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28 Scope of Project: Year 2 Bi-Annual Face to Face Taskforce Meeting Annual MN STEMI Conference Local, Regional, and State STEMI system of care development, optimizing the destination plans, rural protocols and feedback recommendation development. Referring Hospital and EMS Education Curriculum Development and Delivery Learn Rapid STEMI ID and STEMI Provider Manual Public Awareness Campaign Assessment, Development, and Delivery Improving the System of Care for STEMI Patients 28

29 Scope of Project: Year 3 Bi-Annual Face to Face Taskforce Meeting Annual MN STEMI Conference EMS/Hospital education Data Analysis and Quality Improvement Model sharing Public Media and Awareness campaign Sustainability Plan Development 29 Improving the System of Care for STEMI Patients

30 Rural MN Primary PCI Capable Hospitals Bemidji Duluth (2) Mankato St. Cloud Improving the System of Care for STEMI Patients 1/ 22 /

31 MN EMS Regions 1/22/

32 EMS Regional Application and Allocation Plan Round 1, NW & WC regions Open July 26, 2013 Close Aug 23, 2013 Final Review and Award Sept. 13, 2013 Round 2, NE & Central regions Open Oct. 7 th, 2013 Close Nov. 8 th, 2013 Final Review and Award Week of December 9 th, 2013 Improving the System of Care for STEMI Patients 32

33 EMS Regional Application and Allocation Plan Round 3, SW & Metro Open February 3 rd, 2014 Close March 3 rd, 2014 Final Review and Award Week of April 7 th, 2014 Round 4, SC & SE Regions Open April 28 th, 2014 Close May 30 th, 2014 Final Review and Award Week of June 30 th, 2014 Improving the System of Care for STEMI Patients 33

34 M:L MN STEMI Conference Planning Annual STEMI Summit Conference Highlight MN successes and Lessons learned Hear from clinical experts about new science Network with peers to advance collaboration STEMI Survivor Celebration Recognize System excellence and award achievements Continuing education will be provided and the event will be free for all attendees Save the Date! April Arrowwood Resort & Conference Center 2100 Arrowwood Lane NW Alexandria, MN Improving the System of Care for STEMI Patients 34

35 Historical Insight on STEMI System Development in MN Dr. Ganesh Raveedran Proposed DRAFT ONLY (Feb. 22 nd, 2010) Minnesota Statewide Inter-Hospital STEMI Transfer Protocols Protocol 1 Primary PCI (Percutaneuos Coronary Intervention) Protocol 2 Half-Dose Fibrinolytic & Direct to PCI Protocol 3 Full-Dose Fibrinolytic & Delayed PCI (Direct to PCI if fails to re-perfuse) DEFINITION FOR STEMI ECG demonstrates ST elevation greater than 0.1 MV in at least 2 contiguous precordial leads (V1-V6) or at least 2 adjacent limb leads ECG demonstrates new LBBB (If initial ECG is not diagnostic but suspicion is high for STEMI, obtain serial ECG at 5-10 minute intervals) Top Priority: URGENT TRANSPORT TO PCI CAPABLE HOSPITAL STANDARD MEDICATIONS Aspirin 324 mg chewed x 1 Plavix 600 mg (Reduce to 300 mg if using Full Dose Lytic) Heparin IV Bolus 60 Units/kg, max 4,000 Units OPTIONAL MEDICATIONS Heparin IV Drip 12 Units/kg/hr, max 1,000 Units/hr (If convenient, and does not delay transport) Metoprolol 25 mg oral x 1 PRN meds per local preference and discretion (i.e. Nitro, Morphine, etc.) STANDARD ORDERS & LABS Apply Cardiac Monitor Routine Cardiac Lab Panel Start (2) peripheral IV s Protocol 1 - DIRECT TRANSFER PATHWAY Primary PCI - Goal 1 st Door to Balloon: minutes Transport to PCI Hospital: Direct to Cath Lab for PCI Preferred strategy of all PCI hospitals over lytics when anticipated door to balloon time is less than 120 minutes Preferred strategy of St. Cloud, regardless of anticipated door to balloon time Protocol 2 HALF DOSE LYTIC PATHWAY Goal 1 st Door to Needle: 30 minutes Choose Pathway Protocol 3 FULL DOSE LYTIC PATHWAY Goal 1 st Door to Needle: 30 minutes Transport to PCI Hospital: Direct to Cath Lab For Pharmacoinvasive PCI Preferred strategy of Minneapolis Heart Institute when anticipated door to balloon time is greater than 120 minutes Transport to PCI Hospital: Admit to CCU Plan delayed PCI if patient chest-pain free Cath Lab will be activated for urgent PCI if patient fails to re-perfuse, or is still having pain Preferred strategy of Duluth and Rochester when anticipated door to balloon time is greater than 120 minutes, and symptom onset Is less than 2 hours Improving the System of Care for STEMI Patients 35

36 Improving the System of Care for STEMI Patients

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38 MN PCI Hospitals Symposium September 24 th, 2009 Four Seasons Hotel San Francisco 757 Market Street San Francisco, California

39 Improving the System of Care for STEMI Patients

40 October 12, 2009 Meeting Priorities Presented Transparency of data across institutions Central database/registry Sharing best practices Standard pre-cath lab strategy for transfer patients Determine which is best and for whom Transfer STEMI patients to nearest PCI hospital Collaborate with ACC/AHA 12 lead ECG for all Access to all PCI hospital cath lab activation system Improving the System of Care for STEMI Patients

41 Meeting Objectives Present the Plan Achieve Action Requested Review plan, discuss and arrive at consensus Confirm sub-committee membership and chairs Determine Future Meeting Dates Time and Venue Stay on Time Improving the System of Care for STEMI Patients

42 Infra Structure Support Committees identified by Jan 30 th Steering committee Data management committee EMS Committee Improving the System of Care for STEMI Patients

43 Steering Committee Wendy Shear: North Memorial Hospital Nancy Hassinger: St Mary s Hospital, Duluth Ken Baran: United Hospital Stephen Batista: Southdale Hospital Richard Aplin: St Cloud Hospital Jeff Chambers: Mercy Hospital Tim Henry: Abbott Northwestern Hospital Carmelo Panetta: Methodist Hospital Vish Nadig: St. Joseph s Hospital Stefan Bertog: VA Robert Wilson: University of Minnesota Michael Thurmes: Regions Hospital Arashk Motiei: ISJ, Mankato Henry Ting: Mayo Clinic Fouad Bachour: HCMC Lee Giorgi: St Like s Hospital, Duluth? Improving the System of Care for STEMI Patients

44 Protocol Committee Jeff Chambers Richard Aplin Stephen Batista Richard Mullvein Ganesh Raveendran Tim Henry Henry Ting? Improving the System of Care for STEMI Patients

45 Proposed Models Less than 90 minutes door to balloon time : PCI A B C Full Dose Lytics & Transfer ½ Dose Lytics and Transfer Transfer all Cath Next day Cath ASAP Cath ASAP Heparin Heparin Heparin Bivalirudin Bivalirudin Bivalirudin No GP IIb IIIa receptor antagonist No GP IIb IIIa receptor antagonist GP IIb IIIa receptor antagonist Prasugrel Prasugrel Prasugrel Clopidogrel Clopidogrel Clopidogrel Improving the System of Care for STEMI Patients

46 MN STEMI Systems Registered Code 31 system Fairview Health Services Fast Track for STEMI Hennepin County Medical Center North Memorial Heart & Vascular Institute Regions Hospital Level 1 Cardiac Program St. Luke s Regional Heart Center United Hospital Level One Cardiac Program University of Minnesota Medical Center Fairview STEMI Program Minneapolis Heart Institute at Abbott Northwestern Hospital Central Minnesota Heart Center STEMISC SMDC STEP (ST-Elevation Myocardial Infarction Program) Saint Louis Park Edina Rochester Minneapolis Robbinsdale Saint Paul Duluth Saint Paul Minneapolis Minneapolis Saint Cloud Duluth Improving the System of Care for STEMI Patients

47 STEMI Referral Hospital Protocol Plan (7 7:30) Facilitator: To be announced Present STEMI Referral Hospital Protocol Plan Action Requested:» Review plan, discuss, arrive at consensus» Share information on protocols that have been developed» Confirm STEMI Referral Hospital Protocol membership and Chair Improving the System of Care for STEMI Patients

48 Emergency Medical Systems Plan (7:30 7:50) Facilitator Katherine Burke Moore Background on Plan Development Present EMS Plan Action Requested:» Review plan, discuss, arrive at consensus» Confirm EMS Sub-Committee membership and Chair Improving the System of Care for STEMI Patients

49 2013 ACCF/AHA Guideline for the Management of ST-Elevation Myocardial Infarction Developed in Collaboration with American College of Emergency Physicians and Society for Cardiovascular Angiography and Interventions American College of Cardiology Foundation and American Heart Association, Inc.

50 MN STEMI State of the State: Regional MN STEMI Referring Hospital Protocol Discussion goal: to allow each regional system that treats patients in the Rural MN Region to share an overview of current protocols in place. We request that a representative of each of the following systems review their current protocol with the goal to start building a picture of MN s current protocols, coverage areas, and commonalities. Improving the System of Care for STEMI Patients 50

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52 Mission: Lifeline Colorado STEMI Guideline Improving the System of Care for STEMI Patients 52

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55 Improving the System of Care for STEMI Patients 55

56 North Dakota Improving the System of Care for STEMI Patients 56

57 South Dakota Improving the System of Care for STEMI Patients 57

58 Improving the System of Care for STEMI Patients 58

59 DRAFT ONLY: Proposed Change to DASH Protocol Duluth Area STEMI Hospital Interhospital Transport Protocol

60 Mayo Fast Track Protocol for Regional STEMI 60

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62 St. Cloud STEMI Protocol 62

63 Sanford Bemidji STEMI Zone 1, Zone 2 Protocol 63

64 Fairview University STEMI Protocol

65 Abbott Northwestern /Minneapolis Heart Level One Protocol

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67 Regional EMS STEMI Pathways, Protocols and Transport Guidelines 67

68 EMS STEMI Protocol and Transport Guidelines: North Dakota 68

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70 Mayo Pre Hospital ECG Protocol 70

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72 MISSION: LIFELINE MINNESOTA Taskforce Structure MN Misson: Lifeline Taskforce Quality Committee Composition: Quarterly teleconference with Hospital Participants involved in Cardiovascular Care Quality improvement and/or the ACTION-GWTG Registry tool members. Facilitated by: Katie Watkins MN Quality Improvement Director Time commitment: 1 hr. monthly teleconferences or webinars for the first 6 months then quarterly teleconferences or webinars thereafter Task Assignment: Discuss ways to creatively utilize data to drive process change and protocol development. Review Case studies Review Mission: Lifeline ACTION GWTG reports and features to increase knowledge and understanding of data analysis and how it relates to quality improvement Suggest agenda items and talking points for monthly calls Contribute to discuss and share lessons learned with statewide partners 1/22/ AHA Mission: Lifeline 72

73 Quality Subcommittee Teleconference Schedule Sept 19th, 2013 Mission Lifeline 101: Basics, Review goals/objectives timeline of quality committee. Look for volunteers for future meetings as we get into data reporting. Starting with Jan Meeting we will have 1 PCI Center share case studies. All will be given opportunity to present (5 Rural PCI Centers and 3 metro PCI Centers) October 17th, 2013 Data definitions, comparison of ACTION vs. ML Limited versus premier forms November 21st, 2013 Review Baseline Reports Understanding Individual Reports Understanding System Reports January 16 th, 2013 (December meeting rescheduled) ACC/NCDR Q&A Mission Lifeline EMS Recognition 1/22/ AHA Mission: Lifeline 73

74 Mission Lifeline MN Data Basics All participating sites will be required to enter data into ACTION-Registry to create a blinded, regional Mission Lifeline report to show outcomes for the region. Sites will need to be active with data collection for STEMI patients starting 1/1/ st Blinded Regional Report will be Q Data Deadline for Q data end of May Reports generated late-june Include all 5 funded PCI Centers, SD/ND border hospitals, 3 Metro PCI Centers 1/22/2014

75 Inclusion Population Acute Myocardial Infarctions-STEMI & NSTEMI only Patient must present to 1 st Facility with symptoms of ACS, within 24 hours of arrival Patient must have positive ECG- ST elevation, new LBBB, or documented Posterior MI OR Positive Biomarkers- Troponin or CK-MB Transfer In patients- STEMI must arrive within 72 hours, NSTEMI within 24 hours If presents with any other symptoms, or procedures, the patient is excluded

76 ACTION Registry Data Requirements NCDR/ACC contracting requires all STEMI/NSTEMI patients per inclusion criteria. All funded sites are required to enter all included patients. Sites not eligible for FTE funding support can look at alternative pathway to off-set initial data burden of NSTEMI population Mission Lifeline data pulls STEMI only population for individual hospital and system reports. Premier Form is required. Eliminates blank data fields for critical information for pre-hospital data elements that will be used to drive our protocols, education, and pertinent to tracking our outcomes. 1/22/ AHA Mission: Lifeline 76

77 Limited Users Premier Users 77

78 Mission Lifeline System Sample Reports 1/22/ AHA Mission: Lifeline 78

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91 Award Recognition Review Action-Registry ARG awards Mission Lifeline Referral or Receiving awards Mission Lifeline EM Recognition 1/22/ AHA Mission: Lifeline 91

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94 Mission Lifeline Hospital Recognition Basics 85% or greater composite score with no single measure <75% compliance Award Duration: May-May Award period looks at data Jan-Dec of previous year Volume Requirements Receiving Center- 9 or more STEMI patients in the award quarter or an average of 9/quarter for the year to equal a minimum of 36 per year Referring Center- 4 or more STEMI patients in the award quarter or an average of 10 minimum for the year. 1/22/2014

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98 Mission Lifeline: EMS Recognition WORKING WITH EMS ON DATA/QI EMS Recognition: Award Applications Due 2/28. Awards announced in the Spring Free for EMS Agencies

99 Why Work With Our EMS Agencies to Apply? Helps facilitate the communication/engagement between EMS and hospitals Helps EMS start to understand how QI and data can help enhance the services they provide and how they impact the overall continuum of patient care Promotes teamwork and recognition EMS looks for Helps break down the barriers of data/communication Improves pre-hospital data accessibility I challenge you to take an EMS agency you currently work closely with to offer this opportunity to get recognized on a national level and then we can continuum this momentum as we move into the year and growing Mission Lifeline across Minnesota. 1/22/ , American Heart Association 99

100 What are the Achievement Measures? 1. Percentage of patients with non-traumatic chest pain > 35 years treated by EMS who get a pre-hospital 12-lead electrocardiogram 2. Percentage of STEMI patients with first (pre-hospital) medical contact to device time within 90 minutes (non-transfer) 3. Percentage of STEMI patients taken to a referral hospital who administers fibrinolytic therapy with a door to needle time within 30 minutes. 1/22/ , American Heart Association 10 0

101 Must all 3 measures be reported? Transport Destination Protocols determine achievement measures required to complete: Agencies with STEMI patients transported to STEMI Receiving Centers only Reporting Measures #1 and #2 required Agencies with STEMI patients transported to STEMI Referring Centers only Reporting Measures #1 and #3 required Agencies with STEMI patients transported to both STEMI Receiving Centers and STEMI Referring Centers Reporting Measures #1, #2, and #3 required 1/22/ , American Heart Association 10 1

102 What is the volume requirement for EMS Recognition? BRONZE eligibility = At least 2 STEMI patients in the reporting quarter with a minimum of 4 total for the year 2 Q1 = Eligible for Bronze Q2 = Not Eligible for Bronze Q3 = Not Eligible for Bronze Q4 = Not Eligible for Bronze 4 Annual Q1 Bronze 1/22/ , American Heart Association 10 2

103 What is the volume requirement for EMS Recognition? SILVER eligibility = At least 2 STEMI patients in EACH reporting quarter with a minimum of 8 total for the year. Each quarter must meet achievement criteria. 2 Q1 = Eligible for Bronze Q2 = Eligible for Bronze Q3 = Eligible for Bronze Q4 = Eligible for Bronze 8 Annual Q1 Eligible for SILVER or BRONZE 1/22/ , American Heart Association 10 3

104 How will AHA collect the Pre-Hospital Data? Self reported summary Web based submission Demographics Online Mission: Lifeline System Registration Information Data Summary/Submission Affirmation of truth of statement 1/22/ , American Heart Association 10 4

105 Referring Hospital Education Curriculum and Training Plan 1. ND and SD Curriculum and Training Plan Overview Content and Delivery Summary 2. MN Training Hospital Education Budget In person education for 100 referring hospitals Learn Rapid STEMI ID Course (# 500) STEMI Provider Manuals 10 per hospital Adjunctive Training materials Orderable 12 L placement guides Protocol pathways Training Curriculums 3. Referring Hospital Survey Review and alignment of Curriculum Core Elements Delivery Plan Development Discussion Survey Results Review 10 5

106 MN Referring Hospital Survey (N=43) Do you utilize a STEMI inter-facility transfer protocol? If so, please identify the number of regional protocols you may possibly use within your facility. Yes - 1 Protocol Yes - 2 Protocols Yes - 3 or more Protocols No Protocol 69.77% % % % 3 Comments: DASH(Duluth Area STEMI Hospitals) Utilize Abbott North Western, St. Mary's, Fairview STEMI Protocol I would prefer that we only have one so as to not cause a decision point at the beginning of care which hospital will be the destination. 10 6

107 What is your Primary STEMI patient triage and treatment strategy? Transfer for Primary PCI utilizing established protocol Lytic Administration and urgent transfer for PCI utilizing established protocol Mixed Reperfusion strategy depending on estimated time to treatment utilizing established protocols Referral Reperfusion strategy varies depending on PCI receiving facility discretion No established plan or protocol in placed for STEMI patient triage Non-Transfer and Non-PCI hospital % % % % 6 0%

108 Identify your principle mode of transfer for STEMI patients. Air Transport by Helicopter ALS Ground transport Mixed Strategy depending on conditions Air Transport by Fixed Wing 47.62% % % 19 30% transport by ground; 2 local services have pre-hospital 12 lead capability % Helicopter we use whatever is available Primarily Air unless weather does not permit 15% ground 50% Prehospital 12 lead capable No EMS capable pre-hospital ECG at this time. Depending on capability of Sanford Bemidji, we try to transfer there by ground, otherwise mostly by air- so 30-40% ground the rest air 40% by ground but no EMS capable of pre-hospital 12 L ECG at this time. We have used all of the options above depending on availability and weather. 0%

109 What is your estimated transfer time to the closest PCI receiving facility or the PCI receiving facility you have an established transport plan with? < 30 minutes by Air < 30 minutes by Ground minutes by Air minutes by Ground 60-90minutes by Air minutes by Ground >90 minutes by Ground or Air 34.88% % % % % % %

110 Please indicate which of the topics below providers within your facility would find most valuable as the focus of the first wave of Rural MN Mission: Lifeline STEMI Education: STEMI Mock Scenarios Fibrinolytic Administration Regional STEMI Case Reviews 12 L ECG Interpretation STEMI Patient Triage & Protocol Utilization ACC/AHA STEMI Guidelines 50% % % % % %

111 What delivery method of education that works best for physicians within your facility? In-Person Facilitated Training with AHA M:L Educators at your facility Facilitated Webinar Series Regionalized Mini-Conferences Responses Other (please specify) 69.77% % % % 4 Comments: materials for review. Lunch and learns over the noon hour at the clinic setting Our physicians rarely ever attend education that is planned specifically for them onsite. Again, I can't speak for physicians. Send guidelines and protocols by . Our ED physicians only meet quarterly as a group. 11 1

112 What delivery method of education that works best for Nurses, Ancillary Staff and EMS within your facility? In-Person Facilitated Training with AHA M:L Educators at your facility Facilitated Webinar Series Regionalized Mini-Conferences 86.05% % % 10 Comments: In person training is the best, hands on training if at all possible although difficult to get all staff to attend due to limitted staffing available. Sanford Bagley Medical Center and EMS We are open to whatever is available - we have 12 hour shifts with 6 week block schedules -so we try to plan events that all can get to either in person or webinars Case studies to read followed by a quiz, with CEU's offered. Red Lake Hospital 11 2

113 Do you receive regular feedback regarding STEMI patients from your regional PCI receiving facility? Yes 92.86% (39) No 7.14% (3) door to reperfusion times; total time spent in regional ED All of it. For data collection, getting a periodic report is helpful as to seeing our treatment and intervention times. It would be helpful to receive more immediate feedback on immediate cases as to what we did well or what we can learn from the case, as well as learning outcome. Door to vessel open time. The times at each level EKG to transfer time. Sometimes- and it is great to see areas where we can improve our care here and better "package" our patient Each portion of the STEMI is tracked by minutes with a goal time, (Ex. EKG time 5 min, call to transport, Meds given, our package time In Rural Hospital to Out Rural Hosp within 30 minutes is helpful to assure out times are good, and where we need to work on. And then total in Rural hosp to Open vessel time within 90minutes. Timeframes 11 3

114 Please describe a specific barriers or challenges that you have identified within your local STEMI system of care. Pre-Hospital Identification and Recognition of STEMI EMS Transport Hospital or EMS Communication Feedback and Process Improvement Inter-facility Provider to Provider Communication Responses Other Barriers or Suggested Solutions 38.46% % % % % %

115 Responses: Distance of helicopters and dispatch sending the closest most appropriate one. Feedback is often done several weeks after the fact. In our rural area- we have BLS services that provide ambulance services which is a barrier to getting anything reported or started on some of our patients Our providers (ED physicians) don't always recognize STEMI's via EKGs. We have EMT-basic here- no paramedic and no pre-hospital ECG which delays care especially if we plan to fly the patient. Contracted providers in the ED Geographically LaCrosse is closer to our facility and we are part of the SW Wisconsin region. However, we are hesitant to send patients to Skemp because all of the Cardiology out reach providers are from Rochester. All our local ambulances are basic, if air ambulance not flying ground must be dispatched and could be a 2 hour transer (one hour here and back to transfer hospital) Location/availability of air ambulance 11 5

116 Would your STEMI System be interested in forming a regional task force to meet quarterly to support system improvement. Yes 70.73% (29) No 29.27% (12) Northeast MN Meetings are difficult. Webinars and teleconferences would be best. South central/south west Northwest MN Fargo region- I'm not in favor of this. West Central Minnesota Northeast Minnesota. Itasca county Could Northeast region, we already have one with Essentia & St Lukes Pipestone County Medical Center, Southwest MN South west Wisconsin. SE MN SouthWest We belong to the West region of Essentia Health Fargo. 11 6

117 ND Referring Hospital Ed Outline 1. Diagnostic Criteria for STEMI, 12 L ECG Interpretation 2. Role of Pre-Hospital Providers in ideal STEMI Systems of care 3. State Demographics and MI Statistics 4. M:L Grant Scope of Project and Role in System Development and Support 5. Current Literature Review including ACC/AHA Guidelines 6. ACTION Registry Data Collection, system achievement measures for EMS, Referring, and Receiving Hospitals 7. Pt. Signs and Symptoms and ECG Acquisition 8. Pt. Triage and Transfer: Local Implementation of Referring Hospital STEMI Protocol and EMS STEMI Transport Guidelines 9. Process Improvement and how to stay engaged in your regional network 11 7

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122 MN M:L Public Awareness Campaign a. Campaign goals b. Overview c. Proposed plan Flint Communications 12 2

123 Sustainability and Advocacy in STEMI Systems of Care 12 3

124 Future Meeting Schedule March , April July , October Discuss future meeting schedule and feasibility of video conferencing (determine sites) for future meetings, arrive at consensus Adjournment Travel safely on your way home 12 4

125 Questions? Mindy Cook, RN BSN Director Mission: Lifeline North Dakota, Minnesota American Heart Association, Midwest Affiliate Mobile: (218) Katie Watkins BSN, MSN Director of Quality & Systems Improvement Minnesota and Wisconsin American Heart Association, Midwest Affiliate Office: (414) Justin Bell - J.D. Government Relations Director American Heart Association Midwest Affiliate 4701 W. 77th St. Minneapolis, MN (952) justin.bell@heart.org 2013, American Heart Association 12 5