Region 8 5-21-10 [Compatibility Mode]

Region 8 5-21-10 [Compatibility Mode]

Region 8 STEMI Initiative:

One Team

Peter Kerwin, M.D.,

Medical Director Cardiac Cath Lab

Advocate Good Samaritan Hospital

Chairman Interventional Cardiology

Midwest Heart Specialists

May 20, 2010

Glen Oaks



Good Sam




Rush Oak Park






La Grange


Time is Muscle!

And Mortality!

Door to balloon 90 min, 6.4% mortality

Absolute risk reduction mortality of 5.4%;

Relative risk reduction mortality of 84%

Berger, Circulation 1999;100:14-20.

Gusto 2B Trial

Estimated in-hospital mortality by


to-balloon times

Time (min)

Adjusted mortality*

15 2.9 (2.8–3.1)

30 3.0 (2.9–3.2)

60 3.5 (3.4–3.6)

90 4.3 (4.2-–4.4)

120 5.6 (5.4–5.7)

180 8.4 (8.2–8.7)

240 10.3 (10.0–10.7)

*Adjusted for age, sex, race, findings on presentation, medical

history, procedural characteristics, angiographic findings, and

hospital factors

Rathore SS, et al. BMJ 2009; 339:b1807. (Analysis NCDR 43801 pts STEMI 05/06)

D2B 2005/2006 NCDR

43801 STEMI patients

Median D2B 83 min.

Includes patients with cardiogenic shock

Clear relationship between D2B and mortality

“No floor to mortality reduction that can be

achieved by reducing time to treatment”.

STEMI Timeline

2002-ACC STEMI guidelines D2B< 90 min

2002- CMS core measure D2B< 90 min

2004 ACC STEMI guidelines D2B< 90 min (1A)


Region 8

Percentage of STEMI Cases with D2B

Region 8 STEMI project

3 years of work involving ACC, AHA, EMS and

IDPH at state level.

Working group initiated by Diane Wallis as ACC

governor meeting regularly in Chicago.

Goal of this group to advance STEMI care

throughout state.

Region 8 STEMI Initiative Goal

To provide access to excellent level of STEMI

care throughout region.

Start with an existing guidelines and then improve

process of STEMI care throughout the region.

Achieve ACC/AHA guideline of D2B and


D2B Alliance:

Evidence Bases Strategies

ED physician activates the cath lab;

One call activates the cath lab;

Cath lab team ready in 20-30 minutes;

Prompt data feedback;

Senior management commitment;

Team based approach.

Team Based Approach

Integration of EMS, Emergency Department,

Cardiology into a single team caring for the

STEMI patient


EMS medical directors given responsibility to

direct EMS within region.

EMS is to deliver patients to nearest “appropriate


ACC has working group within region advising

EMS (Larry Barr, Jerry Hines, Peter Kerwin,

Timothy Larkin, Fred Leya, Frank Saltiel, Gary

Schaer, Ronald Stella)

Region 8- STEMI Centers

Identify STEMI Receiving Centers- Mission


Train Paramedics

Deliver EMS patients only to STEMI centers

EMS regulations require patients to be brought

to nearest “appropriate hospital”.

All hospitals should have a plan for appropriate

STEMI care.

STEMI Receiving Centers

24/7 availability for primary PCI

No bypass for STEMI

Protocol driven care

Cooling Protocol

Be inclusive- Any institution committing to

quality requirements will be included.

Meet quality requirements for D2B

Region 8 Initiative

Year 1- D2B

Region 8 Initiative

Year 1- D2B

Region 8 STEMI Timeline

Feb 2007- Linder Center Conference on STEMI


Jan 2009- Draft of Region 8 Protocol

Jan 2009- Panel of cardiologists formed to advise

EMS directors

May 2009- Region’s hospitals invited to first

meeting reviewing protocol.

October 2009- Region’s hospitals invited to second

meeting reviewing protocol.

December 2, 2009- Region’s hospitals invited to

third meeting reviewing protocol.

Region 8 STEMI Timeline

March 2010- Region 8 guidelines submitted to

IDPH for approval.

April 19 2010- Region’s hospitals meet for fourth

review (Draft 9) STEMI protocol with IDPH


Points of concern

What quality data should be followed?

Core measures data?

Action registry data?

Mortality data?

Should Action registry be required?

Who will collect and have access to data?

On site CABG backup?

Should onsite anesthesiology be part of protocol?

Points of concern

New programs?

Re-designation after failing to meet quality


Cardiology advisory panel composition.

Time is Muscle and Mortality

Recommendations defining appropriate STEMI

care have been in place for 8 years.

Literature documenting patient outcome benefits

has been available for at least past 8 years.

Protocols are and have been widely available for

achieving appropriate treatment goals over the

past 4 years.

Protocol is consistent with medical literature,

ACC/AHA guidelines and AHA Mission Lifeline


Time is Muscle and Mortality

Region 8 Protocol is inclusive and gives every

hospital in the region opportunity to meet

acceptable goals.

Improvement in care is an ongoing evolutionary

process and continued input is necessary and

welcome from all stakeholders.

Continued inaction is costing lives. How many

more patients have to die before we do


Region 8 Goals

Achievable, sustainable and consistent with other

initiatives nationwide.

Data suggests that attaining these goals will

decrease mortality in STEMI patients.

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