Cardiac Level 1

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• Cardiac Level 1
• A Rural-Urban Partnership forEmergency Cardiac
  Care
• Michael Ring, FACC
• Medical Director, Cardiac Service Line
• Providence Sacred Heart Medical Center

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Challenges in the Inland NW

• Geography of region (4 states)
• Weather challenges
• Transport Single Helicopter service for region
• 2 competing PCI hospitals in town (often at
  capacity)
• Additional Acute PCI only hospital in North
  Spokane
• 4 competing cardiology groups
• Staff education at rural hospitals
• Implementation of protocol when few pts seen
• EMS education
• Mostly BLS units
• Few ALS units

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COAP Primary PCIDoor to Balloon Times
Desired Direction ?
62


Deac.
2008 ACC NCDR 84 of STEMI pts lt90 min (Nat.
avg. 77) 97 of Deac STEMI patients
lt90 minutes
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EMS Activation of Cardiac Level 1

• EMS trained to interpret ECGs
• EMS has authority to activate CL1
• Average transport time less than 10 minutes
• About 3/4 CL1 at PSHMC ED arrive via EMS
• False activation rate 2008 16 2009 10
• Average D2B time (2008-2009 YTD n 97)
• Walk-in patients 89 minutes
• EMS patients 60 minutes

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How about outside Spokane?Major Complaint of
Referring MDs!

• Inconsistent treatment approach to STEMI
• It depends on Who we talk to and When we talk to
  them

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Cardiac Level 1 (CL1) History

• Fall 2006 - Lincoln Hospital,Davenport WA,
  received a RHQN grant for improvement of the care
  of AMI patients
• Nov. 2006 - Representatives from Lincoln, SHMC
  and NW MedStar visited MHI Level 1 Heart Attack
  Program
• Dec. 2006- MHI Level 1 Coordinator Cardiologist
  presented Level 1 program in Spokane
• March 2007 - Cardiac Level 1 pilot project with
  Lincoln Hospital and Sacred Heart Medical Center

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CL1 History

• Spring 2007
• Standardized CL1 protocol agreed upon by all 4
  cardiology groups
• Collaboration between 2 PCI hospitals PSHMC and
  Deaconess Medical Center and MedStar
• Dr Bloom from RHQN promoted the program
• Education to all staff
• No diversion of Level 1 patients
• June 2007 - Workshop at SHMC with rural hospitals
  to learn details of the Level 1 program and
  secure interest in the program
• Fall 2007 - 2008 Rural hospital outreach to 25
  hospitals
• Visits to each rural hospital by Cardiac Level 1
  Coordinators, MedStar Educator and
  Cardiologist(s)
• Hospitals officially on board when protocol
  approved by Medical staff

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Participating Hospitals Zone 1 2
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Cardiac Level 1 Activation

• Referring hospital or cardiologist notifies
  MedStar
• MedStar also contacts operator at DMC or SHMC
• Cardiac Level 1 page/notification at DMC or SHMC
• Cath Lab Crew and Supervisor
• ED Charge Nurse
• CICU and ACU Charge Nurse
• Chaplaincy
• Security
• Hospital Transporter
• Level 1 Coordinator
• Administrative/Nursing Supervisor
• Admitting
• Cardiologist and CL1 Coordinator provide feedback
  

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Data Medical History Hand off transfer tool
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Medications
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Reperfusion Strategy

• Zone 1- lt 60 miles, lt 30 min transport (one way)
• Candidates for Primary PCI
• Goal PPCI lt120 min
• Zone 2 - 61 -175 miles, gt 30 min transport (one
  way)
• Fibrinolytic candidates, unless contraindicated
• Goal D2N lt30 min
• Strongly consider full dose lytics in the
  following cases, if no contraindications
• lt 65 years of age with anterior STEMI
• Presenting within 2 hours of symptom onset
• Consult with cardiologist if decision is unclear

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PSHMC Cardiac Level 1 Summary

• Official Patients 2008 2009 YTD
• Total n130
• Zone 1 n59
• Zone 2 n71
• Male / Female 72 / 28
• Average age 63.3 years
• Anterior MI or LBBB 39
• Cardiogenic shock 8.5
• Pre-PCI cardiac arrest 3
• Transport
• Ground / Air / Combo 16 / 83 / 1

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PSHMC Cardiac Level 1 Summary Official Patients
2008 2009 YTD
N mean median
ED Door to Balloon Time
Zone 1 36 123 min 113 min
Zone 2 40 175 min 172 min

Cath Lab Arrival to Balloon 76 33 min 29 min

Door to Needle Time 46 41 min 36 min
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(No Transcript)
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Reperfusion Strategy Results Zone 2n 69

• About two thirds received lytics
• Strategy not influenced by infarct location or
  patient age

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Sacred Heart Medical Center Door to Balloon
Times Zone 1
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Sacred Heart Medical Center Process times and
D2N Zone 1 2
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Deaconess Medical Center D2N Average times
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Deaconess Medical Center ACTION Database
Transfer-in D2B times
n 59 for 2008
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Future Directions

• Reduce the inconsistencies for both our own ED
  and transfer STEMI patients
• Expand hypothermia and acute CVA program
• Wishful thinking
• ECG transmission capability to rural EMS
• Reposition our helicopters away from Spokane
• 24/7 in-hospital cath lab team/cardiologist