Toronto STEMI Project

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Toronto STEMI Project

• 24/7 Primary PCI in the GTA

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GENERAL BACKGROUND

• Centres offering PCI 24/7 (St. Michaels
  Hospital, Sunnybrook and UHN), Toronto EMS and
  hospitals across the GTA have agreed to improve
  and optimize existing emergent interventional
  services by joining forces to provide a
  guaranteed accept 24/7 service within the city
  of Toronto boundaries for heart attack patients
  who will benefit most from an emergency
  angioplasty
• Other hospitals in Toronto EMS catchment area may
  also take part by either referring patients to
  PCI centres and repatriating patients or by
  providing angioplasty where available
• Heart Attack Committee formed January 2007 -
  focused on developing a model and generating
  buy-in from participating organizations and other
  stakeholders
• EMS advanced life support paramedics will use
  12-lead ECGs to identify STEMI patients in
  pre-hospital setting, and will bring those
  patients directly to a PCI centre to enable a
  90-minute door-to-balloon time. These patients
  will go directly to the Cath Lab, seen in the PCI
  centre's ER only if  unstable despite
  pre-hospital treatment
• Where applicable, following PCI, stable patients
  will be transferred back to their local hospital
  within 24 hours of procedure

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GEOGRAPHICAL AREA

• Steeles to the North
• Etobicoke Creek/Hwy 427 to the West
• East to Rouge Valley and South to the Lake
• Anticipated total STEMIs within boundary 1,200 a
  year based on data extrapolated from the Ottawa
  experience and population data from City of
  Toronto

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CLINICAL BACKGROUND

• Timely reperfusion of STEMI patients improves
  short and long-term survival and has become the
  mainstay of therapy in this setting
• As an alternative to primary PCI, patients are
  given thrombolytic pharmacotherapy
• numerous studies and analyses show that PCI
  achieves better outcomes, with much lower risk of
  intracerebral hemorrhaqe
• Primary PCI to be of benefit when the door to
  balloon time in the range of 60 to 90 minutes.
  Subsequent data from large registries have
  indicated, the actual door-to-balloon time is
  considerably longer than these optimal clinical
  trial times
• Recent analysis of a large US National Registry
  of Myocardial Infarction (NRMI) indicates that
  the benefit of primary PCI relative to
  thrombolysis is not related just to PCI-related
  delay, but also by patient characteristics

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CLINICAL BACKGROUNDcontinued

• Figure 1
• relationship between patient age, infarct
  location and the time from symptom onset to
  presentation
• apparent that mode of reperfusion therapy needs
  to be taylored to individual patient, based on
  all parameters, not just door-to-balloon time.

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TORONTOS SITUATION

• Majority of emergeny cath lab procedures for
  STEMIs occur when thrombolytic therapy fails
• Provision of emergent interventional cardiology
  care in Toronto has three major challenges
• frequent shortage of critical care beds at all
  institutions with interventional cardiology
  programs
• lack of an efficient and timely transport system
  to transfer patients to PCI centres
• current lack of an organized and efficient 24/7
  primary PCI service in the region

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• Toronto STEMI Project
• The Challenges

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TRANSPORATION SYSTEM

• Current EMS is equipped with very few critical
  care trained paramedic units needed to handle
  possible emergencies during transport
• Majority of units not available to transport
  patients with STEMI from community hospitals
  unless a physician provides advanced care during
  transport
• rarely occurs in Toronto - on-call cardiologist
  in the community hospital is responsible for many
  other patients

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CARDIAC INTENSIVE CARE BED CAPACITY

• Shortage of critical care beds to accept a
  patient with a STEMI
• Shortage of nurses to care adequately and safely
  for extra patient(s)
• Result physicians in community hospitals must
  commonly contact as many as four tertiary centres
  and still may not find a bed and thus timely care

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• Toronto STEMI Project
• The Benefits

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COLLABORTATION

• the STEMI program is a coordinated effort, which
  will improve the integration of care with EMS,
  referring hospitals and PCI facilities
• Need to ensure efficient flow of patients from
  hospitals without PCI capability to PCI centres
  and vice versa

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SAVING LIVES

• The STEMI initiative optimizes door to balloon
  time, which may decrease
• co-morbidities
• reduce complications
• limit the need for prolonged hospital stays and
  readmissions

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SUCCESS STORIES

• Well-studied and recommended process of care that
  benefits patients and practitioners
• Most recently, an article about Ottawa Heart
  Institutes usage of the protocol was published
  in the January 2008 issue of the New England
  Journal of Medicine

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HOSPITAL LEADS
Hospital Name ER Lead Cardiology Lead CEO
LHIN Dan Cass Toronto Central Matthew Anderson Central Hy Eliasoph Central East Deborah Hammons
North York General Kuldip Sidhu / Tim Rutledge Philip Myron Bonnie Adamson
St. Josephs Marco Duic Marco.duic_at_gmail.com Mark Fisher Carolyn Baker
Scarborough General/Grace Tom Chan Chris Li (Grace) / Sharon Roth (General) Lewis Hooper (CIO)
Etobicoke General Naveed Mohammad David Borts Judy Middleton (CIO)
Humber River Rakesh Kumar Robert Bauer Rueben Devlin
St. Mikes Simon Kingsley Jeff Lozon
UHN Anil Chopra Bob Bell
Mount Sinai Howard Ovens Howard.ovens_at_utoronto.ca N/A Joseph Mapa
Toronto East General Paul Hannum phann_at_tegh.on.ca Charles Lefkowitz Rob Devitt
Sunnybrook Jeff Tyberg Jeffrey.tyberg_at_sunnybrook.ca Barry McLellan
Womens College Doug Beattie Douglas.beattie_at_wchospital.ca N/A Marilyn Emery
Rouge Valley / Centenary Tom Stavro Joe Ricci / Saleem Kassam Rik Ganderton
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FOR MORE INFORMATION

• www.stemitoronto.ca
• Project Overview
• List of Partners
• Resources
• - detailed PowerPoint
• - models of reference (Ottawa Heart Mayo
  Clinic)
• Upcoming Events / News
• Tools
• - canned ppt
• - QA
• - Community Consultation Plan
• Contact Information for questions/feedback