· Web viewIt is different from ECG time. ... The key word that I just said there is acting on...

Transcript for EMS Recognition Webinar 2017 - Criteria and Measures

Operator: Welcome.

Speaker 1: Thank you for calling [inaudible 00:00:03].

Operator: Welcome and thank you for standing by at this time. All participants will be on a listen only mode until the question and answer session of today's conference. At that time, please press star followed by the number one on your phone if you would like to ask a question and record your name at the prompt. I would now like to turn the call over to David Travis. You may begin.

David Travis: Good afternoon and on behalf of the American Heart Association and the Mission Lifeline program, I'd like to welcome you to our EMS Recognition webinar. This is the first webinar we're having regarding the 2017 EMS Recognition program cycle and we will have other webinars to be determined in the future. Our objectives today are to provide you with some rationale regarding the importance of reducing first medical contacts to device time and particularly EMS’ role in that and to provide you with an overview of the 2017 Mission Lifeline EMS Recognition criteria and the new reporting measures and to also provide you with an overview of the data collection worksheet which has been completely reworked for this year and then finally we will answer any questions you may have about the Mission Lifeline EMS Recognition program.

Today’s speakers are; Dr. Lee Garvey, who is a professor of emergency medicine with Carolinas Healthcare System and he is a longtime AHA and Mission Lifeline volunteer and is also now the chair of the Mission Lifeline Steering Committee. We also have Ben Leonard who is an AHA EMS director for quality systems improvement with our Mid-West affiliate and myself, I'm the EMS program manager and work out of the National Center. With that I will turn over the presentation to Dr. Garvey who will be going through a few slides and speaking about first medical contact to device time and the EMS role and Dr. Garvey, please let me know when you have control.

Dr. Lee Garvey: Okay thank you. As this is switching over, looks like that's the end of my presentation. I don't know how I can get back up there.

David Travis: [Inaudible 00:02:48] with the arrow to the left.

Dr. Lee Garvey: Yeah, let me try that.

David Travis: There you go.

Dr. Lee Garvey: Here we go, all right. Well, thank you all and it's my pleasure to participate in this discussion especially focusing on the EMS Recognition for 2017 and I'd like to just draw attention to the role that EMS plays in reducing first medical contact to device time. It's the key role, I think, in this whole scenario of STEMI patient care.

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This slide is probably very familiar to almost everybody. I really like it as an anchor for these discussions. It's from the Mission Lifeline and some of the guideline work I think summarized here and it really focuses appropriately on the interface between the patient and EMS and then EMS and the hospitals or care facilities. It's really a central illustration I think, of the role that EMS plays and how key EMS professionals are in interacting with both the patients and the receiving facilities.

If ever there is a question that comes up about the Mission Lifeline and STEMI system of care, this is the slide I would refer to as to kind of get an anchoring point. First of all, first medical contact is defined as the time of eye to eye between the STEMI patient and the first caregiver and so we typically think of that as EMS personnel. It may however be a medical first responder, a physician at a clinic and so forth but the vast majority of cases and in the usual systems, that's the EMS personnel who is on site with the patient at the patient’s side. This is different from response time. It is different from scene arrival time. It is different from ECG time. It is the time of physical connection between the first medical contact provider and the patient so that's just to kind of orient us.

That is first medical contact and I think we all know that now that device time is the time of the deployment of the first device for PCI, which is not the guide wire but either the balloon or thrombectomy which is not done quite so much anymore but those kinds of devices so first medical contact to device time. In just [inaudible 00:05:33] again, this is really emphasized in the guidelines statements that all communities should create and maintain a regional system of STEMI care. The twelve ECG that is obtained by EMS personnel is really the anchor and the primary piece of data and this is guidelines level one B recommendation from the most guidelines.

In addition, I draw your attention to the third down here that EMS transports to the PCI capable hospital is recommended strategy with an ideal first medical contact to device system goal of ninety minutes or less and so that's the focus that we're talking about. This whole concept of first medical contact to device time bridges the pre-hospital care and the professional work that is done at the pre-hospital environment and the work that is done at the institution. It intentionally bridges that two groups of professionals involved in this part of the system. We used to talk about door to balloon. Door to balloon is no longer the measure to watch.

Door to balloon is really for the most part solved. Most systems now have in place robust responses and once a patient arrives, the likelihood that they will receive reperfusion care within ninety minutes of arrival is very very good and much improved over the last nearly decade of work with all the different initiatives. However, we want to push that foundry out towards really first symptom time. The closest that we have to that is really EMS arrival on first medical contact. We'd like to push it out further but for incremental gains and for the reality of our ability to ... I'm sorry, there's something that jumped around

Mission Lifeline EMS Recognition 2017-20160824 1647-1 of 18

on my screen here.

David Travis: Hey Dr. Garvey, we're having trouble. The slides do not seem to be advancing if you’re advancing them. It seems to be stuck on slide three.

Dr. Lee Garvey: Do you see slide four there? Five? I see it on my screen as slide six is presently displayed on my screen.

David Travis: Yeah we're looking at it. Okay it just changed. I guess taking it’s a little time to-

Dr. Lee Garvey: Okay. Something just popped up and said, “I am now the presenter.” We are on slide six. Is that correct?

David Travis: Yes sir, thank you.

Dr. Lee Garvey: All right so just to emphasize, door to balloon is our first medical contact, is now our focus and it brings our work into the pre-hospital environment. They're moving forward. Can you see slide seven now?

David Travis: Yes, yes we can.

Dr. Lee Garvey: All right. In this work a pre-hospital twelve lead to destination hospital protocol, pre-hospital notification and activation of Cath Lab, minimizing on scene time and maximizing the system use of the transport time and then EMS integration with the hospital to minimize time in the ED; are all the areas of effort that I think will encompass our first medical contact to device. Typically we refer to this as a code STEMI system care activation with the pre-hospital providers as the center piece of that. Now, I think most people are quite familiar also with the value of the pre-hospital electrocardiogram equipment and training has been the focus of effort over the last decade. It's been well studied and well proven that the pre-hospital ECG’s are quality recordings.

Our EMS providers have the appropriate interpretation skills and that there is quite a benefit in time to treatment by utilizing pre-hospital ECG's and acting on that information. The key word that I just said there is acting on the information. That is that is our entire goal of integration with pre-hospital. Those who require an electrocardiogram, it's been studied a bit and one of the well-received schemes for that was published by Luke Graff in around 2000 on triage patients and I think the same criteria apply. This is just an example but most EMS agencies have as part of their decision tree identification of patients that require an immediate twelve lead on presentation with them.

Then the question becomes; how do we get that information interpreted most efficiently and with a high degree of accuracy and confidence and there are a lot of different solutions to this. I would encourage each of you to consider your current circumstances the assets that you have as far as education and quality management and the transmission capabilities but straight up; paramedic read,


algorithm interpretation statements, a combination of both. Rarely what I say, it is required that a physician is required to interpret the ECG alone or even an emergency physician or a cardiologist. We really want to have that skill set in the pre-hospital environment with the paramedics and so different agencies have training for their paramedics and or the incorporation of some of the automated interpretation algorithm statements but we can talk about that in the questions section potentially.

To optimize a Cath Lab, if the STEMI diagnosis is clearly apparent on the ECG and the patient is a clear Cath Lab candidate then at the first opportunity the entire system should be activated and on the other kind of orange colored blocks. If there is either a question about the ECG diagnosis or a question about the candidacy of the patient for Cath lab management, then STAT consultation with physicians at the receiving center is indicated and a joint individualized decision can be made. This is just an illustration of one of the Mission Lifeline regional reports that shows a system of care in a region.

The system bar is to the left and each of the individual hospitals are labeled on the bottom; A, C, E, F, etc. and the blue bar shows the first medical contact to arrival at the hospital door time and then the tan bar in the middle is the time spent primarily in the emergency department between arrival at the hospital and arrival at the Cath Lab. Then the green bar on each shows the time in the Cath Lab from arrival until reperfusion. Our goal is to use that time in the blue bars to minimize the time in the tan bars.

You'll see at the far right Hospital M uses that thirty nine minutes of pre-hospital time to really minimize their ED develop time. You can see that's only about six minutes in that example and so most of the patients are being moved very quickly through the emergency department in to the Cath Lab and you can see the profound effect that that has on their overall time to treatment. I think that is a just a good example of how a system of care in the data that it generates can be useful in informing how the EMS participates, how the hospital can utilize that information and maximize their system response to that. I just wanted to mention briefly some of the work that John Studnek did here in my home town here Charlotte, looking at some benchmarks for STEMI system performance by pre-hospital.

We didn't talk much about response time. That is a whole discussion in and of itself so I put that in parentheses but time to ECG from arrival at the patient's bedside until the ECG is acquired. Eight minutes is the target. Scene time; less minimizing scene time. Less than fifteen minutes on scene is the target. Notification time, that is from the time of the diagnostic ECG until the receiving hospital is notified, target of ten minutes and then a bridge that covers both the transport time and that ED dwell time. From the time the EMS leaves the scene until the time the patient arrives at the Cath Lab table with a goal of thirty minutes.


You can see with the odds ratios in that last column. That is the greatest predictor of treatment within guidelines, recommended ninety minutes from first medical contact time. Only second to that is the scene time minimization with targets of less than fifteen minutes on scene. All of the supply implies rapid assessment, timely and immediate communication and then integration with the hospital processes. I believe that with that I can hand our discussion back to Dave if I can figure out how to do that.

David Travis: Click on my name.

Dr. Lee Garvey: It's coming your way and I'll look forward to discussion at the end. Thank you.

David Travis: Very good and thank you very much Dr. Garvey, really appreciate you joining us today. To continue on, I'm going to go over just a few points about the EMS Recognition program with Mission Lifeline and discuss the new reporting criteria plus measure and that sort of thing. Consistent with what Dr. Garvey said, Mission Lifeline is about improving systems of care for patients with time sensitive conditions. The goal of the EMS Recognition program is to acknowledge the role EMS plays and implementing guideline based care, their coordination with the hospital to get the data to find out how their patients are doing. To improve their performance based on that data with the overall goal of better care for our patients and I'm having trouble advancing the slide. I'm sorry. Operator, I don't know if you have a suggestion. Is there just a delay or I'm I unable to advance the slides?

Operator: I don't have the view of your presentation.

Dr. Lee Garvey: Did that move? This is Lee Garvey. Do I still have control here?

David Travis: It looks like I have control now. Are you all seeing slide five right now? Slide five?

Dr. Lee Garvey: Yes.

David Travis: Okay, it just takes a while I guess. 2017 will be the fourth year of the Mission Lifeline EMS Recognition program. This year for 2016 we did have more than five hundred and forty EMS agencies who actually received awards and over an additional four hundred more team agencies that were included in those award winning applications that we also acknowledged. Each year since the program began, we’ve published a list of the award recipients and JEMS magazine and that was in the July issue for 2017 and to get everybody in this year we needed eight pages for the list and I'm sorry my slides are just taking a long time to advance here.

This map displays the levels of participation around the country by state. You see the darker blue states; Texas, Ohio, Pennsylvania we have the highest levels of participation and then the different colors indicate how many award recipients were in each state. We had a total of two hundred and sixty six agencies who


achieved the gold award this year. A hundred and forty seven achieved silver and a hundred thirty three achieved bronze. The EMS Recognition application period will open on January 1st and will remain open through March 31st and this is an online survey tool that you actually use to apply. If you have your data all together before you go to the application site, it generally takes between twenty five and forty five minutes to complete the process and again, it's all achieved online.

The actual award achievement for 2017 criteria is the same as it was last year. We do have a new plus measure which enables you to get a plus distinction on your work so you can get silver plus, gold plus, etc. and we have a new group of reporting measures this year. Those reporting measures are optional but encouraged and they now include stroke and resuscitation measures for the first time. Now there are resources available to help you with ... We have a guide to recognition, a list of the criteria. We have an FAQ sheet and that sort of thing, all available online at heart.org/missionlifeline and if you get to this home page you will then see a section for EMS providers. If you click on that it will bring you up the EMS Recognition resources.

As I mentioned, the achievement measures for 2017 to actually getting awards remain the same. Achievement measure one is the percentage of patients with non-traumatic chest pain. Thirty five or older who were treated and transported by EMS, who received the pre-hospital twelve lead ECG and depending on which hospitals you transport your STEMI patients to, you'll either also have to report on achievement measure two or achievement measure three or both.

Achievement measure two is for those patients who are treated and transported directly to a STEMI receiving center, STEMI patients that is, where the pre-hospital first medical contact to devise time less than or equal to ninety minutes. Achievement measure three is the percentage of lytic eligible STEMI patients who are treated and transported to a STEMI referring hospital which is non PCI hospital for fibrinolytic therapy where the door to needle time is less than or equal to thirty minutes. Again, if you only transport to a STEMI receiving center you would only have to report on measures one and two but if you transport to a referring hospital as well you would also have to report on an achievement measure three and if you only transported STEMI patients to a referring hospital you would report on achievement measures one and three.

All right. The new plus measure for this year, again this is an optional measure to report on however, also encouraged. This is the percentage of twelve led ECGs performed on patients in the field with an initial complaint of non-traumatic chest pain. It's that same group as measure one for achievement. They are thirty five years or older within ten minutes of EMS arrival to the patient and for this instance it's a little bit different than our traditional first medical contact definition. We're only holding the time accountable to the EMS who is twelve lead capable. The inclusion criteria for the plus measure are patients with non-traumatic chest pain, thirty five years of age or over who were transported by


EMS and the denominator would be those patients in the inclusion criteria.

The numerator is the total number of patients in the denominator to receive the pre-hospital twelve lead within ten minutes of EMS arrival. The reporting measures for 2017 are different. There is actually eight of them this year. They don't all apply to all agencies. However, if they do apply we're encouraging all agencies to report on them. As you all are probably aware, the pathway to achievement measures is usually through the reporting measure. Initially so some of these reporting measures may become achievement measures in the future. The first one is the percentage of hospital notifications or twelve lead transmission suggesting a STEMI alert or Cath Lab activation that are performed within ten minutes of the first positive twelve lead in the field.

It's the time from the first positive twelve lead until the hospital notification of semi alert or code STEMI or whatever terminology you use within ten minutes. The inclusion criteria of those patients assessed and transported by EMS who had a STEMI positive ECG and then the numerator would be the total number of the patients in the denominator for whom a successful hospital notification of STEMI or a successful transmission of the twelve lead ECG occurred within ten minutes of the first STEMI positive ECG. Some agencies perform the notification through alert systems that include the twelve lead ECGs so either way either a radio, phone call or successful transmission of the twelve lead.

The second reporting measure is one of our new stroke measures and this is the percentage of patients with a suspected stroke. We're talking a new onset stroke here for whom EMS provided advance notification to the receiving hospital. Again, as a stroke alert or code stroke, whatever terminology you use and with this one there's no time frame. We just want to ensure that there is a documented advance notification to the receiving hospital, the stroke patient. The inclusion criteria are those patients assessed and transported by EMS who had an EMS impression of suspected stroke. The numerator will be the number of those patients in the denominator for whom advance notification of stroke was provided to the destination hospital.

Reporting measure three is also a new stroke measure and this is the percentage of patients with suspected stroke evaluated by an EMS who had an EMS documented Last Known Well time. Within the EMS chart PCR there is a documented Last Known Well time and the inclusion criteria are just those patients who are treated and transported by EMS who had an EMS impression of suspected stroke. The numerator is the total number of patients and that the nominator for whom EMS documented the Last Known Well time.

Reporting measure four is one of two new resuscitation measures and this is the percentage about a hospital cardiac arrest patients with sustained ROSC maintained to the arrival at the emergency department who had a twelve lead ECG performed. These are patients who were resuscitate in the field on the way to the hospital and who maintained that resuscitation status until they arrived,


who had a twelve lead ECG. The inclusion criteria are all those patients with ROSC maintained to the ED and then the numerator is the total number of those patients who had EMS performed a 12 lead on them.

Reporting measure five is the percentage of resuscitation measure, percentage of out of hospital cardiac arrest patients with sustained ROSC maintained to arrival at the emergency department who were transported to a PCI capable hospital. More and more literature are coming out about potential benefits of this and of course this goes hand in hand with the twelve lead ECG and our commitment to improve systems of care for time sensitive patients. The inclusion criteria here is patients with out of hospital cardiac arrest with a return of spontaneous circulation maintained to arrival of the ED. The numerator is those patients who are transported to a STEMI receiving center or a hospital capable of PCI.

Reporting measure six is, this was debated about potentially becoming an achievement measure this year. There is some concern about EMS agencies ability to gather all this data and there was discussion about who would be the most relevant age groups etc. as some which Dr. Garvey alluded to in his presentation but this is similar to achievement measure one. This is the percentage of twelve lead ECGs performed on patients in the field with an initial complaint of acute coronary syndrome symptoms. Those listed out by AHA include; chest pain, discomfort, pressure, tightness or fullness, pain or discomfort in one or both arms, the jaw, neck, back or stomach, shortness of breath, dizziness or lightheadedness, nausea and diaphoresis.

Those are the patients, thirty five years or older who would be included in the nominator and then the numerator is the number of those patients who received a pre-hospital twelve lead ECG. Very similar to achievement measure one which deals with chest pain expanding it to other acute coronary syndrome symptoms. Reporting measure seven is for those EMS agencies who transport patients to a non PCI center and then complete the transport later to a PCI center. This is the percentage of patients initially transported to a referring non-PCI hospital who were later transported to a STEMI receiving center with an EMS first medical contact to PCI time less than or equal to a hundred twenty minutes.

A hundred twenty minutes is the Mission Lifeline AHA benchmark for patients who are transferred in and so we understand that EMS has a role in that and so this is a reporting measure that speaks to that. The inclusion criteria would be the percentage of STEMI patients initially transported to a non-PCI hospital who were later transported to a STEMI receiving center capable hospital. The numerator would be the total number of those patients with the first medical contact t device time of less than or equal to a hundred twenty minutes. This one is a little bit different and again, this doesn't apply to all agencies, only those who were transported initially to a referring facility and then complete the transport to the receiving center.


The last of the reporting measure is the percentage of patients with non-traumatic chest pain, thirty five years or older. They were treated and transport by EMS who received aspirin and that's either by EMS administration, Dispatch instruction or patient self-administration. The inclusion criteria would be patients with a traumatic chest pain, thirty five years of age or over who were transported by EMS for whom aspirin was indicated. We understand that there are other contrary indications here for aspirin etc. Those patients would not be included but then the numerator would be the total number of patients in the denominator who received aspirin either by self-administration, dispatch assisted instruction or EMS provider administration, that was documented in the EMS report.

Again, obviously very important to get aspirin on board early for patients with chest pain of cardiac ideology and a reporting measure to address that. One of the biggest complaints we've had with the EMS Recognition program has been the mandatory volume requirements, the minimum volume requirements. While those remain the same for 2017, we did make an allowance for those agencies that are unable to meet the volume requirements for the bronze and that is; right now you have to have four patients in a year and two in a reporting quarter to achieve bronze. All of the Mission Lifeline EMS Recognition program 2017 is based on calendar year of 2016, so the patients for this year.

What's new for 2017 is we are extending the opportunity for those low volume agencies to also use reporting quarters from 2015 as long as those patients weren’t include in a previous Mission Lifeline Recognition program application that resulted in an award. For example, if the volume criteria for your agency is not met using quarters one, two, three, and four for 2016, you can go back and use quarter four and quarter three, two and one in that order for 2015 to meet the minimum volume requirements. The actual work criteria for the different awards remain the same as in previous years. Bronze award is a minimum of seventy five percent compliance for each required measure. You have to have at least two STEMI patients in one quarter with at least four in a calendar year and again, low volume agencies can use 2015 as well.

The silver, you need to have a minimum of at least eight STEMI patients in the 2016 calendar year and you need to have an aggregated annual score on the achievement measures of seventy five percent. The gold criteria is the same as the silver criteria, at least eight patients in calendar year 2016, seventy five percent performance for the achievement measures as an aggregate and you have to have achieved the silver recognition last year.

With the plus award, to achieve the bronze plus, silver plus or gold plus award, an agency must meet the threshold for the respective award and they need to report on the new plus measure and achieve at least seventy five percent compliance on that. The types of applications for 2017 remain the same. There is an individual application for agencies that do both the transportation and the twelve lead ECG. A joint application for agencies that work with another agency


where one does a twelve lead and one does the transport etc. They can apply together so long as the volume criteria is met and there is no limit to the number of joint applications. You can have multiple choice applications.

The team application is really an individual application with what's called a team option where the individual agency does the twelve lead and the transport but there are first responders or other agencies who also have a role in the patient's care that they wish to acknowledge. We've had, last year I think we had one agency that named thirty different team agencies in their application and that's strongly encouraged because it is a system of care and it’s a lot more than one agency on a lot of these cases.

For additional questions or resources, we are going to have some time to answer some questions today but if you visit our web site heart.org/missionlifeline and my e-mail is [email protected] or you can e-mail [email protected] and I thank you all very much. I will turn the presentation over to Ben Leonard who is actually with the Southwest affiliate. I mistakably said the Midwest affiliate. He is with the Southwest affiliate of the American Heart Association. Thank you.

Ben Leonard: Hi, thanks Dave. Are you able to hear me okay and see the screen?

David Travis: Yes we can hear you. I can hear you and we can see your screen.

Ben Leonard: All right, good news. Technology is working in our favor. As you all have listened to Dave's talk here on the new reporting measures, the additional, the expanse of what we're wanting to do in terms of helping with some of these other time critical emergencies being stroke and out of hospital cardiac arrest, the need to expand the capability of our data collection tool which was pretty great. With the help of multiple players and with this we actually, as Dave mentioned, we kind of did a whole rewrite of the tool itself, trying to reduce the congestion as well as redundancy and doing a lot of the data entry. As you can see, the layout of the tool is pretty much the same from before in terms of initial formatting and we've got a welcome page here. There's tabs at the bottom with the words summary, monthly results, patient entry and achievement plus measure.

I've got to give kudos to a colleague of mine, Diana Barrett, who helped come up with this other option to help track data on a monthly basis that we included into this tool as an additional option, additional resources for you. I'll go over that here briefly. The award summary is kind of a breakdown of the measures as well as the volume requirements that they've just explained and this is another contribution by Diana Barrett on that. I really appreciate your help with that. The monthly results attracts if you have ... The thought process was higher volumes that do have the capabilities already to do these types of data mining if you will, to be able to track in your numerators and denominators for each one of the quarters, for each one of the measures.


Very very handy tool and as those are entered in you'll see that there's calculations in there that will calculate your percentages for you to help you track as you go along. Additionally, when you get to the application periods you'll be able to take this information and as Dave mentioned, plug it right into your application, reducing your time required to get that app completed. As you can see like I said, it's the achievement measures as well as reporting measures that they just went over are all included into this tab on the monthly results. The other option we looked at, it does kind of go along with that single patient entry assistance.

Like I said, these are tools available for you guys and just use it to add to your benefits make it work for your process. Starting with a column A, we want to keep that blinded patient identifier available. If you can see here in the title of the column itself, I went through and added the applicable nemesis definitions version two as well as version three. If there wasn't a definition for version two obviously it's not in there and vice versa but version three definition e-patient at zero one is going to be your blinded patient identifier. If you go to your e-PCI to do the data mining, these reports builds utilizing these definitions might provide some assistance when this happens. That's kind of that's the reasoning behind those different terminologies but once again, we're looking at age, the date of the incidence of first medical contact here in column D.

Once again you can pull that from these nemesis definition fields. Time of emergency department arrival and departure if applicable and then we get into some of the characteristics of the call and as these columns are laid out you can kind of see the definitions of the inclusion criteria that Dave discussed on his review of the measures in these columns. Did the patient complained of non-traumatic chest pain? It’ sa simple yes or no. Do they complain of signs and symptoms consistent with acute coronary syndrome or stroke? That's where we can kind of start to differentiate where are our volume’s going to be collected. I'm going to scroll over here just a little bit so we're not looking just at this side of the screen. This column I, patient experienced cardiac arrest? Was ROSC achieved? If the patient did have a stroke was the Last Known Well time captured?

A lot of these are yes no questions or marking the time stamps as well as some very limited descriptives. As of Column L, the classification of the hospital which you can see if we're looking at trying to determine if the patient's going to be under measure two or measure three and then tracking those treatment times accordingly. We get into the yellow columns. This is just a little bit longer. Was there a twelve lead ECG acquired or a pre-hospital stroke screening completed? Once again, we're trying to capture those patients that potentially could be a STEMI, include this into the potential stroke in a way that the sheet has been set up and calculated. These will filter out into the different measures that we're looking at. Did the patient receive aspirin? EMS screening. Once again, we're looking at twelve lead ECG screening or that pre-hospital stroke scale screening and the timestamp for that performance as well.


Was that screening positive? Did they have a positive 12 lead? Did they have positive findings for stroke and then was the hospital team activated base from that screening? The date and time of that activation and then the reperfusion strategy; whether it be primary PCI or thrombolytics and of course thrombolytics can be translated over to the stroke as well and so we can narrow that down as we go through these calculations. The date and time with that reperfusion strategy and then if there is any exclusion criteria and once again, we've got this little box that will kind of get into the different cases of where these patients could be excluded and really that is all that we need to do in terms of our data entry on this level. Once this information was plugged in, if you come over to the achievement and plus measure we have nice pictures that, I don't know if you are like me but I do a lot better with pictures, but we have our graphs here.

These darker colored graphs are the achievement measures, obviously the ones that we're looking for that are based on the recognition and the way these are broken down. Obviously we have a denominator for achievement measure one and the numerator for achievement measure one and if you remember, if you've done the application form we do have the application broken into quarters. If you come to this little box here and you get quarter one it will calculate and these are your numerators and your denominator needed to enter into your application for quarter one. With the achievement measure two we have two patients in our denominator. One patient met the ninety minute window, one patient fell from the ninety minute window and that patient did qualify as an exclusion.

The thought is, if you're able to enter the state into this level the calculations are completed through different functions and then graft over onto this page here to help with that. Also, as you're doing quality improvements, measures and processes for your service it would be very easy to do a copy and paste of these charts to help with your continuing quality assurance programs. The grey boxes here and I apologize for the quick move there. The gray boxes are the reporting measures which as Dave described are not required but we would like to ... If you have the capabilities to collect this information, it’s going to help drive not only the program as a whole but your system as a whole forward in terms of improving what you can measure, type of type of concept.

Dave is there anything else really? Any questions based on this report? We wanted to make it as, like I said, we wanted to reduce the congestion with the time required to track your data. We wanted to give a tool that is utilized that can be a resource for the efforts within your organization and always open for constructive criticism on how we can make this better and I guess with that Dave kind of kick it back over to you.

David Travis: Thank you so much Ben and thanks for all of the work that you and Dian did on this. We hope to have this up on the website with the other tools by next week and we're also working on the actual application. Future webinar will focus on a


walk through the application, the online tool that is used to actually enter the data and that is almost complete and we should have a PDF of the new application up on the website very soon as well so that you all can access that but thank you very much Ben. I guess at this point we had allowed some time for some questions and answers. If there are any questions. Operator I don't know if you wanted to explain the process.

Operator: Thank you. We will now begin the question-answer session for today's conference. To ask a question press star followed by the number one on your phone. Unmute your phone and record your name clearly when prompted. Your name is required to introduce your question then to cancel your question press star followed by number two. One moment for the first question. We do have our first question. Give me a moment to get the name. Our first question is coming from Vivian. Vivian your line is open.

Vivian: Okay, hi. My name is Vivian [Enkansa 00:47:10]. I'm calling from [inaudible 00:47:12] medical center in Texas. Thank you for this call. It was very educational to me. My first question is, my facilities are very small facility and I just want to make sure that I understood what you said about the volumes of the STEMI that we have. We are a very small facility and we average anywhere between five to two STEMI’s a month. Did I understood you correctly that if we have a low volume for maybe this quarter I can always go back and use the previous quarters or previous months’ volumes to submit?

David Travis: Yes. However, if you ... I think you said you had approximately five STEMI’s per month, is that correct?

Vivian: Yes sir, five to two a month. Yes sir.

David Travis: The minimum is eight for the silver award. If you have that many you're in good shape. You won’t need to. You only need to have a minimum of eight in the year for the silver and it's for any year for the bronze. The extended time frame is offered for those agencies that are unable to meet before within one year so you should be in good shape there.

Vivian: Okay and for me to be able to submit this data, we are already in [inaudible 00:48:50] and we’re also in Iraq for the area of Texas that we are in and we already submit data through our processes to Lifeline. Is that different from this submission or is it the same thing?

David Travis: This is the Mission Lifeline but what we are talking about here is the EMS Recognition piece. As long as you're talking about EMS patients, any EMS agency working with the hospital then this is correct program. We also have Mission Lifeline programs and award programs for STEMI receiving centers and referring hospitals as well but those are separate. Today we're talking about EMS Recognition, Emergency Medical Services Recognition.


Vivian: Okay I got it and would this call be, say if I want to access this information, how would I be able to do that?

David Travis: Yes. This entire webinar will be uploaded onto our website which is heart.org/missionlifeline and that will be probably up in a week or so.

Vivian: All right, thank you so much.

David Travis: Thanks you for joining us.

Operator: Next question is-

Ben Leonard: I'm sorry operator. If I can just interject just real quickly here. Dave, I want to make a point real quick about the spreadsheet if I could please. If people are going in to delete information, make sure you just delete the information from the cells in the spreadsheet and not the entire ... Don't select the entire row, if that makes sense. There's a lot of hidden calculations, hidden functions in there that will kind of interfere with those calculations. Once again, questions on that, reach out so I can explain it further but I wanted to make that point before I moved on.

David Travis: Thank you Ben.

Operator: Thank you. Next question is from Jason [Heartfield 00:50:58]. Jason your line is open.

Jason: Hi good morning or afternoon, I guess depending on what part of the country you're in. For me it’s Nevada. First of all thank you guys for putting together this webinar. It’s been very beneficial. I had one request in regards to the data collection worksheet on it though with the optional reporting data of the stroke. Would it be possible to, and I guess this would be best suited for Ben, to create separate tabs on the bottom for STEMI and stroke? We use Crystal Reports to extract our data from our EPCR system and then we import that into the Excel spreadsheet and the data becomes pretty convoluted.

It's very difficult to capture those two different data sets. For instance was this STEMI patient or a stroke patient in that STEMI stroke column that you have out there. It seems like that might be a little bit more user friendly if we had like a Mission Lifeline STEMI tab on the bottom and then Mission Lifeline stroke tab on the bottom. Does it make sense?

Ben Leonard: Absolutely yeah and I think, like I said earlier, I welcome the insight and the ideas to make this tool more user friendly. I will absolutely play round with that and see if we can separate the STEMI and the stroke measures and go from there. The goal was to try to reduce the number of lines and pages but I totally understand how you are seeing it and we're coming in terms of collecting that data and with mining that data from the PCR if we are able to copy and paste to


reduce that process. Absolutely, I welcome that and I'll see what I can do with it.

Jason: Okay.

Ben Leonard: Thank you, I appreciate it.

Operator: Thank you. Next question is from Matthew Hart Matthew your line is open.

Matthew: Hi, this is Matt Hart from [inaudible 00:53:12] ambulance in Bismarck in North Dakota. We applied last year for the first time. We did achieve the criteria for gold. However, due to past submission did receive silver status. This year we are going for gold status. My question is to you David. When I do submit my application, do you require a special notification that we did in the past receive for last year or is that information that is readily available once I submit my application to you?

David Travis: Well, thank you for participating and thank you for the question. That's a good question but actually we go through and make those calculations so you don't have to worry about that one. If you received silver last year, this year and you apply next year and you achieve silver you'll get gold. We’ll make sure that happens.

Matthew: Great thank you very much.

David Travis: Thank you.

Operator: As a reminder, to ask a question please press star followed by number one on your phone and our next question is from Danial Kordic. Daniel your line is open.

Daniel: Yes, thank you for this webinar. It’s very useful information. I was wondering if maybe I just missed this but how can we access that Excel sheet for tracking these measures?

David Travis: You’re talking about the worksheet that Ben Leonard went through? How can you access that?

Daniel: Yes.

David Travis: That will be available with the other tools on the website. It should be uploaded next week. We have a number of tools up there now but we don't have the worksheet up there yet. That along with a PDF of the online application will be available soon.

Daniel: Thank you so much.

David Travis: Ben, don't you think that will be up next week, we'll be able to get that up?


Ben Leonard: Oh yeah absolutely if not before. I should be able to try to get those stroke and STEMI tabs separated out and send to you in the next day or so. It should be pretty quick.

Daniel: Awesome. That looks like it's going to be a really really useful tool in this process.

David Travis: Great, thank you very much.

Operator: Our next question is from Angel Mason. Angel your line is open.

Angel: I just wanted to ask, and thank you for the call, if we participate in the action registry, isn't that where you obtain all of our EMS information for your measures?

David Travis: That is generally the primary source of information for the EMS agencies but remember that's only the hospital part of the information. While there is some EMS information included in [inaudible 00:56:09] that EMS agencies will have to report for example on twelve leads for chest pain patients etc. and the reporting measures as well. That is a great source for EMS agencies to get the feedback that they need from hospitals but that's not the whole picture. Does that make sense to you?

Angel: I think so.

David Travis: There are, like achievement measure one for example is the number of twelve lead ECGs performed on chest pain patients thirty five and older. You would not have that information available for the EMS agency in action. That would be something the EMS agency would have to provide themselves.

Angel: Okay.

David Travis: That makes sense?

Angel: Yes.

David Travis: Very good, thank you.

Operator: Our next question is from Tyler Christopher. Tyler your line is open.

Tyler: Hi, I have a question regarding the criteria. As far as, let's say we have a patient that has chest pain, has objective signs of ACS yet their EKG maybe doesn't show the textbook ST elevation. Maybe we see some other objective EKG signs of ischemia and their chest pain is refractory to nitro aspirin. We transport those patients to a Cath Lab. Can we count those patients even if their EKG did not show that ST elevation?

David Travis: Not at the present time. The way the system is geared up, we have a definition of


what a STEMI patient is. We don't have any particular millimeters of the elevation or anything like that but within the criteria it is a STEMI positive patient. We certainly understand there is another subset of patients that are going to warrant intervention but that's not the intent of this program right now.

Tyler: Okay, so if you have a patient who has T-wave inversions and ischemic chest pain, that at this point if you get them to a Cath Lab that does not count towards that criteria.

David Travis: That's correct. It's ST Elevation MI.

Tyler: Okay and my other question was the hundred twenty minutes of the new criteria that we have. Does that have to be the same service transporting that patient to the hospital that is non-PCI and then the same service transporting them to a PCI capable facility or could that be two different services in that?

David Travis: Yeah, that was the goal of this reporting measure was that it's the same agency that had the role in the patient's care initially and then performed the transport. That's the way this is set up, as a reporting measure that could change in the future but that's the way it is right now.

Tyler: Just so because we are working in an area where there are first responders EMT basics and I work for Life star in West Penn and generally we get called to take the STEMI transport out to a PCI facility. Is that something you could join up under the team application then for that?

David Travis: Potentially if that measure becomes an achievement measure there’ll be more criteria established for it that may include opportunities for multiple agencies etc. but right now as a reporting measure it's just for those agencies that transport and then perform the inner facility transport as well.

Tyler: That's it. Thank you very much.

David Travis: Thank you. Thanks for joining us.

Operator: Next question is from Kim [inaudible 00:59:57]. Kim your line is open.

Kim: Hi, thank you for taking my call and thank you for the webinar today. It’s been very informative. I am a STEMI coordinator for a PCI hospital here in Arkansas and my question is; I am working with about five different EMS agencies and I really joined the call today to try to figure out exactly what information they would need from us at the end of the year. Other than the device time and I'm not seeing a whole lot else that we could provide that they wouldn’t already have. Is that correct?

Operator: That's right. For those, if you're a STEMI receiving facility they will need that device time so they can report on measure two if they transport to you. That's


the only criterion for achievement and I'm thinking about the reporting measures and I don't think there's actually any information as far as feedback goes for them at this time either so yeah, I think that's right. Just the device time. Others, correct me if I'm wrong on that but that's my thought.

Kim: [Inaudible 01:01:13] that, from what I've been told is that when I enter our information into the-


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