STRAC’s Regional Cardiac System of Care

• Where we have come from

• Seeing the 12-lead still matters for us

• Regional protocol: Drip and Ship

• What we have shared publicly

• 2.4 Million People

• 26,000 Square Miles

• 22 Counties

• 71 EMS Agencies

• 53 Hospitals

• 16 PCI Centers

4 Hour Drive

UvaldeMemorial

DimmitRegional

Fort DuncanRegional

Val Verde Regional

CSR New Braunfels

Connally Memorial

Frio Regional

GonzalesHealthcare

Guadalupe Regional

Hill Country Memorial

Peterson Regional

MedinaRegional

NixCommunity

OttoKaiser

S.Tx RegMed Ctr

2

Kerrville VA

SA• Baptist Medical Center

• North Central Baptist

• Northeast Baptist

• St. Luke’s Baptist

• Methodist

• Metropolitan Methodist

• Methodist Stone Oak

• Methodist Texsan

• Northeast Methodist

• San Antonio Military

Medical Center

• Christus Santa Rosa

Medical Center

• Christus Santa Rosa

Westover Hills

• Christus Santa Rosa New

Braunfels

• Southwest General

• University Hospital

• Nix Hospital

State Trauma Service Area Comparison

Total Land Area = MassachusettsRhode IslandConnecticut

(combined) 17,312 Sq. Miles

Texas State Trauma Service Area P26,912 Sq. Miles

PCI Centers

PCI Centers = 16

54 4

David Wampler, PhD., LP, FAEMSAssociate Professor - UTHSCSA

Department of Emergency Health Sciences

6

Reported: February 8th, 2018

2017 Heart Alert Review

7

• True ActivationEMS activated the Heart Alert & patient had a stentable lesion

• Activation Without Intervention

EMS activated the Heart Alert, there was sufficient evidence of a STEMI (i.e. Heart Alert criteria were met), but there was no verified lesion

• False ActivationEMS activated the Heart Alert, the Heart Alert criteria were not met, and the patient did not have a stentable lesion

• Missed ActivationEMS did not activate the Heart Alert, the initial 12-lead at the PCI center indicated STEMI

8CY 2017

So you know the

definitions,

let’s see how well you

interpret actual

EKGs transmitted to local PCI Centers by MEDCOM!

9

Patient Scenario

• Initial Complaint: Diabetic Problems

• 66 year old male complaining of blurry vision and high BGL

• Previous Medical History: ✓CABG 12 years ago✓Hepatitis✓NKDA

• Patient was at church talking with friends

• Speech became slurred, required assistance to lift to the stretcher.

Prehospital Times:

911 Call 11:26 am

EMS Dispatched 11:26 am

At Patient Side 11:34 am

Transport 11:56 am

At Hospital 12:04 pm

10CY 2017

Patient Scenario

ECG was transmitted to Medcom and forwarded to receiving facility

12

Patient Outcome

✓TRUE ACTIVATION

Two Stents• Circumflex• Obtuse

Marginal

Hospital Times:

• 16 minutes in the ED

• 53 minutes in the Cath

Lab

• 69 minute Door to

Balloon

• 110 minute 911 to Device

• 3-Day hospital stay

13

STRAC Heart Alert 2017

EMS Walk-IN

Total # of Heart Alerts 619 129

True Activations 226 (44%) 74 (57%)

Activations without Intervention 99 (19%) 27 (21%)

False Activations 177 (34%) 27 (21%)

Missed Activations 7 (0.1%) 1 (0.1%)

Incomplete Data 110 (18%) N/A

Accuracy Rate 64% 78%

CY 2017

14

EMS With Top 5 Scene Times

CY 2017

Mean (min) 13SD 7N 181 95% CI 13 to 14Min/Median/Max 1/12/58

EMS Agency Scene Time

SAFD M33 1 min

Acadian EMS 766 1 min

SAFD M36 3 min

SAFD M17 4 min

New Braunfels FD M6 5 min

15CY 2017

EMS With Top 5 911 to ED

Mean (min) 35SD 11N 187 95% CI 33 to 36Min/Median/Max 7/32/90

EMS Agency 911 to ED

SAFD M33 7 min

SAFD M37 12 min

SAFD M46 18 min

SAFD M36 20 min

SAFD M22 20 min

16CY 2017

EMS/Hospital Pairs with Top 5

911 to Balloon Times

Mean (min) 35SD 11N 187 95% CI 33 to 36Min/Median/Max 7/32/90

Hospital EMS 911-B Time

Metropolitan Meth SAFD M05 37 min

Methodist Stone Oak SAFD M31 44min

CSR New Braunfels NBFD 45min

Methodist Stone Oak BSB EMS 46min

Methodist Stone Oak BSB EMS 48min

17CY 2017

Hospitals with Top 5 D2B Times*

*All were Prehospital activations

Mean (min) 55SD 26N 213 95% CI 52 to 59Min/Median/Max 13/54/262

Hospital D2B Time

Metropolitan Meth 13 min

Methodist Stone Oak 13 min

Methodist Hospital 16 min

CSR New Braunfels 17 min

Metropolitan Meth 17 min

18CY 2017

2017 Descriptive Statistics: Heart Alerts

*The two-tailed P value is less than 0.0001

EMS Walk-IN

Mean D2B (min) 55 72

SD (min) 26 39

N 214 67

95% Cl 52 to 59 62 to 81

Range (min) 13 to 262 11 to 251

Median (min) 54 68

Odds ratio of meeting 60-min goal 3.2 if by EMS

19CY 2017

151

48

98

0

20

40

60

80

100

120

140

160

7am - 5pm 5pm - 10pm 10pm-7am

Nu

mb

er

of

He

art

Ale

rts

51% of EMS Heart Alert Patients receiving stents arrived 07:00-17:00

Heart Alert Demographic: Time of Day

20CY 2017

3436

31

19

27

23

11

18

29

17

21

28

0

5

10

15

20

25

30

35

40

Nu

mb

er

of

He

art

Ale

rts

All EMS Heart Alerts

21

CY 2017

Participating RACs:✓ BRAC✓ CTRAC✓ DETRAC✓ JRAC✓ STRAC

22

This platform represents the combined efforts of

participating RAC's to improve the quality of not only their

care to the stroke and STEMI patients of their region

through improved data collection and analysis; but also

thereby raising the bar for the entire state of Texas.

What is RDC?

✓ Compliance: Data collection satisfies state reporting requirements

while maintaining HIPAA information security compliance in a

HITECH compliant data center.

✓ Convenience: With an intuitive interface, authorized users have

access to a streamlined data entry portal and robust reporting

features to enable a clear and simple way to mine their data.

✓ Coordination: Serving each region with their data, each RAC and

the clinicians in its region are empowered with quantifiable data

they can leverage to improve systems and patient outcomes.

23

How to Interpret Bars and Whiskers

24

Demographics:STEMIs by Gender

25

Demographics:STEMIs by Age

CY 2017

26

Demographics: STEMIs By Age Distribution

CY 2017

27

STEMI Volume:Direct Presentation with

Device Activation CY 2017

28

STEMI Time to EKG:Prehospital Time to EKG –

EKG Obtained Prior to Hospital Arrival CY 2017

STEMI Time to EKG:Prehospital Time to EKG –

EKG Obtained Prior to Hospital Arrival CY 2017

STEMI Time to EKG:Arrival Time to EKG –

EKG Obtained After Hospital Arrival CY 2017

CY 2017

STEMI Time to EKG:Arrival Time to EKG –

EKG Obtained After Hospital Arrival

STEMI Door to Balloon:Direct Presentation (All)

CY 2017

STEMI Door to Balloon:Direct Presentation by Arrival Mode

Ambulance Self/Family

CY 2017

STEMI Door to Balloon:Direct Presentation by EMS

CY 2017

STEMI Door to Balloon:Direct Presentation by Self/Family

CY 2017

36CY 2017

Mean Door to Balloon Time

84

72

6460

57 57 5752

57 55

94

8579

6570 69

75 75 73 72

0

10

20

30

40

50

60

70

80

90

100

2008 2009 2010 2011 2012 2013 2014 2015 2016 2017

Do

or

to B

allo

on

(m

in)

STEMI - EMS STEMI - Walk-ins

37CY 2017

Percent of PatientsWith <90 Minute D2B

67

80

8993 94 92 92

95 93 95

56

63

78

9388 86

7682 82

77

0

10

20

30

40

50

60

70

80

90

100

2008 2009 2010 2011 2012 2013 2014 2015 2016 2017

% M

eet

ing

90

Min

ute

Go

al

STEMI - EMS STEMI - Walk-ins

David Wampler, PhD., LP, FAEMSAssociate Professor - UTHSCSA

Department of Emergency Health Sciences

38

Reported: February 8th, 2018

2017 Heart Alert Review

Questions?

The 12-lead still matters

• Original goal in 2008

• Tried tons of technology without success

• Using smart phones but low tech

• Getting the 12-lead to the cardiologist helps grow our system

✓Cost to Hospitals:

iPad & Wall Mount;

estimate $1K

✓Cost to EMS: ZERO

• Date, Time, Agency, Unit #

• No PHI on EKG

MEDCOM forwards EKG by

email to the receiving PCI

Center ER prior to EMS arrival

MEDCOM stores the EKG

image for historical data

Step 1: EMS Performs

12-Lead EKG

Step 2: EMS

Determines 12-Lead

is STEMI

Step 3: EMS takes

picture of 12-Lead

w/ iPhone or Android

Step 4: EMS texts

image to

(210) 417-7016

Step 5: EMS calls

report to receiving

PCI Center

• Receiving ER already has EKG on ER iPad sent by

MEDCOM

• ER iPad has Security Software to prevent misuse

• ER can share with Cardiology

MEDCOM 24/7 Dispatch: (210) 233-5815

Text: (210) 417-7016

MEDCOM

12-Lead EKG

Transmission

Project

(210) 417-7016

www.strac.org/12Lead

43

STRAC-MEDCOM EKG Transmission Project

12-Lead Transmissions for January, 2018

BM

C

CSR

NB

CSR

WH

MET

RO

MH

MSO

H

MTH

NB

H

NC

B

NEM

H

SAM

MC

SWG

UH

TOTA

LS

Acadian Ambulance 2 0 4 0 1 0 1 2 1 3 1 1 0 16

Bandera Co EMS 0 0 0 0 1 0 0 0 0 0 0 0 0 1

Converse EMS 0 0 0 0 0 0 0 0 0 1 1 0 0 2

Karnes Co EMS 3 0 0 0 0 0 0 0 0 0 0 0 0 3

New Braunfels EMS 0 12 0 0 0 0 0 0 0 0 0 0 0 12

SAFD/EMS 13 0 5 9 4 4 2 6 1 1 1 6 6 58

TOTALS 18 12 9 9 6 4 3 8 2 5 3 7 6 92

44

STRAC-MEDCOM EKG Transmission Project

12-Lead Transmissions for January, 2018

BMC 29% (4)

NBH 22% (3)

SLB7% (1)

CSRNB21% (3)

CSRWH7% (1)

METRO7% (1)

MSOH7% (1)

BMCNCBNBHSLBCSRNBCSRWHMHMETROMSOHMTHNEMSAMMCSWG

Dec 201712-Lead

TransmissionsBy Destination

N=14

✓Cost to Hospitals:

iPad & Wall Mount;

estimate $1K

✓Cost to EMS: ZERO

• Date, Time, Agency, Unit #

• No PHI on EKG

MEDCOM forwards EKG by

email to the receiving PCI

Center ER prior to EMS arrival

MEDCOM stores the EKG

image for historical data

Step 1: EMS Performs

12-Lead EKG

Step 2: EMS

Determines 12-Lead

is STEMI

Step 3: EMS takes

picture of 12-Lead

w/ iPhone or Android

Step 4: EMS texts

image to

(210) 417-7016

Step 5: EMS calls

report to receiving

PCI Center

• Receiving ER already has EKG on ER iPad sent by

MEDCOM

• ER iPad has Security Software to prevent misuse

• ER can share with Cardiology

MEDCOM 24/7 Dispatch: (210) 233-5815

Text: (210) 417-7016

MEDCOM

12-Lead EKG

Transmission

Project

(210) 417-7016

Regional Plan for Care

• There is no such thing as too close

• Care for STEMI patients should be the same no matter where you choose to have yours

But wait…we are real close

“Firbrinolysis Use Among Patients Requiring Interhospital Transfer for ST-Segment Elevation Myocardial Infarction Care”, JAMA Intern Med.doi:10.1001/jamainternmed.2014.6573; Published online December 8, 2014.

Thrombolytic Algorithm• Confirmed STEMI on 12 lead?

• Begin thrombolytic contraindications checklist immediatelya. Onset of symptoms <12 hours: administer full dose

thrombolytic* and transfer urgently to PCI Center.b. Onset of symptoms >12 hours: consider

thrombolytic and consult with receiving facility.*Fibrin-specific agents preferred: tenecteplase (TNKase) or reteplase (Retavase)

YES: Activate “Heart Alert” as early as possible.

STEMI Management Guidelines for Inter-facility Transfer

Bexar County PCI Centers:• Baptist Medical Center • Christus Santa Rosa Medical Center• Christus Santa Rosa Westover Hills• Methodist Hospital• Methodist Stone Oak Hospital• Methodist TexSan Hospital• Metropolitan Methodist Hospital• Nix Medical Center• North Central Baptist Hospital• Northeast Baptist Hospital• Northeast Methodist Hospital• San Antonio Military Medical Center• Southwest General Hospital• St. Luke’s Baptist Hospital• University HospitalComal County PCI Centers:• Christus Santa Rosa New Braunfels• Resolute Health Hospital New Braunfels

Heart Alert Criteria1. Patients with signs & symptoms of an Acute Coronary Syndrome (ACS)*

------------ AND ---------------2. ST segment Elevation of 1mm or more in 2 contiguous leads

If your patient does not meet Criteria 1 AND 2, a consult should be done with the receiving ED physician prior to declaring a Heart Alert.*ACS Symptoms include but are not limited to chest pain/tightness; radiation to back, abdomen, arm(s), neck, jaw or any combination; dyspnea; diaphoresis; nausea/vomiting; fatigue; weakness; palpitations; indigestion; syncope; pulmonary edema.

NO: patient not in STEMI guideline at this time.

Green County Goal: Door to Thrombolytic in< 30 minutes and urgent transfer to PCI Center • Counties that do not have a PCI Center: administer

full dose thrombolytic

Red County Goal: Door to PCI in < 120 minutes• Counties with PCI Centers: consider administering full

dose thrombolytic if delay in arrival to PCI Center

STRAC Regional Cardiac Systems Committee, www.strac.org v7 May, 2018

Thrombolytic Algorithm• Confirmed STEMI on 12 lead?

• Begin thrombolytic contraindications checklist immediatelya. Onset of symptoms <12 hours: administer full dose

thrombolytic* and transfer urgently to PCI Center.b. Onset of symptoms >12 hours: consider

thrombolytic and consult with receiving facility.*Fibrin-specific agents preferred: tenecteplase (TNKase) or reteplase (Retavase)

YES: Activate “Heart Alert” as early as possible.

STEMI Management Guidelines for Inter-facility TransferHeart Alert Criteria

1. Patients with signs & symptoms of an Acute Coronary Syndrome (ACS)*------------ AND ---------------

2. ST segment Elevation of 1mm or more in 2 contiguous leads

If your patient does not meet Criteria 1 AND 2, a consult should be done with the receiving ED physician prior to declaring a Heart Alert.*ACS Symptoms include but are not limited to chest pain/tightness; radiation to back, abdomen, arm(s), neck, jaw or any combination; dyspnea; diaphoresis; nausea/vomiting; fatigue; weakness; palpitations; indigestion; syncope; pulmonary edema.

NO: patient not in STEMI guideline at this time.

STRAC Regional Cardiac Systems Committee, www.strac.org v7 May, 2018

Green County Goal: Door to Thrombolytic in< 30 minutes and urgent transfer to PCI Center • Counties that do not have a PCI Center: administer

full dose thrombolytic

Red County Goal: Door to PCI in < 120 minutes• Counties with PCI Centers: consider administering full

dose thrombolytic if delay in arrival to PCI Center

Bexar County PCI Centers:• Baptist Medical Center • Christus Santa Rosa Medical Center• Christus Santa Rosa Westover Hills• Methodist Hospital• Methodist Stone Oak Hospital• Methodist TexSan Hospital• Metropolitan Methodist Hospital• Nix Medical Center• North Central Baptist Hospital• Northeast Baptist Hospital• Northeast Methodist Hospital• San Antonio Military Medical Center• Southwest General Hospital• St. Luke’s Baptist Hospital• University HospitalComal County PCI Centers:• Christus Santa Rosa New Braunfels• Resolute Health Hospital New Braunfels

Questions?