Transcript Statewide Improvement Through Systems of Care Barry D. Bertolet Vice President Disclosures Nothing to disclose Mississippi Healthcare Alliance Founded August 2009 with 5 hospitals …today our membership includes all.

Statewide Improvement Through
Systems of Care
Barry D. Bertolet
Vice President
Disclosures
Nothing to disclose
Mississippi Healthcare Alliance
Founded August 2009 with 5 hospitals
…today our membership includes
all 19 PCI Centers
Mission and Vision
Mission: Improve the health status of
Mississippians
Vision: Unite stakeholders to bring about an
alignment of efforts that reduce morbidity,
mortality, and cost associated with
problematic disease process that plague our
community
Goals
1
2
3
Create collaborative quality improvement
efforts involving Mississippi Hospitals, EMS
Services, & medical professionals
Develop state and regional network of
hospitals and EMS services based on best
care protocols
Institutional level heart attack and stroke
teams used to collect, analyze and react to
quality outcomes
Areas of Focus
Phase I: Primary PCI Hospital Implementation
Phase II: Non PCI Hospital Implementation
Phase III: EMS
Phase IV: Public Education Campaign
“Dial Don’t Drive”
Phase I : Primary PCI Hospital
Implementation
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Basic requirements/capabilities
Standardized drug protocols
Involvement of all Mississippi PCI hospitals;
Policy of Inclusion
Regional Coordinators/Regional Leadership
Primary PCI requirements
1. Institution specific written STEMI care
plan/ protocols to achieve rapid primary PCI
(D2B < 90 minutes >90%)
2. ED ECG < 10 minutes
3. 24/7 primary PCI capability within 30
minutes
4. ED physician activates the STEMI team
5. Single call activation of the STEMI team
(immediate)
6. Universal acceptance of STEMI transfers (regardless
of bed availability/no diversions for STEMI patient)
7. Ongoing data monitoring/quality improvement
(ACTION GWTG)
8. Multidisciplinary STEMI Committee: Cardiology
Champion, ER Physician, Quality, Administration, CL
Nurse, ER Nurse, EMS
9. Ongoing STEMI education: EMS, Emergency
Department, CCL
10. Feedback to Non PCI hospitals
11. Commitment to improve STEMI care for all hospitals
regardless of affiliation
Phase II: Non PCI Hospital
Implementation
 MHCA Introduction Letter/Invitation to join (70
Non PCI hospitals)
 Survey of current practices in Non PCI Hospitals
 Basic Requirements
 Education/Training : Regional Symposiums
- Standardized Protocols
- Transportation Protocols
- EMS
- Data Collection/ACTION
GWTG Registry
- Standardized PPT
Presentations
Non PCI Hospital Requirements
 Written institute specific plan for early identification and
management of STEMI patients: parallel processes
 Standard orders and drug protocols
 Standardized reperfusion STEMI care protocol that
designates primary PCI as preferred strategy if D2B <120
minutes from FMC
 Standardized reperfusion STEMI care plan that designates
fibrinolysis when D2B<120 minutes from FMC not
obtainable
 Streamlined standardized protocol for rapid transfer and
transport of STEMI patient to primary PCI hospital
regardless of POE: direct transfer to CCL
The Ideal Non PCI Hospital
 Early STEMI identification: ECG < 10 minutes
Transfer
 Parallel Processes: ✓Initiate
Protocols EMS
✓Activate PCI Hospital
✓Initiate MHCA Drug
Protocols
GOAL
 Goal: Door in – Door out < 30 minutes for transfer patients
 Goal: Door to Needle of < 30 minutes for fibrinolytic
patients
 Data Transfer: Fax Face sheet, Lab, ECG directly to CCL
North
Central
South
North
PCI/Non PCI
Hospitals
Central
PCI/Non PCI
Hospitals
South
PCI/Non PCI
Hospitals
Primary PCI
Non PCI
NORTH
• Baptist
Desoto
• Baptist
Golden
Triangle
• Baptist
Oxford
• Delta
Regional
• North MS
Med Center
• Magnolia
Regional
CENTRAL
• Anderson
Regional Med
Center
• Central MS
Med Center
• MS Baptist
Health
Systems
• River Region
• Rush
• St. Dominic
• UMMC
SOUTH
• Forrest
General
• Memorial
Hospital @
Gulfport
• Singing
River-Ocean
Springs
• Singing
RiverPascagoula
• Southwest
Regional
• Wesley
MHCA STEMI – Primary PCI Protocol
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Activate referral PCI hospital and EMS
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Monitor, Oxygen, IV with saline
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Nitroglycerin 0.4 mg SL (repeat as needed or IV)
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Aspirin 325 mg PO chew and swallow
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Second Anti-platelet Agent (PICK ONLY ONE)
Ticagrelor (Brilinta) 180 mg PO (PREFERRED)
OR
Clopidogrel (Plavix) 600 mg PO
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Heparin 60 units/kg IV bolus (max 4000 units)
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Morphine sulfate IV as needed for pain
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Attach hands-free defibrillator pads
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Transfer to PCI hospital
2013 MHCA Approved STEMI Protocols
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Door-in to door-out goal is less than 30 minutes
www.mshealthcarealliance.org
MHCA STEMI - Lytic Protocol
Recommend lytic therapy when First Medical Contact to PCI is anticipated
to be > 120 minutes
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Activate referral PCI hospital and EMS
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Monitor, Oxygen, IV with saline
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Nitroglycerin 0.4 mg SL (repeat as needed or IV)
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Aspirin 325 mg PO chew & swallow
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Clopidogrel (Plavix)
Age ≤ 75 yrs: 300 mg PO
Age > 75 yrs: 75 mg PO
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TNKase (tenecteplase) Weight Based:
<60 kg: 30 mg IV Push
60-69 kg: 35 mg IV Push
70-79 kg: 40 mg IV Push
80-89 kg: 45 mg IV Push
>90 kg: 50 mg IV Push
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Heparin 60 units/kg IV (max 4000 units) BOLUS, THEN 12 units/kg/hr INFUSION (max 1000 units/hr)
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Morphine sulfate IV as needed for pain
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Attach hands-free defibrillator pads
2013 MHCA Approved STEMI Protocols
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Transfer to PCI hospital
www.mshealthcarealliance.org
EMS Requirements
 Ambulance services should obtain
EKG within 15 minutes
(typical ACS 30 and older, atypical 50 and older)
 Initiate EMS early notification to PCI hospital
 + EKG patients directly to PCI hospital if 90 minutes window
obtainable from first medical contact to PCI or if shock or
thrombolytic contraindicated
 If patient stops at non-PCI hospital then patient must be
treated on stretcher for EKG/results + transferred to PCI
hospital with SAME ambulance
EMS Territorial Boundaries Broken
It is imperative for EMS to be
able to cross county lines when necessary for
reperfusion.
EMS services should cross-cover for adjacent EMS
in another county.
STEMI should take priority over many non-life
threatening medical conditions.
Achievements:
✓Initiated “Dial Don’t Drive” campaign for public education
in 2012 in partnership with AHA and Medicaid increasing
911 calls approximately 30% in central region
First EKG Obtained Prehospital
90
80
70
Percentage
81
80
75
75
73
73
72
71
71
70 6870 6970
6969
85
76
60
MS
50
Nation
40
30
20
10
0
2Q2012 3Q2012 4Q2012 1Q2013 2Q2013 3Q2013 4Q2013 1Q2014 2Q2014
FMC to PCI
(minutes)
100
90
95
89
91
86
89
88
82
80
79
82
82 81
81
81.581
82.581
70
Minutes
60
MS Average
50
Nation Average
40
30
20
10
0
2011
2012
1Q2013
2Q2013
3Q2013
4Q2013
1Q2014
2Q2014
In-hospital Mortality
7
6
6.7
5.9
6.46.2
6.66.5
6.5
6.2
6.4
5.6
6.9
6.4
6.3 6.56.3
6
5
Percentage
4
MS Average
Nation Average
3
2
1
0
2011
2012
1Q2013 2Q2013 3Q2013 4Q2013 1Q2014 2Q2014
Where We Were…
In-Hospital Mortality
Trending 12 Months
Last 12 Months
6.35
6.3
6.3
Percentage
6.25
6.2
6.15
6.1
6.1
6.05
6
MS
Nation
Expected Mortality: MS 7.2% Nation 6.8%
Achievements:
 Second statewide system for STEMI as recognized by
CMS
 Increased EMS 12 lead EKG capabilities from 70% in 2010
to 84% in 2013 to near 100% in 2015
 Increased EKG transmission to PCI hospitals with early
STEMI activation from the field
 Mississippi is the FIRST STEMI system of care to
demonstrate a reduction in mortality
Stroke System of Care
Mississippi Stroke System of Care was approved
by MSDH in October 2013
Education began January 2014 with regional
rollouts for hospitals, healthcare providers and
EMS providers regarding stroke protocol and
expectations of stroke readiness for care
All three Regional Rollouts completed as of June
2014
GWTG Stroke data registry is required for
participation
Do WE Need It?
Definition: The Brain Attack Coalition has published recent
recommendations for the establishment of a primary
stroke center & stroke systems of care.
• The hospital directors, administrators, medical and
nursing staff should demonstrate a commitment to
quality stroke care.
• The governing body of the hospital should establish
policy and procedures to ensure the maintenance of
quality stroke care.
• The participating hospitals shall agree to accept all
stroke patients appropriate for their established level of
care.
• The hospital shall establish a stroke program which will
be available on a 24/7 basis in which to evaluate for
stroke appropriately, treat and transfer when
appropriate.
Stroke Center-Levels of Care
30
Level 1—Comprehensive Stroke Center
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Consists of a core team of personnel, infrastructure, and expertise to diagnose and treat
stroke patients who require intensive medical, surgical, and interventional vascular care. The
team consists of a neurologist, neurosurgeon, and endovascular specialists.
Fully equipped Emergency Department (ED) for rapid diagnosis and treatment using standard
CT imaging within 25 minutes and ability to have results reported within 45 minutes of test
completion.
Lab services available 24/7 with appropriate result reporting.
Neurology, Neurosurgery, and Endovascular specialists available 24/7.
Intensive Care capability available with critical care specialist available 24/7.
Complete rehabilitation services (physical therapy, occupational therapy, and speech
therapy) staffed by trained professionals and available for all patients within 24 to 48 hours of
admission.
Readily available for transfer of patient from field or lower care facility.
Maintenance of adequate helicopter landing site on campus.
Operating room and appropriate support staff available 24/7 for emergency surgery when
necessary.
Radiologic and diagnostic imaging with expedited reporting available 24/7, this should
include angiography with endovascular capabilities.
Must participate in the American Heart Association (AHA) “Get With The Guidelines”
(GWTG) Stroke Registry. A multi-disciplinary quality improvement team, should meet at least
quarterly to review data and lead quality improvement initiatives.
Stroke team members must document at least eight hours of Continuing Medical Education
(CME) annually.
Community and professional educational projects should be ongoing.
Level 2 -- Primary Stroke Center (must have all of the
requirements of Level 1 EXCLUDING endovascular
capabilities)
• Consists of a core team of personnel, infrastructure, and expertise to
diagnose and treat stroke patients who require intensive medical and
surgical care. The team consists of a diagnostic radiologist, neurologist,
and neurosurgeon. Fully equipped ED for rapid diagnosis and treatment
using standard CT imaging within 25 minutes and ability to have results
reported within 45 minutes of test completion.
• Lab services available 24/7 with appropriate result reporting.
• Radiology, Neurology, and Neurosurgery specialists available 24/7.
• Intensive Care capability available with critical care specialist available
24/7.
• Complete rehab services (physical therapy, occupational therapy and
speech therapy) staffed by trained professionals and available for all
patients within 24 to 48 hours of admission.
• Readily available for transfer of patient from field or lower care facility.
Level 2-- Primary Stroke Center (continued)
• Maintenance of adequate helicopter landing site on campus.
• Operating room and appropriate support staff available 24/7
for emergency surgery when necessary.
• Radiologic and diagnostic imaging with expedited reporting
available 24/7.
• Must participate in the AHA GWTG Stroke Registry. A multidisciplinary quality improvement team should meet to review
data and lead quality improvement initiatives at least
quarterly.
• Stroke team members must document at least eight hours
of CME annually.
• Community and professional educational projects should be
ongoing.
North
Level I / II
Hospitals
Central
Level I and II
Hospitals
South
Level II
Hospitals
NORTH
• North MS
Med Center*
* Becoming
Level I in 2015
CENTRAL
• MS Baptist
Health
Systems
• St. Dominic*
• UMMC*
* Level I in 2013
SOUTH
• Forrest
General
• Memorial
Hospital @
Gulfport
• Singing
RiverPascagoula
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Level 3— Stroke Capable (must have the ability to diagnose
and stabilize patient for transfer to Level 1 or 2 Referring
Center) Hospital
ED physician, other qualified physician, or physician extender available 24/7 to
diagnose and initiate appropriate treatment.
Rapid diagnosis and treatment using standard CT imaging within 25 minutes and
ability to have results reported within 45 minutes of test completion.
Lab services available 24/7 with appropriate result reporting.
Acute stroke-trained providers should be available 24/7 to direct IV Alteplase (t-PA)
administration.
Transition plans must be established for rapid transfer of patient to Level 1 or 2
Stroke Center. Factors that may necessitate transfer include:
 Consider utilizing “Drip and Ship” after initiation of Alteplase if neurosurgery
coverage is not available.
 Patients with rapid clinical decline.
 Patients without response to IV Alteplase or outside IV Alteplase window
who may benefit from neuro intervention.
 Other factors as clinically necessary.
Must participate in the AHA GWTG Stroke Registry. A multi-disciplinary quality
improvement team should meet to review data and lead quality improvement
initiatives at least quarterly.
Community and professional educational projects should be ongoing.
Level 4—Non Stroke Hospital
• Facility is able to assess and evaluate for possible
stroke, but lacks essential components to treat
patient with IV thrombolytics.
• Transition plans must be established to facilitate
rapid transfer of patient to Level 1 or 2 Stroke Center
• May be bypassed in accordance with this plan or an
EMS Medical Control Plan.
EMS Protocol
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Pre-hospital Stroke Protocol
1) Initial assessment, transport ASAP:
ABCs
Obtain time of symptom onset (Last time known well) ___________; Source of information
_____________________________________; Contact information:___________________
2) Administer high concentration oxygen, as needed, to maintain O2 Sat >94 percent.
3) Position patient with head/shoulders elevated to 15-30 degrees (unless contraindicated).
4) Maintain NPO.
5) Blood glucose < 60, treat per protocol.
6) Do not treat high blood pressure without physician approval.
7) Perform Stroke Scale – Cincinnati Stroke Scale.
8) Transport patient to the appropriate facility:
– a. Transport patient to the closest hospital capable of treating the patient with IV Alteplase (Stroke
Capable or Primary/Comprehensive Stroke Center). Hospitals not able to diagnose and treat stroke
patients (Level 4 hospitals) may be bypassed. EMS may use discretion based on transport time or
other unforeseen factors.
– b. Consider transport of the stroke patient with severe symptoms (hemiplegia, aphasia, neglect, stably
intubated) to a Comprehensive Stroke Center if symptom onset to hospital arrival time is greater than
3 hours and less than 6 hours.
– c. Transport patient to the closest appropriate facility if unstable (e.g., cardiac arrest, unstable
airway).
9) IV NS KVO once en route.
10) EKG once en route.
11) Notify receiving facility of estimated arrival time of acute stroke patient, Stroke Scale finding, and time
of onset.
Cincinnati Prehospital Stroke Scale
Acute Stroke Interventions
Rationale:
• IV Alteplase
• Intervention
• IA Alteplase
• Clot retrieval
• Early treatment = better outcomes
Ischemia Penumbra
• A stroke results in death of neuronal
tissue. There is surrounding brain that is at
risk of death if blood flow is not restored.
• This potential region of infarct or stroke is
termed the Ischemic Penumbra.
Stroke = death of brain cells
Treatment Window
• Protocol sensitive to treatment window for IV
Alteplase.
– Initial Alteplase trial defined a 3 hour window
• NINDS trial (NEJM 1995, 333: 1581-1588)
– Subsequent trial revealed benefit in the 3 to
4.5 hour window
• ECASS-3 trial (NEJM 2008, 359: 1317-1329)
• Protocol also allows for EMS diversion for higher
level of care outside this window
– Comprehensive Stroke Center (Intervention)
4.5 hour Window
• Treatment using Alteplase to 4.5 hours
– Supported by Advisory statement of AHA/ASA
– Statement of Affirmation by American
Academy of Neurology
• Stroke 2009, 40: 2945-2948
4.5 hour window
• Joint policy Statement of American
College of Emergency Physicians and
American Academy of Neurology
– Level A evidence for treatment within 3 hours
– Level B evidence for treatment 3 to 4.5 hours
• [Ann Emerg Med. 2013;61:225-243.]
tPA dose for Acute Ischemic
Stroke
AIS
• 0.9 mg/kg IV infused over 1 hour
– ≤100 kg: Administer 10% of total dose as
initial bolus over 1 minute; THEN 0.81 mg/kg
as continuous infusion over 60 min; not to
exceed total dose of 90 mg
– >100 kg: Administer 9 mg (10% of 90 mg) as
IV bolus over 1 min; THEN 81 mg as a
continuous infusion over 60 min
Blood Pressure Management
American stroke association
• Ischemic stroke current recommendation:
– SBP <220, DBP < 120 :
• no treatment unless end organ involvement
– SBP >220 or DBP 121-140:
• Nicardipine or labetalol
– DBP > 140 :
• Nitroprusside
Stroke 2003: 34: 1056-1083
Hospital tPA Protocol
Alteplase (t-PA) “Drip and Ship” Transfer Protocol for Ischemic Stroke
******************************Use only Alteplase***************************************
1) Symptom onset time: __________________ (Last time known well).
2) Document BP < 180/105 prior to departure: ___________________.
3) Initial NIHSS ________________; NIHSS at departure: ______________ (scored by ER physician/staff).
4) Activate EMS for transfer (consider air transport).
5) Two (2) peripheral IVs (18 gauge, AC or higher, if possible).
6) Time t-PA initiated: Total dose: __________, weight (kg) __________. a. Bolus dose time: __________,
Dose __________ mg.
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b. Infusion dose time: __________, Dose __________ mg. (1 hour infusion)
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c. Completion time: __________.
7) After t-PA infusion completed, start NS at 80cc/hr to infuse remaining t-PA in tubing.
8) O2 as necessary to maintain O2 sat > 94%.
9) HOB 15-30 degrees (unless contraindicated).
10) If IV infusion blood pressure medication has been initiated, record: a. Medication __________; current
dose __________.
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b. Titration instructions to maintain BP < 180/105:
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____________________________________________________.
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c. Hold infusion blood pressure medication for BP < 140/80.
11) Vitals and neuro checks every 5 minutes.
12) Hypertension: If BP > 180/105. a. HR > 60: Labetalol 10mg IV over 2 minutes, repeat as needed after 5
minutes. May repeat 3 times.
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b. HR < 60: Nicardipine (Cardene) 5 mg/hour (at a concentration of 0.1 mg/ml); increased by 2.5
mg/hour every 15 minutes to
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maximum of 15 mg/hour; consider reduction to 3 mg/hour after response is achieved.
13) Stop t-PA for: a. Neurologic deterioration.
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b. Airway edema.
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c. Time discontinued: __________.
Current Mission: Lifeline STEMI and Cardiac
Resuscitation systems of care coverage area
(11/05/2014)
Achievements:
 First state in the nation to have both STEMI and Stroke
Systems of Care recognized by CMS
On the Horizon
S
Prehospital System of Care for SCD/Induced Hypothermia
www.mshealthcarealliance.org
Thank you