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HomeMy WebLinkAboutMINUTES - 08122008 - SD.3 (2) t r� TO: BOARD OF SUPERVISORS Contra FROM: William B. Walker, MD, Costa Health Services Director S; 3aii��ii "~~ CountyDATE: August 12, 2008 °s'rA 6oUri SUBJECT: Report on Emergency Medical Services STEMI Program SPECIFIC REQUEST(S)OR RECOMMENDATION(S)&BACKGROUND AND JUSTIFICATION RECOMMENDATION: Accept Emergency Medical Services (EMS)report on implementation of an ST-elevation myocardial infarction (STEMI)program. FISCAL IMPACT: No general fund impact. EMS staff costs to be covered under County Service Area EM-1 and charges to participating hospitals. BACKGROUND: In collaboration with hospitals, fire first-responders and emergency ambulance services, and the Contra Costa Emergency,,Medical Care Committee, Contra Costa EMS has been working towards implementation of a program that will provide quicker access to definitive cardiac care for certain high-risk heart attack patients. A STEMI, or ST-elevation myocardial infarction, is the most deadly type of heart attack. Research has shown significant reduction in mortality when STEMI patients are identified in the field and transported, with advance notification, to a hospital staffed and equipped to provide rapid cardiac care. A nationally recognized goal is to provide cardiac catheterization within 120 minutes of onset of symptoms. Since most patients do not immediately recognize heart attack symptoms, Contra Costa has established a goal of 90 minutes from EMS arrival on the scene to cardiac catheterization in the hospital. To meet this, STEMI centers will strive to meet a 60-minute "door-to-balloon" time. Identification of a STEMI in the field requires use of a specialized 12-lead electrocardiogram device. All ambulance.and most fire first responder paramedics in the county have been trained and equipped in use of this device. Five hospitals in Contra Costa currently have cardiac catheterization capability and cardiac teams able to respond promptly when notified of the pending arrival of a STEMI patient. These five hospitals—Doctors Medical Center San Pablo, John Muir Medical Center Concord, John Muir Medical Center Walnut Creek, Kaiser Medical Center Walnut Creek, and San Ramon Valley Medical Center—have participated with EMS Agency staff in development of a comprehensive program to assure rapid intervention for these high-risk heart attack patients. All five hospitals have agreed to meet jointly set STEMI center standards, including participation in an EMS quality review . and improvement program. All five ho'spitals'have had site reviews conducted by the EMS Medical Director and EMS'Quality Improvement Coordinator. Contra Costa will also recognize STEMI centers established in Alameda County including Oakland Summit Hospital and Valley Care Health System_in Pleasanton. Hospitals that do not currently have cardiac catheterization capability will be brought into the program if they develop that capacity in the future. CONTINUED ON ATTACHMENT: X YES SIGNATURE: RECOMMENDATION OF COUNTY ADMINISTRATOR RECOMMENDATION OF BOARD COMMITTEE APPROVE OTHER SIGNAURE(S): ACTION OrBOARD ONAPPROVE AS RECOMMENDED 0 'ER VOTE OF SUPERVISORS I HEREBY CERTIFY THAT THIS IS A TRUE AND CORRECT COPY OF AN ACTION TAKEN V UNANIMOUS(ABSENT ) AND ENTERED ON THE MINUTES OF THE BOARD OF SUPERVISORS ON THE DATE AYES: NOES: SHOWN. ABSENT: ABSTAIN: ATTESTE JO N CULLEN,CLER,OF THE BOARD OF SU RVISORS AND COUNTY ADMINISTRATOR Originating Department: Emergency Medical Services 646-4690 cc: County Administrator County Counsel Health Services Administration Emergency Medical Services Contra Costa County Fire Chiefs Association Each Fire Chief BY' r , DEPUTY Coordinator. Contra Costa will also recognize STEMI centers established in Alameda County including Oakland Summit Hospital and ValleyCare Health System in Pleasanton. Hospitals that do not currently have cardiac catheterization capability will be brought into the program if they develop that capacity in the future. The formal launch date for the program is scheduled for September 8th. Beginning on that date, ambulances will begin transporting identified STEMI patients directly to a STEMI center. Of the some 7,000 chest pain/cardiac patients that EMS responds to annually in Contra Costa County, only about 100 to 150 are identified in the field as STEMI patients. Thus, the impact of this change in EMS transport protocol will have little impact on hospital patient volume, but may save lives of STEMI patients that otherwise would have to be transferred from a receiving hospital', without cardiac catheterization capability to one with that capability. The attached report describes the Contra Costa EMS STEMI program in greater detail. Page 2 CONTRA COSTA HEALTH SERVICES July 30, 2008 Contra Costa Emergency Medical Services STEMI System Overview Executive Summary Introduction On September 8, 2008 Contra CostaHealth Services Emergency Medical Services Agency will implement a new EMS program designed for early identification and rapid transport of certain heart attack patients to one of five local hospitals with highly specialized resources for cardiac care. Paramedics, using a specialized 12-lead ECG machine to assess patients exhibiting chest pain or other signs and symptoms ofa heart attack, will be able to determine if a patient is having a ST-elevation myocardial infarction (STEMI) heart attack. Patients determined to have a STEMI are then transported to a nearby STEMI receiving center within 30 minutes transport time. In situations where transport to the nearest STEMI receiving center would exceed 30 minutes, transport will be made to a closer"hospital in accordance with existing protocols. While any hospital with the necessary facilities and staff can be designated a STEMI receiving center, the five hospitals in Contra Costa currently prepared to receive that designation include: ■ Doctors Medical Center San Pablo ■ John Muir Health Walnut Creek,Campus ■ John Muir Health Concord Campus ■ Kaiser Permanente Medical Center Walnut Creek ■ San Rainon Regional Medical,Center STEMI is a type of high-risk heart attack associated with very high mortality and morbidity. Effective treatment of this type of heart attack depends on early identification and rapid transport of these.STEMI high-risk heart attack patients to recognized receiving hospitals specializing in life-saving;cardiac interventions. These specialized hospitals are known as STEMI receiving centers. Nationally communities with a STEMI system have improved outcomes for the victims of these deadly heart attacks. Contra:Costa's STEMI system will shorten the time to definitive care for 9-1-1 responses to persons with these high-risk heart attacks. Page 1 Statement of the Problem A heart attack, or myocardial infarction (MI), occurs when blood flow to a section of the heart becomes blocked. If not treated promptly,heart tissue begins to die from lack of oxygen. In a non-STEMI heart attack, the blockage may be partial or temporary so that damage to the heart muscle may be relatively minor. A STEMI heart attack involves major blockage of blood flow to heart muscle and, if not treated promptly, in most cases leads to death. While there are a number of treatments for heart attack patients, including administration of thrombolytic agents and other drugs to dissolve clots and help restore blood flow, the most effective treatment for a STEMI heart attack is primary percutaneous;transluminal coronary angioplasty(PTCA). Angioplasty is performed in a catheterization laboratory(cath lab)by a specialized team led by a cardiologist. The procedure involves inserting a tube through an artery to the blocked coronary artery in the heart and using a balloon or other device to open the blockage. Angioplasty and other interventions are most effective when performed within 120 minutes of onset of symptoms and more effective when performed even sooner. A national objective of 90 minutes from arrival at the hospital to performance of angioplasty("door-to-balloon"time) has been recognized. However many hospitals with STEMI programs strive to achieve a 60-minute door-to-balloon time, acknowledging the delays in patient recognition of symptoms and transport time to the hospital. Not all hospitals have facilities to perform angioplasty and, even those that do, may find it difficult to assemble team members to perform the treatment within a short time frame. The goal of a STEMI system is reduce the total time from STEMI onset to angioplasty for those patients for whom angioplasty is appropriate. This is accomplished through (1) public education so that persons experiencing a heart attack call 9-1-1 promptly, (2) training and equipping EMS responders to recognize STEMI and to provide advance notification of the STEMI receiving center to begin assembling a treatment team, (3) EMS transport protocols that assure that STEMI patients are only transported to hospitals with a catheterization laboratory, and (4) a system-wide quality monitoring and improvement process. In Contra Costa County, EMS responds to over 7,000 chest pain/cardiac events per year. Of these 7,000 responses, about 5,000 involve patients showing symptoms of a possible heart attack and result in paramedic evaluation in the field using a 12-lead ECG. Based on evaluation of 12-lead ECG data over a six-month period, EMS estimates that about 100 to 150 field-identified STEMIpatients are transported by EMS annually. These are the patients that will benefit from transport to a STEMI receiving facility and early activation of the STEMI treatment team. Page 2 The national standard and timeline for treatment of a STEMI is shown below. --Fos O Moir to Nede tOn 30 minutes Patient ©ispkctt EMS on scene EMS Trans# 5 min alter; mit the Nn 8 minutes EMS to Balloon within 50 Minutes i Syilt�ltorrt opset T8 151Wh1�6 mites The American Heart Association and the American Academy of Cardiology strongly support the development of STEMI programs nationally and have launched national initiatives such as "Mission Lifeline"to promote the development of STEMI programs. Information on these initiatives can be found at americanheart.org/missionlifeline. Background: Contra Costa STEMI System Development The development of Contra Costa's STEMI system was carried out in collaboration with hospitals, first-responders, emergency ambulance services, and with the Contra Costa Emergency Medical Care Committee. By 2006, approximately 600 paramedics were trained in use of 12-lead ECGs, and ECG monitors with special STEMI diagnostic capability were placed on all emergency ambulance units and most paramedic engines. At the hospital level, all hospitals were surveyed to determine current and planned cardiac catheterization capability. All hospitals,both those with and those without cardiac catheterization capability, were invited to participate in an interdisciplinary STEML advisory group to provide input on the design and implementation of the STEMI system in Contra Costa County. This group, led by EMS Medical Director Dr. Joseph Barger, included administrators, emergency physicians, cardiologists, cardiac intervention specialists and nursing representatives. The advisory group spent many hours in developing protocols and processes to assure appropriate transition from field care to STEMI center care and to assure appropriate STEMI system monitoring and oversight. Protocols were developed to deal with such issues as longer travel times from some areas of the county, patient deterioration en route to a STEMI center, and patient preference for a more distant STEMI center. The Contra Costa STEMI system incorporates plans for the treatment and transfer of patients who may present at a non- STEMI receiving hospital. Patients who are not able to reach a STEMI receiving center can be effectively stabilized and treated with medication until they receive appropriate cardiac intervention. Page 3 This process is described in the schematic below. Hospital — - Door to Needle within 30 minute Patient 5 min afte *Dispatch EMS on scene EMS Transport symptom onsetWithin 8 minute EMS to Balloon within 90 Minutes Total Ischemic Time Within 120 minutes Call 9-1-1 i Call Fast : Not t. 5iY PCI Capable Hospital I Onset of g_1-1 EMS EMS on-scene EMS Inter-Hospital symptoms of 12-Lead ECGs Triage Dispatch Transfer STEMI STEMI Alert Plan a r d PCI Capable STEMI Receiving —rJ Center ,off _2 . STEMI Treatment Timeline 93 "Time is Muscle" F Adapted from:Antaman,ef.al.`Management of Patients i with STEMI:Executive Summary'Circulation,Oct.2007 i In April 2008 the STEMI receiving center designation process started. By August 5, 2008 five hospitals had submitted letters of intent and applications. Receiving center site visits were conducted by EMS and all applicants have met the criteria for designation. A full description of the STEMI receiving center criteria is available on our EMS website at www.cccems.org. Each STEMI receiving center must meet these criteria 24/7, 365 days a year. Simultaneously, during this period, prehospital and emergency department provider training was being conducted and will be completed by August 30, 2008. STEMI systems require a strong commitment to quality improvement and a clearly defined quality improvement plan has been developed in collaboration with appropriate stakeholders. This plan incorporates an interdisciplinary STEMI QI Advisory Council that will have oversight responsibility for the STEMI system. The initial plan is for this group to meet quarterly. Day-to-day oversight of operations for the overall STEMI system will be the responsibility of EMS Medical Director and EMS Quality Improvement (QI) Coordinator in partnership with fire and ambulance EMS QI Coordinators Page 4 and STEMI Receiving Center Program Managers. These groups will meet at regular intervals to work on process improvement opportunities. In addition to the STEMI receiving centers recognized in our own community, the implementation of a STEMI system enables Contra Costa EMS providers to utilize STEMI receiving centers in Alameda County. Alameda County STEMI facilities accessible to Contra Costa include ValleyCare Health System in Pleasanton and Oakland Summit Hospital. EMS staff have participated on Alameda County's EMS STEMI QI Advisory Council. Risks and Benefits The risks are unnecessary lives lost in our community. The American Heart Association "Conference on STEMI Programs of Care" called communities to action with following findings for those without STEMI programs.I ■ 30% of STEMI patients receive no reperfusion therapy despite availability and absence of contraindications. ■ Less that 50% of STEMI patients have treatment times within the 30-minute requirement for clot busting drug therapy. ■ Only 35% of patients treated with cardiac interventions such as clot extraction or balloon angioplasty had treatment times within the 90-minute timeframe desired for best outcomes. ■ 75% of patients drive themselves or are transported by family or friends to the hospital. ■ EMS activation of the cardiac catheterization laboratory speeds the time to diagnosis and reperfusion of the heart. Similar to trauma programs, cooperation, coordination and a highly efficient program of care that speeds the diagnosis and provides the right treatment at the right time are paramount to reducing mortality and optimizing the benefit of cardiac care. Contra Costa County will join a growing number of communities that are committed to these life-saving goals. The benefits for Contra Costa are enormous and include: Reduced mortality and morbidity for high-risk heart attack victims; Reduced delays in treatment; Enhanced collaboration between Prehospital and Emergency Department Providers. Enhanced public education support for: ■ Heart Attack signs and symptoms, ■ Early access 911 for chest pain, ■ AED & CPR; and Support of"Heart Safe Community" Initiatives currently in progress throughout the county. American Heart Association,"STEMI Provider Manual,"2008. Page 5