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  • In North Carolina we have 3 times more deaths occurring due to AMI than MVAs. However, our response to STEMI (the artery is closed down and death of myocardium/life is imminent) is grossly lacking behind our trauma response.
  • Building upon the Duke success, the 2004 president of the NC ACC, Joseph Babb (ECU, Pitt County Cath Lab Director), Chris Granger, and Jamie Jollis obtained a million dollar grant from Blue Cross/Blue Shield of NC to take the project to 5 additional centers. In stead of 5 centers, 5 regions and 10 PCI centers were approached. The centers were asked to co-fund regional coordinators to lead the effort along with regional steering committees. Although, this delayed the start----created buy-in from PCI administrations and ultimately was a success.
  • Building upon the Duke success, the 2004 president of the NC ACC, Joseph Babb (ECU, Pitt County Cath Lab Director), Chris Granger, and Jamie Jollis obtained a million dollar grant from Blue Cross/Blue Shield of NC to take the project to 5 additional centers. In stead of 5 centers, 5 regions and 10 PCI centers were approached. The centers were asked to co-fund regional coordinators to lead the effort along with regional steering committees. Although, this delayed the start----created buy-in from PCI administrations and ultimately was a success.
  • What is the point of mentioning the database inconsistencies? Define ACTION/ Code STEMI data
  • What is the point of mentioning the database inconsistencies? Define ACTION/ Code STEMI data
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    1. 1. R eperfusion of A cute Myocardial Infarction in C arolina E mergency Departments ( RACE ) Project
    2. 2. <ul><li>Death from heart attack is 3 times more common than death from motor vehicle crashes. </li></ul><ul><li>Rapid reperfusion is the most important way to improve early survival. </li></ul><ul><ul><li>rapid PCI (or fibrinolysis if not available) </li></ul></ul><ul><li>Before the RACE project, 1 st door-to-balloon for patients transferred for PCI from non-PCI center was nearly 3 hours. </li></ul><ul><li>Lack of “systems” and coordination to rapidly and effectively treat heart attacks. </li></ul>The Problem
    3. 3. Background <ul><li>Transfer for PCI shown to be possible and effective in Europe </li></ul><ul><li>While RACE project was ongoing, we collaborated with other programs (Minneapolis, Boston, Maine, Los Angeles, D2B) </li></ul><ul><li>None in US had reported a comprehensive approach involving multiple PCI centers and multiple EMS systems in a statewide program </li></ul><ul><li>We hypothesized that such an approach could provide an umbrella to manage barriers of competing practices and hospitals and encourage broad participation </li></ul>
    4. 4. RACE Objectives <ul><li>Establish a state-wide system for reperfusion, as exits for trauma care, to overcome systematic barriers to: </li></ul><ul><ul><ul><li>1) Increase speed of reperfusion </li></ul></ul></ul><ul><ul><ul><li>2) Increase reperfusion rate </li></ul></ul></ul>Organize regions Baseline data Intervention Post data 2005 Q3 2005 2006 Q1 2007
    5. 5. 10 PCI centers 16 Transfer for PCI 28 Lytics 11 Mixed RACE Centers and Regions 65 hospitals (10 PCI, 55 non PCI) Asheville Winston-Salem Durham-Chapel Hill- Greensboro Charlotte East Carolina Each non-PCI center was assessed for reperfusion designation based on resources, transfer ability, and transfer time to PCI center
    6. 6. RACE Participating Hospitals by Region 5 Regions, 65 hospitals <ul><li>Asheville: </li></ul><ul><ul><li>Mission Hospitals, Asheville (PCI) </li></ul></ul><ul><ul><li>Angel Medical Center, Franklin </li></ul></ul><ul><ul><li>Harris Regional Hospital, Sylva </li></ul></ul><ul><ul><li>Haywood Regional Medical Center, Waynesville </li></ul></ul><ul><ul><li>Highlands-Cashiers, Highlands </li></ul></ul><ul><ul><li>Mc Dowell Hospital, Marion </li></ul></ul><ul><ul><li>Murphy Medical Center, Murphy </li></ul></ul><ul><ul><li>Pardee Hospital, Hendersonville </li></ul></ul><ul><ul><li>Park Ridge Hospital, Fletcher </li></ul></ul><ul><ul><li>Rutherford Hospital, Rutherfordton </li></ul></ul><ul><ul><li>Spruce Pine Community Hospital, Spruce Pine </li></ul></ul><ul><ul><li>St. Luke's Hospital, Columbus </li></ul></ul><ul><ul><li>Transylvania Community Hospital, Brevard </li></ul></ul><ul><li>Charlotte: </li></ul><ul><ul><li>Carolinas Medical Center (CMC) (PCI) </li></ul></ul><ul><ul><li>CMC-Mercy (PCI) </li></ul></ul><ul><ul><li>Presbyterian Hospital (PCI), Charlotte </li></ul></ul><ul><ul><li>CMC- Lincoln, Lincolnton </li></ul></ul><ul><ul><li>CMC- Pineville, Charlotte </li></ul></ul><ul><ul><li>CMC-Union, Monroe </li></ul></ul><ul><ul><li>CMC-University, Charlotte </li></ul></ul><ul><ul><li>Cleveland Medical Center, Shelby </li></ul></ul><ul><ul><li>Lake Norman Regional Hospital, Mooresville </li></ul></ul><ul><ul><li>Presbyterian Hospital, Huntersville </li></ul></ul><ul><ul><li>Presbyterian Hospital, Matthews </li></ul></ul><ul><ul><li>Rowan Regional Medical Center, Salisbury </li></ul></ul><ul><li>Durham-Greensboro-Chapel-Hill: </li></ul><ul><ul><li>Duke University Medical Center, Durham (PCI) </li></ul></ul><ul><ul><li>Moses H. Cone Memorial Hospital, Greensboro (PCI) </li></ul></ul><ul><ul><li>North Carolina Memorial Hospital, Chapel-Hill (PCI) </li></ul></ul><ul><ul><li>Alamance Regional Medical Center, Burlington </li></ul></ul><ul><ul><li>Annie Penn Hospital, Reidsville </li></ul></ul><ul><ul><li>Chatham Hospital, Siler City </li></ul></ul><ul><ul><li>Franklin Regional Medical Center, Louisburg </li></ul></ul><ul><ul><li>Maria Parham Medical Center, Henderson </li></ul></ul><ul><li>Durham-Greensboro-Chapel-Hill (continued) </li></ul><ul><ul><li>Morehead Memorial Hospital, Eden </li></ul></ul><ul><ul><li>Person Memorial Hospital, Roxboro </li></ul></ul><ul><ul><li>Randolph Hospital, Asheboro </li></ul></ul><ul><ul><li>Sampson Regional Medical Center, Clinton </li></ul></ul><ul><ul><li>Wesley Long Community Hospital, Greensboro </li></ul></ul><ul><li>East North Carolina: </li></ul><ul><ul><li>Pitt County Memorial Hospital, Greenville (PCI) </li></ul></ul><ul><ul><li>Beaufort County Hospital, Washington </li></ul></ul><ul><ul><li>Bertie Memorial Hospital, Windsor </li></ul></ul><ul><ul><li>Chowan Hospital, Edenton </li></ul></ul><ul><ul><li>Duplin General Hospital, Kenansville </li></ul></ul><ul><ul><li>Halifax Regional Medical Center, Roanoke Rapids </li></ul></ul><ul><ul><li>Heritage Hospital, Tarboro </li></ul></ul><ul><ul><li>Lenoir Memorial Hospital, Kinston </li></ul></ul><ul><ul><li>Martin General Hospital, Williamston </li></ul></ul><ul><ul><li>Nash General Hospital, Rocky Mount </li></ul></ul><ul><ul><li>Onslow Memorial, Jacksonville </li></ul></ul><ul><ul><li>Our Community Hospital, Scotland Neck </li></ul></ul><ul><ul><li>Pungo District Hospital, Belhaven </li></ul></ul><ul><ul><li>Roanoke-Chowan hospital, Ahoskie </li></ul></ul><ul><ul><li>Washington County Hospital, Plymouth </li></ul></ul><ul><li>Winston-Salem: </li></ul><ul><ul><li>Forsyth Medical Center, Winston-Salem (PCI) </li></ul></ul><ul><ul><li>Wake Forest University/Baptist Medical Center, Winston-Salem (PCI) </li></ul></ul><ul><ul><li>Alleghany Memorial Hospital, Sparta </li></ul></ul><ul><ul><li>Ashe Memorial Hospital, Jefferson </li></ul></ul><ul><ul><li>Davis Regional Medical Center, Statesville </li></ul></ul><ul><ul><li>Hugh Chatham Memorial Hospital, Elkin </li></ul></ul><ul><ul><li>Iredell Memorial Hospital, Statesville </li></ul></ul><ul><ul><li>Northern Hospital of Surry County, Mount Airy </li></ul></ul><ul><ul><li>Lexington Memorial Hospital, Lexington </li></ul></ul><ul><ul><li>Thomasville Medical Center, Thomasville </li></ul></ul><ul><ul><li>Twin County Regional Hospital, Galax </li></ul></ul><ul><ul><li>Wilkes Regional Medical Center, N. Wilkesboro </li></ul></ul>
    7. 7. Organization <ul><li>Supported by grant from Blue Cross Blue Shield of North Carolina </li></ul><ul><li>Nurse coordinator and steering committee (EMS, ED, nursing, hospital administration, QI experts, cardiology) for each region </li></ul><ul><li>Buy-in from all PCI centers in each region </li></ul><ul><ul><li>Co-funded RACE Regional Coordinators </li></ul></ul><ul><li>Co-sponsored by NC Chapter of ACC with focus on the patient by promoting ACC/AHA STEMI guidelines </li></ul><ul><li>Data systems support from Genentech </li></ul>
    8. 8. Organization <ul><ul><li>Physician leaders </li></ul></ul><ul><ul><li>(continued) </li></ul></ul><ul><ul><li>Joseph Shiber </li></ul></ul><ul><ul><li>Greg Tarleton </li></ul></ul><ul><ul><li>F. Scott Valeri </li></ul></ul><ul><ul><li>Bradley Watling </li></ul></ul><ul><ul><li>Hadley Wilson </li></ul></ul><ul><ul><li>Oversight Board </li></ul></ul><ul><ul><li>Robert M. Califf </li></ul></ul><ul><ul><li>Pamela Douglas </li></ul></ul><ul><ul><li>Robert Harris </li></ul></ul><ul><ul><li>Greg Mears </li></ul></ul><ul><ul><li>William O’Neill </li></ul></ul><ul><ul><li>Regional Coordinators </li></ul></ul><ul><ul><li>Marla Jordan, RN </li></ul></ul><ul><ul><li>Lourdes Lorenz, RN, MSN </li></ul></ul><ul><ul><li>Lisa Monk, RN, MSN </li></ul></ul><ul><ul><li>Mary Printz, RN, FNP-C </li></ul></ul><ul><ul><li>Stephanie Starling-Edwards, RN </li></ul></ul><ul><ul><li>Jenny Underwood, RN </li></ul></ul><ul><ul><li>Central Steering Committee and Statistics </li></ul></ul><ul><ul><li>James Jollis, MD </li></ul></ul><ul><ul><li>Chris Granger, MD </li></ul></ul><ul><ul><li>Mayme Roettig, RN, MSN </li></ul></ul><ul><ul><li>Kevin Anstrom, PhD </li></ul></ul><ul><ul><li>Physician leaders </li></ul></ul><ul><ul><li>Akinyele Aluko </li></ul></ul><ul><ul><li>Robert Applegate </li></ul></ul><ul><ul><li>Joseph Babb </li></ul></ul><ul><ul><li>Peter Berger </li></ul></ul><ul><ul><li>David Bohle </li></ul></ul><ul><ul><li>Sidney Fletcher </li></ul></ul><ul><ul><li>J. Lee Garvey </li></ul></ul><ul><ul><li>Robert Hathaway </li></ul></ul><ul><ul><li>James Hoekstra </li></ul></ul><ul><ul><li>Robert Kelly </li></ul></ul><ul><ul><li>William Maddox </li></ul></ul>
    9. 9. RACE Interventions <ul><li>OPERATIONS MANUAL </li></ul><ul><li>Optimal system specifications by point of care </li></ul><ul><ul><li>EMS </li></ul></ul><ul><ul><li>Non-PCI and PCI ED </li></ul></ul><ul><ul><li>Transfer </li></ul></ul><ul><ul><li>Catheterization lab </li></ul></ul><ul><ul><li>Other system issues – payers, regulations </li></ul></ul><ul><ul><li>Choice of PCI or lytic reperfusion regimens </li></ul></ul>available at www.nccacc.org
    10. 10. RACE Interventions <ul><li>Focus on SYSTEMATIC BARRIERS to care </li></ul><ul><li>STEMI team – hospital administration, ED, EMS, nursing, cardiology </li></ul><ul><li>Prespecified reperfusion plan for hospital and region </li></ul><ul><li>Prehospital ECGs, interpretation, and earliest activation </li></ul><ul><li>Emergency physician (or paramedic) able to activate the cath lab </li></ul><ul><li>Intense education with focus on EMS and EDs </li></ul>
    11. 11. RACE Interventions <ul><li>PCI Hospitals </li></ul><ul><ul><li>Single number cath lab activation </li></ul></ul><ul><ul><li>Accept all STEMI patients regardless of bed availability </li></ul></ul><ul><ul><li>Ongoing QI and data feedback– NRMI database </li></ul></ul><ul><ul><li>RACE Regional Coordinator </li></ul></ul><ul><ul><ul><li>Responsible for improving process in every hospital - EMS system in the region </li></ul></ul></ul>
    12. 12. Data Collection Distinct but overlapping databases <ul><li>Non-PCI hospital data </li></ul><ul><ul><li>Regional coordinators abstracted data from (10) consecutive charts from STEMI reperfusion candidates in non-PCI EDs </li></ul></ul><ul><ul><li>Emergency Department data only </li></ul></ul><ul><ul><li>Feedback to all stakeholders </li></ul></ul><ul><ul><li>Not linked to PCI hospital data to satisfy HIPPA restrictions </li></ul></ul><ul><li>PCI hospital data </li></ul><ul><ul><li>RACE NRMI 5 system report </li></ul></ul>
    13. 13. Patient Flow Diagram 1164 patients at PCI Centers and 925 at non-PCI centers Pre-intervention Post-intervention July to Sept 2005 Jan to Mar 2007 n= 579 n= 585 10 PCI Centers presented directly transferred from non-PCI 61% presented directly transferred from non-PCI 39% 53% 47% 55 Non-PCI Centers Pre-intervention Post-intervention Jul 05 to Mar 06 Jan to Mar 2007 n= 518 n= 407 lytic treated transferred for 1 ° PCI 15% 40% 45% no reperfusion lytic treated transferred for 1 ° PCI 15% 46% 39% no reperfusion
    14. 14. RACE results Patient features PCI hospital Non-PCI hospital Pre Post Pre Post n 579 585 518 407 Age (years, median) 60 61 62 61 ≥ 75 years 20% 19% 22% 20% Female 33% 28% 33% 30% Chest pain at presentation 93% 96% 90% 89% Killip III/IV 4.7% 4.3% 2.7% 5.5% Initial reperfusion strategy No reperfusion 23% 11% 15% 15% Fibrinolysis 28% 25% 45% 39% Primary PCI 48% 63% 40% 46% CABG 1.7% 1.5% -- --
    15. 15. RACE results Arrival and transfer features PCI hospital Non-PCI hospital Pre Post Pre Post n 579 585 518 407 Arrival mode Self-transport 11% 12% 57% 56% Ambulance 71% 63% 42% 44% Helicopter 16% 21% -- -- Pre-hosp ECG 41% 61% 38% 43% Transferred from another hosp 61% 53% -- -- Transferred to a PCI hosp -- -- 92% 95% Transfer mode EMS ground 40% 43% Critical care transport 34% 24% Helicopter 25% 43% AMI Hotline used 32% 85%
    16. 16. RACE results PCI hospital interventions 10 total hospitals
    17. 17. RACE results PCI hospital interventions 10 total hospitals
    18. 18. RACE results Non-PCI hospital interventions 55 total hospitals
    19. 19. RACE results Non-PCI hospital interventions 55 total hospitals
    20. 20. RACE results Non-reperfusion rates % without reperfusion P<0.001
    21. 21. RACE results PCI hospitals: Door to device times P<0.001* P<0.001 median times in minutes P<0.001 P=0.01 * Remained significant in analysis accounting for clustering
    22. 22. RACE results Non-PCI hospitals: Reperfusion times P<0.001* P<0.001 median times in minutes P=0.002 * Remained significant in analysis accounting for clustering
    23. 23. RACE results Reperfusion rates % of patients PCI centers Direct presenters Non-PCI centers P<0.001 P<0.001
    24. 24. RACE results vs secular trends: PCI hospitals Median time in minutes *NRMI participating hospitals 7 143 150 National* 11 74 85 RACE 7 81 88 National* Non transfer 37 128 165 RACE Transfer Change Post Pre
    25. 25. Clinical outcomes *To show a 0.5% reduction (7.0 to 6.5%) with  0.05, 80% power would take 80,000 randomized patients 45 (7.7%) 18 (3.1%) 1 (0.2%) 44 (7.5%) Post (n=585) 0.88 0.33 0.06 0.38 p 46 (7.9%) Cardiogenic shock (n, (%)) 24 (4.2%) Cardiac arrest (n, (%)) 6 (1.0%) Stroke (n, (%)) 36 (6.2%) Death* (n, (%)) Pre (n=579)
    26. 26. Summary and Conclusions <ul><li>RACE represents the largest regional STEMI reperfusion system in the United States. </li></ul><ul><li>We focused on moving care forward: enabling EMS to diagnose and ED personnel to initiate treatment, with improved communication, integration, and data feedback. </li></ul><ul><li>All times – door-to-balloon at PCI centers, door-in to door out in non-PCI centers, 1 st door-to-balloon in transfer patients, and door-to-needle for fibrinolysis – were significantly improved. </li></ul><ul><li>Improved application of reperfusion care on a broad scale is possible and should be a high national priority. </li></ul>
    27. 27. Now available online at http://jama.ama-assn.org/

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