STEMI Systems of Care in New Jersey: interview with Bil Rosen of Capital Health EMS and Chair of the NJ Association of Paramedic Program's Education Committee
STEMI Systems of Care in New Jersey: An interview with Bil Rosen of Capital Health EMS and Chair of the NJ Association of Paramedic Programs Education Committee By David B. HiltzThere are nearly 250,000 cases of ST-Elevation Myocardial Infarction (STEMI) each year in theUnited States. Tragically, a significant number dont receive prompt reperfusion therapy, whichis critical in restoring blood flow. Additionally, 30 percent of STEMI victims dont receivereperfusion treatment at all.In the ideal STEMI system of care, stakeholders (parties with a vested interest in the treatmentof STEMI patients) including EMS providers, cardiologists, emergency physicians, hospitaladministrators to policymakers and from third-party payers to the public - share a common beliefthat quality and timely patient care is the top priority. There is a mutual respect for the criticalrole of each player in the STEMI system. Individual parties are not out to promote their own self-serving interests. Rather, everyone works together to build a consensus on what the idealSTEMI system looks like for their region, considering its unique challenges.In this interview, Bil Rosen and I will discuss STEMI systems of care, Mission: Lifeline andefforts to improve recognition, care and outcomes for Acute Coronary Syndrome (ACS) patientsin New Jersey.
HILTZ-Bil, tell me about yourself, New Jersey Association of Paramedic Programs (NJAPP) and theircollective goals in NJ.ROSEN-I have been involved in NJ EMS and EMS education since the mid 80s. I became a paramedicin 1995 and aside from per diem jobs, have been with Capital Health EMS in the Capital City ofTrenton since paramedic school. I became the NJ Association of Paramedic ProgramsEducation Committee chair in 2001. As an association, we represent all of the NJ Mobile Intensive Care Units (MICU), we have seats, voices and votes on the NJ EMS Council and the MICU Advisory Committee, as well as on two NJ legislative committees. We lobby for EMS Legislation and recommend actions that affect MICUs across the state. We promote, develop and maintain standards of operation, practice, education and ethics for the paramedic profession.HILTZ-The State of New Jersey conducted a study http://www.nj.gov/health/ems/emsreport.shtml toassess its Emergency Medical Services (EMS) system back in 2006. This study was mandatedby the New Jersey State Legislature to evaluate the current EMS system and determine shortand long term needs. The study outlined over 50 recommendations for New Jersey to consider.Could you tell us a little about how the study is driving systems change and NJAPPs role in thatprocess?ROSEN-As an ALS system, we received a pretty decent review. As quoted from the study report "NewJersey’s ALS system provides excellent clinical care by well-trained paramedics and an activecadre of physicians who provide medical oversight." However, the fiscal, dispatch and BLSissues affect us every day.NJAPP was identified as a major player in the focus groups and evaluations. As anassociation, we lobby the government to consider and act on our recommendations. Werepresent all MICU agencies in the state and although some disagreements may occur, ourrecommendations and association opinions represent the consensus of the states MICUprograms. Having a seat on legislative committees makes our voice heard.
NJAPPs position is that improvement of the overall system is needed and based on the yearsof experience and knowledge of our members and constituents, and we truly believe that wehave some sound recommendations. They originate from research and best practices fromacross the state and nation. We want the entire system to work well and believe the citizensand visitors of our great state deserve the best prehospital care there is to offer.The NJAPP education committee works closely with the New Jersey Department of Health andOffice of Emergency Medical Services to identify needs of the paramedic colleges, assessevaluators and students, and look for opportunities and methods to improve results.PREHOSPITAL ECG PROGRAMSFrom the AHA Scientific Statement: Implementation and Integration of Prehospital ECGs intoSystems of Care for Acute Coronary Syndrome Circulation 2008; 118: 1066-1079“Prehospital ECG programs have the potential to improve the way care is delivered to patientswith STEMI in the United States. Current American Heart Association guidelines recommendthat paramedics perform and evaluate a prehospital ECG routinely on patients with chest painsuspected of having STEMI (Class IIa, Level of Evidence B). 1,3 The central challenge forhealthcare providers is not to simply perform a prehospital ECG, but to use and integrate thediagnostic information from a prehospital ECG with systems of care. The potential savings intime from first medical contact to reperfusion therapy by integrating prehospital ECGs withhospital systems of care are considerable and clinically relevant. However, the gaps betweenuse under ideal circumstances and in routine practice remain substantial (Table 3). There aremany logistic barriers, including the need for increased patient use of EMS; increased EMScapacity; improved education and quality assurance for EMS providers; improved collaborationamong EMS, emergency departments, and cardiology; improved organization of hospitalsystems and providers; and improved coordination of regional hospital networks to provide theideal patient care rather than optimize market share. It also is apparent that several financialbarriers, including reimbursement and cost-effectiveness of this diagnostic technology, will needto be overcome for prehospital ECGs to gain widespread support across payors, providers, andhealthcare systems. But these barriers are not insurmountable and can be overcome withdedicated efforts to improving systems of care. Future investigations and policy measures areneeded to encourage EMS, hospitals, and healthcare systems to adopt and maximize the fullpotential of this technology, as well as monitor unintended consequences.”
ROSEN-Sure, NJ MICU regulations have standing orders that paramedics and MICNs may follow priorto contacting medical command.At this time, all of the revisions to the NJ Standing Orders have been approved and rolledout. The orders include: Administering Acetylsalicylic Acid (ASA, Aspirin), obtaining 12-leadECG, administering Nitroglycerine, establishing vascular access and reviewing patient’seligibility for thrombolytic therapy. One of the additions to this revision is to follow the 2009 NewJersey Department of Health and Senior Services’ STEMI Triage Guidelines.The NJDHSS STEMI Guidelines for MICUs provide for determining which patients may benefitfrom transportation directly to a Primary Percutaneous Coronary Intervention (PCI) hospitallicensed to perform primary percutaneous coronary intervention. Many systems are bypassingEDs for direct admission to the cath lab. We are able to send 12-lead ECGs from the field rightto the ED, Base Command and, at times, directly to the cath lab. This helps activate the CCL inan expedient manner.
The NJEMS Council and MICU Advisory Council, the 2 legislative committees I mentioned, have a BLS Subcommittee in which NJAPP participates. We are working on a BLS protocol for Aspirin administration. NJ Emergency Medical Dispatch Guide cards allow for the dispatcher to advise the person experiencing chest pain to self administer aspirin.The Centers for Medicare and Medicaid Services (CMS) measures are prettystrict with regards to aspirin administration in cardiac patients. Theguidelines for AMI patients dictate that the patient should receive ASA withinthe last 24 hours. This can be accomplished by dispatcher instruction, EMSadministration or documentation of daily home meds.So we are tackling improved response and care on all levels of emergencyresponse and provision of care.HILTZ-As I understand, NJ uses a tiered response model. Assuming this is correct, could you tell us alittle bit about how that works and what your MICU program is doing to maximize performancewhen it comes to working with area BLS agencies and responders to improve interactions,response and care?ROSEN- In New Jersey, EMS is essentially a two-tiered system. First tier is Basic Life Support (BLS) and next is Advanced Life Support (ALS). There are a few other first responders in some areas such as Fire Department or Police Department. Anyone who calls 9-1-1 for a medical complaint will get a BLS ambulance. There is a special group of more critical complaints or reported incidents that would get ALS response for example, Stroke, Chest Pain, Respiratory Distress or Significant Traumatic injury. In theory, there is a simultaneous dispatch of ALS and BLS when certain criterion is met. Other times BLS may request ALS due to assessment findings.Most MICU Programs have a robust education division. These Training Centers and instructorshold open classes to the BLS and first response agencies as well as their own staff. Most alsooffer an instructor or instructors to go to an agency to provide a course. When new policies orprotocols are developed and released, these agencies often have additional training sessionsas well. So when the STEMI protocols were approved and disseminated, many training centersbrought it out to the local BLS agencies as a training and information session. We also attendlocal and county EMS group meetings to advise EMS providers of new practices.
Additionally, there is a NJ Conference on EMS annually. Since the STEMI protocol came out, it has been a session topic for ALS and BLS personnel. This years conference will be held on November 2nd -5th.HILTZ-Education certainly seems to be a critical aspect of system improvement and overallperformance. But, before we talk about that, give us a sense for how STEMI alerts are called inNJ and what criteria is used?ROSEN-In New Jersey, there are some differences from MICU program to MICU program.Most of the programs carry Lifepak 12s with a few planning to the purchase the Lifepak 15’ssoon. There are a few Phillips monitors our there as well. The machines interpretivealgorithms are pretty accurate but we also incorporate the paramedic’s analysis as well.Occasionally the interpretive algorithms don’t work due to the nature of the business (variablessuch as moving ambulance, etc). In these cases, the interpretation is determined by theparamedic.12-lead ECGs remarkable for STEMI are usually transmitted to base command and/or receivingED and in some programs directly to the cath lab.While only a few MICU systems take patients directly to the cath lab, the time saved withprehospital 12-lead transmission and notification can shave critical minutes off of the Door toTherapy time.In 2009, the NJ Department of Health and Senior Services, Office of EMS, our regulatory bodypublished the NJ STEMI Triage guidelines. These guidelines assist all EMS Providers withtransport decision making.
HILTZ-Bil, through the efforts of many, improvements in STEMIcare, reperfusion times and outcomes have been madeboth in New Jersey and across the U.S. Regretfully, manypatients still do not heed early warning signs, delay seekingmedical care and often drive themselves to the hospitalrather than calling 9-1-1. Additionally, delays continue tooccur, particularly in transferring patients from non-PCIcapable hospitals to those that perform artery-openingangioplasty.In a recent study, published in Circulation, researchers examined data from 2,034 STEMIpatients transferred from 31 local non-PCI hospitals in Minnesota and Wisconsin from March2003 to December 2009. In this study, they found that 34.2 percent of patients experienced adelay in total treatment time, and the study found delays most frequently occurred at the referralhospital (64 percent), followed by the PCI center (15.7 percent) and during transport (12.6percent).The issue around symptom recognition and 9-1-1 activation are beyond the scope of ourdiscussion today but could you describe how transfers from referral hospitals to those with PCIcapability are handled in the NJ system and what measures are being taken, if any to improvetime to reperfusion for these patients?ROSEN-That is a great question, David. Transfers from non PCI centers to more appropriate facilitiesoccur through Specialty Care Transport Units (SCTU). Hospitals have agreements and/orcontracts with SCTUs either hospital owned and operated commercial or MICU run. SCTUshave a separate set of regulations (NJAC 8:41 subchapter 10-A sending health care facility mayrequest a patient to be transferred according to N.J.A.C. 8:43G-12.2(c) and the Federalregulations at 42 C.F.R. 489.24.).The SCTUs are usually pretty close and ready to move at a moments notice with a dedicatedunit. This is the easy part and typically keeps times to a minimum. The tougher part is getting the patient directly to the PCI center without going elsewhere first. Many citizens do not recognize or even deny having ACS symptoms and either delay arrival to the hospital or go to the wrong one. IF EMS is involved, the 12-lead assists with STEMI recognition as we have discussed and the destination is more appropriate.
What we need to do is educate the public. They need to have early recognition and activateEMS. AS EMS and Hospital Agencies, we need to promote prevention and recognition and theentire lay person chain of survival. The Fire Service has done a great job of this with fireprevention (This month is Fire Prevention Month!). This is probably the best way to improvetime to reperfusion. The Hospital transfer/transport system is pretty well designed. The issue iseverything leading up to this.HILTZ-Bil, it certainly appears that NJ isactively implementing the currentAHA recommendations for an idealsystem for EMS and EDs including:“standardized point of entry protocols(created by state-based coalitions ofEMS personnel, emergency physiciansand cardiologists, and supported bypayers and administrators) wouldestablish which patients aretransported to the nearest hospitaland which patients are transported tothe nearest STEMI-Receiving hospital.This will be based in part on theacquisition, interpretation andtransmission of a pre-hospital 12-lead NJ HOSPITAL MAPelectrocardiogram (ECG).”Knowing that EMS education plays a strong role in supporting early reperfusion, what do youlook for as an ideal educational program for preparing MICPs and MICNs to evaluate andassess ACS patients, acquire and interpret 12 lead ECGs, and determine an appropriate pointof entry, potentially diverting from nearby hospitals to those who are recognized as beingcapable of emergent PCI?ROSEN-Education needs to be a blend of delivery models. EMS professionals all learn differently andtime is always a factor.I do see a real benefit to having some classroom time. Face- to- Face interaction is importantas is the ability to ask questions in real-time and to discuss and clarify issues in person.Additionally, protocols are easier to explain and discuss in a classroom or round-table, peerreview type of session. Some providers will have a real hard time accepting the fact ofbypassing the closest hospital. We saw this when trauma centers first popped up. But with theright education, this is second nature now. Conferences are great opportunities to not onlylearn but to also network with peers from all over the country or world. Mass gatherings of EMSproviders also afford us the opportunity to compare and contrast protocols.
However, I think there is a huge value in distance and distributive education such as web basedor video/DVD based programs. With the schedules we all keep, it is often difficult to findenough downtime or "spare" time to attend a classroom for every educational opportunity.What I liked about the AHA Rapid STEMI ID was the opportunity to have a self paced programthat could be stopped and started at will. This program also afforded the learner some practicalapplications with the interpretation of 12-lead ECGs. This gave an online course a practicalapplication. All NJ Paramedics, MICNs and Paramedic students were afforded this course forfree based on an anonymous contributor to the system.HILTZ-For the benefit of others, Learn:™ Rapid STEMI ID is a self-paced course intended to prepareindividuals like paramedics to evaluate and assess victims with potential symptoms ofmyocardial infarction, interpret their ECG for signs of STEMI, as well as activate a system ofcare for rapid reperfusion of an occluded coronary artery.This course is web-based and supports the American Heart Association’s Mission: Lifeline™, anational initiative to advance the systems of care for patients with STEMI and features narratedlessons, animated graphics, interactive mini-games, and self-study cards. Those whosuccessfully pass the cognitive and ECG recognition post-course tests can receive a completioncertificate and are eligible for CE credits.In addition to offering a convenient, flexible means to improving STEMI identification andtraining, Learn: Rapid STEMI ID also provides learners with access to course for 12 monthsfollowing initial activation, allowing for at-will and as needed refresher options.Based on your experience and what you have heard from your peers at other programs, howwas Learn:™ Rapid STEMI ID received by MICPs and MICNs in NJ?ROSEN-As a group, we have found this education program very valuable and well put together. Many ofthe paramedics with whom I spoke felt that the courseware was effective, was a great class andpresented very useful information. For some, it was a true learning experience, others a greatrefresher. Together with the new NJ Statewide STEMI Guidelines, I think there will be, oralready has been a huge improvement in total STEMI recognition and care.HILTZ-Well, I am pleased to hear how well the program was received by the paramedics and mobileintensive care nurses in the NJ system. Given the large number of MICPs and MICNs in NewJersey, there must have been some big challenges in delivering the program. Could youdescribe how course delivery was accomplished?
ROSEN-That’s an understatement! From a regulatory stand point, even though the Department ofhealth co sponsored this, they werent able to mandate it. Therefore, it was up to the MICUprogram Educators to administer, track and assure completion of the course. Some programspaid their employees and others didn’t. There really was no way to standardize this.The Online Key Manager (OKM) was a fantastictool. It tracks all those who were assigned to thecourse and broke down into who started,completed and passed or failed. I was able toprint certificates to an adobe PDF file and save inmy employee’s electronic folders.Another challenge was tracking those who work formultiple MICU programs. It was up to us aseducators to assist each other and reduceduplicate course assignments. We partially reliedupon the paramedics to let us know that they weregiven a key code by someone else. Still, there are a few who have not started or completed this course. There really is no way to force them to do so. But I think a majority have successfully completed the course and are happy with both the program and the results. We extended the training out to all paramedic students as well. These students were added to and tracked by the MICU program that sponsored them. This lessened the burden on a single school and alleviated the need to have them sign up as a site on OKM.We can all teach 12-lead courses in house and our staff can attend different courses around theconference circuit. But to have a standardized process where all ALS folks can take theidentical class is a great way to accomplish continuity and standardization. I think the RapidSTEMI ID program was a great way to get all ALS providers on the same page with STEMIcare.HILTZ-Well, based on your remarks, it sounds like the Online Key Manager made your life and workeasier, and I am not at all surprised. When we set up the effort, I felt that providing the OKMwould be instrumental to streamlining and improving record keeping, facilitate ongoingcommunication with your MICPs/MICNs, and enable better overall training management.Again, for the benefit of our readers, the OKM was used by yours and other MICU programs toassign and distribute keys, send e-mail reminders, reassign lost or unused keys, monitorcompletion status, as well as create and print reports.
It has been my pleasure to have worked with you on this effort and article, as well as the manyproductive discussions we have had on this subject.Do you have any closing remarks or thoughts you would like to share, Bil?ROSEN-David, it has been a pleasure working with you. Thanks go to the American Heart Associationand Foundation who afforded this program to NJs Paramedics and MICNs. Also, to the Clinicalfolks of NJs MICU programs for sticking together and managing their programs use of thiscourse. Part of the reason NJ MICUs have been so highly rated and recognized is thecohesiveness of the program administrators and educators. As chairman of the educationcommittee, I commend all of the educators who make up the group and who do all of the worknot just for their program but for the education and enrichment of NJs entire EMS community. Iwould also commend the NJ Department of Health and Senior Services Office of EmergencyMedical Services for working with NJAPP and the Mobile Intensive Care Advisory Council(MAC), facilitating our recommendations and assisting with the continuous improvement in NewJerseys Emergency Medical Service System. Lastly, but most importantly, I thank all of theNew Jersey Paramedics, MICNs and Paramedic Students who dedicated the time tocompleting this program. Without them, the system would not exist. The ALS providers of theGreat Garden State are truly committed to caring for their patients in the best possible way.SUMMARY-Hats off to the New Jersey Association of Paramedic Programs (NJAPP) and their support ofMission: Lifeline, a national initiative by the American Heart Association that recognizes leaderswho are helping improve the response and treatment of ST-elevation myocardial infarction(STEMI), the most serious and deadly type of heart attack.By joining Mission Lifeline, NJAPP and their member agencies are committing to facilitate asystem of evidence-based care, and helping to save the lives and preserve the quality of life ofSTEMI patients.Every year, countless citizens suffer a STEMI, caused by the sudden, total blockage of acoronary artery and we know that unless reperfusion is quickly restored, a victim’s health andlife are at serious risk. With the proper equipment, strategies and actions, healthcare providerscan quickly recognize and treat a STEMI to reduce heart damage, but it calls for a fast andsystematic response on many fronts.Through partnerships, we can develop systems of care and strategies aimed at quicklyactivating the appropriate chain of events critical to treating STEMI victims and achieving thevery best outcomes possible. It is recommended that STEMI patients receive PCI procedureswithin 90 minutes of having STEMI. Regretfully, a significant number don’t receive prompt,recommended therapy to restore blood flow and 30 percent of STEMI victims dont receivereperfusion treatment at all.The entire NJ healthcare system should be recognized and commended for their collectiveefforts to improve STEMI care. Additionally, NJAPP and their agencies are to be congratulatedfor successfully and efficiently delivering standardized STEMI education to nearly all of thepracticing MICPs and MICNs across the entire state of New Jersey.
Many thanks to Bil Rosen and all countless others who endeavor, every day, to improveresponse, care, systems, and outcomes for patients. I, along with the American HeartAssociation continue to acknowledge and share in the EMS community’s goal of improvingpatient outcomes through the development and delivery of the highest quality prehospital careavailable.We are grateful for the EMS community’s steadfast dedication tocompassionate and competent care for people in need, anywhere,and under any conditions. You make the world a safer and betterplace every day.CONNECTING WITH BIL ROSENBil Rosen, BA, NREMT-PClinical Coordinator at Capital Health EMS609email@example.com://www.chsems.orgABOUT DAVE HILTZDavid has over 25 years experience in the healthcare industry with a special interest inemergency medicine and resuscitation. His current full time occupation is with the AmericanHeart Association’s Emergency Cardiovascular Care Program-Public Safety Team. David is amember of the Massachusetts Department of Public Health’s Emergency Medical Care AdvisoryBoard and Vice Chair of the Board’s EMS Education and Public Education and InformationResource Committees.David is also known for his work with the HEARTSafe Community concept and was recognizedby JEMS and Physio-Control as an Innovator in EMS. Visit David on Facebook or email him firstname.lastname@example.org .