Mission: Lifeline® EMS 2016 Recognition Webinar Transcript
December 2, 2015
Paul:Welcome and thank you all for standing by. At this time, all of our participants are in a listen only mode. For the Q&A session of today's call, if you would like to ask a question, please press * followed by the number 1. This call is also being recorded. If you have any objections, you may disconnect at this time. Now, I'm going to go over to your host, Mr. David Travis. Sir, you may now begin.
David Travis:Well thank you very much Paul, and on behalf of the American Heart Association and Mission Lifeline, I want to thank you all for joining us on today's webinar on Mission: Lifeline EMS Recognition Program for 2016.
My name is David Travis and I am the EMS manager for Mission Lifeline and we have some other panelists who are joining us today, Dr. Lee Garvey, who is a professor of emergency medicine from the Carolina Medical Center. Alex Kuhn, who is also with the American Heart Associate, is the Senior Director of Quality and Systems Improvement. Ben Leonard, also with the American Heart Association, the EMS Director in Mission Lifeline, Quality and Improvement Initiatives from Wyoming. And we have Joshua Roberts who is from Susquehanna Valley, EMS, in Pennsylvania.
Just a few points about EMS recognition. The EMS Recognition Application period will open on January 1st and remain open through March 31st, 2016. The EMS Recognition for 2016 will remain focused on STEMI patients. There will likely be additional measure for stroke and resuscitation in the future, but for 2016, we have just been focusing on STEMI as we did in 2015. And in fact, the criteria for achievement for 2016 remains the same as for 2015. However, we have added new optional reporting measures for this year.
So with today's webinar, Dr. Garvey will be discussing the importance of achieving First Medical Contact to device times of within 90 minutes or less. Alex Kuhn will be reviewing the EMS Recognition program overall and the criteria and the new reporting measures. Joshua Roberts will review the process his agency uses for gathering necessary data. And Ben Leonard will review the spreadsheet available for all agencies to use. And then we will have a period of open discussions and questions as time permits.
So without further due, I'll introduce Dr. Lee Garvey. He is a professor of emergency medicine from Carolina's Medical Center, based out of Charlotte, North Carolina and a very long time Mission Lifeline volunteer. Thank you Dr. Garvey.
Dr. Lee Garvey:Well thanks David. Welcome everyone to this webinar. I am delighted to be a participant and look forward to all of the good work you are doing and the recognition that is so well deserved. If we can help facilitate that today and answer any questions. That's my number one goal.
If we could move to the background slide where the STEMI Point of Entry Protocol please.
I think I could spend my entire allocated 15 minutes on this slide alone. I think it is one of the real punch lines and I would call attention to this anytime you're working on STEMI protocols. I think it really helps define where the important parts of the process are and how they are integrated together, how they overlap and our intent is to work in parallel, not sequentially or in serial processing. If you notice the ambulance is at the key center of of this diagram and we are going to focus a lot on the ERS role in providing Excellent care to STEMI patients, focusing on first medical contact and integrating with the hospital's reprefusion strategy.
Next slide please.
I think it's a very important slide here as well. To call your attention to the definitions that are used for the Mission Lifeline ERS Recognition strategy. Highlighted in red is the definition of first medical contact is the time of eye to eye contact between the STEMI patient and the first caregiver. So, if that caregiver is the first responder, under EMS, paramedic, physician at clinic and documented, that is what we use first. We'd like to know if its the first responder, whether or not, they are able to perform a 12 lead ECG, but that is the definition that we will be using for this program of ERS recognition.
Next slide please.
I think that just drawing your attention to the fact that these polls, community initiatives are now part of the guidelines published by the American Heart Association and the American College of Cardiology. It now acknowledges and it emphasizes how EMS is central to the community's performance on this critical measure. Even in the guidelines, it states that it can be. This performance can be facilitated by participating in programs such as Mission Lifeline and the Door to Balloon alliance and specifically wants to acknowledge the EMS recognition portion of this.
Next slide.
Also emphasizes that first medical contact, as we've defined it, until device time with the system goal of 90 minutes or less. To those patients who are taken directly from their first site of care to the PCL Center that is different for transferred patients. We will speak just very briefly about that at the end of this section if we have some time.
But I think our country has adopted primarily PCL as a recommended measure of reperfusion when it can be performed in a timely manner, very very well. And a lot of hospitals are becoming very expert to the door to balloon portion of that and a lot of doors systems and community systems are really addressing how this can be established with destination protocols, integration, EMS services, and then hospital performance.
Next slide please.
I think that ... I mean, click through this a little bit, through the graphics of the fly-ins if you will. The doors to balloon, which has been such an emphasis over the last decades, almost is really solved. The door to balloon is no longer the measure that we need to watch. We are now much more focused on first medical contact to device time. How do we facilitate this? Or EMS delivered patients, just through the use of pre-hospital ECG. You can see over the years that we've been increasing our performance in these metrics as the systems have matured, more systems have been brought into the fold.
Next side please.
The slide EMS, the first medical contact to device here just outlines a few bullet points that I would like to emphasize. For the EMS component of this, it really begins with call capture, dispatch protocols response. Response times are what they are. It is a fact that it takes time to process the call, it takes some time to activate the responding, the first medical responders and or paramedics. We want to have that operated in a smooth manner as possible. That's work that you all do, and are familiar with, or not only STEMI, buT all sorts of other acute, highly acutely patients. But for the STEMI programs, the key piece of information is the pre-hospital 12 lead ECG. So having the skilled providers, being able to bring the device to the patient, acquire a 12 lead ECG, interpret that ECG in some manner, which we can talk about as well, and make a decision about the destination that is most appropriate for that STEMI patient is really key. I would say that that element is new to EMS in the last 10 or 15 years and really critical to the overall performance of STEMI systems of care.
In an effort to maximize efficiency and again use parallel processing, not serial, sequential processing, the earlier the pre-hospital providers can notify and activate the receding cath lab, the better. There is some transportation time to seeing departure until hospital arrival or if you are going directly to cath lab to cath lab arrival that we need to use. The earliest time point that communication can occur between the pre-hospital providers who have made that diagnosis based on the 12 lead ECG and the receiving facility. We want that to be able to use that time to the best advantage at the receiving facility, to accommodate the scheduling, if it's a day time event or to recruit staff and to perform the cath lab procedures if it's a after hours event. Well we do want to minimize the seen time, we don't have much influence over transportation time. So we want to maximize the systems use of that transportation time however. As introduced, I practiced emergency medicine and I am one of the strongest believers I think that these patients don't need to come to the emergency department most of the time. If we can get an accurate appraisal of the patients clinical condition, an accurate interpretation of the ECG, early activation of the cath lab team, it's very appropriate for patients to go directly to a cath lab and even bypass the emergency department.
Next slide please.
Many successful and mature STEMI systems of care have developed such protocols and are working, and Mission Lifeline is working on this actively to assist, on developing protocols where EMS patients may go directly to the cath lab and bypass the emergency department when it's appropriate. We can talk about that a little bit more in the question and answer if we have the time. Next slide does outline a little bit of the criteria for ECG acquisition. Most of these STEMI protocols in the EMS world have criteria that are somewhat similar to this. This was published actually regarding patients who present to triage and how to select patients for an immediate ECG upon arrival. I think the same applies to those patients where EMS personnel encounter them and have to decide is this a patient who needs an ECG right away. So there are some aged based criteria. 30 years old with chest pain that is not obviously traumatic or 45 years older with either chest pain or these other potential inguinal equivalents of synchope weakness, palpitations, rapid heart, difficulty breathing and so forth. I think that's a useful scheme to use and would advise adopting this in your systems if you don't already a scheme in place for that.
Next slide please.
Again, the pre-hospital 12 lead ECG is the key piece of information and the information contained in that is crucial to the timely care of the STEMI patients presenting through the pre-hospital system. We get into the discussion about how the information ... Or how the decisions are made and how the diagnosis is made. There are a lot of options that are used in various programs from paramedics performing the interpretation and read independently or some systems use the ECG machine interpretation statement generation and act on those. Many systems I think use a combination that either uses the algorithm plus paramedic confirmation or a paramedic screening of appropriate cases and transmission or either a physician reader at online medical control or at there receding facility. Some systems are trying to transmit the ECG to all the decision makers. Through email distribution systems or some other commercial distribution system so that all the decision makers have access to the ECG imaging at the first opportunity. My personal opinion is that it's necessary to institute a system that meets your local requirements and equipment and expertise but then also to do a quality management program and see how many of these are being accurately interpreted. Is there any advantage to getting a different set of eyes on that and so forth.
Next slide sort of outlines some of the work done across the state in North Carolina where we wanted to see how well we were performing on STEMI system activation. So of all those cath lab activations, we deemed about 85% of them were done appropriately. About 15% we would've considered inappropriate because the emergency department ECG was interpreted as STEMI originally and then reinterpreted as not or the EMS ECG was called STEMI and then later readers and decision makers decided it was not STEMI. Or something that is also new I think to EMS and emergency departments is considering how suitable a cath lab candidate is, this particular patient is. Generally speaking about 5% of the cath lab activations were cancelled or deemed inappropriate for each of those three red clocks of ED or EMS ECG or cath lab candidacy issues. What I am adovcating, whenever I get to work with a system is ...
The next slide please.
Is that, if there is a definite ECG STEMI diagnosis and the paramedics have confidence in that and the patient is a definite cath lab candidate then the entire system is activated immediately. If there are questions about either the ECG diagnosis or the cath lab candidacy, then a core group of individuals, whether that's the interventionalists and, or emergency physician with the EMS providers, makes decisions individually and then a decision is made whether to activate the entire system or not after there is a consultation and individualized decision making. I think a lot of systems are going to that block to activate the entire STEMI system when there is good confidence in the ECG diagnosis and the cath lab candidacy has been worked out. Certain things are in that are typical cath lab candidacy dis-qualifiers such as advanced directives indicating hospice or comfort care or non-intervention if there are other comorbidities that disqualify patients such as active hemorrhage or multiple severe system comorbidities, some of those things then may be individualized and decisions made that way.
Will you look at the next slide, which is a stacked bar graph. I wanted to just talk a little bit about how we are using this information in system use. Each of these bars represents an individual hospital and the blue bars at the bottom are the first medical contact until hospital arrival. The tan bars in the middle are from the hospital arrival until cath lab arrival and then the green bars at the top are the time intervals for cath lab arrival until device deployment. Our emphasis today is on this entire stacked bar and our intent is to use the first medical contact until device, broken down this way, so we can maximize each of those efforts and minimize the time spent. Some of the most successful programs, even high volume programs, who are able to coordinate with their EMS providers and their cath labs, are able to minimize that tan bar in the middle where patients spend very little time in the emergency department, mainly because they have been using the time of transport, seen time, and transport time in the EMS world to prep their cath lab. You'll see most of those green bars at the top, the cath lab times are pretty close on generally speaking. There's a bit more variation in the tans bars so our intent is to use the EMS time to reduce the time necessary to spend in the emergency department.
Next slide.
I just wanted to mention STEMI transfers because I know a lot of EMS agencies are evolved in that process and we focus on door in, door out times. There are lots of issues there's that are outside the EMS responsibility but some of them have to do with transfer vehicle availability and crew response times. And also integrating the care from hospital one through the EMS transport agency to hospital two and limiting barriers such as IV, infused medicines, waiting for x-rays and documentation. I think that are EMS colleagues can help a bit there but most of it is in having a system designed so that the EMS response to that first hospital is optimized.
Next slide shows again, just a stacked bar graph for individual hospitals in a system where the blue bars on the bottom are door in, door out of hospital one time, transport time is the tan bar, and the green bars at the top are the time spent from arrival at the PCI center until reperfusion or device deployment. So for transport patients with EMS issues that door in, door out and transport time are our targets.
With that I will switch to the last slide. My portion of the discussion, which I'll say is really just the background and hopefully most of it is very familiar to you. Just to kind of key it up for the rest of the presentations which are focused on specifics related to the Mission Lifeline EMS Recognition program. Again, its been my pleasure to participate in this and I look forward to the other presentations and further discussion. Thank you.
Alex Kuhn:Thank you Dr. Garvey. This is Alex Kuhn with the American Heart Association. I know many of the folks on the line have probably from from me, seen emails from me, actually may have participated the past few years in recognition. I am certainly happy that you guys continue to explore opportunity and improvement. I'm going to run through the recognition measures and some other information related to the recognition program. But I know Dave and James from the HA will hop on here later and explain that there will be other opportunities for outreach related to the measures and completing successful applications and I know that you have local Mission Lifeline or quality directors in your region that will be eager to help you submit a successful application of your interest.