Transcript for EMS Recognition Webinar 2017 - Criteria and Measures
Operator: / Welcome.Speaker 1: / Thank you for calling [inaudible 00:00:03].
Operator: / Welcome and thank you for standing by at this time. All participants will be on a listen only mode until the question and answer session of today's conference. At that time, please press star followed by the number one on your phone if you would like to ask a question and record your name at the prompt. I would now like to turn the call over to David Travis. You may begin.
David Travis: / Good afternoon and on behalf of the American Heart Association and the Mission Lifeline program, I'd like to welcome you to our EMS Recognition webinar. This is the first webinar we're having regarding the 2017 EMS Recognition program cycle and we will have other webinars to be determined in the future. Our objectives today are to provide you with some rationale regarding the importance of reducing first medical contacts to device time and particularly EMS’ role in that and to provide you with an overview of the 2017 Mission Lifeline EMS Recognition criteria and the new reporting measures and to also provide you with an overview of the data collection worksheet which has been completely reworked for this year and then finally we will answer any questions you may have about the Mission Lifeline EMS Recognition program.
Today’s speakers are; Dr. Lee Garvey, who is a professor of emergency medicine with Carolinas Healthcare System and he is a longtime AHA and Mission Lifeline volunteer and is also now the chair of the Mission Lifeline Steering Committee. We also have Ben Leonard who is an AHA EMS director for quality systems improvement with our Mid-West affiliate and myself, I'm the EMS program manager and work out of the National Center. With that I will turn over the presentation to Dr. Garvey who will be going through a few slides and speaking about first medical contact to device time and the EMS role and Dr. Garvey, please let me know when you have control.
Dr. Lee Garvey: / Okay thank you. As this is switching over, looks like that's the end of my presentation. I don't know how I can get back up there.
David Travis: / [Inaudible 00:02:48] with the arrow to the left.
Dr. Lee Garvey: / Yeah, let me try that.
David Travis: / There you go.
Dr. Lee Garvey: / Here we go, all right. Well, thank you all and it's my pleasure to participate in this discussion especially focusing on the EMS Recognition for 2017 and I'd like to just draw attention to the role that EMS plays in reducing first medical contact to device time. It's the key role, I think, in this whole scenario of STEMI patient care. This slide is probably very familiar to almost everybody. I really like it as an anchor for these discussions. It's from the Mission Lifeline and some of the guideline work I think summarized here and it really focuses appropriately on the interface between the patient and EMS and then EMS and the hospitals or care facilities. It's really a central illustration I think, of the role that EMS plays and how key EMS professionals are in interacting with both the patients and the receiving facilities.
If ever there is a question that comes up about the Mission Lifeline and STEMI system of care, this is the slide I would refer to as to kind of get an anchoring point. First of all, first medical contact is defined as the time of eye to eye between the STEMI patient and the first caregiver and so we typically think of that as EMS personnel. It may however be a medical first responder, a physician at a clinic and so forth but the vast majority of cases and in the usual systems, that's the EMS personnel who is on site with the patient at the patient’s side. This is different from response time. It is different from scene arrival time. It is different from ECG time. It is the time of physical connection between the first medical contact provider and the patient so that's just to kind of orient us.
That is first medical contact and I think we all know that now that device time is the time of the deployment of the first device for PCI, which is not the guide wire but either the balloon or thrombectomy which is not done quite so much anymore but those kinds of devices so first medical contact to device time. In just [inaudible 00:05:33] again, this is really emphasized in the guidelines statements that all communities should create and maintain a regional system of STEMI care. The twelve ECG that is obtained by EMS personnel is really the anchor and the primary piece of data and this is guidelines level one B recommendation from the most guidelines.
In addition, I draw your attention to the third down here that EMS transports to the PCI capable hospital is recommended strategy with an ideal first medical contact to device system goal of ninety minutes or less and so that's the focus that we're talking about. This whole concept of first medical contact to device time bridges the pre-hospital care and the professional work that is done at the pre-hospital environment and the work that is done at the institution. It intentionally bridges that two groups of professionals involved in this part of the system. We used to talk about door to balloon. Door to balloon is no longer the measure to watch.
Door to balloon is really for the most part solved. Most systems now have in place robust responses and once a patient arrives, the likelihood that they will receive reperfusion care within ninety minutes of arrival is very very good and much improved over the last nearly decade of work with all the different initiatives. However, we want to push that foundry out towards really first symptom time. The closest that we have to that is really EMS arrival on first medical contact. We'd like to push it out further but for incremental gains and for the reality of our ability to ... I'm sorry, there's something that jumped around on my screen here.
David Travis: / Hey Dr. Garvey, we're having trouble. The slides do not seem to be advancing if you’re advancing them. It seems to be stuck on slide three.
Dr. Lee Garvey: / Do you see slide four there? Five? I see it on my screen as slide six is presently displayed on my screen.
David Travis: / Yeah we're looking at it. Okay it just changed. I guess taking it’s a little time to-
Dr. Lee Garvey: / Okay. Something just popped up and said, “I am now the presenter.” We are on slide six. Is that correct?
David Travis: / Yes sir, thank you.
Dr. Lee Garvey: / All right so just to emphasize, door to balloon is our first medical contact, is now our focus and it brings our work into the pre-hospital environment. They're moving forward. Can you see slide seven now?
David Travis: / Yes, yes we can.
Dr. Lee Garvey: / All right. In this work a pre-hospital twelve lead to destination hospital protocol, pre-hospital notification and activation of Cath Lab, minimizing on scene time and maximizing the system use of the transport time and then EMS integration with the hospital to minimize time in the ED; are all the areas of effort that I think will encompass our first medical contact to device. Typically we refer to this as a code STEMI system care activation with the pre-hospital providers as the center piece of that. Now, I think most people are quite familiar also with the value of the pre-hospital electrocardiogram equipment and training has been the focus of effort over the last decade. It's been well studied and well proven that the pre-hospital ECG’s are quality recordings.
Our EMS providers have the appropriate interpretation skills and that there is quite a benefit in time to treatment by utilizing pre-hospital ECG's and acting on that information. The key word that I just said there is acting on the information. That is that is our entire goal of integration with pre-hospital. Those who require an electrocardiogram, it's been studied a bit and one of the well-received schemes for that was published by Luke Graff in around 2000 on triage patients and I think the same criteria apply. This is just an example but most EMS agencies have as part of their decision tree identification of patients that require an immediate twelve lead on presentation with them.
Then the question becomes; how do we get that information interpreted most efficiently and with a high degree of accuracy and confidence and there are a lot of different solutions to this. I would encourage each of you to consider your current circumstances the assets that you have as far as education and quality management and the transmission capabilities but straight up; paramedic read, algorithm interpretation statements, a combination of both. Rarely what I say, it is required that a physician is required to interpret the ECG alone or even an emergency physician or a cardiologist. We really want to have that skill set in the pre-hospital environment with the paramedics and so different agencies have training for their paramedics and or the incorporation of some of the automated interpretation algorithm statements but we can talk about that in the questions section potentially.
To optimize a Cath Lab, if the STEMI diagnosis is clearly apparent on the ECG and the patient is a clear Cath Lab candidate then at the first opportunity the entire system should be activated and on the other kind of orange colored blocks. If there is either a question about the ECG diagnosis or a question about the candidacy of the patient for Cath lab management, then STAT consultation with physicians at the receiving center is indicated and a joint individualized decision can be made. This is just an illustration of one of the Mission Lifeline regional reports that shows a system of care in a region.
The system bar is to the left and each of the individual hospitals are labeled on the bottom; A, C, E, F, etc. and the blue bar shows the first medical contact to arrival at the hospital door time and then the tan bar in the middle is the time spent primarily in the emergency department between arrival at the hospital and arrival at the Cath Lab. Then the green bar on each shows the time in the Cath Lab from arrival until reperfusion. Our goal is to use that time in the blue bars to minimize the time in the tan bars.
You'll see at the far right Hospital M uses that thirty nine minutes of pre-hospital time to really minimize their ED develop time. You can see that's only about six minutes in that example and so most of the patients are being moved very quickly through the emergency department in to the Cath Lab and you can see the profound effect that that has on their overall time to treatment. I think that is a just a good example of how a system of care in the data that it generates can be useful in informing how the EMS participates, how the hospital can utilize that information and maximize their system response to that. I just wanted to mention briefly some of the work that John Studnek did here in my home town here Charlotte, looking at some benchmarks for STEMI system performance by pre-hospital.
We didn't talk much about response time. That is a whole discussion in and of itself so I put that in parentheses but time to ECG from arrival at the patient's bedside until the ECG is acquired. Eight minutes is the target. Scene time; less minimizing scene time. Less than fifteen minutes on scene is the target. Notification time, that is from the time of the diagnostic ECG until the receiving hospital is notified, target of ten minutes and then a bridge that covers both the transport time and that ED dwell time. From the time the EMS leaves the scene until the time the patient arrives at the Cath Lab table with a goal of thirty minutes.
You can see with the odds ratios in that last column. That is the greatest predictor of treatment within guidelines, recommended ninety minutes from first medical contact time. Only second to that is the scene time minimization with targets of less than fifteen minutes on scene. All of the supply implies rapid assessment, timely and immediate communication and then integration with the hospital processes. I believe that with that I can hand our discussion back to Dave if I can figure out how to do that.
David Travis: / Click on my name.
Dr. Lee Garvey: / It's coming your way and I'll look forward to discussion at the end. Thank you.
David Travis: / Very good and thank you very much Dr. Garvey, really appreciate you joining us today. To continue on, I'm going to go over just a few points about the EMS Recognition program with Mission Lifeline and discuss the new reporting criteria plus measure and that sort of thing. Consistent with what Dr. Garvey said, Mission Lifeline is about improving systems of care for patients with time sensitive conditions. The goal of the EMS Recognition program is to acknowledge the role EMS plays and implementing guideline based care, their coordination with the hospital to get the data to find out how their patients are doing. To improve their performance based on that data with the overall goal of better care for our patients and I'm having trouble advancing the slide. I'm sorry. Operator, I don't know if you have a suggestion. Is there just a delay or I'm I unable to advance the slides?
Operator: / I don't have the view of your presentation.
Dr. Lee Garvey: / Did that move? This is Lee Garvey. Do I still have control here?
David Travis: / It looks like I have control now. Are you all seeing slide five right now? Slide five?
Dr. Lee Garvey: / Yes.
David Travis: / Okay, it just takes a while I guess. 2017 will be the fourth year of the Mission Lifeline EMS Recognition program. This year for 2016 we did have more than five hundred and forty EMS agencies who actually received awards and over an additional four hundred more team agencies that were included in those award winning applications that we also acknowledged. Each year since the program began, we’ve published a list of the award recipients and JEMS magazine and that was in the July issue for 2017 and to get everybody in this year we needed eight pages for the list and I'm sorry my slides are just taking a long time to advance here.