The Duke / AHA STEMI Accelerator story has been one of progress in STEMI care across many regions of the nation. Nowhere is that more evident than in the “Tidewater Region” of Eastern Virginia. As the southeast section of Virginia, it is so named for its proximity to the Atlantic Ocean and Chesapeake Bay and the tidal effects on its many rivers, marshes and sounds. It is also home to 1.7 million people living in the Norfolk/Chesapeake/Virginia Beach metro area, served by eight 24/7 PCI centers and the Tidewater EMS Council (TEMS).
One of the first to support the Virginia Heart Attack Coalition in 2009, a statewide organization committed to improving cardiac care in the Commonwealth, Tidewater early on demonstrated a desire to better serve their STEMI patients. Within several years of joining VHAC, all eligible PCI centers had signed on to the ACTION-GWTG Registry and committed to regular meetings and a Regional Report. But like many populated regions with competing health systems, complex referral patterns, political and geographic barriers, this area struggled to achieve STEMI performance commensurate with the ACC/AHA guidelines. First Medical Contact to Balloon times did not change significantly in the 4 years prior to STEMI Accelerator 2.0.
The reasons for this gap were manifold. Unified protocols and algorithms were lacking. Regular meetings were held by a “committed few”, but lacked broad stakeholder participation. Feedback to cath labs, emergency departments and EMS agencies was inconsistent and varied in format and definition. Although AHA Mission Lifeline performance data had been available for nearly 16 quarters, disseminating this information to the majority of providers and staff proved challenging. The “STEMI activists”—TEMS and handful of regional and VHAC leaders — remained committed to optimizing STEMI care. Beyond this group, widespread recognition of the problems and the political will necessary to effect substantive change didn’t exist.
STEMI Accelerator 2.0 has been able to build on the original VHAC/Mission Lifeline foundation and transcend many of these barriers. After an intensive pre-assessment and planning period, the Regional Launch occurred in the summer of 2016. Paula Feather was hired as the Mission Lifeline coordinator — an enormous boon to these efforts. An Executive Leadership team was formed and committed to regular calls and other events. The Regional Plan was devised, with distance and strategy maps, protocols, EMS activation and destination outlines. A comprehensive manual is currently in development.
Four workgroups were then formed, which reported back to the Executive Team. The Prehospital Activation group focused on EMS identification and activation from the field. ED “Pitstop” worked on protocols to speed patient transit through Emergency Department, and discussed ways to bypass altogether. Data Collection was charged with standardizing data collection, reporting and the education of ACTION data abstractors. Finally, the Transfer work group engaged Referral hospitals to help more quickly identify STEMI patients, reduce Door In-Door Out times, and improve transfer STEMI metrics.
What has been the result of these efforts? Pre-hospital ECG use has increased to 91%. ED dwell times, typically in the mid-30’s, dropped to 24 minutes last quarter. FMC2b has fallen from 84 to 77 to 72 minutes over the past 3 quarters. Transfer times have declined from 110 to 92 minutes. These successes have only further fueled enthusiasm and a desire for change.
Clearly much work remains. Time must tell if these improvements are part of an enduring trend. In order to ensure sustainability and further improvement, ambitious goals have been set. These include a median FMC2b of less than 70 minutes. This will require even greater PHECG use, and a target of 100% has been endorsed. ED dwell times of less than 20 minutes are feasible, relying on only a brief “pit stop” or even bypass to the cath lab. For STEMI transfer times to be optimized, door in door out will need to be less than 45 minutes, or ideally below 30. This will require greater use of PHECG’s and field activation prior to arrival at the Referral, Non-PCI hospital.
The Tidewater STEMI Accelerator project was featured at the 2016 Virginia Heart Attack Coalition meeting this year in Williamsburg. This provided an opportunity for STEMI Accelerator participants to regroup, share data and activities, review protocols and care pathways, and chart a course for the coming year. This project was also presented to the State and viewed with great interest by the nearly 100 participants from across the Commonwealth. Other areas of Virginia continue to face similar challenges, and many felt Tidewater’s approaches have much to offer. Perhaps the “Lessons of Tidewater” will serve as a catalyst for improvement in STEMI care across all of Virginia.
Peter O’Brien, MD, FACC
Faculty Advisor, STEMI Accelerator 2.0
VHAC/ML Co-founder and Steering Group Member