Updated June 2015
As a paramedic for a hospital-based EMS system in North Carolina, Claire Corbett had an ECG on her ambulance for use with chest pain patients. When the ECG showed STEMI (ST-segment elevation myocardial infarction), she would relay that information to the hospital. But she could never be sure what would happen next—sometimes ED physicians would activate the catheterization lab; sometimes they wouldn’t, and instead would repeat the ECG at the hospital and wait for a cardiologist to make the cath lab call. “It was based on which physicians were working that day, did they know me, and did they feel confident in my work,” Corbett says. “There was no consistency.”
But that’s changed, thanks to the development of the nation’s first statewide coordinated STEMI network: the Regional Approach to Cardiovascular Emergencies, or RACE. (RACE initially stood for Reperfusion in Acute Myocardial Infarction in Carolina Emergency Departments but has since been renamed.) Spearheaded by Duke University Medical Center, RACE began as a pilot program in 2003 with the goal of diagnosing and getting STEMI patients to definitive care as quickly as possible by having prehospital providers bypass non-PCI (percutaneous coronary intervention) hospitals or by streamlining the transfer of patients to PCI centers. A decade later, RACE has grown to include 21 PCI hospitals in the state, about 100 referring hospitals and more than 500 EMS agencies.
Key aspects of the program are spelled out in a 32-page operations manual that largely follows the American Heart Association’s “Mission: Lifeline” STEMI guidelines. (Several of the leaders for the North Carolina STEMI network were involved with developing the AHA guidelines.) For EMS responders, RACE calls for equipping ambulances with 12-lead ECGs to diagnose STEMI in the field, encouraging crews to bypass closer hospitals to get a patient to a PCI center when feasible, and enabling paramedics to diagnose STEMI and activate the cath lab with a single call. For EMTs, RACE guidelines call for either transmitting ECG results to doctors for interpreting, or for EMTs to make the cath lab call based on the ECG computer’s interpretation of the results.
“EMS is empowered to make a good clinical decision based on the condition of the patient, not which provider they’re taking the patient to,” says Corbett, who is now a RACE coordinator and AMI/stroke manager for the New Hanover Regional Medical Center.
Hallmarks of the program
As part of RACE, hospitals—both PCI centers (receiving hospitals) and non-PCI centers (transfer hospitals)—also agree to follow certain protocols, including:
- PCI centers will have catheterization available in 30 minutes, 24/7.
- PCI centers will never go on diversion and will always accept STEMI patients.
- The transfer of STEMI patients from non-PCI hospitals to PCI centers will be streamlined so that the non-PCI hospital can have an ambulance dispatched, connect with a cardiologist at the PCI center and have other logistics handled with a single phone call.
- All hospitals will submit data, including EMS data, to the ACTION Registry-GWTG, a benchmarking and quality improvement program administered by the National Cardiovascular Data Registry.
- A STEMI coordinator will gather data and offer feedback to EMS and hospital staff on each
- STEMI call.
“Treatment of STEMI has been completely transformed by regional EMS protocols, including prehospital diagnosis; communication to PCI centers; transport to PCI-capable hospitals, even if farther than a closer non PCI-capable hospital; and prehospital activation of cath labs,” says Christopher Granger, M.D., co-medical director of RACE and a cardiologist at Duke. “Statewide programs add to this by setting standards for a whole state that provide a structure to share best practices, benchmark one region against others, incentivize all regions to participate and improve, and provide statewide EMS standards to improve care.”
Bringing people together
Every year, 300,000 Americans experience STEMI, which occurs when an artery in the heart is totally blocked. In STEMI, time is muscle, goes the adage, meaning the longer the patient goes without having blood flow restored, the more damage is done to the heart—and the higher the chances of death. Though extremely dangerous, STEMI is relatively straightforward to diagnose, and research shows paramedics can do it successfully, says James Jollis, M.D., co-medical director for RACE and a cardiologist with Duke Clinical Research Institute in Durham.
But research also shows that just having EMS providers doing the ECG isn’t enough, he says. What matters is what hospitals do with the information, and that can vary from hospital to hospital, and doctor to doctor. Some emergency departments accept the ECG reading done by EMS and act on it; others want to repeat the test. Some hospitals require a cardiologist to activate the cath lab after consulting with an ED physician; others allow ED physicians to do it—all of which has the potential to add up to delays.
“The way it traditionally works is that … there may be five to 10 cardiologists who work in the cath lab, and each one may have different criteria,” Jollis says. “Some may only accept patients with ST elevation of 1 mm or 2 mm. Some may say, I know this paramedic, and I believe him, or, I don’t. Others might say, Only activate the cath lab if the ECG is transmitted to me, or, Only give patients Plavix and not aspirin, or, The ER physician has to be consulted before coming to me.”
To put into practice proven strategies, Granger and his colleagues started the STEMI network as a pilot in 2003. In 2005, they received a two-year, $1 million grant from Blue Cross Blue Shield of North Carolina to expand the network to 55 hospitals and 10 PCI centers. The funding went largely to hire regional STEMI network coordinators to handle data collection; to do the legwork to seek buy-in from EMS agencies, cardiologists and hospitals who would have to put aside their competitive instincts and work together to improve care; to develop the protocols; and to provide case feedback for each STEMI case. In 2007, the program was expanded to include every hospital in the state and every PCI center. (The PCI centers generally cover the cost of their STEMI coordinator.)
Lee Garvey, M.D., director of emergency cardiac care at Carolinas Medical Center in Charlotte, was among those eager to get on board. Prior to being approached by RACE, his hospital worked with local EMS agencies and physicians to implement a 24/7 cath lab and a STEMI network activated by emergency physicians. Median time to treatment was 92 minutes—pretty close to guidelines that called for patients to be treated within 90 minutes. “We thought that was a pretty good time, except that the median means that half the patients are being treated in less time, but half of them are being treated longer than that,” he says.
It took the RACE team to get Charlotte’s two major competing hospital systems to work together. “We had our system and they had their system and we had little discussion between the two,” says Garvey, who has since become co-chair of the North Carolina Mission: Lifeline executive committee. “Each individually would speak to Mecklenburg EMS agency [MEDIC], but we were doing one thing and they were doing another, and MEDIC was in the middle. MEDIC tried to initiate a system-wide response to STEMI a few years before, but we had never been able to come to an agreement.
“It took the RACE initiative to come to town, with the concept that if we come together, everyone’s patients will be treated more rapidly, more appropriately, and the whole notion of competitive market share was dismissed,” Garvey adds. “The competition between hospitals was put completely on the sideline. The beauty of the RACE program is they were able to broker that.”
Research shows promise
In North Carolina, the research coming out of RACE is promising. A study in the June 4, 2012, issue of Circulation involving data from 6,800 STEMI patients taken to 100 hospitals found that the STEMI network cut time to treatment and might even improve mortality. Here’s a rundown:
From July 2008 to December 2009, about 3,900 of the STEMI patients were taken directly to 21 PCI hospitals; 2,900 patients were transferred from 98 non-PCI hospitals.
About 88 percent of patients received prehospital ECGs, up from 67 percent prior to implementation of RACE. (In 2010, RACE organizers received an additional boost of more than $2 million from the Duke Endowment to buy hundreds of ECGs and capnography equipment for ambulances.)
Time to treatment for patients who first went to a non-PCI hospital and were transferred to a PCI hospital fell from 117 to 103 minutes, while time to treatment for patients taken directly to a PCI hospital fell from 64 to 59 minutes. (Under RACE, hospitals can also designate themselves “mixed strategy,” meaning they don’t do PCI but do offer fibrinolysis, or clot-busting drugs. Time to catheterization at hospitals with a mixed strategy fell from 195 minutes to 138 minutes.)
More than nine in 10 patients (91 percent) transported by ambulance were treated within the recommended 90 minutes, including more than half (52 percent) treated within 60 minutes.
About 39 percent of patients transferred from one hospital to a PCI center had a door-to-device time under 90 minutes, “the highest such rate reported in a multicenter study,” according to the study.
The faster treatment times may also be improving patients’ odds of survival. Among patients who received PCI within the recommended 90 minutes, 2.2 percent died, compared to 5.7 percent who received PCI after the 90-minute window. However, researchers note that the primary goal of the STEMI network is to implement the therapies found to be most effective in clinical trials, not to improve outcomes in and of itself.
“RACE and Mission: Lifeline are … aimed to implement proven effective therapy based on hundreds of clinical trials and well-established guidelines,” Granger says. “They are not designed, and cannot be used, to define the effect of the program on mortality. We have seen improved survival over time, but it is not possible to determine how much of that improvement is due to RACE and similar programs.”
Researchers are continuing to mine the data coming out of RACE to build the evidence base for the protocols. For example, the guidelines call for EMS to bypass non-PCI hospitals to get STEMI patients to PCI hospitals, the assumption being that it would reduce the time to reperfusion. However, there wasn’t a lot of research backing that up, researchers say.
Yet a study presented in May 2012 at the AHA’s Quality of Care and Outcomes Research 2012 Scientific Sessions in Atlanta backed that up. The research found that patients who went directly to a PCI center were reperfused an average of 31 minutes faster than patients taken elsewhere and then transferred.
Beyond STEMI: stroke and cardiac arrest
To continue to improve STEMI treatment in the United States, North Carolina researchers aren’t stopping with their state. In partnership with the AHA, Duke Clinical Research Institute is working to establish similar STEMI systems in 20 regions across the country, including Tampa, Manhattan, Detroit and San Antonio, as part of a program called Mission: Lifeline STEMI Systems Accelerator.
And in North Carolina, researchers are using lessons learned from building the STEMI network and applying them to a statewide system for responding to and treating cardiac arrest and stroke. RACE-CARS (Cardiac Arrest Resuscitation System) is being done with the HeartRescue Project, while RACE-Stroke is under development, Corbett says. (For more on the HeartRescue Project’s involvement, see the sidebar, below left.)
The process of developing more coordinated systems puts EMS front and center in overcoming a major issue facing health care in the United States, Granger says. “One of our biggest problems in U.S. health care is fragmentation of care, and in particular EMS and hospital networks, and RACE and related programs are addressing an enormous opportunity to improve care on a broad scale,” he says. “Anytime we can engage EMS leaders, paramedics and policy makers to measure and improve care through collaborative efforts, we are doing something that is of major importance.”
