Download Advancing the One Acute Care Network and Our

Advancing the One Acute Care Network
and Our Strategic Aims
Regional Cardiac Services
December 2009
Patient Story
No local access to PCI results in more extensive
heart damage for patients.
A 62 year old man presented to the emergency department by ambulance at 0930
hours. He reported an episode of chest pain at work followed by a loss of
consciousness and collapse. His ECG showed ST elevation in the anterior leads.
He received TNK (pharmacotherapy) after he had undergone a CT scan of his
head to rule out a hemorrhage related to the fall. Following the TNK his chest pain
and ECG changes persisted and the patient was transferred at 1250 hours to
Kingston General Hospital for rescue PCI. He was found to have an occlusion of
his mid left anterior descending coronary artery which was successfully opened
and stented, more than 8 hours after the onset of pain. The left ventriculogram
done during the procedure showed that the patient had substantial damage to his
heart which after 8 hours of ischemia would be very likely permanent. He was
discharged home after the usual stay with extensive bruising on his face and on his
hip as a result of the fall and TNK administered after admission.
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Objectives
• Obtain CE LHIN Approval to sustain the RVHS STEMI Pilot Project
• Obtain CE LHIN Endorsement of the PRHC Plan to establish a PCI /
STEMI service
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Our Shared Vision
‘One Acute Care Network’
Improved and equitable patient access
to an integrated hospital system
that provides the highest quality of care
across the Central East LHIN
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‘One Acute Care Network’ - Role of Hospitals
Role 1: Local Centre
• Services needed by the local population, access through the Local facility and utilization
of resources and expertise pertinent to the patient needs.
• Ability to provide core, emergency-driven services as they relate to the respective
clinical programs.
Role 2: District Centre
• Services are located at one institution for populations with several or many surrounding
communities.
• Hospitals will capture a large proportion of residents who may require certain types of
subspecialty programs, yet do not need to travel to a LHIN-wide Centre
Role 3: LHIN-wide Centre
• Specialized services that will promote access LHIN-wide.
• Programs may be located at 1 or 2 sites.
• These site(s) will have the critical mass required to sustain quality standards of care and
clinical efficiencies.
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Definitions
Diagnostic Cardiac Catheterization
• Procedure in which the cardiologists can view the blood flow in the
arteries and see any blockages.
Percutaineous Coronary Intervention (PCI)
• Invasive procedure that treats narrowed coronary arteries via the use of
a catheter which could occur using several strategies.
STEMI
• ST-Elevation Myocardial Infarction.
Code STEMI
• Strategy of PCI as the first definitive maneuver to achieve reperfusion
of the occluded infarct related artery replacing use of thrombolytics and
treatment time within 90 minutes.
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Vascular and Related In Patient Hospital Days 2008-09
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Cardiac Services
Recommended Future State Model
Recommendation
Timelines
1. Cardiac services across the LHIN should be organized to reflect two
clusters – North East/Durham, Scarborough/Durham. Percutaneous
Coronary Intervention (PCI) services should be located at PRHC and
RVHS-Centenary to serve the Central East LHIN.
Short-Term
2. Inherent in this model is the role that the other sites will continue to play in
the overall delivery of care; Local facilities will continue to provide core,
emergency-related cardiac services with Local and District sites offering
general cardiac consults, and non-interventional diagnostics.
Short-Term
3. This option will also weave in an integrated approach to delivering cardiac
rehabilitation services, similar to a hub-and-spoke manner.
Medium-Term
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Proposed Cardiac Service Delivery Model
• LHIN residents receive the most
appropriate cardiac services as close
to home as possible
• Integrated program delivery through
effective communication channels
and appropriate transfer/repatriation
agreements
• Leverage established cardiac
expertise, infrastructure, and
resources at PRHC and RVHSCentenary
• Strategic decision-making to
minimize service duplication and
effectively plan for program
expansion
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‘One Acute Care Network’ – Cardiac Services
Cluster
Level of Care
Local Centres
Basic Diagnostic,
Stabilization &
Rehabilitation
District Centres
LHIN-wide Centre*
Basic Diagnostic,
Stabilization
&
Basic
Diagnostic,
Rehabilitation
Stabilization
&
Rehabilitation
Specialized
Physicians
& Equipment
Basic Diagnostic,
Stabilization &
Rehabilitation
Specialized Physicians
& Equipment
Advanced
Procedures *
North East
Cluster
Haliburton Highlands
Campbellford Memorial
Northumberland Hills
Ross Memorial
Peterborough Regional
Durham
Cluster
Lakeridge Bowmanville
Lakeridge Port Perry
Rouge - Ajax/Pickering
Lakeridge Oshawa
Peterborough Regional
OR Rouge - Centenary
Scarborough Grace
Scarborough General
Rouge - Centenary
Scarborough
Cluster
Note: * Patients return to Local and District Centres after receiving advanced procedures,
for closer to home care when appropriate
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PCI and STEMI
CSP Cardiac Objective
• For patients with ST-segment Elevation Myocardial Infarctions
(STEMI), access to primary angiography and revascularization
treatment will be provided within 90 minutes.
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Efforts to Date
CE Cardiac Steering Committee Formed
– Rouge Valley Health System: Dr. Joe Ricci, Bryna Rabishaw
– Peterborough Regional Health Centre: Dr. Peter McLaughlin,
Jayne White
• Development of Terms of Reference
• Principles and Priorities agreed upon
– PCI and STEMI
• Assumptions of Integration passed
• CE LHIN Cardiac Integration Consultant Posted
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PCI / STEMI Current Status
PRHC
• Cath lab support by local and UHN
cardiologists
• Seeking MOHLTC approval on
Stand-Alone PCI Centre since 2008
– MOHLTC/CNN Evaluation
underway hindering approvals
• No PCI / STEMI – Patients
primarily transferred to UHN
(Toronto Central)
• Meeting Cardiac Volumes
RVHS
• MOHLTC Approved Stand-Alone
PCI Centre
• Partnership with St. Mike’s
(Toronto Central)
• STEMI Pilot underway
• STEMI program requires LHIN
support for sustainability
• Meeting/Exceeding Cardiac
Volumes
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PCI and STEMI: Background
• 1997: Cardiac Care Network (CCN)’s Expert Panel on Intracoronary
Stents recommended an increase in the number of Percutaneous
Coronary Interventions (PCI) performed relative to the number of
Coronary Artery Bypass Graft Surgeries (CABG), considered the
standard of care at the time.
• 2001: MOHLTC pilots first stand-alone PCI centre at RVHS.
Following promising evaluation, MOHLTC funded two additional
stand-alone PCI centres at Thunder Bay Regional Health Sciences
Centre and Windsor’s Hotel-Dieu Grace Hospital
• 2004: CCN’s Target Setting Consensus Panel recommended provincial
targets for diagnostic catheterizations and PCI of 728 per 100,000 and
260 per 100,000 respectively.
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Cardiac Pathway: Emergency Patients
• Patients present to the Emergency Department (ED) exhibiting acute cardiac
symptoms such as pain and discomfort, shortness of breath, and/or nausea.
• Patient is triaged as CTAS Level 2 by a nurse.
• An ECG and blood work are completed immediately in order to distinguish
among Unstable Angina (UA), Non-ST-segment elevation myocardial
infarction (NSTEMI), or a ST-segment elevation myocardial infarction
(STEMI).
• Classification of each patient is established by changes on the ECG and by the
presence or absence of cardiac markers in the blood. This classification is
important as the prognosis and treatment differs for each pathology.
– Both UA and a NSTEMI are similar clinical pathologies and therefore are
treated by following the same clinical pathway.
– STEMI is considered to be distinct clinical entity requiring a separate
clinical pathway.
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Cardiac Pathway
NSTEMI/UA Pathway
• Following diagnosis, medications are administered based on
standardized pre-printed orders as part of an evidence-based clinical
pathway.
• Within a day of admission, the patient is sent to the Cath Lab for a
semi-urgent catheterization to ascertain the coronary anatomy and the
plan for further management if suitable for PCI.
• Patient is transferred to a tertiary cardiac centre for the PCI. Dependent
on patient stability, wait times for the PCI proceedure can be up to 7
days.
• Following transfer and procedure, patient is discharged after a 24 hour
inpatient stay. The patient is then followed up by his or her cardiologist
or family doctor.
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Cardiac Pathway
STEMI Pathway
• Once the patient is diagnosed with a STEMI, thrombolytic medications are
administered. If the patient is successfully reperfused (if circulation in the heart
is restored), he or she is transferred from the emergency department to the ICU.
• If the reperfused patient is deemed to be medically stable, a transfer to the cath
lab is arranged and the patient undergoes an angiogram to determine the need
for a PCI or CABG. In the case where the angiogram reveals that a blockage
remains, the CCN coordinator makes the appropriate arrangements for a
transfer to a tertiary centre for a PCI or CABG.
• If the reperfused patient became unstable in the ICU, or if the thrombolytic
medications were ineffective and the patient was not reperfused, an urgent
transfer to the tertiary centre via Emergency Medical Services (EMS) for a
rescue PCI is quickly arranged.
• The patient is discharged post PCI after a 24 hour inpatient stay, and is then
follow-up by a cardiologist or family doctor and referred to a rehabilitation
program.
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PCI/STEMI Supports CE LHIN Strategic Aims
• PCI is the treatment of choice as it is less invasive than CABG,
reducing the risk of complications, inpatient lengths of stay, overall
recovery time, and improving quality of care.
• ED Strategic Aim
– PCI as initial treatment of STEMI rather than pharmacotherapy
(i.e., "Primary PCI") results in reduced recurrent myocardial
infarction (MI) and reducing re-admissions
• Vascular Strategic Aim
– PCI as initial treatment of STEMI rather than pharmacotherapy
(i.e., "Primary PCI") results in reduced stroke and hospital length
of stay.
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ED Strategic Aim
RVHS Pilot results show reduced ED visits:
• ED utilization will be more efficient with direct or early transfer to
Catheterization laboratory (Cath Lab). For those STEMI cases that are
identified in the field, EMS transfers directly to the Cath Lab and
therefore bypasses the ED entirely.
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ED Strategic Aim
RVHS Pilot results show reduced ED LOS
• The goal of Code STEMI is 90 minutes D2B as per the Primary PCI
protocol. As a result, the length of the stay for a STEMI patient in ED
was significantly reduced by 7 hours as compared to Q1, 2008.
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Vascular Aim
RVHS Pilot results show reduced vascular-related hospital days
• Overall ALOS is reduced for STEMI patients through the
implementation of Code STEMI as a result of early recognition and
immediate access to interventional cardiology and PCI. The ALOS of
all STEMI patients is reduced by 0.6 days and the ALOS of STEMI
patient whose entry is through Emergency is reduced by 2 days.
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RVHS STEMI Pilot
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CE LHIN Code STEMI Pilot:
Volume Distribution
Code STEMI Cases
(excluding False Positives, Aborted Cases and Urgent Caths)
February - November 2009
Field (EMS)
21%
RVHS
32%
Scar Gen
26%
Scar Grace
21%
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CE LHIN Code STEMI Pilot: Outcomes
RVHS
RVHS
February 2009 November 2009
Median Door to
Balloon Time
(DTBT)
% patients DTBT
within
90 minutes
Total RVHS
Pilot
(10 months)
84 minutes
70 minutes
84 minutes
53%
75%
59%
# Day PCI Cases
Rescheduled
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Code STEMI Pilot
Median Door to Balloon Time by Source
February - November 2009
120
98
100
Time (minutes)
82.5
80
RVC
60
Regional
42
40
20
0
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Field
CE LHIN Regional Code STEMI Pilot Successes
• More than half of patients in pilot met 90 minute Door to Balloon Time
(DTBT) target
• Significant improvement in DTBT during the course of 10 month pilot
period
• Engagement and collaboration between interdisciplinary professionals
from all regional partners
• Regular multidisciplinary implementation rounds for case review and
continuous process improvement
• Quality improvements implemented to maximize resource utilization
for DTBT
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Current Status of CE LHIN Regional Code STEMI Initiative
• 24/7 Primary PCI service implemented with Toronto EMS with
significant financial and patient flow impact on current RVHS
resources
• 24/7 service not extended to Durham patients
– Durham EMS ready to initiate service but requires operational
support
RVHS cannot continue pilot or extend service to Durham without additional
resource allocation of at least the highest priority resource requirement
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RVHS Code STEMI Program Resolution
Integration Through Funding
• Integration/Letters of Support from
– TSH, LHC
• Funding Required:
– 2009-10: $239,000 One Time Start Up; $350 ICU/CCU Bed
– 2010-11: $500,000 for additional ICU / CCU Bed
• RVC ICU/CCU:
– CCU Occupancy higher than provincial average (84%)
– High rates of Inter-LHIN patient transfers (14.5%)
– ICU – very high % of Ventilator Patient Day (71%)
– Proposal supported by CE LHIN Critical Care Lead
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Peterborough Regional PCI / STEMI
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PRHC PCI / STEMI Program
• CE LHIN Endorsement of PRHC’s intention receive MOHLTC
approval to establish a stand-alone PCI service
– Funding requirements and timelines to be negotiated following
MOHLTC approval of PRHC’s request
• CE LHIN Endorsement recognizing PRHC PCI/STEMI as the most
significant priority for regional cardiac program.
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Benefits of a Stand-Alone PCI Centre (PRHC)
• Improving patient flow by being able to offer treatment to the patient
on-site rather than sending them out of the region; reducing wait times
by adding PCI capacity to the system; improving the standard of care
and outcomes for STEMI patients via the availability of Primary PCI
– Best practice prescribes a door-to-balloon time of 90 minutes or
less for Primary PCI. The current distance which must be travelled
in order to receive PCI compromises clinical outcomes and
prognosis.
– prevent up to 4-5 patients from experiencing death, repeat MI, or
stroke per year, and translate into a $228,000 treatment cost
savings to the system within the first six months post MI, annually,
based on CCN estimates
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Benefits of a Stand-Alone PCI Centre (PRHC) – cont’d
• Reducing Cath Lab utilization by avoiding a second procedure via the
availability of ad hoc PCI
• Free up Intensive Care Unit (ICU) and telemetry beds as semi-urgent
patients are no longer waiting for a transfer to a tertiary centre for the
PCI proceedure.
• Reduce transportation costs on system, patients and families.
– Costs of a second admission and patient transfer would also be
incurred. Patient transfer costs for emergency medical services
could be as high as $750 for a 150km transfer.
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Support for PRHC PCI / STEMI
• PRHC Underserved for Cath and PCI
– potential projected need for 1,062 PCI cases by 2008/09 in the
Peterborough region, which is almost twice the volume currently
being offered via referral to other institutions (574 in 2006/07).
• The gap between projected targets and volumes is greater when one
factors in the higher AMI rates in PRHC’s four counties, and the
accordingly increased specific target procedure rates.
800
700
Procedures
600
500
400
300
200
100
0
Target
Actual
Cath
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Target
Actual
PCI