RECOMMENDATIONS FOR BEST-PRACTICE STEMI MANAGEMENT IN ONTARIO JUNE 2013 4100 Yonge St., Suite 502, Toronto, ON M2P 2B5 tel 416.512.7472 fax 416.512.6425 www.ccn.on.ca Copyright 2013 Cardiac Care Network 1 | RECOMMENDATIONS FOR BEST-PRACTICE STEMI Table of Contents EXECUTIVE SUMMARY ........................................................................................................................................... 5 1 INTRODUCTION ........................................................................................................................................... 11 1.1 CCN'S ROLE IN CARDIAC SERVICE DELIVERY ......................................................................................................... 11 1.2 INTRODUCTION TO STEMI ................................................................................................................................ 11 1.3 CCN'S CONTRIBUTIONS IN STEMI CARE ............................................................................................................. 13 1.4 2012 RECOMMENDATIONS FOR BEST PRACTICE ................................................................................................... 15 1.5 ORGANIZATION OF THIS REPORT ........................................................................................................................ 16 2 SURVEY METHODOLOGY ............................................................................................................................. 17 2.1 SURVEY DESIGN .............................................................................................................................................. 17 2.2 SURVEY DISTRIBUTION ..................................................................................................................................... 17 2.3 SURVEY ANALYSIS ........................................................................................................................................... 19 3 APPROPRIATE CARE ..................................................................................................................................... 20 3.1 TREATMENT FOR STEMI PATIENTS ..................................................................................................................... 20 3.2 ACCESS TO STEMI DIAGNOSIS AND TREATMENT IN REMOTE NORTHERN COMMUNITIES .............................................. 29 3.3 POST-PROCEDURAL MANAGEMENT OF STEMI PATIENTS ........................................................................................ 30 4 TIMELY CARE ............................................................................................................................................... 35 4.1 TIMELY DIAGNOSIS OF STEMI PATIENTS ............................................................................................................. 36 4.2 TIME TO TREATMENT ....................................................................................................................................... 41 4.3 REAL-TIME ACCESS TO PATIENT DATA ................................................................................................................. 53 5 QUALITY OF CARE ........................................................................................................................................ 55 5.1 REGIONAL STEMI NETWORKS ........................................................................................................................... 55 5.2 PROVINCIAL QUALITY ASSURANCE PROGRAM ....................................................................................................... 56 5.3 QUALITY MONITORING .................................................................................................................................... 59 6 PERFORMANCE MEASUREMENT ................................................................................................................. 63 6.1 SYSTEM MEASURES ......................................................................................................................................... 63 6.2 PROCESS MEASURES ........................................................................................................................................ 65 6.3 OUTCOME MEASURES ..................................................................................................................................... 66 6.4 OTHER REPORTABLE MEASURES ........................................................................................................................ 66 7 SUMMARY AND CONCLUSIONS ................................................................................................................... 67 7.1 APPROPRIATENESS OF CARE .............................................................................................................................. 67 7.2 TIMELINESS OF CARE ........................................................................................................................................ 67 7.3 QUALITY OF CARE ........................................................................................................................................... 68 7.4 CONCLUSIONS ................................................................................................................................................ 68 REFERENCES ......................................................................................................................................................... 70 GLOSSARY OF TERMS ......................................................................................................................................... 145 RECOMMENDATIONS FOR BEST-PRACTICE STEMI | 2 APPENDIX A: PCI CENTRES IN ONTARIO ................................................................................................................................ 76 APPENDIX B: CARDIAC CARE NETWORK STEMI WORKING GROUP MEMBERSHIP ......................................................................... 77 APPENDIX C: RECOMMENDATIONS ...................................................................................................................................... 79 APPENDIX D: PCI HOSPITAL SURVEY .................................................................................................................................... 81 APPENDIX E: REFERRING HOSPITAL SURVEY ........................................................................................................................... 88 APPENDIX F: EMS SURVEY ................................................................................................................................................. 95 APPENDIX G: LHIN SUMMARIES ....................................................................................................................................... 102 APPENDIX H: DRAFT PATIENT INFORMATION REQUIREMENTS ................................................................................................. 141 APPENDIX I: AHSC AFP INNOVATION FUND REPORT EXCERPT– HIGHLIGHTS OF DATA ISSUES ...................................................... 142 3 | RECOMMENDATIONS FOR BEST-PRACTICE STEMI List of Figures FIGURE 1: NUMBER OF ACUTE MIS AND STEMIS PER 100,000 ADULT POPULATION, ONTARIO, 2007-2010 ................................... 12 FIGURE 2: WHAT IS THE DOMINANT REPERFUSION STRATEGY YOUR HOSPITAL OFFERS TO STEMI PATIENTS THAT ARE TRANSFERRED OR WALK-IN TO AN ED OF A NON-PCI HOSPITAL IN YOUR REGION? (N=16) ............................................................................ 21 FIGURE 3: WHAT TYPE OF REPERFUSION STRATEGY DOES YOUR HOSPITAL OFFER TO PATIENTS DIAGNOSED WITH STEMI BY EMS IN YOUR REGION? (N=16) .................................................................................................................................................... 22 FIGURE 4: WHAT IS THE PRIMARY STEMI REPERFUSION STRATEGY AT YOUR FACILITY? (N=89) ...................................................... 22 FIGURE 5: NUMBER OF STEMIS AND NUMBER REPERFUSED PER 100,000 ADULT POPULATION, ONTARIO, 2007-2011 .................... 23 FIGURE 6: DISTRIBUTION OF STEMI PATIENTS WITHIN 30 AND 60 MINUTES (BY CAR) OF A PCI CENTRE, SOUTHERN ONTARIO, 2011/12 ............................................................................................................................................................................ 25 FIGURE 7: DISTRIBUTION OF STEMI PATIENTS WITHIN 30 AND 60 MINUTES (BY CAR) OF A PCI CENTRE, GTA AND CENTRAL ONTARIO, 2011/12 ............................................................................................................................................................... 26 FIGURE 8: DISTRIBUTION OF STEMI PATIENTS WITHIN 30 AND 60 MINUTES (BY CAR) OF A PCI CENTRE, SOUTH EASTERN ONTARIO, 2011/12 ............................................................................................................................................................... 27 FIGURE 9: WHAT TYPE OF COVERAGE DOES YOUR HOSPITAL PROVIDE FOR STEMI PATIENTS REQUIRING EMERGENT PCI? (N=16) ......... 28 FIGURE 10: HOW LONG DO STEMI PATIENTS STAY IN CRITICAL CARE BED POST PROCEDURE? (N=16) .............................................. 31 FIGURE 11: WHAT IS THE TYPICAL LENGTH OF STAY (LOS) POST PROCEDURE AT YOUR INSTITUTION? (N=16)..................................... 31 FIGURE 12: REPATRIATION DESTINATION (N=86) .................................................................................................................. 32