RACE Reperfusion of Acute Myocardial Infarction in Carolina Emergency Departments The Reperfusion of Acute Myocardial Infarction in Carolina Emergency Departments (RACE) project is a collaborative effort to increase the rate and speed of coronary reperfusion through systemic changes in emergency care. The project is based upon the collaborative efforts of EMS personnel, physicians, nurses, administrators, and payers from six regions and 122 hospitals throughout North Carolina. The recommendations of this project are based upon established guidelines, published data, and the knowledge and experience of numerous individuals specializing acute myocardial infarction care. NEWS from RACE Central The RACE acronym has been modified to encompass our overall mission, “Regional Approach to Cardiovascular Emergencies”. Based upon the input of thousands of participating health care providers across the state, we will expand our model to expedite emergency care to cardiac arrest and stroke victims. This approach embraces existing leadership, institutions and resources to develop coordinated plans of care across every hospitals and emergency medical service. Supported by regional coordinators, ongoing data collection and feedback, regional meetings, state-wide consensus documents, and customized training of health care professionals, our interventions speed diagnosis and treatment. According to this approach, every North Carolinian can receive the best cardiovascular care regardless of geographic location or socioeconomic status. Recently, the Medtronic Foundation HeartRescue project selected North Carolina as one of five states to implement and regional cardiac arrest system, termed RACE-CARS (Cardiac Arrest Regional System). This will not only involve the same partners as the STEMI program, EMS and hospitals, but will also include a community education plan. The next initiative that begs for a regional system implementation model will be RACE-STROKE. Initial conversations with state partners and physician leadership in neurology and emergency medicine have occurred. This initiative would in no way replace existing work being done at the state and regional level. RACE STROKE will seek to work in tandem and support ongoing efforts and with other organizations with vested interest in the stroke patients. As soon as funding is secured, more information will be posted and communicated directly at state RACE regional meetings. RACE and RACE CARS Fall 2011 Update The RACE/RACE CARS projects had a joint meeting with both North Carolina and South Carolina hospitals, EMS agencies, and AHA Mission Lifeline representatives. NC/SC ACC hosted the meeting at the Grove Park Inn in Asheville on September 23rd. The objective of the meeting was to establish standard protocols that cover both North and South Carolina. Drs. Powers and Foster from South Carolina and Drs. Jollis and Granger from North Carolina discussed current work with STEMI, Stroke, and Cardiac Arrest in their respective states. There was great discussion on STEMI topics: when to activate, who can activate, how to activate, how far is too far for transfer, and treatment regimen by EM, treatment regimen by transferring hospital. Both states had common areas for improvement including First medical Contact to Device and Transfer First Door to Device. Mission Lifeline is guiding both states in process improvement efforts to improve the timeliness of treatment for the STEMI patient. NC has 2 state meetings schedule for the fall: November 29th in Greenville and December 1 in Morganton from 11-4 both dates. Mission Lifeline will also host a presentation on October 4th at EM Today. North Carolina is leading the way in setting up a systems approach to caring for the cardiac arrest patient. NC was selected as 1 of 5 states to participate in the Medtronic Foundation HeartRescue Project. Its aim is to double survival from out of hospital cardiac arrest over the next 5 years. Currently, only 1 in 4 cardiac arrest victims receive bystander CPR and only 1 in 20 survive. RACE CARS will be hosting a cardiac arrest symposium at EM Today in Greensboro on October 2 and a lunch on Oct 4th to gain commitment from the EMS community in their efforts to save lives in NC. Dr. Jollis also discussed NC’s intent to create a RACE Stroke project based off o the RACE/RACE ER and RACE CARS projects. The American Southeast has long been labeled the “stroke belt”—an epidemiologic curiosity of an unexplained 10% increase in stroke mortality in a large swath of geography extending from North Carolina to eastern Texas. As the “buckle” of the stroke belt, Eastern North Carolina has two times the death rate for stroke compared to national figures. Additional barriers to acute stroke care in North Carolina are similar to the rest of the nation: lack of established stroke diagnosis and treatment protocols, limited ability to rapidly interpret computed tomography (CT) at smaller and critical access hospitals, ED physicians’ unfamiliarity with stroke, lack of neurology consultants, and a fear of litigation across both specialties. Undoubtedly, the small risk of intracranial hemorrhage is well documented, but the life-changing and life-saving potential benefits of treatment are unreasonably overshadowed. The 50 participants that included physicians, nurses, cath lab reps, administrators, and EMS reps left the meeting with an understanding of opportunities for both NC and SC to work together in improving care of patients with Cardiovascular Emergencies. Next steps include a follow up call with NC and SC representatives to create a plan for future efforts to work together. Contact Lisa Monk, MSN, RN, CPHQ lisa.monk@duke.edu - RACE/RACE CARS Project Leader for additional information. Fall 2010 Update RACE ER Data Summary The RACE ER Data will be released at the AHA Scientific Sessions on November 16th. We are hoping for simultaneously release of a manuscript. PCI Centers across the state are receiving individual hospital reports compared to other NC hospitals. Plans are being made for next steps in improvement of care for their STEMI patients. The focus will be on First Medical Contac to Device Activation in < 90 minutes and Transfer Patients timeliness to treatment; First Hospital Arrival to Device < 90 minutes and Door to Lytic < 30 minutes. Reevaluation of regional strategies will be evaluated for effectiveness as well. RACE CARS: Regional Approach to Cardiovascular Emergencies Cardiac Arrest Resuscitation System The Medtronic Foundation is leading an effort to increase overall Sudden Cardiac Arrest (SCA) survival rates in the United States. The Foundation will support community to state-wide initiatives that focus on a “systems-based” approach to SCA. The Foundation will look to its partners to coordinate training, community and system-wide response, and the application of “best practice” treatments among the general public, first responders (police/fire), emergency medical services (EMS) and hospitals. The recipients of the grant will be announced in December with a media release to follow. NC will be hosting 4 meetings across the state to begin the implementation of the program. Agenda topics will include NC data, an overview of the HeartRescue Grant, current evidence, and discussion of strategies to implement regional plans. Summer 2010 Update RACE ER State Meeting June 15, 2010 100 participants from across the state including MD’s, RN’s, EMS Staff, and hospital administrators gathered at Lowe’s Motor Speedway in Concord, NC to review the preliminary data from this phase of RACE ER. Stay tuned for the release of our final data set. Cath Lab Activation Registry (CLAR) The purpose of the Cath Lab Activation Registry (CLAR) was to use a quality improvement tool to accurately capture patient disposition after implementation of a STEMI emergency response system. 14 of 21 PCI Centers across NC participated in data collection. The relatively low cancellation rate and high rate of acute coronary occlusions suggests that systematic catheterization laboratory activation by emergency personnel on a broad scale is feasible and accurate. These rates set a standard for STEMI systems. Look for the CLAR registry manuscript to be published soon. CLAR has also been presented at the following conferences: The National Association of EMS Physicians Phoenix -2010 (will be published in the January/March 2010 issue of Pre-hospital Emergency Care) The American College of Cardiology Atlanta -2010 AHA Mission Lifeline Regina Fleenor BSN, RN, EMT-P is the new Mission Lifeline Director for NC. She will be guiding the RACE ER project in our continued work in improving STEMI Care in NC. She has been traveling across the state to award the AHA ML Bronze Recognition awards to 7 of our 21 PCI Centers. Her hope is to see all 21 centers achieve recognition next year. RACE ER Regional Meetings The RACE Central Team and ML Director have been hosting regional meetings with the following objectives: Review National and NC work on Cardiac Arrest, Hypothermia, and Stroke Discuss the impact of RACE ER Data Define next steps for STEMI care in NC We have had 3 meetings with 100 plus participants. Regional presenters gave us updates on Stroke and Cardiac Arrest and Hypothermia care in NC. Please visit the AHA Mission Lifeline website for information on recognition, ECG on-line training, and the new community for sharing resources. We have 3 more regional meetings in the next month. RACE CARS: Regional Approach to Cardiovascular Emergencies Cardiac Arrest Response System On May 3rd, 90 participants from across the state including MD’s, RN’s, EMS Staff, and hospital administrators gathered at Forsyth Medical Center to discuss an opportunity to set direction for Cardiac Arrest and Hypothermia care in NC. North Carolina is hoping to secure a grant from The Medtronic Foundation. The Medtronic Foundation is leading an effort to increase overall Sudden Cardiac Arrest (SCA) survival rates in the United States. The Foundation will support community to state-wide initiatives that focus on a “systems-based” approach to SCA. The Foundation will look to its partners to coordinate training, community and system-wide response, and the application of “best practice” treatments among the general public, first responders (police/fire), emergency medical services (EMS) and hospitals. RACE Central Coordination 2400 Pratt St-Room 7005-7th Floor Durham, NC 27705 RACE Faculty & Staff Co-Medical Directors: Christopher B. Granger, MD christopher.granger@duke.edu James G. Jollis, MD jamie.jollis@duke.edu Executive Director: Mayme Lou Roettig, RN, MSN mayme.roettig@duke.edu State Project Leader: Lisa Monk, RN, MSN lisa.monk@duke.edu Regions of RACE RACE Directory Fall 2009 Update The RACE ER project recently completed 6 regional blitz meetings across the state that was attended by 300 participants representing EMS, Non PCI, and PCI systems. The overall program goal was for participants to return to their system with the ability to refine interventions to meet the project goals. The agenda topics allowed for participants to discuss regional issues and strategies to improve the timeliness of treatment for their STEMI patients. Inspirational success stores of STEMI patients were shared across the state. Additional topics included the review of the updated RACE manual, the future of the RACE project, and Mission: Lifeline's exciting move towards recognition for systems involved in STEMI care. With the anticipation of the final quarter of data, the meeting concluded with a challenge from the RACE central team, Drs Granger and Jollis, co-investigators, Lisa Monk RN, MSN, State Project Leader, and Mayme Lou Roettig RN, MSN, Executive Director and Mission Lifeline consultant, to implement the "Top 10 To Do List" and call to action to make NC the safest place to have a heart attack. RACE Operations Manual 2009 Download PDF RACE Update Summer 2008 The success of RACE has been based on the efforts and contributions of hundreds of health care professionals across the state of North Carolina. For the initial project, state level cardiology leadership has included Yele Aluko, Bob Applegate, Joe Babb, Dave Bohle, Bruce Brodie, Paul Colavita, Chris Granger, Bill Hathaway, Jamie Jollis, Bill Maddox, Tom Stuckey, Scott Valeri, and Hadley Wilson. The partnership between our cardiology community and key emergency medicine physicians, nursing leadership through the RACE coordinators and emergency department nurse managers, quality assurance colleagues, and CV administration was critical to the project. The results of the initial RACE project were published in the Journal of the American Medical Association in November 2007, demonstrating substantial improvements in all treatment times across the state (please see power point labeled Final RACE Results for detail). The RACE project was named one of the top 10 advances in heart disease by the American Heart Association, and the North Carolina model is being adopted by other state Chapters. With the continued support of ACC members and councillors across the state, the Reperfusion in Acute Myocardial Infarction in Carolina Emergency Departments (RACE) project has developed into the leading state-wide system in the United States. The American Heart Association (AHA) has recently launched an initiative - Mission: Lifelineâ„¢- which focuses on the entire STEMI system of care from point of entry into the healthcare system to reperfusion and back to the local community for follow up. The RACE model was one of the models used in construct of Mission: Lifeline. The next phase of RACE has an expanded acronym, RACE- ER (Emergency Response) and will invite voluntary participation of all acute care emergency departments and emergency medical services (EMS) serving North Carolina to work together in this continued quality improvement project of the North Carolina Chapter of the ACC and in partnership with the AHA initiative- Mission: Lifeline. The objectives for RACE-ER will be providing timely coronary reperfusion for all eligible STEMI patients. To date, 5 regions spanning the entire state have been organized (Coastal Plains, Triangle, Triad, Charlotte- Metro, and Western NC). Within each region, integrated STEMI treatment plans have been and are continuing to be implemented by teams of physicians, nurses, technicians, administrators, and public officials at hospitals and emergency medical service agency level. Similar to the trauma system, the emergency medical service, emergency departments, critical care transport, and cardiac catheterization laboratories work in a concerted and urgent fashion to rapidly diagnose and most effectively open occluded coronary arteries. In order to support these efforts in the most impoverished regions in the state (tier 1 and tier 2 counties and critical access hospitals), the Kate B. Reynolds Foundation has provided a 2 year $400,000 grant. Through the hospitals and emergency medical services participating in RACE, we will attempt to further improve our rate and speed of coronary reperfusion, with a particular focus on the emergency medical service aspect of STEMI care. North Carolina has over 800 emergency medical service agencies, many of which are challenged in covering large rural regions and obtaining the necessary equipment and training to diagnose STEMI. The RACE project provides an important opportunity to provide training and support to the emergency medical technicians and emergency department personnel on the front lines of cardiac care. All 21 primary interventional facilities (see NC RACE PCI Hospital list for key contact) that provide 24/7 emergency PCI STEMI care have come to consensus on criteria to participate and serve as many North Carolinians with the preferred reperfusion therapy of primary percutaneous coronary intervention (PCI). The most recent meeting is recorded in attached pdf from May 15, 2008. Optimal System Specification by Point of Care Operations Manual 2008 Download PDF RACE 2005-2007 The RACE project is a collaborative effort to increase the rate and speed of coronary reperfusion through systemic changes in emergency care. The project is based upon the collaborative efforts of EMS personnel, physicians, nurses, administrators, and payers from five regions and 68 hospitals throughout North Carolina. The recommendations of this project are based upon established guidelines, published data, and the knowledge and experience of numerous individuals specializing acute myocardial infarction care. Key collaborators in this project include the councilors of the NC Chapter, and in particular Drs. Colavita, Babb, Bohle, and Hathaway; Dr. James Jollis who is co-director of the project; Mayme Lou Roettig who is executive director; and cardiology and emergency care leaders from the five regions. Over the two years of the program, physicians collected information on 2,000 patients, measuring pre and post-intervention times for key processes: the time from when the patient arrives at the hospital door to either angioplasty or clot-busting therapy, and the time it takes for a patient at a feeder hospital to enter and leave the transferring hospital, and the time a patient enters a feeder hospital to treatment at a second, receiving hospital. Times improved substantially in all areas. Median time from door to treatment for hospitals offering angioplasty fell from 85 to 74 minutes. (22 percent) Median time from door to infusion of clot-busting therapy fell from from 35 to 29 minutes. (17 per cent) Median time from door-in to door-out at transfer hospitals fell from 120 to 71 minutes. (41 per cent) Median time from arriving at a feeder hospital to beginning treatment at a receiving hospital fell from 149 minutes to 106 minutes. (29 per cent) RACE AHA Final Results View the AP story that also appeared in the Philadelphia Inquirer, NY Times and more than 400 other news outlets. View the FOX News story. News Release Blue Cross and Blue Shield of North Carolina and Statewide Health Care Consortium Team Up to Win the Race Against Heart Attacks November 1, 2005 RACE Poster - Download PDF RACE Referring Hospitals Data Collection Form- Download PDF RACE Sponsors Kate B. Reynolds Charitable Trust Sanofi-Aventis Genentech, Inc. Medtronic, Inc. Phillips, Corp.