It All Started With STEMI.. Now Look At Us 10 Years Later
Now look at us 10 years laterby Melissa Gatchel-North (originally published on www.heart.org)
Good ideas often spark other good ideas. While the champions of Mission: Lifeline originally focused on developing a better system of care to treat patients with ST-segment elevation myocardial infarction (STEMI), they knew it's long-term success could only be ensured by a clear, objective look at its day-to-day performance.
"If you don't measure, nothing gets better. When you do measure, everything gets better," says James Jollis, MD, with Duke University Hospital in Durham, North Carolina, and one of the early forces behind Mission: Lifeline. "Data measurement is so important."
Years before the debut of Mission: Lifeline, the American Heart Association (AHA) launched Get With The Guidelines-Coronary Artery Disease (CAD) in 2001. Leveraging performance data from the beginning, the quality improvement program grew to encompass more than 600 hospitals before merging with ACTION Registry in 2008 to become ACTION Registry-GWTG. The shared registry was a natural fit for driving Mission: Lifeline's system of care in hospitals across the country.
Most importantly, registry data was used to generate Mission: Lifeline reports that offered hospitals feedback about their performance and adherence to program guidelines. The reports empowered care providers and facilities to track outcomes, successes and gaps from the system-of-care perspective. Mission: Lifeline field staff also began working individually with hospitals and regional stakeholders to identify opportunities for system improvements—improvements that would lead to better patient outcomes.
"Creating reports was important because they gave us a way to look at systems data," explains Lori Hollowell, national senior program manager for Mission: Lifeline Acute Coronary Syndrome (ACS) and GWTG-CAD. "For example, the data might show a hospital's door-to-balloon times are great, but a delay identified in the prehospital setting means heart tissue is still dying before the patient gets to the care facility."
USING MISSION: LIFELINE DATA TO NURTURE BETTER PERFORMANCE
Mission Lifeline data reports set the stage for another critical component of the program—recognition and accreditation. In 2010, the American Heart Association introduced the Mission: Lifeline STEMI recognition program for both STEMI receiving centers (PCI-capable) and STEMI referring hospitals (non-PCI-capable). "Mission: Lifeline recognition really takes quality improvement outside the walls of the hospital and into the STEMI system of care," adds Hollowell.
With well-defined criteria, hospitals are recognized for three levels of performance—bronze, silver and gold. STEMI-receiving centers are eligible for an additional level of Mission: Lifeline recognition—plus.
"From a hospital's perspective, recognition is an important motivating factor for better performance," say Puja Patel, senior manager of hospital accreditation and certification for AHA.
Indeed, with the ability to compare performance against competitors, Mission: Lifeline recognition propelled a broader adoption and implementation of program protocols. It's high-profile impact on positive performance eventually led to the Mission: Lifeline recognition program for EMS in 2014.
"The EMS agencies appreciate the local recognition because we try to acknowledge them in front of their county councils and other leaders who make decisions about their funding," says Hollowell. "Who will say yes to the 12-lead ECG machines they want to purchase? Or placing more paramedics on the truck? Who's going to approve adding a quick-response vehicle to their fleet? We really want to showcase the true work that EMS organizations are doing and how much they directly affect STEMI care. Mission: Lifeline recognition allows us to do that."
In 2011, Mission: Lifeline leveraged its recognition program as the backbone for STEMI accreditation.
The coveted accreditation designation positions hospitals as leaders in improving STEMI systems of care. Today, there are 65 hospitals across the country that are accredited as either a STEMI heart attack receiving or STEM heart attack referring hospital.
"Those hospitals are placed on our online quality map so patients and consumers can enter their zip codes and locate hospitals that are recognized by the American Heart Association for treating heart attack," says Patel.
Soon, EMS agencies may also be recognized through accreditation for their quality cardiovascular care.
THE NEXT LOGICAL STEP: MISSION: LIFELINE RESUSCITATION
As Mission: Lifeline's STEMI system began to hit its stride, a convergence of events was sparking advocacy for better protocols to treat out-of-hospital cardiac arrest.
"We realized that certain cases of cardiac arrest are actually STEMI with a chief complaint of sudden death," says Ivan Rokos, MD, an emergency medicine physician at University of California, Los Angeles. "It's all about blocked arteries, so that's why Mission: Lifeline Resuscitation was built on Mission: Lifeline STEMI."
In order to survive a cardiac arrest, the heart needs to start effectively beating again as quickly as possible. Cardiac activity following a period of arrest is known as "return of spontaneous circulation" (ROSC). "Based on some very large cardiac arrest studies, it became clear that 75 percent of patients who have an out-of-hospital cardiac arrest never achieve ROSC—only about 25 percent do," Rokos explains. "In Los Angeles County, we determined that these ROSC patients should not just be transported not to the nearest hospital, but to the nearest STEMI center."
At the same time, Dr. Gordon Ewy, MD, at the University of Arizona, and Ben Bobrow, MD, then director of Arizona's Bureau of Emergency Medical Services, called for hands-only cardiopulmonary resuscitation (CPR) over traditional mouth-to-mouth resuscitation based on findings that it saved more lives.
"There was also an emphasis for EMS to administer minimally interrupted chest compressions," Rokos adds. "It seemed that just by doing better chest compressions we were getting more people back with ROSC."
In Minneapolis, Mike Mooney, MD, was putting together hypothermia protocols for out-of-hospital cardiac arrest based on data that suggested cooling and cathing certain patients once they reached a STEMI receiving center improved outcomes. The "cool and cath" theory was backed up by "some very intriguing data coming out of Paris, the PROCAT registry," Rokos notes.
While Mission: Lifeline Resuscitation is making strides, it is still a work in progress. "It's much more complicated than the STEMI program," Rokos explains. "STEMI is a very linear process. Paramedics identify patients using a 12-lead ECG and quickly get them into the cardiac cath lab via direct pre-hospital transport (ideal plan) or inter-hospital transfer protocols (alternate plan). In contrast, cardiac arrest and resuscitation is a very non-linear process. Was the patient's collapse witnessed or not? What kind of rhythm did they have? How long before ROSC was achieved? The patient's age and comorbidities. So many factors can affect the outcome—especially the patient's brain recovery and long-term functional status."
Another issue has been the lack of a national quality-improvement database. "That is a big issue," says Rokos. "Even today, unfortunately, we still don't have great data."
DEFINING A BETTER SYSTEM OF CARE FOR STROKE VICTIMS WITH MISSION: LIFELINE STROKE
A shortage of data is also an issue for the Mission: Lifeline Stroke program launched in 2015. "While we do have Get With The Guidelines-Stroke as a data source, it has a very limited number of EMS-related data elements, so at this point it is very hospital centric," says Mic Gunderson, national senior consultant for clinical systems and new program development with AHA. "Our goal is to expand the reach of GWTG-Stroke to provide EMS with a robust data infrastructure that is linked to the data infrastructure for in-hospital care. By having those two components together, we'll have a much richer picture of how the overall system of care is working."
Unlike the non-linear challenges presented by cardiac arrest and resuscitation, treating ischemic and hemorrhagic stroke is better defined.
"The treatment for acute ischemic stroke is to dissolve the clot or remove the clot so blood flow can be restored quickly. That typically involves the use of thrombolytic drugs to dissolve the clot completely or make it easier to remove," says Gunderson. "If there's a ruptured blood vessel in the brain, though, the last thing you want to do is administer a thrombolytic drug. One of the major challenges with stroke is distinguishing between a hemorrhagic stroke and an ischemic stroke. The best technology for doing that right now is a CT scanner."
As part of the system of care, Mission: Lifeline Stroke is closely monitoring research about the use of mobile CT scanners inside ambulances in major metropolitan areas. With the ability to conduct CT scans on the scene, EMS can determine if the individual is suffering from an ischemic stroke, then administer life-saving thrombolytic medication right away.
When several research papers presented at the International Stroke Conference clearly demonstrated that a large vessel obstruction (LVO) in the brain is best treated with thrombolytic drugs and endovascular therapy, Mission Lifeline: Stroke began developing a protocol for EMS that would enable them to identify LVO stroke patients and route them to a comprehensive stroke or primary stroke center that could provide endovascular therapy. Last February, Mission: Lifeline Stroke introduced The Severity-Based Stroke Triage Algorithm for EMS.
The algorithm is designed to help EMS weigh many factors," Gunderson explains. "The algorithm gives EMS a process to identify which patients seem to be having a stroke, whether the patients seem to be having a large vessel obstruction stroke, and calculate the possible elapsed duration of the stroke. Based on all that information, the EMS team then factors in travel times in order to route the stroke patient to the most appropriate facility—whether that's an acute stroke-ready hospital, primary stroke center, comprehensive stroke center, or primary stroke center with endovascular capability. It was an extremely complex issue to address, and the release of the algorithm marks the first major initiative of the Mission: Lifeline Stroke committee."
Released just ahead of Mission: Lifeline's second anniversary, the algorithm puts the program on a solid path for greater adoption nationwide.
UNVEILING A SYSTEM OF CARE FOR NSTE-ACS
While Mission: Lifeline cut its teeth with STEMI, its founders always envisioned creating systems of care for a wide range of time-sensitive, life-threatening heart and stroke conditions. In 2016, Mission: Lifeline launched guideline recommendations for non-ST-elevation - acute coronary syndrome (NSTE-ACS) patients.
"Non-ST-elevation represents a larger proportion of MI patients and is not as easy to diagnose as STEMI," says Alice Jacobs, MD, an interventional cardiologist at Boston Medical Center, former president of the American Heart Association, and initial leader of Mission: Lifeline.
The addition of new and innovative Mission: Lifeline NSTEMI measures and tools help care providers close gaps and better coordinate efforts between EMS and hospitals, as well as hospitals and cardiac rehabilitation facilities. To aid caregivers, five process measures were added to Mission: Lifeline data reports to improve adherence to NSTEMI patient care guidelines and define criteria for Mission: Lifeline NSTEMI hospital recognition. Just as it always has been, actionable data remains a key driver for quality improvement and better patient outcomes.
THE ARRIVAL OF NEXT-GEN MISSION: LIFELINE AND GWTG-CAD DATA
Modeled in part after the University of California Los Angeles Cardiovascular Hospitalization Atherosclerosis Management Program (CHAMP) pioneered by Gregg Fonarow, MD—along with the 2001 pilot program conducted by Gray Ellrodt, MD, and Kenneth LaBresh, MD—GWTG-CAD was the first quality module introduced across the country by the American Heart Association. Today, GWTG has grown to encompass many clinical modules and more than 2,200 hospitals. In fact, more than 50 percent of acute-care hospitals in the United States participate in GWTG. The 2017 incarnation leverages lessons learned over the years to provide healthcare professionals and care facilities with a more robust, streamlined and meaningful quality improvement tool.
From Mission: Lifeline's inception through early 2017, the program's data reports were generated by Duke Clinical Research Institute using data hospitals entered into Action Registry-GWTG—a jointly owned and operated registry of the American Heart Association and American College of Cardiology. With significant changes, the data source for Mission: Lifeline transitioned back to GWTG-CAD—the innovative data source that made such a positive impact in the early years of the GWTG quality improvement program. Relaunched by the American Heart Association in April 2017, GWTG-CAD now serves as the primary solution for data and reports that fuel real-time, cutting-edge continued improvement as STEMI systems of care expand to more regions of the nation.
"One of the great things about this generation of CAD is we can be more responsive and tailor the tool to better serve patients, care providers and facilities in the timeline needed," says Christine Rutan, national director for Quality and IT Health. "There were pieces of data we felt would drive important improvement—including direct feedback to EMS. Now that we have our own data collection tool and reporting mechanism, we'll be able to deliver all the things we know our communities need to improve AMI care moving forward."
That unwavering quest for new and better ways to serve patients was the genesis of Mission: Lifeline 10 years ago and is still part of its DNA. While it all began with developing systems of care for STEMI, the initial vision was always to address other time-sensitive cardiovascular disorders by bringing EMS together with referral and receiving hospitals. Although there is still much work to do, advocates find it gratifying to see out-of-hospital cardiac arrest, stroke and NSTEMI as part of the Mission: Lifeline initiative.
"I remember in the beginning people saying Mission: Lifeline was going to be a two-year project," Hollowell recalls. "Ten years later, thank goodness, we're still evolving. To me, it's just amazing how it's grown and matured. I think it's a true example of how the American Heart Association/American Stroke Association—as a whole and our quality team—are meeting systems of care, meeting hospitals and EMS agencies where they are. We're growing with them."