It’s All About the Decision (EMS)
Circa 1840: STEMI… It starts with an ECG… David R. Burt, MD Virginia Heart Attack Coalition
Circa 2012: Collaborative Circa 2012: Collaborative Circa 2012: Collaborative Circa 2012: Collaborative Strategery Strategery Strategery Strategery The “STEMI Bill of Rights” succinctly outlines ten fundamental concepts so essential in principal that each one should be individually addressed within every STEMI System of Care
2012: STEMI Bill of Rights
Background: Background: Background: Background: After the framing of the US Constitution was complete, The Bill of Rights was drafted by our Founding Fathers to underscore essential Rights that were deemed so fundamental in the preservation of personal liberty as to merit individual discussion....
2013: “The Other 15%” Initiative Goal: Partner with OEMS to achieve 100% PHECG in Virginia 2 15% Yes No 85%
2015: Rapid Reperfusion is STILL THE treatment for STEMI Cath Lab Symptom Call to PreHospital ED Recognition Medical System Increasing Loss of Myocytes Delay in Initiation of Reperfusion Therapy Antman EM et al. Circulation, 2004 Reperfusion delay increases both short and long-term mortality!
The Cardinal Rule: Once STEMI is identified � � it must trigger a clear � � response downstream! ECG Acquisition EMS ECG Evaluation EMS/ED Communication !Decision !
Fact: Viewing the PH ECG can reduce time to Reperfusion • Treatment decisions can be made pre-arrival • The ER is aware of the incoming patient • The hospital reperfusion system can be activated immediately • Patients can be routed to the best destination ......all contribute to faster treatment!
Current PH ECG Transmission: • Fax the pre-hospital ECG to the ER – Slow, tech bottlenecks • Snap a photo and text/email it to the doctor – Unreliable due to poor cell service in field, hospital rules, broadband bottlenecks • Use a commercial/proprietary system – Expensive, unreliable, compatibility issues
STEMISEND: A possible solution • A low-cost (free) app to acquire & send an ECG image for real-time viewing • Works with all ECG sources • No proprietary technology involved! • Works with any cell phone network • Performance can be improved significantly with cell phone boosters.
STEMISEND: The system… EMS ECG image ECG image STEMISEND obtains sent to accessed by Physician Reperfusion acquires ECG ECG (any server receiving views ECG decision! image source) mailbox facility Cell Network
3 Simple Goals: 1. Simplify the process Creation of STEMISEND front-end app – 2. Level the playing field – Optimize cell signal environments 3. Try to break it!! – Extensive Beta Testing. EMS involved. Field conditions. Sunday at 4am. Try to provoke failure. Drop the phone. Can a doctor use it?
The Skit A walkthrough of the process
Designing and Executing a Beta Test • Analyze geography to identify suspected signal limited environments • Analyze most recent census data to identify populations centers, populations most at risk for STEMIs • Work with local EMS providers to identify signal limited environments • Design routes to be driven through identified areas • Periodically, stop the vehicle. Test STEMISEND on each cell network both boosted and without the cell booster. Test the commercial systems in the same conditions.
STEMISEND Field Testing
STEMISEND: Initial Testing in Albemarle and Orange Counties (No Booster) Conclusion: • At 3-5 bars of cell Comparative Efficacy of STEMI Send service, STEMISEND for Major Carriers (Boosted ) s. Commercial Systems performance (on 3 1.0 Point of 0.9 equivalent networks) is performance 0.8 (approx. 3 bars) equivalent to 0.7 Average Durationof Transmission (within 120s) commercial systems 0.6 • At 1-2 bars, all 0.5 systems show 0.4 Carrier 1 Unboosted Carrier 2 Unboosted 0.3 decreased success Carrier 3 Unboosted Commercial System1 0.2 Commercial System2 0.1 0.0 0 1 2 3 4 5 Environment Bar Strength (accordingto iPhone)
2015: The Great Equalizer…
STEMISEND: Initial Testing in Albemarle and Orange Counties (With Booster) Comparative Efficacy of STEMI Send Conclusion: Extremely for Major Carriers (Unboosted) vs. Commercial Systems 1.0 effective! 0.9 Rate of Absolute Reliability (Success within 120s) -A STEMISEND + Booster 0.8 0.7 > 93% at any system is equivalent or signal 0.6 strength > 0 superior to commercial 0.5 systems at all signal 0.4 Boosted Carriers Commercial System 1 0.3 strengths Commercial System 2 0.2 0.1 0.0 0 1 2 3 4 5 Environment Bar Strength (according to iPhone)
STEMISEND: Recent Testing Across Central Virginia = No Transmission = Transmission (booster only) = Transmission
STEMISEND: Recent Testing Across Central Virginia
Farmville Catchment Area Test Results • Nottoway County:
Farmville Catchment Area Test Results Boosted Data • Nottoway County:
Farmville Catchment Area Test Results • Lunenburg County
Farmville Catchment Area Test Results Boosted Data • Lunenburg County
Sentara-Rockingham Catchment Area Testing • Rockingham County – To east and west of county, highly mountainous terrain provides severely signal limited environments – North, South, and Center of county relatively flat, have much more reliable service
Sentara-Rockingham Catchment Area Testing • Rockingham County
Sentara-Rockingham Catchment Area Testing • Rockingham County
Current Rockingham-Sentara ECG Transmission Issues Email Forwarding Chains Destination Inbox
Summary: • In “Signal Rich” environments (3-5 bars) STEMISEND (unboosted) is comparable to commercial systems • With use of a cell phone booster, STEMISEND is comparable/superior to commercial systems (in all signal strength environments) • Strong correlation between signal bars and probable success (non-boosted environments) • Extreme simplicity and low cost are assets
Absolute vs. Relative Dead Zone • Conclusion: looking for areas of rapid change between full service, relative, and absolute dead zones.
Summary: • STEMISEND unboosted is comparable to existing commercial systems in a 3-5 bar environments – Regardless of provider or iPhone model • STEMISEND plus booster equalizes performance across all cell signal environments if ANY cell signal exists • In ALL instances, STEMISEND is comparable or superior to commercial systems
STEMISend: The Future • Culpeper, Virginia catchment area beta test will begin in June. – Widespread EMS involvement in testing – Remote loading of app to phones – Preferential eval of SLE sites – Standardization of Installation
CVILLE System Deployment Plan Phase II: Testing the system locally Phase I: Testing the system at UVa • Multiple receiving destinations • UVa EMS crews • Hospital agnostic application • In and around UVa • 911 contracts in three counties • Multiple agencies and types • Pegasus aeromedical • ALS/BLS • Career/Volunteer • UVa as initial receiving destination Phase III: Full system roll-out • Open enrollment of agencies and hospitals • Customized application for each EMS agency • Voluntary hospital participation • ECGs delivered to destination email/fax of their choice
Future Goals • Set up a Public Demo Version on the iTunes App Store – Anyone can download, send images to the server – Access server to see the latest image • If interested, contact STEMISEND team to build your agency a custom version of STEMISEND with preprogrammed hospital ECG image Destinations
Interested? Try it yourself! • To Download STEMISEND PDV: – See Dr. David Burt or Zack Ballinger after this presentation – Sign your name and email. We will email you the required information. • General Process –after that: – Email Zack your UDID (easily attainable on iTunes) – Zack will email you a STEMISEND version specific to your phone – Simply Add to your iTunes library, sync, and snap!
Questions? • App, booster, and other materials are available for demonstrations after this presentation. • Feel free to ask Dr. Burt, Zack, Will, or Tristan any questions you may have.
Contact Information David R. Burt, MD Will Barnhardt University of Virginia University of Virginia, davidrburt@virginia.e Medic V du wfbz@hscmail.virginia.edu O: (434) 924-8488 Zack Ballinger Tristan Jones University of Virginia University of Virginia zcb9cb@virginia.edu taj3tp@virginia.edu 571-223-9982
STEMISEND: • A low-cost (free) app • Works with all ECG sources • No proprietary technology! • Works with any cell phone Performance improved significantly with boosters. • www.STEMISend.com
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