October 2011
The Utah STEMI System: A Coordinated Emergency Response to a Time-Critical Condition
busters) or mechanically by using a balloon and a stent inserted into the blocked vessel through a long catheter (called angioplasty). While both treatments are effective and can be lifesaving, research has determined that, when available, the most effective treatment involves opening the blocked artery via angioplasty. However, this treatment is only available in specialized centers with cardiac catherization laboratories (cath labs) and interventional cardiologists. Conversely, thrombolytic medications are available at virtually every hospital statewide. Over the past three years, the Utah Bureau of Emergency Medical Services and Preparedness (BEMS) has enlisted the expertise of hospital cardiac care experts, cardiologists, emergency physicians, EMS providers, the Utah Hospital Association, and the American Heart Association to develop a system to speed the recognition and treatment of STEMI patients. The focus of the Utah STEMI System is to integrate EMS and hospitals to get patients with STEMIs to the hospital best able to treat them in the shortest possible time. Nationally, many cities and regions have developed such formal systems to facilitate the care of these patients. The Utah STEMI System development process has involved three phases: 1. The development of both pre-hospital (EMS) and hospital protocols for integration of patient care from the field to the ED/cath lab. 2. The funding and fielding of 12-lead field ECGs to EMS agencies throughout the state. 3. The identification and designation of STEMI/PCI Centers (those specialized centers with interventional cardiac catherization laboratories) meeting standardized criteria, to which EMS will preferentially transport field-identified STEMI patients. The Utah STEMI system involves a multi-faceted approach to heart attack victims. EMS agencies, utilizing field ECGs, identify STEMI patients and alert hospital emergency departments of the patient condition and time of arrival. The field ECG is transmitted to the receiving hospital directly from the patients location, allowing immediate review by the hospital physicians. This allows them to assist in the field care of the patient, as well as to activate their hospital STEMI team to ready the cath lab. As a result of this coordinated response, precious minutes are saved. Nationally, this approach has saved an average of over 20 minutes per patient in the time it takes a patient to move from the field to definitive care in the cath lab. The Utah Hospital Association and its member hospitals have contributed funds to help purchase these ECGs for EMS agencies statewide. Through these efforts, over 90% of the population in Utah has access to EMS agencies with lead ECG capabilities. Plans to cover the other 8% are in the works (see Figure 1). Where and when appropriate, it is anticipated that EMS providers may bypass a non-PCI hospital to facilitate timely definitive care for STEMI patients at a STEMI/PCI Center hospital.
Utah Health Status Update:
ST-Elevation Myocardial Infarction (STEMI) is commonly referred to as a heart attack. It involves a blockage of an artery supplying critical blood flow to the heart muscle. This blockage can cause death of part of the heart muscle, leading to heart failure, heart rhythm problems, and death. Like trauma and stroke, STEMI is a time-critical illness and immediate recognition and treatment are critical to optimal patient outcomes. Literally, time is muscle, as each minute of blood flow interruption increases the death of precious heart muscle. Two effective treatments are available for patients suffering from a STEMI; both involve opening the blocked vessel and restoring the blood flow to the heart muscle. The blocked vessel can be opened chemically by use of intravenous thrombolytic medications (also called clot ST-Elevation Myocardial Infarction (STEMI) is commonly referred to as a heart attack. STEMI is a time-critical illness and immediate recognition and treatment are critical to optimal patient outcomes. Research has determined that, when available, the most effective treatment involves opening the blocked artery via angioplasty. Over the past three years, the Utah Bureau of Emergency Medical Services and Preparedness (BEMS) has enlisted the expertise of hospital cardiac care experts, cardiologists, emergency physicians, EMS providers, the Utah Hospital Association, and the American Heart Association to develop a system to speed the recognition and treatment of STEMI patients. Beginning September 15, 2011, hospitals will be invited to become officially designated as STEMI/PCI Centers. Today, many EMS agencies and receiving hospitals around the state are already utilizing the new ECG technology to speed lifesaving care to heart patients.
Hospitals designated as STEMI/ PCI Centers must meet nationally accepted criteria to receive these patients. These include the ability to receive ECGs transmitted by EMS from the field; 24 hour availability of a cardiac cath lab team that will respond to a STEMI alert with in 30 minutes of notification; and the ability to provide care to STEMI patients who may have a difficult airway, arrange for emergency cardiac surgery, if needed, and provide the intensive care required by STEMI patients after appropriate intervention is provided. STEMI/ PCI Centers must also agree to monitor and report Performance Improvement (PI) results to the Bureau of EMS, which will monitor results of the PI. Presently, there are 15 hospitals in Utah that may qualify as PCI Centers. Since not all STEMI patients are located in areas with access to STEMI/PCI Centers, smaller hospitals will utilize emergency treatment with thrombolytics, followed by consultation with cardiac experts at STEMI/PCI Centers for possible transfer for PCI treatment as needed. NonPCI facilities will be encouraged to develop a relationship with larger STEMI/PCI Centers to facilitate such communication and patient-care coordination. Beginning September 15, 2011, hospitals will be invited to become officially designated as STEMI/ PCI Centers. Today, many EMS agencies and receiving hospitals around the state are already utilizing the new ECG technology to speed lifesaving care to heart patients. As it continues to develop and mature, the Utah STEMI System will help improve the emergency cardiac care available to all Utah residents, regardless of their location.
Counties in Utah Covered by 12-Lead ECG
Figure 1. Counties in Utah covered by 12-lead ECG as of August 2011
October 2011 Utah Health Status Update
For additional information about this topic, contact Peter Taillac, M.D. ([email protected]) or Robert Jex, RN ([email protected]), both of the Bureau of EMS and Preparedness; or the Office of Public Health Assessment, Utah Department of Health, Box 142101, Salt Lake City, UT 84114-2101, (801) 5389191, email: [email protected]
Spotlights for October 2011
Breaking News, October 2011
Trends in Leading Causes of Death for the State With the publication of mortality data for 2010 a new decade of trend data on leading causes of death in Utah became available. While the overall ranking of the leading causes of death in Utah remained fairly stable over the decade 2000 to 2010, some important trends are evident in the data. Age-adjusted death rates have declined significantly for many of the big killers. There was a 29% decline in the death rate for diseases of the heart (the leading cause of death at both the beginning and the end of the decade) and a 46% decline in the death rate for cerebrovascular disease. Age-adjusted death rates for cancer, chronic obstructive pulmonary disease, diabetes and influenza and pneumonia all declined over the decade. Small (not statistically significant) increases in ageadjusted mortality were seen for suicide and nephritis, nephrotic syndrome and nephrosis. Over the decade unintentional injuries passed chronic lower respiratory disease and diabetes to become the 4th leading cause of death (age-adjusted) in Utah.
Ten Leading Causes of Death of Utah Residents per 100,000, Utah Population, 2000 and 2010
Diseases of the Heart Malignant neoplasms Cerebrovascular diseases Unintentional injuries Chronic lower respiratory disease Diabetes melitus Alzheimers disease Suicide Influenza and pneumonia Nephritris, nephrotic synd. and nephrosis
0
135.9 128.6 35.2 34.1 34.8 34.5 31.7 34.2 21.8 23.3 18.7 14.5 17.0 25.4 16.5 11.2 12.6
50 100 150
191.6
150.1
65.2
2000 2010
200
250
Age-adjusted Rate per 100,000
Community Health Indicators Spotlight, October 2011
Binge Drinking in Utah Binge drinking is defined as the consumption of five Binge Drinking by Local Health District, Utah, 2010 or more drinks on an occasion for men, or four or Weber-Morgan more drinks on an occasion for women one or more Wasatch County times during the past 30 days. Binge drinking is an Utah County indicator of potentially serious alcohol abuse, and can TriCounty lead to serious health problems, injuries, and violence. In Utah, the percentage of adults who reported binge Tooele County drinking in the past 30 days fluctuated between highs Summit County of 12% in 1989 and 1993 to a low of 7.7% in 1997. Southwest Utah In 2010, 8.7% (crude rate) of Utahns were at risk Southeastern Utah for binge drinking. However, there was a significant Salt Lake Valley difference in risk between men and women: 5.6% Davis County of women are at risk for binge drinking and 11.9% Central Utah of men are at risk. Younger adults had higher rates of binge drinking than older adults. Amongst Utahs Bear River local health districts, the highest age-adjusted rates of 0% 5% 10% 15% 20% Percentage of Adults at Risk for Binge Drinking binge drinking were found in Summit County LHD (16.03%), TriCounty LHD (11.9%), and Salt Lake Data Sources: Utah Behavioral Risk Factor Surveillance System, 2010. Valley LHD (11.2%), but only Summit County and Salt Lake Valley were statistically significantly higher than the state rate. The lowest rate of binge drinking was found in the Utah County LHD (3.3%) and this rate was statistically significant.
10.7% 7.5% 3.3% 11.9% 7.5% 16.0% 6.7% 9.5% 11.2% 6.3% 7.8% 6.2%
Monthly Health Indicators Report
(Data Through August 2011)
% Change From Previous Month Current Month # Expected Cases (5-yr average) % Change From 1 Year Ago State Rank # (1 is best) 11 (2010) 1 (2010) 23 (2010) n/a 15 (2007) 49 (2007) n/a 15 (2010) 17 (2010) 1 (2007) 1 (2007) 14 (2007) 19 (2008) n/a 4 (2007) 16 (2009) % Change From Previous Year +5.9% +5.9% +22.9% +14.7% Previous Month Current Month
# Expected YTD (5-yr average)
YTD Standard Morbidity Ratio (obs/exp)
Current Month # Cases
Monthly Report of Notifiable Diseases, August 2011 Campylobacteriosis (Campylobacter) Shiga toxin-producing Escherichia coli (E. coli) Hepatitis A (infectious hepatitis) Hepatitis B, acute infections (serum hepatitis) Meningococcal Disease Pertussis (Whooping Cough) Salmonellosis (Salmonella) Shigellosis (Shigella) Varicella (Chickenpox) West Nile (Human cases)
Program Enrollment for the Month of August 2011 Medicaid 247,627 PCN (Primary Care Network) 15,820 CHIP (Childrens Health Ins. Plan) 38,641
# Cases YTD
Current Quarter # Expected Cases (5-yr average)
# Expected YTD (5-yr average)
Current Quarter # Cases
YTD Standard Morbidity Ratio (obs/exp)
# Cases YTD
Quarterly Report of Notifiable Diseases, 2nd Qtr 2011 HIV/AIDS Chlamydia Gonorrhea Tuberculosis
21 1,687 66 11
30 1,443 146 9 Expected/ Budgeted for Month
43 3,405 119 23 Fiscal YTD
60 2,946 297 17 Budgeted Fiscal YTD
0.7 1.2 0.4 1.4 Variance over (under) budget
Medicaid Expenditures (in Millions) for the Month of August 2011 Capitated Mental Health Inpatient Hospital Outpatient Hospital Long Term Care Pharmacy Physician/Osteo Services TOTAL HCF MEDICAID
$ 21.6 $ 19.3 $ 8.7 $ 13.2 $ 13.4 $ 6.8 $139.6
$ 22.7 $ 24.6 $ 7.4 $ 18.7 $ 6.6 $ 6.6 $ 146.8
$ 28.8 $ 27.5 $ 11.9 $ 20.4 $ 26.6 $ 9.8 $ 210.3
$ 30.3 $ 33.9 $ 11.5 $ 26.3 $ 23.6 $ 10.0 $ 226.5
$ (1.5) $ (6.5) $ (0.4) $ (5.9) $ (3.0) $ (0.2) $ (16.2)
Annual Community Health Measures Obesity (Adults 18+) Cigarette Smoking (Adults 18+) Influenza Immunization (Adults 65+) Health Insurance Coverage (Uninsured) Motor Vehicle Traffic Crash Injury Deaths Poisoning Deaths Suicide Deaths Diabetes Prevalence (Adults 18+) Poor Mental Health (Adults 18+) Coronary Heart Disease Deaths All Cancer Deaths Stroke Deaths Births to Adolescents (Ages 15-17) Early Prenatal Care Infant Mortality Childhood Immunization (4:3:1:3:3:1)
2010 2010 2010 2010 2009 2009 2009 2010 2010 2009 2009 2009 2009 2009 2009 2009
454,700 180,100 175,900 301,900 227 543 445 128,000 296,100 1,469 2,543 734 992 38,562 285 41,500
23.1% 9.1% 68.2% 10.6% 8.1 / 100,000 19.4 / 100,000 15.9 / 100,000 6.5% 15.0% 52.5 / 100,000 90.8 / 100,000 26.2 / 100,000 16.5 / 1,000 71.6% 5.3 / 1,000 76.6%
Current Month
Diagnosed HIV infections, regardless of AIDS diagnosis. Budget has been revised to include supplemental funding from 2011 General Session. Only includes the gross pharmacy costs. Pharmacy Rebate and Pharmacy Part-D amounts are excluded from this line item. % Change could be due to random variation. # State rank based on age-adjusted rates. Notes: Data for notifiable diseases are preliminary and subject to change upon the completion of ongoing disease investigations. Active surveillance for influenza virus has ended until the 2011-2012 season.
% Change From Previous Year -4.0% -6.9% -0.8% -5.6% -16.6% +7.0% +15.3% +0.2% +6.8% -4.4% +1.1% -2.2% -10.6% -9.6% +11.4% +4.1%
48 16 0 1 0 18 25 7 11 1
38 23 1 2 0 27 33 7 15 31
329 67 4 6 7 301 216 37 226 1
253 81 8 10 5 255 226 29 446 39
1.3 0.8 0.5 0.6 1.5 1.2 1.0 1.3 0.5 0.0
243,762 16,347 37,994 Annual Visits Rate per 100 Population
+1.6% -3.2% +1.7%
225,703 +9.7% 14,620 +8.2% 40,975 -5.7% Annual Charges Total Charges in Millions $ 5,416.2 $ 4,552.5 $ 1,081.4 $ 1,465.7
Health Care System Measures Overall Hospitalizations (2010) Non-maternity Hospitalizations (2010) Emergency Department Encounters (2009) Outpatient Surgery (2009)
274,576 167,340 684,176 311,442 Current Data Year
9.0% 5.3% 23.3% 10.6% Number Affected
Percent/ Rate
% Change From Previous Year -2.6% -0.9% -1.1% +1.9%
Number of Events
1 Year Ago
