Abstract 357: Statewide Collaboration in Rural STEMI System Development in Resource Limited Environments- Where You Live Shouldn't Determine If You Live: North Dakota Mission: Lifeline
Authors: Haldis Thomas , Sather Jeffrey , Reddy Karthik , Oatfield Robert , Almanaseer Yassar , AbouFakher Rabeea , Cook Mindy , Moe Pamela 
Published: July 2021

Background:
Mission: Lifeline is a strategic initiative to save lives and reduce disability by improving emergency readiness and response to heart attack patients. Heart disease is the number one killer in North Dakota and nationally. North Dakota consists of 53 counties over 69,001 square miles with a population of 680,000. Thirty-four entire counties are designated medically underserved areas and 13 counties have some part of them designated medically underserved. A large number of residents reside in the 36 frontier counties 21% (142,800/680,000) with a population density of < 6 people/mile, and 9 rural counties 15% (102,000 of 680,000): < 5000 residents Population density of > 6/mile together making up just over one third of the state population and 85% (45 of 53) of the physical territory. Eight urban counties with a city of at least 15,000 make up the remaining population at 63% (428,400 of 680,000). In 2011, ND M:L received a $7.1 million grant to bridge gaps in disparities in access to care by streamlining statewide STEMI systems.

Methods:
A statewide initiative was implemented for pre-hospital recognition, education, triage, and treatment of STEMI patients to the most appropriate reperfusion strategy.

• Ninety eight percent (123 of 125) licensed ground EMS received funding to enable pre-hospital 12 lead ECG acquisition and transmission to both referral and receiving hospitals
• In person facilitated education were provided to each EMS agency in 3 rounds with focus on acquisition, recognition and triaging of STEMI patients utilizing the ACC/AHA guidelines.
• PCI receiving hospital physician and nurse educator teams facilitated a standardized in person clinical STEMI education session at each of the 38 referring hospitals focused on utilizing a state recommended referring hospital STEMI protocol, EMS transport guideline, and a STEMI feedback process
• Six of six PCI receiving hospitals collected data utilizing the ACTION GWTG Registry

Results:
• In ND aggregate data from Quarter 3 2012 to Quarter 3 2013 there have been marked improvements in several measures.

The ND Mission: Lifeline composite score 93% (557/ 596) to 97% (471/482)
1ST EKG obtained Pre-hospital 46% (56/122) to 76% (92/121)
ED Arrival to First In-Hosp ECG % within 10 minutes 66.% (81/122) to 84% (103/122)
Arrival to Primary PCI <= 90 min. from 86% (32/37) to 100% (43/43)

Conclusions:
To sustain STEMI system of care for patients in ND, collaboration with regional partners, care standardization, aggregate data sharing and feedback have been identified as vital. Regional champions committed to systemization are central to EMS and referral hospital engagement and state level process improvement. PCI receiving hospitals lead the way in convening regional multidisciplinary teams meetings, and facilitating data feedback on STEMI systems at a state level to support a unified platform of sustainability.