Hello, my name is Karen Avila, and I am one of the 2020 ACC Quality Initiative grant recipients for my work entitled Promoting Awareness of Heart Attack Symptoms and Responsive Actions. I am currently the Professional Practice Coordinator at Capital Health Medical Center in Hopewell, New Jersey, as well as the lead for the Chest Pain Center Accreditation. Before I begin my presentation, I would like to provide some background information about Capital Health. Capital Health System is comprised of two hospitals. Capital Health Medical Center on the regional campus is located in Trenton, New Jersey, serving our urban population. Capital Health Medical Center Hopewell is located in Pennington, New Jersey, serving the suburbs and extending into Pennsylvania. The two acute care hospitals are located only a few miles apart in Mercer County, New Jersey. There are 458 licensed beds. In 2021, inpatient discharge volume was over 22,000, and in 2021, the emergency department had over 114,000 visits. The mission of Capital Health is to be committed to improve the health and well-being of the populations we serve in urban and suburban communities. Capital Health will be the region's provider of choice, bringing our community superior clinicians and partners who improve services and quality of care while maintaining local control. The Hopewell campus has been an accredited chest pain center with primary PCI since 2013. We continue to utilize the ACC guidelines to further advance our program and reach our community to provide excellent cardiac care. Capital Health has a vast community health program. The chest pain center coordinator and the community health team work together to offer multiple programs for our youth, adults, and senior population on a monthly basis. The chest pain center coordinator has created, organized, and taught Heart School. Heart School is a youth-based educational program that teaches local fourth grade classrooms, EHAC education, and how to live a heart-healthy lifestyle. This program has been very popular over the past few years, and we look at expanding it to other grades in the future. One area of focus that has been highlighted in the last few years is our collaboration with EMS. EMS is employed by Capital Health and covers a large area of Trenton and its surrounding areas in both New Jersey and Pennsylvania. EMS works closely with the chest pain center steering committee to provide support with educational efforts made in the local area. EMS also helps this current initiative by using EHAC materials during its CPR classes as well as educational opportunities completed by their team. Our collaborative goal is to increase the usage of EMS services for our chest pain patients. Despite all of our collaborative efforts with community health and EMS, general knowledge of ACS and heart attacks remains inadequate among the community. Evidence still shows that acute myocardial infarction is the leading cause of premature death in developed countries. Approximately only 42% of adults can name five symptoms of an MI and know when to call 911. Adults continually ignore beginning signs, drive their loved ones or their self to the emergency room, or delay care due to fear or lack of urgency. Delay in seeking attention after the onset of symptoms delays reperfusion and interventional care. There is a need to initiate a program that creates community awareness regarding the recognition of heart attack beginnings and the rapid need for attention. Media campaigns can promote healthy lifestyles and increase awareness. Campaigns can not only educate but break down barriers or assumptions that people have about a certain health condition or in this case, maybe even EMS. For example, a campaign could help debunk the myth that a person can drive faster than waiting for EMS to arrive to their house. The education can show that care can begin when EMS arrives. As the Chest Pain Center coordinator, I was always looking for a way to push ahead in our community health program. How could I broaden the education of EHAC? How can I reach a broader spectrum of people to heighten the community awareness of the symptom recognition and responsive action of ACS? My goal was to reach those people who weren't coming to the senior center, the church program, or that neighborhood function to learn how to adopt a healthier lifestyle. After much researching, I found that mass media marketing strategies were often used for health concerns and conditions. And I noted that many of them had a positive impact among people, so I questioned would a mass media marketing strategy increase activation of 911 and EMS use among our patients? What I wanted to do was conduct my own mass media marketing strategy to examine the impact on our community members and their recognition of the signs and symptoms of a heart attack and whether or not they would initiate that 911 call. In the spring of 2020, I submitted my proposal targeting January of 2021 as a starting point. I chose to do this initiative over six months, ending in the summer of 2021. Emergency room patients seeking care for the signs and symptoms of a heart attack that arrived via EMS were included. And the NCDR was used as my data source, providing a randomized sample of ACS patients. The National Cardiovascular Data Registry, or the NCDR, was used as a primary data source to determine the baseline for the perceptions and adjusting for signs and symptoms of ACS and activated 911. The baseline time period was the year of 2020. For each quarter, the blue boxes on the graph display a randomized sample of patients who experienced symptoms of an MI and sought medical treatment in the emergency department. The green shows the number of those patients that activated EMS to get to the ED. In the year of 2020, at Capital Health, approximately 18% of patients who sought medical care arrived via EMS. Data was also collected to determine the baseline for patients who had activated EMS from a rare diagnosis for the study. The blue box represents the total number of patients who arrived via EMS, and the green displays the number of patients who were diagnosed for the study. In 2020, approximately 15% of all of our study patients activated 911 when symptoms began. After reviewing the baseline data, I saw a lot of potential in instituting a mass media marketing strategy. My objective for this project was to evaluate the impact of a marketing or educational program using the EHAC materials to educate all community members, regardless of age, through different media sources. The six-month campaign would use multiple sources, focusing on a streamlined message. A multifaceted media strategy would use consistent messaging, including the chest pain picture, the early heart attack care symptom wheel, and other early heart attack care slogans, such as, heart attacks have beginnings, did you know, and survive, don't drive. The messages would be consistent across each vehicle. As well as links to the Capital Health site, where patients can learn more about the EHAC program, as well as the Chest Pain Center at Capital Health Hopewell campus. Due to the restrictions of COVID-19, community outreach programs were put on hiatus. And face-to-face forums were restricted for a long period of time. So now, how do I reach an audience if everyone's in lockdown? People are scared to leave their home and come to the hospital or a doctor's appointment to see medical treatment. So initially, my plan was to go to the community and hold informational sessions in different places, such as fitness centers, college campuses, large businesses, and other community places where people frequently go. I was wanting to try and reach a broader population that focused on the young and older adults that aren't your typical audience to attend a health seminar, classes, or informational sessions. I wanted to reach these people who may be at a high risk, but may not know. And the EHAC education allowed me to share easily with people of all ages, backgrounds, and health statuses on how to recognize the signs and symptoms of a heart attack and when to seek help. However, when I initially began this project, I didn't realize that I was going to be stepping into the time of a pandemic. A random distribution of materials would not have worked as originally I had perceived. So new pathways to connect to the community members had to be implemented. Some of the pathways are listed below. Pathways such as positive, positive, positive, positive, positive, positive, positive, positive, Pathways such as podcasts, newspapers, mailers, billboards, and hold messages were implemented. New pathways had to be creative, though. They needed to catch and grasp the attention of the audience in order to have the information read and retained. In collaboration with our public relations department, I created with them a chest pain advertisement. The advertisement shows a man clenching his chest where the heart is highlighted, surrounded by signs and symptoms of an MI, and accompanied by the tagline, survive, don't drive. So let me share with you a few ways that this advertisement was used. One of the largest ways that we used this advertisement was having poster clings. So because virtual and telemed appointments became all the new thing as a result of the pandemic, instead of placing posters in an office waiting room, they were placed behind the provider, or where the provider would sit, and we placed the posters behind them, but in sight of whoever was the patient attending a virtual visit. This way, the patient could see the poster, and for those patients who were high risk, the provider could easily review the information with the patient. Posters of the EHAC circle of symptoms, as I call it, was also displayed in the emergency department waiting room, in the individual ED rooms, as well as on electronic charging stations located at the hospital's entranceways, the ED waiting room, and the ED holding area. Many of the electronic charging stations still contain this message today, but have expanded into the cafeteria. The chest pain advertisement was also made into mailers, and the mailers were sent to 400,000 random households in Mercer County, New Jersey, and then Bucks County, Pennsylvania. We also took advantage of the Sunday newspaper displaying the same information and the same message to increase patient recall. In addition to these more traditional mass media ways, I also turned to podcasts and social media. We began our program podcast with the help of an interviewer, the chest pain center medical director, as well as the chest pain center coordinator. The podcast was broadcast on social media platforms, as well as local radio and the hospital website. An interviewer was given a list of questions to ask to both the medical director and the chest pain coordinator, questions about the signs and symptoms of an MI, what to do when these signs are recognized, what happens in the process, so what happens when EMS comes to pick you up at your house, what happens when you're en route to the emergency room, and then lastly, what happens when you get to the hospital. The podcast not only reached or looked at the health process or the healthcare providers that were involved, but we also addressed COVID-19. We talked about what the hospital would look like in COVID-19 to help sidetrack any fears that a patient might have or a person might have, and that's the reason why they wouldn't go to the emergency room. We also talked about the cleaning process of the ED and the PPE that healthcare providers were wearing. Listeners were able to call in and ask questions as well. The podcast was placed on many platforms so that a broad range of listeners could hear it, but the chest pain center medical director and I also felt that it would be great to actually have something that the patients could see also on the platforms, and so we worked with a videographer to make a video, an eight-minute video featuring our chest pain center medical director, the director of EMS, as well as the cath lab director was created. The video featured the process of what happens from the time a patient is picked up from EMS as they go into the emergency room, if they needed the cath lab, and then ultimately what that discharge and post-discharge process looks like. We were able to use an EMS crew to feature in the video so that we were not only talking about what happens, but we could also show what happens. We were able to use a room in the emergency department that we were able to have a stand-in act as a patient to show that process as well as walking through a discharge process with our patient. The video was displayed on different platforms from social media, on the Capital Health website, and we continue to use this video to this day. Lastly, one of the mass media marketing strategies that was used was by placing two billboards near high-traffic areas. Although this was not an original media source or a source of media that I had originally planned, it seems to have the most recall among our community members. Oftentimes, we hear of, you know, I've seen that billboard of the heart and the man clenching his heart. I chose the billboards because I felt like during a time of lockdown, when there are many businesses closed and not a lot of places to go to, I felt that as a community member myself that oftentimes just to leave the house that I would drive around and just take the kids and the family for a drive. And to this day, I still hear, I've seen your billboard on the side of the road. So, those are just some of the ways that we have used newer pathways or more creative pathways to reach our patient population. Social media played a large role in this initiative. Higher social media use due to quarantine was noted. Capital Health experienced a higher traffic to the website and to social media accounts during this time. 72% of the public use some type of social media. With Facebook being the most widely used, it is followed by Instagram, Pinterest, LinkedIn, Snapchat, and Twitter. 75% of Facebook account holders are daily users, as well as 66% of Instagram account holders. Knowing this information, I was able to partner with my public relation team to create ongoing social media posts featuring the signs and symptoms of ACS, the importance of 911 activation, as well as the risks associated with not seeking medical care. In addition to simple posts, we were also able to repost our podcast and snippets of the video audio to further educate our community, as well as others who don't even live near New Jersey. Here are some examples of printed media sources and materials that was used throughout this initiative. Each source has an image that was created to be consistent across all sources of media. Whether it be a sign in the hallway, a poster behind the physician during a telehealth visit, a mailer that was sent to individuals' houses, or a billboard. The key was to keep the message consistent so that community members would recall the message, recognize, respond, and call 911. The campaign took place in the first and second quarter of 2021. Looking at the NCCDR data for this time period, an increase of patients activating 911 was increased to 21%. I also looked at the two quarters after the pandemic. And for three and quarter four of 2021, there was continued increase in 911 activation. The NCCDR also provided information for asking patients to activate 911. In addition to updating the NCCDR website, we were also able to update the NCCDR website for asking patients to activate 911. In this process, we see the total number of patients that arrived by EMS, and the group of high-risk patients who were later diagnosed with STEMI that originally arrived by EMS. Throughout our campaign in the first and second quarter of 2021, we do see an increase in EMS activation. This activation among the STEMI patients also continued throughout the remainder of 2021. We used the EMS activation of 911 to increase 3% during our trial period. And we used the EMS activation of 911 for the STEMI patient increase as well, from 15% to 19% during the campaign period. A mass media marketing campaign to increase the awareness of signs and symptoms of a heart attack and ACS was associated with a slight increase in EMS use by activation of 911 in chest pain patients. There was also an increase in the utilization of EMS by the patient later diagnosed with the STEMI. Mass media marketing and community education can positively influence healthcare decisions in patients with symptoms of ACS. It can also be noted that many of the patients who sought medical treatment in the emergency department stated that they knew at least one symptom or sign of a heart attack, which led them to seek medical treatment. I would like to thank you for your time in listening to this presentation today. If you have any questions and would like to contact me, I am available by email at kavilla2 at capitalhealth.org. Thank you and have a great day. Thank you.

heart attack symptoms

Capital Health

EMS collaboration

mass media marketing

EHAC materials

STEMI