Transcript Our STEMI Program

Our STEMI Program
Leesa Wright, RN, CCCC, CCRN
Methodist University Hospital
2015 Annual Tennessee STEMI Meeting
October, 2, 2015
Objectives
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Recognize the alignment of structure with
AHA Mission: Lifeline
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Identify the focuses within the roles of
each team within the AHA Mission: Lifeline
structure
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Identify interventions for common barriers
Disclosures
Leesa Wright, RN, CCCC, CCRN
Our STEMI Program
FINANCIAL DISCLOSURE:
No relevant financial relationship exists
I
Our Past: In the Beginning………….
Our Past: Our Team
Our Present: Our Team
Our Future: Why We Still Strive to
be Better
Estimated In-Hospital Mortality by
Door to Balloon Times
Time (minutes)
Adjusted Mortality
15
2.9
(2.8-3.1)
30
3.0
(2.9-3.2)
60
3.5
(3.4-3.6)
90
4.3
(4.2-4.4)
120
5.6
(5.4-5.7)
180
8.4
(8.2-8.7)
240
10.3
(10-10.7)
Our Team
EMS
Referral
Hospital
2013 ACCF/AHA Guidelines for the
Management of ST-Elevation
Myocardial Infarction
Class 1 Recommendation
Receiving
Hospital
Air
Transport
All communities should create and maintain a regional systems of care that includes assessment and
continuous quality improvement of EMS and hospital based activities. Performance can be facilitated
by participation in programs such as Mission Lifeline and D2B Alliance
AHA Mission: Lifeline
EMS Providers
EMS
Criteria
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Champions:
Review the data, make the processes,
present the results
Enhance Transmission Capability:
1. Each EMS system should maintain a standardized algorithm for evaluating and
FastECG.com
treating patients with symptoms suggestive of MI that should include acquisition of a
Lifenet
12-lead ECG and appropriate communication of the ECG findings(via direct
paramedic interpretation/voice communication, automated computer
algorithm interpretation, wireless transmission and MD interpretation, or an
combination of these 3 strategies) to the receiving hospital.
Improvement in time from obtaining
ECG to transmission of ECG:
2. Each EMS system should maintain a standardized reperfusion STEMI care
EMR book with FMC
pathway that designates primary PCI as the preferred reperfusion strategy if
initiated within 90 minutes of FMC or fibrinolytic therapy in eligible patients when
primary PCI within 90 minutes is not possible.
Scene Time:
Education of 15 minute goal for
3. Prearranged EMS destination protocols for STEMI patients should include:
STEMI
a. Bypassing non-PCI hospitals/STEMI Referring Centers and going directly to
Primary PCI hospitals for patients with anticipated short transport interval(
EMS Obtains Blood in the field:
< 30 minutes in urban/suburban settings to achieve PCI within 90 minutes
EMS providers will draw blood in the
b. Emergency transfer of EMS or other agencies to a STEMI-Receiving Center
field for STEMI and Stroke
of pts. who transport themselves to STEMI Referring Centers
c. Air Transport if possible(or default to ground transport)to STEMI-Receiving
Center or stabilization in STEMI Referring Center for patients with anticipated long
transport time and/or fibrinolytic ineligible and/or cardiogenic shock
AHA Mission: Lifeline
EMS
Criteria
(continued)
d. Administration of fibrinolytic therapy pre-hospital or in STEMI Referral Center
for fibrinolytic eligible patients with anticipated primary PCI time > 120 min
e. Emergency transfer to a STEMI PCI Center of patients who develop STEMI in
Non-PCI Center
4. When taken directly to a STEMI Receiving Center, all STEMI patients should be
transported to the most appropriate facility as determined by Mission Lifeline
hospital criteria of D2B
5. EMS Medical Director or designate should monitor care related to EMS patients
by meeting at least quarterly with pre-hospital providers, ED physicians,
interventional cardiologists, nursing staff, receiving hospital representatives,
and other appropriate individuals.
6. The following measurements should be evaluated on an ongoing basis:
a. Symptom onset to 911 call
b. 911 call received to arrival at hospital door
c. FMC to balloon (FMD)
d. EMS ECG to balloon (FMD)
e. Proportion of non-traumatic CP patients with ECG and STEMI patients with ECG
f. Patients with field diagnosis of STEMI with CL activation who do not undergo
PCI due to misdiagnosis or with no change in cardiac biomarker
AHA Mission: Lifeline
EMS Criteria
g. Proportion of patients with field diagnosis of STEMI and activation of Cath Lab
for intended primary PCI
1)do not undergo acute catheterization because of misdiagnosis
2)undergo acute catheterization and found to have no elevation in cardiac
biomarkers and no revascularization in the first 24 hours
h. Proportion of patients with EMS treated VF who are taken to the Cath Lab
i. Survival to hospital DC of all STEMI patients and of patients with VF (EMS and
STEMI- receiving facility to monitor jointly.)
AHA Mission: Lifeline
Non-PCI : Referral Center
Criteria
Non-PCI Hospital/STEMI Referral Center:
1. Appropriate protocols and standing orders should be in place to identify STEMI.
These should be present in ED, ICU (and for MRT)
2. Each ED should maintain a standardized reperfusion STEMI care pathway that
designates primary PCI as preferred reperfusion strategy if transfer to a primary
PCI hospital/STEMI Receiving Center can be achieved within ACC/AHA guidelines
Early Activation of Transport Team:
First Call – Air
Immediate Back Up Plan
3. Each ED should maintain a standardized reperfusion STEMI pathway that
designates fibrinolysis in the ED (for eligible patients)when the system cannot
achieve ACC/AHA PCI time
4. If reperfusion strategy is for Primary PCI transfer, a streamlined, standardized
protocol for rapid transfer and transport to a STEMI Receiving Center should be
operational.
5. If reperfusion strategy is for Primary PCI transfer, all patients should be transported
to the most appropriate STEMI-Receiving Center where the expected first D2B
(FMD) time should be within 120 minutes.
6. Ongoing quality improvement process, including data measurement and feedback
for the STEMI population and submit to Mission Lifeline
Transition of care to Transport:
10 minute TAT
AHA Mission: Lifeline
Non-PCI: Referral Center
Criteria
Referral Center (continued)
7. Program to track and improve treatment (acutely and at discharge) with
ACC/AHA guideline-based Class I therapies.
8. A multidisciplinary STEMI team, including EMS, should review hospital specific
STEMI data on a quarterly basis: Door to first ECG
Proportion of patients receiving therapy
Referral Center D2B
AHA Mission: Lifeline
Inter-hospital Transfer
EMS
-STEMI patient for reperfusion has same priority as 911 and trauma
-Patient stays on EMS stretcher for STEMI evaluation for inter-hospital transfer
-Transfer plan including preferred transport modality and backup transport modality
is established
-Transport directly to cath lab when lab is staffed and available for PCI without
reevaluation in the ED
-When possible, minimize or avoid continuous IV infusions such at Nitroglycerin and
heparin
-Transfer protocol should focus on rapid transport to cath lab rather than pain relief
with medications
-Transfer pts to STEMI-Receiving hospital with similar consideration to pt registration,
bed availability and accepting MD (use of dummy reg., acceptance regardless of bed
availability and reliance on single accepting MD 24/7)
-When transporting pt treated with fibrinolysis who has continued CP and <50%
resolution STE(in lead with worst initial elevation)after 90 minutes following initiation of
fibrinolytic, notify the receiving hospital about the need for rescue PCI
-Hospital records faxed to receiving cath lab so as not to delay pt pickup
-EMTALA/COBRA medical necessity transfer form should be completed ASAP after decision
to transfer
Treat as 911 :
All STEMI inter-hospital
transfers should be treated as
911 status
AHA Mission: Lifeline
Helicopter
Transfer
Local EMS should generally be used if available and 30 minute transportation
time to destination hospital
Whenever possible, helipad adjacent to ED
Ground/Air Transfer:
Enhance First Responders
Early activation of Air
Onsite Helipad:
Availability of Transport
Helicopter capable of transporting patients on 10 minute notice 24/7. When not
available alternate transport options identified.
Immediately activate helicopter transport during initial communication between
referring hospital ED and receiving hospital regarding need for reperfusion
Establish a system whereby all patient transfers of any type can be specified as
time critical within one hour versus diversion possible
When Helicopter Not
Available:
Identify Plan B: Who is next
Referral team activates:
AHA Mission: Lifeline
Primary PCI: Receiving Center
Criteria
STEMI-Receiving Center
1. Protocols for triage, diagnosis and Cardiac Catheterization Laboratory activation
established. Single activation phone call should alert the STEMI team. Criteria for
Cath Lab activation should be established in conjunction with EMS offices.
2.
STEMI Receiving Center available 24/7 to perform PCI
3. Cath lab staff and interventionalist should arrive within 30 minutes of activation
call.
4. Universal acceptance of STEMI patients (no diversion). There should be a plan for
triage and treatment of simultaneous presentation of STEMI patients.
5. Interventional cardiologist should meet ACC/AHA criteria for competence.
They should perform at least 11 primary PCI procedures per year and 75 total
PCI procedures per year.
6. STEMI Receiving Center should meet ACC/AHA criteria for volume and perform
a minimum of 200 total PCI procedures annually.
7. The STEMI Receiving Center should participate in the Mission: Lifeline-approved
data collection tool ACTION Registry-GWTG.
Interventional coverage plan:
Compliance with 30 arrival time
Logistics of coverage
Operational within 30 minutes:
Arrival and operational are not
the same
Quick Reg in Cath Lab:
Would not require any ED visit
AHA Mission: Lifeline
Primary PCI: Receiving Center
Criteria
STEMI Receiving Center(continued)
8. Program placed in place to track and improve treatment(acutely and at discharge)
with ACC/AHA guideline based Class I therapies.
9. Recognized STEMI-Receiving Center liaison/system coordinator and a recognized
physician champion.
10. Monthly multidisciplinary team meeting to evaluate outcomes and quality
improvement data. Operational issues should be reviewed, problems identified,
and solutions implemented. The following should be evaluated on ongoing basis:
a) D2B (FMD) within 90 minutes
b) STEMI Referral Hospital D2B within 120 minutes
c) FMC to balloon (FMD) non-transfer within 90 minutes
d) FMC to balloon inflation (FMD) transfer
e) Proportion of eligible patients receiving reperfusion therapy
f) Proportion of eligible patients administered guideline-based Class 1
recommendations
g) Proportion of patients with field diagnosis of STEMI and activation of
cath lab for intended primary PCI that 1) do not undergo cath because
of misdiagnosis and 2) undergo acute cath with no ^ biomarker or
revascularization in first 24 hours
h) In-hospital mortality