1511 pulsenewsletter summer13 d1

The PulseThe Pulse

A quarterly publication of Cardiovascular Services at Advocate BroMenn Medical Center

In this issue:• STEMIPatientCare

• HotWeatherPrecautionsWhenExercising

–Don’tForgetAboutYourPets!

• CMECalendar

Summer 2013

sT-elevation Myocardial Infarction Patient Care: 2013 updates & National InitiativesBev Glendon RN, BSN, cardiac data and quality specialist, Cardiovascular Services, Advocate BroMenn Medical Center

AST-elevationmyocardialinfarction(STEMI)isasevereheartattackwherebythebloodflowisblockedtotheaffectedheartmuscle.Thislackofbloodflowcausesheartmuscletodie.Hence,thesoonerthearteryisopenedthelesscelldeaththerewillbe.

Formorethan20years,evidencehasdemonstratedthatmortalityinpatientshavinganST-segmentelevationmyocardialinfarction(STEMI)isreducedwithrapidcoronaryreperfusion.Percutaneouscoronaryintervention(PCI)withballoonangioplastyand/orstentdeploymentisthepreferredtreatmentoverintravenousfibrinolytics,ifitcanbedoneinatimelymanner.TransferstoPCIhospitalsfromnon-PCIhospitalscanposechallengestotimelyreperfusion.

AsurveyconductedbytheAmericanHeartAssociationbetweenApril2008andJanuary2010receivedfeedbackonSTEMIcarepracticesfrom899PCIhospitalsin47states,

including381systemsofcare.ASTEMIsystemisdefinedasanintegratedgroupofseparateentitiesinvolvedinSTEMIreperfusiontherapywithinageographicarea.ItinvolvesatleastonePCIhospitalandoneemergencymedicalservice(EMS)agency.

ThesurveyresultsdemonstratedprocessesthathospitalsandEMSpractice:• AcceptingpatientsataPCI

hospitalregardlessofbedavailability(97%)

• Singlephonecallactivationofthecatheterizationlaboratory(92%)

• EmergencyDepartmentphysicianactivationofthelabwithoutcardiologyconsult(87%)

• Pre-hospitalactivationoftheSTEMIteamthroughemergencydepartmentnotificationwithoutcardiologynotification(78%).

Thebarriersincluded:• Hospital(37%)andcardiology

groupcompetition(21%)• EMStransportandfinances(26%)

Ofinterestisthat61%ofthesystemsreportedhavingprotocolsthatallowedfordiversiontoaPCIhospitalforpatientswithapre-hospitalECGdemonstratingaSTEMI.Someprotocolswereindependentof

legislation.Also,21%ofsystemsreporteduseofpre-hospitalfibrinolytictherapy.Themostfrequentreperfusionstrategyusedbynon-PCIhospitalsinclude:• MixoffibrinolyticandPCI(52%)• ReferredforPCI(36%)• Fibrinolytictherapy(18%)

Atthebeginningof2013,revisedAmericanCollegeofCardiologyFoundation/AmericanHeartAssociationGuidelinesfortheManagementofST-ElevationMyocardialInfarctionwerepublished.TheguidelinesemphasizedRegionalSystemsofSTEMICare,ReperfusionTherapy,andTime-to-TreatmentGoals.Specificguidelinerecommendationsare:• Allcommunitiesshouldcreateandmaintain

aregionalsystemofSTEMIcarethatincludesqualityimprovementofEMSandhospital-basedactivities.

• A12-leadECGbyEMSpersonnelshouldbeperformedatthesiteoffirstmedicalcontact(FMC)inthefield.

• ImmediatetransporttoaPCIhospitalforpatientswithSTEMIwhoarriveatortransportedtoanon-PCIhospital.GoalforFMC-to-devicetimeiswithin120minutes(Thishasincreasedfrom90minutes).

• FibrinolytictherapyshouldbegiventoSTEMIpatientsatnon-PCIhospitalswhentheanticipatedFMC-to-devicetimeisexpectedtoexceed120minutesbecauseofunavoidabledelays.

• ReperfusiontherapyshouldbegiventoalleligibleSTEMIpatientswithonsetofsymptomswithintheprevious12hours.

• PrimaryPCIisthetreatmentofchoicewhenitcanbeperformedbyexperiencedoperators.

• EMStransportdirectlytoaPCIhospitaltodeviceactivationforaSTEMIpatientiswithin90minutes.

Asyoucansee,allhealthcareprovidersneedtoactquicklyinordertosaveheartmuscleinaSTEMIpatient.Forpatientsarrivingtoanon-PCIhospital,thegoalisdoor-in-door-outwithin30minutes.TheMcLeanCountyAreaEMSSystemsetastandardforChestPainpatients

tohaveanimmediateECGonarrivaltothepatientandleavethesceneforthehospitalwithin10minutes.

Collaboratively,STEMIteamsstrivetoreviewprocessesforcontinuousqualityimprovement.InitiativesthathaveoccurredinthepastyearinMcLeanCountyare:• DestinationProtocolsapprovedbytheIllinois

DepartmentofPublicHealthin2012(decisiontreetopossiblybypassanon-PCIhospitalandgodirectlytoaPCIhospital).

• InitiationofwirelessECGtransmissionbyEMStotheEmergencyDepartment.

• InitiationofcallingtheCodeSTEMIfromtheearlyEMSnotificationversusthefullEMSreport.

• Encouragingnon-PCIhospitalstodispatchtheambulancefirstfortransport,thencallthePCIhospitalforacceptance

• AdvocateBroMennwillnowhavetheEDphysiciansaccepttheSTEMIpatientfromthenon-PCIhospitalED(Thiswillavoidwaitingforareturncallfromtheinterventionalist).

• InOctober,2013EMSandAmericanHeartAssociationrepresentativeswillpresentontheimportanceofcalling9-1-1attheAdvocateBroMennMedicalCenter’schurchdelegatesmeeting.Theywillbeofferededucationalmaterialstodistributetotheircongregations.

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AdvocateBroMennMedicalCenterisproudofitsachievementsovertheyears,workingcollaborativelywithallteamplayersfromEMS,ED,catheterizationlaboratory,interventionalcardiologists,cardiologists,EmergencyDepartmentphysicians,pharmacy,CardiacRehab,inpatientnursing,casemanagement,communityeducators,andadditionalmembers.Ittakesateamtodevelopstreamlinedcare.Someofouraccomplishmentsinclude:• Initiatedpre-hospitalactivationoftheSTEMI

teamin2009showingan18minutedecreaseinhospitalarrival-to-deviceactivation.

• 2012mediantimeforSTEMIhospitalarrivaltodeviceactivationis44minutes(national90thpercentileis48minutes)

• InitialChestPainCenterAccreditationwithPCIfromtheSocietyofCardiovascularPatientCarein2010.

• AmericanHeartAssociation’sMission:LifeLinerecognitionforthepast4years(recognizesexcellentSTEMIcarefrompointoffirstmedicalcontacttodeviceactivation).

• AccreditedSTEMIReceivingCenterfromtheAmericanHeartAssociationandtheSocietyofCardiovascularPatientCarein2012.

• AwardedACTIONRegistry-GetwiththeGuidelines2012PlatinumPerformanceAchievementAwardfromtheAmericanCollegeofCardiology/AmericanHeartAssociation

Asexpected,thefutureofChestPain/STEMIcarewillbeinthedevelopmentofenhancedregionalcoordinationofEMSandhospitalsinprovidingoptimalcareforthispopulation.

O’Gara PT, Kushner FG, Ascheim DD, Casey DE Jr., Chung MK, de Lemos JA, Ettinger SM, Fang JC, Fesmire FM, Franklin BA, Granger CB, Krumholz HM, Linderbaum JA, Morrow DA, Newby LK, Ornato JP, Ou N, Radford MJ, Tamis-Holland JE, Tommaso CL, Tracy CM, Woo YJ, Zhao DX. 2013 ACCF/AHA guideline for the management of ST-elevation myocardial infarction: executive summary: a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines J Am Coll Cardiol 2013:61:xxx-xxx. Doi:10,1016/j.jacc.2012.11.018.

Jollis JG, et al. Systems of care for ST-segment-elevation myocardial infarction: A report from the American Heart Association’s Mission: Lifeline. Circ Cardiovasc Qual Outcomes 2012;5:00-00.

hot Weather Precautions When exercisingCheryl Richards, exercise physiologist, Cardiac Rehab, Advocate BroMenn Medical Center

Summerweather,withsunnydaysandtemperaturessteadilyclimbingthroughthe80sintothe90s,ishere.Warmweathercanmotivateyoutogetoutsideandexercise,butwhenhightemperaturesaremixedwithhumidity,youshouldtakecaretoavoiddehydrationorheat-relatedillnesses.

Undernormalconditions,yourskin,bloodvesselsandperspirationleveladjusttotheheat.Butthesenaturalcoolingsystemsmayfailifyouareexposedtohightemperaturesandhumidityfortoolong.Sweatingisthebody’sfirstmethodofcooling,but,insomecases,can’tlowerthebody’stemperatureenough.Illnessessuchasheatexhaustionandheatstrokearepreventable,butmanypeoplestilldiebecauseofthiseachyear.Heat-relatedillnessesoccuralongaspectrum,startingoutmildbutworseningifleftuntreated.Heatillnessesinclude:• Heatcramps.Heatcrampsarepainful

musclecontractions,mainlyaffectingthecalves,quadricepsandabdominals.Affectedmusclesmaybefirmtothetouch.Yourbodytemperaturemaybenormal.

• Heatexhaustion.Withheatexhaustion,yourbodytemperatureraisesashighas104Fandyoumayexperiencenausea,vomiting,headache,fainting,weaknessandcold,clammyskin.Ifleftuntreated,thiscanleadtoheatstroke.

• Heatstroke.Heatstrokeisalife-threateningemergencyconditionthatoccurswhenyourbodytempisgreaterthan104F.Yourskinmaybehot,butyourbodymaystopsweatingtohelpcoolitself.Youmaydevelopconfusion.Andirritability.Youneedimmediatemedicalattentiontopreventbraindamage,organfailureorevendeath.

Weallknowthatwhenweareoutdoorsitisimportanttostayhydrated.Somethingwemaynotbeexactlysureaboutiswhatweshould

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drinkandwhen.Ordinarywater,ofcourse,istheclassicchoice.Butthestoreshelvesarefullofsportandenergydrinks,andvariousflavoredandfortifiedwaters,howdoyouknowwhensportsdrinksarenecessaryinadditiontoplainwater?

Expertssayitalldependsonthelengthandintensityoryourworkouts…aswellasyourtaste.

Exercisinganhourandahalftothreehoursislongenoughtowarrantfluidreplacementduetosweat.Howmuchsweatislostinfluenceshowmuchsodiumandpotassiumislost.Thelongeryouexerciseandthemoreheavilyyousweat,thegreatertheneedisforsportsdrinkstoreplacetheselostmicronutrients.

Asportsdrinkcandomanythingstoincreaseenergylevelswithoutthecomplicationsofeatingandabsorbingameal.Basically,asportsdrinkoffersyourbodythreethingsitmightneedbefore,duringoraftervigorousexercise.• Hydration.Itisrecommendedthatyoudrink

1–2cupsofwaterpriortoexerciseand1cupforevery15minutesofexerciseinordertotakeinfluidsattheratethatyouarelosingthemthroughsweat.

• Fuel.TheCarbohydratesinsweetenedsportsdrinksprovideenergytohelpdelayfatigue.Theoptimalpercentageofcarbohydratesforspeedingfluidandenergybackintothebodyis6%carbohydrate(14gramsofcarbobydrateper8ouncesofwater).

• ElectrolytesorMinerals.Thesearethingslikesodium,potassium,andchloridethatarelostthroughsweat.Whenwatergoesoutofthebody,sodoelectrolytes.

• Whileaddingenergyandelectrolytesmaybebeneficial,itisstillbesttogetvitaminsandmineralsnaturallyfromfoodsandbeverages.Inadditionenergydrinkswithcaffeinedohavetheirplaceinimprovingalertness,motorskillandconcentration,theyshouldbeusedwithcaution.

Herearesomeadditionaltipstomakeworking/exercisingoutdoorsinthesummersafeandmorebearable.• Easeintohotoutdoorworkouts,anddon’t

pushyourselftoohard.Exerciseforlesstimeandatalowerintensity,thengraduallybuilduptolonger,harderworkouts.Listentoyourbody,anddon’tbeafraidtotakebreaksifyouneedto.

• Alteryourscheduletoexerciseduringcoolertimesoftheday.Earlymorningsorlateeveningstendtobethebest.

• Exerciseinshadyplaceslikethewoods,orbreezyplaceslikethebeachoralongalake.

• Wearlight-coloredandlightweightclothingthat’smadewithfabricthatwicksmoistureawayfromyourskinanddriesquickly.Avoidcottont-shirtsandshortssincethey’llgetsweaty,staydamp,andmakeyoufeelhotter.

• Wearwickingsocksandlightweightshoestokeepyourfeetcoolanddry,andtopreventblisters.

• Wearalightweighthat.It’llabsorbthesweatfromyourheadandkeepthesunoffyourface,whichwillprotectyourskinandkeepyoucooler.

• Wearsweat-proofsunscreenthatwon’tdripintoyoureyeswhenyouperspire.Alsobesuretowashyourhandsafteryouapplyit,sowhenyougotorubsweatoffyourface,youwon’trubsunscreeninyoureyes.

• Forfun,weighyourselfbeforeandafterexercise.You’llfindthatyouloseapoundormore(it’sjustwaterweight).Besuretorehydrateyourselfwith16ouncesofwaterforeverypoundyou“lose.”

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AdvocateBroMennMedicalCenter||1304FranklinAvenue,Normal,IL61761||advocatehealth.com/bromenn

Everyoneisatriskforheat-relatedillnesses,buttherearecertainpeopleatgreaterrisk:• Elderlypeople.• Peoplewithchronic(long-term)illnesseswho

aretakingcertainmedicines.• Peoplewhoareseverelyobese.• Patientswithheartfailureandotherchronic

medicalconditions.

Theseindividualsshouldnotexerciseoutsideinveryhotandhumidweather,duetoalimitedreservecapacitytotransportheatfromthebody.

Don’t Forget About Your PetsPetownersareurgedtorememberthefollowingtips:Neverleavepetsinaparkedcar.Onawarmday,temperaturescanrapidlyrisetodangerouslevels.Ifyouseeananimalindistressinaparkedcar,contactthepolice.Evenwiththewindowsslightlyopen,thetemperatureinacarona93-degreedaycansoarto125degreesinjust20minutesandapproximately140degreesin40minutes.

Shadeandwaterarevitaltopets.Petownersmustprovideadequateshelterprotectinganimalsfrominjury,rain,sleet,snow,hail,directsunlight,andadverseeffectsofheatorcold.Adoghouseinthebackyardwithnoaccesstoshadedoesnotprotectanimalsfromsun.

Limitexerciseonhotdays.Takecaretoadjustintensityanddurationofexercise.Watchforshortnessofbreathandrememberthatasphaltgetsveryhotandcanburnpaws;walkyourdogonthegrassifpossible.

Ifyourpetshowsanyofthefollowingsignscontactyourveterinarianimmediately:• heavypanting• glazedeyes• rapidheartbeat• vomiting• fever• dizziness

• restlessness• excessivethirst• profusesalivation

Takestepstoreducetheanimal’sbodytemperature;applyicepacksorcoldtowelstohead,neckandchest,providewaterandicecubesforhydration,andmovetheanimalintotheshadeorair-conditioning.

Understandingthesafetyofexerciseandactivityinthesummerheatwillhelpyoukeepyourlovedonessafeandhavefunatthesametime.

Continuing Medical education Calendar

Tuesday,August20from7amto8am–Cardiaccathcaseconference–HeartCenterClassrooms,AdvocateBroMennMedicalCenter

Thursday,September17from7amto8am–ECHO–OSFSt.JosephMedicalCenter

Tuesday,October15from7amto8am–ACS/HeartFailure–HeartCenterClassrooms,AdvocateBroMennMedicalCenter

Tuesday,November19from7amto8am–Cardiaccathcaseconference–OSFSt.JosephMedicalCenter

Tuesday,December17from7amto8am–ECHO–HeartCenterClassrooms,AdvocateBroMennMedicalCenter.