Download - 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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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.