STEMI Case Review Improving System of Care for the AMI

Population

June 20th, 2011

Review Process

•  Introductions •  Background •  Communication •  Diagnosis •  Care Provided •  Hand-off of Patient

•  Results •  - times •  - patient outcome •  Barriers and

Opportunities •  Conclusions •  Follow Up Needed

Participants

•  Patient •  RN in Charge of Medic Tent at Scottish Games* •  Mobile Care Ambulance Service •  Chest Pain Center •  Call Center •  STAT RN •  Cardiac Catheterization Lab * •  Cardiologist* * Presenters

2011 Scottish Games at Furman University MEDIC TENT

Freedom Weekend Aloft MEDIC TENT (Mobile Care also covering)

First Aid/Medic Tent Jeanne Sandahl, Nurse Manager

Scottish Games Sword Fights

Scottish Games Caber Toss

Method of Travel to Patient (in Bagpiper Tent)

GHC Mobile Care Ambulance Service

•  Mission: Transport GHS patients

•  Mobile Care established in April of 1972 and is an affiliate of GHS UMC •  Primarily inter facility, discharges and Referral Center transports •  EMTs and Paramedics •  Second highest transport volume in Greenville County; approximately

10,000 annually

•  Mutual Aid Agreement with GC EMS •  - Provides 911 ‘back-up’

•  All ambulances ‘advanced life support’ staffed and equipped

MCAS Staff

•  30 Paramedics (8 CC EMT-P)

•  13 EMTs •  2 RNs •  2 in Nursing School •  11 also work for GC EMS or other 911 agencies •  9 also work for Fire Departments (3

Lieutenants and 1 Captain)

MCAS Medical Control •  Martin E. Lutz, M.D.

•  Medical Director, Emergency Services •  Vice President Medical Staff

•  Also Medical Control for:

•  Greenville County EMS •  GHS Med Trans (medical helicopter)

Mobile Care Crew John Reid, CC EMT-P

•  EMT since 1998

•  Works also PT for GC EMS

•  CC EMT-P in 2010

•  John also provided Medic coverage at 2010 Scottish Games, to Prince Edward

Mobile Care Crew Beth Smith, EMT-I

•  EMT for 13 years •  Started EMT career in New York •  Fire Department – 6 years •  Life Link at Roper St. Francis Hospital •  Mobile Care •  EMT –I 2009

Patient Chief Complaint, Symptoms and History •  Patient: 60year old male •  History •  Family history of coronary artery disease •  Sedentary lifestyle

•  Chief Complaint •  Chest Pain

•  Symptoms •  Chest pain since approximately 7:30 am; most severe in substernal area and radiating to left arm •  Diaphoretic •  SOB •  Nauseated

Mobile Care Ambulance Service Initial EKG 10:20:36 am

Chest Pain Center Activates STEMI Alert

•  STEMI activated via CPC; Dr. Crumpler at 10:36

•  Play Recording

Mobile Care Ambulance Service Care Provided

•  Oxygen initiated via nasal cannula •  Cardiac monitor for ECG •  Nitroglycerin, 0.4 MG •  Peripheral IV initiated •  Heparin •  Taken to GMH Chest Pain Center 4

Mobile Care Ambulance Service Times

•  10:00 – Request received via radio •  10:06 – At patient •  10:22 – enroute to GMH •  10:37 – arrived at GMH

•  37 minutes from initial notification to arrival at GMH/Chest Pain Center

GMH Cardiology Stat RN •  STEMI Role •  - Meet EMS crew at ambulance bay/CPC or approach landing pad and assist with

patient transfer (training required). •  - Receive brief report from flight/EMS crew regarding patient stability or changes

during transport •  - Introduce self/role to patient and family; verbalize next steps and provide support •  - Review and confirm pre-GHS meds given specific to AMI/cardiac cath •  - Review targeted health history with patient, and biometrics pertinent to cardic cath

procedure •  - Perform targeted assessment if time allows •  - Assist with tracking times and documentation •  - Support CPC/CC-ER, cath lab personnel, and cardiologist as required and within

scope of practice •  - assist with patient transfer in CCU •  Note: crossed trained for CCL for 2nd STEMI situations

Greenville Memorial Hospital Cardiac Catheterization Lab

Cardiac Cath Lab Team

•  Dr. Josh Doll - Interventional Cardiologist •  Beth Cook, RN – Circulator •  Mary Sturges, RN – Circulator •  Joelle Bridgesm RN - Scrub •  Leigh Godbee-Stephens, RN, BSN -

Monitor •  Gary Szeto, RN – Stat/STEMI RN

Cardiologist Carolina Cardiology Consultants

•  Hometown: Batesville, Indiana •  Area of Specialization: •  Interventional Cardiology, Structural Heart Disease Therapies, Cardiac Pacing •  College:

Indiana University, Bachelor of Science-Biology, Cum Laude, 1996 •  Medical School:

Indiana University of Medicine, Doctor in Medicine, 2000 Residency: Vanderbilt University Medical Center, 2000-2003

•  Cardiology Fellowship: •  Medical University of South Carolina, Interventional Cardiology

Medical University of South Carolina, Cardiology

Cardiac Cath Vital Signs at 11:04 am

•  Sp02 98%, HR 66, BP 118/69/76

•  11:02:59 – GMH Door Time •  11:03:00 – Greet/table •  11:11:54 – Case Start •  11:23:42 – Balloon

E2B D2B

•  77 minutes – E2B (EMS to Balloon)

•  43 minutes – GMH D2B (Door to Balloon)

Pre Cath

Stent

Final

Procedure Performed

•  INDICATION FOR PROCEDURE:

•  Acute anterior ST-elevation myocardial infarction with occlude proximal LAD

•  1. Left heart catheterization with coronary angiography and left ventriculography

•  2. Percutaneous coronary stenting of the proximal left anterior descending

Cath Report Findings •  Intervention

•  Lesion is a complete thrombotic occlusion of the proximal LAD with TIMI-zero flow

•  Conclusions

•  Coronary disease with acute thrombotic proximal left anterior descending occlusion

•  Successful stenting of the proximal left anterior descending with a bare-metal stent after aspiration thrombectomy

•  Mild left ventricular systolic dysfunction

Questions and Thanks to All!