Our STEMI Program

Leesa Wright, RN, CCCC, CCRNMethodist University Hospital

2015 Annual Tennessee STEMI MeetingOctober, 2, 2015

Objectives

• Recognize the alignment of structure with AHA Mission: Lifeline

• Identify the focuses within the roles of each team within the AHA Mission: Lifeline structure

• Identify interventions for common barriers

Disclosures

Leesa Wright, RN, CCCC, CCRNOur STEMI Program

FINANCIAL DISCLOSURE:No relevant financial relationship exists

IOur 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

2.9 (2.8-3.1)15

30 3.0 (2.9-3.2)

60

90

120

180

240

3.5

4.3

5.6

8.4

10.3

(3.4-3.6)

(4.2-4.4)

(5.4-5.7)

(8.2-8.7)

(10-10.7)

Our Team

EMS

ReferralHospital

Air Transport

ReceivingHospital

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

2013 ACCF/AHA Guidelines for the Management of ST-Elevation

Myocardial InfarctionClass 1 Recommendation

AHA Mission: Lifeline

• 1. Each EMS system should maintain a standardized algorithm for evaluating and• treating patients with symptoms suggestive of MI that should include acquisition of a • 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.

• 2. Each EMS system should maintain a standardized reperfusion STEMI care • 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.

• 3. Prearranged EMS destination protocols for STEMI patients should include:• a. Bypassing non-PCI hospitals/STEMI Referring Centers and going directly to• Primary PCI hospitals for patients with anticipated short transport interval(• < 30 minutes in urban/suburban settings to achieve PCI within 90 minutes• b. Emergency transfer of EMS or other agencies to a STEMI-Receiving Center• 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

EMS Criteria

Enhance Transmission Capability:FastECG.com

Lifenet

Improvement in time from obtaining ECG to transmission of ECG:

EMR book with FMC

Scene Time:Education of 15 minute goal for

STEMI

EMS Providers

Champions:Review the data, make the processes,

present the results

EMS Obtains Blood in the field:EMS providers will draw blood in the

field for STEMI and Stroke

AHA Mission: Lifeline

(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

EMSCriteria

AHA Mission: Lifeline

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.)

EMS Criteria

AHA Mission: Lifeline

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

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

Non-PCI : Referral CenterCriteria

Early Activation of Transport Team:First Call – Air

Immediate Back Up Plan

Transition of care to Transport:10 minute TAT

AHA Mission: Lifeline

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

Non-PCI: Referral CenterCriteria

AHA Mission: Lifeline

-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

Inter-hospital TransferEMS

Treat as 911 :All STEMI inter-hospital

transfers should be treated as 911 status

AHA Mission: Lifeline

Local EMS should generally be used if available and 30 minute transportation time to destination hospital

Whenever possible, helipad adjacent to ED

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

HelicopterTransfer

Onsite Helipad:Availability of Transport

Ground/Air Transfer:Enhance First Responders

Early activation of Air

When Helicopter Not Available:

Identify Plan B: Who is next

Referral team activates:

AHA Mission: Lifeline

STEMI-Receiving Center1. 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.

Primary PCI: Receiving Center Criteria

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

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

Primary PCI: Receiving CenterCriteria