STEMI Systems of Care and Learn: Rapid STEMI ID

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Every year, almost 400,000 people experience ST-Elevation Myocardial Infarction (STEMI) …

Every year, almost 400,000 people experience ST-Elevation Myocardial Infarction (STEMI)
-- the deadliest type of heart attack. Unfortunately, a significant number don't receive prompt reperfusion therapy, which is critical in restoring blood flow. Worse yet, 30 percent of STEMI victims don't receive reperfusion treatment at all.
Mission: Lifeline™ seeks to save lives by closing the gaps that separate STEMI patients from timely access to appropriate treatments.

Although Mission: Lifeline is focusing on improving the system of care for the nearly 400,000 patients who suffer from a STEMI each year, improving that system will ultimately improve care for all heart attack patients.

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  • All taken from
  • Jacobs, A.K.
  • Ting, H. H. et al. Circulation 2008;118:1066-1079
  • Moyer, P. and Ornato, J.P. et al. Circulation 2007;116:e43-e48
  • In response to the training needs, ECC developed the Learn Rapid STEMI ID Program and released the product in August 2009.
  • Healthcare providers, specifically pre-hospital personnel responsible for acquiring12-lead ECGs and identifying potential STEMI—also for those individuals promoting education and training for Mission: Lifeline™ providers.
  • This on-line training is part of a suite of tools already available for system providers.
  • "interactive self-study cards to allow the learner to remember important facts in the course"… example
  • Students who successfully pass the cognitive and ECG recognition post-course tests can receive a completion certificate and are eligible for CE credits, and may also enroll in a Mission: Lifeline™ Recognized Provider program.
  • There are various levels of involvement with Mission: Lifeline. This slide shows the upward progression of involvement.
  • In the ideal system for EMS, standardized point-of-entry (POE) protocols (created by regional or state-based coalitions of EMS personnel, emergency physicians and nurses, and cardiologists and supported by payers and administrators) would advocate which patients are transported to the nearest hospital and which patients are transported to the nearest primary PCI/STEMI-receiving hospital based in part on the acquisition, interpretation, and transmission of a pre-hospital 12-lead ECG. EMS plays a role in activating the primary PCI staff when proper equipment, training in 12-leads ECG interpretation and relaying the 12-lead information with adequate medical control is in place to STEMI-receiving hospital. If EMS takes patient to a non-PCI or STEMI-referral hospital, a strategy of leaving the patient on the EMS stretcher with EMS present for potential STEMI transfer to STEMI-receiving hospital would be time saving. In addition, when walk-in patients present to STEMI-referral hospital in need of primary PCI, activation of EMS, as in a call to 9-1-1, to transport should occur.
  • Patient point-of-entry (POE) protocols should be developed with the understanding that a patient may call 9-1-1 and be in an EMS zone that transports to a STEMI-referral or STEMI-receiving hospital. Also, patients may directly present to a non-PCI center and be in need of inter-hospital transfer or present to a primary PCI center. The ACC/AHA guidelines encourage EMS on scene be equipped with 12-Lead ECG technology. Advanced systems may consider pre-hospital fibrinolysis, but the majority in the U.S. EMS should have a destination protocol in place. [Note to Presenter: Following text from the 2004 Full Text STEMI ACC/AHA Guidelines caption (pg 19).] Patient transported by EMS after calling 9-1-1. 1: Reperfusion in patients with STEMI can be accomplished by the pharmacologic (fibrinolysis) or catheter-based (primary PCI) approaches. Implementation of these strategies varies based on the mode of transportation of the patient and capabilities at the receiving hospital. Transport time to the hospital is variable from case to case, but the goal is to keep total ischemic time within 120 minutes. There are three possibilities: a) If EMS has fibrinolytic capability and the patient qualifies for therapy, pre-hospital fibrinolysis should be started within 30 minutes of EMS arrival on scene; b) If EMS is not capable of administering pre-hospital fibrinolysis and the patient is transported to a non-PCI-capable hospital, the hospital door-to-needle time should be within 30 minutes for patients in whom fibrinolysis is indicated; c) If EMS is not capable of administering pre-hospital fibrinolysis and the patient is transported to a PCI-capable hospital, the hospital door-to-balloon time should be within 90 minutes. Inter-hospital transfer: It is also appropriate to consider emergency inter-hospital transfer of the patient to a PCI-capable hospital for mechanical revascularization if: 1: There is a contraindication to fibrinolysis; 2: PCI can be initiated promptly (within 90 minutes after the patient presented to the initial receiving hospital or within 60 minutes compared to when fibrinolysis with a fibrin-specific agent could be initiated at the initial receiving hospital); fibrinolysis is administered and is unsuccessful (i.e.,"rescue PCI"). Secondary non-emergency inter-hospital transfer can be considered for recurrent ischemia. Patient self transport: Patient self-transportation is discouraged. If the patient arrives at a non-PCI capable hospital, the door-to-needle time should within 30 minutes. If the patient arrives at a PCI-capable hospital, the door-to-balloon time should be within 90 minutes. The treatment options and time recommended after first hospital arrival are the same.
  • Taken from Garvey, Lee. et al. Journal of the American College of Cardiology Volume 47, Issue 3 , 7 February 2006, Pages 485-491
  • 25 srcs 10 million people
  • Mission: Lifeline is the American Heart Association’s national community based multidisciplinary initiative to advance the systems of care for patients with ST-segment elevation myocardial infarction (STEMI). The overarching goal of the initiative is to reduce mortality and morbidity for STEMI patients to and improve their overall quality of care.
  • Q17. Does your organization have 12-lead ECG devices available at the scene for at least 80% of the patients with chest pain?  Yes  No
  • Q29. Are there destination protocols (i.e. bypass non-PCI hospitals to go directly to PCI centers) for patients that have had a pre-hospital identification of a STEMI?  Yes  No ŒDon’t know/ not applicable
  • Q16. In your Agency/Organization, is the field provider’s 12-lead ECG information used to activate the cath lab prior to arrival at the receiving facility?  Yes, for all receiving facilities  Yes, sometimes or for some receiving facilities  No  Don’t know
  • Ting, H. H. et al. Circulation 2008;118:1066-1079

Transcript

  • 1. The Mission: Lifeline Provider Recognition Program and Learn:™ Rapid STEMI ID Customer Webinar September 24, 2009 Moderator: Mayme Lou Roettig, RN, MSN Presenters: Joseph P. Ornato, MD, FACP, FACC FACEP Mike Willingham, CCEMT-P Lee Garvey, MD, FACEP
  • 2. The Need for Pre-Hospital ECGs in Systems of Care for STEMI Patients and Learn:™ Rapid STEMI ID Objectives Joseph P. Ornato, MD, FACP, FACC FACEP Past Chair of AHA’s National Emergency Cardiovascular Care Committee
  • 3. The Call to Action
    • The majority of STEMI deaths occur in the first 2 hours due to cardiac arrest after onset of symptoms
    • <50% of STEMI patients call 911 and are transported to the hospital by EMS
    • Pre-hospital 12-lead ECG acquisition is critical for determining which chest pain patients need to be transported to a PCI facility because the majority of chest pain patients do not have a STEMI..
    • Prehospital ECGs are acquired on <10% of suspected STEMI patients even though they can decrease door to needle and door to balloon times.
  • 4. Other Statistics
    • 30% of STEMI patients receive no reperfusion therapy despite the availability and absence of contraindications
    • Of the 20% of STEMI patients who have contraindications to fibrinolytic therapy, 70% do not receive reperfusion treatment with PCI
    • <50% of patients treated with fibrinolysis have a door-to-needle time within 30 mins
    • Only 35% of patients treated with PCI have a door-to-balloon time within 90 mins
  • 5. Ornato, J. P. Circulation 2007;116:6-9 The STEMI Chain of Survival
  • 6. Current Versus Ideal Processes to Integrate Prehospital ECGs into Systems of Care
  • 7. Ting, H. H. et al. Circulation 2008;118:1066-1079 Reperfusion Time Goals for Patients With STEMI
  • 8. Recommendations
    • A module for EMS providers should be developed that addresses STEMI care with particular emphasis on 12-lead acquisition, transmission, and interpretation. Consideration should be given to including extension of ECG training to basic level EMS providers.
    • EMS agencies need to have sufficient personnel, training and resources to ensure that a prehospital 12-lead ECG can be acquired from prehospital patients with clinical presentations suggestive of a STEMI to assist in triage, treatment and point-of-entry decisions.
    Moyer, P. and Ornato, J.P. et al. Circulation 2007;116:e43-e48
  • 9. The Training
    • Learn:™ Rapid STEMI ID is a dynamic online program that is designed to prepare healthcare professionals to evaluate and assess victims with potential symptoms of myocardial infarction, interpret their ECG for signs of STEMI, and activate a system of care of rapid reperfusion of an occluded coronary artery. 
  • 10. Learn:™ Rapid STEMI ID Objectives
    • Upon successful completion of this course the learner should be able to:
    • See the need for an improved STEMI System of Care…and close the gap on timely access to needed treatment
    • Distinguish an ST-Elevated Myocardial Infarction from ECG mimics of STEMI
    • Name the Leads, Regions of the Heart, and Measure ST Deviation
  • 11. Learn:™ Rapid STEMI ID Objectives
    • List immediate action steps to identify patients with symptoms of ACS and ECG findings of STEMI to reduce time to perfusion
    • Describe ACS Pathophysiology
    • Describe how to acquire a technically good 12-lead ECG
  • 12. Learn:™ Rapid STEMI ID Objectives
    • Differentiate a normal 12-lead ECG from a 12-lead with ischemic changes
    • Identify patterns of ECG abnormalities including those that require rapid reperfusion and team activation
  • 13. Learn:™ Rapid STEMI ID Product Information and The Mission: Lifeline Provider Recognition Program Mike Willingham, CCEMT-P Senior Director, Mission: Lifeline
  • 14. Product Info
    • Learn: ™ Rapid STEMI ID
      • Product # 80-1473
      • $69.95 SRP
      • EMS – 4.50 Advanced CEHs (CECBEMS)
      • Nurses – 4.62 contact hours
      • Available August 18 th 2009
      • Audience
  • 15. Current STEMI Tools from ECC
      • STEMI Provider Manual (2008)
      • ECG ACS Ruler (2008)
        • Combined as 1 product (ruler still available as a single item)
      • ECC Handbook (updated 2008)
      • Learn Rapid STEMI ID (August 2009)
  • 16. Product Features
    • Self-paced
    • Accessible Anytime/Anywhere (OnlineAHA)
    • Access for 12 months to course material
    • Audio, Animation, Interactive activities
    • “ learn more toolboxes” - Self Study Cards
    • It can be used to educate any healthcare provider and
    • also helps support the AHA Mission: Lifeline™ initiative.
  • 17. Product Benefits
    • Emphasizes immediate recognition and treatment of ACS STEMI
    • Includes self assessment quizzes
    • Contains dynamic ECG Scope to measure ST deviation
    • Includes the STEMI Practice Exam
  • 18. User Experience
  • 19.
    • Student registers on OnlineAHA.org
    User Experience
  • 20. User Experience
    • Student then activates a key they have received or they can purchase a key
  • 21. User Experience
    • Student then activates a key they have received or purchased
    • Terms and Conditions are agreed to
    • Once they click “Activate” they will arrive back at the ‘my courses’ page where they can select the course
  • 22. User Experience On the ‘my courses’ page the student can select desired courses that have been activated
  • 23. User Experience Student then chooses the active link to access course.
  • 24. User Experience Student must review course overview to proceed And also complete the evaluation to complete the course and collect a certificate, CE, and option of recognized provider program
  • 25. User Experience Certificate of Completion, Application for Continuing Education Credit, and Recognized Provider Program Can all be accessed from the completed courses page
  • 26. Mission: Lifeline Provider Recognition
    • In 2007, Mission: Lifeline volunteers felt it was important to recognize providers in addition to hospitals, EMS and STEMI Systems
    • Mission: Lifeline ECC Task Force volunteers suggested that a provider recognition program be tied to current ACLS products
    • So, only upon successful completion, do providers have an opportunity to participate in the Mission: Lifeline Provider Recognition program
    • Not tied to the current system and system component programs
  • 27. Mission: Lifeline Provider Recognition
  • 28. Mission: Lifeline Involvement
    • Participation
    • M.O.U.
    Recognition Certification Examples Examples
  • 29. Pre-Hospital Activation Issues Within a STEMI System Lee Garvey, MD, FACEP Mission: Lifeline ECC Task Force Vice-Chair
  • 30. Optimizing the System
    • Focus on the prehospital environment
    • USE the time the paramedics are with the patient:
      • ECG
      • Data to decision makers
      • Drug treatment – ASA, nitroglycerin, (?lytic)
  • 31. The Ideal EMS
    • In an ideal system:
      • Ambulances are equipped with 12-lead ECG machines
      • EMS providers are trained to:
        • Use and transmit 12-lead ECGs
        • Care for STEMI patients
        • Provide feedback on performance and compliance with guidelines
      • Standardized point-of-entry (POE) protocols define patient transport rules
      • When there is STEMI, the cath lab is activated promptly
      • Patients transported to a STEMI-referral hospital remain on the stretcher with EMS present pending a transport decision
      • When “walk-in” patients present to a STEMI-referral hospital and require primary PCI, activation of EMS occurs
      • Hospitals close the communication gap with EMS
  • 32. POE Protocol
  • 33. System Administrative Barriers
    • Barriers to the implementation of prehospital12-Lead ECG programs
      • significant investment of time, effort, personnel, and resources.
      • costs of device acquisition and replacement, paramedic training, and ongoing competency assessment
      • ECG Image transmission? Failures can occur in 20% to 44% of cases where wireless dead zones occur.
  • 34. RAPID EKG CRITERIA Door to decision 10 minutes
    •  30 YEARS OLD with suspicious CHEST PAIN
    • ( EXCLUDING OBVIOUS TRAUMA )
    •  50 YEARS OLD with :
      • Syncope
      • Weakness
      • Rapid Heart Beat / Palpitations
      • Difficulty Breathing / Shortness of Breath
    Graff L, et al. Triage of patients for a rapid (5-minute) electrocardiogram: a rule based on presenting chief complaints. Ann Emerg Med. December 2000;36:554-560.
  • 35.  
  • 36. Prehospital 12 lead ECG
    • *** ACUTE MI *** Diagnostic statement
      • 96-98% specificity
      • Only 50’ish% sensitivity
        • Kudenchuck 1991; JACC 17:1486-91
      • P12 ECG reduces mean time to treatment by ~33 minutes
  • 37. Prehospital Code STEMI Activation
    • Activation of Code STEMI
    • (REQUIRES ALL THREE)
      • Patient with symptoms suggestive of ACS
      • Prehospital ECG diagnostic interpretation algorithm identifies Acute Myocardial Infarction
      • Paramedic reviews ECG to confirm STEMI findings
  • 38. Los Angeles County Franklin Pratt, MD, FACEP 25 STEMI Receiving Centers - SRCs
  • 39. EMS Assessment for STEMI: results of the Mission Lifeline National Survey EMS Agency Respondents N=5410
  • 40. 12 Lead Devices Availability at the Scene Does your organization have 12-lead ECG devices available at the scene for at least 80% of the patients with chest pain?
  • 41. Destination Protocols Are there destination protocols (i.e. bypass non-PCI hospitals to go directly to PCI centers) for patients that have had a pre-hospital identification of a STEMI?
  • 42. 12 Lead Activates the Cath Lab In your Agency/Organization, is the field provider’s 12-lead ECG information used to activate the cath lab prior to arrival at the receiving facility?
  • 43. Pre-hospital Activation. EMS identifies STEMI and: (Select all that apply.)
  • 44. Interpretation Issues
  • 45. Cath Lab Activations “False Positive” vs “Over-activations”
    • Significant resources activated with STEMI response
    • Definition of “False Positive” activations
    • What is an acceptable rate for over-activations
  • 46. Definitions of “False Positive” Cardiac Cath Lab Activation
    • No culprit
    • No significant coronary disease
    • Negative cardiac biomarkers
    Larson, DM et al JAMA 2007;298(23):2754-2760
  • 47. Summary: Incidence of “False Positive” Cath Lab Activation
    • No culprit: 14%
    • Normal or Minimal CAD: 9.5%
    • Negative cardiac markers: 11.2%
    • Combination of no culprit and negative biomarkers: 9.2%
    Larson, DM et al JAMA 2007;298(23):2754-2760
  • 48.  
  • 49. RACE: Cath Lab Activation Registry
    • Cath Lab Cancellations
      • Resolution of symptoms or ECG abnormalities
      • Old ECG findings, patient death, other
    • Overactivations –
      • Cath lab cancelled due to
        • ECG interpretation issues – prehospital or ED
        • Patient not a cath lab candidate
    • Other –
      • CABG, medical management only, normal coronaries, other
  • 50. Questions?