Non-PCI Hospitals: STEMI Diagnosis -- Treatment Decreasing ...

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Non-PCI Hospitals: STEMI Diagnosis -- Treatment Decreasing ...

  1. 1. Non-PCI Hospitals: STEMI Diagnosis -- Treatment Decreasing Delays and Improving Outcomes J. Lee Garvey, MD Emergency Medicine Carolinas Medical Center Charlotte, NC
  2. 2. Disclosure Statement Title: “Non-PCI Hospitals: STEMI Diagnosis -- Treatment Decreasing Delays and Improving Outcomes” Presenter: J. Lee Garvey, MD No financial conflicts
  3. 3. STEMI Diagnosis • ECG based diagnosis – Need for SPEED 10 minutes • Prehospital ECG • Triage ECG • Once STEMI identified trigger a response • Goal is reperfusion
  4. 4. “10 minute” ECGs
  5. 5. PROBLEM: A clinical history of ischemic-type chest discomfort (JAMA 2000;283:3223-29 ) • Primary symptoms (67%): – Retrosternal chest pain (discomfort) with radiation to the neck, jaw, shoulders, or down the inside of either arm • Secondary symptoms (33%): – Shortness of breath, weakness, syncope, palpitations, diaphoresis, nausea, or vomiting
  6. 6. A clinical history of ischemic-type chest discomfort: Lee Arch Int Med 1985:145;65-9 100 C est P inP (%) 80 a t's 60 A t y p i c al C P 40 T yp i ca l C P 20 h 0 MI No MI
  7. 7. Since 1/3 of AMI patients do not have “chest pain”, how do I screen for rapid ECG?!?
  8. 8. Triage of patients for a rapid (5-minute) electrocardiogram: A rule based on presenting chief complaint. Graff et al. Ann Emerg Med. Dec 2000;36;554-560. • Symptoms derived from ED MI database – Tested retrospectively and prospectively • Outcomes: – STEMI -- Door to ECG decreased • 10.0 --> 6.3 minutes – STEMI -- Door to drug decreased • 36.9 --> 26.1 minutes – 1% increase in ECGs performed • 6.3% --> 7.3% – 100% sensitive for patients with STEMI
  9. 9. 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 Reference: Graff L, Palmer AC, LaMonica P, Wolf S. Triage of patients for a rapid (5-minute) electrocardiogram: a rule based on presenting chief complaints. Ann Emerg Med. December 2000;36:554-560.
  10. 10. ECG = STEMI
  11. 11. Attack Program for AMI • Reperfusion strategy is institution dependent • Do not allow “confusion about reperfusion” • PCI favored at interventional facilities – 24/7? What about ‘off hours’ presentation – Requires commitment of entire hospital • Lytic drug if PCI not available within 90 minutes of first contact
  12. 12. Primary Goal In STEMI: Achieve Coronary Patency Class I All patients should undergo rapid evaluation for reperfusion therapy & have a reperfusion strategy implemented promptly after contact with the medical system Initial Reperfusion Therapy • 3 Major Options: • Pharmacological Reperfusion (Fibrinolytics) • Primary Percutaneous Coronary Intervention (PCI) • Acute Surgical Reperfusion Antman et al. JACC 2004;44:680.
  13. 13. Non-PCI Hospital STEMI Care • Transfer for PCI • Lytic and transfer • Lytic and keep?
  14. 14. The system is as important as the treatment
  15. 15. Optimizing the System • Understand what the System is: – Begins with the patient – Prehospital environment – Emergency Department – Cardiology consultants – Fibrinolytic drug administration, or catheterization laboratory for PCI
  16. 16. Optimizing the System Parallel • Serial processing of individual steps: – Medic/ Hospital arrival – ECG acquired – Data to decision maker – Physician evaluation (EP, Primary care?) – Transfer call initiated – Treatments administered – Patient transported (transferred?) – Procedure initiated – Reperfusion accomplished
  17. 17. System Barriers to Reperfusion • Lack of Standardized Protocols/ Standing Orders • Ambiguity of Leadership and Responsibility – ED / EMS / Cardiology / Hospital / Government • Inter Facility Transfer Issues – Majority of STEMI patients present to a facility w/o PCI capability – EMTALA (Emergency Medical Transfer and Active Labor ACT) Hospital liability for transferring “unstable” patients – Locally funded and administered EMS – Ability to transfer across single or multiple county lines may be restricted by coverage and/or guideline issues – 50% of STEMI admissions come directly to local ED- EMS is not activated 17
  18. 18. Prehospital 12 lead ECG
  19. 19. AMI Guidelines 2004 JACC 2004;44:686. 19
  20. 20. 20
  21. 21. Cardiac Destination Hospitals • Should EMS ‘drive by’ one facility to deliver patient to a PCI center? – This should be well coordinated within the EMS community • Distance/ time involved • High risk STEMI patient • Lytic ineligible patient 21
  22. 22. Reperfusion Checklist
  23. 23. Primary PCI or Lytics The Importance of Time Absolute Risk Difference in Death (%) Absolute Risk Difference in Death (%) 15 15 Circle sizes = sample size of the Circle sizes = sample size of the individual study. individual study. 10 10 Solid line = weighted meta-regression. Solid line = weighted meta-regression. 5 5 62 min Favors PCI Favors PCI 0 0 Favors Lysis Favors Lysis P = 0.006 P = 0.006 -5 -5 0 0 20 20 40 40 60 60 80 80 100 100 PCI-Related Time Delay (DTB - PCI-Related Time Delay (DTB - DTN) DTN) Every 10 min delay to PCI: 1% increase in mortality difference Every 10 min delay to PCI: 1% increase in mortality difference Nallamothu BK et al., Am J Cardiol. 2003 Nallamothu BK et al., Am J Cardiol. 2003
  24. 24. Develop a reperfusion strategy for your institution • Have a well thought-out strategy that fits the patients’ needs to the resources of your institution • Communicate strategy to all care givers • Minimize branch points/ decision points • Empower decision makers: EMS, EP • Anticipate needs (registration, lab, Rx)
  25. 25. Code STEMI Protocol • Prehospital (or ED) activation of STEMI Team – EPs, ED RNs, Techs, ?Cardiology, Nursing Supervisor • Short stay in ED for evaluation, medicines (ASA, heparin, ?lytic). • Labs, XR, etc only if time permits • No infusions – Goal is to leave ED within 30 min of arrival
  26. 26. Transfer for PCI • PCI Center selection – How to chose, if several available – Patient request – Ease and timeliness of transfer • Single call to arrange transfer • Hotline – Accepting site should activate their plan on your call
  27. 27. Transfer for PCI • Transportation issues – Air vs. ground • Weather and availability – Your EMS • Backfill issues • Limitation of local resources
  28. 28. 95.8% of patients treated after 90 minutes 1st Door to Balloon Door to Door Circulation 2005;111:761-767 2005;111:761-767
  29. 29. NRMI-5: North Carolina July 2003-June 2004 NC NC Nation Nation Guidelines Guidelines N N 2,738 2,738 79,927 79,927 % eligible treated % eligible treated 81% 81% 80% 80% Door-balloon Door-balloon 101 min 101 min 100 min 100 min <90 min <90 min 11PM to 7AM 11PM to 7AM 107 min 107 min Weekend Weekend 105 min 105 min Transfer Transfer 1st door – balloon 1st door – balloon 191 min 191 min 165 min 165 min <90 min <90 min 1st d-b <90 min 1st d-b <90 min 0.8% 0.8% 5.5% 5.5% 100% 100%
  30. 30. RACE Need for improvement in timeliness of STEMI reperfusion To do so the SYSTEM is as important as the SPECIFIC TREATMENT
  31. 31. RACE Key results: All hospitals showed improved processes Median reperfusion times improved D2B PCI: 85 min 74 min % Pts PCI within 90 min (non transfer): 56% 72% D2Needle: 35 min 29 min Door1In to Door1 Out: 120 min 71 min % Pts PCI within 90 min (transfer): 4% 13% Median D12B : 165 min 128 min No change in hospital mortality Did not measure morbidity
  32. 32. Top Ten List 10. Use local ambulance to transport pts within 50 miles 9. Keep patient on local ambulance stretcher 8. Give heparin bolus (70 U/kg) and no IV infusion 7. Establish protocol for lytics vs. PCI for each ED 6. Establish single call number to PCI centers that "automatically" activates cath lab 5. Apply Process Improvement techniques to STEMI care/ referrals 4. Provide standardized feedback reports to each ED 3. Prehospital ECG’s for all CP patients 2. Train all Paramedics to read ST elevation on ECG’s, call from ambulance to activate cath lab 1. Create EMS, ED, cardiology team with committed leadership
  33. 33. Accreditation – Cycle II 2006 - 2008 www.scpcp.org
  34. 34. Chest Pain Center • A Chest Pain Center is not a section of the hospital that treats STEMIs • Nor is it an area dedicated to evaluation of ‘low risk’ chest pain patients • A Chest Pain Center, like a Trauma Center, is a facility wide process based system that starts from the time a patient activates EMS until that patient is discharged from the hospital.
  35. 35. 8 Key Elements of a Chest Pain Center 1. ED Integration with EMS 2. Emergency Assessment - Diagnosis and Treatment of ACS 3. Evaluation of Low Risk Patients 4. Functional Facility Design 5. Personnel, Competencies, Training 6. Organizational Structure 7. Process Improvement Orientation 8. Community Outreach
  36. 36. Process Improvement – Case review and feedback • Questions to ponder in each case review: – Meet regularly – Post timeline of reperfusion intervals for each case – Let the staff know what the outcomes were – Identify areas that were done well by EMS, ED, Cardiology – Identify areas that need improvement by EMS, ED, Cardiology – Decision makers can modify institution’s process
  37. 37. Questions?? lgarvey@carolinas.org

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