Impact of transmitted ECG, pre-arrival activation of cath lab

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In patients with ST-elevation myocardial infarction, there is no question that "time is muscle". Indeed, time to reperfusion is critical for outcome in patients with STEMI.
In fact, every 30 minutes of delay to treatment results in an 8% increase in one-year mortality. Since Percutaneous Coronary intervention (PCI) has become the preferred approach for treating STEMI…

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Impact of transmitted ECG, pre-arrival activation of cath lab

  1. 1. IMPACT OF TRANSMITTED ECG, PRE-ARRIVAL ACTIVATION OF CATH LAB. Francisco Malagón Caussade. Emergency Department. Hospital Universitario Puerta de Hierro Majadahonda. Madrid, Spain.
  2. 2. <ul><li>In ST-elevation myocardial infarction (STEMI), “Time is muscle”. </li></ul><ul><ul><li>Time to reperfusion is critical for outcome in patients with STEMI . </li></ul></ul><ul><ul><li>(Every 30 minutes of delay to treatment -> + 8% in 1-year mortality) (18) </li></ul></ul><ul><li>PCI has become the preferred approach for treating STEMI. (4) </li></ul><ul><ul><li>t (Door-to-balloon)= Delay to reperfusion = D2B . </li></ul></ul>A- Background:
  3. 3. <ul><li>AHA / ACC Guidelines recommend D2B ≤ 90 min . (4) </li></ul><ul><li>However, few hospitals meet this objective . (2/6) </li></ul><ul><li>EMS, EDs and cardiologists are seeking ways to reduce D2B : </li></ul><ul><ul><li>D2B campaign: “Door-to-balloon: an alliance for quality” . </li></ul></ul><ul><ul><li>Identify hospital strategies associated with a faster D2B. </li></ul></ul>A- Background:
  4. 4. <ul><li>Hospital strategies significantly associated with a faster D2B: </li></ul><ul><li>A lways perform a prehospital 12-lead ECG. (4/5/7) </li></ul><ul><li>Rerouting of patients directly to interventional hospital. (2) </li></ul><ul><li>Cath lab is pre-activated while the patient is en route . (6/20) </li></ul><ul><li>- This is the single most important factor in reducing the D2B time. </li></ul><ul><li>Direct ambulance admission to the Cath Lab (bypass ED). (7) </li></ul>A- Background :
  5. 5. <ul><li>The Prehospital 12- lead ECG is the common point. </li></ul><ul><li>“ Prehospital 12-lead ECG programs” (AHA Class I recommendation). </li></ul><ul><li>Despite all these efforts, < 40% are treated within 90 – min. window . </li></ul><ul><li>What can we do? </li></ul>A- Background :
  6. 6. <ul><li>“ TIME Trial documented a 27% reduction of time (109 to 80 minutes) from EMS paramedic arrival to scene to successful PCI by implementing prehospital ECG transmission to the ED”. Wall et al, 2005 (13) </li></ul><ul><li>“ Significant improvement in D2B time as a result of the ability to transmit the prehospital electrocardiogram has been demonstrated” Moscucci et al, 2006 (12) </li></ul><ul><li>“ Transmission of the ECG from the ambulance to a cardiologist’s handheld computer reduced the D2B time by 50% (101 to 50 min)”. Adams et al, 2006 (9) </li></ul><ul><li>“ Wireless transmission of prehospital electrocardiograms to receiving stations in hospitals has been shown to reduce time from symptom onset to reperfusion”. Sejersten et al, 2008 (1) </li></ul>A- Background:
  7. 7. B.1- What is the transmitted ECG? B.2- How can transmitted ECG improve D2B strategies? B.3- Other impacts to the Cath Lab? B.4- Who should receive the transmitted ECG? B.5- ED role? B- Questions:
  8. 8. B.1- What is the transmitted ECG? B.2- How can transmitted ECG improve D2B strategies? B.3- Other impacts to the Cath Lab? B.4- Who should receive the transmitted ECG? B.5- ED role? B- Questions:
  9. 9. B- Questions: B.1- What is the transmitted ECG?
  10. 10. That is the “transmitted electrocardiogram” in the pre-arrival activation of the cab lab.
  11. 12. B- Questions: B.1- What is the transmited ECG? Emergency Department Science fiction?
  12. 13. B.1- What is the transmitted ECG? B.2- How can transmitted ECG improve D2B strategies? B.3- Other impacts to the Cath Lab? B.4- Who should receive the transmitted ECG? B.5- ED role? B- Questions:
  13. 14. <ul><li>B.2.1- In the rerouting of patients directly to interventional hospital: </li></ul><ul><li>Tekelsen et al : “ shorter delay before PCI is observed if patients are diagnosed pre-hospitaly and directly referred to an interventional center with the use of telemedicine ”. (10) </li></ul><ul><li>Sejersten et al : “ transmission of a prehospital 12-lead ECG directly to the attending cardiologist’s mobile telephone decreased door-to-balloon time by >1 hour when patients were transported directly to PCI centers, bypassing local hospitals”. (1) </li></ul>B- Questions: B.2- How can transmitted ECG improve D2B strategies?
  14. 15. <ul><li>B.2-2 In the Cath Lab pre-activation while the patient is en route: </li></ul><ul><li>Bradley et al: “hospitals that activated the Cath Lab on the basis of real-time data transmitted while the patient was en route had faster D2B” (3) </li></ul><ul><li>Sejersten et al : achieved a “30-minute maximum response time of on-call PCI team even during nights and weekends with the use of transmitted ECG ” (1) </li></ul><ul><li>Sejersten et al “ the true-positive rate of STEMI diagnosis by paramedics is high but decreases when the ECG has confounding factors (e.g., prior MI, poor-quality ECG, bundle branch block, left ventricular hypertrophy or pacemaker).” (19) </li></ul><ul><li>-> That’s why many hospitals are reluctant to activate a cath lab team based on the recommendation of paramedics. </li></ul>B- Questions: B.2- How can transmitted ECG improve D2B strategies?
  15. 16. <ul><li>B.2-3 In the direct admission to the Cath Lab (bypass ED). </li></ul><ul><li>Dorsh et al : (7) </li></ul><ul><li>“ Direct ambulance admissions had substantially shorter D2B (58 vs 105 min.) and call-to-balloon times (105 vs 143 min.) than patients admitted via the ED”. </li></ul><ul><li>“ Even with the introduction of direct admissions, the 90-minutes target was not achieved in 43% of patients, indicating that further measures were required”. </li></ul><ul><li>“ Then, the greatest benefit would be obtained from increasing the proportion of patients admitted directly. This was done by introducing telemetry to enable transmission of ECGs ”. </li></ul>B- Questions: B.2- How can transmitted ECG improve D2B strategies?
  16. 17. <ul><li>All these improvements shorten: </li></ul><ul><li>The door-to-balloon time… </li></ul><ul><li>but also EMS arrival-to-door time. </li></ul>B- Questions: B.2- How can transmitted ECG improve D2B strategies?
  17. 18. B.1- What is the transmitted ECG? B.2- How can transmitted ECG improve D2B strategies? B.3- Other impacts to the Cath Lab? B.4- Who should receive the transmitted ECG? B.5- ED role? B- Questions:
  18. 19. <ul><li>A rerouting strategy may result in some patients being transported for longer distances -> longer time to the first hospital : </li></ul><ul><ul><li>Hospital physicians can support ambulance personnel in the treatment of malignant arrythmias with the use of continuous real-time ECG transmission during such transportations. (2) </li></ul></ul><ul><ul><li>ECG transmission helps prehospital true diagnosis and then allows early pre-medication to the patient with suspected STEMI. </li></ul></ul><ul><li>Continuous ST-segment monitoring performed in the prehospital phase and during primary PCI may provide important prognostic information: </li></ul>B- Questions: B.3- Other impacts to the Cath Lab? ¿¿ ??
  19. 20. Favourable outcome. Intermediate outcome. Less favourable outcome. Intermittent occlusion of the coronary artery Persistent occlusion of the coronary artery Dynamic ST-segment changes occur in patients with STEMI before initiation of PCI. Equipment used for transmitted ECG has built-in features for continuous ST-segment monitoring…
  20. 21. B.1- What is the transmitted ECG? B.2- How can transmitted ECG improve D2B strategies? B.3- Other impacts to the Cath Lab? B.4- Who should receive the transmitted ECG? B.5- ED role? B- Questions:
  21. 22. <ul><li>“ The presence of an attending cardiologist at the hospital at all times was associated with a faster D2B.” (3) However, that may be impractical and too many expensive to implement in many hospitals. </li></ul><ul><li>“ Pre-arrival activation of the Cath Lab is extremely efficient with the use of telemedecine but delays increase when attending cardiologists are located distant to the ECG receiving station in the ED”. (1) </li></ul><ul><li>“ Cardiologists make similar decisions about initiation of reperfusion therapy when viewing an ECG on paper or on a handheld liquid crystal display (LCD)” (1/17). </li></ul>B- Questions: B.4- Who should receive the transmitted ECG?
  22. 23. <ul><li>ECG can be directly transmitted to a handheld device so an attending cardiologist can respond reliably , at all times and irrespective of presence within or outside the hospital. </li></ul><ul><li>The transmission to the cardiologist adds the benefit of involving a specialist who has indeed real decision-making competence , and so a profound impact on the speed in providing reperfusion therapy to patients with STEMI. </li></ul>B- Questions: B.4- Who should receive the transmitted ECG?
  23. 24. B.1- What is the transmitted ECG? B.2- How can transmitted ECG improve D2B strategies? B.3- Other impacts to the Cath Lab? B.4- Who should receive the transmitted ECG? B.5- Does it mean that the ED must by ignored? B- Questions:
  24. 25. <ul><li>Although bypassing the emergency department is faster, concerns have been raised about c onsideration of alternative diagnoses (aortic dissection, intracranial haemorrhage …). </li></ul><ul><li>During off hours, the catheterization team may not have arrived at the hospital before the ambulance. </li></ul><ul><li>Hospitals must have a plan B protocol in place for cath lab activation in the event of transmission problems (Handheld device coverage can be spotty ) . The ED serves as a backup if transmission to cardiologist fails. </li></ul>B- Questions: B.5- ED role?
  25. 26. x x x
  26. 27. <ul><li>Although bypassing the emergency department is faster, concerns have been raised about c onsideration of alternative diagnoses (aortic dissection, intracranial haemorrhage). </li></ul><ul><li>During off hours, the catheterization team may not have arrived at the hospital before the ambulance. </li></ul><ul><li>Hospitals must have a plan B protocol in place for cath lab activation in the event of transmission problems (Handheld device coverage can be spotty ) . The ED serves as a backup if transmission to cardiologist fails. </li></ul><ul><li>In cases of complete communication failure , the ambulances follow “old” procedures and transport patients to the nearest hospital, to the ED. </li></ul>B- Questions: B.5- ED role?
  27. 28. B- Questions: B.1- What is the transmited ECG? Emergency Department
  28. 29. B- Questions: B.1- What is the transmited ECG? Emergency Department
  29. 30. Conclusions
  30. 31. <ul><li>Time to reperfusion is critical for outcome in patients with STEMI. </li></ul><ul><li>Despite the use of strategies significantly associated with a faster D2B time, <40% of patients who receive PCI are treated within the 90-minutes window. </li></ul>C- Conclusions:
  31. 32. <ul><li>Transmitted ECG reduces time from EMS arrival to reperfusion and not only the door-to-balloon time. We can say that this technology has moved the proverbial “door” to the patient’s home . </li></ul><ul><li>Transmitted ECG improves EMS arrival-to-balloon time because of: </li></ul><ul><ul><li>The faster rerouting . </li></ul></ul><ul><ul><li>The faster pre-arrival activation of the Cath lab . </li></ul></ul><ul><ul><li>The faster Cath Lab personnel response . </li></ul></ul><ul><ul><li>The better proportion of patients admitted directly to the Cath Lab. </li></ul></ul>C- Conclusions:
  32. 33. <ul><li>Other impacts of the transmitted ECG are: </li></ul><ul><ul><li>To Support EMS during longer transportations. </li></ul></ul><ul><ul><li>To allow early pre-medication in STEMI. </li></ul></ul><ul><ul><li>Continuous ST-segment monitoring which provide independent prognostic information with triaging high-risk patients for additional pharmacological and interventional treatment during PCI. </li></ul></ul><ul><li>If possible, prehospital 12-lead ECG must be transmitted to the on-call cardiologist. </li></ul><ul><li>However, ED continues on playing a leading role for the patient with STEMI. </li></ul>C- Conclusions:
  33. 34. <ul><li>We need to help parties better understand each other’s roles through the entire continuum of care from the scene to the cath lab. </li></ul><ul><li>The goal of every prehospital ECG program should be to use technology to become part of an integrated system of patient care. </li></ul><ul><li>EMS, ED staff, Cardiologists and hospital leadership should work together to implement these readily available techniques. </li></ul>FUTURE GOALS:
  34. 35. Thank you.
  35. 36. 1- Maria Sejersten, MDa et al. Effect on Treatment Delay of Prehospital Teletransmission of 12-Lead Electrocardiogram to a Cardiologist for Immediate Triage and Direct Referral of Patients With ST-Segment Elevation Acute Myocardial Infarction to Primary Percutaneous Coronary Intervention; Am J Cardiol 2008;101:941–946. 2- Christian Juhl Terkelsen, MD, PhDT et al. Prehospital evaluation in ST-elevation myocardial infarction patients treated with primary percutaneous coronary intervention; Journal of Electrocardiology 38 (2005)187– 192. 3- Elizabeth H. Bradley, Ph.D et al. Strategies for Reducing the Door-to-Balloon Time in Acute Myocardial Infarction; N Engl J Med 2006;355:2308-20. 4- Antman EM, Anbe DT, Armstrong PW, et al. ACC/AHA guidelines for the management of patients with ST-elevation myocardial infarction — executive summary: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines; Circulation 2004;110:588-636. 5- Curtis JP, Portnay EL, Wang Y, et al. The pre-hospital electrocardiogram and time to reperfusion in patients with acute myocardial infarction, 2000-2002: findings from the National Registry of Myocardial Infarction-4 ; J Am Coll Cardiol 2006;47:1544-52. D- References:
  36. 37. 6- Elizabeth H. Bradley, PhD et al. Summary of Evidence Regarding Hospital Strategies to Reduce Door-to-Balloon Times for Patients With ST-Segment Elevation Myocardial Infarction Undergoing Primary Percutaneous Coronary Intervention; Crit Pathways in Cardiol 2007;6:91–97. 7- Michael F. Dorsch, PhD et al. Direct ambulance admission to the cardiac catheterization laboratory significantly reduces door-to-balloon times in primary percutaneous coronary intervention; Am Heart J 2008;155:1054-8. 8 - Sekulic, M et al. Feasibility of early emergency room notification to improve door-to-balloon times for patients with acute ST elevation myocardial infarction. Catheter Cardiovasc Interv. 2005 Nov;66(3):316-9. 9- Adams, GL et al. Effectiveness of prehospital wireless transmission of electrocardiograms to a cardiologist via hand-held device for patients with acute myocardial infarction (from de TIME-NE); Am J Cardiol. 2006 Nov 1;98(9); 1160-4. 10- Tekelsen, CJ et al. Reduction of treatment delay in patients with ST elevation myocardial infarction: impact of prehospital diagnosis and direct referral to primary percutanous intervention; European Heart Journal (2005) 26, 770-777. D- References (cont.):
  37. 38. 11- Dhruva, VN, Abdelhadi, SI, Anis, A, et al. ST-Segment Analysis Using Wireless Technology in Acute Myocardial Infarction (STAT-MI) trial. J Am Coll Cardiol 2007; 50:509. 12- Moscucci, M, Eagle, KA. Reducing the door-to-balloon time for myocardial infarction with ST-segment elevation. N Engl J Med 2006; 355:2364. 13- Paul T. Campbell, MD. Prehospital triage of acute myocardial infarction: wireless transmission of electrocardiograms to the on-call cardiologist via a handheld computer; Journal of Electrocardiology 38 (2005) 300–309. 14- Henry H. Ting, Harlan M. Krumholz, Elizabeth H. Bradley et al. Implementation and Integration of Prehospital ECGs Into Systems of Care for Acute Coronary Syndrome: A Scientific Statement From the American Heart Association Interdisciplinary Council on Quality of Care and Outcomes Research, Emergency Cardiovascular Care Committee, Council on Cardiovascular Nursing, and Council on Clinical Cardiology; Circulation 2008;118;1066-1079. 15- Scholz KH, Hilgers R, Ahlersmann D, Duwald H, Nitsche R, von Knobelsdorff G, Volger B, Möller K, Keating FK. Contact-to-balloon time and door-to-balloon time after initiation of a formalized data feedback in patients with acute ST-elevation myocardial infarction. Am J Cardiol. 2008;101:46 –52. D- References (cont.):
  38. 39. 16- Wall T, Albright J, Livingston B, et al: “Prehospital ECG transmission speeds Reperfusion for patients with acute myocardial infarction.” North Carolina Medical Journal. 61(2):104–108, 2000. 17- Leibrandt PN, Bell SJ, Savona MR, et al: “Validation of cardiologists’ decisions to initiate reperfusion therapy for acute myocardial infarction with electrocardiograms viewed on liquid crystal displays of cellular telephones.” American Heart Journal. 140(5):747–752, 2000. 18- De Luca G, Suryapranata H, Ottervanger JP, et al: Time delay to treatment and mortality in primary angioplasty for acute myocardial infarction: Every minute of delay counts. Circulation. 109(10):1223–1225, 2004. 19- Sejersten M, Young D, Clemmenson P, et al: “Comparison of the ability of paramedics with that of cardiologists in diagnosing ST-segment elevation acute myocardial infarction in patients with acute chest pain.” American Journal of Cardiology. 90:995–998, 2002. 20- Jason P. Brown, et al: Effect of Prehospital 12-Lead Electrocardiogram on Activation of the Cardiac Catheterization Laboratory and Door-to-Balloon Time in ST-Segment Elevation Acute Myocardial Infarction; Am J Cardiol 2008;101:158 –161. D- References (cont.):
  39. 40. IMPACT OF TRANSMITTED ECG, PRE-ARRIVAL ACTIVATION OF CATH LAB. Francisco Malagón Caussade. Emergency Department. Hospital Universitario Puerta de Hierro Majadahonda. Madrid, Spain.

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