# Cardiac Cath Lab - Specialty Referral?



## RedZone (Jun 28, 2007)

Here in NYC, our protocols demand that "under no circumstances" we bring unstable patients anywhere but the nearest "911 receiving hospital". The only exceptions are for specialty care referrals or by telemetry physician order. Presently, the fire department (which regulates the 911 EMS system), is taking steps to enforce protocol issues with hospital selection. 

Recognized Specialty Care Centers: 
- Trauma Center 
- Burn Center (Trauma takes precedence) 
- Hyperbaric Center 
- Replantation Center 
- Spinal Cord Injury Center 
- Venomous Bite Center 
Most recently (Aug. 2006), Stroke Center is now recognized. 

My bass ackwards city (and state) DOES NOT recognize cardiac center! If I have a patient having an acute MI, I am required to bring that patient to the nearest emergency room even if that hospital does not have a cardiac cath lab. Because I have a close working relationship with one particular cath lab (from several jobs, past and present), I know how important it is for an AMI pt to be on the cath table ASAP. 

I've been able to manipulate the system sometimes in the past, but now I am just going to have to call telemetry for every MI unless they shut me up or change the rule. 

Does your region recognize cardiac centers?


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## Ridryder911 (Jun 28, 2007)

We have been discussing this issue in class (I finish another CCP course Saturday) and as well majority of the systems still transport to local ED's. There are a few using "blue tooth" technology, that allows XII lead to be transmitted into ED's and then transmitted to the cath lab so the patient can be diverted straight to the cath lab. 
 I believe we will see a change, since the new recommendations are door to door instead of thrombolytics (<90 minutes).

R/r 911


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## Flight-LP (Jun 28, 2007)

All acute MI's and new onset left BBB's, regardless of location, go to our tertiary cardiac center within our district. We go directly to the cath lab, do not pass go, do not collect $200.........................

Hopefully in the near future we will have 3-4 other hospitals in our district set up to do the very same thing, will definately reduce transport time and will offset some of the workload off of one hospital.


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## lfsvr0114 (Jun 28, 2007)

We have a couple of hospitals that are staffed by day, but have to call in the staff by night.  In the event we catch one at night, we have protocols to fly them downtown to the level 1 hospital (it is 42 miles ground).


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## Bongy (Jun 28, 2007)

Well...Lucky us.. We have cardio cath centers in ALL  hospitals... So in case of AMI we just inform and go directly to CICU.
Btw... What is the reason to transfer pt from MICU to ED,without option of cath? What else can they do,that you can't in a truck? If you have no cath centers - have trombolitycs in a truck


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## RedZone (Jun 28, 2007)

Bongy said:


> Btw... What is the reason to transfer pt from MICU to ED,without option of cath? What else can they do,that you can't in a truck? If you have no cath centers - have trombolitycs in a truck



I don't know who is transferring from MICU to ED.  Maybe you misunderstood?

Here, all prehospital patients always go to emergency department.  We used to have an exception for females who were a certain # of weeks into pregnancy.  They would go directly to L&D unit, but for some reason the powers that be raised a big stink about that and now ED staff must triage the mother and take her to the L&D unit themselves.

When I am doing inter-facility transfers, it is actually against federal law to transfer a patient from one hospital to another hospital's emergency department except in very specific circumstances.  We will take from an MICU to a cath lab or from ED to cath lab.

Also, ALS ambulances in my area generally do not carry thrombolytics.  We also don't have platelet aggregators (Aggrastat), IV nitroglycerine (tridil), or heparin.  I will transfer patients who are already on these medications, but I don't initiate those therapies.  

Our drug therapy for AMI in the pre-hospital setting is generally 162 mg Aspirin, 0.4 mg sublingual nitroglycerine (while patient is hemodynamically stable, it may repeated every 5 minutes while patient has chest pain.  Med control must be called after 3 doses), 1 1/2 inches of nitro-paste transdermally (if hemodynamically stable and chest pain still present after 3 SL nitros).  We can also call for IV Morphine.

Any other treatment focuses on treating dysrhytmias or cardiogenic shock.


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## Flight-LP (Jun 28, 2007)

RedZone said:


> I don't know who is transferring from MICU to ED.  Maybe you misunderstood?
> 
> Here, all prehospital patients always go to emergency department.  We used to have an exception for females who were a certain # of weeks into pregnancy.  They would go directly to L&D unit, but for some reason the powers that be raised a big stink about that and now ED staff must triage the mother and take her to the L&D unit themselves.
> 
> ...



I think Bongy was referring to a Mobile Intensive Care Unit (i.e. a Paramedic staffed Ambulance, thats also what we call them here in Houston) vs. Medical ICU...............

I agree that if cath intervention isn't IMMEDIATELY available (I'm talking now, not 3 hours from now, not in the morning), then you need to go to an ER that will lyse the clot (not an ER that has thrombos, but one that will actually use them). If neither are available, fly'em to the nearest cath lab.


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## RedZone (Jun 28, 2007)

Flight-LP said:


> I think Bongy was referring to a Mobile Intensive Care Unit (i.e. a Paramedic staffed Ambulance, thats also what we call them here in Houston) vs. Medical ICU...............
> 
> I agree that if cath intervention isn't IMMEDIATELY available (I'm talking now, not 3 hours from now, not in the morning), then you need to go to an ER that will lyse the clot (not an ER that has thrombos, but one that will actually use them). If neither are available, fly'em to the nearest cath lab.



Oh!  I guess it was me that misunderstood!  Thanks for clearing that up... I forgot about that Mobile ICU term.

We don't fly here.  But, nearest 911 receiving ED is rarely more than 10 minutes away (usually less than 5), and '911 receiving ED' means they have to meet certain standards of care.  They all have ICUs, they all have thrombos, and I never heard of any that would hesitate to use them.

The state DOH does have to approve a hospital to do invasive heart procedures.  They're very strict about it.  I just hope that one day soon, the state (or the region, whichever acts first) recognizes the AHA standard and informs EMS crews which hospitals are approved, and allows us to drive a few extra minutes with an acute MI patient.

But then again, our state requires defibrillators at all sorts of public places (schools, stadiums, concert halls) and still has yet to require one on an ambulance.  Go figure.


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## Guardian (Jun 29, 2007)

RedZone said:


> My bass ackwards city (and state) DOES NOT recognize cardiac center! If I have a patient having an acute MI, I am required to bring that patient to the nearest emergency room even if that hospital does not have a cardiac cath lab. Because I have a close working relationship with one particular cath lab (from several jobs, past and present), I know how important it is for an AMI pt to be on the cath table ASAP.




About once a week I read something about NYC or NJ ems that just floors me.  What's going on there?  It seems you'll are obsessed with following protocols wrought with bureaucratic nonsense.  Where I work, a protocol is a guideline.

To me, not taking an MI pt to a hospital with a cath lab is barbaric.


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## Bongy (Jun 29, 2007)

RedZone... Flight-LP is right,I refferd to  Mobile ICU - I work in one like this... Our AMI protocols include Heparine(4000 IU) IV,Aspirine 300 mg to chew,SL and IV nitrates,if nessesary,and we can trasport directly to CICU(Cardiac ICU) for "Door to Stent"... Usualy,we make an AMI diagnosis on rule of 2 of 3:
ST Elev.
Clinical Findings
Troponin level(that can not be checked in prehospital...at least in Israel)...
So a bottom line - ST elev + Chest Pain - direcly to the cath unit...


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## Guardian (Jun 29, 2007)

Bongy said:


> RedZone... Flight-LP is right,I refferd to  Mobile ICU - I work in one like this... Our AMI protocols include Heparine(4000 IU) IV,Aspirine 300 mg to chew,SL and IV nitrates,if nessesary,and we can trasport directly to CICU(Cardiac ICU) for "Door to Stent"... Usualy,we make an AMI diagnosis on rule of 2 of 3:
> ST Elev.
> Clinical Findings
> Troponin level(that can not be checked in prehospital...at least in Israel)...
> So a bottom line - ST elev + Chest Pain - direcly to the cath unit...




The more you type, the more I'm impressed with Israel.


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## airmedic_8 (Jun 29, 2007)

Guardian said:


> The more you type, the more I'm impressed with Israel.



I certainly agree with this statement.  I am very impressed with the amount of interventions Israeli medics can perform.  The US is far advanced in prehospital medicine compared to most countries however, when compared to Israel; it appears we have some catching up to do.  You are truly blessed to have medical directors that allow you to aggressively treat your patients.


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## Ridryder911 (Jun 29, 2007)

FYI: Tropinin and CK levels are useless in the field. Since the markers take up to 4-6 hrs post injury, it would be a little too late for interventional therapy. I do agree that we need to be more aggressive, and we can learn off anyone else that is providing better and more appropriate care. 

R/r 911


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## VentMedic (Jun 29, 2007)

airmedic_8 said:


> I certainly agree with this statement.  I am very impressed with the amount of interventions Israeli medics can perform.  The US is far advanced in prehospital medicine compared to most countries however, when compared to Israel; it appears we have some catching up to do.  You are truly blessed to have medical directors that allow you to aggressively treat your patients.



Most of the MICUs in Israel are staffed with a physician on board. That is a whole different playing field.  

Physicians were also on many of the ALS ambulances in the U.S. during the 1980s, but it was shown that paramedics could function fairly well without them in most areas. 

MICUs are not unknown to the U.S.  They were popular in the 1980s. However in the city areas they were used in, it was not alway cost effective to keep them running for every call. Several hospitals still have these units and can mobilize them for special cases or disaster situations. The crew can consist of physicians, Critical Care RNs. RRTs and paramedics depending on the circumstances of the call.  There are some services that call their ALS units MICU and the services vary greatly. The certification of these units and staff again vary in different areas and states.

Thrombolytics were also thought to be a save all in the field in the 1980s when the 12 lead EKG gained popularity.  Again, in the metro areas utilizing them, there was a hospital within 15 minutes. 

The advances in HEMS and flight have given quicker access to specialty centers.

In Florida, we have hospital systems such as  SDA Florida Hospital, who have large cath centers and the transport teams that can move the patients quickly. High levels of expertise is then maintained when the resources are handled by a good medical over sight board for many facilities.  

I was never a fan of the "cath in a can" days.  

There are some good articles that can be Googled about medicine in Israel. Many of our physicians and nurses have done educational tours there to both teach and to learn.


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## Bongy (Jun 29, 2007)

VentMedic said:


> Most of the MICUs in Israel are staffed with a physician on board. That is a whole different playing field.


This is not correct...Most of Israeli MICU are NOT staffed with a physician... The standart is "2 of 6" or "2 of 8"...That means,that only on 2 MICUs in a region have a doctor on board,of total 6 working...In a bigger regions is only 2 on every 8... In hebrew it calls "NATAN" (with a doctor) or "ATAN" without a doctor - only paramedics(sometimes EMT-P and EMT-I).
So...For examle,in Dan region(that I work in) we have 4 MICU without physicians and 2 with a physician on board... We work on protocol basis and in case that we need to do something that extend protocol limitation we inform a physician on one of the "NATANs". They are our medical directors in a real time. In general,physician role in Israel EMS is quite innert,all case managment done by paramedic.(of couse,there are some exeptions... Some times you find youself with so great energency medicine specialist,that there is nothing to do but to learn from him - but it is very rare)


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## VentMedic (Jun 29, 2007)

So essentially it is like our  "with" physician U.S. MICUs and the other classifications of ALS and MICU where the EMT-P or RN follow protocols and orders according to the system.  Some of our systems are very advanced also.  Many of our inter-facility units are very impressive, especially in the pedi and neonatal transport specialty.


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## RedZone (Jun 29, 2007)

Guardian said:


> About once a week I read something about NYC or NJ ems that just floors me.  What's going on there?  It seems you'll are obsessed with following protocols wrought with bureaucratic nonsense.  Where I work, a protocol is a guideline.
> 
> To me, not taking an MI pt to a hospital with a cath lab is barbaric.



Yeah, our system is hampered by too much bureaucratic bs.  We do get taught "Don't be a cookbook medic, a protocol is just a guideline" over and over again in class.  Our "treatment protocols" are preceeded by "General Operaing Procedures".  I believe that it even says somewhere in those procedures that the treatment protocols are merely guidelines, and are not meant to excuse us from sound medical judgment.  But also in those procedures, there are many RULES, including hospital destination decision.

I work for both a hospital (911) and for a private ambulance.  The fire department strictly monitors and regulates the 911 EMS system, and I have a lot less ability to make my own decisions.  One medic I know was suspended from working anywhere in the 911 system for about 2 months because an FD field supervisor determined he made an innapropriate decision by not going to the closest ED. When with the private, I have a lot more choice.  Even the medical director of a hospital EMS department has much less control than the medical director of a private ambulance.

Oh well, enough ranting from me, but thanks for the opportunity.


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## RedZone (Jul 14, 2007)

Well, I came across an answer to my question.  It appears in May 2007 issue of JEMS in an article titled "Specialty Center Boom: Is transport to the closest ED a thing of the past?"



			
				Marc Eckstein said:
			
		

> Cardiac center designation is currently in vogue. Good science supports treating ST elevation myocardial infarction (STEMI) patients with emergent percutaneous coronary intervention (PCI) instead of fibrinolytic therapy, as long as the door-to- balloon time is less than 90 minutes. *However, the American Heart Association has not yet formally supported EMS diversion of STEMI patients to cardiac centers. Rather, it recommends having an internal process to get the door-to-balloon time under 90 minutes if PCI is available, or else have a formal process in place to rapidly transfer STEMI patients to PCI-capable facilities.*



I guess my system is actually in compliance with recommended guidelines.  As I realized myself, hospitals are making internal changes as recommended.  The article does explain that many EMS systems have begun adjusting their own procedures despite AHA's lack of formal support.  Definitely an article that answered a lot of my questions!


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## VentMedic (Aug 7, 2007)

Good video about Minnesota's Cardiac referral program "Level One Heart Attack Protocol".

http://www.marketwatch.com/tvradio/bcPlayer.asp?bcpid=203719194&bclid=86272812&bctid=1132448960

And a little extra information about Minnesota's Ambulances.

http://www.health.state.mn.us/divs/chs/rhpc/cah/rasstudy.htm


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## Grady_emt (Aug 8, 2007)

Here at Grady EMS, we were involved in a trial program through Emory University Hospital that involved transmitting 12leads of suspected AMI pts to Emory University Hospital (EUH), or Emory Crawford Long (CWL), where the pt would be accellerated throught the ER processing for basically a fast-track to the Cath lab.  
Here is a link to the press release about the trial http://whsc.emory.edu/press_releases2.cfm?announcement_id_seq=2299

After the success of that program, it has been expanded to five Metro Atlanta hospitals, EUH, CWL, Piedmont Hospital, Atlanta Medical Center, and Saint Joseph's Hospital.  It is now called TIME, Timely Intervention of Myocardial Emergencies.  I have posted a link to a Copy of our chest pain, and the TIME protocol.  
Chest Pain    http://i63.photobucket.com/albums/h151/willalexander/Documents/TIMECPprotocol0002.jpg

TIME   http://i63.photobucket.com/albums/h151/willalexander/Documents/TIMECPprotocol0001.jpg

Basically for a chest pain Pt who presents with clincal findings consistent with cardiac chest pain, an ST elevation on the 12lead we proceed with normal chest pain protocol, and transmit the 12lead from the LP12 to one of the 5 hospitals above that have 24hr Cathlabs.  

Also, if after explaining to the pt their condition and that they will be best suited at one of those hospitals, they still refuse transport to one of them, we are to have that pt sign a refusal and write on it that they refused transport to the closest appropriate facility.


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