Confirmed STEMI to PCI-center or closest community hospital?

[MrJones]

That might be true. Can you ask him which specific studies he has read that promote this view? I would really be interested in them.

I don't know Handsome Robb's medical director so sorry, no.

 

[ERDoc]

What contraindications are you using before infusing UFH?

We are only giving a bolus and not starting a drip so until they have obviously bleeding, not really any.

 

[Alan L Serve]

Primary PCI (pPCI) is the treatment of choice for STEMI, so take the STEMI to the cath lab. I cannot even believe we are having this discussion.

Thrombolysis is reserved for those patients who cannot receive PCI within a reasonable time frame (varies a little bit internationally - but approximately two hours from symptom onset).

That option simply isn't available in many systems. I cannot even believe people think PCI is so readily available that other options do not even need to be discussed.

 

[Alan L Serve]

I see posts were removed. Anyone know why?

 

[SpecialK]

That option simply isn't available in many systems. I cannot even believe people think PCI is so readily available that other options do not even need to be discussed.

Regardless of how far the cath lab is, the patient should go to the cath lab first time (regardless of whether it's by road or air (either plane or helicopter)) unless it is not physically possible because the aircraft cannot fly or ambulance cannot drive.

The Royal Flying Doctor Service, Scottish Ambulance Service, Ambulance Service of New South Wales and similar services' (particularly in Australia) and New Zealand get people directly to the cath lab despite great distances, in the case of Australia, often thousands of kilometers.

This includes transfers for pPCI and urgent transfers post-thrombolysis.

Essentially, if your jurisdiction does not have a formalised system to get the patient to the cath lab as fast as possible or thrombolyse them en-route to a cath lab, well, that is, pragmatically, unacceptable, because it means the patient is receiving sub-optimal care.

 

[Alan L Serve]

Regardless of how far the cath lab is, the patient should go to the cath lab first time (regardless of whether it's by road or air (either plane or helicopter)) unless it is not physically possible because the aircraft cannot fly or ambulance cannot drive.

The Royal Flying Doctor Service, Scottish Ambulance Service, Ambulance Service of New South Wales and similar services' (particularly in Australia) and New Zealand get people directly to the cath lab despite great distances, in the case of Australia, often thousands of kilometers.

This includes transfers for pPCI and urgent transfers post-thrombolysis.

Essentially, if your jurisdiction does not have a formalised system to get the patient to the cath lab as fast as possible or thrombolyse them en-route to a cath lab, well, that is, pragmatically, unacceptable, because it means the patient is receiving sub-optimal care.

How do you reconcile your opinion with the study I cited in the original post which says that in fact a STEMI should go to a community ED first to receive antiplatelet and anticoagulant therapy and then go for facilitated PCI?

 

[gotbeerz001]

I think his point is that if your system doesn't have the capability of getting a patient to a Cath Lab in a reasonable timeframe, the system sucks.


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[Alan L Serve]

I think his point is that if your system doesn't have the capability of getting a patient to a Cath Lab in a reasonable timeframe, the system sucks.


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Welcome to 80% of America.

 

[Tigger]

Welcome to 80% of America.

Citation?

 

[NomadicMedic]

Welcome to 80% of America.

Really?

A study from 10 years ago estimated that 79% of the US population in 2001 lived within a 60-minute drive of a PCI-capable hospital.

Driving times and distances to hospitals with percutaneous coronary intervention in the United States: implications for prehospital triage of patients with ST-elevation myocardial infarction.
Nallamothu BK, Bates ER, Wang Y, Bradley EH, Krumholz HM
Circulation. 2006 Mar 7; 113(9):1189-95.

 

[SpecialK]

How do you reconcile your opinion with the study I cited in the original post which says that in fact a STEMI should go to a community ED first to receive antiplatelet and anticoagulant therapy and then go for facilitated PCI?

Easy. Carry ticagrelor and LMWH as part of your "STEMI bundle". This might not be necessary in an urban area with fast access to pPCI but certainly in rural areas is practical, maybe not on every ground ambulance but on the helicopter certainty.

 

[Alan L Serve]

Citation?

Good point and I really need to take my own advice before offering up an opinion. I did some research and it's clear that the numer is not as high as 80% of America lives outside a 60 minute drive directly to a PCI-center. In fact it seems nearly 80% does live within a 60 minute transport directly to a PCI center. The problem is that STEMI patients aren't getting to those centers within 60 minutes of activating 911 for several reasons, one of which is the PCI-center is outside the service area of the EMS geographical service area. It also appears many patients simply self-present to the ER of non-PCI hospitals when experiencing STEMI symptoms .

By using data from the American Hospital Association survey, they found that the proportion of US hospitals providing PCI increased from 25.5% in 2001 (1176 of 4609) to 36.2% in 2006 (1695 of 4673), a 44% relative increase in the proportion of hospitals with PCI.11 Despite the addition of >500 new PCI programs, geographic access for patients improved little during the period of study. In particular, the percentage of the US population residing within 60 minutes of a PCI-capable hospital increased by a mere 0.9% (79.0% in 2001; 79.9% in 2006). Moreover, the average driving time and total elapsed time from 9–1-1 call to hospital arrival decreased by 48 and 30 seconds, respectively, suggesting that most new PCI programs have opened in areas with preexisting PCI hospitals. Although the improvement in geographic access from new PCI programs appears to have been small, the costs of these new programs are likely substantial. The fixed costs of setting up a new cardiac catheterization laboratory (construction and equipment) have been estimated at $3.1 million, without including the cost of physicians, nurses, and technologist staffing.12 Thus, the capital costs of the new PCI laboratories that have opened in this 5-year period are likely to have exceeded $1.5 billion Souce: http://circoutcomes.ahajournals.org/content/5/1/9.full

Bolding was something I did. It doesn't help too much when two hospitals a few miles from one another are competing for patients and each are operating a state-of-the-art PCI-center and duplicating services when the more rural hospitals are without PCI yet getting plenty of STEMI and NSTEMI patients. That's when we have to get creative in our treatment of STEMIs in a non-PCI area just like our friends in Georgia and elsewhere have.

Geez! $3.1 million just to open the PCI-center which doesn't account for operating costs.

I have a feeling if our medical system was more social in nature and not run by competing organizations there would be more PCI centers in rural areas, but that'd require major changes in politics and also big differences in bottom lines. Sorry for pulling a number out of my butt and please feel free to call me out on it in the future. Pot, meet kettle.

 

[Alan L Serve]

Easy. Carry ticagrelor and LMWH as part of your "STEMI bundle". This might not be necessary in an urban area with fast access to pPCI but certainly in rural areas is practical, maybe not on every ground ambulance but on the helicopter certainty.

Instead of MONA we should grand her an officer's commission and she should become LT MONA. (L=LMWH, T=Ticagrelor or another such as Clopidogrel).

 

[gotbeerz001]

Sounds like the focus needs to be public education for symptoms of STEMI and benefits of early detection... If someone chooses to live in a rural area, odds are they are not the type to call 911 very often; it's likely ignorance and stubbornness are the confounding factors.


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[NomadicMedic]

Sounds like the focus needs to be public education for symptoms of STEMI and benefits of early detection... If someone chooses to live in a rural area, odds are they are not the type to call 911 very often; it's likely ignorance and stubbornness are the confounding factors.


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Amen. If you live in the sticks, you can't expect instant care at a fully equipped medical facility.

 

[kev54]

Cost effective care is important along with the volumes to support quality care for PCI centers. If you live in a rural place advocate for developing resources to reducing the door to balloon time may be useful. The US could probably learn from other areas of the world with other rural populations like Australia and Canada. See here for a Australian study on regionalized care for rural patients. https://www.mja.com.au/journal/2014...cardiac-support-network-mortality-among-rural
We might need overall health system improvements along with protocol development for certain regions as well. Public health education is key.

 

[NomadicMedic]

I certainly transport my sure of STEMI patients from the community ED to the PCI center, but if I can identify a STEMI in the field, it just makes more sense to just go the extra 20 minutes to the PCI center. I can get them to the balloon faster.

 

[palmer1121]

Amen. If you live in the sticks, you can't expect instant care at a fully equipped medical facility.

I work in a system that is "in the sticks" as you say. Anywhere from 15-90+ mins from the closest PCI capable hospital, the 2 counties I work in being the most rural where a 45 min emergency transport to the cath lab is the quicker, not the exception. Over the last several years we have done some impressive work with STEMI patients, i.e. Sub 90 min 911toBalloon times and Sub 20 min D2B times. It takes training, field activation of the cath team, and coordination with the PCI center. Also note that this is not just one service, that is 12 counties with 12 different services ranging from fire/EMS, private, county third service and hospital based 911 provider.

 

[Tigger]

Good point and I really need to take my own advice before offering up an opinion. I did some research and it's clear that the numer is not as high as 80% of America lives outside a 60 minute drive directly to a PCI-center. In fact it seems nearly 80% does live within a 60 minute transport directly to a PCI center. The problem is that STEMI patients aren't getting to those centers within 60 minutes of activating 911 for several reasons, one of which is the PCI-center is outside the service area of the EMS geographical service area. It also appears many patients simply self-present to the ER of non-PCI hospitals when experiencing STEMI symptoms .

Rest assure I'm not trying to be a pain, that number just seemed way high.

The part I bolded is a real issue. We take at least twice as many cardiac alerts from our local non-PCI ED to PCI centers than we have cardiac alerts from the field. We try to educate and while the transfer time is a good teaching moment, it's a bit late. We have great HEMS coverage in our area and can offer great D2B times provided the weather is good. The local services and flight teams work efficiently and the advent of established LZs makes transfers much quicker.

Our local facility will allegedly offer Ateplase but it's yet to be administered. Our next project is trying to streamline STEMI and CVA transfers from there, currently patients stay in the ED for vastly inappropriate times (three hours is the norm), which is less than ideal. The local urgent care does a better job with that honestly.