STEMI...How Can we Improve??

[Craig Alan Evans]

The reason we perform 12 Lead EKGs in the field is to find out if the patient is having an acute MI. EMS has made great strides in the recent past to make sure their ALS providers have been trained to perform and interpret 12 Lead EKGs. So what can we do now to make it better? I serve on the regional STEMI committee for my area representing prehospital providers within 30 minutes of a PCI center and I have put a lot of thought into this very topic. We all know that time is muscle so simply put we need to remove absolutely every obstruction that causes any delay from the time the coronary artery is first blocked to the time the cardiologist clears the obstruction and returns coronary perfusion to the cardiac tissues. Sounds like a good plan. The first step is to form a regional STEMI committee and bring representatives from each step of the patient’s journey to the same table so we can all get onto the same page. I could write an entire article on the importance of this aspect alone but today let's look at the improvements I see the prehospital system can contribute to the cause.

1) Patient Education: We need to educate the public as to the importance of arriving at a PCI center when their chest pain occurs. By dialing 911 and getting the prehospital system involved they will have decreased their onset to balloon time tremendously. In my area most of the extended times to a PCI center have come from inter facility transfers and not from prehospital initiation.

2) EMS vs. ER...The first 10 minutes should be the same: I am a firm believer that the patient's hospital stay should begin at the time the paramedics walk through the front door of the patient's residence. Door to balloon times are misleading as we need to start recording and improving first healthcare contact to balloon time. This is the 21st century and EMS around the nation needs to acknowledge they are not just a ride to the hospital; they are not just there to fix life threatening conditions and then hand the patient off to the ER. EMS should encompass all the initial actions just as if the patient walked into the front door of the ER. This should include patient registration, placing a gown on the patient, and any other initial actions or treatment taken by the ER in the first 10 minutes. If you want to know what actions and interventions EMS should be adding to its tool box all you need to do is watch what occurs in the first 5 minutes after you arrive with a critical patient. If you see any standard treatment or intervention occurring immediately then that is something EMS should be considering implementing into their protocols.

3) Prehospital 12 Leads: As I said previously we have made great strides in this area but what we have done is only scratching the surface. Most EMS systems have 12 leads on the ambulances staffed by paramedics. We need to extend that out at least another tier and make sure every fire truck and BLS provider can perform a 12 Lead EKG. Any patient suspected of having an acute coronary event should have a 12 lead as one of their initial vital signs. It is not an ALS intervention to place stickers and attach cables to a patient’s chest. Everyone should be doing it. Sure, paramedics are needed to interpret the squiggly lines, but certainly not to attach the cables and print out an EKG and have it waiting for the arriving paramedic to interpret. I have seen far too many paramedics perform an initial assessment and then move the patient to "their office" and then perform a 12 lead EKG. This is flawed thinking. Our goal should be a 12 Lead within 5 minutes of patient contact by any prehospital provider. How long should we wait to find out if they are having the big one? Any barrier in your EMS system that prohibits a 12 lead EKG from being acquired within 5 minutes should be removed. As we all know the first step of any 12 step improvement program is recognizing the problem. We can do nothing to improve the patient’s journey to a PCI center until we first recognize they are having a STEMI.

4) Transmitting EKGs: It is absolutely imperative you find some way of transmitting the 12 Lead EKG for the receiving ER physician to see. It is not that the hospital doubts our ability to interpret EKGs, although, in some parts of the country this may be true. It is simply a team sport. If the physician and the paramedic were standing beside each other when the 12 lead came out of the machine they would both look at it. It's just best practice to share this type of information. Just like all the prehospital providers hand the EKG off and show it to each other on the scene. This is just not the type of information you keep to yourself and the cost of falsely activating the cath team is extensive. You want as many people involved in this decision as possible. False activations occur in the ER. We do not need any bad press from false activations occurring from a prehospital EKG. If paramedics feel this is an insult to their intelligence...get over it. Anything that slows down onset to balloon time needs to be eliminated, and that includes your pride.

5) STEMI ??: So the squiggly lines look bad...what next? I propose a two tiered prehospital response to a possible STEMI:

a) Confirmed STEMI: This is a patient that both the prehospital providers and the ER physician agree is a STEMI. The EKG has been transmitted and everyone is on the same page so game on. The PCI team should be activated and every barrier that will slow down the time to the patients cath should be removed. The patient should be placed in a hospital gown and their groin should be shaved. No drips should be started and any interventions routinely performed by the ER physician should be moved to the prehospital arena such as heparin or integrelin boluses. If a chest x-ray is required prior to the patient going to the cath lab then a portable chest should be waiting in the ER and it should be performed on the EMS stretcher and then the patient should be immediately transferred to the cath lab. If your EMS system has extremely long transport times to an ER or PCI center and your STEMI patient would undergo TPA at the closest ER then this should be moved into the prehospital arena. IF the training or care level of the EMS system does not support this effort then a plan should be put into place to make it so. Whatever requirements your nearest PCI center will require prior to the cath being performed on a patient should be implemented in the prehospital setting. This is where it is crucial to have all the stakeholders at the same table with one goal in mind, decreasing the time from event to balloon.

b) Non-Confirmed STEMI: This is a patient that the ER physician has not seen the EKG but EMS suspects a STEMI. No drips, rapid transport, and all the interventions listed above outside of activating the cath lab, pre PCI treatments, or TPA should be implemented.

6) Transport: The patient should then arrive at the PCI center within 30 minutes. How this is accomplished depends on the local resources and the location of the PCI center. If air transport is the only way then EMS should be authorized to initiate this from the scene as transporting to the nearest ER and then transferring the patient will be an obvious delay.
7) No Bed Transfer: It takes time to move a patient from an EMS stretcher to a hospital bed. The patient should be moved directly from the stretcher to the cath table. If the patient needs to be seen in the ER for any reason they should stay on the EMS stretcher and be ready to roll to the awaiting helicopter or to the cath lab, whatever is the next step of the journey to a successful PCI.
8) STEMI Drills and QA/QI: We should be continually evaluating the system and looking for improvements. STEMI drills will make sure the machine stays well oiled and ready to perform when needed. Any improvements in time, procedures, and interventions that can be safely incorporated into the prehospital setting should be implemented as they become available.

I cannot stress enough that this is a team effort. All phases of the system from the patient, the dispatcher, to the intervening cardiologist need to communicate with each other and develop a cohesive plan with only one goal in mind, the well being of the STEMI patient!

 

[Veneficus]

sounds great

Who pays?

 

[Craig Alan Evans]

Who pays for what?

 

[Rettsani]

I think the question was asked in reference to the Text written by you.

This all sounds very expensive. -_-

 

[Veneficus]

The whole thing.

Educating and training paramedics to provide increased interventions.

Equipment, you need some way to transmit, something to transmit to.

Collaborative patient registration, sure, the technology exists, who buys the toys?

You are going to screen every patient for a STEMI or even every at risk patient for a STEMI? You couldn't possibly limit it to classic textbook presentation.

Resources, if you have every patient who thinks they might be having a stemi call 911, you will probably need a few more unitson the road.

What is the plan for the patients where the EKG fails to pick up the pathology?

Istats are a great tool, but not really practical prehospital, daily controls, refrigerated cartriges, etc.

TpA from a protocol? I could think of a dozen ways that could go wrong.

What happens when you have a 65 y/o male patient complaining of chest or abd pain, history of CAD, uncontrolled HTN, and no stemi detected?

Are you going to give him the TpA prior to determining if he has a ruptured aneurysm?

How about a untreated or subclinical GI bleed?

Esophageal varicy?

If the patient sits on an EMS stretcher, that unit is out of service. You once again need more units. At the very least more stretchers.

Who pays for the helo rides? how much?

Safety equipment for air med doing scene runs?

Drills. Who is paying for the overtime and resource cost?

Why should a doc or hospital lose time or take an operating theatre (cath lab) out of service for it with associated cost?

How much over triage/treatment is acceptable?

It all costs money.

 

[Craig Alan Evans]

I disagree. It is not expensive to create a STEMI committee and plan on how to improve times. It shouldn't be expensive to query your nearest PCI center and ascertain what interventions they require before performing a cath. It is fairly inexpensive to formulate a local plan to ascertain a 12-Lead in less than 5 minutes. If you do not presently have 12-lead machines you can start with a modified chest lead EKG that will be fairly diagnostic. My intent was not to lay out an expensive plan. It was to put my opinion out there based on the system I work in and see what everyone's thoughts were around the world and hopefully learn something.

 

[Rettsani]

In what for a world are you living ?

To ensure the functionality of a system, you must first invest. Ever considered what a 12-lead ECG with data transmission system costs?
Alone this component of the system will cost as much as a new car ...

 

[Craig Alan Evans]

Educating and training paramedics to provide increased interventions.
Yes, expensive

Equipment, you need some way to transmit, something to transmit to.
Yes, could be expensive or you could develop a system based on existing technology like 3g, picture of EKG with an iPhone or iPAD and email to a predetermined receiving email at the ED.

Collaborative patient registration, sure, the technology exists, who buys the toys?
Simply garnering key patient demographic info and passing it along prior to arrival is not expensive.

You are going to screen every patient for a STEMI or even every at risk patient for a STEMI? You couldn't possibly limit it to classic textbook presentation.
This is correct.

Resources, if you have every patient who thinks they might be having a stemi call 911, you will probably need a few more unitson the road.
Yes, more units on the road means more business.

What is the plan for the patients where the EKG fails to pick up the pathology?
Give me an example.

Istats are a great tool, but not really practical prehospital, daily controls, refrigerated cartriges, etc.
ISTATS are not practical in the field at this time.

TpA from a protocol? I could think of a dozen ways that could go wrong.
Me too. I included this option into my discussion for more rural areas where the patient would be receiving TPA at the nearest receiving facility that is located greater than 30 min from the location of the call.

What happens when you have a 65 y/o male patient complaining of chest or abd pain, history of CAD, uncontrolled HTN, and no stemi detected?
No STEMI detected by what means? If there is no STEMI detected then the patient is not treated as a STEMI patient.


Are you going to give him the TpA prior to determining if he has a ruptured aneurysm?
No. Absolutely not.

How about a untreated or subclinical GI bleed?
They should not receive TpA either.

Esophageal varicy?
Definitely not. Are you implying that Esophageal varicies or a GI bleed will present as a STEMI. I have not seen this before.

If the patient sits on an EMS stretcher, that unit is out of service. You once again need more units. At the very least more stretchers.
They should not be sitting on the stretcher longer than a few minutes. The idea is that you do not waste time at a PCI center transferring them to a ED hospital bed just so they can then be wheeled to the cath lab, clearly a waste of time.

Who pays for the helo rides? how much?
The patient or the patient's insurance. The same people who pay for the ambulance rides.

Safety equipment for air med doing scene runs?
Not sure what you are getting at here.

Drills. Who is paying for the overtime and resource cost?
Each individual locality or company. Try to incorporate the drills into straight time or continual ed. Several options here.

Why should a doc or hospital lose time or take an operating theatre (cath lab) out of service for it with associated cost?
No need to take a cath lab OOS to practice transferring a patient over to their bed or learning how to prepare the patient for a cath. I'm sure they don't take these resources OOS to train techs in the cath lab.

How much over triage/treatment is acceptable?
Please expand on this question. Not sure what you are asking here.

It all costs money.
Yes. I agree 100%. It all costs money and we should be in the business of moving our vocation forward and providing better patient care at all times. If you are not moving forward in EMS you are moving backwards. Please don't construe my answers as curt or brash I'm just trying to address your flurry of questions. lol I appreciate the discussion. Thanks!
__________________

 

[Craig Alan Evans]

I don't think it has to cost that much. Maybe the EKG but the transmission systems on the market are very overpriced and there is a better way. We have existing technology in place. Most of us carry them in our pockets. Just a thought.

 

[Craig Alan Evans]

One of the main points of my discussion was obtaining a 12 lead in less than 5 minutes from patient contact. Are you not performing 12 leads in the field now? Do you think a 12 lead on a potential STEMI patient can wait?

 

[Rettsani]

We write a lot of 12-lead ECG 's, but our device can not transmit data. The devices are just too expensive. The appointment for PTCA, runs by cell phone, without data transmit. This clarifies for us, by the emergency physician on site.

 

[Craig Alan Evans]

Rettsani,

Are you a physician or do you have a physician with you on the ambulance in Germany?

 

[Brandon O]

I find that the best solutions are invariably local rather than broadly applied, because conditions vary. The biggest one may be how far your hospitals are, and how many of them are PCI-capable.

The issue is two-sided:

1: How can we streamline the process for STEMI patients to get from EMS to the cath lab? Your ideas are good. Probably the most important thing is getting early 12-leads and having providers who can reliably recognize ST elevation (not too difficult, I think). That way they can get to the right destination, and ideally activate from the field and facilitate things in other ways.

2: How can we reduce the impact of "false positive" activations of the above process? This ends up being the key, because local hospitals complain about losing business from diversions, it's bad for the patients, and it's a resource hit to the receiving centers to keep activating for nothing. If it's too egregious it breaks the system, or the parties just won't buy in to start with. The two popular solutions to this seem to have been train the hell out of your medics (works for smaller systems), or transmit the ECGs. The latter doesn't necessarily solve the problem, because doctors mess it up too, but it can be easier than really getting a whole region to reliably differentiate ST elevation. The technical challenges are large, though, not through any concrete obstacles but just through real life; people are on different devices that don't talk, and nobody's really stepped up to do this elegantly. One upside, though, is that Physio at least has a system for BLS 12-lead transmission -- just hook up electrodes and push the button -- so that's an option to extend your capabilities too.

Are you familiar with the AHA Mission: Lifeline program?

Edit: by the way, a multi-tiered activation system has been used in Boston and seems to work. "Suspected" STEMIs are met at the door by the doc to over-read; "Definite" STEMIs are (or should) go straight to the cath lab.

 

[Craig Alan Evans]

Yes...I am familiar with the AHA Mission: Lifeline program. My discussion is centered around the prehospital component. You have hit the nail on the head with your analysis. It seems simple in discussion. I work in an area that is within 10-15 minutes from a PCI center and the medics don't always obtain a 12 lead here until after the patient is moved to the unit. Way too long in my opinion. One case I know of the medic ran the 12 while en route to another hospital that was in the opposite direction from the PCI center and it was a big MI. Not an ideal situation.

 

[fast65]

I'm gonna have to agree with Vene here, this plan costs money, plain and simple.

Educating paramedics to provide increased interventions is not cheap, it's going to require a decent amount of time and money. It's not going to be as simple as having your medical director come in and teach a 3 hour class on administering TpA, it's going to take time, and time equals money. This is a particular problem for the rural areas in which you suggest it is implemented.

The technology for transmitting EKG's over 3G or WiFi may not be expensive in the larger metropolitan areas, but in the rural setting it just won't work. There's a vast majority of my district that I hardly have cell service, let alone have 3G or access to WiFi, what's the solution there? It won't be cheap, that's for sure.

I won't continue on with the expenses, as it's kind of been covered already, but the fact of the matter is, a lot of agencies won't be able to afford all of these changes. Rural departments are having a hard enough time keeping paramedics on staff, or evening staying open, paying for extra training and equipment is out of the question.

Expenses aside, there are a couple of other issues I see. It's not going to be easy to change the inside view of EMS. There are plenty of paramedics out there who have the very idea that we exist just for the serious calls, or just to provide a ride to the hospital, I work with a few of them. Convincing them to expand their skill set and use it appropriately is asking them to change their ways, and again, that is not easy for some people.

In conjunction with that, you have a lot of paramedics who have just become lazy over the years, and asking them to perform duties such as patient registration or placing the patient in a gown, will not go over well.

Those are just some of the concerns I see with this plan.

 

[Rettsani]

Rettsani,

Are you a physician or do you have a physician with you on the ambulance in Germany?

I am something like an EMT-P. We run ambulance service in the Rendezvous system. The Ambulances are on the fire and rescue Departments and the emergency physcian vehicles are at the Hospitals. Ambulances and emergency physcian vehicles are alarmed at the same time here in the regular for AMI. The paramedics and EMT-P are the first at the site most of the time. They supply the patient until the doctor arrives at the site.

 

[Brandon O]

One thing I would like to see is the "harm" of bringing someone to the wrong ED reduced. As it is, oftentimes just be tagging the door at a community hospital you've sentenced the patient to an extra 30 minutes before reperfusion, even if the cath lab is down the street; they'll have to go through the whole rigmarole there before they can be finally transferred. It would be nice, particularly in areas where the PCI hospital may not be far off, if referring hospitals got on board with an "escape" protocol where suspected ACS patients got a 12-lead immediately upon arrival, the physician interprets it at the bedside, and if a STEMI is present (or high-risk NSTEMI), with no major suspicion of other confounders (dissection?), and the times are right to skip tPA, the patient goes right back out the door and back onto the same ambulance for transfer to the PCI center. No new lines, imaging, labs, questions; no need to call and get them accepted; treat it just like the medics had taken that 12-lead in the field and gone directly to the right destination.

That'll probably happen right after pigs fly, though.

Edit: just as a note, I believe South Dakota actually got a grant to set up their area with 12-leads (see http://www.codestemi.tv/ ). It's not easy to make these systems happen, and you have to get the right parties to buy in, but it's possible. Cardiac arrest systems of care are dealing with similar stuff. No single pieces, all very much an interlinking chain...

 

[Rettsani]

Show me a patient who chooses at the right time the emergency call. It would be a dream....:unsure::sad:

here is taught ...
- Maximum tolerable delay PCI over lysis 90 minutes
- time from first contact to PCI (contact-to-balloon) <120 minutes
- time from emergency call to lysis (call-to-needle) <60 Minutes
- Time from initial contact to prehospital lysis (contact-to-needle) <30minutes
- Time from arrival to emergency room for lysis (door-to-needle) <20 - 30 minutes
- Time from arrival to the emergency room PCI (door-to-balloon):
a) with Announcement by the ambulance service <30 minutes
b) without notice by the ambulance service <60 minutes

 

[WolfmanHarris]

The first step is to form a regional STEMI committee and bring representatives from each step of the patient’s journey to the same table so we can all get onto the same page. I could write an entire article on the importance of this aspect alone but today let's look at the improvements I see the prehospital system can contribute to the cause.

This may just be a quirk of the mixed public/private system of the USA, but with the increased regionalization of health care in Ontario there are not an abundance of PCI centres nor is there any disincentive for any service or hospital to transport a patient there.

1) Patient Education: We need to educate the public as to the importance of arriving at a PCI center when their chest pain occurs. By dialing 911 and getting the prehospital system involved they will have decreased their onset to balloon time tremendously. In my area most of the extended times to a PCI center have come from inter facility transfers and not from prehospital initiation.

Agreed. We need to cut times from symptom onset to seeking help. Interfacility transfer times have been cut in my region significantly. When a Pt. presents to the two (of three) hospitals in the region that are not the PCI centre and the hospital identifies a STEMI by 12-lead, they will not delay care for bloodwork or serial ECG. They will call our dispatch, book a stat transfer and a crew will attend and transport the Pt. the same as if they recieved the STEMI call in the community.

2) EMS vs. ER...The first 10 minutes should be the same: I am a firm believer that the patient's hospital stay should begin at the time the paramedics walk through the front door of the patient's residence.

We compare apples to apples when judging our STEMI bypass system. Pt. contact balloon time for EMS is compared to Pt. contact at ED (at our PCI centre) to balloon time. We don't currently track times spent by the pt. in ED at our non-PCI centres before our contact with them as we don't have access to that data as an EMS service. We track symptom onset to balloon time though on all pt.'s though that's a somewhat inexact number.

3) Prehospital 12 Leads: As I said previously we have made great strides in this area but what we have done is only scratching the surface. Most EMS systems have 12 leads on the ambulances staffed by paramedics. We need to extend that out at least another tier and make sure every fire truck and BLS provider can perform a 12 Lead EKG. Any patient suspected of having an acute coronary event should have a 12 lead as one of their initial vital signs.

I don't agree with placing increased skills without requisite knowledge in the hands of providers. Our BLS and ALS providers all perform 12/15 lead acquisition and interpretation, but our BLS (Primary Care Paramedic) providers have a two year college diploma to enter practice and ALS (Advanced Care Paramedic) a further year. We want to have sensitivity for STEMI certainly, but without proper education to identify and rule out STEMI-mimics we won't have specificity and the cost to the system for false activation increases quickly.

Our goal should be a 12 Lead within 5 minutes of patient contact by any prehospital provider. How long should we wait to find out if they are having the big one?

On all Patients? If so, I disagree. ECG quickly, but when warranted.
Time is of course important in the effective treatment of STEMI's, but let's not lose site of how long this condition has likely been developing before Pt. contact. I'm afraid I don't have supporting data, but within my own Pt.'s, symptom onset to pt. contact times of multiple hours are the rule, not the exception. With a window for treatment of less than 12 hours from onset and within two hours of patient contact, is six minutes to ECG clinically significant? Is seven? Don't delay, but let's not be too quick to apply arbitrary benchmarks.

4) Transmitting EKGs: It is absolutely imperative you find some way of transmitting the 12 Lead EKG for the receiving ER physician to see. It is not that the hospital doubts our ability to interpret EKGs, although, in some parts of the country this may be true. It is simply a team sport.

I don't disagree with the sentiment, I disagree with the system design. Let's cut the ED right out of the loop at in the process make some real cuts in Pt. contact to balloon time. In my system with activate the cath lab by cell phone from the field on our interpretation only, we transport to the cath lab and bypass ED directly going right into the PCI room. Certainly we bring the ECG's, but they're going right to the cardiologist when they take report from us. We have the ability to transmit and did during the STREAM thrombolytics trials, but don't use it now that the trial has ended.

False activations occur in the ER. We do not need any bad press from false activations occurring from a prehospital EKG. If paramedics feel this is an insult to their intelligence...get over it. Anything that slows down onset to balloon time needs to be eliminated, and that includes your pride.

Once again education and QI is key. We have an extremely low false activation rate, but they do happen. With regular communication between the PCI lab and the service these can be mitigated and used as an opportunity for education. How does adding more people assessing the patient prior to activating the cath speed up onset to balloon time? By activating from the road the team is ready and waiting when we roll in.

5) STEMI ??: So the squiggly lines look bad...what next? I propose a two tiered prehospital response to a possible STEMI:

a) Confirmed STEMI:
- The patient should be placed in a hospital gown and their groin should be shaved.

Interesting idea and worth considering.

- No drips should be started and any interventions routinely performed by the ER physician should be moved to the prehospital arena such as heparin or integrelin boluses.

What is the rationale for no-drips? Here we just coordinated with the PCI lab that peripheral lines must be started in the R-arm only so as not to interfere with their treatment. I do find the heparin and integrelin bolus idea very interesting; unfortunately given the provincial directive we operate under we won't see that added to our scope unless as part of a research study in the foreseeable future.

- If a chest x-ray is required prior to the patient going to the cath lab then a portable chest should be waiting in the ER and it should be performed on the EMS stretcher and then the patient should be immediately transferred to the cath lab.

See above. Skip the ED all together.

- If your EMS system has extremely long transport times to an ER or PCI center and your STEMI patient would undergo TPA at the closest ER then this should be moved into the prehospital arena.

Agreed.

 

[Craig Alan Evans]

Fast 65 where do I begin?

Let's skip the part where you imply that improving our vocation will actually cost money and go straight to the part where one of your arguments against improving our STEMI response is that lazy medics and medics who believe that EMS is a glorified taxi service wouldn't like it so therefore we just shouldn't try. :wacko:

I'm afraid that based upon your sardonic signature that we are simply going to have to agree to disagree. I hope that your participation in a forum such as this places you in the "not lazy" and the "No Cadillac EMS Taxi" category of prehospital providers.

If we are going to improve we need to start somewhere. I think we can agree that improving STEMI times and performance is a worth while endeavor. If so any improvement will do. You have to evaluate your own system. Where can you improve? What would be the next step?

I'm not trying to be curt with my response just calling it how I see it. Please correct me if I have it wrong. Sometimes quite a bit of the tone and intent is lost in the written word.