During the past several years the Tidewater EMS region and many places across the nation have worked to improve the outcome of patients experiencing ST-elevation myocardial infarction, or STEMI. Hospitals and emergency medical systems are organizing coordinated regional plans for STEMI diagnosis and rapid reperfusion. The work is being done through heart attack coalitions, and in our region the Eastern Virginia Heart Attack Coalition has achieved amazing success.
Why are we doing this? Didn’t we improve EMS cardiac care back in the 70’s and 80’s with portable cardiac monitors and defibrillators, cardiac medications and advanced life support providers? Hospital care has come a long way, too. But it’s not enough. Newer techniques like reperfusion therapy can reverse the blockages that cause heart damage, especially those associated with deadly ST segment elevation. We’ve learned that time is (heart) muscle, and the faster we can identify deadly blood clots in the heart, and reverse them, the better the outcome. Amazing outcome.
Opening the blood vessel and restoring blood flow is done in the hospital with emergency angioplasty or thrombolytic medications. Some hospitals, called PCI centers, now specialize in these interventions. Similar to a trauma center for the most severely injured patients, a PCI center has resources and personnel at the ready to quickly treat blood clots.
STEMI patient outcome improvement is linked to a fresh emphasis on rapid identification and rapid patient movement to reperfusion therapy. There are many parts of this including recognition of symptoms, quickly calling 9-1-1, early 12-lead and recognition of a STEMI, aspirin administration, notification of the PCI center, and a quick trip through the emergency department directly to the cath lab. Any misstep along the way can add minutes. The key is a team approach. Every 30 minutes means a 7.5% increase in mortality.
In December 2016 the Tidewater region celebrated the end of a two-year Duke University/American Heart Association STEMI Accelerator project. This project had dedicated staffing and medical direction that helped the region focus on:
• Shared mission
• Engagement of all stakeholders (EMS/ED/Cardiology)
• Visible, accountable Leadership
• A disciplined schedule of meetings and task delivery
• Protocol driven care
• Data and case reviews
During the final accelerator meeting case presentations highlighted things that go right and things that can go wrong. The contrasts were evident: if any one part of the system fails, the delays to angioplasty or thrombolytic medications can be significant.
The numbers demonstrate the improvements in this region. Early EMS 12-leads have increased. ED bypass has increased. Door-to-balloon times have decreased. "False” STEMI alerts are low. Important indicators have all changed from red and yellow to green for the Tidewater region.
But, “we must sustain the gains,” says Peter O’Brien, MD, FACC, a cardiologist from Lynchburg, and medical advisor for the Duke/AHA STEMI Accelerator.
O"Brien points out we need EMS-ED engagement to minimize scene time (less than 15 min), immediately get and send EKGs to the hospital, immediately call the hospital (to include name, DOB and a patient report), preactivate the cath lab, bypass the ED or perform a brief pit stop, and continually measure and improve the process.
Dr. O’Brien points out that “preactivation” is now expected, and we need to minimize the EKG to decision time. He says “never give up” and lists these important steps to continue and improve our STEMI system:
• Regular stakeholder team meetings
• Prompt case by case feedback—collaborate, don’t point fingers!!!
• Data measurement and presentation – data leads discussions
• ED/EMS engagement and Feedback
• Hardwire processes
• Admin involvement
• Regional System organization
• Succession Planning
Forrest Winslow, a lieutenant with the Chesapeake Fire Department and chairman of the TEMS STEMI Performance Improvement Committee, says the region will focus on several of these initiatives.
“We want to continue work on the ED “pit-stop” process and decrease ED times at all the facilities,” says Winslow. Other items include:
• Finalizing an updated regional STEMI Plan
• EMS 12 Lead Education – Early Transmission
• Innovative ways to decrease times to the lab and sharing best practices
For example, Winslow says, Chesapeake Regional and Chesapeake Fire have a goal to direct load STEMI patients with the ED and EMS staff. This allows the Cath Lab staff to remain in the lab to ready the room and minimize ED and transport times.
Several revisions to the TEMS STEMI Triage Decision Scheme are anticipated during the year. They include changing 30 to 45 minutes or less to go by ground vs air and changing 1 mm ST elevation (or more) in 2 or more contiguous leads” to 1.5mm for women and 2mm for men. The current decision scheme is shown below.