STEMI CenterSTEMI Centerand 12and 12--Lead Lead

UpdateUpdate

Contra Costa Emergency Medical ServicesContra Costa Emergency Medical Services

What’s New…What’s New…STEMI Centers Are Almost Here!STEMI Centers Are Almost Here!

STEMI Triage and STEMI Triage and Destination Policy beginsDestination Policy begins–– Sufficient STEMI center Sufficient STEMI center

approvalapproval–– Anticipate between JulyAnticipate between July--

September September STEMI patients to STEMI STEMI patients to STEMI CentersCenters

STEMI CentersSTEMI Centers

Hospitals requirementsHospitals requirements–– Personnel, Policy, Equipment Personnel, Policy, Equipment

Requirements Requirements –– Contract with EMSContract with EMS

24/7/365 cath lab capability24/7/365 cath lab capability–– No diversion processNo diversion process

Final list to be determinedFinal list to be determined

STEMI Triage and DestinationSTEMI Triage and DestinationNew EMS GoldenrodNew EMS GoldenrodApplies Applies onlyonly to to STEMIs identified by STEMIs identified by 12 lead.12 lead.Other messagesOther messages–– Do notDo not qualify as qualify as

STEMISTEMI–– Do not merit transport Do not merit transport

to STEMI Centerto STEMI Center

(Zoll) ** * ACUTE MI * ** (Zoll) ** * ACUTE MI * **

(LP(LP--12)***ACUTE MI SUSPECTED*** 12)***ACUTE MI SUSPECTED***

STEMI Triage and DestinationSTEMI Triage and Destination12-lead needs to be rapidly obtained – Acceptable quality

» good QRS in all 12 leads » no significant artifact

STEMI determined by 12 lead– Determine destination – Contact of STEMI center ASAP – Do not wait

STEMI Report needs to give critical information to hospital

STEMI DestinationSTEMI Destination

Flexible specialty destination policyFlexible specialty destination policyFacilities are considered “equidistant” Facilities are considered “equidistant” –– If within 15 minutes difference of each otherIf within 15 minutes difference of each other

Patient transport should not exceed 30 minutesPatient transport should not exceed 30 minutes

STEMI STEMI DestinationDestination

When no STEMI Center within 30 minutes, (e.g. When no STEMI Center within 30 minutes, (e.g. far east county) patient should be transported to far east county) patient should be transported to closest basic ED facilityclosest basic ED facility

Patients retain right to choose destination, whether Patients retain right to choose destination, whether it is a STEMI Center or notit is a STEMI Center or not

Patients without preference should go to closest Patients without preference should go to closest STEMI CenterSTEMI Center

STEMI DestinationSTEMI DestinationReason for Flexibility on DestinationReason for Flexibility on Destination

Gets patient to their Gets patient to their desired facility and desired facility and physicianphysicianCath lab startup is most Cath lab startup is most timetime--consuming step consuming step ED arrival delay does not ED arrival delay does not impact final time to cath impact final time to cath lab or interventionlab or intervention

STEMI DestinationSTEMI Destination

Once list of STEMI Once list of STEMI Centers finalized, Centers finalized, destination patterns will destination patterns will be more clearbe more clear

Anticipate 3Anticipate 3--5 hospitals 5 hospitals will initially participatewill initially participate

STEMI Radio ReportSTEMI Radio ReportSituationSituation–– “STEMI Alert” confirmed by 12 “STEMI Alert” confirmed by 12

leadlead»» ** ACUTE MI** ** ACUTE MI** »» ***ACUTE MI SUSPECTED******ACUTE MI SUSPECTED***

–– ETAETA–– Patient Age and GenderPatient Age and Gender

STEMI Radio ReportSTEMI Radio ReportBackgroundBackground–– Past Cardiac HistoryPast Cardiac History–– History of pacemakerHistory of pacemaker

STEMI Radio ReportSTEMI Radio ReportAssessment Assessment –– Stable or unstableStable or unstableIf unstable If unstable –– whywhy–– Vital SignsVital Signs–– Shock; SOB; ALOCShock; SOB; ALOC–– Uncontrolled PainUncontrolled Pain

STEMI Radio ReportSTEMI Radio ReportRx & RecapRx & Recap–– Treatments Given Treatments Given –– Patient ResponsePatient Response

Report at HospitalReport at HospitalHospital report should include:Hospital report should include:–– Patient IdentificationPatient Identification–– Recap of radio report with any updatesRecap of radio report with any updates–– Allergies, Meds (especially anticoagulants, Allergies, Meds (especially anticoagulants,

insulin, erectile dysfunction drugs)insulin, erectile dysfunction drugs)–– More detailed past history if known (e.g. More detailed past history if known (e.g.

history of MI, clot busters, cath, or surgery)history of MI, clot busters, cath, or surgery)–– Name of patient’s cardiologist if knownName of patient’s cardiologist if known

1212--Lead ECGLead ECGFirst responders doing 12-lead– Provide 2 copies for transport

» Hospital» Transport Agency Pt Record

Provide copy of 12-lead to ED– Include multiple if done

Hand directly to nurse caring for patient

DocumentationDocumentationAll electronic PCR systems All electronic PCR systems have documentation have documentation specifically for 12specifically for 12--lead lead performance and readingperformance and readingePCR documentation is very ePCR documentation is very important whether STEMI or important whether STEMI or notnotCan’t evaluate STEMI Can’t evaluate STEMI system performance without system performance without this!this!

ECG UploadECG UploadWorking to enable upload of 12Working to enable upload of 12--lead into lead into patient recordpatient record

Some barriers encountered Some barriers encountered –– particularly in particularly in first responder systems in which mobile first responder systems in which mobile computer not available for uploadcomputer not available for upload

1212--Lead Lessons LearnedLead Lessons Learned

Quality of ECG’s has markedly increased since Quality of ECG’s has markedly increased since startupstartupStill have occasional issues with artifact or Still have occasional issues with artifact or incomplete ECG or incorrect lead placementincomplete ECG or incorrect lead placementAll 12 leads must have readable complexes with All 12 leads must have readable complexes with stable baselinestable baseline

1212--Lead Experience with STEMILead Experience with STEMI

33--4% of ECG’s show STEMI4% of ECG’s show STEMIMany tremendous casesMany tremendous casesDoorDoor--toto--balloon (intervention) balloon (intervention) has been reduced to under 60 has been reduced to under 60 minutes in many casesminutes in many casesE2B (911 call time to E2B (911 call time to intervention) has been under intervention) has been under 90 minutes on occasion90 minutes on occasion

1212--Lead Experience with STEMILead Experience with STEMI

Several instances Several instances where initial ECG is where initial ECG is abnormal but second abnormal but second ECG confirms MIECG confirms MI

Leaving leads on and Leaving leads on and repeating ECG is repeating ECG is appropriateappropriate

1212--Lead Lessons LearnedLead Lessons LearnedSkin Prep remains the Skin Prep remains the single most important single most important issue in getting good issue in getting good tracingtracing

Rub vigorously with Rub vigorously with gauze to remove gauze to remove superficial layer of superficial layer of skinskin

1212--Lead Lessons LearnedLead Lessons Learned

Scene TimesScene Times–– STEMIs < chest pain STEMIs < chest pain –– Average 13Average 13--14 min14 min

Some cases >20 minSome cases >20 min–– Want to minimizeWant to minimize

1212--Lead Lessons LearnedLead Lessons LearnedFalse positive rate around 20% False positive rate around 20% Issue: ECG says **Acute MI** Issue: ECG says **Acute MI** but is NOTbut is NOTREASON: REASON: –– Baseline artifact most Baseline artifact most

common causecommon cause–– Tachycardia may fool machineTachycardia may fool machine–– Paced rhythmsPaced rhythms

STEMI or NO STEMI?STEMI or NO STEMI?

STEMI or NO STEMI?STEMI or NO STEMI?

STEMI or NO STEMI?STEMI or NO STEMI?

STEMI or NO STEMI?STEMI or NO STEMI?

STEMI or NO STEMI?STEMI or NO STEMI?

STEMI or NO STEMI?STEMI or NO STEMI?

1212--Lead Lessons LearnedLead Lessons Learned

Most younger 12Most younger 12--lead lead patients with STEMI’s patients with STEMI’s have presented with chest have presented with chest painpain

Atypical presentations Atypical presentations seen occasionally in seen occasionally in older patientsolder patients

Overall ExperienceOverall ExperienceMany hospitals are “stoked” Many hospitals are “stoked” by what we are doing by what we are doing alreadyalreadyWe have helped them We have helped them decrease time to intervention decrease time to intervention in many casesin many casesHospitals still concerned Hospitals still concerned because can’t find ECG later because can’t find ECG later –– make sure you leave it in make sure you leave it in their hands!their hands!