STEMI Systems of Care and Learn: Rapid STEMI ID

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Improving the System of Care for STEMI Patients The Mission: Lifeline Provider Recognition Program and Learn:™ Rapid STEMI ID Customer Webinar September 24, 2009 Moderator: Mayme Lou Roettig, RN, MSN Presenters: Joseph P. Ornato, MD, FACP, FACC FACEP Mike Willingham, CCEMT-P Lee Garvey, MD, FACEP

description

Every year, almost 400,000 people experience ST-Elevation Myocardial Infarction (STEMI) -- the deadliest type of heart attack. Unfortunately, a significant number don't receive prompt reperfusion therapy, which is critical in restoring blood flow. Worse yet, 30 percent of STEMI victims don't receive reperfusion treatment at all. Mission: Lifeline™ seeks to save lives by closing the gaps that separate STEMI patients from timely access to appropriate treatments. Although Mission: Lifeline is focusing on improving the system of care for the nearly 400,000 patients who suffer from a STEMI each year, improving that system will ultimately improve care for all heart attack patients.

Transcript of STEMI Systems of Care and Learn: Rapid STEMI ID

Page 1: STEMI Systems of Care and Learn: Rapid STEMI ID

Improving the System of Care for STEMI Patients

The Mission: Lifeline Provider Recognition

Program and Learn:™ Rapid STEMI ID

Customer Webinar

September 24, 2009

Moderator: Mayme Lou Roettig, RN, MSN

Presenters: Joseph P. Ornato, MD, FACP, FACC FACEP

Mike Willingham, CCEMT-P Lee Garvey, MD, FACEP

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Improving the System of Care for STEMI Patients

The Need for Pre-Hospital ECGs in Systems of

Care for STEMI Patients and

Learn:™ Rapid STEMI ID Objectives

Joseph P. Ornato, MD, FACP, FACC FACEP

Past Chair of AHA’s National Emergency Cardiovascular Care Committee

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Improving the System of Care for STEMI Patients

The Call to Action

The majority of STEMI deaths occur in the first 2 hours due to cardiac arrest after onset of symptoms

<50% of STEMI patients call 911 and are transported to the hospital by EMS

Pre-hospital 12-lead ECG acquisition is critical for determining which chest pain patients need to be transported to a PCI facility because the majority of chest pain patients do not have a STEMI..

Prehospital ECGs are acquired on <10% of suspected STEMI patients even though they can decrease door to needle and door to balloon times.

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Other Statistics

30% of STEMI patients receive no reperfusion therapy despite the availability and absence of contraindications

Of the 20% of STEMI patients who have contraindications to fibrinolytic therapy, 70% do not receive reperfusion treatment with PCI

<50% of patients treated with fibrinolysis have a door-to-needle time within 30 mins

Only 35% of patients treated with PCI have a door-to-balloon time within 90 mins

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Ornato, J. P. Circulation 2007;116:6-9

The STEMI Chain of Survival

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Current Versus Ideal Processes to Integrate Prehospital ECGs into Systems of Care

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Ting, H. H. et al. Circulation 2008;118:1066-1079

Reperfusion Time Goals for Patients With STEMI

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Recommendations

A module for EMS providers should be developed that addresses STEMI care with particular emphasis on 12-lead acquisition, transmission, and interpretation. Consideration should be given to including extension of ECG training to basic level EMS providers.

EMS agencies need to have sufficient personnel, training and resources to ensure that a prehospital 12-lead ECG can be acquired from prehospital patients with clinical presentations suggestive of a STEMI to assist in triage, treatment and point-of-entry decisions.

Moyer, P. and Ornato, J.P. et al. Circulation 2007;116:e43-e48

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The Training

Learn:™ Rapid STEMI ID is a dynamic online program that is designed to prepare healthcare professionals to evaluate and assess victims with potential symptoms of myocardial infarction, interpret their ECG for signs of STEMI, and activate a system of care of rapid reperfusion of an occluded coronary artery. 

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Learn:™ Rapid STEMI ID Objectives

Upon successful completion of this course the learner should be able to:

See the need for an improved STEMI System of Care…and close the gap on timely access to needed treatment

Distinguish an ST-Elevated Myocardial Infarction from ECG mimics of STEMI

Name the Leads, Regions of the Heart, and Measure ST Deviation

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Learn:™ Rapid STEMI ID Objectives

List immediate action steps to identify patients with symptoms of ACS and ECG findings of STEMI to reduce time to perfusion

Describe ACS Pathophysiology

Describe how to acquire a technically good 12-lead ECG

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Learn:™ Rapid STEMI ID Objectives

Differentiate a normal 12-lead ECG from a 12-lead with ischemic changes

Identify patterns of ECG abnormalities including those that require rapid reperfusion and team activation

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Learn:™ Rapid STEMI IDProduct Information

and The Mission: Lifeline Provider Recognition

Program

Mike Willingham, CCEMT-P

Senior Director, Mission: Lifeline

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Product Info

Learn:™ Rapid STEMI ID

•Product # 80-1473

•$69.95 SRP

•EMS – 4.50 Advanced CEHs (CECBEMS)

•Nurses – 4.62 contact hours

•Available August 18th 2009

•Audience

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Current STEMI Tools from ECC

•STEMI Provider Manual (2008)

•ECG ACS Ruler (2008)

°Combined as 1 product (ruler still available as a single item)

•ECC Handbook (updated 2008)

•Learn Rapid STEMI ID (August 2009)

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Product Features

Self-paced

Accessible Anytime/Anywhere (OnlineAHA)

Access for 12 months to course material

Audio, Animation, Interactive activities

“learn more toolboxes” - Self Study Cards

It can be used to educate any healthcare provider and

also helps support the AHA Mission: Lifeline™ initiative.

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Product Benefits

Emphasizes immediate recognition and treatment of ACS STEMI

Includes self assessment quizzes

Contains dynamic ECG Scope to measure ST deviation

Includes the STEMI Practice Exam

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User Experience

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Student registers on OnlineAHA.org

User Experience

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User Experience

Student then activates a key they have received or they can purchase a key

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User Experience

Student then activates a key they have received or purchased

Terms and Conditions are agreed to

Once they click “Activate” they will arrive back at the ‘my courses’ page where they can select the course

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User Experience

On the ‘my courses’ page the student can select desired courses that have been activated

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Student then chooses the active link to access course.

User Experience

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User Experience

Student must review course overview to proceed

And also complete the evaluation to complete the course and collect a certificate, CE, and option of recognized provider program

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Certificate of Completion, Application for Continuing

Education Credit, and Recognized Provider

ProgramCan all be accessed from the

completed courses page

User Experience

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Mission: Lifeline Provider Recognition

In 2007, Mission: Lifeline volunteers felt it was important to recognize providers in addition to hospitals, EMS and STEMI Systems

Mission: Lifeline ECC Task Force volunteers suggested that a provider recognition program be tied to current ACLS products

So, only upon successful completion, do providers have an opportunity to participate in the Mission: Lifeline Provider Recognition program

Not tied to the current system and system component programs

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Mission: Lifeline Provider Recognition

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Mission: Lifeline Involvement

Participation

M.O.U.

Participation

M.O.U.

RecognitionRecognition

CertificationCertification

Examples

Examples

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Pre-Hospital Activation Issues Within a STEMI

System

Lee Garvey, MD, FACEP

Mission: Lifeline ECC Task Force Vice-Chair

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Optimizing the System

• Focus on the prehospital environment

• USE the time the paramedics are with the patient:

• ECG

• Data to decision makers

• Drug treatment – ASA, nitroglycerin, (?lytic)

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The Ideal EMS

In an ideal system:

•Ambulances are equipped with 12-lead ECG machines

•EMS providers are trained to:

°Use and transmit 12-lead ECGs

°Care for STEMI patients

°Provide feedback on performance and compliance with guidelines

•Standardized point-of-entry (POE) protocols define patient transport rules

•When there is STEMI, the cath lab is activated promptly

•Patients transported to a STEMI-referral hospital remain on the stretcher with EMS present pending a transport decision

•When “walk-in” patients present to a STEMI-referral hospital and require primary PCI, activation of EMS occurs

•Hospitals close the communication gap with EMS31

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POE Protocol

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System Administrative Barriers

Barriers to the implementation of prehospital12-Lead ECG programs

• significant investment of time, effort, personnel, and resources.

• costs of device acquisition and replacement, paramedic training, and ongoing competency assessment

• ECG Image transmission? Failures can occur in 20% to 44% of cases where wireless dead zones occur.

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RAPID EKG CRITERIA

Door to decision 10 minutes

30 YEARS OLD with suspicious CHEST PAIN

(EXCLUDING OBVIOUS TRAUMA)

50 YEARS OLD with:

• Syncope

• Weakness

• Rapid Heart Beat / Palpitations

• Difficulty Breathing / Shortness of Breath

Graff L, et al. Triage of patients for a rapid (5-minute) electrocardiogram: a rule based on presenting chief complaints. Ann Emerg Med. December 2000;36:554-560.

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Prehospital 12 lead ECG

*** ACUTE MI *** Diagnostic statement

• 96-98% specificity

• Only 50’ish% sensitivity

° Kudenchuck 1991; JACC 17:1486-91

• P12 ECG reduces mean time to treatment by ~33 minutes

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Prehospital Code STEMI Activation

Activation of Code STEMI

(REQUIRES ALL THREE)

• Patient with symptoms suggestive of ACS

• Prehospital ECG diagnostic interpretation algorithm identifies Acute Myocardial Infarction

• Paramedic reviews ECG to confirm STEMI findings

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Los Angeles CountyFranklin Pratt, MD, FACEP

25 STEMI Receiving Centers - SRCs25 STEMI Receiving Centers - SRCs

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EMS Assessment for STEMI: results of the Mission Lifeline National Survey

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EMS Agency RespondentsN=5410

EMS Agency RespondentsN=5410

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12 Lead Devices Availability at the Scene

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No38%

Yes62%

Does your organization have 12-lead ECG devices available at the scene for at least 80% of the patients with chest pain?

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Destination Protocols

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No43%

Don't know/not applicable

20%

Yes37%

Are there destination protocols (i.e. bypass non-PCI hospitals to go directly to PCI centers) for patients that have had a pre-hospital identification of a STEMI?

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12 Lead Activates the Cath Lab

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No49%

Don't know6%

Yes, for all receiving facilities

17%

Yes, for some receiving facilities

28%

In your Agency/Organization, is the field provider’s 12-lead ECG

information used to activate the cath lab prior to arrival at the

receiving facility?

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Pre-hospital Activation. EMS identifies STEMI and:(Select all that apply.)

20%

12%

73%

0% 10% 20% 30% 40% 50% 60% 70% 80%

Alerts ED & ED activates STEMITeam/Cath Lab (no cardiology

consult)

Alerts ED & Cardiologist activatesSTEMI Team/Cath Lab

Activates STEMI Team/Cath Lab

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Interpretation Issues

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Cath Lab Activations“False Positive” vs “Over-activations”

- Significant resources activated with STEMI response

- Definition of “False Positive” activations

- What is an acceptable rate for over-activations

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Definitions of “False Positive” Cardiac Cath Lab Activation

No culprit

No significant coronary disease

Negative cardiac biomarkers

Larson, DM et al JAMA 2007;298(23):2754-2760

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Summary: Incidence of “False Positive” Cath Lab Activation

No culprit: 14%

Normal or Minimal CAD: 9.5%

Negative cardiac markers: 11.2%

Combination of no culprit and negative biomarkers: 9.2%

Larson, DM et al JAMA 2007;298(23):2754-2760

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RACE: Cath Lab Activation Registry

Cath Lab Cancellations

• Resolution of symptoms or ECG abnormalities

• Old ECG findings, patient death, other

Overactivations –

• Cath lab cancelled due to

° ECG interpretation issues – prehospital or ED

° Patient not a cath lab candidate

Other –

• CABG, medical management only, normal coronaries, other

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Questions?