Stroke & STEMI Survey12-Lead ECG Inferior STEMI VR3, VR4*, VR5, VR6 Lung sounds Clear Decrease SpO2...
Transcript of Stroke & STEMI Survey12-Lead ECG Inferior STEMI VR3, VR4*, VR5, VR6 Lung sounds Clear Decrease SpO2...
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Stroke & STEMI
SurveyEast Texas Gulf Coast
Regional Advisory CouncilPerformance Improvement Committee
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Performance Improvement 2
Objectives
• TX-DSHS CVD and stroke statistics
• RAC-R data submission requirements by TX-DSHS
• Members participation of recent Monkey Survey
(requests for data)
• Analysis of 1st, 2nd & 3rd quarters Stroke & STEMI
data
• Issues and concerns
• Case Study: STEMI
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TX-DSHS Data Submission
• EMS Agencies– # of stroke runs < hrs
– # of stroke runs 2 – 7 hrs.
– Total acute stroke transfers to
higher level of service
– Total # of STEMI runs
– Total # of STEMI runs with 12
lead ECGs transmitted
– Total # of STEMI runs < 30
minutes
• Hospitals
– Designated and Non-
designated• # of patients receiving IV
fibrinolytics (tPA)
• # of patients receiving
endovascular treatments
• # of Acute stroke admissions
Performance Improvement 3
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TX-DSHS Submission
• Quarterly Reporting by RAC-R
– January – March
– April – June
– July – September
– October – December
Performance Improvement 4
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RAC-R Members Participation
• EMS– 30 Ground transport EMS organizations
– 4 Air transport organizations
– 13 completed the survey monkey for
Stroke & STEMI
• 1st quarter
• 2nd quarter
– 13 completed the survey
• 3rd quarter
– 4 additional EMS
organizations added;
– 4 existing EMS did not submit
• 43% contribution
• Hospitals– 15 Facilities
– 10 completed the survey monkey for
Stroke
• 1st quarter
• 2nd quarter
– 10 completed the survey
• 3rd quarter
– 4 new Hospitals
submission
– 6 existing did not submit
– 67% contribution
Performance Improvement 5
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EMS Stroke Analysis
Performance Improvement 6
1st Qtr % 2nd Qtr % 3rd Qtr %
Total # of Acute Stroke Runs 329 337 242
# of Strokes arrived < 2 hours 111 33.74% 66 19.58% 124 51.24%
# of Strokes arrived 2 - 7 hours 153 46.50% 124 36.80% 32 13.22%
# of Strokes transferred 105 31.91% 76 22.55% 37 15.29%
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EMS STEMI Analysis
Performance Improvement 7
1st Qtr % 2nd Qtr % 3rd Qtr %
Total # of STEMI Runs 78 79 131
# STEMI 12-lead Transmitted 63 80.77% 58 73.42% 77 58.78%
# STEMI first contact to Hospital < 30 minutes 34 43.59% 40 50.63% 46 35.11%
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Performance Improvement 8
Designated
1st Qtr 2nd Qtr 3rd Qtr
Total number of patients receiving IV fibrinolytics (tPA) 44 45 16
Total number of patients receiving endovascular treatments 16 31 7
Total number of Acute Stroke Admissions* 223 205 85
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Performance Improvement 9
Non-designated
1st Qtr 2nd Qtr 3rd Qtr
Total number of patients receiving IV fibrinolytics (tPA) 7 9 2
Total number of patients receiving endovascular treatments 0 0 0
Total number of Acute Stroke Admissions* 0 0 3
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Issues/Concerns with Data
• EMS– Obtaining data from source.
– Filtering to capture times; < 2
hours, etc.
– Unable to transmit 12-lead ECGs
– Possible fixes:
• Work with vendor to extract
data
• Internal QA/QI form for
sentinel call(s)
• Verbal activation
• Hospitals
– Delayed in coding of
records
– Personnel to
consolidate the data
– Possible fixes:
• Designating backup
personnel
Performance Improvement 10
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Performance Improvement 11
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CASE STUDY
Performance Improvement 12
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Performance Improvement 13
EMS One was dispatched at 18:48, to a 50 year-
old male having chest pain, with his wife by his
side. Patient was sitting at a table. Patient is
AO to person, place, time and event. Associated
symptom: shortness of breath
Skin Cool, pale and diaphoretic
Onset 20 minutes prior (18:28)
Provocation Racing go-cart
Quality Chest pain
Radiate Chest to left arm
Severity 2/10
Time Continuous
Allergies NKDA
Medications None
History None; family hx of cardiac
1 adult ASA Taken prior to EMS arrival.
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Performance Improvement 14
Initial Patient Assessment (19:02)
LOC AO x 4
BP 96/65
SpO2 98% Room air
Lung sounds Clear bilaterally upper and lower
Pulse Rate 50 - regular
Respiratory 14 - normal
Pupils PERRIL (left and right)
BGL 126 mg/cl
GCS 15
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Performance Improvement 15
(19:04) 12-Lead ECG performed
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Interventions
Performance Improvement 16
Time Intervention Description
19:01 Patient Contact
19:05 Air Medical Service Request for air transport called
19:11 Oxygen NRB @ 15 LPM; patient condition was improving
19:12 Vitals BP=88/65, P=51, R=14, SpO2=98%
19:14 IV 300cc NS bolus
19:16 EKG 12-Lead Performed
19:19 En route to LZ
19:21 Arrived at LZ
19:22 Vitals BP=104/78, P=50, R=14, SpO2=100%
19:24 EKG 12-Lead Performed
19:27 Air Medical Service Landed
19:39 Air Medical Service Departed Scene
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Air Medical Service
Performance Improvement 17
Time Intervention Description
19:40 Depart scene
19:52 Arrived at PCI facility 45 minutes via ground transport
19:41 12-Lead ECG 43 bpm-bradycardia, Inferior MI, lateral MI; ST
elevation in II, III, aVF, V5, V6; ST depression in I,
avL, V1, V2, V3. Pain=3/10
19:41 Fentanyl 50mcg IV
19:45 Vitals BP=86/56, P=48, R=18, ETCO2=41mmHg;
GCS=14
19:49 Vitals BP=116/76, P=48, R=17, ETCO2=40mmHg
20:00 Vitals BP=90/56, P=54, R=16, SpO2=97%
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PCI Facility
Performance Improvement 18
Time Intervention Description
20:04 Patient Contact Transfer of care from Air Medical Service
20:05 Code STEMI activation
20:27 Transfer to Cath Lab Patient out of ED.
20:28 Arrived at Cath Lab
20:35 Physician in Cath Lab
20:35 Case start
20:54 Intervention FMC2B = 110 minutes
D2B = 50 minutes
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Outcome
Performance Improvement 19
• 100% distal RCA occlusion with TIMI 0 flow.
• Aspiration Thrombectomy performed.
• DES was deployed.
• Final angiography revealed a residual < 10% stenosis
with TIMI 3 flow.
• Patient transferred to CCU for further care.
• No complications
Follow-up 2 days later, patient transferred to step down
unit, plan to discharge home soon.
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PCI Facility
Performance Improvement 20
Pre Post
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RCA
Performance Improvement 21
Assessment Indication Comments
12-Lead ECG Inferior STEMI VR3, VR4*, VR5, VR6
Lung sounds Clear Decrease SpO2
Blood Pressure Hypotensive
Pulse Rate Bradycardia
Skin Pale, cool, diaphoretic
Neck JVD Extended delay in care
Extremities Edema Extended delay in care
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Performance Improvement 22
Contact Information:
Max NguyenCity of Beaumont Public Health – EMS
EMS Manager
Email: [email protected]
Office: (409) 880-3922