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STEMI/ Stroke Boot Camp

STEMI/ Stroke Boot Camp. Lessons from the Trenches. My Roots (North of Everywhere). Devils Lake = Home. 2. 1. 4. 3. FYI: ND has 4 PCI centers…. North Dakota – The Four “F’s”. F1) Freezing… Coldest temp in Devils Lake last year? -32 degrees (below zero).

raphael-delacruz
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STEMI/ Stroke Boot Camp

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  1. STEMI/Stroke Boot Camp Lessons from the Trenches

  2. My Roots (North of Everywhere) Devils Lake = Home 2 1 4 3 FYI: ND has 4 PCI centers…

  3. North Dakota – The Four “F’s” F1) Freezing… Coldest temp in Devils Lake last year? -32 degrees(below zero)

  4. North Dakota – The Four “F’s” F2) Farming… Life in the “Vast Lane”

  5. North Dakota – The Four “F’s” Snow plow on Devils Lake… F3) Fishing (ice) Ice House Ice = 3.5’

  6. North Dakota – The Four “F’s” F4) And Flooding… • 1997 Red River of the North flooding Grand Forks, ND • Photo: “Come Hell or High Water” (left) won Pulitzer Prize

  7. Why “STEMI Boot Camp”? • The US Marines: Every Marine IS a rifleman • STEMI 2010: Every STEMI provider must know the basics of the system • Boot Camp: In order to improve a team-based process you must strengthen “all the links”

  8. ST elevation myocardial infarction • Sudden complete obstruction of a blood vessel to the heart that results in muscle destruction.

  9. STEMI: Flagship Product or “Canary in a Coal Mine?” Got STEMI? STEMI patients: Small numbers but highly visible versus a barometer of the entire system?...or both?

  10. Today’s Goal: • We are going to discuss STEMI Systems Engineering: This involves a discussion of the optimization of the Essential Elements of Reperfusion as they relate to pre-hospital STEMI Care. GOAL: Optimization, NOT improvement!

  11. In simpler words…… “Git -R- done!” Larry the Cable Guy’s opinion about STEMI treatment decision making at a non-PCI center.

  12. The “STEMI Care Continuum”Cemented by Relationships! THE PATIENT EMS personnel ED triage personnel Medical Command ED nursing staff ED physician EMS transfer staff Paging system personnel Cath lab staff Cardiologist Quality Improvement staff Recognition! Relationships Reperfusion!

  13. The Cardinal Rule: Once STEMI is identified  it must trigger a clear response downstream! ECG Acquisition EMS Evaluation Communication !Decision!

  14. I. Remember…Most of the Time …the easy ones are easy! So, make more of them easy!

  15. II. STEMI Fact: If it Can Go Wrong, it Will (sooner or later) Leave nothing to chance! Approach STEMI systems building like a system’s engineer… Don’t try to error-proof your providers. Error-proof your system!

  16. III. STEMI 2010: There is NO New Frontier! • Every STEMI case has the same fixed endpoints (R2R) • Model success, but don’t copy it! (???) • Adapt principles to the situations not vice versa!

  17. So, what's new in STEMI??? • 2011: ACC/AHA update on STEMI • So, what has changed in STEMI science?

  18. Not Much! Time Still Equals Muscle! I I IIa IIa IIb IIb III III A B • STEMI patients presenting to a hospital without PCI capability and who cannot be transferred to a PCI center for intervention within 90 minutes of first medical contact should be treated with fibrinolytic therapy within 30 minutes of hospital presentation, unless contraindicated. ACC/AHA 2007 STEMI Focused Update Circulation 2007; on line, December 10.

  19. STEMI 2010: “60 is the New 90” Mortality Reduction (%) 100 Shifts in Potential Outcomes i.e. 44 is better than 66!!! D 80 A-B – No Benefit 60 A-C – Benefit Mortality Reduction, (%) C B-C – Benefit D-B – Harm 40 D-C – Harm 20 B A Extent of Salvage(% of area at risk) 0 0 4 8 12 16 20 24 Time From Symptom Onset to Reperfusion Therapy(hours) Gersh BJ, et al. JAMA. 2005;293:979-986.

  20. Recognition to Reperfusion (R2R) STEMI Engineering Lingo: • Time interval from STEMI Recognition (regardless of location) to Reperfusion(regardless of the chosen strategy)! • Focused on actions not location • Engineers: Think “Before the Door” and “Options Beyond Angiography”

  21. Recognition to Reperfusion • TRUTH: Without early recognition there can be no progress towards early reperfusion • The focus must be on the earliest possible recognition followed by fast and precise reperfusion • Again, it all begins with Recognition!

  22. Thought Provoking Question As far as your next potential STEMI patient is concerned, who is THE most important person in the STEMI Care Continuum?

  23. It’s Whoever Does That First ECG! No Recognition = No Reperfusion!

  24. Use of the prehospital ECG improves door-to-balloon times in ST segment elevation myocardial infarction irrespective of time of day or day of week. • Cleveland Clinic Florida • Hypothesis: use of the prehospital ECG, coupled with an emergency department initiated "Cath Alert" system,could neutralize D2B delays related to time of day or day of week. • RESULTS: • D2B - mean 69 mins. • 78% achieving the recommended D2B of 90 mins. OLD NEWS! Afolabi BA , et al

  25. Would You Miss This?

  26. Recognition: How is Your System Doing? Do you have a written “Screening ECG Protocol” within your institution & system –including EMS? Is it visibly posted in your ED/triage areas & EMS vehicles? Do ED, EMS and triage staff follow it 25/8? Have you specifically trained your staff regarding their key role in obtaining the screening ECG? Do you have multiple backup pathways in place to ensure that the screening ECG gets done during busy times? Is each ECG immediately shown to a physician?

  27. However, it is as it is…. Several reasons why pre-hospital STEMI care will always remain a challenge…

  28. All Americans are Not Distributed Equally! Rokos et al. J Am Coll Cardiol Intv, 2009; 2:339-346

  29. “STEMI Vision” –Just Say No! 95%+ of EMS calls are NOT STEMI! Etoh Chest Pain Need ride Ab Pain MVA Altered STEMI ??? Weak/dizzy

  30. Quiz: STEMI Finances 101 • How much is an EMS provider in Missouri reimbursed for: A) Learning to do an ECG? B) Completing an ECG on Grandma? C) Interpreting an ECG D) Discussing the ECG with MedCom? 2) How much does a helicopter flight cost?

  31. STEMI: A Needle in the Haystack • STEMI cases are few and far between • Without Recognition there can be no Reperfusion • So, you have to do a lot of ECG’s! ! …Its a cost of doing business!

  32. The “STEMI/Sick Patient” Paradox… Sick EMS patients (usually) look sick(trauma, VFIB, hypoxia, asystole) Motto: Keep ‘em alive, & diagnose ‘em after arrival! …Not so with STEMI!

  33. The EMS Environment…Chaos Theory Run Rampant! • Multiple patients types and illnesses • Everyone thinks they are the “emergency” • Dramatic does not mean emergent • Constant provider turnover • Improvising is often an essential skill • Multitasking required

  34. Non-PCI capable PCI capable STEMI Systems of Care Awareness Activate EMS Avoid delay Patient & Community 12-lead ECG 9-1-1 inter-hospital transport EMSED Activate team No diversion STEMI Referral SYSTEM OF CARE CENTER OF CARE Treatment protocols and clinical pathways STEMI Receiving CENTER OF CARE Jacobs. Circulation 2007;116:217-230.

  35. Transport Time: “Jokers Wild!” Transportation issues • Air vs. ground • Local EMS issues • Inter-facility issues • Weather • People factors

  36. EMS STEMI Care: Lessons Learned… • Situational decision making important • Standardization and flexibility are key • Essential Elements must be simplified • PROVIDER SKILLS and PLANS first • TECHNOLOGY second!

  37. Think Globally, Act Locally • EMS STEMI solutions must be locally driven based on national suggestions • Change items that really matter.

  38. So, Where Do We Start?

  39. REVIEW: Once STEMI is identified  it must trigger a clear response downstream! ECG Acquisition EMS Evaluation Communication !Decision!

  40. EMS: The Big Picture Ensure that every patient has timely access to an EMS provider who has: • ECG equipment… • ECG acquisition training, • A Screening ECG Protocol to follow • A Downstream communication plan • A STEMI ALERT plan to activate

  41. STEMI Engineering: Recognition Rigid adherence to a Screening ECG Protocol is crucial! “All portals at All times” Forgetting the screening ECG is simply not permitted!

  42. Lesson: Avoid “Fred Sanford Syndrome” Developing optimal STEMI recognition practices at every STEMI portal Goal: Every qualifying patient receives a timely screening ECG!

  43. Solution? • Print It • Post It • Expect It • Measure It

  44. All Patients (in Your EMS Catchment Area)…Do They… have timely access to an EMS provider with: • ECG equipment…? • ECG acquisition training…? • A Screening ECG Protocol to follow…? • A downstream communication plan…? • An area-specific STEMI ALERT plan to activate…?

  45. 4 a.m. Sunday night, Raining… Grandma’s house …44 miles out…

  46. ECG done! Three key questions now matter! How is the ECG interpreted? How is this info relayed ahead? How will this info change the destination facility or facility response?

  47. Once STEMI is identified  it MUST trigger a clear response downstream! ECG Acquisition EMS Evaluation Communication !Decision!

  48. Three Options for EMS Evaluation Evaluation = Interpretation

  49. A. Computer Interpretation (Evaluation) • Most ECG machines use similar algorithms • Can Detect 75 - 80% of STEMI cases • 90% Specific • Not as accurate as transmission but maintains a low false positive rate

  50. B. On-site Provider (Evaluation) • The most variable situation • Highly dependent on provider skill • Highest rate of false positives • Can work with intensive training • Not feasible in many areas

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