STEMI ALERT! Craig M. Hudak, MD, FACC,FACP 24 January 2015

Transcription

1 STEMI ALERT! Craig M. Hudak, MD, FACC,FACP 24 January 2015

2 STEMI Overview ST segment Elevated Myocardial Infarction Patient Outcome Goals: Save myocardium Reduce CHF Reduce arrhythmias Improve quality of life

3 The STEMI Network Greenville Memorial Hospital 750 bed tertiary referral center Chest Pain Center, Call Center, Referral Center, Cardiac Cath Lab, Coronary Care Unit, STEMI RN, Laboratory, EKG, Emergency Department Physicians, Cardiology Physicians GHS Hospitals Greer, Hillcrest, Laurens, North Greenville Baptist Easley Hospital (Easley) Cannon Hospital (Pickens) Greenville County EMS Mobile Care Pelzer Rescue Squad Pickens County EMS Laurens County EMS Oconee EMS Oconee Medical Center (Seneca) Wallace Thompson Hospital (Union) Spartanburg EMS Med-Trans Life Flight PLUS: MD 360, Doctor s Care, Urgent Care Centers and Doctor s Offices

4 STEMI 2010 STEMI 2011 STEMI 2012 STEMI 2013 STEMI 2014 STEMI 2015 So we are doing this just about every day practice make perfect?

5 The STEMI Program -Development Began in house at GMH Establish Protocols Train our ED/ CPC staff Establishment of Call Center and Referral Center Coordinate with EMS Monitor times and intervals Provide ongoing feedback and training STEMI Nurse position created in 2007 STEMI Coordinator position created in 2010 Weekly STEMI meeting for real-time QI Monthly AMI meeting Extending the Network Relationship building with referring facilities and EMS companies Case reviews with physicians in referring facilities Case reviews and training with EMS companies In-services for staff in referring Emergency Departments Ongoing feedback and dialogue

6 With a single call

7 STEMI Collaborative Components: STEMI Activation System STEMI Work Team (Weekly) STEMI Tracking Forms STEMI Feedback ( ) STEMI Monthly Summation Report AMI Oversight Committee (Monthly) CMS Publically Reported Submissions Mission Lifeline Participation (AHA and SCHA)

8 STEMI Collaborative Work Team STEMI/CPC Co-Medical Directors: Cardiology and Emergency Medicine STEMI/CPC Coordinator: Christina Freeman Representatives from ER, CCU, Cath Lab,GHS Laboratories, EMS,Transport, Call/Referral Center, all campuses Review of EVERY Cath Lab Call Back/STEMI

9 STEMI Collaborative Work Team Membership Executive Operations Director, Cardiology Services Manager, Cardiology Services Manager, ED Services Supervisor, CCL Director and Senior Paramedics, Mobile Care Practice Liaison, Carolina Cardiology Consultants Clinical Data Specialist, Quality Management Manager, GMH Bed Management Regulatory Affairs Specialist, Cardiac Research GMH STEMI RN Nurse Manager, CCU Lead ECG Tech, ECG Department Etc.!

10 THE TAKE HOME MESSAGE! Mortality Reduction % Mortality Reduction % Myocardial Salvage % 20 0 Myocardial Salvage 0 3 % Hours Gersh JAMA 2007

11 Impact of Door-to-Balloon Time on One Year Mortality: All Patients in CADILLAC and HORIZONS-AMI Trials D2B > 90 min 4.3% 3.1% D2B < 90 min Unadjusted HR 0.72 ( ) p = 0.045

12 Impact of Door-to-Balloon Time on One Year Mortality: Early (< 1.5 hrs) vs. Late Presenters Time to Presentation < 1.5 hours Time Time to to Presentation > hoursti HR 0.49 ( ) p = D2B > 90 D2B < % 1.9% HR 0.86 ( ) p = 0.47 D2B DBT > 90 > 90 min D2B < 90 DBT < 90 min 4.6% 4.6% 4.0%

13 Impact of Door-to-Balloon Time on One Year Mortality: High Risk* vs. Low Risk Patients High Risk Low Risk D2B > % D2B < % HR 0.64 ( ) p = 0.25 HR 0.75 ( ) p = 0.12 D2B > 90 D2B < % 1.1% * TIMI Risk Score > 2

14

15 Multivariable analysis estimating the treatment effect of reperfusion therapy with PCI or fibrinolysis based on increasing PCI-related delay Pinto, D. S. et al. Circulation 2006;114: Copyright 2006 American Heart Association

16 THE WHOLE PICTURE Symptom onset EMS call Arrival at PCI center PPCI Fieldtriaged to a PCI center Patient delay Transportation delay Treatment delay D2B delay Health Care System delay Arrival at local hospitall Departure from local hospital Arrival at PCI center PPCI Transferred from local hospitals Patient delay Transportation delay Local hospital delay Interhospital delay Health Care System delay D2B delay Treatment delay

17 E2B First Medical Contact (EMS, or ER if patient drives self to hospital) to Balloon Time D2B, though heavily emphasized as Quality measure, is only part of the story! Our goal is E2B less than 90 minutes

18 PATIENT DELAYS Community Education programs It s called heartburn because although it could just be burning from acid reflux it could also be your heart! Time is Muscle Call 911: Do not drive yourself to the ER! EMS can diagnose and start treatment immediately

19 EARLY ACTIVATION OF STEMI ALERT BY EMS Must empower EMS to make this call! Reduces PCI hospital D2B: Get the team in! Allows local hospitals to be bypassed EMS education is crucial, and very effective 15 lead EKG: Posterior or RV MI We welcome EMS paramedics in Cath Lab

20 NON PCI HOSPITALS: DIDO Goal: Door In Door Out within 30 minutes Interchangeable equipment: stretchers No drips: So no need to change IV tubing/pumps at transfer points Recognize potential tension between DIDO and E2B: ground vs. air transport?

21 PROTOCOLS: KISS! Chew 4 baby aspirins (total about 325 mg) Plavix 600 mg load Heparin 5,000 units IV, not weight-adjusted, no drip! SL NTG if BP allows, no IV drip! (coronary spasm) IV beta blockers only if needed for HTN/tachycardia! (causes hypotension, bradycardia, and shock!)

22 D2B Considerations STEMI RN: a GMH innovation! Crucial role in coordination, transport, and in Cath Lab Be aware of door time! Address Infarct Related Artery first? Simultaneous STEMI S:? Triage low risk patient to lysis and PCI--**Communication between ER MD and cardiologists is essential** Reversal of cardiogenic shock must take precedence over achieving D2B

23 False positives? Inherent tension also between low D2B and potential situations that do not represent STEMI Pros and cons of accepting patients directly to Cath Lab: role of non cardiologists Need low threshold for calling STEMI Alert Constant reassurance of MD s and EMS about this new paradigm Recurring 12 lead EKG training for EMS, ER MD s, RN s, EKG techs

24 Rates: Cancel and False Positive STEMI Cancel Total % Cancel False + % False + Jan % 4 7.4% Feb % 6 9.1% Mar % % Apr % 4 9.8% May % % Jun % % Jul % % Aug % 5 9.6% Sep % 4 8.7% Oct % % Nov % % Dec % 5 7.9% % Cancel % False % 25.0% 55.0% 50.0% 20.0% 45.0% 40.0% 35.0% 15.0% 10.0% % False % 25.0% 5.0% 20.0% Month % Month

25 SOME CONCLUSIONS The first priority is prompt reperfusion By any modality! D2B--and even E2B times--are only part of the story! We (patients, EMS, aircrews, ER MD s, cardiologists, Cath Lab Techs, nurses indeed, all GMH physicians) need to be all in to work TOGETHER to minimize delays!!

26

27 IT S AMAZING THIS ACTUALLY WORKS!

28