San Joaquin County Emergency Medical Services Agency http://www.sjgov.org/ems DATE: Mailing Address PO Box 220 French Camp, CA 95231 TO: FROM: SUBJ.: All Prehospital Personnel and Providers Emergency Department Physicians and Nurse Liaisons Interested Parties Dan Burch, EMS Administrator STEMI System Performance Report Health Care Services Complex Benton Hall 500 W. Hospital Rd. French Camp, CA 95231 Phone Number (209) 468-6818 Fax Number (209) 468-6725 The EMS Agency is releasing its first report following implementation of the STEMI program on April 1,, with the designation of Dameron Hospital and the St. Joseph s Medical Center as STEMI Receiving Centers. The attached STEMI System Performance Report covers the final three quarters of, using data provided by ambulance providers and the designated STEMI Receiving Centers. Please direct any questions or comments to Rick Jones, MPA, EMS Analyst, at rrjones@sjgov.org.
STEMI System Performance Report Background The developed and implemented a system to identify heart attack patients experiencing an ST elevated myocardial infarction (STEMI) and to direct these patients to specially designated hospitals staffed and equipped with cardiac catheter laboratories capable of providing immediate life-saving intervention. The ability of the EMS Agency to evaluate the STEMI system relies upon data measuring the performance of prehospital and hospital timeliness and adherence to policies and procedures. Report Content This report analyzes data collected during the first nine months following the designation of St. Joseph s Medical Center and Dameron Hospital as STEMI Receiving Centers (SRCs) and implementation of the STEMI system on April 1,. Two criteria determine whether information from an ambulance transport record or hospital record is included as data in this report. Criteria #1: The ambulance crew notified the SRC that they have identified a STEMI patient. Criteria #2: A patient transported by ambulance is identified by the hospital as a STEMI patient. There were a total of sixty-six (66) cardiac cases (n) reviewed that comprise the data in the charts. The data is grouped into the last three quarters of, (April-June, July- September, and October-December respectively). The first chart on the next page illustrates the difference in the volume of ambulance patients transported to each SRC with suspected STEMI and the number of those cases that received PCI. In the Second Quarter, there were twenty (20) cardiac cases transported by ambulance to SRCs (five to Dameron and fifteen to SJMC). Of those cases eight (8) resulted in PCI in the cath lab at SJMC, and none (0) at Dameron Hospital. In the Third Quarter, there were twenty-one (21) cases transported by ambulance (two to Dameron and nineteen to SJMC). Of those cases, ten (10) resulted in PCI in the cath lab at SJMC, and none (0) at Dameron Hospital. In the Fourth Quarter, there were thirty-one (31) cases transported by ambulance (seven to Dameron and twenty-four to SJMC. Of those cases thirteen (13) resulted in PCI in the cath lab at SJMC, and seven (7) at Dameron Hospital. Page 1
STEMI System Performance Report The Number of Suspected STEMI Patients Transported by Ambulance and the Number of those Patients that Received PCI during by SRC 30 25 20 15 10 5 0 Ambulance Transports to Dameron Ambulance Transports to SJMC Number of PCIs at Dameron Number of PCIs at SJMC 2nd Quarter 5 15 0 8 3rd Quarter 2 19 0 10 4th Quarter 7 24 7 13 Analysis The analysis of the data focused on the following areas: 1) The difference between the volume of STEMI cases identified in the prehospital setting and those cases confirmed or identified in the hospital setting e.g. true positives, false positives; 2) The compliance of both prehospital and in-hospital personnel with policies that require appropriate and timely response e.g. prehospital patient treatment and STEMI alert protocols; 3) Multiple time intervals using nationally established metrics, and; 4) Trends that track improvement and identify opportunities for improvement. Due to the low volume of cases available for analysis, the following charts combine the data collected from SJMC and Dameron Hospital. Page 2
Number of Cases STEMI System Performance Report 35 30 25 20 15 10 5 0 Number Cath Lab Activations Compared to the Number of Reported Field Diagnosis of STEMI 2nd Quarter 3rd Quarter 4th Quarter Number of Cath Lab Activations Field Diagnosis of STEMI This chart provides information about the volume of Cardiac Cath Lab (CCL) activations for patients that were transported by ambulance. The finding that there were more CCL activations than field diagnosis of STEMI is not consistent with the expectation that there would be a number of false positive field diagnoses that would cause the field diagnosis to exceed the number of CCL activations. Because of this finding, each CCL activation that was not associated with a field STEMI alert was reviewed. This review showed that the primary reason for the relatively lower number of field diagnosis of STEMI is that ALS field personnel failed to either identify a STEMI patient or failed to call a STEMI alert when appropriate. In a few cases, patients that did not have obvious cardiac symptoms or did not present with a STEMI based upon the 12 Lead ECG developed symptoms after arriving at the hospital. Page 3
Number of Minutes Percentage STEMI System Performance Report Percent of STEMI Alerts with ECG Transmitted 70% N=24 This chart shows 60% the percentage of 50% STEMI alerts from N=16 N=12 the field that 40% included the 30% transmission of an ECG. Currently, 20% transmission of 10% ECGs to SRCs from the 0% prehospital setting 2nd Quarter 3rd Quarter 4th Quarter is not required to complete a STEMI alert. In addition, not all ALS ambulances in the county are equipped with the capability to transmit 12 lead ECGs. 0:10 0:08 0:07 0:05 0:04 0:02 Average time gap from field notification to SRC internal alert N = 24 N = 12 N = 16 This chart shows how quickly (on average) hospitals respond to STEMI alerts called in the prehospital setting by calling an internal STEMI alert. 0:01 0:00 2nd Quarter 3rd Quarter 4th Quarter Page 4
Number of Minutes Percent STEMI System Performance Report Percent < 90 Minutes to Balloon/Device by Quarter in 120% 100% 80% 60% 40% 20% 0% N=8 2nd Quarter N=9 N=20 3rd Quarter 4th Quarter ED Door to Balloon EMS Pt Contact to Balloon The current national standard for arrival of a patient at the hospital (Door) to inserting a device to open the coronary artery (Balloon) is < 90 minutes. In the future, STEMI systems may be challenged to meet the < 90 minute standard as measured from the time the patient is contacted in the field to balloon. 0:25 0:23 0:20 0:17 0:14 0:11 0:08 0:05 0:02 0:00 Median Ambulance Transport Times for STEMI Patients in April - June July - Sep Oct - Dec N-20 N=21 N=31 Time of Dispatch of EMS to Time of Arrival On-Scene Patient Contact Time to Depart Scene Median Transport Time from Scene to ED Time from 12 Lead ECG to ED Arrival Minimizing time spent on-scene with patients that have been identified as experiencing a STEMI is vital. This chart shows that the median time spent onscene (Patient Contact Time to Depart Scene) rarely exceeds the goal of 10 minutes. Page 5
Number of Cases STEMI System Performance Report Comparison of Confirmed vs False STEMI Alerts/Cases 20 18 16 14 N-23 Number of Field STEMI Indicated Confirmed in ED (True Positives) 12 10 8 6 N=12 N=17 Number of False Positives Per Field Reporting Number of False Negatives 4 2 0 2nd Quarter 3rd Quarter 4th Quarter Number of Evolving/Subsequent Note: One of the False Positives shown in the 2 nd quarter was considered a correct reading in the field, but did not require Cath Lab intervention because ECG changes were from a previous cardiac episode. One of the True Positives in the 4 th quarter was derived from the paramedic s interpretation of the 12 Lead ECG rather than the read-out message ***Acute MI Suspected***. One of the False Positives in the 4 th quarter was derived from the paramedic s interpretation of the 12 Lead ECG rather than the read-out message ***Acute MI Suspected***. The ability of prehospital personnel and by association (EMS policies) to accurately identify STEMI patients must be monitored carefully. By comparing the number of STEMI cases confirmed in the hospital ED with the number of STEMI patients identified in the prehospital setting, the effectiveness of the methods to identify STEMI patients can be assessed over time. After three quarters of data, the percentage of false positive cases is 23% (11 out of 47 cases). We will also carefully monitor the cases in which a STEMI is identified in the ED but not in the field (false negatives) and those cases in which a patient is determined to be a STEMI candidate based upon paramedic judgment (rather than based upon ECG computer analysis). Page 6