OLOL Pre-Hospital Cardiac Review January July 2003

Transcription

1 OLOL Pre-Hospital Cardiac Review January July 23 Maria Berry, RN, Nurse Manager ED OLOL Frank Ciallelo, Director, SREMS Program Agency E. James Radin, MD, SREMS / OLOL ED CQI

2 Clarification of Data There are some variations in the number of total cardiac related presentations to EMS In selection of patients to include in the study, we tried to limit the data to just pure cardiac patients but the patients with a discharge diagnosis of MI had a multitude of non chest pain complaints. Factoring this into the data was difficult, and presents the Pre Hospital provider with his greatest challenge in the field Hence, you may notice some variations in the numerical totals at times, the trends are consistent

3 Cardiac related, Regional, sex, January to August 23 47% 53% male female

4 Cardiac related, OLOL, sex, January to August 23 37% 63% male female

5 Total MI, n =81 6% Yes No 94%

6 Cardiac related, ALS skills, January to August N = number Oxygen monitor IV Regional OLOL

7 2 Cardiac related, Meds, January to August N = 3568 / 727 number NTG ASA Lasix 36 Regional OLOL

8 Cardiac related, Monitor and Meds, January to August N = 3568 / 727 number No Monitor No Meds Monitor No Meds No Monitor Meds Monitor Meds Regional OLOL

9 Cardiac related, Number of Meds Administered, January to August number N = 3568 / one med two meds three meds four meds over four meds Regional OLOL

10 Cardiac related, Narcotics for Pain, January to August number Regional 49 OLOL 4 Total Patients Narcotics Given

11 OLOL cardiac medications, cardiac monitor, 1-7 / 23, n = 28 7% 93% cardiac monitor no cardiac monitor

12 OLOL inpatient / ems, prehospital rhythms, January 23 - June number Sinus Sinus Brady Sinus Tach 1st deg HB 2nd deg HB 3rd deg HB Afib SVT IMI Paced Vfib

13 OLOL inpatient / ems, Prehospital monitor interpretation, January 23 - June 23 12% 88% Incorrect Interpretation Correct Interpretation

14 Computer Interpretation, n = 81 17% Not Accurate Accurate 83%

15 OLOL cardiac medication study, age, 1-7 / 23 n = age m = 72.43

16 OLOL cardiac medication study, scene time, 1-7 / 23, n = minutes m = 14.6

17 OLOL cardiac medications, total care time, 1-7 / 23, n = minutes m = 29.8

18 OLOL cardiac medications, Oxygen, 1-7 / 23, n = 28 4% 96% oxygen applied no oxygen applied

19 OLOL cardiac medications, IV, 1-7 / 23, n = 28 7% 93% IV placed No IV placed

20 OLOL cardiac medications, cardiac monitor, 1-7 / 23, n = 28 7% 93% cardiac monitor no cardiac monitor

21 OLOL cardiac medications, 12 Lead EKG, 1-7 / 23, n = 28 25% 75% no 12 lead 12 lead

22 OLOL inpatient / ems, cardiac discharge diagnosis, 12 lead acquisition, January 23 - June 23 25% 75% Prehospital 12 lead No Prehospital 12 lead

23 OLOL inpatient / ems, ems transported, cardiac dischage diagnosis, January 23 - June % 87% Admitted Cardiac Not Admitted Cardiac

24 OLOL Discharge Diagnosis Data January 23 June 23

25 OLOL Overview OLOL had 1766 cardiac related EMS calls from January 23 through June 23 About 5 % of these calls were an acute MI Only 3 % were transferred for catheterization ( 5 or so patients / month ) 27 % diagnostic EKG rate, I suspect these numbers with time will be the same. The vast majority were transferred within 6 minutes of arrival at triage ( of the 5 / month )

26 OLOL pre-hospital hospital, presenting complaints on patients with discharge diagnosis of MI, January 23 - June number Weakness SOB Chest Pain SOB CP Fall Abdominal pain ALOC

27 OLOL pr4e-hospital / hospital Patients with discharge Diagnosis of MI, 12 lead EKG Acquisition, January 23 - June Total Patients 12 Leads Done 12 Leads Diagnostic MI Recognised

28 OLOL cardiac pre-hospital medication times, January 23 - June 23, n = minutes TPCT ASA TPCT NTG1 NTG2 NTG3 NTG4 NTG5 TPCT Lasix TPCT Albuterol mean values

29 OLOL inpatient / ems, CHF discharge diagnosis, Pt # 1, January 23 - June minutes / days Scene Time TPCT Time to Lasix Prehospital 12 Lead LOS 1

30 OLOL inpatient / ems, CHF Discharge Diagnosis, Pt #2, January 23 - June minutes / days Scene Time TPCT Times to NTG Prehospital 12 Lead LOS

31 OLOL inpatient / ems, Subendocardial MI Discharge Diagnosis, Pt # 3, January 23 - June minutes / days Scene Time TPCT Time to ASA TPCT Time to NTG TPCT Time to Lasix DM no CS Prehospital 12 lead LOS

32 OLOL inpatient / ems, CAD Discharge Diagnosis, Pt #4, January 23 - June minutes / days Scene Time TPCT Time to ASA TPCT Time to NTG Prehospital 12 Lead LOS

33 Patient 5, AMI, Weakness Scene TPCT ASA NTG LOS Monitor 12 Lead

34 Patient 6, AMI, SOB Scene TPCT ASA NTG LOS Monitor 12 Lead

35 Patient 7, IMI, CP Scene TPCT ASA NTG1 NTG3 LOS Monitor 12 Lead Diagnostic Recognised

36 Patient 8, IMI, SOB / CP Scene TPCT ASA NTG LOS Monitor 12 Lead

37 Patient 9, Subendo MI, SOB Scene TPCT ASA NTG1 NTG3 NTG5 Lasix LOS Monitor 12 Lead 1

38 Patient 1, Subendo MI, CP Scene TPCT ASA NTG1 NTG3 NTG5 LOS Monitor 12 Lead Diagnostic

39 Patient 11, Subendo MI, SOB / CP Scene TPCT ASA Albuterol LOS Monitor 12 Lead Diagnostic

40 Patient 12, Subendo MI, SOB Scene TPCT ASA NTG Lasix LOS Monitor 12 Lead

41 Patient 13, Subendo MI, Fall Scene TPCT ASA NTG LOS Monitor 12 Lead

42 Patient 14, Subendo MI, SOB / CP Scene TPCT ASA NTG Lasix LOS Monitor 12 Lead Diagnostic

43 Patient 15, Subendo MI, CP Scene TPCT ASA NTG LOS Monitor 12 Lead

44 Patient 16, AMI, midepigastric pain Scene TPCT ASA NTG1 NTG3 LOS Monitor 12 Lead Diagnostic Recognised

45 Patient 17, IMI, CP TPCT, NTG2, ASA, 6 4 NTG1, 4 2 Scene, 2 LOS, 1 Monitor, 1 12 Lead, 1 Diagnostic, 1 Recognised, 1 Scene TPCT ASA NTG1

46 Patient 18, IPMI, CP Scene TPCT ASA NTG1 NTG3 LOS Monitor 12 lead Diagnostic Recognised

47 Patient 19, Subendo MI, SOB Scene TPCT ASA NTG Albuterol LOS Monitor 12 Lead

48 Patient 2, Subendo MI, SOB Scene TPCT ASA NTG LOS Monitor 12 Lead

49 Patient 21, Subendo MI, ALOC Scene TPCT ASA NTG LOS Monitor 12 Lead

50 Patient 22, Subendo MI, SOB Scene TPCT ASA NTG LOS Monitor 12 Lead

51 Patient 23, Subendo MI, SOB / CP Scene TPCT ASA NTG1 NTG3 LOS Monitor 12 Lead Diagnostic

52 OLOL cardiac medications, Documentation, 1-7 / 23, n = quality of documentation

53 OLOL inpatient / ems LOS, January 23 - June Days m = 3.78 days

54 OLOL inpatient / ems, Discharge diagnosis, age / LOS, January 23 - June years / days CAD Chest Pain CHF MI Arrhythmia Average age LOS

55 OLOL inpatient / ems sex distirbution, January 23 - June 23, n = % 54% Female Male

56 OLOL inpatient / ems, CAD sex distribution, January 23 - June 23 42% 58% Female Male

57 OLOL inpatient / ems, Chest Pain sex distribution, January 23 - June 23 52% 48% Female Male

58 OLOL inpatient / ems, CHF sex distribution, January 23 - June 23 37% 63% Female Male

59 OLOL inpatient / ems, MI sex distribution, January 23 - June 23 44% 56% Female Male

60 OLOL inpatient / ems, Arrythmia sex distribution, January 23 - June 23 52% 48% Female Male

61 Summary OLOL received 1766 cardiac related patients via EMS from January 23 through June 23 This represents 294 / month of which about 5 % ( 15 patients / month ) have a discharge diagnosis of MI ( these numbers are a little variable and do not include walk in ) Of the 5 %, only 3 % of these were transferred for catheterization Of the 5 %, Only 5 % complained of CP. The others were weakness, SOB, falls, ALOC, and abdominal pain.

62 Summary Very few of the EMS transported patients with the cardiac related complaint actually had a discharge diagnosis of MI. Approximately 5 %. Only 27 % of the patients with MI had a diagnostic 12 lead in the ED. ( that is 27 % of the 5 % ) Of the patients with a discharge diagnosis of MI, only 39 % had pre hospital 12 Leads. ( ditto ) Of the patients with a discharge diagnosis of MI, only 17 % had a diagnostic pre hospital 12 Lead and only half of these were recognized. ( ditto )

63 Summary Overall data looks good, but the times could improve Documentation was 3 + out of 4 + for the majority of cases ; and PMH, medications, and allergies were recorded most of the time There was a trend that suggested that the patients that received more aggressive Pre-Hospital treatment had shorter length of stay in OLOL One bothersome trend ; you were more likely to have a glucose checked if you were not diabetic, than if you were diabetic.

64 Summary Time from on scene to first NTG averaged 13 minutes. ( 14, 21 minutes for the second and third ) Scene times were about the same as in prior studies 14 minutes, the TPCT did seem longer than on prior studies 29 minutes One agency did have a patient with GI Bleed and signs of shock that received Adenosine and Diltiazem for the compensatory tachycardia. Medical command did deny an order for amiodarone but did allow diltiazem, outcome unknown as yet One agency seemed to have problems with documentation, inclusion of monitor strips, and glucose analysis more often than the other agencies.

65 Summary Currently there are 45 EMS cardiac related calls / year ( 1 % of the calls or so ) Only 5 % - 1 % of these calls actually have a patient with an MI ( 45 patients / year or 37 patients / month in our region as a whole ) Only 27 % of the 45 have a diagnostic EKG ( 121 patients / year or about 1 patients / month ) Only half of the Pre-Hospital EKGs that showed an acute MI were recognized in the field

66 Summary Remember that only about 5 % of the patients with a discharge diagnosis of MI came via EMS. This access of EMS for cardiac related complaints does not reflect the degree of illness in the patient, you are as likely to have a critical patient walk-in as utilize EMS One must bear in mind that while we can promote patient education etc., a 5 % increase in EMS volume let alone a 1 % increase in cardiac related calls alone, would represent an increase from 45 calls / year to 8 calls / year. This would increase our overall call volume to 4, + and your yield of acute MI would only increase to 1 % of those calls or about 2 patients / month.

67 Summary Overall inpatient discharge diagnosis carried a varied average age and LOS after presenting as cardiac related via EMS CAD discharge diagnosis carried an average age of 77.4 years and an average LOS of 2.5 days Chest pain discharge diagnosis carried an average age of 57.3 years and an average LOS of 1.65 days CHF discharge diagnosis carried an average age of 78.8 years and an average LOS of 5.1 days Acute MI discharge diagnosis carried an average age of 77.2 years and an average LOS of 4.3 days

68 Summary Arrhythmia discharge diagnosis carried an average age of 73.7 years and an average LOS of 2.3 days The sex distribution was about equal except in CHF, where there was a female preponderance of 63 % and longer length of stay.