Presenters: Disclaimer. Definitions. Deanna Jones, RN, CCRN. Annmarie Keck, RN, CEN

Transcription

1 Presenters: Deanna Jones, RN, CCRN Cardiac Level 1 Coordinator, Providence Sacred Heart Medical Center and Children s Hospital, Spokane, WA Annmarie Keck, RN, CEN Clinical Outreach Educator Northwest MedStar, Spokane, WA Disclaimer Always follow your local protocols for the treatment and transport of any patient- Definitions STEMI ST segment elevation myocardial infarction (Heart attack) D2N Door to Needle time (fibrinolytic) (goal <30 mins) D2B Door to Balloon time (goal <90 mins) PPCI Primary Percutaneous Coronary Intervention - balloon angioplasty usually with a stent 1

2 Regional STEMI Network A regional program developed for the rapid treatment and timely transfer of patients with STEMI from the rural hospital to a PCI capable hospital using a standardized protocol. Patient Population STEMI - Anterior, Inferior, Lateral and True Posterior (Heart Attack) New onset or unknown onset Left Bundle Branch Block patients- (LBBB) Cardiac Emergencies- Cardiopulmonary Arrest Currently in the US 1.4 million heart attacks annually 400,000 STEMI 30% of STEMI patients fail to receive PPCI or lytics (clot busting drugs) Only 50% of patients who receive lytics have a D2N time of <30 minutes Only 40% of patients who receive PPCI have a D2B time of <90 minutes Challenges in the Inland NW Geography of region Weather challenges Transport: 1 Helicopter service for region 2 competing PCI hospitals in town 4 competing cardiology groups Staff education at rural hospitals Efficiency of protocol when few pts seen EMS education-scattered ALS available Few ALS units 2

3 EMS Goals Rapid ECG (if available) STEMI identification Scene time <15 minutes-time critical transport Emergent Transport-Consider Air-medical/ALS rendezvous Transport of patients should not be delayed by treatment protocols and whenever possible diagnostic and treatment activities should be done while in transit. -AHA Cardiac Level 1 patients should be transported to the closest appropriate facility E2B: EMS to Balloon Challenge Goal for E2B <= 90minutes EMS, ED, and Cath Lab each have 30 minutes and then hand-off. The E2B clock starts with the first prehospital ECG that shows a STEMI heart attack The E2B clock stops with the first balloon inflation in the Cardiac Cath Lab Use a Triage Tool- >35 years of age with Symptoms lasting >10 mins but < 12 hours (suspected to be caused by CAD) Chest discomfort Epigastric (stomach) discomfort Shortness of breath Radiating pain or discomfort in 1 or both arms Sweating, nausea or vomiting Women, diabetics and geriatric patients might have N/V, back or jaw pain, fatigue/weakness or generalized complaints 2009, State of Washington ECS TAC, Pre-hospital Cardiac Triage (Destination) Procedure- Draft Program is based on: Time is muscle! Best practice Standardized protocol Early recognition of STEMI Pre Hospital Emergency Department 3

4 ACC / AHA Guidelines Cardiac Level 1 Activation 12 Lead ECG < 10 minutes Rapid STEMI identification New or presumed new LBBB Decision- Reperfusion strategy PCI < 90 minutes Door-to-Balloon Fibrinolytic > 90 minutes Door-to-Balloon No contraindications Chest pain duration < 2 hours Goal: Door-to-Needle < 30 minutes Notify MedStar or transporting agency Specify Cardiac Level 1 Notify cardiologist Time critical transport No diversion policy Patient delivered to the cath lab for PCI Unless lytics administered and pt reperfused Northwest MedStar Communication Center Cardiac Level 1 Minimal Patient information Patient weight Patient name, DOB Receiving facility Will contact receiving facility MedStar Flight Team Standardized approach to patient care Heparin and Tridil infusions prepared enroute Focused physical assessment Minimal verbal report Pilot to remain with aircraft Warm off load CUT 5-10 MINUTES OFF GROUND TIME! 4

5 Early ECG Cardiac Level 1 Network Early Recognition of STEMI Early Cardiac Level 1 Activation Timely PCI Spokane Results: 2008 Zone 1 ( < 60 Miles ) Door to Balloon Times Zone 1- < 60 miles, < 30 min transport, one way Goal: PPCI <120 min Zone 2 - > 60 miles, > 30 min transport, one way Fibrinolytics, unless contraindicated Goal D2N <30 min Minutes (Median) % Improvement 102 Jan July 2007 Jan Dec 2008 n - 24 n

6 Overall Process Times Zone 1 and Zone 2 Deaconess Medical Center ACTION Database Transfer-in D2B times M inutes ( Median) Door to ECG Time Door to Activation Transport at Door to Needle Time Jan July Jan Dec Percent Change 14% 46% 46% 38% Process Interval 50 Jan July 2007 Jan Dec Q1 08 Q2 08 Q3 08 Q Deaconess Medical Center D2N Q1 08 Q2 08 Q3 08 Q Participating Hospitals Valley Medical Center, Spokane, WA Okanogan Douglas, Brewster, WA Lincoln Hospital, Davenport, WA Othello Community, Othello, WA Whitman Hospital, Colfax, WA Samaritan, Moses Lake, WA East Adams Rural, Ritzville, WA Newport Community, Newport, WA Implementing: St Joseph s, Chewelah, WA Mid-Valley, Omak, WA Mt Carmel, Colville, WA North Valley, Tonasket, WA Ferry County Memorial, Republic, WA VA Medical Center, Spokane, WA Pullman Regional, Pullman, WA St. Joseph Regional, Lewiston, ID Syringa General, Grangeville, ID Gritman Medical Center, Moscow, ID Clearwater Valley, Orofino, ID St. Mary, Cottonwood, ID Tri-State Memorial, Clarkston, WA Odessa Memorial, Odessa, WA Coulee Community, Grand Coulee, WA Garfield County PHD, Pomeroy, WA 6

7 Scenario #1 ECG 62 year old female with chest pain History: Previous PCI, previous MI, dyslipidemia, HTN, current smoker 1 ppd 12:15 Onset of CP 12:51 Arrived at ED per ambulance 62 year old female Risk Factors: CAD, previous PCI, previous MI, dyslipidemia, HTN, current smoker 1 ppd Cardiac Level I activation? Initial assessment? Initial treatment? Destination? 7

8 Scenario #2 47 year old male, indigestion/cp x 18 hours History: HTN, Diabetes, Smoker 02:00 CP 8/10 06:35 EMS on scene 47 year old male Cardiac risk factors: HTN, Diabetes, Smoker Indigestion/CP x 18 hours Cardiac Level I activation? Initial assessment? Initial treatment? Scenario # 3 61 year old male Cardiac Risk Factors: HTN, previous MI with PCI 13:00 Onset of chest pain 15:00 EMS - 1 st medical contact 15:21 Arrival to ED per EMS Destination? 8

9 61 year old male Cardiac Risk Factors: HTN, previous MI with PCI Cardiac Level I activation? Initial assessment? Initial treatment? Destination? Scenario # 4 54 year old male with sudden onset diaphoresis, abdominal pain radiating to the chest History of meth use, family history of CAD 1200 Onset of pain 1210 Call to EMS on scene 9

10 54 year old male with midsternal chest pain x 2 hours 9/10 History of meth use, family history of CAD Cardiac Level I activation? Initial assessment? Initial treatment? Destination? Scenario #5 65 year old female complaining of shortness of breath and overwhelming fatigue History of Type II Diabetes, smoking, HTN 1000 Onset of breathlessness 1130 Call to EMS on scene 65 year old female complaining of shortness of breath and overwhelming fatigue History of Type II Diabetes, smoking, HTN Cardiac Level I activation? Initial assessment? Initial treatment? Destination? 10

11 Post Test 1. Which of the following is a goal of EMS Cardiac patient transport? A. Place two large bore IV s, no matter how much time it takes B. Limit scene time to less than 15 minutes, if a heart attack is suspected C. Go really fast D. Transfer every patient to a PCI capable hospital 2. Using the name Cardiac Level 1 instead of Acute MI or STEMI is important because: A. It is a standardized term recognized by everyone in the system B. It is cool C. It helps the ED identify a cardiac patient from a respiratory patient D. All of the above 3. Which one of these symptoms is not listed in the DOH triage tool as a possible heart attack presentation? A. Chest discomfort B. Shortness of breath C. Nausea D. Leg pain 4. The purpose of the Cardiac Level 1 program is to reduce morbidity and mortality in heart disease patients by reducing time to treatment. A. True B. False 5. The Cardiac Level 1 program is a regional STEMI network based in which city? A. Philadelphia, PA B. Spokane, WA C. Missoula, MT D. Seattle, WA Questions? Contact: Renee Anderson Fax: Phone: