AHA Dallas Caruth Initiative Subcommittee Minutes: Protocols December 14, 2010

Transcription

1 Subcommittee Minutes: Protocols American Heart Association Dallas Office 8200 Brookriver Drive, Classroom A Conference Call Number , Participant Pass code # Co-Chairs: Chris Chiara and Mark Till AHA Liaisons: Duane Davis and Leilani Stuart 1. 7:30 Welcome & Introductions Chris Chiara Exhibit 1A Subcommittee Roster Background: Introduction of new subcommittee members Goal of this subcommittee is to establish and implement regional transport, triage and treatment protocols Action: Edit the subcommittee roster Minutes: Information Only 2. 7:35 Data Review Mark Till Exhibit 2A Pre-Assessment review of gaps and opportunities Background: The Stakeholder Committee met on December 02, 2010 and presented the pre-assessment data with regards to the current strengths and opportunities within Dallas County Action: Prioritize next steps from data analysis Minutes: Mark presented to the committee the below information Question Yes No 23 EMS Agencies Do you have STEMI and Non-STEMI protocols in place? 17 6 Do you bypass the ED and go straight to the cath lab for STEMI patients? Does your EMS transmit pre-hospital 12-Lead EKGs? Page 1 of 6

2 Subcommittee Minutes: Protocols Do you have a single call number to activate the cath lab from the field? 9 14 Do you have a bypass protocol to go directly to a PCI Hospital? Do you receive feedback from hospitals on STEMI and Non- STEMI patients? Education offered for 12-Lead ECG interpretation? Hospitals Do you have STEMI order sets in place? 13 3 Do you bypass the ED and go straight to the cath lab for STEMI patients? 3 13 Do you receive EMS or pre-hospital 12-Lead EKG transmissions? 8 8 Do you have a single call number to activate the cath lab from the field? 7 9 Does your hospital offer PCI services 24/7? 14 2 Do you have a standardized feedback process to notify EMS of quality control? 5 11 As for the pre-assessment data, the biggest areas to work on are the EMS agencies that currently do not have protocols in place. 6/23 did not have protocols in place. However, the pre-assessment question may not have been clear as to which EMS agencies currently have protocols. Dallas Fire Rescue answered they do not have a protocol in place, but under Biotel guidelines they have a standardized protocol. The areas to work on with the pre-assessment data for hospitals is making sure all 16 hospitals currently have protocols or AMI order sets. 3/16 hospitals do not have protocols at this time. 3. 7:50 Assessment of Protocols Chris Chiara Exhibit 3A List of different protocols needed for EMS, PCI, non-pci hospitals Background: Each community should develop a STEMI system of care that follows standards at least as stringent as those developed for the AHA s national initiative and per the 2009 ACC/AHA Guidelines Action: Identify best structure to create standardized protocols, how to achieve (prioritize) and set timelines Minutes: Knowing the above preliminary data where should we start: Page 2 of 6

3 Subcommittee Minutes: Protocols A. Start with 12-Lead ECG screening guideline As for the ECG screening, who s getting this information and where is it going, we don t want it piling up EMS discretion Anyone with chest pain symptoms 20 years old and above. Chest pain is defined as any pain from the jaw down to the umbilicus Shortness of breath EMS begins to determine cause by asking the following: do you have wheezes? do you have rales? what is your history? If these are negative then the next line of questions are: with exertion? does it go away? does it come back? 12-Lead ECG should happen if the shortness of breath cannot be explained The problem will be with diabetics and women and you have to be liberal This is an area where education will help because some medics will know more about it than others Currently 85% of EMS are using Lifenet and only 2 hospitals won t have it, but sure to get it once they know everyone else has it Here is what the subcommittee suggested as to who gets a 12 lead ECG: Age 20 and above unless known recreational drug use Pain definition chest pain from jaw to umbilicus What about diabetics that don t present with classic symptoms if not sure do ECG How about doing a checklist to include risk factors, having these questions asked in the field will help hospitals Is this person a woman? Is this person a diabetic? Does this person have generalized fatigue that can t be explained? Unexplained nausea/vomiting and anything else we would like to include on the checklist Do you take a statin drug? Are you a smoker? Has a blood relative ever had a heart attack or stroke? Include duration of symptoms Caution about making a checklist for medics because you may get medics that don t drive patients to hospital until checklist is complete Page 3 of 6

4 Subcommittee Minutes: Protocols As for Dallas Fire when chest pain is checked, computer will automatically require you to complete certain dataset fields. The patient is still driven to the hospital, but data fields must be completed before it closes out Onset Provocation, basically your whole OPQRST history is going to be required, but diabetes are not on the list This is coming from the Rescue Medic program It has been brought up that once a list is established, EMS agencies can go back to their vendor and request certain data fields be activated if not already part of the list B. Start with what determines if a patient is a STEMI and what is the criteria to activate the cath lab 100% of time? Is it 1 or 2 mm ST elevation and should LBBB be included? The definition of acute MI for a physician is based on three primary criteria and you are supposed to have two of the three: EKG findings This has to be liberal, 1 mm and 2 leads Clinical scenario Elevated cardiac enzymes Judgment call - Is this a patient with risk factors? How about requiring EMS to state 2 or 3 reasons why they are calling a patient a STEMI in order to activate cath lab, for example: ST elevation Patient is diaphoretic It appears patient is going into cardiogenic shock The patient only has 1 mm elevation, but they have chronic fatigue that can t be explain and they are diabetic This will also help with feedback and training, so that even if ECG was read incorrectly these could still be referenced as teaching points Is it possible to have the data from the field submitted to an AHA web base and once the data from the hospital is entered everyone has access (using a password and is HIPPA compliant) to see if it was an AMI? Then we would have a citywide database to see what we are doing This grant is working to get this done, but if Page 4 of 6

5 Subcommittee Minutes: Protocols everyone agrees to this and wants to continue doing it beyond the grant then the next step will be to figure out a way to self-sustain it C. Start with EMS treatment guideline One thing that was discussed is to develop a plan if there is a double hit, meaning you have two STEMI patients arriving at the ED at the same time. How do we want to deal with that? Do we want to try and re-route one patient or allow both to arrive at the same ED and is it possible that this will be real time data? As for developing a plan for two simultaneous STEMI patients, this can be addressed after all other items. We want to develop standardized protocols first Starting in the field is easier to develop How about taking a look at other area s EMS guidelines and see if we can work off theirs. If after reviewing their guidelines and EMS states something may not work, we can change it where we won t have to start completely from scratch Taking a look at Austin s protocols, the only difference from Biotels protocols is that they give lytics in the field. They also give plavix and heparin, however, giving lytics in the field in Dallas may not be necessary since the longest time transport time is 15 minutes or less with lights and sirens. Austin gives lytics in the field because they transport from rural areas Just as an FYI, Austin s and other protocols we have received are posted on our website EMS drugs used for chest pain include: Aspirin Nitro Morphine, Phenergan, some type of Analgesic Oxygen Add Consider administration of Benzos for cocaine patients, yes it is the norm For a suspected inferior MI they are getting an IV before they get Nitro. Everyone else gets Nitro D. Start with Non-PCI hospital protocol Set up a Non-PCI hospital protocol for less than 90 minute D2B timeline or greater than 90 minutes D2B adding lytics. This protocol can also be used for PCI hospitals when they have two STEMI patients come in at the same time with only one team onsite. There are Non-PCI hospitals that transfer patients into Dallas county that do not have PCI capabilities Destination plan should be to go to a STEMI receiving center Page 5 of 6

6 Subcommittee Minutes: Protocols 4. 8:35 Next Steps Mark Till Action: Review and list action items Minutes: Two protocol guidelines have been addressed from Exhibit 3A: #7 What criteria will activate the cath lab 100% of the time? Signs/Symptoms of Acute Coronary Syndrome (ACS) AND ST segment elevation of 1 mm or more in two contiguous leads or new LBBB AND Risk Factors (DM, HTN, smoker, etc) #5 12 lead ECG Screening Guideline if approved by subcommittee will use Austin s protocol Leilani will send out Austin s 12 lead ECG screening guideline for members to vote on Next meeting on Jan 11 at 7:30 Paula and Chris volunteered to review current EMS treatment guidelines in Dallas and compare differences and similarities as a starting point for a standardized EMS treatment guideline before our next meeting 5. 8:45 Adjourn Chris Chiara Adjourned 8:40 am Page 6 of 6

7 AHA Dallas Caruth Inititative Subcommittee Roster: Protocols November 2010 Baylor Heart and Vascular Hospital Andres Sisneros Baylor Heart and Vascular Hospital Nancy Vish Baylor Medical Center at Garland Janice Walker Baylor Medical Center at Irving Barry Allen Baylor Medical Center at Irving John Stricklin Baylor University Medical Center Nestor Zenarosa Coppell Fire Department Gregg Loyd Dallas Fire Rescue Chris Chiara Dallas Medical Center Patti Cantu Dallas Medical Center Don Timm Dallas Regional Medical Center Daniel Cervantez Dallas Regional Medical Center Juliet Horne Denton Regional Medical Center Todd Gray Doctors Hospital of Dallas Tracy Campbell Garland Fire Department Todd Peele HCA-North Texas Division Ronnie Ikeler Highland Park DPS Ryan Dikes Highland Park DPS Janet Sandman Hutchins Fire Department Chris Fason JPS Kathleen Whelan Medical City Dallas Hospital Eric Eichhorn Medical City Dallas Hospital Jennifer Ledbetter

8 AHA Dallas Caruth Inititative Subcommittee Roster: Protocols November 2010 Methodist Charlton Medical Center Kristi Marino Methodist Charlton Medical Center Dudley Wilcoxson North Central Texas Trauma Regional Advisory Council Carrie Hecht Parkland Hospital Thomas Tierney South Hampton Community Hospital Sandra Hernandez Texas Health Presbyterian Dallas Sean Black Texas Health Presbyterian Dallas Paula Spencer Texas Health Presbyterian Dallas Mark Till Texas Regional Medical Center Sunnyvale Misty Thomas UT Southwestern St. Paul Hospital David Pillow

9 Pre-Assessment Data for EMS Agencies Do you have STEMI and Non-STEMI protocols in place? 6 17 Do you bypass the ED and go straight to the cath lab for STEMI patients? Does your EMS transmit pre-hospital 12- Lead EKGs? No Yes Do you have a single call number to activate the cath lab from the field? 9 23 EMS Agencies 14 Improving the System of Care for AMI Patients

10 Pre-Assessment Data for EMS Agencies Do you have a bypass protocol to go directly to a PCI Hospital? Do you receive feedback from hospitals on STEMI and Non-STEMI patients? No Yes Education offered for 12-Lead ECG interpretation? EMS Agencies Improving the System of Care for AMI Patients

11 Pre-Assessment Data for PCI/Non-PCI Hospitals Do you have STEMI order sets in place? 3 13 Do you bypass the ED and go straight to the cath lab for STEMI patients? 3 13 No Yes Do you receive EMS or pre-hospital 12- Lead EKG transmissions? Hospitals Improving the System of Care for AMI Patients

12 Pre-Assessment Data for PCI/Non-PCI Hospitals Do you have a single call number to activate the cath lab from the field? 7 9 Does your hospital offer PCI services 24/7? 2 14 No Yes Do you have a standardized feedback process to notify EMS of quality control? Hospitals Improving the System of Care for AMI Patients

13 Subcommittee: Protocols Assessment of Protocols and Timelines: 1. PCI hospital guidelines/protocol including back-up plan/double hit strategy 2. Non-PCI hospital protocol <90 minute timeline 3. Non-PCI hospital protocol >90 minute timeline/lytic 4. EMS treatment guideline that includes destination plan 5. ECG Screening Guideline. Who gets 12 lead ECG? 6. Minimum feedback loop/template for PCI hospitals to use when reporting back to referral hospital or EMS 7. For the region, what criteria will activate the cath lab 100% of the time? include new LBBB? 1 or 2 mm ST elevation? 1 P age