What is cardiac pain? Check out our great STEMI figures! Neuro exam training session. Stroke care at Pinner complex

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1 The latest figures are from May 2011 yes I know its nearly Christmas that was months ago! Why such a delay? You may ask what are they doing at CARU, sitting around drinking coffee and watching day time TV? (Ahhh remember the good old days?!) I have caught the odd person sneaking out to buy cake or discussing the X Factor results but they really do work non stop! Stroke data is behind as they have so many Stroke cases to review across the LAS in May alone. All done by one person as they have a vacancy hmmm I m now looking for a job??!! Pinner Stroke Care May: Care Bundle 88% (BM/BP were 100% so just the FAST side that let us down a bit maybe by now we are near 100%??) Dr Raj Bathula is returning to demonstrate the full monty neurological exam and teach us a shorter version we can use on the road! 23 rd November Kenton Training Book a place by texting or Georgina.Jones@lond-amb.nhs.uk Every morning 21st - 25th Nov and 5th - 9 th Dec. Numbers limited so get in touch with Sharon LeGall to book your place Pain scoring tool and STEMI process chart being tested by a couple of crews now. We will make changes suggested and then spread it out to more people. Direct to CT Scanner Trial proposal being written for approval (fingers crossed) will keep you updated! Starting work on the Stroke training package soon. Any questions just shout! Thanks everyone George What is cardiac pain? Check out our great STEMI figures! Neuro exam training session 23 rd NOV STROKE AND NEURO ASSESSMENT TRAINING. BOOK A PLACE NOW! See back for details. Stroke care at Pinner complex Welcome to the second edition of ASCQI news, don t worry it s not a hefty volume of information like last time just a quick update of what we (and you!) have been up to this month.

2 one and all! Now I know its early days so not everyone has heard me groan on about the importance of analgesia for STEMIs but in September: How good are we Martin take note! With numbers being so small, only 2 patients not being given ENTONOX or MORPHINE (or perhaps it not being scribbled on the PRF?) caused a drop from 100%. Next month the glory shall be ours But its not all about the numbers see last ASCQI news about the benefits of analgesia. The whole point of ASCQI is to improve patient care evidence shows us analgesia is important! So with our phenomenal analgesia figures our care bundle jumped to 75%! Just hoping it s not a Chesney Hawkes one hit wonder this month and we are on the way up 100% of patients had GTN and 100% had their pain assessed twice I m sooooooo proud Aspirin administration dropped to 92% One patient did not receive 300mg of lemon chalk so very close to perfection though. We know we give excellent cardiac care here on Pinner Complex but we have to prove it to everyone else in order to back up our smugness. So the ASCQI group had a look at PRFs (don t worry all identifiable info was removed so we didn t know who we were discussing!) to see if we could identify any odd things. We discovered some blooming marvellous PRFs, but also uncovered some rather unusual practices! Cardiac type pain is pain right? Yeah I know sounds easy but how many times do you ask a patient to score their pain and hear an annoyed response I told you it isn t a pain, it is a tightness, were you not listening?! So if it isn t pain how do we pain score? As you know cardiac pain description is often atypical so yes they may say pain (hurrah for the easy patient!) but they may also describe it as a: So in that case we still count it as a pain as it is their type of pain sensation but we may have to ask them to score it from 0-10 as a sensation and record that figure as our pain score. This way we can still monitor if our treatment is working and reducing it. By the way I have to mention something a little OCD I know but I noticed some people write descriptors in the pain score box, or a couple draw a face, very artistic BUT this doesn t count as a score. It has to be number!!

3 Given GTN? Yes - great, as we all know the benefits but GTN doesn t count as analgesia! Yes I know it does decrease pain and that s all good stuff but as its primary purpose is not to relieve pain you still need to offer analgesia for a pain score greater than 0! Morphine refused or EMT crew? Don t forget the benefits of Entonox (more on this to follow). The Department of Health decree that if morphine is refused and Entonox is not offered (or no reason written as to why it wasn t given) then the care bundle is incomplete. They don t make it easy do they!!! For more information about the project see The Pulse Patients tab. Or contact Georgina.Jones@lond-amb.nhs.uk / Considered analgesia? I know we all do (while trying to calm relatives, interpret that awkward ECG, and work out where the nearest cath lab may be to SW7) but if for whatever reason you don t give analgesia, document why as it may be possible for the CARU ladies to make it an exception. CASE STUDY 64 year old male with 2 hour sub-sternal tight chest pain, accompanied by SOB, nausea and sweating. He looks uncomfortable and worryingly rather unwell. The FRU has obtained a pain score of 7/10 and just given Aspirin and GTN. Once you finally get him to the ambulance and the ECG dots to stick long enough, the printout shows an anterior STEMI. Now he seems calmer and a better shade of grey, his pain score is 2/10 and he reports just a mild ache which isn t so bad. Hurrah job done, he looks comfortable and you head off to the cath lab relatives in tow. You complete both pain score boxes - that ASCQI woman can t tut at you now first pain score 7, second only 2. Sounds good, except that the last pain score was not 0 and you didn t offer any analgesia so the care bundle is not complete!!! If the pain score you obtain is greater than 0 (despite some relief by GTN) then analgesia (remember Entonox?!?) must be offered even for lesser scores of 1 or 2!!

4 Done a FAST test? ALL BOXES must be filled to complete the care bundle. So if the patient only has slurred speech (you already suspect that it is a Stroke) you still have to complete the other boxes. Boxes left blank not good! Unable to complete an element of FAST? Don t just leave it blank tick unable and explain why in the free text. If the patient already has some deficit from a previous Stroke tick unable and explain if this has changed or not. Unable to do BM/BP? Don t leave it blank - explain why, it could be an exception, or if missing equipment DEFINITELY DOCUMENT as without evidence it is harder to argue a point with the powers that be! CASE STUDY 79 year old female with a dull achy headache and no associated symptoms, she gets them often but called 999 today as her GP couldn t see her and she wants to go to hospital. She is alert and orientated, has no facial droop or slurred speech and appears well as she chats away laughing at your awful jokes. She has carried her bags to the ambulance and you notice no gait disturbance or weakness. You take her to the urgent care centre (brownie points there!) and classify her complaint as 39 neurological. Sounds good EXCEPT you didn t do a FAST test, well she obviously wasn t having a Stroke! Here s the catch, as it is a code 39 and neurological you must complete the FAST boxes to be successful!!! A talk from Fionna Moore on STEMIs and analgesia. Biscuits. A presentation by Dr Bathula and Emanuel Ariate from Northwick HASU. Cakes. More on this later no not the cake! Quality Improvement... A.K.A. wallpaper and post it notes! Those attending were asked why we don t give enough STEMI patients analgesia? Sounds easy and we can all immediately think of a couple of reasons but there are plenty out there and by exploring them all we can then develop ideas to fix them. Check out the wallpaper at Kenton and Pinner (sorry Wembley you are too small it would take over your station!) to see what reasons we came up with and add your own ideas. Scribble away! This can be the most interesting part of the project and one which results in plenty of debate and questions... a few I overheard are answered below! Why can we not give Oromorph to STEMI patient? Absorption from the stomach is much slower and the rate of drug availability variable so should be given IV. Also the blood supply to the stomach is decreased during a STEMI, due to a reduced cardiac output decreasing blood supply to the GI tract, further slowing absorption. Why not convey on blue lights after 4.5 hours for a FAST +ve Stroke? 4.5 hours from time of Stroke onset is the window for thrombolysis. After 4.5 hours there is less need for speed but patients will still benefit from going to a HASU for specialist care and rehabilitation. Do cocaine induced MIs get the same treatment as STEMIs?

5 Generally, yes, and bear in mind they are at a greater risk of MI due to associated lifestyle factors and they may also present with added symptoms such as agitation, tachycardia and hypertension (remember Diazemuls as per JRCALC). A focused history is vital as treatment with GTN may cause ST elevation to disappear if due to coronary artery spasm - they may get an echo at the cath lab to assess ventricular wall motion (normal if due to coronary spasm). Mark Whitbread advises if the patient is unwell and ST elevation disappears still convey to cath lab and remember patients who DO NOT take cocaine can have coronary artery spasm and also that it may not always be spasm - it could be a very unstable area within an artery. Do we tell people they are having an MI? Does it cause more harm? Yes we should inform them that based on the ECG it shows that they are having a heart attack. This should be done in a professional manner as it may cause additional anxiety and therefore increased stress on myocardium but they need to be informed of their treatment plan eg being conveyed to cath lab. Doing so will also prepare them for what will be discussed by cardiologist. Fionna Moore, demonstrated her support for the ASCQI project at the launch... The real advantage of ASCQI is that it is the opportunity to get ideas from staff about what will work for you so you generate these ideas, these are not ideas that you are being told to do. You can then decide if they work for you or not. I think that s really important. and answered the following question What are the benefits of morphine for STEMI patients? Morphine is the analgesia of choice for STEMI patients as it: Reduces pain and discomfort. Reduces preload (volume of blood in ventricle before contraction) and therefore myocardial oxygen demand. Reduces anxiety by decreasing levels of circulating catecholamines (hormones such as adrenaline). A tick box mentality to medicine? Andy Dunne (Hillingdon Team Leader) highlighted a very good point at the launch are our low figures for STEMI care really a true reflection of our care? Fionna and I both jumped up to highlight that patient care in London is of an extremely high standard especially in my rather biased opinion from Pinner Complex crews! So the care we provide is good (always room for improvement!) but is our documentation capturing this? One of the issues raised was that even if we give the right treatment we don t know exactly what we need to write to get it right! One of our ASCQI ideas is to produce a crew friendly PRF completion guide, particularly for students, so we can understand why we are ticking the box! So until then I give you the CARU ladies (thanks to Yvette, Holly and Milda) but... Buried behind computers, biscuit tins and journals in a small office corner the guys from CARU (Clinical Audit and Research Unit) work hard to...improve patient care! I was surprised to find out how much of what they do has such a direct impact on our patient treatment. Yes it may involve thousands of PRFs, numbers and sitting behind a desk (and lets face it most of us would rather drive cannulas into our eyeballs than sit at a computer everyday no offence lovely CARU people!) but without the evidence they provide then we can t develop our patient care. So, what did we learn...