Rural STEMI System of Care Success. Nicole Huber, PA-C Cumberland Healthcare Emergency Department
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1 Rural STEMI System of Care Success Nicole Huber, PA-C Cumberland Healthcare Emergency Department
2 DISCLOSURES I HAVE NO ACTUAL OR POTENTIAL CONFLICT OF INTEREST IN RELATION TO THIS PRESENTATION
3 Ideal Process EMS acquires EKG Transmission of EKG to ED Cellular hot spot to cloud, results in EKG faxed and ed directly to ED ED provider interpretation prior to arrival of patient Initiate transport Activate Cath lab
4 Case Study 61-year-old male patient who arrives via Cumberland Ambulance for evaluation of sudden onset chest pain. Patient was working at the Turtle Lake Liquor Store; he was manual lifting heavy boxes at the time of onset He relates onset was approximately 11:45 a.m. Pain location sub sternal anterior chest Radiates into his left arm. Currently his pain is rated 4/10. Associated symptom nausea and sweats Patient denies radiation of pain to his neck, back or jaw. Patient denies other previous cardiac history or similar type symptoms. Patient also denies recent illnesses, fevers, chills, cough, cold, vomiting, diarrhea, black stools, SOB and dizziness
5 EMS EKG
6 EMS Intervention ASA 324 unchanged discomfort O2 Low flow NC IV 18 G Left AC Obtain EKG Nitro 0.4 mg SL improved discomfort
7 PAST MEDICAL HISTORY: None. PAST SURGICAL HISTORY: Carpal tunnel, right, approximately one year ago. SOCIAL HISTORY: Patient denies alcohol, tobacco or illicit drug use. MEDICATIONS: None. ALLERGIES: NKDA.
8 Physical Exam Vitals: Blood pressure 132/85, pulse 61, respirations 14. Oxygen saturation is 98% on four liters via nasal cannula. Pain is rated 4/10. General: The patient is A & O x 3. He is pale and moderately diaphoretic with beats of sweat pooled on his brow. Neck: Neck is supple. No lymphadenopathy, masses or thyromegaly. Trachea is midline. No JVD. No carotid bruits. Heart: Regular rate and rhythm. S1 and S2 are heard without clicks, rubs, gallops or murmurs. Patient is in a sinus bradycardia on the cardiac monitor with rates in the mid to upper 50s. There is no pedal edema bilaterally. Lungs: Full and symmetric chest rise bilaterally without increased work of breathing. Lungs sounds are clear to auscultation in all fields. Abdomen: Soft, nontender, nondistended. Bowel sounds are active in all four quadrants. No CVA tenderness. Neruo: GSC 15, complete coherent sentences, no slurring. No facial asymmetry. Moving all extremities
9 Recap Symptoms onset 11:45 EMS arrived at patient 12:09 EMS EKG TIME 12:20 EKG Reviewed in ED 12:22 EMS enroute to Hospital 12:22 Air transport activated 12:25 CATH Lab Activated 12:30 Arrival to ED 12:35
10 ED Work-up and Treatment RADIOLOGIC IMAGING: 1) AP chest x-ray: No acute cardiopulmonary abnormalities. LABORATORY STUDIES: 1) CBC: All parameters within normal limits. 2) Comprehensive Metabolic Panel: Sodium 145, potassium 3.5, chloride 107, CO2 28.8, BUN 12, creatinine 1.2, LFTs all within normal limits. Blood glucose is 117. Magnesium 1.8. All other parameters within normal limits. 3) Cardiac Enzymes: Troponin I 0.12, CK 82, CK MB 0.90, CK MB index 1.1. PTT 24.8, INR 1.1. MEDICATIONS GIVEN IN ER: 1) Sublingual Nitro 0.4 mg. tab (second). 2) Normal saline started at 50 cc an hour. 3) Zofran 4 mgs. IV. 4) Nitro 0.4 mgs. sublingual tab (third). 5) Morphine 2 mgs. IVP. 6) Heparin 5000 unit bolus IV.
11 ED EKG
12 Recap # 2 Arrival to ED 12:35 Arrival of Transport 12:43 Depart Cumberland 12:55 Arrive Scared Heart Cath Lab 13:30 Procedure start time 13:40 Balloon 13:58 First Medical Contact to Balloon 108 min First Door to Balloon 88 min Distance traveled by patient 69.8 miles Ground 13 miles Air 56.8 google
13 Outcome
14 How did we get here? Education EKG techs, nursing, Lab, HUC, Transfer center, Resources ED techs, Istat, Medications (kit) Relationships Transferring services, Receiving facility Hot loads Feedback (two way street) Friendly competition
15 Easy Fixes Times clocks, EKG machines, tracking similar times Delay between and fax to ED Delays transport IV lines, patches, Audits
16 Continued Focus Hot loads Location of patient Audits EMR EKG location in EMR, EKG software Consistency
17 Questions? Contact Information
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