King County EMS STEMI Patients Receiving PCI at King County Hospitals in 2012

Transcription

1 King County EMS STEMI Patients Receiving PCI at King County Hospitals in 2012 Objective The goal of this report is to evaluate demographics, pre hospital and hospital response times and outcomes of ST segment elevation myocardial infarction (STEMI) patients who were treated by King County Emergency Medical Services (KCEMS). We hope to understand the demographics and continuum of care provided to these patients in order to identify strategies to improve treatment. The analyses in this report are based on a collaborative effort to link STEMI patients in the Cath/PCI hospital database to patients seen by KCEMS personnel. A sample of three King County hospitals provided us with information on STEMI patients who were admitted through the emergency department and subsequently treated in the catheterization lab. The hospitals chosen for this report received 66% of the STEMI cases identified in the field by KCEMS in Results The sample of King County hospitals reported 233 STEMI patients who were admitted through the emergency department from January to December Of those patients, 151 linked to King County patient records. STEMI patients who were treated or transported by KCEMS but who died in the emergency department, those who were not stable enough to receive PCI and patients for whom KCEMS was not able to obtain either a name or date of birth could not be included in this analysis. There were 187 additional patients who were identified as possibly having a STEMI in the field by paramedics but did not present as a STEMI in the hospital or were not treated in the cath lab. Data from these patients are not included in this report. Study population Demographics of the 151 STEMI patients receiving PCI at the sample of King County hospitals: Male 76% Median Age (years) 64 Male Median Age (years) 62 Female Median Age (years) 71

2 Initial Dispatch Code for STEMI Patients Receiving PCI at a sample of King County hospitals who Received Initial Dispatch Description Chest Pain Highest Level of Care Dispatched Number (%) Unconscious or not breathing ALS 1 (<1%) Male age > 40 ALS 78 (52%) Female age > 45 ALS 23 (15%) Male or female age > 25 with shortness of breath ALS 4 (3%) Rapid heart rate with chest pain or shortness of breath, ALS 1 (<1%) diaphoresis or syncope Diabetic ALS 1 (<1%) Cardiac Arrest Breathing Difficulty Female age <45 BLS 1 (<1%) Male age <40 ALS request from scene 3 (2%) Indigestion, male age >40 or female age >45 BLS 1 (<1%) Unconscious or not breathing ALS 12 (8%) Respiratory distress ALS 2 (1%) Unconscious or not breathing ALS 2 (1%) With chest discomfort, male/female age >25 ALS 1 (<1%) Unconscious/Unresponsive/Syncope BLS red response ALS request from scene 1 (<1%) Single syncope ALS request from scene 2 (1%) No verifiable information available from reporting party ALS request from scene 1 (<1%) Request from Medical Clinic Abnormal EKG/arrhythmia ALS 3 (2%) Sick (Unknown) ALS request from scene 2 (1%) No verifiable information available from reporting party ALS request from scene 2 (1%) Vertigo/dizziness BLS 1 (<1%) Generalized weakness/unspecified pain ALS request from scene 1 (<1%) Stroke Disoriented, incoherent or trouble speaking ALS request from scene 1 (<1%) Falls/Accidents/Pain Minor head/neck/shoulder injury BLS 1 (<1%) Abdominal/Back Pain BLS code red ALS request from scene 1 (<1%) BLS code yellow BLS 1 (<1%) With signs of shock BLS 1 (<1%) Unable to assign initial dispatch code ALS 5 (3%)

3 Patient Type Codes Assigned by KCEMS for STEMI Patients Receiving PCI at a sample of King County hospitals who Received One hundred forty five patients were treated by BLS and ALS. The other six patients received the following patient type code designations from the BLS providers: non cardiac chest pain, musculoskeletal pain, other illness, trauma closed minor injury and syncope. Below are the patient type codes assigned by the agency providing the highest level of EMS care: KCEMS Patient Type Code Number (%) Suspected MI STEMI 110 (73%) Suspected MI Other 4 (3%) Angina 5 (3%) Cardiac arrest due to presumed heart disease 18 (12%) Cardiac arrest due to other causes 2 (1%) Cardiac arrhythmia, not arrest 1 (<1%) Other cardiac 2 (1%) Trauma to the chest closed internal injury 1 (<1%) Trauma closed minor injury 1 (<1%) Syncope 1 (<1%) Suspected CVA 1 (<1%) Non cardiac chest pain 2 (1%) Undefined musculo skeletal pain 2 (1%) Other illness 1 (<1%) Compared to women, a significantly higher proportion of men were coded as having Suspected MI STEMI or Cardiac arrest due to presumed heart disease. In this sample 90% of men received a patient type code of Suspected MI STEMI or Cardiac arrest due to presumed heart disease compared to 68% of women.

4 Patient for STEMI Patients Receiving PCI at a sample of King County hospitals who Received ALS Patient Type Code Suspected MI STEMI 110 Suspected MI Other 4 Angina 5 Cardiac arrest due to presumed heart disease 18 Cardiac arrest due to other causes 2 Cardiac arrhythmia, not arrest 1 Other cardiac 2 Trauma to the chest closed internal injury 1 BLS Agency Private BLS Trauma closed minor injury 1 Syncope 1 Suspected CVA Non cardiac chest pain 1 1 Undefined musculo skeletal pain 2 Other illness 1 Private Vehicle Pre Hospital and Hospital Response Times for STEMI Patients Receiving PCI at a sample of King County Hospitals who Received The following table describes the time intervals between the 911 call, EMS response, hospital arrival and a patient s access to PCI for cases where there was no documented circumstances leading to delay. The BLS response times were not included when the 911 system was initiated by the patient s arrival at the fire station. Time Interval N Median 911 Call to BLS Arrival (Min) Call to ALS Arrival (Min) Call to Hospital Arrival (Min) Call Needle In Time (Min) Call to Balloon Inflation (Min) First EMS personnel arrival to Start of Patient (Min) The mean time from first EMS personnel arrival to the start of patient transport ( on scene time ) for all patients in the hospital sample was significantly higher for women compared to men (27.4 minutes vs minutes).

5 Circumstances Leading to Delay in PCI for STEMI Patients Receiving PCI at a sample of King County hospitals who Received Circumstances Leading to a Delay in PCI Number (%) No delay 118 (78%) Cardiac arrest and/or need for intubation before PCI 10 (7%) Difficult vascular access 1 (<1%) Difficulty crossing the culprit lesion during PCI 6 (4%) Patient delays in providing consent for the procedure 3 (2%) Treated medically with anti vasospasm medication 1 (<1%) Delay in contacting cath lab MD 1 (<1%) Reason for delay not documented 11 (7%) Discharge Status for STEMI Patients Receiving PCI at a sample of King County hospitals who Received Discharge Status Number (%) Alive 141 (93%) Deceased 10 (7%) Conclusions These data describe some of the successes and challenges of treating STEMIs. The 2012 ACCF/AHA Guidelines for the Management of ST Elevation Myocardial Infarction sets a goal of less than 90 minutes from first medical contact (first EMS arrival on scene) to balloon inflation in order to reduce morbidity and mortality. The data in this report shows that KCEMS and area hospitals are approaching this aim with a median time from the 911 call to balloon inflation of 95.2 minutes. Shortening the time on scene with patients with suspected STEMI remains a goal for EMS in order to continue to reduce the overall time from the 911 call to balloon inflation time. This goal is of a particular importance when caring for female STEMI patients because they had longer average on scene times than men. Identifying an evolving condition with a range of possible symptoms in the field remains a challenge. Many of the patients who were identified as having a STEMI in the field did not present as having a STEMI in the hospital. Conversely, 90% of men and 86% of women with STEMIs received a diagnosis of STEMI or cardiac arrest due to presumed heart disease in the field. Providers should maintain a high level of suspicion when patients present with any STEMI symptoms and continue to notify the receiving hospital if a STEMI is suspected.