STEMI in the State of Jefferson ASSET - 5 Years Later. Brian W. Gross, MD, FACC Mary Barnum, RN, BSN Karen Bales, RN, BSN Rogue Valley Medical Center

Transcription

1 STEMI in the State of Jefferson ASSET - 5 Years Later Brian W. Gross, MD, FACC Mary Barnum, RN, BSN Karen Bales, RN, BSN Rogue Valley Medical Center Sept 22, 2008

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3 Percent # Procedures Performed Coronary Artery Reparative Procedures RVMC 1978 to 2007 CABG PTCA STENTS ROTOBLADE BRACHY STEMI s Stent Type 2005 to 2007 RVMC 100% 90% 80% DES BMS CABG vs PCI 70% 60% 50% 40% 30% DES 20% 10% BMS 0%

4 The Mortality History of ST Elevation Heart Attacks 1970 s 1980 s STEMI 1990 s 2008 State of Jefferson The Rogue Valley

5 Plaque Rupture & Vessel Thrombosis STEMI Plaque 3 mm The Process Plaque Rupture 3 mm

6 Heart Attacks & Time 2 hrs 4 hrs 6 hrs Time is Muscle

7 Emergent STEMI PCI Primary Percutaneous Coronary Intervention (PCI) is the most complex, multi-disciplinary, and time-sensitive therapeutic intervention in the world of medicine today. The Process is measured in Minutes The Outcomes are measured in Mortality Teamwork and smooth Transitions are essential Dr. Ivan Rokos,STEMI Systems, May 2007

8 Beyond a D2B Time of 90 Minutes Every 15 minutes of Delay leads to Increased Mortality

9 The Challenge is to Synchronize all the Individual Components and seamlessly move STEMI patients safely & rapidly to the cath lab from throughout the region?

10 NRMI DATA For PCI Capable Hosp <40% of STEMI Pts have D2B time <90 min For Inter-Hosp Transfers 4% have D2B <90 min 15% have D2B <120 min Circirculation.2005;111:761-7 Data Analyzed from

11 80% Of US population live <60 minutes from a PCI Hospital 5% live > 90 minutes Nallanothu BK, et.al., Circulation 2006;113: D2B Alliance Member US Hospitals

12 ASSET Mission Statement (Acute ST Segment Elevation Taskforce) To facilitate the accurate and rapid diagnosis, treatment, & transport of patients with Acute ST Segment Elevation Myocardial Infarction (STEMI) from throughout the region to the Rogue Valley Hospital Cath Lab for Emergent Percutaneous Coronary Intervention (PCI).

13 11/26/06 Paramedic ASSET 1) Good History of Heart Equivalent Discomfort <12 hrs and < 86 y.o. and 2a) Paramedic notes 2 mm ST Elevation in 2 Contiguous Leads V1-3 or 1 mm ST Elevation in 2 Contiguous Leads Inferiorly or Laterally or b) LifePak-12 ECG Printout c/w Acute ST Elevation MI (LBBB or > 86 y.o. patients - evaluate initially in nearest ED) (Nursing Home patients with STEMI will be seen at the closest hospital ED unless they are only there for a brief convalescence) 3) ASA 162 mg chewed, NTG s.l., Morphine prn STAT ASSET Activation ( STEMI Cath Alert ) Radio or Phone RVMC ED Com Center - Name, Age, DOB - ECG Findings & History - ETA - Cardiologist (if any) RVMC ED will call cath team, cardiologist of record (or OnCall), Nursing supervisor & obtain old records. ED Physician will assume primary care if cardiologist delayed. Cardiologist will contact Interventionalist Triage directly to RVMC Cath Lab ( ) if semi-stable and team is ready or to RVMC ED if cath lab is not ready (ALL patients will stop briefly in ED for Registration)

14 Triage directly to RVMC CATH LAB ( ) if they are ready to accept to RVMC ED if not ready (Brief RVMC ED Registration will occur) 12/31/06 Referring Hospital ED ASSET Referring Hospital Physician - Hx + ECG c/w STEMI < 12 hrs + < 86yo - No contraindications to Cath - Discuss with cardiologist first if LBBB or > 86 y.o. -GOAL: < 10 min Door to ECG 1) ACTIVATE ASSET by Calling RVMC Nursing Supervisor They will call you back with Cardiologist (of Record or OnCall) to have mandated clinical transfer conversation prior to transfer 2) Immediately Call for Paramedic Transfer 3) Give ASA 162 mg chewed, NTG sl, Morphine prn, Heparin 70 Units/kg IV (No Heparin drip is necessary), 4) Draw Lab: CBC, CMP, Cardiac Enzymes, Protime (FAX results to both: RVMC Cath Lab ) RVMC ED Com Ctr ) 5) Initiate if time permits, but do not delay paramedic transfer for: CXR, IV NTG or IV Beta-Blockers (avoid IV Beta-Blockers if hemodynamically unstable or CHF) 6) No Thrombolytics unless anticipated delay to arrival in cath lab > 90 minutes Aim for 30 minute Door to Transfer Time

15 RVMC ED ASSET RVMC ED Physician - Hx + ECG c/w STEMI < 12 hrs + < 86 yo - No contraindications to cath - Discuss with cardiologist first if LBBB or >86 - GOAL: < 10 min Door to ECG Activate ASSET Call Switchboard ( They will contact Cath Team, & Nursing Supervisor). - Call Cardiologist of Record or OnCall ASA 162 mg chewed, NTG sl, Morphine prn IV Heparin 70 Units/kg, (No Heparin drip necessary) Lab CBC, CMP, Cardiac Enzymes, Protime (FAX to cath lab ) Initiate if time, but don t delay transfer to cath lab for: CXR, IV NTG or IV Beta-Blockers (avoid IV Beta-Blockers if hemodynamic unstable or CHF) Obtain Emergent Consent for Cath / Intervention Obtain Old Records & ECG s from Med Records or Office ED Physician available for care issues until Cardiologist arrives Avoid Thrombolytics unless anticipated delay to arrival in cath lab > 60 minutes Aim for 30 minute ED Door to Cath Lab Cardiologist contacts Interventionalist. Transfer to Cath Lab when 3 of 4 Cath Lab Team members are ready 11/26/06

16 A Brief History of Time - ASSET th Pt AJC Publication 5/07 ASSET 1 st STEMI Pt 6/03 Cath Conference Concept 9/02 ACC Abstract 2/06 Paramedics Direct to Cath Lab 1/06 STEMI Systems 12/07 ACC Abstract 4/ s, Countless Meetings, Q/A, Presentations, Adjustments, & Discussions

17 American Journal of Cardiology 2007;99:

18 STEMI Mortality In Hospital Mortality NRMI (2001) "Like Hospitals" PCI Hospital ASSET Source of Arrival % 6 Referring Hospital Total PCI Hospital Paramedic

19 Percent Mortality 20 ASSET ASSET In-Hospital Mortality by Age Mortality by Age (June June 2008 n=663) June 2003 June 2008 (663 consecutive STEMI patients) Total In-Hospital Mortality 3.5% (n=2) (n=1) (n=7) (n=25) (n=37) (n=79) (n=87) (n=92) (n=86) (n=90) (n=78) (n=57) (n=20) (n=1) - If patient was <55 (0.0%... 0 of 151) - If patient was <65 (0.6%...2 of 330) - If patient was <75 (1.7%...9 of 506) - If patient was (9.6%...13 of 135) - If patient was >85 (5.0%...1 of 21)

20 Awards