Upload
david-hiltz
View
8.605
Download
8
Embed Size (px)
DESCRIPTION
Every year, almost 400,000 people experience ST-Elevation Myocardial Infarction (STEMI) -- the deadliest type of heart attack. Unfortunately, a significant number don't receive prompt reperfusion therapy, which is critical in restoring blood flow. Worse yet, 30 percent of STEMI victims don't receive reperfusion treatment at all. Mission: Lifeline™ seeks to save lives by closing the gaps that separate STEMI patients from timely access to appropriate treatments. Although Mission: Lifeline is focusing on improving the system of care for the nearly 400,000 patients who suffer from a STEMI each year, improving that system will ultimately improve care for all heart attack patients.
Citation preview
Improving the System of Care for STEMI Patients
The Mission: Lifeline Provider Recognition
Program and Learn:™ Rapid STEMI ID
Customer Webinar
September 24, 2009
Moderator: Mayme Lou Roettig, RN, MSN
Presenters: Joseph P. Ornato, MD, FACP, FACC FACEP
Mike Willingham, CCEMT-P Lee Garvey, MD, FACEP
Improving the System of Care for STEMI Patients
The Need for Pre-Hospital ECGs in Systems of
Care for STEMI Patients and
Learn:™ Rapid STEMI ID Objectives
Joseph P. Ornato, MD, FACP, FACC FACEP
Past Chair of AHA’s National Emergency Cardiovascular Care Committee
Improving the System of Care for STEMI Patients
The Call to Action
The majority of STEMI deaths occur in the first 2 hours due to cardiac arrest after onset of symptoms
<50% of STEMI patients call 911 and are transported to the hospital by EMS
Pre-hospital 12-lead ECG acquisition is critical for determining which chest pain patients need to be transported to a PCI facility because the majority of chest pain patients do not have a STEMI..
Prehospital ECGs are acquired on <10% of suspected STEMI patients even though they can decrease door to needle and door to balloon times.
Improving the System of Care for STEMI Patients
Other Statistics
30% of STEMI patients receive no reperfusion therapy despite the availability and absence of contraindications
Of the 20% of STEMI patients who have contraindications to fibrinolytic therapy, 70% do not receive reperfusion treatment with PCI
<50% of patients treated with fibrinolysis have a door-to-needle time within 30 mins
Only 35% of patients treated with PCI have a door-to-balloon time within 90 mins
Improving the System of Care for STEMI Patients
Ornato, J. P. Circulation 2007;116:6-9
The STEMI Chain of Survival
Improving the System of Care for STEMI Patients
Current Versus Ideal Processes to Integrate Prehospital ECGs into Systems of Care
Improving the System of Care for STEMI Patients
Ting, H. H. et al. Circulation 2008;118:1066-1079
Reperfusion Time Goals for Patients With STEMI
Improving the System of Care for STEMI Patients
Recommendations
A module for EMS providers should be developed that addresses STEMI care with particular emphasis on 12-lead acquisition, transmission, and interpretation. Consideration should be given to including extension of ECG training to basic level EMS providers.
EMS agencies need to have sufficient personnel, training and resources to ensure that a prehospital 12-lead ECG can be acquired from prehospital patients with clinical presentations suggestive of a STEMI to assist in triage, treatment and point-of-entry decisions.
Moyer, P. and Ornato, J.P. et al. Circulation 2007;116:e43-e48
Improving the System of Care for STEMI Patients
The Training
Learn:™ Rapid STEMI ID is a dynamic online program that is designed to prepare healthcare professionals to evaluate and assess victims with potential symptoms of myocardial infarction, interpret their ECG for signs of STEMI, and activate a system of care of rapid reperfusion of an occluded coronary artery.
Improving the System of Care for STEMI Patients
Learn:™ Rapid STEMI ID Objectives
Upon successful completion of this course the learner should be able to:
See the need for an improved STEMI System of Care…and close the gap on timely access to needed treatment
Distinguish an ST-Elevated Myocardial Infarction from ECG mimics of STEMI
Name the Leads, Regions of the Heart, and Measure ST Deviation
Improving the System of Care for STEMI Patients
Learn:™ Rapid STEMI ID Objectives
List immediate action steps to identify patients with symptoms of ACS and ECG findings of STEMI to reduce time to perfusion
Describe ACS Pathophysiology
Describe how to acquire a technically good 12-lead ECG
Improving the System of Care for STEMI Patients
Learn:™ Rapid STEMI ID Objectives
Differentiate a normal 12-lead ECG from a 12-lead with ischemic changes
Identify patterns of ECG abnormalities including those that require rapid reperfusion and team activation
Improving the System of Care for STEMI Patients
Learn:™ Rapid STEMI IDProduct Information
and The Mission: Lifeline Provider Recognition
Program
Mike Willingham, CCEMT-P
Senior Director, Mission: Lifeline
Improving the System of Care for STEMI Patients
Product Info
Learn:™ Rapid STEMI ID
•Product # 80-1473
•$69.95 SRP
•EMS – 4.50 Advanced CEHs (CECBEMS)
•Nurses – 4.62 contact hours
•Available August 18th 2009
•Audience
Improving the System of Care for STEMI Patients
Current STEMI Tools from ECC
•STEMI Provider Manual (2008)
•ECG ACS Ruler (2008)
°Combined as 1 product (ruler still available as a single item)
•ECC Handbook (updated 2008)
•Learn Rapid STEMI ID (August 2009)
Improving the System of Care for STEMI Patients
Product Features
Self-paced
Accessible Anytime/Anywhere (OnlineAHA)
Access for 12 months to course material
Audio, Animation, Interactive activities
“learn more toolboxes” - Self Study Cards
It can be used to educate any healthcare provider and
also helps support the AHA Mission: Lifeline™ initiative.
Improving the System of Care for STEMI Patients
Product Benefits
Emphasizes immediate recognition and treatment of ACS STEMI
Includes self assessment quizzes
Contains dynamic ECG Scope to measure ST deviation
Includes the STEMI Practice Exam
Improving the System of Care for STEMI Patients
User Experience
Improving the System of Care for STEMI Patients
Student registers on OnlineAHA.org
User Experience
Improving the System of Care for STEMI Patients
User Experience
Student then activates a key they have received or they can purchase a key
Improving the System of Care for STEMI Patients
User Experience
Student then activates a key they have received or purchased
Terms and Conditions are agreed to
Once they click “Activate” they will arrive back at the ‘my courses’ page where they can select the course
Improving the System of Care for STEMI Patients
User Experience
On the ‘my courses’ page the student can select desired courses that have been activated
Improving the System of Care for STEMI Patients
Student then chooses the active link to access course.
User Experience
Improving the System of Care for STEMI Patients
User Experience
Student must review course overview to proceed
And also complete the evaluation to complete the course and collect a certificate, CE, and option of recognized provider program
Improving the System of Care for STEMI Patients
Certificate of Completion, Application for Continuing
Education Credit, and Recognized Provider
ProgramCan all be accessed from the
completed courses page
User Experience
Improving the System of Care for STEMI Patients
Mission: Lifeline Provider Recognition
In 2007, Mission: Lifeline volunteers felt it was important to recognize providers in addition to hospitals, EMS and STEMI Systems
Mission: Lifeline ECC Task Force volunteers suggested that a provider recognition program be tied to current ACLS products
So, only upon successful completion, do providers have an opportunity to participate in the Mission: Lifeline Provider Recognition program
Not tied to the current system and system component programs
Improving the System of Care for STEMI Patients
Mission: Lifeline Provider Recognition
Improving the System of Care for STEMI Patients
Mission: Lifeline Involvement
Participation
M.O.U.
Participation
M.O.U.
RecognitionRecognition
CertificationCertification
Examples
Examples
Improving the System of Care for STEMI Patients
Pre-Hospital Activation Issues Within a STEMI
System
Lee Garvey, MD, FACEP
Mission: Lifeline ECC Task Force Vice-Chair
Improving the System of Care for STEMI Patients
Optimizing the System
• Focus on the prehospital environment
• USE the time the paramedics are with the patient:
• ECG
• Data to decision makers
• Drug treatment – ASA, nitroglycerin, (?lytic)
Improving the System of Care for STEMI Patients
The Ideal EMS
In an ideal system:
•Ambulances are equipped with 12-lead ECG machines
•EMS providers are trained to:
°Use and transmit 12-lead ECGs
°Care for STEMI patients
°Provide feedback on performance and compliance with guidelines
•Standardized point-of-entry (POE) protocols define patient transport rules
•When there is STEMI, the cath lab is activated promptly
•Patients transported to a STEMI-referral hospital remain on the stretcher with EMS present pending a transport decision
•When “walk-in” patients present to a STEMI-referral hospital and require primary PCI, activation of EMS occurs
•Hospitals close the communication gap with EMS31
Improving the System of Care for STEMI Patients 32
POE Protocol
Improving the System of Care for STEMI Patients
System Administrative Barriers
Barriers to the implementation of prehospital12-Lead ECG programs
• significant investment of time, effort, personnel, and resources.
• costs of device acquisition and replacement, paramedic training, and ongoing competency assessment
• ECG Image transmission? Failures can occur in 20% to 44% of cases where wireless dead zones occur.
Improving the System of Care for STEMI Patients
RAPID EKG CRITERIA
Door to decision 10 minutes
30 YEARS OLD with suspicious CHEST PAIN
(EXCLUDING OBVIOUS TRAUMA)
50 YEARS OLD with:
• Syncope
• Weakness
• Rapid Heart Beat / Palpitations
• Difficulty Breathing / Shortness of Breath
Graff L, et al. Triage of patients for a rapid (5-minute) electrocardiogram: a rule based on presenting chief complaints. Ann Emerg Med. December 2000;36:554-560.
Improving the System of Care for STEMI Patients
Improving the System of Care for STEMI Patients
Prehospital 12 lead ECG
*** ACUTE MI *** Diagnostic statement
• 96-98% specificity
• Only 50’ish% sensitivity
° Kudenchuck 1991; JACC 17:1486-91
• P12 ECG reduces mean time to treatment by ~33 minutes
Improving the System of Care for STEMI Patients
Prehospital Code STEMI Activation
Activation of Code STEMI
(REQUIRES ALL THREE)
• Patient with symptoms suggestive of ACS
• Prehospital ECG diagnostic interpretation algorithm identifies Acute Myocardial Infarction
• Paramedic reviews ECG to confirm STEMI findings
Improving the System of Care for STEMI Patients
Los Angeles CountyFranklin Pratt, MD, FACEP
25 STEMI Receiving Centers - SRCs25 STEMI Receiving Centers - SRCs
Improving the System of Care for STEMI Patients
EMS Assessment for STEMI: results of the Mission Lifeline National Survey
39
EMS Agency RespondentsN=5410
EMS Agency RespondentsN=5410
Improving the System of Care for STEMI Patients
12 Lead Devices Availability at the Scene
40
No38%
Yes62%
Does your organization have 12-lead ECG devices available at the scene for at least 80% of the patients with chest pain?
Improving the System of Care for STEMI Patients
Destination Protocols
41
No43%
Don't know/not applicable
20%
Yes37%
Are there destination protocols (i.e. bypass non-PCI hospitals to go directly to PCI centers) for patients that have had a pre-hospital identification of a STEMI?
Improving the System of Care for STEMI Patients
12 Lead Activates the Cath Lab
42
No49%
Don't know6%
Yes, for all receiving facilities
17%
Yes, for some receiving facilities
28%
In your Agency/Organization, is the field provider’s 12-lead ECG
information used to activate the cath lab prior to arrival at the
receiving facility?
Improving the System of Care for STEMI Patients
Pre-hospital Activation. EMS identifies STEMI and:(Select all that apply.)
20%
12%
73%
0% 10% 20% 30% 40% 50% 60% 70% 80%
Alerts ED & ED activates STEMITeam/Cath Lab (no cardiology
consult)
Alerts ED & Cardiologist activatesSTEMI Team/Cath Lab
Activates STEMI Team/Cath Lab
Improving the System of Care for STEMI Patients
Interpretation Issues
Improving the System of Care for STEMI Patients
Cath Lab Activations“False Positive” vs “Over-activations”
- Significant resources activated with STEMI response
- Definition of “False Positive” activations
- What is an acceptable rate for over-activations
Improving the System of Care for STEMI Patients
Definitions of “False Positive” Cardiac Cath Lab Activation
No culprit
No significant coronary disease
Negative cardiac biomarkers
Larson, DM et al JAMA 2007;298(23):2754-2760
Improving the System of Care for STEMI Patients
Summary: Incidence of “False Positive” Cath Lab Activation
No culprit: 14%
Normal or Minimal CAD: 9.5%
Negative cardiac markers: 11.2%
Combination of no culprit and negative biomarkers: 9.2%
Larson, DM et al JAMA 2007;298(23):2754-2760
Improving the System of Care for STEMI Patients
Improving the System of Care for STEMI Patients
RACE: Cath Lab Activation Registry
Cath Lab Cancellations
• Resolution of symptoms or ECG abnormalities
• Old ECG findings, patient death, other
Overactivations –
• Cath lab cancelled due to
° ECG interpretation issues – prehospital or ED
° Patient not a cath lab candidate
Other –
• CABG, medical management only, normal coronaries, other
Improving the System of Care for STEMI Patients
Questions?