STEMI...How Can we Improve??

The reason we perform 12 Lead EKGs in the field is to find out if the patient is having an acute MI. EMS has made great strides in the recent past to make sure their ALS providers have been trained to perform and interpret 12 Lead EKGs. So what can we do now to make it better? I serve on the regional STEMI committee for my area representing prehospital providers within 30 minutes of a PCI center and I have put a lot of thought into this very topic. We all know that time is muscle so simply put we need to remove absolutely every obstruction that causes any delay from the time the coronary artery is first blocked to the time the cardiologist clears the obstruction and returns coronary perfusion to the cardiac tissues. Sounds like a good plan. The first step is to form a regional STEMI committee and bring representatives from each step of the patient’s journey to the same table so we can all get onto the same page. I could write an entire article on the importance of this aspect alone but today let's look at the improvements I see the prehospital system can contribute to the cause.

1) Patient Education: We need to educate the public as to the importance of arriving at a PCI center when their chest pain occurs. By dialing 911 and getting the prehospital system involved they will have decreased their onset to balloon time tremendously. In my area most of the extended times to a PCI center have come from inter facility transfers and not from prehospital initiation.

2) EMS vs. ER...The first 10 minutes should be the same: I am a firm believer that the patient's hospital stay should begin at the time the paramedics walk through the front door of the patient's residence. Door to balloon times are misleading as we need to start recording and improving first healthcare contact to balloon time. This is the 21st century and EMS around the nation needs to acknowledge they are not just a ride to the hospital; they are not just there to fix life threatening conditions and then hand the patient off to the ER. EMS should encompass all the initial actions just as if the patient walked into the front door of the ER. This should include patient registration, placing a gown on the patient, and any other initial actions or treatment taken by the ER in the first 10 minutes. If you want to know what actions and interventions EMS should be adding to its tool box all you need to do is watch what occurs in the first 5 minutes after you arrive with a critical patient. If you see any standard treatment or intervention occurring immediately then that is something EMS should be considering implementing into their protocols.

3) Prehospital 12 Leads: As I said previously we have made great strides in this area but what we have done is only scratching the surface. Most EMS systems have 12 leads on the ambulances staffed by paramedics. We need to extend that out at least another tier and make sure every fire truck and BLS provider can perform a 12 Lead EKG. Any patient suspected of having an acute coronary event should have a 12 lead as one of their initial vital signs. It is not an ALS intervention to place stickers and attach cables to a patient’s chest. Everyone should be doing it. Sure, paramedics are needed to interpret the squiggly lines, but certainly not to attach the cables and print out an EKG and have it waiting for the arriving paramedic to interpret. I have seen far too many paramedics perform an initial assessment and then move the patient to "their office" and then perform a 12 lead EKG. This is flawed thinking. Our goal should be a 12 Lead within 5 minutes of patient contact by any prehospital provider. How long should we wait to find out if they are having the big one? Any barrier in your EMS system that prohibits a 12 lead EKG from being acquired within 5 minutes should be removed. As we all know the first step of any 12 step improvement program is recognizing the problem. We can do nothing to improve the patient’s journey to a PCI center until we first recognize they are having a STEMI.

4) Transmitting EKGs: It is absolutely imperative you find some way of transmitting the 12 Lead EKG for the receiving ER physician to see. It is not that the hospital doubts our ability to interpret EKGs, although, in some parts of the country this may be true. It is simply a team sport. If the physician and the paramedic were standing beside each other when the 12 lead came out of the machine they would both look at it. It's just best practice to share this type of information. Just like all the prehospital providers hand the EKG off and show it to each other on the scene. This is just not the type of information you keep to yourself and the cost of falsely activating the cath team is extensive. You want as many people involved in this decision as possible. False activations occur in the ER. We do not need any bad press from false activations occurring from a prehospital EKG. If paramedics feel this is an insult to their intelligence...get over it. Anything that slows down onset to balloon time needs to be eliminated, and that includes your pride.

5) STEMI ??: So the squiggly lines look bad...what next? I propose a two tiered prehospital response to a possible STEMI:

     a) Confirmed STEMI: This is a patient that both the prehospital providers and the ER physician agree is a STEMI. The EKG has been transmitted and everyone is on the same page so game on. The PCI team should be activated and every barrier that will slow down the time to the patients cath should be removed. The patient should be placed in a hospital gown and their groin should be shaved. No drips should be started and any interventions routinely performed by the ER physician should be moved to the prehospital arena such as heparin or integrelin boluses. If a chest x-ray is required prior to the patient going to the cath lab then a portable chest should be waiting in the ER and it should be performed on the EMS stretcher and then the patient should be immediately transferred to the cath lab. If your EMS system has extremely long transport times to an ER or PCI center and your STEMI patient would undergo TPA at the closest ER then this should be moved into the prehospital arena. IF the training or care level of the EMS system does not support this effort then a plan should be put into place to make it so. Whatever requirements your nearest PCI center will require prior to the cath being performed on a patient should be implemented in the prehospital setting. This is where it is crucial to have all the stakeholders at the same table with one goal in mind, decreasing the time from event to balloon.

     b) Non-Confirmed STEMI: This is a patient that the ER physician has not seen the EKG but EMS suspects a STEMI. No drips, rapid transport, and all the interventions listed above outside of activating the cath lab, pre PCI treatments, or TPA should be implemented.

6) Transport: The patient should then arrive at the PCI center within 30 minutes. How this is accomplished depends on the local resources and the location of the PCI center. If air transport is the only way then EMS should be authorized to initiate this from the scene as transporting to the nearest ER and then transferring the patient will be an obvious delay.

7) No Bed Transfer: It takes time to move a patient from an EMS stretcher to a hospital bed. The patient should be moved directly from the stretcher to the cath table. If the patient needs to be seen in the ER for any reason they should stay on the EMS stretcher and be ready to roll to the awaiting helicopter or to the cath lab, whatever is the next step of the journey to a successful PCI.

8) STEMI Drills and QA/QI: We should be continually evaluating the system and looking for improvements. STEMI drills will make sure the machine stays well oiled and ready to perform when needed. Any improvements in time, procedures, and interventions that can be safely incorporated into the prehospital setting should be implemented as they become available.

I cannot stress enough that this is a team effort. All phases of the system from the patient, the dispatcher, to the intervening cardiologist need to communicate with each other and develop a cohesive plan with only one goal in mind, the well being of the STEMI patient!