1. Integrating EMS with Hospital PCI: The DC Experience by James J Augustine, MD

2. James J. Augustine, MD DISCLOSURES
I have no real or apparent conflicts of interest to report.

3. District of Columbia Fire & EMS Department
STEMI Transport Program Overview
February, 2010
James Augustine, MD, Medical Director
Rafael Sa’adah, Assistant Fire Chief of EMS
Dennis L. Rubin, Fire & EMS Chief
© 2010 District of Columbia Fire and EMS Department
♦ The District’s First Response All Hazards Agency ♦

4. STEMI Transport Program Overview
Date of implementation: January 18, 2009
Program Goal:
Reduce mortality in STEMI patients by shortening the reperfusion interval.
© 2010 District of Columbia Fire and EMS Department
♦ The District’s First Response All Hazards Agency ♦

5. STEMI Transport Program Overview
Program features:
Timely recognition of symptoms
Use of 12-lead EKG
Appropriate medications
Timely transport to a PCI capable hospital
© 2010 District of Columbia Fire and EMS Department
♦ The District’s First Response All Hazards Agency ♦

6. STEMI Transport Program Overview
DC Fire & EMS
Primary response resources
20 Paramedic Engine Companies
13 BLS Engine Companies
16 BLS Truck Companies
39 transport units
7 EMS supervisors
Average daily EMS workload:
347 incidents
225 transports
Workforce
Certification Levels
Totals
EMT-P
213
EMT-I 48
EMT-B
1,668
 total:
1,929
© 2010 District of Columbia Fire and EMS Department
♦ The District’s First Response All Hazards Agency ♦

7. STEMI Transport Program Overview
Designated STEMI receiving facilities:
George Washington University Hospital
Howard University Hospital
Washington Hospital Center
Veterans Medical Center
Walter Reed Army Medical Center
© 2010 District of Columbia Fire and EMS Department
♦ The District’s First Response All Hazards Agency ♦

8. STEMI Transport Program Overview
DC Fire & EMS Training Program
Phase One: standardized 8 hour
12 Lead ECG - STEMI Interpretation Class
© 2010 District of Columbia Fire and EMS Department
♦ The District’s First Response All Hazards Agency ♦

9. STEMI Transport Program Overview
STEMI Training, Feb/March 2009:
227 students:
150 move to advanced
77 completed refresher
© 2010 District of Columbia Fire and EMS Department
♦ The District’s First Response All Hazards Agency ♦

10. STEMI Transport Program Overview
Hospital Implementation
Support of STEMI Centers
Support of Non-STEMI Centers
Acknowledge cardiac centers in MD and NoVa
Establish a STEMI QI group and format
Establish a Peer Review protected program
© 2010 District of Columbia Fire and EMS Department
♦ The District’s First Response All Hazards Agency ♦

11. STEMI Transport Program Overview
Results from quarterly QI meeting, June 19, 2009
HUH. 7 activations, with time to lab of 54 minutes. 4 false positive activations, in patients with pericarditis and IHSS. No false negatives.
GWU. 33 acute MIs. 8 cath lab activations by EMS, with a median time to lab of 69 minutes. For 25 other activations, the median time is 80 minutes.
WHC. 45 acute MIs. 5 cath lab activations by EMS, with a median time to lab of about 30 minutes. 2 were not MIs, in patients with significant underlying EKG abnormalities. 1 missed activation.
© 2010 District of Columbia Fire and EMS Department
♦ The District’s First Response All Hazards Agency ♦

12. DC Fire EMS STEMI Transport Program

13. STEMI Transport Program Overview
9 sequential cath lab patients from HUH who arrived by DC Fire & EMS transport unit:
Median time from dispatch of 911 resources to arrival in cath lab: 73 minutes
© 2010 District of Columbia Fire and EMS Department
♦ The District’s First Response All Hazards Agency ♦

14. STEMI Transport Program Overview
Complete the Data Gathering
The ED Directors at UMC, Providence, PG, Sibley, and Georgetown report no patients with acute MIs that arrived by a DC ambulance.  Each have had MIs that arrived by car or otherwise, but none by DC Fire EMS.
© 2010 District of Columbia Fire and EMS Department
♦ The District’s First Response All Hazards Agency ♦

15. STEMI Transport Program Overview
Sample actual narrative from a DC Fire & EMS patient care report
“pt. was placed on EKG and found to have ST elevation in LII, LIII and AVF. No sign of axis deviation, no signs of BBB. A V4R 12L was obtained and found to have no ST-elevation… 12-lead repeated q 3-5 min during transport… the STEMI team was alerted.”
© 2010 District of Columbia Fire and EMS Department
♦ The District’s First Response All Hazards Agency ♦

16. STEMI Transport Program Challenges
Ongoing QI of Medical Care
Wide Range of Presentations of STEMI
Appropriate use of 12 Lead EKG
Appropriate Activation and Communication
12 Lead Transmission to Hospital
Access to old EKGs
© 2010 District of Columbia Fire and EMS Department
♦ The District’s First Response All Hazards Agency ♦

17. Ahead: The 80 Lead EKG

18. 80 Lead ECG Readout

19. STEMI Transport Program Overview
© 2010 District of Columbia Fire and EMS Department
♦ The District’s First Response All Hazards Agency ♦