1. Telemedicine to Expedite Patient Transfer-the Cell Phone Experience
Lowell Satler, MD
Director Of Cardiac Catheterization Lab
Washington Hospital Center
Washington, DC

2. I/we have no real or apparent conflicts of interest to report.
Lowell F. Satler, MD
I/we have no real or apparent conflicts of interest to report.

3. Telemedicine to Expedite Patient Transfer-the Cell Phone Experience
Lowell Satler, MD
Director Of Cardiac Catheterization Lab
Washington Hospital Center
Washington, DC
Better Triage

4. Hospital fibrinolysis: Onset of symptoms of STEMI
Options for Transport of Patients With STEMI and Initial Reperfusion Treatment
Hospital fibrinolysis:
Door-to-Needle
within 30 min.
Not PCI
capable
Call 9-1-1
Call fast
EMS on-scene
Encourage 12-lead pre-hospital ECGs
Onset of symptoms of STEMI
9-1-1
EMS
Dispatch
Inter-Hospital
Transfer
PCI
capable
GOALS 5
min. 8
min.
EMS Transport
Options for Transportation of STEMI Patients and Initial Reperfusion Treatment: Goals
Reperfusion in patients with STEMI can be accomplished by the pharmacologic (fibrinolysis) or catheter-based (primary PCI) approaches. The overarching goal is to keep total ischemic time within 120 minutes (ideally within 60 minutes) from symptom onset to initiation of reperfusion treatment.
The medical system goal is to facilitate rapid recognition and treatment of patients with STEMI such that door-to-needle (or medical-contact-to-needle) for initiation of fibrinolytic therapy can be achieved within 30 minutes or door-to-balloon (or medical-contact-to-balloon) for PCI can be achieved within 90 minutes. These goals should not be understood as “ideal” times, but rather the longest times that should be considered acceptable for a given system. Systems that are able to achieve even more rapid times for treatment of patients with STEMI should be encouraged.
Note “medical contact” is defined as the “time of EMS arrival on scene” after the patient calls EMS/9-1-1 or the “time of arrival at the emergency department door” (whether PCI-capable or non-PCI-capable hospital) when the patient self-transports.
Patient
EMS
Prehospital fibrinolysis
EMS-to-needle
within 30 min.
EMS transport
EMS-to-balloon within 90 min.
Patient self-transport
Hospital door-to-balloon
within 90 min.
Dispatch
1 min.
System delay

6. Currently Available System: STEMI Management Solution
How does it work?
EMS Transmits Data
via Broadband
Hospital Receives Data
via internet
Care Teams Share Data and Act on Data

7. Prehospital ECG transmission
Advantages
Limitations
Improves system performance-allows team to prepare cath lab and secures additional staff interventionalist Reorganizes ED priorities Creates rapid pathway through ED-identification, authorization
Fails to establish two way communication for feedback and interaction May not link “walk-ins” to CODE HEART Team response

8. Defibrillator
WOW
Desktop
Cell phone

9. EMR
HIPPA Compliant

10. Code Heart

17. Cloud storage and retrieval
LiveCast
CODE Heart
WIFI
Cloud storage and retrieval 4G
Monitor multiple live streams
Comprehensive real-time feed statistics
Auto-archiving for download and editing

18. STEMI+PCI: WHC (Jan 2013) DTB 52’ DTB 115’ DTB 62’ DTB 42’
2/5: Chandler; 32 min door-lab, 41 min lab-start; 13 min start-PCI. Delay with interventionalist arrival (Waksman)
DTB 42’

19. DTB

20. STEMI System Activations CHap Activations versus Standard Activations (3/14/2011 to 3/31/2012)
470 STEMI System Activations (Transfers 288)
83 CHap Activation (Transfers 37)
49 STEMI (Transfers 25)
47 PCI (Transfers 24)
2 No PCI (Transfers 1)
34 Not STEMI (Transfers 12)
2 PCI (Transfers 1)
32 No PCI (Transfers 11)
387 Standard Activation (Transfers 251)
193 STEMI (Transfers 145)
178 PCI (Transfers 134)
15 No PCI (Transfers 11)
194 Not STEMI (Transfers 106)
45 PCI (Transfers 30)
149 No PCI (Transfers 76)
CHap Activation
Standard Activation
CHap PCI
Standard PCI

21. Quality measures for STEMI management
CHap (n=47)
Minutes mean [95%CI]
Standard (n=178)
p Value
Door to balloon time
102.6 [ ]
149.4 [ ]
<0.0001
First call to balloon
70.2 [ ]
92.3 [ ]
0.0002
CathLab arrival to balloon
37.8 [ ]
36.9 [ ]
0.706
CathLab arrival to case start
16.7 [ ]
15.9 [ ]
0.655
Electrocardiogram to first call
34.8[ ]
96.7 [ ]
0.091
Case start to balloon
21.1 [ ]
21.0 [ ]
0.948

22. Recent Changes
EDs have lower threshold for trigger CODEHEART protocols
desire to meet expected time standards
borderline ECG
“troponinitis”

23. Enhances real time two way communications between providers
In the last months, the CodeHeart app has been activated 300 times-only 30 True STEMI’s were identified
Enhances real time two way communications between providers

24. 62 yo male; DM, Hypertension; new onset CP

25. 57 yo female; CP for 2 hours; elevated lipids known FH (sister with recent MI

26. 76 yo male, intermettent CP for last week; now SOB

27. 42 yo strong FH with coughing x 2 weeks; woke up this morning with ongoing CP

28. 82 yo with fatigue; recently discharged after subdural 2 weeks ago; SOB this AM; trop 0.3

29. 59 yo diabetic with abdominal and epigastric pain for 2-3 hours

30. Interest in post-resuscitation care has risen with the development of treatment modalities that can affect
long-term survival rates even when begun after the systematic ischemia/reperfusion insult associated
with cardiac arrest. Mild therapeutic hypothermia has become the foundation for improvement of
neurologically favorable survival after cardiac arrest. Reperfusion therapy, specifically early percutaneous
coronary intervention, is becoming an important adjunct to therapeutic hypothermia. Identifying
which post– cardiac arrest patient had an occluded or unstable coronary vessel is difficult because such
events are not reliably predicted by precedent symptoms or standard electrocardiographic analysis.
Increasing clinical experience suggests that resuscitated cardiac arrest victims without an obvious noncardiac etiology should undergo emergency coronary angiography and, where indicated, percutaneous coronary intervention.

31. “Dumas et al. (38), reporting for the PROCAT (Parisian Region Out of-Hospital Cardiac Arrest) registry, on 435 cardiac arrests taken directly to coronary angiography status after resuscitation, found no differences in age, initial rhythm, or other common risk factors between those with ST-segment elevation (n 134) or those without ST segment elevation (n 301). Those without ST-segment elevation had a variety of ECG findings, including St segment depression (29%), conduction abnormalities (20%), and nonspecific changes (9%), with some even being normal
(11%). Significant coronary lesions were found in 58% of those without ST-segment elevation, and nearly one-half of these had PCI (78 of 176). Hospital survival was significantly higher in patients with successful PCI versus those having no or unsuccessful PCI. This was true for patients with and without ST-segment elevation. Multivariable analysis showed successful PCI to be an independent predictor of good outcome, regardless of the initial post– cardiac arrest electrocardiographic pattern. These investigators concluded that immediate PCI (combined with therapeutic hypothermia) results in improved survival for OHCA patients with no obvious noncardiac cause, whether or not their electrocardiogram manifests ST-segment elevation”.

32. Prompt initiation of mild hypothermia in unresponsive patients
Critical Care Pathway for Post Cardiac Arrest Patients with Return of Spontaneous Circulation
Prompt initiation of mild hypothermia in unresponsive patients
Cardiac Arrest with ROSC
First Documented Rhythm?
VT / VF
PEA / Asystole
Most patients are unlikely to benefit from invasive cardiac intervention
ST Elevation or
Hemodynamic instability
No ST Elevation nor
Hemodynamic instability
ECG after ROSC
Code Heart
CCU
ST Elevation
No ST Elevation
Consult with interventionalist for further management
Consider admission to MICU

33. Critical Care Pathway for Patients with Moderate to High Acuity Illness Other Than Cardiac Arrest or STEMI Referred to WHC Cardiologists (usually presumptive NSTEMI)
Patient at OSH
Patient brought by EMS
Clinical Triage by WHC Cardiologist
Is it clear that patient will benefit from urgent invasive cardiac intervention?
WHC ED
Yes
No or Uncertain
Is chief clinical problem clearly due to cardiac disease?
ED Team assumes patient care with prompt consultation with Fellow and/or Cardiologist for rapid final disposition
Yes
No or Uncertain
Direct Admit to Cath Lab
Clinical instability?
Yes No
Uncertain
Admit to CCU
Admit to other Unit at WHC
Triage in MedStar by Cardiology Fellow

34. Prehospital ECGs & Activation Conclusions
An EMS-based PH ECG protocol involving prehospital interpretation without physician oversight, direct cardiac catheterization laboratory activation, and ED bypass resulted in significant reductions in median DTB and FMCTB intervals for those identified as STEMI in the prehospital setting.
Nestler DM et al: Circ Cardiovasc Qual Outcomes 4: , 2011

35. Delays to reperfusion Patient delay System Delay Treatment delay
Arrival
At PCI
center
Symptom
onset
Contact to health
care system
Arrival at
local hospital
Departure from
local hospital
PPCI
Patient delay
System Delay
Treatment delay

36. Conclusions – Emergency medical services transportation to the hospital is underused among contemporary ST-segment-elevation myocardial infarction patients. Nevertheless, use of EMS transportation is associated with substantial reductions in ischemic time and treatment delays. Community education efforts are needed to improve the use of emergency transport as part of system-wide strategies to improve ST-segment-elevation myocardial infarction reperfusion care.

37. Conclusions Continue to optimize system performance
IC should have an important role in communication with the EMS and the Referring ED and review the ECG to better identify and select optimal use of emergency angiography
Follow algorithms for out OHCA to avoid treatment of the futile patient
Encourage broader programs of education regarding patient awareness and recognition, promoting use of EMS transport to ED to further shorten patient and system delay to treatment

38. Thank you!

39. STEMI
Stroke
Trauma
Dermatology
Home Monitoring