1. Our STEMI Program Leesa Wright, RN, CCCC, CCRN
Methodist University Hospital
2015 Annual Tennessee STEMI Meeting
October, 2, 2015

2. Objectives Recognize the alignment of structure with
AHA Mission: Lifeline
Identify the focuses within the roles of
each team within the AHA Mission: Lifeline
structure
Identify interventions for common barriers

3. Disclosures Leesa Wright, RN, CCCC, CCRN Our STEMI Program
FINANCIAL DISCLOSURE:
No relevant financial relationship exists

4. Our Past: In the Beginning………….

5. Our Past: Our Team

6. Our Present: Our Team

7. Our Future: Why We Still Strive to be Better
Estimated In-Hospital Mortality by Door to Balloon Times
Time (minutes) Adjusted Mortality 15
( ) 30
3.0
( ) 60
3.5
( ) 90
4.3
( )
120
5.6
( )
180
8.4
( )
240
10.3
( )

8. In 2008 MUH and CRH devloped a process for PCI as Primary Reperfusion Strategy
Our Team
EMS
Referral
Hospital
Receiving
Hospital
In 2009 MUH expanded and offered PCI as Primary Reperfusion Strategy to other facilities throughout the region
Air
Transport
2013 ACCF/AHA Guidelines for the Management of ST-Elevation Myocardial Infarction
Class 1 Recommendation
All communities should create and maintain a regional systems of care that includes assessment and continuous quality improvement of EMS and hospital based activities. Performance can be facilitated by participation in programs such as Mission Lifeline and D2B Alliance

9. AHA Mission: Lifeline EMS Criteria EMS Providers Champions:
Review the data, make the processes,
present the results
EMS
Criteria
1. Each EMS system should maintain a standardized algorithm for evaluating and
treating patients with symptoms suggestive of MI that should include acquisition of a
12-lead ECG and appropriate communication of the ECG findings(via direct
paramedic interpretation/voice communication, automated computer
algorithm interpretation, wireless transmission and MD interpretation, or an
combination of these 3 strategies) to the receiving hospital.
2. Each EMS system should maintain a standardized reperfusion STEMI care
pathway that designates primary PCI as the preferred reperfusion strategy if
initiated within 90 minutes of FMC or fibrinolytic therapy in eligible patients when
primary PCI within 90 minutes is not possible.
3. Prearranged EMS destination protocols for STEMI patients should include:
a. Bypassing non-PCI hospitals/STEMI Referring Centers and going directly to
Primary PCI hospitals for patients with anticipated short transport interval(
< 30 minutes in urban/suburban settings to achieve PCI within 90 minutes
b. Emergency transfer of EMS or other agencies to a STEMI-Receiving Center
of pts. who transport themselves to STEMI Referring Centers
c. Air Transport if possible(or default to ground transport)to STEMI-Receiving
Center or stabilization in STEMI Referring Center for patients with anticipated long
transport time and/or fibrinolytic ineligible and/or cardiogenic shock
Enhance Transmission Capability:
FastECG.com
Lifenet
Improvement in time from obtaining ECG to transmission of ECG:
EMR book with FMC
Scene Time:
Education of 15 minute goal for STEMI
EMS Obtains Blood in the field:
EMS providers will draw blood in the field for STEMI and Stroke

10. AHA Mission: Lifeline EMS Criteria
(continued) d. Administration of fibrinolytic therapy pre-hospital or in STEMI Referral Center for fibrinolytic eligible patients with anticipated primary PCI time > 120 min e. Emergency transfer to a STEMI PCI Center of patients who develop STEMI in Non-PCI Center 4. When taken directly to a STEMI Receiving Center, all STEMI patients should be transported to the most appropriate facility as determined by Mission Lifeline hospital criteria of D2B 5. EMS Medical Director or designate should monitor care related to EMS patients by meeting at least quarterly with pre-hospital providers, ED physicians, interventional cardiologists, nursing staff, receiving hospital representatives, and other appropriate individuals. 6. The following measurements should be evaluated on an ongoing basis: a. Symptom onset to 911 call b. 911 call received to arrival at hospital door c. FMC to balloon (FMD) d. EMS ECG to balloon (FMD) e. Proportion of non-traumatic CP patients with ECG and STEMI patients with ECG f. Patients with field diagnosis of STEMI with CL activation who do not undergo PCI due to misdiagnosis or with no change in cardiac biomarker

11. AHA Mission: Lifeline EMS Criteria
g. Proportion of patients with field diagnosis of STEMI and activation of Cath Lab
for intended primary PCI
1)do not undergo acute catheterization because of misdiagnosis
2)undergo acute catheterization and found to have no elevation in cardiac
biomarkers and no revascularization in the first 24 hours
h. Proportion of patients with EMS treated VF who are taken to the Cath Lab
i. Survival to hospital DC of all STEMI patients and of patients with VF (EMS and
STEMI- receiving facility to monitor jointly.)

12. Early Activation of Transport Team: Transition of care to Transport:
AHA Mission: Lifeline
Non-PCI : Referral Center
Criteria
Non-PCI Hospital/STEMI Referral Center: 1. Appropriate protocols and standing orders should be in place to identify STEMI. These should be present in ED, ICU (and for MRT) 2. Each ED should maintain a standardized reperfusion STEMI care pathway that designates primary PCI as preferred reperfusion strategy if transfer to a primary PCI hospital/STEMI Receiving Center can be achieved within ACC/AHA guidelines 3. Each ED should maintain a standardized reperfusion STEMI pathway that designates fibrinolysis in the ED (for eligible patients)when the system cannot achieve ACC/AHA PCI time 4. If reperfusion strategy is for Primary PCI transfer, a streamlined, standardized protocol for rapid transfer and transport to a STEMI Receiving Center should be operational. 5. If reperfusion strategy is for Primary PCI transfer, all patients should be transported to the most appropriate STEMI-Receiving Center where the expected first D2B (FMD) time should be within 120 minutes. 6. Ongoing quality improvement process, including data measurement and feedback for the STEMI population and submit to Mission Lifeline
Early Activation of Transport Team:
First Call – Air
Immediate Back Up Plan
Transition of care to Transport:
10 minute TAT

13. Non-PCI: Referral Center
AHA Mission: Lifeline
Non-PCI: Referral Center
Criteria
Referral Center (continued) 7. Program to track and improve treatment (acutely and at discharge) with ACC/AHA guideline-based Class I therapies. 8. A multidisciplinary STEMI team, including EMS, should review hospital specific STEMI data on a quarterly basis: Door to first ECG Proportion of patients receiving therapy Referral Center D2B

14. All STEMI inter-hospital transfers should be treated as 911 status
AHA Mission: Lifeline
Inter-hospital Transfer
EMS
-STEMI patient for reperfusion has same priority as 911 and trauma
-Patient stays on EMS stretcher for STEMI evaluation for inter-hospital transfer
-Transfer plan including preferred transport modality and backup transport modality
is established
-Transport directly to cath lab when lab is staffed and available for PCI without
reevaluation in the ED
-When possible, minimize or avoid continuous IV infusions such at Nitroglycerin and
heparin
-Transfer protocol should focus on rapid transport to cath lab rather than pain relief
with medications
-Transfer pts to STEMI-Receiving hospital with similar consideration to pt registration,
bed availability and accepting MD (use of dummy reg., acceptance regardless of bed
availability and reliance on single accepting MD 24/7)
-When transporting pt treated with fibrinolysis who has continued CP and <50%
resolution STE(in lead with worst initial elevation)after 90 minutes following initiation of
fibrinolytic, notify the receiving hospital about the need for rescue PCI
-Hospital records faxed to receiving cath lab so as not to delay pt pickup
-EMTALA/COBRA medical necessity transfer form should be completed ASAP after decision
to transfer
Treat as 911 :
All STEMI inter-hospital transfers should be treated as 911 status

15. AHA Mission: Lifeline Helicopter Transfer
Local EMS should generally be used if available and 30 minute transportation
time to destination hospital
Whenever possible, helipad adjacent to ED
Helicopter capable of transporting patients on 10 minute notice 24/7. When not
available alternate transport options identified.
Immediately activate helicopter transport during initial communication between
referring hospital ED and receiving hospital regarding need for reperfusion
Establish a system whereby all patient transfers of any type can be specified as
time critical within one hour versus diversion possible
Ground/Air Transfer:
Enhance First Responders
Early activation of Air
Onsite Helipad:
Availability of Transport
When Helicopter Not Available:
Identify Plan B: Who is next
Referral team activates:

16. Interventional coverage plan: Operational within 30 minutes:
AHA Mission: Lifeline
Primary PCI: Receiving Center
Criteria
STEMI-Receiving Center
1. Protocols for triage, diagnosis and Cardiac Catheterization Laboratory activation
established. Single activation phone call should alert the STEMI team. Criteria for
Cath Lab activation should be established in conjunction with EMS offices.
STEMI Receiving Center available 24/7 to perform PCI
3. Cath lab staff and interventionalist should arrive within 30 minutes of activation
call.
4. Universal acceptance of STEMI patients (no diversion). There should be a plan for
triage and treatment of simultaneous presentation of STEMI patients.
5. Interventional cardiologist should meet ACC/AHA criteria for competence.
They should perform at least 11 primary PCI procedures per year and 75 total
PCI procedures per year.
6. STEMI Receiving Center should meet ACC/AHA criteria for volume and perform
a minimum of 200 total PCI procedures annually.
7. The STEMI Receiving Center should participate in the Mission: Lifeline-approved
data collection tool ACTION Registry-GWTG.
Interventional coverage plan:
Compliance with 30 arrival time
Logistics of coverage
Operational within 30 minutes:
Arrival and operational are not the same
Quick Reg in Cath Lab:
Would not require any ED visit

17. Primary PCI: Receiving Center
AHA Mission: Lifeline
Primary PCI: Receiving Center
Criteria
STEMI Receiving Center(continued) 8. Program placed in place to track and improve treatment(acutely and at discharge) with ACC/AHA guideline based Class I therapies. 9. Recognized STEMI-Receiving Center liaison/system coordinator and a recognized physician champion. 10. Monthly multidisciplinary team meeting to evaluate outcomes and quality improvement data. Operational issues should be reviewed, problems identified, and solutions implemented. The following should be evaluated on ongoing basis: a) D2B (FMD) within 90 minutes b) STEMI Referral Hospital D2B within 120 minutes c) FMC to balloon (FMD) non-transfer within 90 minutes d) FMC to balloon inflation (FMD) transfer e) Proportion of eligible patients receiving reperfusion therapy f) Proportion of eligible patients administered guideline-based Class 1 recommendations g) Proportion of patients with field diagnosis of STEMI and activation of cath lab for intended primary PCI that 1) do not undergo cath because of misdiagnosis and 2) undergo acute cath with no ^ biomarker or revascularization in first 24 hours h) In-hospital mortality