Cath Lab Digest - January 2008 - (Page 32)

32 STEMI INTERVENTIONS JANUARY 2008 STEMI INTERVENTIONS Sameer Mehta, MD, FACC, MBA, is studying ST-elevation myocardial infarction interventions in his work with the Primary PCI and the Single INdividual Community Experience REgistry for Primary PCI (SINCERE) Database at 5 community hospitals in Miami, Florida. A past chief of interventional cardiology and director of the cardiovascular laboratory at Cedars Medical Center in Miami, Dr. Mehta is also president of the Indo-American Society of Interventional Cardiologists (ISIC) and a course director for the Lumen-Vascular Interventions Symposium. Dr. Mehta will be commenting on the important work going on around the world as societies and their hospitals struggle to educate patients about the importance of timely intervention in ST-elevation myocardial infarction, and work collaboratively to decrease the time from patient arrival to intervention. Commentary: I. “False Positives” In the December 2007 issue of Cath Lab Digest, I provided an editorial comment to the exceptional quality of scientific work that was performed with short door-to-balloon (D2B) STelevation myocardial infarction (STEMI) interventions at St. Episcopal Hospital in Houston, Texas. In that note, besides complementing the institution for its fine work, I cautioned against complacency towards proceeding with emergent cath/percutaneous coronary intervention (PCI), citing precisely the high false alarms that have been mentioned in this outstanding study reported by Dr. David Larson. By the American College of Cardiology (ACC)/American Heart Association (AHA) criteria for primary stenting, the rates for these “false alarms” should be less than 15%. By this standard, the 14% of the false alarms cited by Dr. Larson at the Minneapolis Heart Institute Foundation at Abbott Northwestern Hospital is quite acceptable. Yet the authors have creditably deemed these rates as unacceptably high. The reader must also be made aware that the Minneapolis experience, with its Spoke and Wheel, pharmaco-invasive model of triage for primary PCI is one of the most advanced programs in the world, and one that has established superb guidelines and pathways for very effective triage for STEMI patients. I emphasize the excellent caliber of the work at Minneapolis Heart Institute since their high false alarm rates may actually be some of the lowest in the nation, and that the problems of these false alarms may be much higher at other institutions, in particular, at low-volume STEMI institutions. It must also be understood that a clear dichotomy exists between STEMI intervention results during “off“ hours and “on” hours. Institutions providing 24/7 primary PCI struggle to achieve D2B times <90 minutes during off hours. Although large institutions possessing great expertise in short D2B interventions have not specifically reported on false alarm rates between off and on hours, it can be expected that just as the D2B times are longer during off hours, the rates of false alarms may be expected to be higher during off hours. This provides a double disservice to the patient presenting with STEMI during off hours – not only will the primary PCI be delayed, there is also a higher likelihood of emergently proceeding with the procedure in the absence of a “culprit lesion.” The very high costs involved with these false alarms are also a matter of considerable concern, as is the issue of the false alarms causing a crisis in confidence in the individual institutions. It is very frustrating for the cardiac catheterization laboratory to rush in at 3 am for a normal cath. There are several ways for individual institutions to get their arms around this burgeoning problem. It is obvious that the emergency department (ED) physicians are under great stress to diagnose STEMI – they have to be very accurate and very fast. It is a new responsibility that has been assigned to them quite rapidly. Suddenly, several low-volume institutions have pronounced themselves “Centers of Excellence” providing 24/7 STEMI interventions. Billboards of similar pronouncements have begun cropping on highways as these institutions are riding the bandwagons without mandating quality and without placing in position top-notch ED physicians. Previously, it was routine that the ED physicians were consulting a cardiologist prior to beginning management for STEMI. In the present set-up at several institutions, with the enormous demands placed to meet D2B times, the ED department is all too often rushing to press “Code Heart” and declare itself a winner, achieving high success in low D2B times. The other essential coordinate of quality, the false alarms, have been all too often ignored. In my upcoming “Textbook of STEMI Interventions,” several contributing authors as well as I have strongly emphasized the need to monitor the false alarm rates. We have declared these rates to be the best parameters of measuring the efficacy of a STEMI program. The D2B time is an effective measure of the process (emergency medical services [EMS] + ED + cardiovascular laboratory [CVL]), whereas the false alarm rates are excellent ways to measure the accuracy and quality of the ED, and sometimes the EMS — at institutions where early activation of the CVL is being performed collectively between these two affiliates. In relationship to this critical topic, administrations and medical staff must mandate high caliber for ED physicians that would participate in STEMI programs. Rigorous training in EKG interpretation is the cornerstone of this new role and continuous quality improvement (CQI) processes must be rigid in this assurance. To be perfectly candid, if any institution cannot provide such quality ED physicians, it has no business in declaring its ability to perform 24/7 STEMI interventions. In a situation where the high accuracy of the ED physician cannot be ensured, the institution must seriously consider to reverting to the time-tested method of the cardiologist evaluating the presenting EKG. international cardiology meetings. Several institutions are regularly reporting their exceptional results in achieving the ACC/ American Heart Association (AHA) guidelines of successful recanalization of the infarct-related artery (IRA) within 90 minutes. What began as a massive challenge to hospital systems and processes when the guidelines for D2B times were lowered to 90 minutes from 120 minutes is no longer considered an impossible chore. As a result, thousands of patients presenting nationwide are getting II. Commentary: We Have Picked the Low-Hanging Fruit! Now What? D an Scharbach, Regional Director of Invasive Cardiovascular Services at Providence Health System in Portland, Oregon, has chronicled an exceptional review of the doorto-balloon (D2B) performance within the Portland Service Area. He has elaborated on critical steps that can result in a highly effective pathway that will consistently achieve short D2B times. The critical role of the ST-elevation myocardial infarction (STEMI) coordinator has been highlighted and a physician champion has been mentioned as the force behind a very successful endeavor. The importance of teamwork and clear communication has been appropriately emphasized and an excellent observation has been made to use the American College of Cardiology (ACC) guidelines as the best template for institutions to base their D2B programs upon. Finally, Mr. Scharbach poignantly opens up the forum to seek recommendations from others, therein prompting this review. Cath Lab Digest now has a forum for discussing this very important topic, echoing similar interest at both national and

Table of Contents Feed for the Digital Edition of Cath Lab Digest - January 2008

Cath Lab Digest - January 2008 Central Baptist Hospital Contrast Media Use in High-Risk Patients An Ergonomic Survey of Cath Lab Repetitive Stress Injuries Contents Clinical Editor’s Corner Takotsubo Cardiomyopathy, a.k.a., Transient Left Ventricular Apical Ballooning Syndrome: An Acute Coronary Syndrome Imposter Searching for the Key to D2B STEMI Intervention News STEMI Interventions: Commentary The Massachusetts Stent Study The Value of Educating Staff Ask the Clinical Instructor: A Q&A Column for Those New to the Cath Lab SICP* Chapter Updates The Society of Invasive Cardiovascular Professionals Holds an RCIS Review Course at New Cardiovascular Horizons 18:20 To Denver — One Student’s First Clinical Experience CEU Education Center Meetings Calendar What Do You Think? Clinical & Industry News Classifieds The Ten-Minute Interview with…Heather Vardon, RN Advertisers Index

Cath Lab Digest - January 2008

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