Cath Lab Digest - January 2008 - (Page 35)

JANUARY 2008 STEMI INTERVENTIONS 35 exceptional care from successful reperfusion within the “golden hour.” Unique integrations of hospital processes and indigenous solutions to local challenges are being reported by both high and low-volume percutaneous coronary intervention (PCI) institutions. Coordination between the emergency department (ED) and cardiovascular laboratory (CVL) is occurring at these institutions, and there is seamless transfer and transition of medical and nursing care as the patient is rushed through two very different departments of a hospital. In this aspect, the creation of a charismatic STEMI coordinator is critical and we strongly endorse the role of this individual. We also suggest regular inter-departmental meetings that review every patient that fails to meet the D2B deadline, identify the precise source of delay and seek implementations to correct the anomaly. The above measures and the prudent pathways enunciated by Mr. Scharbach will catch most of the low-hanging fruit in short D2B STEMI interventions. Indeed, achieving this is mandatory and institutions should rapidly reach a status of achieving more than 80% success in meeting D2B times < 90 minutes and “false alarm” rates of < 15%. Once this is achieved, the harder task begins as additional progress requires further intensification of processes, discipline and resource allocation. Further improvements in the success rates will undoubtedly be slower and frustrating, as is eloquently illustrated by Mr. Scharbach. Towards making further progress, we suggest the following strategies: 1. Begin careful review of D2B times during “off” hours — institutions will identify this as the culprit factor limiting overall success. In the “False Positives” commentary in this issue of Cath Lab Digest, we have highlighted the double jeopardy that confronts a patient presenting with STEMI during off hours — there are D2B time delays and higher “false alarms.” Consistency in meeting D2B deadlines during off hours requires greater commitment, allocation of additional resources and even greater teamwork. Additional crew on standby will often be required to respond to the presenting patient in the early off hours when there is bound to be confusion as to whether the tired CVL team can push itself or give way to a fresh crew that must press into action immediately. 2. Incorporate the valuable lessons that more experienced centers have accumulated. For this purpose, I strongly endorse the Mayo Clinic and the superb programs that have been developed at the Abbott Northwestern Center in Minneapolis. Imagine how many of the 1,345 patients at the Minneapolis institution presented in the precise adverse “snowstorm” conditions that Mr. Scharbach alluded to in the beginning of his article. The premier Minneapolis institutions have already mastered this challenge. Let us learn from their invaluable experience. In addition to providing exemplary care for STEMI patients, these two superb institutions have created outstanding models of triage and transfer of STEMI patients. 3. Explore early activation pathways that will further erode STEMI delays. The emergency medical system (EMS) process remains a potent opportunity for significant additional gains in short D2B STEMI interventions. The DANish trial in Acute Myocardial Infarction (DANAMI) investigators were the first to recognize this opportunity and seize it by eliminating the redundancies that exist in the early activation of “code heart” by EMS.1-3 Several other European centers have also encapsulated these methodologies and in addition to early activation by EMS, they are able to provide pre-hospital thrombolysis to eligible patients. The latter is a vital missing link in the U.S. arsenal in STEMI management. Whether this entails the use of pure fibrinolysis or facilitation with GP 2b/3a antagonists is a moot point that merits greater research. Numerous legal, legislative, financial and institutional barriers are delaying the push for early activation and pre-hospital thrombolysis. The resolution of these difficult issues will not be easy. In the interim, individual institutions may succeed in bypassing some of these hurdles to achieve common-sense ground rules and coordinated activity between the inseparable trio of STEMI care — EMS, ED and CVL. Finally, we leave the reader with our last caveat on the subject and that is to provide optimal care to the patient, beyond the mandates of the D2B deadlines. Often, as a result of numerous system delays, the D2B time will not be achieved. However, this should not prevent an institution from providing excellent care for the STEMI patient. The exceptional acute and long-term benefits for the individual patient who achieves a successful, early reperfusion of the IRA must not be dampened by an institution’s inability to meet D2B deadlines References 1. Madsen JK, Grande P Saunamäki K, , et al; on behalf of the DANAMI Study Group. Danish Multicenter Randomized Study of Invasive Versus Conservative Treatment in Patients With Inducible Ischemia After Thrombolysis in Acute Myocardial Infarction (DANAMI). Circulation 1997;96:748-755. 2. Andersen HR, Nielsen TT, Vesterlund T, et al. Danish multicenter randomized study on fibrinolytic therapy versus acute coronary angioplasty in acute myocardial infarction: rationale and design of the DANish trial in Acute Myocardial Infarction-2 (DANAMI-2). Am Heart J 2003 Aug;146(2): 234-241. 3. Busk M, Maeng M, Rasmussen K, et al; for the DANAMI-2 Investigators. The Danish multicentre randomized study of fibrinolytic therapy vs. primary angioplasty in acute myocardial infarction (the DANAMI-2 trial): outcome after 3 years follow-up. Eur Heart J 2007 Oct 23 [Epub ahead of print]. Dr. Mehta can be contacted at mehtas@bellsouth.net. The STEMI Intervention section showcases best practices and pathways to improvement, whether dramatic or incremental. Cath Lab Digest encourages outstanding facilities to submit their work. For author guidelines, email Rebecca Kapur at rkapur@hmpcommunications.com. http://www.safeguardworks.com http://www.safeguardworks.com

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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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