Cath Lab Digest - May 2008 - (Page 17)

17 ASK THE STEMI EXPERT Dear Dr. Mehta, We are having a debate on whether or not the cath lab team should transport the STEMI patient to the lab and set up prior to the cardiologist arriving and seeing the patient. The hospital’s argument is that we should strive to for the 90 minute door-to-balloon time and the staff is highly trained to handle any situation. Get the patient to the cath lab asap, prepped and ready to go. Some of the physicians say do not take the patient to the cath lab prior to the cardiologist seeing the patient because: 1) Patient safety (however, we are about 100 feet from the emergency department); 2) Without seeing a cardiologist, diagnoses are missed (gastritis, abnormal lab values). What is the recommendation? Carter Cardiac Cath Lab Supervisor Paradise Valley Hospital Phoenix, AZ Email: cdegnan@abrazohealth.com Dear Carter, Thank you for your question and hopefully, you will find my reply useful. The correct answer is to move along in the process without waiting for anyone. The system has to be geared to succeed all the time, to achieve door-toballoon (D2B) times of < 90 minutes on every single occasion. As you set up systems to do that, every minute counts. We have had numerous instances where the D2B was 91 minutes and dozens where it was between 9195 minutes! So, every minute is critical. It is victory at 89 min and a loss at 91 minutes — therein lies your answer! As you get busier, you will realize that off hours and weekends will test out your teamwork and prove my point that every minute counts. To specifically answer the cardiologist concerns, yes, patient safety is an issue. At one of the institutions where the Single INdividual Community Experience REgistry for Primary PCI (SINCERE) work is done, the Intensives and the ED nurse accompanies the patient from the ED to the cardiovascular lab (CVL) and then stay with the patient till the interventional cardiologist arrives. This may work for you. I have a habit of being on the phone with the ED or the CVL as I am driving, and I take several steps to treat the patient before I reach the CVL. In this way, the patient gets early treatment and valuable minutes are saved. By waiting for the interventionalist to show up, you will seriously jeopardize your success rates. Regarding the second issue raised by your physicians about the diagnosis being missed, your institution needs to move quickly into the mindset that the STEMI call is made by the ED physician, often without input from the interventionalist. A long time ago, we used to have this a joint decision (in doubt, sometimes, we still do) between the ED physician and the interventionalist. No more — the ED physician calls Code Heart or Code STEMI and everyone, including the interventionalist, heads speedily to the CVL. At 3 of the 5 institutions where I perform STEMI interventions, we have access to the Life Net system, wherein the ED physician is alerted of the STEMI by EMS in the field and the EKG is transmitted to the hospital along a status report and with an expected time of arrival. Simply based upon this interaction between the EMS and ED physician, the Code Alert is called, providing the CVL team additional time to respond. We used to expect the CVL team and the interventionalist to reach the lab within 30 minutes, but this number is slowly moving to 20 minutes. Therefore, the onus needs to shift, and it needs to happen quickly for you to improve. No longer is the interventionalist needed to diagnose AMI nor is it his prerogative to call the Code Alert. This decision is being moved on much earlier in the decision tree to the ED physician and to EMS. In the recently published Ottawa study of primary STEMI, without any fibrinolysis, the advanced paramedics made the STEMI decision.1 I am of the firm opinion that this is going to happen in the United States with time, despite the legal and logistical hurdles.2 I would like to refer to you to my Textbook of STEMI Interventions (www.stemiinterventions.com) and to my interview in the August 2007 issue of Cath Lab Digest (http://cathlabdigest.com/article/7659) for answers to similar issues. Best regards, Sameer Mehta, MD Email your STEMI questions to: mehtas@bellsouth.net References 1. Le May MR, So DY, Dionne R. A Citywide Protocol for Primary PCI in ST-Segment Elevation Myocardial Infarction. N Engl J Med 2008 Jan 17;358(3):231-240. 2. Mehta S. Commentary: A Citywide Protocol for Primary PCI in ST-Segment Elevation Myocardial Infarction. Cath Lab Digest Mar 2008;16(3):87-88. Hospital in Atlanta, Georgia. They instituted a multi-disciplinary team to eliminate redundancies within their ST-elevation myocardial infarction (STEMI) interventional process and incorporated critical strategic changes to achieve exceptional results. The outstanding results, in my opinion, should be viewed as a two-part success story. Firstly, the authors need to be commended for achieving a mean D2B time of 69 minutes and 84% D2B time < 90 minutes for the year 2007. By itself, these are excellent results. A second, even more noteworthy achievement, is the process changes that resulted in these dramatic improvements — in 2004, the same institution was struggling (like most of us) with D2B < 90 min of 16% and mean D2B times of 180 minutes. I would like to highlight some of these process changes and offer them as possible solutions for various other institutions that are in the process of improving their D2B outcomes: 1. STEMI success is rooted in teamwork: It is critical to incorporate a broad-based team, as was done at Saint Joseph’s Hospital, where team members included cardiologists, emergency department (ED) physicians, hospital executives, directors and managers of the ED, cath lab, nursing, information technology, and patient safety and quality. 2. A STEMI intervention is a process, not merely a procedure: This vital concept is mandatory — it is across-theboard process changes that resulted in the success at Saint Joseph’s. Their process began with systematic data collection and problem identification. Based upon this meticulous research, the team collaborated to offer implemental solutions. As a final process, the team conducted evaluation of their process change. 3. Integrated pathways of STEMI triage and transfer must be regional: The broad American College of Cardiology/American Heart Association guidelines provide a framework for performing optimal STEMI interventions. While following these general guidelines, local hospitals http://www.stemiinterventions.com http://cathlabdigest.com/article/7659

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

Cath Lab Digest - May 2008 The King Faisal Specialist Hospital and Research Centre Cell Therapy in the Cath Lab for Heart Failure: A Look at MyoCell® Therapy and the SEISMIC Trial Performance Improvement Strategies Speed Up Treatment Times in the Management of ST-Elevation Myocardial Infarction (STEMI) Patients Contents Clinical Editor’s Corner Commentary: Performance Improvement Strategies Speed Up Treatment Times in the Management of ST-Elevation Myocardial Infarction (STEMI) Patients Ask the STEMI Expert Comparing Drug-Eluting Stents and Bare-Metal Stents SICP: The Ten-Minute Interview with… Christopher Kambak, RT(R) Cardiac Cath Lab Economics in a Public Hospital of a Developing Country Keeping Your Heart & Vascular Employees: Proven Ideas for an Effective Retention Plan Unspoken Words Ask the Clinical Instructor Society of Invasive Cardiovascular Professionals Meetings Calendar Education Center What Do You Think? Clinical & Industry News Classifieds Advertisers Index

Cath Lab Digest - May 2008

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