Cath Lab Digest - December 2007 - (Page 12) 12 STEMI INTERVENTIONS DECEMBER 2007 “STEMI” Protocol (St. Luke’s Episcopal Hospital Emergency Dept.) ST Elevation Myocardial Infarction June 2007 (revised 10/15/07) Triage: Patients with active CP suspicious of ACS-triage Priority 1 1. Brief targeted history and VS including O2 saturation 2. STAT EKG: Obtained and interpreted within 10 minutes of arrival in ER • EKG interpretation done by ER physician. If the ER physician is not immediately available and there is obvious ST elevation in any lead (1 thru 12), the ER triage nurse should: Δ Call the SLEH page operator (# 54146) to activate the “STEMI Protocol” (provide patients name, location, & unit phone #) Δ Notifies the Cardiology House Officer Δ Notifies the AMI Cardiologist on-call Δ Notifies the Cardiac Catheterization Lab team Δ Notifies the Interventional Cardiology Fellow on-call Δ Notifies the Rapid Response Nurse (for transport to CCL) Δ Stemi Nurse & House ICU Nursing Supervisor (Only the AMI cardiologist and the Cardiology House Officer are expected to respond via telephone/in-person to the ER or in-patient unit) 3. Transfer patient to a treatment room • Place patient in a gown • Get patient completely undressed • Notify admitting clerk to check valuables or give to family member. 4. If appropriate, the ER secretary should notify the patient’s private cardiologist. TREATMENT “PRIORITY”: 1. ASA 325 mg P.O. (chewable) if no contraindications and patient has not taken within the last two hours. 2. Clopidogrel (Plavix) 600mg P.O. 3. Start IV Saline Lock with NS TKO via dial-a-flow (preferably left arm) 4. Draw labs: Chest pain panel, (repeat cardiac enzymes in 6 hours), PT/PTT, medication levels if applicable, consider d-dimer (younger patients), consider BNP (patients with SOB or history of CHF). 5. Metoprolol (Lopressor) 5mg over 2-5 minutes IV every 5 minutes x 3 doses. Hold if SB/P < 100mmHg, evidence of overt CHF, HR 92% 8. Transport to CCL — ASAP Note: Unless otherwise instructed by a physician, the patient should be transported to the CCL as soon as the CCL Team is available. If a Rapid Response RN is not available to transport the patient to the CCL, the ER Assistant Nurse Manager/Charge Nurse should be consulted for patient transfer assistance. If appropriate (CCL team not in-house), a Cardiology Fellow and/or the Cardiology House Officer, and an RN (ER nurse or ICU Nursing Supervisor) should accompany the patient to the CCL Holding Area Bed #5 until the CCL call crew is available. Additional STEMI Guidelines: per patient assessment need! • Administer NTG 0.4mg SL; if pain unrelieved, may give up to 3 doses every 5 minutes; if no contraindications (i.e., SB/P< 100mmHg, severe aortic stenosis, Viagra use, caution in known R-sided infarcts) • Morphine 2-4 mg IV x 1 dose if CP not relieved by SL NTG • Complete R-sided EKG if evidence of IWMI; caution with NTG, Beta Blockers, Morphine, and diuretics in RV infarcts. • CXR: Portable if patient unstable; PA/LAT if patient stable Approved: STEMI committee June 2007 (revised 10/15//07) Dr. J. Wilson, Chairman Dr. J. Stroh, Co-Chairman CCL/share/STEMI protocol 11. 12. 13. 14. STEMI patient care priorities of treatment. No system for procedure/ process review. Lack of time performance guidelines for the different segments of patient care. An absence of EKG telemetry transmission between ED and EMS for advanced hospital notification. Parking for cardiac cath lab staff responding to emergency was less than optimal. MI). Yes, STEMI patients are different from other AMI patients. 5. Lack of standard catheterization protocols and equipment. 6. Lack of guidelines for initiating a STEMI page. A less-thanefficient paging system (physician answering services, ED vs. hospital operator paging). 7. Turf issues between ED and cardiac cath lab staff. 8. Turf issues between cardiologists. 9. Less-than-optimal communication between all members of the patient care team. 10. Need for staff education (ED and cardiac cath lab) on This one article does not permit a full accounting of how St. Luke’s addressed each of these challenges and concerns, but essentially, we found solutions in the standardization of protocols and processes. One significant change was to empower the ED triage nurses to initiate the STEMI page without an ED physician’s or cardiologist’s direction. Before instituting this change, only a cardiologist could activate the cardiac cath lab team. We went one step further and empowered the triage nurse to activate the STEMI protocol. If a patient presented with a complaint of chest pain (or associated symptoms) then a 12-lead EKG was immediately performed. Since the triage nurse was the first clinician to look at the EKG, it made sense to empower the triage nurse to initiate the STEMI page. This change in practice easily took 20-30 minutes off the total treatment time. There was some concern expressed that nurses cannot and should not “diagnose,” but having the triage nurse accept this responsibility was a procedural/process issue, not a medical diagnostic issue. The page merely put all the players in motion and got them to the patient more efficiently. Before any patient went to the cardiac cath lab, he or she was seen by one of the cardiology fellows (CCU fellow or Cardiology House Officer) or a staff cardiologist to confirm that the ST-elevation was due to MI. Yes, we initially had a lot of false alarms. Did we care? No. We felt strongly that 100 false positives were better than just one false negative. We also decided that if the cardiac cath lab call crew got paged and then cancelled, then they were still paid. It is hoped that as a result of experience and time, these false alarms will decrease. Another significant change in process was to the notification system.
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