STEMI Care: Evolution of a Benchmark

     Time is the enemy when it comes to prehospital care. Pick a critical injury or illness, and you will usually hear a prognosis dependent on time. Once in a while, however, we manage a minor victory over Father Time, especially when we can steal back precious minutes and put them to better use. We've seen this not only with trauma care, but also in advances in stroke treatment and interventional cardiac care. The mantra we cite now is, "Time is muscle." The faster we can get time-sensitive patients recognized and into functioning systems of care, the better their overall outcomes. With the implementation of a program to recognize and treat suspected STEMI patients from the field to the table, the University of Medicine & Dentistry of New Jersey (UMDNJ) has managed to do just that.

     UMDNJ is the parent organization of The University Hospital (UH), New Jersey's premier Level I trauma center, located in Newark. UH-EMS is a hospital-based tiered service providing ALS and BLS coverage for Newark, Newark Liberty International Airport, Port Newark and Port Elizabeth, as well as primary ALS coverage for Orange and East Orange.

     In 2005, members of the UMDNJ cardiology department reviewed the department's procedures for STEMI patients, because their average door-to-balloon time was exceeding acceptable standards. They wanted a way to give cardiologists earlier notification of STEMI patients, and to consider the possibility of bringing recognized patients from the ambulance directly to the cath lab, bypassing the emergency department. "The name of the game is to open up the artery as soon as possible," says Vivek Dhruva, DO, who was the chief academic fellow of cardiology at the time the STAT-MI (for ST-segment Analysis using wireless Technology in acute Myocardial Infarction) project was proposed.

     Marc Klapholz, MD, FACC, FCSAI, director of cardiology, was the architect behind the program. After sketching out a process, he consulted every department to be involved: EMS, ED, information services and technology (IST), administration, cardiology, cath lab managers, regulatory affairs and the hospital's medical director. Medtronic/Physio-Control and Verizon Wireless were also consulted. Potential roadblocks were identified, such as an ongoing problem with bad or missing wires to connect cell phones to monitors to transmit EKGs.

     Regulatory compliance issues were a priority as well, especially if the ED was going to be bypassed. Completing the medical screening exam is an EMTALA requirement that had to be addressed. Other administrative issues included how to properly register patients and acquire appropriate consent in an expeditious manner. There was also consideration of what to do if the arteries were clear and no MI was present.

     The technology component was a challenge—how to efficiently transmit the EKG, and once it was sent, how to ensure it got to the cardiologists. What would be the best way to notify the paramedics about the patient's destination (cath lab vs. ED), not only during normal hours but after hours as well?

     The original plan included upgrading UMDNJ's LIFEPAK 12 monitors to allow wireless Bluetooth EKG transmission via pre-paired cell phones. An EKG receiving station (Medtronic's LIFENET software on a dedicated PC) was placed in the cath lab. "Smart" phones were issued to all cardiology fellows, several attending physicians and the chief of cardiology. These contained a PDF reader program to view EKGs. We then created e-mail accounts specific to each phone.

     The existing ED receiving station was reconfigured to transmit STEMI EKGs up to the cath lab's station. The cath lab station converts each EKG to a PDF and e-mails it to the smart phone accounts. It then pages designated pagers.

     Once the technology was up and functioning, it was time to implement the procedures. Updated guidelines were put in place for 12-lead EKGs, advocating early acquisition by paramedics on any patient meeting the criteria for chest pain or suspected of having a cardiac event.

     If the paramedics suspect a STEMI and the patient is going to University Hospital, the paramedics transmit the EKG not only to medical control, but to the UH STEMI group as well (via an option on the LIFEPAK 12). Dispatch is also notified. The cardiology fellow receives and views the real-time EKG and then calls dispatch for a phone patch to the paramedics' cell phone. The paramedics then conduct a brief phone consultation with the cardiologist, who directs them either to the ED for evaluation or directly to the cath lab based on their report and the 12-lead.

     For off-hour patients (usually nights and weekends), the hospital committed to a 30-minute lead time for opening the cath lab, so the faster the acquisition time and consultation, the better. Those patients go directly to the ED to await the opening of the cath lab unless otherwise directed.

     The process of calling the dispatch center for patches proved futile. It was time-consuming, and sometimes the paramedics did not (or could not) notify dispatch that they'd transmitted the STEMI. The dispatcher on the radio did not always relay to the ones working the phones, so they had no idea which unit to call or would inadvertently dial the wrong unit. We took the dispatch center out of the loop by embedding the phone number of the cell phone paired with that LIFEPAK 12 onto the actual EKG, so the cardiologist would know automatically which number to dial.

     The next pitfall that arose was when there was a transmission failure or an issue with the cell phones (no signal, dying battery, etc.). The cardiology on-call schedule is given to dispatch each month so dispatchers can notify the cardiologist on call if the paramedics are reporting a STEMI but can't transmit. This is rare but works well as a backup plan.

     In an urban environment, the prehospital acquisition of 12-lead EKGs was not universally viewed as beneficial. With short transport times and unique barriers to care, they can be a time-consuming investment with little return. Most EDs, at least until now, do not factor them into their initial care. The paramedics were dubious at first as to what the actual effect on patient outcomes would be. It was difficult to illustrate how vital the prehospital role was to the success of the system. When the program was implemented, there were some immediate success stories, patients who survived lethal blockages and had terrific outcomes based almost exclusively on the efficiency of this new system. This went a long way toward convincing the line staff that the program worked.

     We were able to demonstrate substantial improvements almost immediately when it came to early recognition and care of STEMI patients. With the advent of the STAT-MI program, cardiologists knew about patients an average of 13 minutes before their arrival, versus 70 minutes after. Door-to-intervention times were literally halved, with a median time (for all comers, including off-hours) of 81 minutes. Plenty of individual cases fall below that, with Klapholz achieving his own personal best D2B time on a recent case at 18 minutes.

     The paramedics quickly saw the advantages as the process worked and went from dubious to enthusiastic about the program. They were excited to have a significant role in STEMI care and be a vital part of this cutting-edge process. They've even developed a sense of competition, seeing who can get the fastest door-to-balloon time or who will catch the most STEMIs. There was initial resistance from the ED, especially since patients were bypassing them, but they came on board in light of the good outcomes.

     Educational gaps that weren't obvious in the past became noticeable. Some of the paramedics had been practicing 10 years or more, and when they became certified 12-leads were not part of the curriculum. Suddenly we had to bring everyone up to basic competency with 12-lead acquisition and interpretation—focusing, of course, on STEMI recognition.

     Fortunately, the way the process was implemented and evolved, any suspected ACS patient going to UH has a 12-lead transmitted. Even when it's not a STEMI, it's a great way of notifying the fellow that there's a potential cardiac patient in the ED, and that alone reduces their consult times with the ED physicians. Since the inception of the program, there have been no missed prehospital STEMIs transported to UMDNJ by our department. That is mostly a result of conservative care on the part of the paramedics. Approximately one in four transmissions results in the patient going directly to the cath lab.

     Each week the cardiology department offers a one-hour conference where it reviews cases from the previous week. Each conference usually features one or two EMS cases. The paramedics have an open invitation to attend and learn, to follow up on their cases and increase their knowledge. We stress cardiology as a focus, routinely encouraging providers to attend educational programs that will help them build a strong foundation not only in 12-lead interpretations, but in emergent cardiac care as a whole.

     The process is dynamic and evolves to meet needs and technology changes. Wireless Internet modems were recently added to the LIFEPAK 12s, making the transmission time even faster and no longer reliant on cell service. We are currently negotiating a similar process with other area PCI centers, as well as looking to allow other paramedic services to transmit directly to the UH STEMI group.

     Entering our third year, we now have the experience and numbers to begin to really look at individual components and introduce them as QA measures. Examples include evaluating intervals from EMS arrival to first 12-lead EKG acquisition or first aspirin administration. While door-to-balloon time is an important benchmark, we think we can do more. We're evaluating EMS-contact-to-balloon time, with a goal of 90 minutes or less. Another parameter we're considering is recognition (onset of symptoms)-to-balloon time.

     As a result of the success of programs like STAT-MI and the proven benefits of rapid cardiac catheterization of the STEMI patient, New Jersey is developing statewide STEMI triage guidelines. Educational programs are being developed along with these protocols in a unique parallel to the prehospital trauma triage guidelines presented over 25 years ago.

     For systems considering implementing programs, get every player involved right from the start, from paramedics to administration, medical directors, IST, cath lab staff, cardiologists and registration—it's easier to identify your roadblocks this way. Feedback to and from the paramedics is huge; listen to what's working and what isn't. When your system works, tell them! Follow up on your cases. Positive reinforcement and case outcomes go a long way with EMS providers. They will feel good about getting STEMI cases to the cath lab with door-to-balloon times of less than 30 minutes, especially when they see a patient discharged with no permanent deficits or damage.

     As EMS providers, we've become a welcome addition to the interventional cardiology process, and we work with our counterparts toward one common goal: to provide optimal patient care in the face of devastating cardiac events—and maybe, for once, beat the clock.

     William Dougan, MICP, is the ALS coordinator for University Hospital EMS in Newark, NJ. Contact him at douganwi@umdnj.edu.

     Tracey A. Loscar, MICP, is the training supervisor in charge of QA/PI at University Hospital EMS in Newark, NJ. Contact her at taloscar@gmail.com.