LUMEN 2009 Workshops Highlight Pertinent Issues in STEMI Interventions

Pre Hospital Management & Establishing Transfer Networks

LUMEN 2009, the world’s premier ST-elevation myocardial infarction (STEMI) meeting, will be held February 26-28, 2009 at the lovely Loews Hotel in resplendent Miami Beach, Florida. Lumen is a STEMI educational rendezvous for paramedics, emergency department staff, critical care nurses, cardiovascular laboratory technologists and nurses, internists, general practitioners, hospitalists, intensivists, clinical and interventional cardiologists, cardiac and vascular surgeons, and hospital administrators. LUMEN 2009 will provide a comprehensive review of the processes and procedures involved in the care of a STEMI patient. In addition, the symposium will provide updates by world experts in key areas of interventional cardiology and vascular interventions. The innovative CME agenda will include lectures, debates, workshops, certification courses and meaningful industry participation. Conducting the CME program for LUMEN 2009 are four co-directors, each of whom is a respective giant in interventional cardiology, door-to-balloon time processes, emergency medicine and in cardiovascular nursing: Samin Sharma, MD, Brahmajee Nallamothu, MD, William Hoekstra, MD, and Barbara Unger, RN. LUMEN 2009 is committed to improving STEMI care globally. Through this powerful meeting, attendees will acquire educational tools that will help them improve both the STEMI process and the STEMI procedure at their respective institutions. In this issue of Cath Lab Digest, we feature interviews with the LUMEN faculty about workshops focusing on pre-hospital STEMI management and the setting up of a STEMI transfer network. We begin our conversation with LUMEN Course Director, Dr. Sameer Mehta, author of the recently published Textbook of STEMI Interventions. Why is there so much emphasis on the two topics of pre-hospital STEMI management and the setting up of a STEMI transfer network? LUMEN is dedicated to improving global STEMI care, particularly door-to-balloon (D2B) STEMI interventions, with both the “procedure” of primary PCI and the “process,” whereby STEMI is promptly diagnosed and the patient is transported via EMS to an appropriate STEMI facility. By itself, the STEMI intervention (the “procedure”) is not very difficult once the focus is maintained on the culprit lesion and compulsive management of thrombus. It is the D2B time constraints of less than 90 minutes, the frequent off-hour presentations and (keeping low) false positive rates, that are the larger challenges. By contrast, the STEMI “process” is the larger and more difficult issue that needs coordination between four entities – the patient, EMS, the emergency department (ED) and the cardiovascular laboratory (CVL). Considerable chaos occurs during this complex interaction. LUMEN 2009 is devoting two full 2-hour workshops to demonstrate the benefits of simulation in improving this process. As far as it relates to achieving early reperfusion with D2B times of less than 90 minutes, pre-hospital management and establishment of transfer networks are two critical areas where major improvement can be made. The most successful regionalized STEMI systems (Abbott, Mayo and RACE) clearly demonstrate the value of early pre-hospital diagnosis and treatment for both the fibrinolysis and primary percutaneous coronary intervention (PCI) arm. On-site EKG and its immediate transmission and interpretation, or on-site interpretation, greatly facilitates the STEMI success as can be seen from results from Ottawa and from the SOCAL investigators. One of the most pertinent debates is whether resources should be spent in optimizing EKG transmission capabilities versus training advanced paramedics who can reliably diagnose STEMI. The workshop on pre-hospital management will discuss this issue as well as demonstrate the technical advancements in this field. Various industry representatives will also showcase their respective systems. In regard to setting up transfer networks, this complex subject is mired in myriad difficulties. It must be noted that most population-based STEMI studies demonstrate the transfer patient subgroup to have the longest D2B time delays. Establishing transfer networks and creating seamless transfer to a STEMI facility is the largest opportunity for improvement in STEMI care. What do you consider the highlights of LUMEN 2009? I think the LUMEN workshops are unique and provide tremendous opportunity for informal interaction with faculty. Each workshop has been carefully selected to address the most important issues in STEMI management — simulation, EKG diagnosis, cineangiographic review, nursing issues, thrombectomy, pharmacology, assist devices, transfer protocols, administrative, financial and legal issues, cooling/hypothermia and of course, the pre-hospital management and setting up of transfer networks. The workshops alone involve a strong 52-member LUMEN faculty! What is the larger mission behind LUMEN? I think we should quickly move towards a national STEMI policy akin to trauma care. Beyond this, I would like operators to master STEMI interventions and compulsively perform a quality primary PCI that achieves D2B time success and excellent long-term results. LUMEN is also dedicated to advancing in situ simulation to improve STEMI care, and finally, I think we are ready to have established protocols (for bivalirudin, as example) for transfer patients. James W. Hoekstra, MD Past President, American Society of Academic Emergency Medicine Chairman, Department of Emergency Medicine Wake Forest University School of Medicine Winston-Salem, NC Do you feel that present technology is adequate for prompt EKG diagnosis for STEMI? The present EKG technology is adequate for promptness of diagnosis, since it takes only a few minutes to do an EKG, and the door-to-EKG target of 10 minutes is easily attainable with the present technology. The current 12-lead technology is not, however, sensitive or specific enough to make the diagnosis of STEMI in a significant percentage of patients. Current EKG technology misses at least 20-30% of STEMIs, many of which are located in the posterior, high lateral, right, and inferior locations of the heart. In addition, the diagnosis of STEMI in the presence of bundle branch blocks remains problematic, with 12-lead sensitivities of only 15-30%. Better technologies, with either more leads, more spacial resolution, computerized mapping, and perhaps even bedside, rapidly available imaging techniques, are needed to increase our sensitivity for STEMI over what is presently attainable with the 12-lead EKG. If we look into the future and postulate that the ED would be bypassed as the patient is urgently taken by EMS to the CVL, where do you see the role of ED in STEMI care? The ED will continue to have a pivotal role in the care of STEMI. I don’t see this changing. At present, only one-third of patients with STEMI even arrive in the ED by EMS, and only 15-20% of those get an EKG in the field. The walk-ins and undiagnosed chest pain that turns out to be STEMI makes up the majority of STEMI care. The ED plays a pivotal role in these patients. The bypassing of the ED on the way to the cath lab is really only possible for a minority of patients, identified by EMS in the field, in care systems with destination protocols and pre-hospital cath lab activation. In those patients who are identified in the field with STEMI, the ED can only be bypassed if the patient is stable enough to transfer to the cath lab. The ED will still be needed to stabilize hemodynamically unstable or coding patients, even if the cath lab is activated from the pre-hospital setting. J. Brent Myers, MD, MPH, FACEP Medical Director Wake County Emergency Medical Services Raleigh, NC What are some of the key advancements in pre-hospital EKG systems? Key advancements include the ability to transmit EKGs via the internet rather than by modem/fax. This allows for rapid, reliable transmission as well as for the images to be emailed to multiple sites, including hand-held PDAs. Thus, the emergency physician, cardiologist and cath lab team can all receive the EKG and store it in the medical record prior to EMS arrival at the hospital. Do you have a wish list of exhibitors who should demonstrate their systems at LUMEN 2009? The main three companies that have transmission are Medtronic/ Physiocontrol, Zoll and Philips. Ralph G. Nader, MD, FACC, FSCAI Program Director, Interventional Cardiology Training Program Mount Sinai Medical Center Miami Beach, FL www.webmd.com/care/ralphnadermd You are an interventional fellowship program director at a major teaching institution. What role does primary PCI play in training of residents and fellows? The fellows take STEMI call with an attending and actively participate in the cath lab. They see the patient before and after. They scrub with the attending and contribute as much as they can. They do not “solo” the case. What are the specific D2B time issues that your institution faces? Ambulance delay, ED physicians misreading the EKGs and late presentation. Ivan Rokos, MD, FACEP (FACC) Emergency Medicine Physician Assistant Clinical Professor Geffen School of Medicine at UCLA Staff, Olive View-UCLA Hospital Staff, Northridge Hospital Los Angeles, CA Our work in southern California has not focused on inter-hospital transfer, but rather pre-hospital cardiac triage, wherein paramedics equipped with pre-hospital electrocardiogram (PH-ECG) machines diagnose STEMI in the field and transport that patient directly to a pre-activated primary percutaneous coronary intervention (PPCI) hospital designated as a STEMI Receiving Center (SRC). At present, we are trying to get inter-hospital transfer operational. You have devoted considerable time in establishing transfer networks in southern California. What were some of your biggest challenges and how did you overcome them? The status quo in STEMI care was that key providers essentially operated in “silos.” Emergency medical services (EMS), emergency medicine (EM), and cardiac catheterization labs (CCL) have co-existed for decades, but only recently have efforts been made to coordinate them into one seamless system that is patient-centered. Since EMS transports about 50% of all STEMI patients to any given hospital, regional EMS agencies are the new “mega-consumer” of quality PPCI. Hence, these regional EMS agencies are able to get a diverse and multi-disciplinary group of individuals from competing hospitals to sit down together and design a system that is truly patient-centered. The final system can really be distilled down to a simple agreement: EMS will transport STEMI patients only to designated PPCI hospitals that have agreed to submit door-to-balloon (D2B) and EMS-to-balloon (E2B) data back to the EMS agency as proof of quality care. The key item is restricting the system to STEMI, not the entire chest pain population. Our Los Angeles County data demonstrates that in a region of 10 million citizens and 32 STEMI Receiving Centers, only about 3 patients per day are diagnosed as STEMI by PH-ECG and preferentially transported to a PPCI hospital. This optimizes care for those STEMI patients, but minimally impacts those hospitals that are no longer receiving STEMI patients from EMS. How does the United States compare with Europe and Canada in pre-hospital management of STEMI care? The “tipping point” for many of the early STEMI system pioneers in the U.S. and Canada was the 2003 publication of two European studies, PRAGUE-2 and DANAMI-2, wherein transfer for PCI demonstrated better outcomes than on-site fibrinolytics. A 2003 NEJM editorial by Dr. Alice Jacobs, chair of AHA Mission: Lifeline, concluded that “PCI is worth the wait,” with the caveat that we have to “minimize the wait.” AHA Mission: Lifeline describes itself as a “national community-based initiative.” Hence I propose that there is ample opportunity for healthcare providers to become “STEMI Activists.” A local STEMI Activist works to get regional stakeholders connected in order to design the optimal system customized to their unique needs, resources, and barriers. A STEMI Activist can be an EMS provider, EM provider, CCL provider, quality improvement specialist, or administrator. The only key requirement is the desire to foster multi-disciplinary collaboration. The local AHA office can provide support to each STEMI Activist via Mission: Lifeline. Barbara T. Unger, RN, BS, FAACVPR Director, Cardiac Level One Services Minneapolis Heart Institute at Abbott Northwestern Hospital Minneapolis, MN You coordinate one of the most efficient STEMI programs in the world. What do you consider your program’s top feature? Open communication in regard to the details. The details of any program need to have a constant when so many people, departments, services and links must stay together during a fragile time. What were the biggest challenges in setting up transfer networks and how did you overcome them? One challenge in setting up the network was the speed at which it took off. Meeting the needs of both the “system” and still allowing for the individualism of 33 outstate hospitals and multiple EMS systems needs was probably the biggest challenge. Michel Le May MD, FRCPC, FACC Professor of Medicine (Cardiology) Director of the Coronary Care Unit and Director of the UOHI STEMI Program University of Ottawa Heart Institute Ottawa, Ontario, Canada The Ottawa STEMI program attributes its success also to its advanced paramedics. Can you share with us more information about the role these paramedics play and the process undertaken to train them? We have two types of paramedics who attend land ambulances in the city of Ottawa: the primary care paramedic (PCP) and the advanced care paramedic (ACP). Community colleges in the province of Ontario offer PCP and ACP diplomas. The requisite training is two and three years, respectively. The training program emphasizes anatomy, physiology, pharmacology, and mechanisms involved in acute injury and illness. Upon course completion, the graduating PCP is required to write a provincial certification exam called the Advanced Emergency Medical Care Assistant (AEMCA) exam. The PCP skill sets include semi-automatic defibrillation, administration of medication such as aspirin, epinephrine and nitro spray, initiation of peripheral IVs, and the application of the 12-lead EKG. The ACP needs a minimum of 2 years of experience in the field to qualify for training at the ACP level. The ACP program requires an additional one year of training in the classroom and in the hospital. The ACP skill set includes airway management (orotracheal and nasotracheal intubation), pharmaceutical therapy such as lidocaine, atropine, dopamine, and fentanyl, treatment of cardiac emergencies according to advanced cardiac life support (ACLS) guidelines, and 12-lead EKG interpretation. Training ACPs to read EKGs for the detection of STEMIs in Ottawa requires 2-3 hours of classroom teaching followed by a written exam. We now train the PCPs as well at interpreting EKGs for STEMIs. It has now become standard practice in Ottawa for all paramedics to interpret EKGs in the field and independently initiate transfer to the Ottawa Heart Institute for primary PCI. In your opinion, where should precious dollars go — funding paramedic training to diagnose STEMI or equipping EMS with EKG transmission capabilities? We have previously shown that paramedics can be trained to read EKGs with a high degree of diagnostic accuracy. The beauty of this system resides in its simplicity. In Ottawa, the current rate of false positives for STEMI is about 10-15% for paramedics and 10-15% for emergency department physicians. This is similar to that reported by centers in the United States. Our present system involves the paramedics directly in the diagnosis and management of STEMI and integrates them well within the circle of patient care. We presently feel no need to upgrade our ambulance equipment within the city boundaries in order to transmit EKGs. Potential problems with transmitting EKGs include 1) difficulty in transmitting the tracing, 2) precious time lost while awaiting a response from the physician interpreting the tracing at a distance, and 3) the cost for additional equipment.

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