Quality Corner: A National Standard for STEMI Care

A half million Americans suffer ST-elevation myocardial infarction (STEMI), out-of-hospital cardiac arrest (OOHCA) or both every year. The latest data from the American Heart Association shows a majority of those STEMI patients fail to receive either percutaneous coronary intervention (PCI) or thrombolytic therapy. They further report 40% of those who receive PCI and 50% of those who receive thrombolytics fail to receive those interventions within the recommended time frame.

The chair of the American Heart Association’s Mission: Lifeline steering committee, Gray Ellrodt, MD, makes a point of stating EMS is critical to their goal of improving those deficiencies.

The challenge for EMS to improve STEMI care is to ensure early acquisition and accurate interpretation of 12-lead ECGs in all possible cases of acute coronary syndrome (ACS), including post-cardiac arrest resuscitation patients. Once identified, early activation of a STEMI alert at the receiving hospital is the next critical step.

Twelve-lead ECG is standard of care in 21st century EMS. And at this point most, if not all, paramedics have received some sort of training in basic 12-lead interpretation. But for many EMS agencies that basic training is all they've ever received. In many cases, EMS providers have been left on their own to become proficient with no system in place to review their interpretations for accuracy and provide feedback, and no additional training being offered to help the provider expand their knowledge base.

The more ambitious providers will do additional research via books or Internet resources on 12-lead interpretation. High performance providers will also perform more ECGs—not just limited to the required chest pain calls, but including unexplained shortness of breath, syncope and other non-specific symptoms where the underlying cause could potentially be myocardial ischemia or injury. Consequently, as with any skill, the more you do, the more you learn and the more proficient you become.

But in order to have the biggest impact on reducing morbidity and mortality of STEMIs, allowing each individual EMS provider to determine the importance of early ECG acquisition and self-educate themselves is not good enough. The solution to the problem is to promote an actual system of patient care, one where EMS, ERs and interventional cardiologists are all on the same page, recognizing the same diagnostic criteria and, most importantly, all committed to working together in a team effort for the benefit of better patient care. This is the goal of the American Heart Association’s Mission: Lifeline project.

As in so many other aspects of reducing risk, morbidity and mortality of cardiovascular disease, the American Heart Association has once more taken the lead in promoting STEMI systems of care via its Mission: Lifeline project.

Systems

Mission: Lifeline offers recommended criteria for EMS, STEMI Receiving (PCI capable) hospitals and STEMI Referral (thrombolytic capable) hospitals to create STEMI systems of care capable of achieving first EMS contact-to-balloon time of 90 minutes and door-to-needle time of 30 minutes.

Accreditation

Mission: Lifeline also offers accreditation of proficiency of ECG interpretation via their online Rapid 12 Lead Interpretation course. The curriculum covers basic anatomy and physiology, proper technique for acquiring and interpreting 12-lead ECGs, and indications for activation of a heart alert. It is a two-part course with module one covering general knowledge of 12-lead ECGs, ACS and STEMIs, and module two requiring the student to interpret 50 different 12-lead ECGs and determine whether or not to call a heart alert.  To successfully pass, the student must achieve a minimum score of 85% in each of the two modules. The course takes three to four hours to complete and upon successful completion a certificate of completion is issued. The Rapid 12 Lead Interpretation course has been approved for 4.5 CEUs by CECBEMS.

Recognition

Achievement awards are available based on 75% compliance of the following criteria:

• Patients over 35 years of age with non-traumatic chest pain receiving a prehospital 12-lead ECG.
• STEMI patients treated and transported directly to a PCI capable hospital, with prehospital first EMS patient contact-to-balloon time of 90 minutes or less.
• STEMI patients treated and transported to a thrombolytic capable hospital with a door-to-needle time of 30 minutes or less.

The Mission: Lifeline bronze award is authorized for meeting the above criteria for one quarter of a year; the silver award is authorized for meeting all criteria for a full year; and the gold award for is authorized for meeting criteria for two full calendar years.

To learn more about the American Heart Association’s Mission: Lifeline and how it can help you create a system of STEMI care, visit www.heart.org/missionlifeline.

Joe Hayes, NREMT-P, is deputy chief of the Bucks County Rescue Squad in Bristol, PA, and a staff medic at Central Bucks Ambulance in Doylestown. He is the quality improvement coordinator for both of these midsize third-service agencies in northeastern Pennsylvania. He has 30 years' experience in EMS. Contact Joe at jhayes763@yahoo.com.