STEMI Alert protocol

I’ve been working on a STEMI Alert protocol for my fire department. Basically, this is how we will notify our receiving hospital of a possible STEMI.

At present, a STEMI Alert will not have the force of a Code STEMI which is the term the ED physicians use to activate the cath lab.

The STEMI Alert will get a time stamp, and our goal is to start tracking the accuracy of paramedic-initiated STEMI Alert when compared with ED physician-initiated Code STEMI. We will also track the time interval between the STEMI Alert and Code STEMI.

This should empower our organization to target continuing education and training to paramedics who fail to call a STEMI Alert when appropriate (false negatives) and paramedics who call a STEMI Alert when they shouldn’t (false positives).

I suspect this will yeild some interesting case studies. I am particularly interested in ECGs that result in false positive cath lab activations. I’ve seen some fascinating STE-mimics from the RACE program in North Carolina. They’re great ECGs to learn from!

The beauty of our proposed STEMI Alert program is that it will give us the safety net of the ED physicians until such time that our STEMI Alerts are in-line with their Code STEMIs.

The process will probably end up looking something like this:

According to this flow chart, patients for whom the GE-Marquette 12SL interpretive algorithm fails to give the ***ACUTE MI SUSPECTED*** message will only get a STEMI Alert when the QRS duration is less than 120 ms and reciprocal changes are present.

It remains to be seen whether or not this will lead to a significant number of false negatives. I suspect the opposite will occur and the flow chart will significantly limit the number of false positives.

I’d love to hear what you guys are doing around the country! What do your protocols look like?

*** Update 12/12/09 ***

The training PowerPoint for our STEMI Alert protocol is now complete. Here is version 1.0 (there have subsequently been minor updates).

HHIFR STEMI Program – STEMI Alert Protocol Traininghttp://static.slidesharecdn.com/swf/ssplayer2.swf?doc=stemialertprotocoltraining-091211184841-phpapp01&stripped_title=hhifr-stemi-program-stemi-alert-protocol-training-2702265

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10 Comments

  • akroeze says:

    Here in my little section of Ontario of the ECG reads ***ACUTE MI SUSPECTED*** we do a "Primary PCI Protocol". We proceed to the local ER, they give the patient Plavix and a Heparin bolus and we then immediately go to the cath lab. This happens in the doorway to the ER and is mandated to take less than 10 minutes from arrive at hospital to depart hospital again. If the patient's onset of symptoms is less than 1 hour they will also get TNK.We then bring the patient to the tertiary care centre (about an hour away) and they get placed straight onto the cath lab table.

  • Tom B says:

    It would be interesting to compare your outcomes with areas that triage straight to primary PCI without stopping at the local community hospital for Plavix and heparin. The requirement that symptom onset be less than 1 hour for TNK to be given en route is particularly interesting! There's no doubt it places the risk/benefit of thrombolytics squarely in the patient's favor, but I thought that "facilitated PCI" had fallen out of favor.Perhaps they found a subgroup (early presenters) who fared better with facilitated PCI. It's been a while since I've looked at any studies. ASSENT-4 and PATCAR come to mind.Has any of your local data been published? Thanks for sharing!Tom

  • medicblog999 says:

    Hi Tom,Well, here's what happens in the North East of England. If a patient presents with Cardiac Chest Pain and the 12 Lead shows ST elevation (same height criteria as yours) and anatomically adjacent leads, then the 12 lead gets transmitted directly to the PPCI centre. We then phone the unit directly to check that they can take them. In the vast majority of cases that is what happens and the patient is taken straight from the ambulance and onto the cath lab table. There have been a couple of occassions when the PPCI centre has refused a patient for various reasons and in this case, we then transmit the 12 lead to a local coronary care unit and then transport the patient there.This has only been active for the past two years. Before that we were autonomously thrombolysisng with STEMIs With TNK in the ambulance once they met our thrombolysis criteria. I was fortunate (or unlucky depending on your view point) to have the opportunity to Thrombolyse over 20 patients in the relatively short time that we were doing it, before we changed to PPCI. Our Cardiac network decided straight away Not to go with facilitated PPCI, so as soon as the centres went live, all the TNK was removed from our vehicles.I will get the algorhythm from work on Thursday and email it to you as soon as I can.

  • Tom B says:

    Mark – It's always interesting getting an international perspective! I personally think you were lucky to give thrombolytics in the field. I'm sure that was quite an experience, even if prompt, expertly performed primary PCI has emerged as the preferred therapy.The question still remains as to whether or not some patients benefit from thrombolytics prior to PCI, how much they benefit, and whether or not it's "worth it" from a risk/benefit standpoint when primary PCI is available in a regionalized system.In the United States there are vast regional differences in how STEMI patients are handled. For example, I live in in South Carolina. We are in the process of building a state-wide STEMI system through AHA Mission: Lifeline and its partner organizations.North Carolina (our neighbor to the north) has already built a very successful state-wide STEMI systems called the RACE program (Reperfusion of Acute Myocardial Infarction in Carolina Emergency Departments) that of course includes a critically important prehospital component.I recently gave a talk at the Georgia EMS & Educator's Conference in Savannah, Georgia (our neighbor to the south) and I took an informal poll at the beginning of the lecture. A small minority of paramedics in the hall worked for an EMS system that was equipped with 12 lead monitors.That's three contiguous southern states at three different stages of STEMI system development.Looking forward to checking out your algorithm!Tom

  • Christopher says:

    In our three county area of NC, there are a few different protocols. The least restrictive basically relies on the paramedic to interpret the 12L and if it meets criteria (set by the RACE program), then a Code STEMI is called and the pt bypasses the ED. If imitators are present (LBBB, LVH, etc) the pt may be pitstopped in the ED first to avoid false positives. The most restrictive counties require that the 12L say ***ACUTE MI SUSPECTED*** and the paramedic must agree.

  • Tom B says:

    Christopher – The STE-mimics are the Achilles heel of paramedic 12-lead ECG interpretation.I personally think there's no good reason that paramedics can't be trained to not only identify the presence of a STE-mimic, but also to identify STEMI in the presence of a mimic.Unfortunately, not everyone agrees. What I find most confusing is that many of the same paramedics who want the authority to read the ECG on their own (without interpretive algorithms or ECG transmission) don't seem to think it's realistic for paramedics to learn how to really interpret a 12-lead ECG.You would think those were incompatable positions to hold.Tom

  • SoCal Medic says:

    Tom, Here they have a couple of options. The Hospital "can" chose to activate based on medic interpretation, they "can" chose to activate based on the monitor interpretation… but they "must" activate if the medic and monitor agree. In San Bernardino County they wanted the Paramedic involvement because not everything is perfect. This is still a very new system in that regard and has only been running for a year under the STEMI Protocol. There is still a lot of room for growth, especially in education, but I think they have a very good start downt he right path.

  • Tom B says:

    SoCal Medic (the other Christopher) – That approach actually seems pretty logical to me, especially if the ED physicians start activating the lab based on the paramedic interpretation after the paramedics prove they can do it.That's what the STEMI Alert process we're designing is all about. Collecting data to prove that paramedics can "make the right call." If it turns out we can't, then we're target our quality improvement mechanisms accordingly!Tom

  • Christopher says:

    Tom,I actually think the RACE program could expand to allow calling Code STEMI with imitators for paramedics in the near future. All paramedics and paramedic students (c'est moi) are supposed to take Tim Phalen's 12L course within a year or so. There will be sections on STEMI in the face of imitators coming soon. Hopefully, after those are released the false positive rates will come down and we'll be back to Code STEMI based on our opinion.

  • Tom B says:

    Christopher – I've taken Tim Phalen's online course through EMSPIC (www.emspic.org). It's free for all NC, SC, and WV paramedics, and I thought it was an excellent basic STEMI recognition course.But, as you say, it stops at identifying the presence of a mimic (and not how to identify STEMI in the presence of a mimic).I wanted to do a review of the class, including "screen shots" (for which I wanted Physio-Control's permission). Tim sent an email to Physio-Control on my behalf, but to my knowledge they never replied.I think the next version that includes "STEMI in the face of imitators" is exactly what EMS needs. Tom

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