10 Questions with Jodi Doering, RN – South Dakota AHA Mission: Lifeline Director
1.) How long have you been working with AHA Mission: Lifeline? Do you enjoy your job?
I have been with MLSD (Mission: Lifeline South Dakota) since September 16, 2010. My background prior to that is in EMS and as an RN in cardiology and Emergency Department nursing-all here in South Dakota.
I seriously with 100% truthfulness love this job. I have the opportunity to distribute an $8.4 million grant to the people of South Dakota to establish an ideal STEMI system of care in a very rural setting. I work with each of the 133 ambulances and 50 hospitals in building this system of care. We are putting at least one 12-lead monitor (Phillips, Physio-Control, or Zoll) in each of the 133 ambulances, as well as implementing Lifenet in each of the 50 hospitals. It is a little like being Santa Clause- with a catch- that you have to use the equipment and be an active participant in the system of care.
2.) How many PCI-hospitals are there in South Dakota and how are they distributed?
I have attached a map to outline.
The population of South Dakota is about 750,000. South Dakota is 76,000 square miles with 6 PCI facilities:
- One in Rapid City (near Mt Rushmore in the SW corner)
- One in Aberdeen (NW corner),
- One in Watertown (NW corner) and
- Three in Sioux Falls (SE corner)
The 3 in Sioux Falls represent two health systems so that’s why it only looks like 2 in Sioux Falls.
The entire NW corner of the state does not have a PCI capable hospital up to as far away as almost 200 miles. In addition, South Dakota only has 4 helicopters. 1 in Rapid City, 1 in Aberdeen, and 2 in Sioux Falls. We have a large area of the state that can only be covered by fixed wing (which we have 2 of-both in Sioux Falls) or ground ALS transport.
3.) Have you found that most urban areas have prehospital 12-lead ECG programs in place and do they transport STEMI patients directly to PCI-hospitals?
When we began this process with the 133 EMS agencies of South Dakota we found the following breakdown:
- ALS complete with 12 leads and transmitting = 8 (6%)
- ALS with 12 leads not transmitting. = 19 (14.3%)
- ALS with neither = 22 (16.5%)
- BLS w/12-Lead not transmitting = 3 (2.3%)
- BLS with neither = 81 (60.9%)
Keep in mind the agencies that are ALS are primarily a part time, volunteer ALS service and up to 80% of the time they are BLS.
The 8 agencies that had 12 leads and were transmitting prior to this process did not go directly go a PCI center. 6 did and 2 are located in very remote areas and were a part time ALS service. Bypassing their critical access hospital could have means as long as a 2 hour transport time. They were going to the nearest facility and calling for a helicopter or an ALS intercept.
4.) South Dakota has a lot of rural areas and one imagines a lot of volunteer BLS rescue squads and Critical Access Hospitals. In areas where STEMI numbers are low have you seen a reluctance to give thrombolytics (or arrange for transfer) without a cardiology consult?
YES! Note the capital letters and emphasis on YES. Part of the process of building or STEMI system of care is that we have a state wide protocol for administration of lytics in the non-PCI centers. The feedback has frequently been from the non-PCI centers:
- "We want to talk to the cardiologist to make sure."
- "We do different processes based on which PCI center they are going to." (lovenox, heparin, nitro, etc).
- "I don’t want to be the one to make that call."
5.) How has AHA M:L been working to help incorporate rural areas into regional systems of care?
At our statewide Mission: Lifeline task force we have representation from all size hospitals and EMS agencies. The reality is that our PCI centers are doing a great job, our focus needs to fall not only to EMS but the hospitals that reside outside of the 30 mile radius of our PCI centers. We involve representation from Critical Access hospitals, volunteer EMS, as well as our PCI centers. We also have a quality and education subcommittee that allows a strong voice from those smaller, rural facilities.
6.) We just saw a press release that indicates every ambulance in North Dakota will be outfitted with 12-lead ECG monitors. Can you tell us anything about that? Is something similar happening in South Dakota?
The North Dakota project will be very similar to South Dakota. Lead funder is The Leona M. and Harry B. Helmsley Charitable Trust, which is providing two-thirds of the total with a grant of $4.4 million. The State of North Dakota has committed $600,000, and a combined $1.3 million will be contributed by North Dakota’s largest healthcare systems:
- Trinity in Minot
- Altru in Grand Forks
- Essentia in Fargo
- MedCenter One in Bismarck
- Sanford Health in Fargo
- St. Alexius-PrimeCare in Bismarck
The Dakota Medical Foundation is supporting the initiative with a $100,000 grant, and the Otto Bremer Foundation has also committed $100,000 to Mission: Lifeline.
Minot, North Dakota already has a strong rural STEMI system with transmission of 12 leads from 12 rural EMS agencies, so while they are not putting in quite as many 12 leads as South Dakota, the models will be very similar. We face a lot of the same hurdles in regards to volunteers, miles, etc.
The grant allows for education of all EMT’s in the state in the “Learn Rapid STEMI ID” module put forth by the AHA, as well as education for all non-PCI center hospitals. In addition a statewide task force comprised of physicians, nurses, EMS, legislators, payors, administrators, etc will meet to direct this project- same as South Dakota. The ultimate goal for both of our states is simple — that we decrease time from calling EMS to reperfusion whether that is primary PCI or lytics.
North Dakota has just hired a Mission: Lifeline director that will start next month.
7.) Change is always hard and often comes with growing pains. What are some of the most difficult challenges you've had to overcome to help shorten treatment intervals for acute STEMI in South Dakota?
For the most part our partners have been very engaged and have realized that an intervention they do in the field (12 leads) can be the difference in life or death for our STEMI patients. Quite frankly, distributing a 12 lead monitor that could cost up to $25,000 is something these EMS agencies would never have been able to afford. That part makes it an easy “sell”.
The reality is that we are about 75-80% volunteer and we are now asking them to do/learn another thing for no pay. There is a fear out there that they could hurt someone by doing a 12-lead. I frequently reference that we are not asking to turn the mailman into a cardiologist — our first step is to put the patches on and push the buttons. The monitor itself can be overwhelming for a volunteer EMT that only runs 2-4 calls/month.
We have provided education to 1600 EMTS thus far and it has all been done in their local communities by an ALS partner from a neighboring community that they are already familiar with-that has helped immensely.
8.) Has anything special been done to help educate EMS personnel with regard to 12-lead ECG interpretation? How have they embraced that education and training?
We have developed a 4 hour education program that is being deployed by 22 “super users” from across the state (21 paramedics and 1 EMT-I). This education is done in their hometowns to decrease travel time. The content does go fairly deep in the process of anatomy, physiology and looking at 12 leads- however our main basis is to get correct lead placement and to transmit to their local hospital where they are transporting the patients. This education process will repeat for each of the 3 years of the grant.
9.) Any problems with "false positive" cardiac cath lab activations? What kind of feedback is given to EMTs, paramedics, nurses and physicians who take part in regional systems of care?
Not so many problems with false activations. We of course had one right away after we went up that was given back to me as “constructive criticism” but I rebut with the fact that in South Dakota we over triage trauma patients up to 50% of the time and as long as the staff believed they were doing what was right for the patient at that time it’s ok.
Feedback loop — that is the million dollar phrase right now. Having worked most of my career in the hospital- we have not done a good job of letting EMS (especially our volunteer services) know how they are doing. Our statewide task force is working on a universal feedback loop that will go back to not only the hospitals but the EMS agencies as well.
Two of 6 PCI centers currently have a feedback loop to the transferring in hospital that they send within 24 hours-but as you know that frequently does not get to the EMS agencies. It has come through loud and clear that involving EMS in the feedback is the one key element most of us are missing.
10.) Do you have any words of wisdom for states that are just getting started?
Be Persistent. Believe in it. Utilize your resources. Make friends with your EMS partners. (I mean that-sometimes we need to put the ER, Cath Lab, and EMS in the same room with some beverages and just let them become friends…..) Find a champion. I don’t care if it is the smallest EMS agency or one of the largest PCI centers-somewhere in that agency is someone who will help you carry the torch.
I have been told that this is impossible many times. My answer becomesm, “You will have to be one of those we just have to prove wrong”. Once you get a save, you are able to put many of those skeptics to rest.