STEMI benchmarks in EMS care

“Medic 1, respond to 101 Main Street for 65-year-old male with chest pain.”

You stop what you’re doing, get in your ambulance and respond to the scene. Upon arrival, your clock starts – it’s “time zero.”

You find your patient alert and sitting upright with pale, diaphoretic skin. His chest pain began 20 minutes ago and is increasing in discomfort. It’s now a seven out of 10.

Your partner assesses the patient’s vital signs while you start connecting your ECG electrodes. At first glance on the monitor screen, you see a sinus rhythm. Once your 12-lead print-out is complete, you make your interpretation: sinus rhythm with a rate of 70, narrow QRS-complex, no ectopy noted and ST-elevation >3 mm in leads V5 and V6 with reciprocal ST-depression noted in additional leads.

“Mr. Smith” is having a lateral wall acute myocardial infarction: a STEMI.

You administer 324 mg of chewable aspirin while your partner starts a large-bore IV and then completes a 15-lead ECG.

While still on-scene, you call your closest STEMI-receiving hospital and notify them of a cardiac alert. You outline the noticeable ST-elevation in V5 and V6, as well as its continued elevation in V8 and V9. You advise them of a 10-minute estimated time of arrival and conclude your call.

After initiating transport, the patient’s condition remains unchanged, despite advanced life support interventions. Upon arriving at the hospital, you’re met outside of room 1 by the emergency department nursing staff and the attending physician.

“Dr. Clark” agrees with your findings and feels the patient is stable enough to be transferred directly to the catheterization lab while its team prepares for the case. Your patient remains on your cot with your monitor leads and defibrillation pads in place while you transport your patient directly to the lab with a nurse at your side.

The interventional cardiologist begins the case and reperfuses Mr. Smith’s distal portion of his left anterior descending (LAD) artery. Mr. Smith is a STEMI save.

EMS benchmarks help provide data-driven solutions

According to an article in Cath Lab Digest by Kevin Miracle, a recruitment consultant for Corazon, Inc., “EMS agencies can play a major role when it comes to deciding transport destinations for patients suffering from an ACS or neurologic events, as well as a host of other conditions. This emphasizes the importance of providing EMS personnel a clear understanding of the organization’s clinical capabilities, as it can impact where patients are transported, consequently affecting patient volumes and accompanying revenue.”

While the patient’s “time zero” starts when their symptoms begin, our clock starts once we arrive on scene and make patient contact. From this point forward, our clinical decision making plays a role in our patient’s care.

This real example of purposeful care, rapid notification, and collaboration between EMS and the emergency receiving staff at a STEMI-receiving hospital illustrates a number of opportunities for data extracting based on a variety of benchmark times that occur throughout the duration of these events:

• Benchmark 1: Arrival/first contact. There are a number of uncontrolled factors that lead to our actual response time, so it’s more reliable to designate our arrival time as the beginning of our clinical care. Once contact is made with the patient, your assessment begins and you start to formulate a differential diagnosis. This is your first medical contact (FMC) time, and will follow your call through its completion.
• Benchmark 2: ECG time. Recognizing that the patient’s symptoms could be cardiac in nature prompts you to obtain a 12-Lead ECG. Based on established criteria, identifying ST-elevation turns your course down an emergent path where “time is muscle,” and immediate notification to a STEMI-receiving hospital is critical. Even though you’ll be on scene for a few more minutes, an early notification can activate cath lab teams and significantly expedite their preparation process. Your goal, from this point forward, is to have your patient reperfused within the next 90 minutes. This presents your first benchmark opportunity, which is first medical contact (FMC) to ECG time (FMC2ECG). Also incorporated into this benchmark are the administration of aspirin time, which should follow shortly after STEMI recognition (FMC2ASA), and the alert time, which will correlate to the overall EMS awareness time of the STEMI event.
• Benchmark 3: Door time. The patient’s arrival at the emergency department represents their door time. This is also the internal start time that hospitals use to benchmark their patients, both walk-ins and those arriving by ambulance. Even though the patient is now at the hospital, our role in EMS shouldn’t stop there. This is the period of time between the patient’s actual percutaneous coronary intervention (PCI); thus, the patient’s door to balloon (D2B) time.
• Benchmark 4: ED out time. Even though the patient is now part of the emergency department’s care, it’s still important to consider the patient’s length-of-stay in the emergency department as a part of their overall treatment plan, and something we can play an active role in. If we can perform time-saving actions, like starting one or two large-bore IVs, removing as much of the patient’s clothing as possible, shaving the patient’s wrists or groin area and applying radio-transparent defibrillation pads to the patient’s chest, then we can actively save the emergency department (and the patient’s heart) minutes off of their overall reperfusion time. We can also work with the hospital staff to facilitate a direct-to-cath process, which limits the patient’s time in the ED and streamlines their timeline toward reperfusion. This benchmark is all about collaboration and represents our total ED time.
• Benchmark 5: Balloon time. The patient’s vessel has successfully been reperfused and vital oxygen-saturated blood can reach the distal portions of his/her coronary vessels. This notes the stop time of our data tracking and completes our first medical contact to balloon (FMC2B), alert to balloon (Alert2B) and door to balloon (D2B) times.

Using data to drive care and cooperation with STEMI-receiving hospitals

Collaboration of care and benchmark tracking tie together the role of data management in EMS. When we’re able to track our on-scene times, correlate them to various interventions on-scene and then combine them with the overall course of events within the emergency department, we’re able to get a comprehensive look at patient care from the patient’s perspective, not just our own.

If we recognize that we’re taking 15 minutes on scene to acquire our first 12-lead ECG with chest-pain patients, then we’ve recognized a problem that we can fix. To mitigate this, work with your crews to prioritize your ECG and decrease your FMC2ECG time down to 10 minutes or less. Accomplishing this will send a cascade of positive influence down the course of this call to affect the FMC2ASA, Alert2B and overall FMC2B times.

If the ECG seems to be the hold-up, identifying standardized STEMI criteria can help crews to recognize a heart attack and begin the alerting process. Examples of cardiac alert criteria may include the following:

1. Chest discomfort consistent with acute coronary syndromes (ACS).
2. 12-lead ECG showing ST-elevation at least 1mm in two or more contiguous leads.
3. Patient age between 35-85.
4. Narrow QRS-complex rhythm.

Photo courtesy of: https://www.centura.org/sites/default/files/inline-files/Cardiac-Stroke-Sepsis-Alert-Cards-Jul-2017.pdf

Identifying our strengths, as well as our weaknesses, in terms of STEMI recognition and hospital notification are all results of data management. When we’re accountable for our actions with patient care, we’re more likely to focus our attention toward successful actions that can lead to successful metrics.

Noticing trends of improper ECG interpretation could present as a teaching point for crews in the future. The same holds true to falsely alerting hospital staff of possible STEMI patients. Perhaps more education is needed regarding your criteria, or perhaps the criteria needs to be evaluated to provide a better catchment of patients.

EMS can also drive hospital improvements through data analysis.

If quality assurance staff and crews notice a hold-up of patients entering a particular emergency department, an opportunity may present itself for greater collaboration with the hospital’s staff to streamline their operations in the best interest of the patient.

In more extreme circumstances, data analysis through comparing benchmark times may also validate a crew’s or agency’s decision to transport patients to a particular hospital. On the surface, this may cause some political strife. But, with data at your fingertips, your justification may hold its merit in your decision-making process.

Data analysis in EMS certainly has its own course of benefits, as well as its own flaws. “Caveat emptor” (let the buyer beware). Data can be one-dimensional, as it doesn’t always account for subjective metrics, such as scene considerations, response or transport times, unstable patient presentations or patient outcomes.

When looking at benchmarks for STEMI care, time tracking is a great opportunity to provide an objective data metric to improve overall patient care – especially when we’re at the leading edge of it.