Background and Clinical Pearls
An ST-elevation myocardial infarction (STEMI) typically occurs when a plaque ruptures within a coronary artery and platelets adhere to it, forming a clot or blockage. Several medications are used to limit the progression of this clot until it can be opened with a stent or dissolved with thrombolytics. Only one of these medications, aspirin, is routinely given prehospital, but aspirin is highly effective and safe.
During a STEMI, heart muscle is lost with each passing minute until reperfusion. Therefore, optimal STEMI care requires a highly coordinated system of care designed to limit the time from the onset of the blockage until reperfusion and reduce the likelihood that the patient will have permanent heart failure or cardiac arrest.
The critical first step of the process is early recognition on a 12-lead ECG. Prehospital 12-lead acquisition and notification of the receiving hospital allow the hospital to mobilize resources before the patient even arrives and has been consistently shown to reduce time to reperfusion.
Performance Improvement and Best Practices
Early recognition of a potential cardiac event enables the prehospital provider to provide the appropriate treatment including transport method and destination decisions and to activate specialized teams to better care for the patient. Depending on the location of the cardiac catheterizing lab, staff may need to be called in or clear the table from a less urgent case.
Depending on the patient demographics, cardiac chest pain may present differently. Females, diabetics, and the elderly may present with vague abdominal pain, back pain, or heartburn-related complaints that should increase the index of suspicion of the prehospital provider. If the patient presents with acute coronary syndrome, aspirin should be administered per local protocol barring any contraindications.
Consider a 12-lead for at least any patient over 35 with risk factors and dizziness, syncope, nausea, poor skin signs or other symptoms between their mouth and belly button. Remember, not all patients present with the classic symptoms of an MI. Prehospital providers should obtain, interpret, and transmit a 12-lead as soon as possible. The 12-lead should be obtained within 5 minutes of patient contact.
Consider obtaining a 15-Lead (V4R, V8, and V9) for non-descript ECG changes or a normal ECG in the presence of acute coronary syndrome complaint. Proper skin preparation and lead placement are essential factors in accurate ECG tracings.
o Shaving, cleaning, and abrading the skin help reduce artifacts.
o Appropriate placement of limb leads will ensure an accurate cardiac axis capture.
Other Relevant Data and Educational Resources
MidMichigan Health’s Streamlined Regional STEMI Alert Program. Educational YouTube video accessible here: MidMichigan Health’s Streamlined Regional STEMI Alert program American Heart Association, developing systems of care for ST-Segment Elevation Myocardial Infarction. The complete AHA policy statement can be accessed here: AHA STEMI Care The American Heart Association recommends EMS leaders work to eliminate barriers in the STEMI system of care by:
Increase public awareness campaigns of heart attack signs and symptoms and the importance of calling 9-1-1; pursue individualized interventions, especially for those at increased risk (patients with prior acute coronary syndromes or known coronary artery disease)
Develop 9-1-1 destination transport protocols by having EMS agencies, referring hospitals, and receiving centers work together
Adopt and implement prehospital cardiac catheterization laboratory (CCL) activation and direct to catheterization laboratory protocols when appropriate for STEMI receiving centers
Improve door-in–door-out (DIDO) times by having STEMI referring hospitals and receiving centers work together with designated interfacility transport providers
Develop and implement regional transfer for PCI protocols and processes
Present and discuss focused feedback with each member in the system of care
Increase participation in active regional STEMI systems of care, including review of regional data and sharing of best practices
Increase attention to cardiogenic shock
Rural EMS Counts Cardiac Measures
Cardiac- 12 Lead Performed by EMS for ED-Diagnosed STEMI
Description:
This report is for EMS Agencies that receive information back from the hospital regarding the patient diagnosis and treatment at the hospital. The EMS ePCR is updated to reflect the ED and hospital diagnosis. If the hospital diagnosed the patient with ST-elevation myocardial infarction (STEMI) or Non-STEMI, the report would flag the ePCRs that did not have a 12-Lead performed by EMS.
This is a learning opportunity for EMS. Knowing the hospital diagnosis allows EMS Agencies to review their assessment, training, and protocols and improve patient care.
Specific filters to identify ED-Diagnoses STEMI include:
1. Patient Age (in Years) ≥ 18
2. Outcome ED Diagnosis = 1) Admitting or 2) Final
3. Outcome Diagnosis ICD-10 Diagnosis Group = STEMI/NSTEMI
Cardiac- 12 Lead Performed for Suspected Cardiac Chest Pain
Description:
This measure calculates how often a 12-lead ECG was performed for patients with an EMS provider impression related to suspected Acute Coronary Syndrome.
Specific filters to identify suspected Acute Coronary Syndrome include:
1. Primary or Secondary Impressions include one of these values: 1) Chest Pain / Discomfort, 2) Angina pectoris, 3) Angina, unstable, 4) ST elevation (STEMI) myocardial infarction of anterior wall, 5) ST elevation (STEMI) myocardial infarction of inferior wall, 6) ST elevation (STEMI) myocardial infarction of other sites, 7) ST-elevation myocardial infarction (STEMI), 8) Myocardial infarction, or 9) Non-ST elevation myocardial infarction (NSTEMI)
Cardiac- Aspirin Administration for Suspected Cardiac Chest Pain
Description:
This report calculates how often aspirin was administered to patients with an EMS provider impression of non-traumatic chest pain. This report is part of a suite of measures defined by the North Dakota Rural EMS Counts project to identify performance measures that matter for EMS in rural settings.
Exceptions:
The following pertinent negatives (reasons procedure not performed) are not included in the measure. These records will be found in the "Exceptions" row in the drill through: Contraindication Noted, Denied By Order, Medication Allergy, and Medication Already Taken.
Note: The following pertinent negatives are not treated as exclusions: Unable to Complete and Refused. These records will be included under "Measure Criteria Not Met.”
Specific filters to identify suspected cardiac chest pain include:
1. Patient Age (in Years) ≥ 18
2. Primary or Secondary Impression includes one of these values: 1) Chest Pain / Discomfort, 2) Angina pectoris, 3) Angina, unstable, 4) ST elevation (STEMI) myocardial infarction of anterior wall, 5) ST elevation (STEMI) myocardial infarction of inferior wall, 6) ST elevation (STEMI) myocardial infarction of other sites, or 7) ST elevation myocardial infarction (STEMI)