Stemming STEMI

A heart attack is caused by a life-threatening clot in a coronary artery to the heart. The most severe form of heart attack is referred to as an ST-segment elevation myocardial infarction (STEMI) and can be initially assessed by electrocardiogram (ECG). The optimal treatment is to open the blockage in a cardiac catheterization lab with a percutaneous coronary intervention (PCI) to re-establish coronary artery blood flow as quickly as possible.

In 2009, Dallas County, TX, had 15 hospitals capable of performing PCI and 24 EMS agencies responding throughout the county on STEMI patient calls. However, there were no common protocols for either prehospital or hospital STEMI patient care, and inconsistent ECG capabilities across all EMS providers.

As Professor of Emergency Medicine and Chief of EMS Operations at UT Southwestern Medical Center in Dallas, Dr. Raymond L. Fowler was aware of efforts around the country aimed at regionalizing STEMI care. In looking at other programs’ successes, he discovered that in Dallas County there were no public awareness programs, minimal coordination of STEMI care between EMS and receiving hospitals, inability for some EMS agencies to transmit ECGs, and a lack of STEMI protocol sets between EMS and hospitals.

Worst of all, there was a complete lack of data accurately reflecting STEMI care in the county. “In other words, we didn’t know what we didn’t know,” Fowler remembers.

A $3.5 million grant was obtained to establish a comprehensive Acute Coronary Syndrome (ACS) network in Dallas County. The funding came from the W.W. Caruth Jr. Foundation of Communities Foundation of Texas (CFT) through the SouthWest Affiliate of the American Heart Association (AHA).

A stakeholders committee was formed with representatives from all EMS agencies and hospitals under the informal oversight of AHA. Of the committee, Fowler says, “We all came together as a group, turned over our name badges, and got the job done.”

In this case, the job entailed signed MOUs between all hospitals and EMS agencies, purchasing equipment, creation of uniform EMS and hospital protocols to be used by all entities, training of more than 4,000 EMS personnel, and creation of a robust data collection system.

“For the first time, we merged EMS medical records with hospital records. We collected data on patients from prehospital, through their hospital stay and into rehabilitation,” Fowler says.

The committee also created a goal titled Symptom Onset to Arterial Perfusion, or SOAR. Fowler says there is a lot of buzz over reducing “door to balloon time,” meaning how long it takes for STEMI patients to get PCI treatment once they arrive at the hospital emergency department. SOAR aims to reduce the time from onset of symptoms—well before the patient arrives at the ED— to balloon time.

Paramedics, nurses and physicians all received intensive training on STEMI recognition via ECG. Three goals were riding on the success of the training: 1) get SOAR times down, 2) gain cardiologists’ trust on field ECG readings by paramedics, and 3) achieving an error rate below 15%. A post-training study showed paramedics correctly recognized STEMIs more than 90% of the time, which was on par with emergency physicians.

As the project wore on, paramedic performance earned them enough trust for cardiologists to allow paramedics to activate the receiving hospital’s cardiac cath lab from the field.

At the end of December 2012, the 21/2-year program had achieved all its goals, including reducing STEMI patient mortality from 4.6% to 1.9% at its lowest point. While the protocols and procedures remain in place, with no current funding some data capture is being missed due to some oversight positions being lost. AHA has committed to maintaining the databases.

As Dallas County looks to the future, participants see that this effort can also do more than reduce STEMI mortality. “Mortality rates are just the tip of the iceberg,” according to Dr. Paul Pepe, co-principal investigator, professor and chairman of Emergency Medicine at UT Southwestern University, and medical director of BioTel EMS System in Dallas.

Myocardium damage from STEMI is a major cause of congestive heart failure (CHF). Pepe sees great potential to reduce CHF by earlier and successful treatment of STEMI patients. “Typically someone with CHF will have reduced quality of life, multiple hospitalizations and then die within four to five years,” Pepe says.

“We could have more people out playing tennis six weeks later instead,” Pepe says, concluding that the savings in healthcare dollars and improvement in quality of life could also be significant.

For more information about the American Heart Association’s Caruth Project in Dallas County, visit www.heart.org/HEARTORG/Affiliate/Dallas-County-Caruth-Program-Initiative_UCM_316168_SubHomePage.jsp.

Ed Mund began his fire and EMS career in 1989. He currently serves with Riverside Fire Authority, an ALS-level fire department in Centralia, WA. His writing and photos have been published in several industry publications. Contact him at mund.ed@comcast.net.