Calling Code STEMI at Princeton Baptist Medical Center
Sunday, February 12, 2012
According to guidelines set forth by the American College of Cardiologists, a patient experiencing a myocardial infarction should have the affected artery opened within 90 minutes of arriving at the emergency department. Thanks to the protocols in place to provide swift, effective treatment for these patients, the STEMI Center at Princeton Baptist Medical Center has been able to achieve a door-to-balloon time of less than 22 minutes.
Photo: Cardiologist David Sibley, M.D., right, assisted by cardiac catheterization technician Charles Dowdell, performs an arteriogram on a patient.
The American Heart Association estimates that approximately 500,000 myocardial infarctions involving ST elevation occur annually in the United States. After receiving Chest Pain Center Accreditation from the Society of Chest Pain Centers in 2009, Princeton Baptist Medical Center decided to expand the reach of its high standards of care to patients who suffer an acute ST-elevation myocardial infarction (STEMI).
The result has developed into such a finely tuned program that patients are consistently treated with intervention in the cardiac catheterization laboratory in an average time of 52 minutes from the time they arrive in the emergency room. Now, the Birmingham hospital is working to create a network of hospitals with improved patient outcomes through rapid identification, minimized door-to-balloon times or rapid thrombolytic treatment, and transfer to a percutaneous coronary intervention (PCI)-capable hospital.
Meeting the Gold Standard
When a patient arrives at Princeton Baptist Medical Center with chest pain, the Emergency Department immediately performs an electrocardiogram (EKG). The exam is quickly reviewed and assessed for possible acute ST elevation. Once the Emergency Department identifies a STEMI case, a Code STEMI is called to alert the supervising house nurse on call, the interventional cardiologist on call and the cardiac catheterization laboratory team of clinicians, as well as a clinical pharmacist, to the situation.
“Our cardiologists with Cardiology, P.C. and Emergency Department physicians and nurses have a great deal of trust among each other and have developed the STEMI Center in a collaborative effort,” says Sarah Dudley, M.S.H.A., Director of Operations and Business Development at Princeton Baptist Medical Center. “The departments work hand in hand. It doesn’t matter who calls the code STEMI, and there’s no second guessing about the need to call the code.”
The interventional cardiologist on call will confirm the diagnosis with the Emergency Department physician as the team assembles in the Cardiac Catheterization Laboratory where PCI is performed. The intervention involves balloon angioplasty usually followed by the placement of an intracoronary stent. Princeton Baptist Medical Center also maintains protocols to use left ventricular assist devices, such as intra-aortic balloon pumping and Impella assist devices. In addition, the cardiovascular surgical team is always available for patients requiring more extensive revascularization.
“It’s vital to identify the patient having a myocardial infarction quickly and then establish the right protocol to get the infarcted related coronary artery open and use adjunctive pharmacology and device protocols to maintain that patency for the long term,” says David Sibley, M.D., FACC, FACP, interventional cardiologist. “Our STEMI protocols are set up to achieve this goal at our PCI-capable institution, because we know that improved mortality and left ventricular function outcomes are determined by the restoration time of blood flow in the infarcted coronary artery.”
To increase the speed at which the proper diagnosis can be made, Princeton Baptist Medical Center physicians and administrators are currently examining new technology that allows physicians to view real-time EKGs sent from the emergency room and/or an ambulance through an app viewed on the physician’s iPad or smartphone to make diagnostic decisions.
Spreading the Knowledge
If a patient arrives with chest pain at a hospital within north and central Alabama that does not have the proper personnel or resources to definitively treat a STEMI case, the Birmingham institution can still offer its expertise. As Dudley explains, Princeton Baptist Medical Center is never on STEMI divert and is always able to accept patients with chest pain either directly or from other hospitals.
She and other members of the STEMI team have reached out to medical centers within a 120-mile radius of Birmingham to help improve education and protocols related to STEMI cases. During these visits, the medical centers are provided with a poster giving straightforward guidelines on how to proceed following the identification of a myocardial infarction with ST elevation and how to prepare for a patient transfer. Princeton Baptist Medical Center also offers a physician consultation hotline to encourage peer-to-peer advice relating to cardiovascular services and issues. This connection not only facilitates a smoother transfer if necessary, but also ensures that patients benefit from the wealth of STEMI knowledge available in the Birmingham area.
“For physicians at a non-PCI hospital who want to consult with one of the interventional cardiologists, the call comes through to us at any time, day or night,” says Dr. Sibley. “Usually from the way the physicians describe the patient’s history and the EKG, we can establish the likelihood that the patient is having a myocardial infarction.”
Such a conversation concludes with a decision about appropriate treatment. If the patient can be transported to Princeton Baptist Medical Center and have the affected artery opened in the Cardiac Catheterization Laboratory within 90 minutes, the STEMI team is put on immediate alert. If this time frame is not possible due to distance, the non-PCI hospital will administer thrombolytic agents, which, as Dr. Sibley explains, have demonstrated a 70% to 80% chance of reopening the artery.
However, lytic therapy should not be the final treatment in all cases. In the higher risk subset of patients, recent studies, such as Transfer AIM show that early transfer for coronary angiography and possible intervention improved long term mortality and heart function. Thus, the patient is then transferred to Princeton Baptist Medical Center, where the STEMI team is set to perform a coronary angiography or other intervention within a six- to eight-hour time frame.
For a STEMI transfer, please call 1-855-PRIN-HRT (1-855-774-6478) to reach the on-call cardiologist and arrange for transfer to Princeton, a PCI facility.
MD News January/February 2012, Birmingham