Download CCW 15-157 - County of Simcoe

COUNTY OF SIMCOE
To:
COMMITTEE OF THE WHOLE
Section:
Consent – Human Services - Paramedic Services
Item Number:
CCW 15-157
Meeting Date:
April 28, 2015
Subject:
Heart Attack (STEMI) Program
Recommendation:
THAT Item CCW 15-157, which outlines the County of Simcoe Paramedic Services (CSPS) role in the
STEMI (S – T segment Elevation Myocardial Infarction) protocol, be received for information.
Executive Summary:
In 2007, the County of Simcoe Paramedic Services in partnership with the Medical Director for the
Simcoe Muskoka Base Hospital Program, staff from both Royal Victoria Hospital (RVH) and Southlake
Regional Health Centre (SRHC) and the Georgian Central Ambulance Communication Centre
established a new practice to provide a higher standard of care to patients suffering heart attacks. The
practice was one of a kind and also represented the first STEMI bypass protocol in central Ontario and
the GTA. This practice was established as a research project and the resulting analysis deemed the
approach to be safe and effective.
This innovative medical protocol utilized by the County of Simcoe Paramedic Services provides the
gold standard level of care for patients who are within the defined medical and geographical criteria.
The introduction of Advanced Care Paramedics in 2010 increases the number of patients who can
access this standard of care though geographic limitations remain.
The development of this protocol is evidence based and the resulting peer reviewed abstract and data
will support the furtherance of prehospital medical care in Ontario and beyond.
Background/Analysis/Options:
In late 2005, the County of Simcoe Paramedic Services began working with partners in both the Royal
Victoria Hospital and Southlake Regional Health Centre as well as the Georgian Central Ambulance
Communication Centre to put a new medical protocol in place for heart attack patients.
April 28, 2015
Committee of the Whole CCW 15-157
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Discussions revolved around the significant body of research and articles supporting the benefits of
treatment of heart attacks using PCI (percutaneous coronary intervention or angioplasty), as opposed to
clot busters for specific patient types. Findings include PCI is superior to clot busters in:

Reducing rates of death.

Reducing incidence on non-fatal recurrence of heart attack

Reducing incidence of stroke.
It is estimated that there would be 23 less deaths, 42 less non-fatal reinfarctions and eleven (11) less
strokes per 1000 patients treated with primary PCI rather than a clot buster.
Research Project
Though there were numerous programs and related literature associated with STEMI programs using
Advanced Care Paramedics, there were no such studies for a STEMI programs utilizing Primary Care
Paramedics exclusively.
Significant preparatory work was undertaken which included the design of the research project, the
establishment of the clinical protocol and research ethics board approvals. There was also a requirement
to secure the agreement of affected hospitals allowing these patients to be sent directly to Southlake
Regional Health Centre as opposed to the closest hospital. Furthermore the training of all paramedics
had to be completed in order to implement the protocol.
The program was launched in January of 2007 and data on every patient who was captured by this
protocol was tracked and analysed.
The Practice
 A patient experiencing chest pain calls 911
 Paramedics arrive and undertake patient assessment including vital signs, medical and incident
history and a detailed electrocardiogram (12 lead ECG)
 Paramedics begin treatment with medications as indicated
 Patient is readied for transport
 Patients meeting the medical protocol (vital signs are within limits and the patient’s ECG is STEMI
positive) and located within an approximately 45 minute drive time of Southlake Regional Health
Centre are transported directly there, bypassing closer hospitals
 On-route to Southlake, Paramedics alert the STEMI team at Southlake to expect a patient
 Upon arrival at Southlake, paramedics bypass the emergency department and taken the patient
directly to the cardiac catheterization suite.
 Southlake staff and cardiologists take over control of patient and perform necessary emergency
interventions such as percutaneous coronary intervention (PCI) where clots are cleared and the
coronary artery is opened up with a balloon.
Limitations
Geographic / Drive Time: Evidence supports the use of PCI if the patient can receive that treatment within
90 minutes of first diagnostic ECG. This intervention therefore is available to the Southern portion of the
County of Simcoe. If the drive time is expected to be greater than this, the patient is taken to the closest
hospital for potential clot busting therapy. A map of the 45 minute drive time guideline is provided as
Schedule 1.
Patient Clinical Status: Primary Care Paramedics can manage some complications associated with
patients having heart attacks but many complications require higher levels of care. As a result, this
protocol prescribes vital sign parameters which a patient must fall within to be eligible to be bypassed by
Primary Care Paramedics.
April 28, 2015
Committee of the Whole CCW 15-157
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In late 2011 and early 2012, data from the period of January 2007 and August 2011 was reviewed and
an abstract of this research was submitted and published in the August 2012 issue of the highly respected
American Heart Journal. The conclusion reached indicated that this protocol of heart attack identification
by Primary Care Paramedics in the field with subsequent treatment, communication and bypass of closer
hospitals to bring the patient directly to the cardiac catheterization suite at Southlake Regional Health
Centre is safe and effective. The peer reviewed published abstract is attached as Schedule 2. This
work represents research based evidence to support the evolution of medical care and adds to the body
of knowledge in prehospital cardiac care.
This research along with other related research is currently under review at the provincial level and may
serve to modify Pre-Hospital Patient Care Standards across Ontario. All such research is referenced
around the world for the advancement of medicine.
Advanced Care Paramedics
Since the establishment of this STEMI program, the County of Simcoe introduced the Advanced Care
Paramedic (ACP) level of care. ACP’s are able to effectively manage a wider variety of complications
associated with patients with acute coronary syndrome. They can manage life threatening heartbeat
irregularities, and blood pressure levels.
With the advent of ACP’s in the field in 2010, patients who would have been excluded from the protocol
due to their clinical acuity can be managed by ACP’s and bypassed directly to Southlake for the standard
of care treatment. Note: the geographic limitations remain.
Current Status
Since the establishment of this program in 2007 until the end of 2014, CSPS has averaged 48 STEMI
bypass patients per year. Since 2011 however with the addition of Advanced Care Paramedics the
average is up to 70 patients per year.
In a review of records from April 2014 to March 2015, the following performance is noted:
 Number of STEMI Bypass Patients: 82
 Time from Paramedic initial contact with patient until diagnostic ECG: Median six (6) minutes
 Time from Diagnostic ECG to arrival at Cath. Lab: Median 61 minutes (target 60 minutes)
 Time from Diagnostic ECG to balloon inflation: Median 90 minutes (target 90 minutes)
Operationally Efficient
The STEMI program provides opportunity for residents of the County of Simcoe to receive the gold
standard of care for those suffering heart attacks. Furthermore, taking the patient to the closest
medical facility would many times necessitate a requirement for a second high priority patient
transportation to the definitive treatment centre. This program directs patients directly to the
appropriate medical facility for definitive treatment and therefore reduces the need for a second
transport.
Financial and Resource Implications:
All STEMI program training was accommodated within existing training budgets.
April 28, 2015
Committee of the Whole CCW 15-157
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Relationship to Corporate Strategies:
Growth Related Service Delivery: Create and strengthen partnerships with key stakeholders to
support communities through the delivery of sustainable services.
Strengthened Social, Health and Educational Opportunities: Establish partnerships to identify
opportunities for strengthened Human Services and Education to support health and well being for
our residents
Culture of Workplace and Operational Excellence: Create and maintain a healthy work environment
that:
 Supports Personal and professional growth
 Provides services to residents in a fiscally sustainable and responsible manner
Reference Documents:
HS 06-170 (November 2006) Heart Attack (STEMI) Protocol
Attachments:
Schedule 1 – Depiction of 45 Minute Drive time to Southlake Regional Health Centre.
Schedule 1.pdf
Schedule 2 – Research Abstract published by American Heart Journal
Schedule 2.pdf
Prepared By:
Andrew Robert, Director & Chief Paramedic Services
Approvals:
Date
Jane Sinclair, General Manager, Health & Emergency Services
Trevor Wilcox, General Manager, Corporate Performance
Mark Aitken, Chief Administrative Officer
April 17, 2015
April 20, 2015
April 21, 2015