Download Attachment 1 - JACC: Cardiovascular Interventions

Online Appendix for the following February JACC: Cardiovascular Interventions article
TITLE: The Methods for a Campaign to Improve the Timeliness of Primary Percutaneous
Coronary Intervention Door-To-Balloon: An Alliance for Quality
AUTHORS: Harlan M. Krumholz, MD, SM, FACC, Elizabeth H. Bradley, PHD, Brahmajee K.
Nallamothu, MD, MPH, FACC, Henry H. Ting, MD, MBA, FACC, Wayne B. Batchelor, MD,
MHS, Eva Kline-Rogers, MS, RN, Amy F. Stern, MHS, Jason R. Byrd, JD, John E. Brush J R,
MD, FACC
Attachment 1.
Examples of Tools Developed by D2B to Assist Hospitals and Clinicians
1A.
Emergency department standard ST-elevation myocardial infarction order form
1B.
Pre-hospital electrocardiogram checklist for field activation of catheterization
laboratory for primary percutaneous coronary intervention
1C.
D2B process flowchart (modified from Bradley et al. J Am Coll Cardiol 2005;46:123641)
Attachment 1A
EMERGENCY DEPARTMENT STEMI STANDARD ORDERS
Patient stamp plate
Chief Complaint:
 CP  SOB  Syncope
 CPR  Weakness
Time of onset of symptoms: ______:______ Date: _______________
Arrival time: _____:______
 Other: _________________
PAST MEDICAL / SURGICAL HISTORY
ORDERS
TIME
 HTN
 DM
 COPD
 PVD
 CVA / TIA  CKD (creat >2)  Hyperlipidemia
 Family history of CAD
 GI Bleeding / PUD
 Cancer
 Bleeding / Coagulation disorder
 Current smoking
 Previous smoking
 ETOH
 Cocaine use
 Surgery < 6 weeks _________________________
___________________________________________
 STAT ECG (< 5 min of arrival)
Show to ED Physician immediately
____:____
____:____
 STEMI confirmed
 Ant
 Inf
____:____
 LBBB
PAST CARDIAC HISTORY
 MI
 CHF
 AICD
 PCI
 AF
 CABG
 PPM
MEDICATIONS
___________________________________________
___________________________________________
___________________________________________
ALLERGIES
___________________________________________
___________________________________________
Contrast allergy:  yes
 no
PHYSICAL EXAMINATION
Appearance: ________________________________
BP: _______ HR:______ RR: ________
Temp: ____ O2 Sat:___ JVD: _______
Lungs: _____________________________________
CV: ________________________________________
Ext: _______________________________________
Pulses: _____________________________________
© 2006 American College of Cardiology. All rights reserved.
 Lat
 Post
If STEMI confirmed, institute immediately:
 STEMI Alert
____:____
 Activate Cath Lab / Notify operator ____:____
 Notify Transport Team
____:____
 Aspirin 81mg x 4 tablets chewed
____:____
NOW - unless contraindicated
 Clopidogrel ____mg p.o. NOW
____:____
 NTG 0.4mg SL x 1
____:____
 Heparin 60u/kg IV (max 4000 units) ____:____
 GPIIb/IIIa Inhibitor:____________ ____:____
 Metroprolol 25mg/p.o. NOW
____:____
Unless HR < 60, SBP < 100, CHF, wheezing
 O2 at _____ L/min nc
____:____
Assure O2 SAT > 92%
 Start 2 IV’s NOW
____:____
 Routine labs
____:____
 Consent for Cath / PCI / CABG
____:____
 STAT portable chest x-ray
____:____
(If indicated)
If uncertain ECG,
 Fax ECG to Cardiologist for review
____:____
 Operator call back (< 5 min) confirming
notification and response of Cath Lab / Interventional
Cardiologist
____:____
 Notify standby Interventional Cardiologist to be in
cath lab if on-call Cardiologist
does not respond in 5 min
____:____
 Transfer patient to cath lab
within 15 min of arrival to ED
____:____
November 6, 2006
Attachment 1B
D2B Pre-hospital ECG Checklist for Field Activation of Cath-lab for Primary PCI
Goals of the Checklist
 Rapid pre-hospital recognition of the patient with STEMI
 Reasonable sensitivity and specificity
Assumptions
 Reasonable transport time to PCI center
 High-quality primary PCI is available at receiving facility
 All items should be easily and reliably ascertained by EMS staff in the field
 This is a checklist for pre-hospital triage for primary PCI not for field fibrinolysis
#
Item
Yes
No
Must-have Items in Your Pre-hospital Checklist
1
Ongoing chest pain symptoms or other symptoms suggestive of cardiac ischemia.
2
Pre-hospital ECG shows ST-elevation greater than or equal to 1 millimeter in at least 2
anatomically contiguous leads.
3
Pre-hospital ECG without evidence of LBBB or paced rhythm.
4
No obvious evidence of acute GI bleed (e.g., hematemesis) or CVA (e.g. new hemiparesis)
Items to Consider for Inclusion in Your Pre-hospital Checklist
5
Age Range:
Lower Bound – issue of specificity, false positives
Upper Bound– issue of complexity of patients vs. high-risk / high-benefit group
6
Major surgery (CNS, CT, GI, or vascular surgery) in the last 48 hours
Risk / benefit needs to be weighed vs. ability of EMS to diagnose in the field
7
Severe intravenous iodinated radiographic contrast media reaction
Risk / benefit needs to be weighed
8
Patient is in hospice / terminal illness
Does not preclude patient from primary PCI
Carefully discuss options with the patient and the goals of therapy
9
Acute STEMI in setting of trauma (e.g., MVA)
Items Best Addressed at the Hospital-level for Inclusion in Your Checklist
(should not preclude field activation of cath lab)
10
Assessment of femoral pulses
Difficult to accomplish reliably in the field
11
Informed consent
Difficult to accomplish in the field and not the job of EMS
12
Assessment of renal function
EMS staff and patients unlikely to know GFR or Cre
13
Assessment of CAD risk factors
May lead EMS to not activate cath lab in STEMI patients without risk factors
14
Duration of continuous symptoms
EMS accuracy in assessing STEMI symptom onset
© 2006 American College of Cardiology. All rights reserved.
November 6, 2006
Attachment 1C.
D2B Process Flowchart