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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