Best Practices for STEMI Care - Essay Example

STEMI CARE al affiliation Pre-hospital phase The pre-hospital phase of STEMI treatment is the most important step in the care of STEMI patients. In Europe, the average delay time before a patient is treated has been high, with roughly 11-15% of the patients being served within the appropriate time. The decision time for patient (PDT) has been constant, ranging between 1-3 hours. The reaction time for the emergency service is crucial to the survival of the patient; and it needs to be limited to the shortest time possible. Several campaigns have been undertaken to shorten the process, though they have had temporary and limited impacts. Lee (2009) suggested that physicians should initiate the catheterization laboratory without necessary consulting the cardiologists. In some cases, some patients that have been referred for PPCI do not get optimum percutaneous reperfusion and at the right time with an experienced group (Tubaro et al., 2011). PCI aims to open the artery as soon as possible after its blockade, preferably within 90minutes (Cardiosmart.org, 2014). The recommended time for the treatment of patients with PCI capability is a maximum of 90 minutes. For those without PCI capability, they should receive medical attention in the first 30minutes of arrival at a hospital. The treatment is basically fibrinolytic therapy. Paramedic bypass of the protocols of emergency care reduced the number of minutes of the door to balloon time. From the study, there was an improvement of over 28 % percent. Before the initiation of paramedic by pass protocol, the average time needed was about 107 minutes. These saw an improvement of about thirty-seven minutes with an average time coming down to 70 percent. However, the study recommends for further studies to determine the outcome of those patients who were taken care of by these paramedics (Cheskeset al, 2011). In the observation by Pitta et al (2010), it was noted that most of the time lost is on the acquisition of an electrocardiogram and most of the patients never had an electrocardiogram conducted on them because of the delays. Hence, from the case study, the authors emphasize on the need to have a Pre-hospital electro cardiogram to conduct to aid in reducing the door to balloon time. In the study conducted by Wilson et al, (2010) to assess the impact of interdepartmental collaboration on door to balloon time reduction, the authors observes that there is a great improvement on time reduction with emergency department physician activation of cardiac catheterization laboratory followed with instantaneous transfer in place. Collaboration of the necessary departments saw a reduction of the mean number of minutes taken to get the patient from door to balloon from 97 minutes to about 77 minutes. Median of door to activation time was reduced to 53 minutes from 63. Proportion of patients attended to within the first 90minutes also increased to 77 percent up from 41 percent. Pre-management Pre-management of STEMI is crucial before the condition gets out of hand. For the general public, in case of an attack, an individual should not drive himself or take a 300mg aspirin tablet. For patients who are known to have CHD, a tablet of GTN is recommended for any persisting pain. When the pin persists, the patient should seek immediate medical attention. The tablet can be taken every 5 minutes, till a maximum of three doses. When the pain shows a liking to STEMI, a dose of sublingual GTN is recommended and seek medical attention ((Merckmanuals.com, 2014) In Australia, clinical networks are emphasized in the care of cardiac emergencies, including STEMI. The influence of such networks is huge on the service provided. Their significance is seen in fostering communication, partnerships and awareness throughout the service delivery boundaries. The boundaries include inter-service, intra-hospital and inter-hospital. The networks also promote links between remote, metropolitan and rural health services (van’t Hof, 2009). Logistics Hospitals that take care and manage STEMI patients need to have a fully equipped coronary. The unit should have the capacity to handle all cases of care to the patients, including the treatment of ischemia, arrhythmias, common comorbidities and severe heart failure. Each EMS should have a standardized algorithm an procedure for treating and evaluation patents who have symptoms that point to STEMI (Heart.org, 2014). Such units should have the ability to keep patients who are undergoing successful and uncomplicated reperfusion therapy for at least 24 hours. After the 24 hours are over, the patient can then be, moved into a step down monitored bed for a further 24-48 hours (ESC, 2012). The vigorous study on the application of the recommended guidelines by the European society of cardiologists and American heart association brings out the various hiccups on the guidelines. As indicated in the study, it is evident that it has been a huge task for hospitals in Canada to comply with the requirements. The points of weakness are highlighted giving the limelight on where to improve in order to meet the international requirements (Fitchett et al, 2011). Terkelsen (2014) explains the international guidelines set to determine performance of the hospital on patient care is emphasized by the author. He allays the confusion on the exact delay time before initiation of primary percutaneous catheter intervention and fibrinolysis. The paper calls for consensus on objectives when taking care of STEMI patients and demonstrates why it is not sufficient to just emphasize on the door to balloon time only. Inter-hospital transfers. The amount of time consumed during inter-hospital is usually a concern for STEMI patients. In Canada, most transfers of patients to a PCI from the referring hospital (80.5%) are by EMS. The biggest challenges in transferring a patient to a PCI were reported as the unavailability of the EMS for the transfer of the patient. 41 out of 86 out of a surveyed population reported a 5, 4 or 3 as chances of the unavailability of EMS, with 5 as the most common barrier. Moreover, the unavailability of a qualified nurse to accompany the EMS also provided a barrier for the transferring process. In the Balloon Times Ambulance Victoria and Monash Heart Acute Myocardial Infarction, the authors agree to the fact that the goal of attending to 75 % of the patients within 90 minutes has been hard to achieve. Thus, they proposed a Pre-hospital 12 lead triage to help in achieving the goal. From the study, there was a phenomenal increased in the percentage of patients who received that care within the time. It was increased by 8% after initiation of the pre-hospital 12 lead triaging. A coordinated system involving the EMS, PCI centers and the referring hospital can overcome this barrier and facilitate a timely transfer of the patients. The register and roll program is aimed at streamlining the triage process and improve transfer times within hospitals. The initiative has been useful in community hospitals that do not have the PCI capabilities (Amruthlal et al, 2012). Figure 1-figue showing barriers in transporting a patient using EMS (RECOMMENDATIONS FOR BEST-PRACTICE STEMI MANAGEMENT IN ONTARIO, 2012) Early diagnosis The physical examination for STEMI should focus on neurologic, respiratory functions, the musculoskeletal and the skin (Unboundmedicine.com, 2014). Characteristic symptoms of a manifesting STEMI include chest pains that are felt as pressure sensations or squeezing at the mid-portion at the thorax, radiation of chest pains into the teeth, jaw or the arm and associated shortness of breath or dyspnea. Other symptoms are syncope and impairment of cognitive functions (Clevelandclinicmeded.com, 2014). Risk factors of STEMI include older age, gender, anterior infarction, gender (with men being at a higher risk), hypertension, myocardial infarction and old age (Tidy, 2014). The primary care of STEMI is early diagnosis (Caa2008.org, 2014). Patients can raise their chances of survival by knowing its warning symptoms, discussing ways of how to reduce the risks and filling survival plans. It is the duty of the health-care providers to target patients and warn them of signs of the condition and ways to manage it. The target population should be people who are at high risk of ACS. Mortality in STEMI cases can be greatly reduced by a quirk of full epicardial obstruction. The main goal in the management of STEMI should be expeditious reperfusion in the occluded artery (Golan and Tashjian, 2012). Treatment For patients that meet the criteria for PPCI, an aimed physical examination and history should be performed. Specific attention needs to be paid to the relevant signs and symptoms, allergies, anticoagulant therapy, functional status and history of renal complications. Examinations should focus on signs of heart failure, mechanical complications and hemodynamic status (Redwood et al, 2010). Patients who have significant LM or a serious multi-vessel condition, particularly if it is caused by cardiogenic shock in 36 hours of STEMI may be given early surgical revascularization. Patients with fibrinolysis and with no high risk conditions can be given functional non-invasive study for further management (Ardehali, Wang & Perez, 2013). Reperfusion can be done at higher rates, with the preference of primary coronary intervention (PCI) to thrombolysis in STEMI patients. Previous studies show that majority of the STEMI patients qualify for this kind of reperfusion strategy. It is superior to a full dose of thrombolysis, and there has been a significant decline in death rates (Chatterjee 2013). Door- balloon A study was conducted on the Maltese island to determine the compliance with set standards by the American heart association. It was evident that the target is not met with a patient that are comes in office hours (8a.m to 5p.m) having a shorter DBT. At the same time, patients who came in with the Pre-hospital electrocardiogram had an even shorter DBT. However, patients attend solely in the hospital, did not meet the target with the average DBT time being recorded as 101minutes (Attard et al, 2013). Brodie et al. (2010), confirm that DTB has a great impact on the patient’s mortality rate. From the study, as the patients stayed longer the higher the risk of death ensued. The research necessitates that the patients be triaged before treatment is initiated so that those with longer DTB time are dealt with. By doing so, the size of ischemia can be reduced. The study done by Hutchison et al confirms that using tele-electrocardiography and the emergency department have greatly reduced the door to balloon time. From the study, there was a great improvement on the door to balloon time upon implementation of the emergency department tele-electro cardiogram initially 44 percent of the patients achieved the recommended deadlines of management before the 90th minute. Nevertheless, with the inclusion of the tele-electrocardiogram, over 77 percent of the patients received the required care within the 90 minutes. In the study by Rathore et al, (2009), it was observed that reduction of the door to balloon time has an impact on the mortality rate. From the study conducted, the mortality rate was as follows on the time taken to get the patient to balloon (30 minutes were 3 %, 60 minutes were 3.5% 90 minutes 4.3% 120 minutes were 5.6% 150 minutes were 7.0% 180 minutes were 8.4%) thus reduction of delay time from 90 minutes to 60 minutes saw a reduction in mortality rate by about 0.8 percent. Concisely delay in initiation of the percutaneous coronary intervention is associated with increased mortality rate among the affected patients. Khare et al. (2013), studies the various phases of patient care in the process of door to balloon care of the patient. Concisely from the study, they confirm that there are about fifty-one failure points in the four phases of patient care. 58pecent of twelve risk failures occurred between cauterization laboratory activation and ECG. Further, the DTB time is much higher during the off hours than during on hours the difference. There is a difference of 22 minutes with patients taking an average of 55 minutes during on hours and 77 minutes during off hours. River et al, (2014) found out that real feedback within the first 24 hours of the patients’ arrival was crucial in the reduction of D2B time and improving long-term clinical outcomes. In post-implementation, the number of EMS STEMI activations rose to 95.37% References 2013 ACCF/AHA Guideline for the Management of ST-Elevation Myocardial Infarction: Executive Summary: A Report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines. (2013). Catheterization and Cardiovascular Interventions, 82(1), E1-E27, doi:10.1002/ccd.24776. Amruthlal Jain, S., Ismail, Y., Shaw, M., David, S., & Alexander, P. (2012). "Register and Roll": A Novel Initiative to Improve First Door-to-Balloon Time in ST-Elevation Myocardial Infarction. Cardiology Research & Practice, 1-4. doi:10.1155/2012/616940 Attard Biancardi, M. A. 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The challenge of reducing time to reperfusion in patients with acute ST elevation myocardial infarction. European Heart Journal, 29(15), 1793-1794. doi:10.1093/eurheartj/ehn225 Read More