stroke & stemi survey12-lead ecg inferior stemi vr3, vr4*, vr5, vr6 lung sounds clear decrease...

Stroke & STEMI

SurveyEast Texas Gulf Coast

Regional Advisory CouncilPerformance Improvement Committee

Performance Improvement 2

Objectives

• TX-DSHS CVD and stroke statistics

• RAC-R data submission requirements by TX-DSHS

• Members participation of recent Monkey Survey

(requests for data)

• Analysis of 1st, 2nd & 3rd quarters Stroke & STEMI

data

• Issues and concerns

• Case Study: STEMI

TX-DSHS Data Submission

• EMS Agencies– # of stroke runs < hrs

– # of stroke runs 2 – 7 hrs.

– Total acute stroke transfers to

higher level of service

– Total # of STEMI runs

– Total # of STEMI runs with 12

lead ECGs transmitted

– Total # of STEMI runs < 30

minutes

• Hospitals

– Designated and Non-

designated• # of patients receiving IV

fibrinolytics (tPA)

• # of patients receiving

endovascular treatments

• # of Acute stroke admissions


TX-DSHS Submission

• Quarterly Reporting by RAC-R

– January – March

– April – June

– July – September

– October – December


RAC-R Members Participation

• EMS– 30 Ground transport EMS organizations

– 4 Air transport organizations

– 13 completed the survey monkey for

Stroke & STEMI

• 1st quarter

• 2nd quarter

– 13 completed the survey

• 3rd quarter

– 4 additional EMS

organizations added;

– 4 existing EMS did not submit

• 43% contribution

• Hospitals– 15 Facilities

– 10 completed the survey monkey for

Stroke

• 1st quarter

• 2nd quarter

– 10 completed the survey

• 3rd quarter

– 4 new Hospitals

submission

– 6 existing did not submit

– 67% contribution


EMS Stroke Analysis


1st Qtr % 2nd Qtr % 3rd Qtr %

Total # of Acute Stroke Runs 329 337 242

# of Strokes arrived < 2 hours 111 33.74% 66 19.58% 124 51.24%

# of Strokes arrived 2 - 7 hours 153 46.50% 124 36.80% 32 13.22%

# of Strokes transferred 105 31.91% 76 22.55% 37 15.29%

EMS STEMI Analysis


1st Qtr % 2nd Qtr % 3rd Qtr %

Total # of STEMI Runs 78 79 131

# STEMI 12-lead Transmitted 63 80.77% 58 73.42% 77 58.78%

# STEMI first contact to Hospital < 30 minutes 34 43.59% 40 50.63% 46 35.11%


Designated

1st Qtr 2nd Qtr 3rd Qtr

Total number of patients receiving IV fibrinolytics (tPA) 44 45 16

Total number of patients receiving endovascular treatments 16 31 7

Total number of Acute Stroke Admissions* 223 205 85


Non-designated

1st Qtr 2nd Qtr 3rd Qtr

Total number of patients receiving IV fibrinolytics (tPA) 7 9 2

Total number of patients receiving endovascular treatments 0 0 0

Total number of Acute Stroke Admissions* 0 0 3

Issues/Concerns with Data

• EMS– Obtaining data from source.

– Filtering to capture times; < 2

hours, etc.

– Unable to transmit 12-lead ECGs

– Possible fixes:

• Work with vendor to extract

data

• Internal QA/QI form for

sentinel call(s)

• Verbal activation

• Hospitals

– Delayed in coding of

records

– Personnel to

consolidate the data

– Possible fixes:

• Designating backup

personnel


CASE STUDY



EMS One was dispatched at 18:48, to a 50 year-

old male having chest pain, with his wife by his

side. Patient was sitting at a table. Patient is

AO to person, place, time and event. Associated

symptom: shortness of breath

Skin Cool, pale and diaphoretic

Onset 20 minutes prior (18:28)

Provocation Racing go-cart

Quality Chest pain

Radiate Chest to left arm

Severity 2/10

Time Continuous

Allergies NKDA

Medications None

History None; family hx of cardiac

1 adult ASA Taken prior to EMS arrival.


Initial Patient Assessment (19:02)

LOC AO x 4

BP 96/65

SpO2 98% Room air

Lung sounds Clear bilaterally upper and lower

Pulse Rate 50 - regular

Respiratory 14 - normal

Pupils PERRIL (left and right)

BGL 126 mg/cl

GCS 15


(19:04) 12-Lead ECG performed

Interventions


Time Intervention Description

19:01 Patient Contact

19:05 Air Medical Service Request for air transport called

19:11 Oxygen NRB @ 15 LPM; patient condition was improving

19:12 Vitals BP=88/65, P=51, R=14, SpO2=98%

19:14 IV 300cc NS bolus

19:16 EKG 12-Lead Performed

19:19 En route to LZ

19:21 Arrived at LZ

19:22 Vitals BP=104/78, P=50, R=14, SpO2=100%

19:24 EKG 12-Lead Performed

19:27 Air Medical Service Landed

19:39 Air Medical Service Departed Scene

Air Medical Service



19:40 Depart scene

19:52 Arrived at PCI facility 45 minutes via ground transport

19:41 12-Lead ECG 43 bpm-bradycardia, Inferior MI, lateral MI; ST

elevation in II, III, aVF, V5, V6; ST depression in I,

avL, V1, V2, V3. Pain=3/10

19:41 Fentanyl 50mcg IV

19:45 Vitals BP=86/56, P=48, R=18, ETCO2=41mmHg;

GCS=14

19:49 Vitals BP=116/76, P=48, R=17, ETCO2=40mmHg

20:00 Vitals BP=90/56, P=54, R=16, SpO2=97%

PCI Facility



20:04 Patient Contact Transfer of care from Air Medical Service

20:05 Code STEMI activation

20:27 Transfer to Cath Lab Patient out of ED.

20:28 Arrived at Cath Lab

20:35 Physician in Cath Lab

20:35 Case start

20:54 Intervention FMC2B = 110 minutes

D2B = 50 minutes

Outcome


• 100% distal RCA occlusion with TIMI 0 flow.

• Aspiration Thrombectomy performed.

• DES was deployed.

• Final angiography revealed a residual < 10% stenosis

with TIMI 3 flow.

• Patient transferred to CCU for further care.

• No complications

Follow-up 2 days later, patient transferred to step down

unit, plan to discharge home soon.

PCI Facility


Pre Post

RCA


Assessment Indication Comments

12-Lead ECG Inferior STEMI VR3, VR4*, VR5, VR6

Lung sounds Clear Decrease SpO2

Blood Pressure Hypotensive

Pulse Rate Bradycardia

Skin Pale, cool, diaphoretic

Neck JVD Extended delay in care

Extremities Edema Extended delay in care


Contact Information:

Max NguyenCity of Beaumont Public Health – EMS

EMS Manager

Email: [email protected]

Office: (409) 880-3922

mailto:[email protected]

stroke & stemi survey12-lead ecg inferior stemi vr3, vr4*, vr5, vr6 lung sounds clear decrease...

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