Stroke & STEMI Survey12-Lead ECG Inferior STEMI VR3, VR4*, VR5, VR6 Lung sounds Clear Decrease SpO2 Blood Pressure Hypotensive Pulse Rate Bradycardia Skin Pale, cool, diaphoretic Neck

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

Performance Improvement 3

TX-DSHS Submission

• Quarterly Reporting by RAC-R

– January – March

– April – June

– July – September

– October – December

Performance Improvement 4

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

Performance Improvement 5

EMS Stroke Analysis

Performance Improvement 6

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

Performance Improvement 7

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%

Performance Improvement 8

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

Performance Improvement 9

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

Performance Improvement 10

Performance Improvement 11

CASE STUDY

Performance Improvement 12

Performance Improvement 13

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.

Performance Improvement 14

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

Performance Improvement 15

(19:04) 12-Lead ECG performed

Interventions

Performance Improvement 16

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

Performance Improvement 17

Time Intervention Description

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

Performance Improvement 18

Time Intervention Description

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

Performance Improvement 19

• 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

Performance Improvement 20

Pre Post

RCA

Performance Improvement 21

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

Performance Improvement 22

Contact Information:

Max NguyenCity of Beaumont Public Health – EMS

EMS Manager

Email: mnguyen@ci.beaumont.tx.us

Office: (409) 880-3922