Stroke & STEMI Survey East Texas Gulf Coast Regional Advisory Council Performance Improvement Committee
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: [email protected]
Office: (409) 880-3922