An electrocardiogram indicating an ST segment elevation myocardial infarction (STEMI) requires either the administration of a thrombolytic such as tenectaplase (TNK) or a percutaneous coronary intervention (PCI). To someone not familiar with cardiac terminology, that seems like a lot of letters. What they really spell out is that someone is having a heart attack and needs medication to dissolve a blood clot or a surgical procedure – an angioplasty- to restore blood flow to the heart muscle.
Recent studies show significant benefits of PCI over thrombolysis to reduce mortality rates, non-fatal re-infarction, total stroke and hemorrhagic stroke… and time in hospital.
Why then are most patients in Canada who present with STEMI treated with thrombolytics?
While each unique health history and set of immediate circumstances needs to be considered, the critical factor is often time and access to a heart catheterization lab. (Sixty minutes from diagnosis of STEMI to surgical intervention is considered an acceptable time limit before the risk of damage to heart muscle outweighs the potential benefits of PCI.) Since most hospitals in Canada do not have onsite facilities for angioplasty, transfer to a tertiary care facility is the most desirable option if time considerations are to be met.
Hamilton General’s Heart Investigative Unit (HIU), led by Dr. Madhu Natarajan, interventional cardiologist and Director of the HIU (PCI division), has been working for several years to expand the availability of primary angioplasty to hospitals in Hamilton and Niagara. In October 2004, Dr. Natarajan contacted Dr. Ian Darcel, cardiologist at JBMH, with an offer to include Joseph Brant in its Primary PCI Initiative.
Dr. Darcel was familiar with the work being done at Hamilton General and committed to making these services available to Joseph Brant patients Ð working in partnership on a new patient transfer initiative to allow JBMH patients with acute myocardial infarction to be treated with PCI.
There were complex issues to resolve: patient safety, interfacility transfer procedures, patient escort personnel, medical responsibility, transport availability and the parameters for that transport.
“Everyone around the table had the patients’ best interests at heart,” said Jackie Barrett, Director, Maternal & Child/Emergency (JBMH). “We looked at the initiative from a systems perspective. Emergency medicine is not about working in isolation; when a person is in crisis and needs to come to Emergency, we rely on other services. We applied that thinking to this situation.”
Dr. Darcel, Dr. Matthew Stempien, Chief, Emergency Medicine and Medical Director of JMBH Base Hospital and the Central Ambulance Communications Centre (CCAC) were instrumental in bringing the medical and transport aspects of the initiative together. Joseph Brant’s ER department, led by Manager Marilyn Hollick and Professional Practice Educator Priscilla Bowler, was key in linking with staff and defining the process.Patients who experience acute heart attack (full blockage) are transferred to Hamilton General for primary angioplasty and repatriated in under 24 hours. CCAC and EMS Services provide the necessary transport. To meet the needs of a patient whose condition may deteriorate during transport, Joseph Brant sends an ER nurse, trained in advanced cardiac life support (ACLS), to escort the patient.
Priscilla Bowler is that ER nurse. “This initiative is very exciting,” she said. “I can’t wait until we can expand the service. Thrombolytics are an excellent choice, but we want to capitalize on the opportunity to do primary angioplasty.” Priscilla worked closely with Dr. Darcel to draft the medical directive for ER nurses to perform ACLS. She also played a key role in developing the algorithm to establish the procedural pathway for patients presenting with STEMI.
There are two scenarios with strict guidelines to avoid risking increased damage to the heart muscle. If the patient comes in by ambulance, an ECG is done before the patient is taken off the ambulance stretcher. If he or she has a STEMI, a call is made to Hamilton General’s cath lab and the patient is transported immediately in that same ambulance.
If the patient walks in with chest pain, he or she is triaged immediately to the Trauma room. To comply with the medical directive, ER nursing staff does an ECG. If the patient has a STEMI, both the cath lab and ambulance services are called. If the ambulance can arrive within 20 minutes, the patient is transported to Hamilton General. “If we can’t guarantee the 20-minute time frame, we won’t risk damage to the patient’s heart muscle. We will opt for TNK.” Priscilla continued: “The transfers we have done to date have gone very smoothly with excellent outcomes.”
The collaborative spirit that marked the STEMI initiative is a credit to all the health-care professionals involved; it has also become a way to build capacity and enhance our hospital’s ability to meet best practice standards for our patients and the community. In short, it is yet another way Joseph Brant lives its vision: Best People. Best Care. Healthiest Community.
Joseph Brant Memorial Hospital acknowledges the support from both Trillium Health Centre and Hamilton General Hospital in the care and treatment of our cardiac patients. For further information about the STEMI initiative, contact Priscilla Bowler or Jackie Barrett at 905-632-3730.