Author

Jane N Miller

Date

March 2013

Document Type

Portfolio

Degree Name

Ph.D.

Institution

Oregon Health & Science University

Abstract

The purpose of the clinical inquiry project is to review current evidence-based literature for pre-hospital ECG's when STEMI is a concern, and analyze regional barriers and challenges to effective and timely PPCI hospital pre-notification of STEMI arrival. Based on the study findings, recommendations for improving quality of care for this critical STEMI population may be formulated. The focus of the study is to assess perceptions and practice efforts of health care (HC) professionals who care for STEMI patient’s throughout Idaho and eastern Oregon. National recommendations for the ideal STEMI treatment process are based on emergency medical systems of care that utilize the pre-hospital ECG and shared protocols. The protocols critically implement best practices, and alert appropriate health care (HC) personnel into action (Brown, Mahmud, Dunford, & Ben-Yehuda, 2008; Krumholz et al., 2008; Ting et al., 2008; Van de Werf et al., 2008). Pre-hospital notification of STEMI arrivals to an ED or PCI center allows time to alert hospital staff and providers who arrive from an "on call" status, to be set up for rapid, emergent cardiac intervention as soon as the patient arrives. The on call response and arrival time expectation is typically 20 minutes, and the set up time may take between 10 to 15 minutes. This system of care expedites the process, and results in fewer delays to reperfusion (Ting et al., 2008). It is known that pre-hospital STEMI ECG's can decrease the time to intervention (Ting et al., 2008) but it is not known how many PCI centers receive information about STEMI's before patient arrival or how the delays may occur. For PCI facilities that have the capability to receive communication about STEMI's before patient arrival, it is not known what methods of ECG STEMI communication are utilized to notify the PCI site, and what barriers or gaps exist to be able to provide pre-arrival notification. Perceived barriers to effective communication based on evidence based practice (EBP) for STEMI populations have not been published for Idaho, or eastern Oregon. According to the most recently published AHA ACTION registry National STEMI database (ACTION Registry2011), a southwest Idaho PPCI facility’s STEMI patient “ED arrival to reperfusion” is 48 minutes, well below the 90 minute benchmark. However, occasionally the FMC “transfer facility-to-PCI time” is greater than the 120 minute benchmark. While the majority of STEMI transfers arrive well below the 120 minute benchmark, the range is 35 to 290 minutes with five cases above the 120 minute benchmark. In order to improve quality of care at the pre-hospital level, an analysis of various pre-hospital STEMI ECG communications that alert PPCI staff of incoming arrivals may demonstrate perceived gaps and barriers that cause delay, and potential geographic areas that may need focused support. Despite national data and guidelines that have been available for many years, approximately 20% of STEMI patients do not receive emergent reperfusion therapy even though there is immediate availability and no contraindication for intervention (Ting et al., 2008). In order to improve outcomes for STEMI patients, “systems of care” have been trialed, and proven to be effective in improving the percent of patients who receive reperfusion within the benchmark goal of less than 90 minutes. However, less than 50% of STEMI patients who do receive the therapy are provided the service within the national benchmark goals (Roger et al., 2012).

Identifier

doi:10.6083/M4Z60M2X

School

School of Nursing

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