ST Elevation Myocardial Infarction Pathway



Canberra Hospital and Health Services

Operational Procedure

ST Elevation Myocardial Infarction (STEMI) Pathway

|Contents |

Contents 1

Purpose 2

Alert 2

Scope 2

Section 1 – STEMI Pathway for SNSW LHD and Ambulance Service NSW 2

Section 2 – STEMI Pathway for ACTAS 4

Implementation 5

Related Policies, Procedures, Guidelines and Legislation 5

References 6

Definition of Terms 6

Search Terms 6

Attachments 6

Attachment 1. STEMI Pathway (Southern New South Wales) 7

Attachment 2. STEMI Pathway (ACT Ambulance Service) 8

|Purpose |

To provide clear guidance for Canberra Hospital and Health Services (CHHS) staff to facilitate timely access to percutaneous coronary intervention (PCI) for patients with acute STEMI in the Australian Capital Territory (ACT) and Southern NSW Local Health District (SNSW LHD).

A STEMI requires prompt restoration of blood flow to the affected area of heart muscle by either primary percutaneous coronary intervention (PCI) or fibrinolytic therapy. Prompt reperfusion minimises the likelihood of death or long-term disability in STEMI patients.

This Standard Operating Procedure (SOP) describes for staff the process to

|Scope |

|Alert |

• This Operational Procedure is relevant only for patients with ECGs suggesting STEMI.

• Ensure the computers with the LifeNet system within CCU are always turned on.

|Scope |

This procedure applies to:

• Coronary Care CHHS – Cardiologists, Clinical Nurse Consultant (CNC), Registered Nurses, Coronary Care Unit Team Leader (CCU TL), Advanced Trainee (AT) in Cardiology, Basic Physician Trainee (BPT)

• Catheter Lab CHHS – Clinical Nurse Consultant (CNC), Registered Nurses, Interventional Cardiologist, Cardiology fellow, Cardiac Technicians

• Emergency Department (ED) CHHS – Registered Nurses, Admitting Officer, Triage

• CHHS Switchboard staff

• Southern NSW LHD (SNSW LHD) - medical and nursing staff

• ACT Ambulance Service (ACTAS)

• Ambulance Service NSW (ASNSW)

• Access Unit CHHS

• After Hours Hospital Manager CHHS

It also applies to persons presenting to the service. It might be at person’s home or transfer to another hospital or might be in the ED.

|Section 1 – STEMI Pathway for SNSW LHD and Ambulance Service NSW |

1. For a patient presenting with signs and/or symptoms suggestive of Acute Coronary Syndrome (ACS) a 12 lead ECG on a LifePak15 must be performed on the patient.

2. If the ECG indicates “***MEETS ST ELEVATION***” and/or “CONSIDER ACUTE INFARCT” the ECG is transmitted to destination ‘CANBERRA’ via the LifeNet system.

3. The ECG will be transmitted simultaneously via the LifeNet system to the Smartphones held by the following CHHS staff: Interventional Cardiologist on-call, ED Admitting Officer and CCU Doctor. Simultaneously the PCs situated at the CHHS CCU Nurse Workstations and two PCs within CHHS ED ‘flight deck’ will also receive the transmission via the LifeNet system.

4. The PCs will sound an alert to let staff know a new ECG has been received and will continue to sound until staff open and acknowledge the ECG. The ECG will be printed at the CCU ward clerk’s desk for review by the CCU Doctor.

5. The CHHS CCU Doctor (Interventional Cardiologist if required) will review the ECG and the CHHS CCU Doctor will phone the referral source phone number outlined on the ECG printout within 10 minutes to confirm or refute a STEMI.

6. If the hospital or ambulance does not receive a phone call within 10 minutes they will retransmit the ECG:

a. If ASNSW is the referral source they will contact their Southern Control Centre to notify that a second transmission has occurred. The Control Centre will contact the CCU Doctor by phone to notify them of the second transmission

b. If SNSW LHD ED is the referral source staff will also phone the CCU Doctor to notify that a second transmission has been sent.

7. The CCU Doctor will inform the referral source whether a STEMI is confirmed.

8. If a STEMI is not confirmed the referral source is to follow their local protocol.

9. If the patient is confirmed as having a STEMI and is within 60 minutes travel time of Canberra Hospital they will be transferred to the Canberra Hospital. The CCU Doctor will inform the CCU TL of the incoming patient and their expected time of arrival (ETA).

10. If the patient is more than 60 minutes away fibrinolysis is to be administered as per local protocol.

11. The CCU Doctor is responsible for activating the Catheter Lab 30 minutes prior to the patient’s ETA via Switchboard by dialling “8” and stating “activate Cath Lab”. Catheter Lab staff are to notify Switchboard by dialling “8” when the Catheter Lab is ready. An automated alert will be sent by the Switchboard via the pager system “Cath Lab ready”. The CCU TL or CNC is responsible for informing the Access Unit or After Hours Hospital Manager (after-hours) of the expected patient.

12. The ASNSW is to contact ED Triage on arrival to Canberra Hospital ED to ensure “Cath Lab ready” has been activated. The patient is to be transferred to the Catheter Lab if “Cath Lab ready” has been activated. If the Catheter Lab is not ready the patient is to be held in ED for a short time until “Cath Lab ready” activation has occurred when the patient will be transferred to the Catheter Lab.

13. If the patient’s condition becomes unstable enroute the ASNSW is to phone the ED Admitting officer and inform them of the need for management in the ED.

See Attachment 1. Southern NSW STEMI Pathway

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|Section 2 – STEMI Pathway for ACTAS |

1. For a patient presenting with signs and/or symptoms suggestive of Acute Coronary Syndrome (ACS) a 12 lead ECG on a LifePak15 must be performed on the patient.

2. If the ECG indicates “***ACUTE MI***” a photo of the 12 lead ECG will be taken by an ACTAS paramedic and sent via Multimedia Messaging Service (MMS) to “TCH”.

3. The ECG will be received simultaneously by the Smartphones held by the Interventional Cardiologist on-call, ED Admitting Officer and CCU Doctor.

4. The CCU Doctor and CCU TL (Interventional Cardiologist if required) will review the ECG and the CCU Doctor will phone the ACTAS referral vehicle’s Smartphone within 10 minutes to discuss whether a STEMI is confirmed.

5. If the ACTAS referral vehicle does not receive a phone call within 10 minutes they will phone the CCU Doctor to notify of transmission and STEMI outcome.

6. The CCU Doctor will inform the ACTAS referral vehicle whether a STEMI is confirmed.

7. If a STEMI is not confirmed ACTAS will follow their local protocol and transfer the patient to the nearest hospital.

8. If the patient is confirmed as having a STEMI they will be transferred to CHHS ED. The CHHS CCU Doctor will inform the CCU TL of the incoming patient and their expected time of arrival (ETA). The CCU TL or CNC is responsible for informing the Access Unit or After Hours Hospital Manager (after-hours) of the expectant patient.

The CCU Doctor is responsible for activating the Catheter Lab 30 minutes prior to the patient’s ETA via Switchboard by dialling “8” and stating “activate Cath Lab”. Catheter Lab staff are to notify Switchboard by dialling “8” when the catheter lab is ready. An alert will be sent via the pager system “Cath Lab ready”.

9. ACTAS is to contact ED Triage on arrival to Canberra Hospital ED to ensure “Cath Lab ready” has been activated. The patient is to be transferred to the Catheter Lab if “Cath Lab ready” has been activated. If the Cath Lab is not ready the patient is to be held in ED for a short time until “Cath Lab ready” activation has occurred when the patient will then be transferred to the Catheter Lab.

10. If the patient’s condition becomes unstable enroute the ambulance service is to phone the ED Admitting officer and inform them of the need for management in the CHHS ED.

See Attachment 2 – ACT Ambulance STEMI Pathway

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|Implementation |

This operational procedure provides SNSW LHD with a STEMI Reading Service as part of the NSW State Cardiac Reperfusion Strategy and aligns with the local policy and procedures used by NSW Ambulance Service and SNSW LHD hospitals. Education and implementation of this procedure relevant to SNSW staff will be carried out by local staff and Agency for Clinical Innovation.

CHHS CCU Medical Staff will receive additional ongoing training and support required to provide this service. New medical staff to CCU will be provided a copy of the procedure as part of their initial orientation.

Nursing staff will receive advanced ECG interpretation training in order to facilitate and support Cardiology Registrars to provide this service.

Education and implementation of this procedure relevant to ACTAS staff will be carried out by ACTAS.

Staff in scope for this procedure will be informed of the new procedure via their local communication strategies (i.e. team meetings, communication book) and provided with the document.

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|Related Policies, Procedures, Guidelines and Legislation |

Procedures

Inter-hospital Transfer: Non Critical Care Patients

Legislation

Health Act 1993

Human rights Act 2004

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|References |

National Heart Foundation of Australia A system of care for STEMI reducing time to reperfusion for patients with ST-segment elevation myocardial infarction. 2012

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|Definition of Terms |

ECG features of STEMI

ST-segment elevation of ≥1mm in two contiguous limb leads; or

ST-segment elevation of ≥2mm in two contiguous chest leads

The Lifenet ( System

Lifenet is a computer software solution that allows ECGs to be rapidly distributed, via the internet, to multiple computer destinations simultaneously. It can also automatically email ECGs and send SMS alerts to specified users

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|Search Terms |

Myocardial Infarction, STEMI, Primary percutaneous coronary intervention, PCI, Coronary Care, Catheter lab activation, ACTAS, NSW Ambulance

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|Attachments |

Attachment 1. STEMI Pathway (Southern New South Wales)

Attachment 2. STEMI Pathway (ACT Ambulance Service)

Disclaimer: This document has been developed by ACT Health, Division of Medicine / Coronary Care Unit specifically for its own use. Use of this document and any reliance on the information contained therein by any third party is at his or her own risk and Health Directorate assumes no responsibility whatsoever.

|Date Amended |Section Amended |Approved By |

|Eg: 17 August 2014 |Section 1 |ED/CHHSPC Chair |

| | | |

Attachment 1. STEMI Pathway (Southern New South Wales)

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Attachment 2. STEMI Pathway (ACT Ambulance Service)

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