Northridge Hospital Medical Center: A Designated STEMI Receiving Center “just like a trauma center”

Northridge Hospital Medical Center, in the heart of the San Fernando Valley, is a 411-bed hospital with two cardiac catheterization laboratories. The emergency department (ED) is a trauma center as well as an official ST-elevation myocardial infarction (STEMI) Receiving Center, as designated by Los Angeles County, California, on December 1, 2006 (more information about this certification is available at the Los Angeles County Health Services website, at https://ems.dhs.lacounty. gov/ STEMI.htm). Cath Lab Digest spoke with Michael Cromwell, RN, BSN, Clinical Supervisor, Cardiac Catheterization Laboratory, Cardiovascular Center, Ed Lopez, RCP Service Line Director, Cardio-Vascular Center & Respiratory Services, and Heidi Ruff, RN, BSN, Program Manager for the Bay Station, Pre-Hospital Care Coordinator, about the organization and processes required to be certified by the county as a STEMI Receiving Center, and what that means for the local patient population, hospital and cath lab. Tell us about the cath lab at Northridge Hospital. M. Cromwell: Our cath lab currently treats about 1,400 patients per year. We’ve had two dedicated cath labs since 1984, but rebuilt one lab approximately five years ago and recently completed construction on a new lab. While that project was under way, we were operating with one lab for a little over a year and a half. E. Lopez: The Northridge cath lab has a staff of 10, with 21 interventional cardiologists utilizing our labs. Our staff includes five registered nurses (RNs), four radiology technologists and one cardiovascular technologist (CVT). When did Northridge Hospital become a STEMI Receiving Center and what did the process involve? M. Cromwell: Northridge Hospital Medical Center became a STEMI Receiving Center in Los Angeles County on December 1, 2006. Of course, we had been taking care of STEMI patients for a long time prior to that designation. Northridge recently treated our 100th patient since officially becoming a STEMI Receiving Center. E. Lopez: We had to go through an application process with California’s Department of Health Services (DHS) and also meet requirements such as having a cath lab, a 24/7 on-call team that includes a cardiologist, an emergency department (ED) that can handle the volume of the patients and still remain open, and on-site open-heart surgical backup. M. Cromwell: In California, while the law still states that facilities must have on-site open-heart surgical backup, a bill is under consideration that will possibly permit this requirement to be waived for elective percutaneous coronary interventions (PCIs). In addition to the requirements Ed Lopez listed, DHS wanted to ensure that the cath lab never shut down due to issues such as staffing. We had to come up with multiple, redundant scenarios to ensure that Northridge is never closed to STEMI patients. We also committed to collection and submission of data to the county. Our ED physician champion, Dr. Ivan Rokos, most recently presented data at the 2008 American College of Cardiology Scientific Sessions, drawn from approved Los Angeles County STEMI Receiving Centers. DHS and emergency medical services (EMS) were also required to conduct a physical walk-through of our facility. At the time, in late 2006, certifying a STEMI Receiving Center was a brand-new step for DHS. Northridge Hospital was the first to be considered. It was a stressful time for all of us, but we were also happy to be the first. It was important to Northridge to establish a collaborative environment for success because we saw the huge benefit it would provide to our community. In the San Fernando Valley, there are eight hospitals within 10 miles of each other. Even though there is competition between hospitals for patients, we made it clear to DHS that treating STEMI patients was too important to the community for Northridge and other area hospitals to try and one-up each other. We made a commitment to freely share information to our competitors for the joint success of the program. DHS wants us to succeed and we want DHS to succeed as well. A true collaboration on many levels has resulted. Northridge Hospital was also the first hospital to be re-certified as a STEMI Receiving Center. How many of the hospitals surrounding Northridge in the San Fernando Valley are also certified as STEMI Receiving Centers? M. Cromwell: In the first few months of 2006, there were only three hospitals in all of Los Angeles county, of which Northridge was one. There are now four in our primary service area, in addition to Northridge. E. Lopez: It is absolutely necessary to have multiple, designated centers, since time is a critical factor, and we also want to ensure that there are enough hospitals in the area to support the volume of patients. M. Cromwell: One of the best features of this program is that STEMI patients are treated just like trauma patients. A serious trauma patient is not taken by EMS to the little local hospital just because it is the closest to the scene. For STEMI, just as for trauma, EMS bypasses hospitals that do not have a cath lab (of which there are several). Patients with a field electrocardiographic (ECG) STEMI are brought directly to a STEMI Receiving Center so they can receive optimal treatment. E. Lopez: From the time that the paramedics arrive at a patient’s home, we are already activating the cath lab team. When the patient arrives at the hospital, the team is ready to go and there is less waiting time for the patient. Can you tell us more about the EMS collaboration with the STEMI Receiving Centers? H. Ruff: In the beginning, one of the local EMS captains, Brent Spankroy, put together a schedule for every single paramedic in the San Fernando Valley to attend continuing education at NHMC. It was a huge undertaking involving several hundred paramedics. Northridge began to collaborate with the Los Angeles Fire Department and designed an hour-long class that I, along with Karen Reid-Wright, RN, taught for pre-hospital care and the rules and regulations established by DHS. It included not only the rules to be followed by the paramedics, but also the procedures we would follow in the ED and the cath lab. After the class, the paramedics took a tour of the cath lab. If there was an catheterization procedure in progress at the time, all were invited to watch. If there wasn’t an active catheterization, then Mike Cromwell and the cath lab staff gave a lecture, once in the morning and once in the afternoon, to the paramedics. The involvement of the cath lab was instrumental in garnering the necessary support from the paramedics. They greatly appreciated the opportunity to actually see what takes place in the cath lab and throughout the entire process of the patient’s care. The tours actually continue to this day — Mike’s invitation still stands. In addition, any time the paramedics bring in a STEMI patient, the city has approved them to go “non-available” and follow their patient to the cath lab if they wish. This program has received a great deal of support from the city fire department and the cath lab staff. When we have a student in the ED and ask the surgeons if the student can watch a surgery, sometimes the answer is yes, but often the answer is no. At Northridge, the ED has such a good working relationship with the cath lab that we do not have to call and ask. The paramedics are always welcome. We take the time with new paramedics who move into the area and who haven’t undergone the initial, intense STEMI training to educate them about our roles in the ED and their role as paramedic, and we let them know that they are always welcome to go up to the cath lab and see their patient. Karen Reid-Wright and I also teach a class every few months at the area fire station, called “Fire Station Friday.” We present case studies of patients, from beginning to end. We listen to the radio call to the paramedics (we will use a call from the local area, so the paramedics are familiar with the patient). We discuss what care was administered in the ED, look at the actual angiographic images and then discuss the outcome of the patient. M. Cromwell: It’s about letting EMS know the difference they are making. In the past, paramedics have said they would come into the ED with an ECG (not necessarily at our hospital), and sometimes the ED staff would look at it and sometimes they wouldn’t. The paramedics knew that more often than not, their ECGs would end up in the trash. The feeling was, What’s the point of doing the ECG if no one will look at it? I made a point of telling these firefighter paramedics that from our perspective as a STEMI Receiving Center (as well as at the other hospitals that were going to be striving for this designation), their initial ECG would be the starting point for all STEMI patients. I gave each paramedic my contact information and told them if they ever had an ECG thrown in the trash, they were to call me. I would talk to DHS and EMS, and it would be the last time their ECG does not receive the attention and respect it deserves. Since then, I’ve not had one phone call. H. Ruff: The opposite is actually true in the ED. If we don’t have an initial ECG or something happens to it, then EMS gets a call from Karen or myself the next day. We go back out to their station, recall it in their computers, reprint it and bring it back. EMS was already trained to do ECGs prior to the implementation of the STEMI Receiving Centers? H. Ruff: Yes. EMS fortunately worked through and eliminated any performance “bugs” about a year before the implementation of the STEMI Receiving Centers. Other training we provided to the paramedics wasn’t necessarily clinical at this point in their careers. However, we went over the typical signs of heart attack such as chest pain and shortness of breath, and provided more in-depth information about silent myocardial infarctions (MIs), where the symptoms don’t necessarily cause one to suspect MI. We discussed how long it actually takes to perform a 12-lead ECG to rule out or confirm an MI. We discussed the importance of moving patients out of the ED within 30 minutes and what a catheterization procedure entails. When the medics bring the STEMI patients in, we reconfirm the 12-lead ECG with whatever time we have, and the ED begins implementing our procedures. When the cath lab staff arrives, the patient is taken immediately to the cath lab. The Northridge ED has one specially-equipped room designated as the STEMI receiving room. We obviously can go mobile if needed, but the staff prefers to have a dedicated STEMI treatment room. The patient is taken to that room, treatment starts, and within 30 minutes, they are taken up to the cath lab. What are your current door-to-balloon (DTB) times and how long has it taken you to get to this point? M. Cromwell: At last count, by paramedic activation, we had 51:56 patients (a little over 91%) with DTB times of less than 90 minutes. The ratio is nearly 50:50 in terms of the number of patients who come in via EMS and those who walk in with a STEMI. It’s easier to achieve our DTB times with 911 activation. It is much more difficult to achieve a less than 90-minute DTB with walk-in patients. All of the STEMI Receiving Centers have found that DTB times are consistently under 90 minutes with EMS activation compared to the walk-in patients. H. Ruff: The reason is pure numbers. When a patient calls 911, they receive the full attention of two paramedics. Often there are two paramedics and four firefighters, all doing something for the patient at the same time. On the other hand, when a person walks into the ED triage, there is one, perhaps two, triage nurses to handle often as many as 20-30 patients. That triage nurse is trying to evaluate people very quickly and process the paperwork. Triage generally takes about four minutes per patient. Even if the triage nurse gets quickly to the patient who complains of chest pain and shortness of breath, it still takes several minutes. We look at the time that the patient actually signed in to triage; the clock starts ticking at that point. To me, it just makes sense that a trained EMS personnel initiate treatment for the patient at his or her home. In two minutes, EMS can observe that the patient is pale, diaphoretic and has chest pain, and can then perform an ECG. Within three minutes, the paramedics know it’s a STEMI and have contacted the ED, which then alerts the cath lab staff. This scenario is vastly different than the one where one or perhaps two triage nurses try to wade through all the patients coming into the ED. M. Cromwell: Plus, when we know the patient is coming in via EMS, we prepare the STEMI room, and the ED and cath lab staff are standing by ready to treat patients as soon as they hit the door, just like with trauma patients. What is the call-in time for the cath team? M. Cromwell: The call-in time is 30 minutes from the time the paramedics call us. Everyone’s pager in the cath lab is activated by one page. What about false alarms? E. Lopez: We still have false alarms, but that just comes with the territory. We are in the process of implementing a system that allows the ECG from the paramedics to be transmitted to the ED. Then the ED physician can make the call as to whether the patient is having a STEMI or not in order to reduce our false activations. I think Northridge has about a 30% false activation rate. The first month it was slightly higher because many of the firefighter paramedics wanted to save lives and might have “pulled the trigger” a bit early due to the initial enthusiasm for the new program. Northridge had 12 real STEMI patients the first month the program was implemented. Currently, only 10 staff members are on-call, and 12 STEMI patients during the night hours over the course of one month is a significant number for that size of on-call staff. We do want the paramedics to bring the patient in if the ECG is positive, but at the same time, we want to avoid activating the staff and cardiologist in the event that it is not a true STEMI. Is there any review after the case is finished? E. Lopez: We review all STEMI cases at a monthly meeting, which includes Dr. Raj Wick, Medical Director, nurses from both the ED and the cath lab, quality control personnel and paramedics. Dr. Rokos, our ED physician, first reviews all the cases with our quality control staff and then gives a full report on each STEMI for the month. H. Ruff: Oftentimes, Mike brings me a picture of the patient’s arteries clogged and then unclogged, with a snappy little caption like “Another life saved!” or “Ride in the ambulance: 20 min. Door-to-balloon: 60 min. Seeing your children again: priceless!” I then send these images out to the fire stations. Recently, we installed a bulletin board in the ED to post images as well. The patient name is removed, but the rescue number is left on, so the paramedics can pick them up and get the feedback. A few of our fire stations have handled STEMI patients several times already, and they don’t need to go to the cath lab. However, without the images, they don’t necessarily know what happens to their patients. The key for keeping up momentum is keeping up the feedback of what actually happens with the patient, and the paramedics really appreciate it. E. Lopez: It’s also important to remember that in the process of getting the patient from the paramedic to the cath lab, the operators play a large role. M. Cromwell: Hospital operators are the lynchpin of communication between the ED and emergency paging of the cath lab staff. When the operators send out the page, we do a four-person emergency call cath team, and the hospital operator is then responsible for making sure that all four staff check in within five minutes of that page going out. If someone doesn’t respond to the page, then the hospital operator tries to reach that person at home or on their cell numbers. If there is no answer, then they call me, and I might be on my way in for that patient. Could you share more about your collaboration with other developing STEMI Receiving Centers in your area? M. Cromwell: Los Angeles County DHS had never done this before, yet they were the governing body. This was such a huge project. Dr. Koenig and Paula Rashi from Los Angeles County DHS did a great job setting this up. Part of DHS coming to see us first was that we made a commitment that we would in turn call the managers of the other cath labs here in the Valley to help them be prepared. Not to give them any kind of unfair advantage, but to help them be ready for DHS. When DHS came to us, we didn’t know what data we would be required to collect, or how many people from different departments of the hospital needed to be involved. Once we had gone through this process, I let the other applying hospitals know what people they needed to have in place. When DHS came during their application process, it made the job a lot easier. We knew we needed other hospitals to be STEMI Receiving Centers as well. That first month we had 12 STEMIs, which is because every STEMI patient who was in need of treatment after regular daytime hours was bypassing every other hospital in the San Fernando Valley and coming to Northridge. H. Ruff: At that time, in all of Los Angeles County, there were only three designated STEMI Receiving Centers. E. Lopez: Every six months, in partnership with the American Heart Association (AHA), representatives from all the different hospitals meet at one of the hospital locations. For the first meeting, we met at the AHA Center in Los Angeles. Northridge hosted the second meeting, and the third will be at Los Robles Hospital. H. Ruff: In addition, once a month, we meet with all the other prehospital coordinators. This is not necessarily always STEMI-related, but it is a great forum to discuss positives and negatives, along with the growing pains we are all experiencing. It’s been useful to discover whether someone has a unique issue or whether we’re all going through the same types of challenges. What have you found regarding the challenges you’re facing? E. Lopez: I think everyone shares the challenge of treating walk-in STEMI patients and trying to make DTB times that are as good as the paramedic runs. Also, the false-positive transmission data have been discussed by most hospitals. An article on the cover of a March 2008 Los Angeles Times states: “911 is best call to make if heart attack strikes.” Were you able to gauge any effect from this type of public service message on your walk-in volume? M. Cromwell: Not yet, although it was good to see that message disseminated to the public. It is such a new way of thinking, and our data collection is so new, that it’s probably going to take a little while before we can track trends. However, one of the things we did emphasize with the firefighter paramedics was that in identifying heart attack patients earlier and getting them treated more quickly, patients not only go home, but they go home with a healthier heart. For the paramedics, it might mean fewer 3:00 am calls for fulminating congestive heart failure (CHF). Yet our data are so new that we don’t know how much of an impact we are making on the CHF population. Feedback from the firefighter paramedics has revealed a decrease in CHF calls in the middle of the night, specifically in the area served by the STEMI Receiving Centers. CHF is one of the diagnoses almost every hospital in the country loses money on; it’s hard to take care of these patients. If we can show change in our local CHF population, and a resulting decrease in CHF admissions in the area served by the STEMI Receiving Centers, other regions throughout the country would have a huge financial incentive to adopt this strategy for rapid treatment of STEMI patients. Do you see different types of time measurements becoming more prominent beyond the simple DTB time measurement? M. Cromwell: Northridge Hospital had been tracking DTB times long before we became a STEMI Receiving Center. We have also been tracking “medical contact-to-balloon” time, i.e., paramedic ECG-to-balloon time (30 minutes to arrive at the ED, 30 minutes to get to the cath lab, and 30 minutes to open the artery). Dr. Ivan Rokos has also begun tracking EMS activation-to-balloon time (i.e., when did dispatch activate the fire station?). It’s a race against time and time is heart muscle. H. Ruff: Every time Dr. Rokos comes up with an idea of what data to track, it opens up a whole new can of worms! For example, how do we know what clock the relevant personnel use to record the time? Even when we began, we would get ECGs from the field that were two hours off because they hadn’t calibrated their time on the ECG. Now, everyone is aware of this, and it has become something as simple as looking at your cell phone for the time instead of at your watch! What about access to the data collected by the county? M. Cromwell: We can see our own data on the DHS registry and we have a designated American College of Cardiology National Cardiovascular Data Registry (NCDR) collector. H. Ruff: There is also a spreadsheet that is emailed after every STEMI, so everyone is provided the data for process improvement. Are staff encouraged to offer time-reduction suggestions? H. Ruff: Most definitely. For example, our staff members identified which room should be designated as the STEMI room in the ED. They wanted to use a different room than what we had originally selected, choosing instead one that was easily visualized and accessible from the nurses’ station. It’s simple things like that, where at 3:00 am, it truly makes a difference. We are not here at that time — they are. Our staff are the energy behind the program, so when they find a way to speed up or simplify the process, we hear about it. Any last thoughts? M. Cromwell: It has been a thrill to be a part of the STEMI Receiving Center program and see how many lives we are saving. I never get tired of seeing the first shot after the artery has been opened up and watching that coronary artery take its first long drink of oxygenated blood! It still gives me goose bumps. So much of heart disease is preventable and treatable. It’s been amazing to be a part of the STEMI program at Northridge Hospital alongside so many dedicated and talented people. H. Ruff: I think that would also be my message — seeing the teamwork and collaboration that goes into every single patient is awe-inspiring. It goes all the way from the 911 operator to the crew that gets dispatched, their communication back to us, and the patient caretakers within the hospital. It’s a huge, multidisciplinary collaboration, and everyone is open to improving the process. Michael Cromwell can be contacted at michael.cromwell@chw.edu Ed Lopez can be contacted at ed.lopez@chw.edu Heidi Ruff can be contacted at heidi.ruff@chw.edu

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