Cardiac Cath Lab - Specialty Referral?

[AZCEP]

After reading some of the replies, all I can say is "HOLY LAWSUIT, Batman."

Transporting to a non-cath lab facility, only to be re-sent to the same place later for transfer to a cath lab is begging for a lawyer's appearance. The JCAHO standard is 90 minutes from entering a facility to be on the cath lab table.

I guess I'm lucky to work in a system with one primary receiving facility that has a cath lab. Although, none of the other receiving facilities that I can transport to have any problem deferring a patient directly to the facilities that can do a cath.

JPINFV, we are supposed to call for morphine as well, but our medical direction understands the limits of communication based on geography for us. Not allowing medics to give ASA is ridiculous. I would hope that your dispatchers are telling these patients to take some Excedrin, or Bufferin before you get there. :shock:

[RedZone]

We have a Cath Alert protocol for our AMI and acute onset LBB pts. They all, regardless of location, go to the same hospital for immediate cath. The protocol calls for the usual AMI stuff (i.e MONA as required), followed by a Heparin bolus and Lopressor if indicated. Upon our interpretation of the 12 lead, the ER charge nurse is notified that we have a "Cath Alert" and in turns activates the cath team. We bypass the ER and head straight to the cath lab (unless its at night and the team hasn't arrived yet, then we'll deliver to the ER until they arrive). We are hoping to add some other facilities to this program to further reduce our transport time, but as we stand now, our current time from 911 call until revascularization is around 85 minutes. The national standard from ER door time to revascularization is 90 minutes, so I guess we aren't doing too darn bad!

Very nice to hear this! It sounds like this particular hospital realizes the potential of your EMS system and looks for ways to implement the EMS resource to improve patient care. A good model for many other hospital / EMS systems nationwide.

A cath lab nurse I was talking with told me she was at a conference recently. What I got from her was that this is something either being promoted or recommended right now.

One hospital implemented a STEMI code policy where ANY patient who walks in complaining of chest pain is to be immediately placed on a stretcher and have a 12-lead done right at walk-in triage. If they interpret it as an ST elevation MI, the nurse activates the code.

This sounds like a great thing, but it also hits me like a slap in the face a little too. I feel like screaming, "Uh... HELLO!!! We've been evaluating STEMIs for 10 years now! How come you're not at least asking EMS to notify you ahead when bringing STEMIs in and consider that sufficient for activating that code?"

[kevkei]

Our system is unique, we will either transport directly to the cath lab, or alternatively, for some patients we will thrombolize prehospitally.

We basically identify the indications, rule out contraindications, obtain consent, initiate treatment O2, IV, (12-lead previously done), ASA, Nitro, Clopidogrel (Plavix), Enoxaparin IV and SC. We will have also contacted the coordinating Physician to determine the best treatment method (cath lab, or lysis) looking at the whole picture (patients age, PMHx, geographical location, time of day, duration of symptoms, cath lab availability, etc) If there is an anticipated delay in door to balloon time, we administer TNK.)

If anyone is interested, I can forward a copy of our worksheet/consent and the flow chart. I don't want to post it because it's too large, and I can't link to it because it is on a secure site.

[RedZone]

Our system is unique, we will either transport directly to the cath lab, or alternatively, for some patients we will thrombolize prehospitally.

We basically identify the indications, rule out contraindications, obtain consent, initiate treatment O2, IV, (12-lead previously done), ASA, Nitro, Clopidogrel (Plavix), Enoxaparin IV and SC. We will have also contacted the coordinating Physician to determine the best treatment method (cath lab, or lysis) looking at the whole picture (patients age, PMHx, geographical location, time of day, duration of symptoms, cath lab availability, etc) If there is an anticipated delay in door to balloon time, we administer TNK.)

If anyone is interested, I can forward a copy of our worksheet/consent and the flow chart. I don't want to post it because it's too large, and I can't link to it because it is on a secure site.

Interesting indeed!! From what I heard (I guess technically that's only rumor), there was a trial done in NYC 10 years ago where one voluntary hospital experimented with TPA prehospitally. Don't know the results, but it never made it on the bus. We rarely have a transport time greater than 10 minutes, and eventually all emergency departments were mandated to have thrombolytics.

But it sounds like you have a much higher scope of training and practice than we do. Awesome!

[RedZone]

After reading some of the replies, all I can say is "HOLY LAWSUIT, Batman."

Transporting to a non-cath lab facility, only to be re-sent to the same place later for transfer to a cath lab is begging for a lawyer's appearance. The JCAHO standard is 90 minutes from entering a facility to be on the cath lab table.

I guess I'm lucky to work in a system with one primary receiving facility that has a cath lab. Although, none of the other receiving facilities that I can transport to have any problem deferring a patient directly to the facilities that can do a cath.

JPINFV, we are supposed to call for morphine as well, but our medical direction understands the limits of communication based on geography for us. Not allowing medics to give ASA is ridiculous. I would hope that your dispatchers are telling these patients to take some Excedrin, or Bufferin before you get there. :shock:

Well, yes, in a way you are lucky to not have to be concerned with destination decision!

As far as lawsuit, you need injury due to negligence. Whether I agree or not, the accepted standard here is: AMI to closest ED. The 90 minute standard is probably being met, even when the patient requires transfer. A year or 2 ago, not every STEMI got an emergency cath here. I don't know the exact criteria used, but many were given thrombolytics, admitted to CCU, and scheduled for a cath a day or two later. If I were to do that same call today, I'd call telemetry and say, "Hey, it makes more logical sense for me to go an extra 5 minutes out of the way with this guy, but I need your ok."

[RedZone]

[AZCEP]

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As far as lawsuit, you need injury due to negligence. Whether I agree or not, the accepted standard here is: AMI to closest ED. The 90 minute standard is probably being met, even when the patient requires transfer. A year or 2 ago, not every STEMI got an emergency cath here. I don't know the exact criteria used, but many were given thrombolytics, admitted to CCU, and scheduled for a cath a day or two later.

For a lawsuit, all an attorney would need to demonstrate was a lack of following accepted standards. Injury would not have to be related to negligence, but it would be pretty easy to demonstrate. Your "accepted standard" flies in the face of JCAHO and AHA guidelines, which will be used to show that the system is negligent.

Two years ago, the guidelines were a bit more open to using fibrinolytics instead of PCI. Recently, those changed to emphasize the use of PCI before fibrinolytics if the delay was less than 30-45 minutes.

[RedZone]

Your "accepted standard" flies in the face of JCAHO and AHA guidelines, which will be used to show that the system is negligent.

I agree 100% that my regional standards differ from AHA guidelines. This wouldn't be the only example of such. And that is why I am curious about other regional standards. From what I am seeing (this site, and elsewhere), it is a fairly common problem in many systems. According to one person, this exact issue was discussed in a critical care class "majority of the systems still transport to local ED's"

Suing the system? Good luck! If it's that easy, I sure hope someone is doing that already.

[p3medic]

We stransport all STEMI's (based on medic interpretation, not machines) to cath capable facilities, and more often than not go direct to cath lab

[JakeEMTP]

We transport all our STEMI pt's to the ED based on medic's interpretation. In the not to distant future, we are hoping to transmit our EKG's to the ED. We are fortunate enough to have a Cardiac centre at the hospital and when we call in to the hospital, the cath team is notified. They usually are waiting in the ED for us upon our arrival. We have on occasion, bypassed the ED and gone directly to the Cardiac Centre. Albeit, that is a rare occurence. They don't trust us that much...................yet.