STEMI Care: Evolution of a Benchmark

     Time is the enemy when it comes to prehospital care. Pick a critical injury or illness, and you will usually hear a prognosis dependent on time. Once in a while, however, we manage a minor victory over Father Time, especially when we can steal back precious minutes and put them to better use. We've seen this not only with trauma care, but also in advances in stroke treatment and interventional cardiac care. The mantra we cite now is, "Time is muscle." The faster we can get time-sensitive patients recognized and into functioning systems of care, the better their overall outcomes. With the implementation of a program to recognize and treat suspected STEMI patients from the field to the table, the University of Medicine & Dentistry of New Jersey (UMDNJ) has managed to do just that.

     UMDNJ is the parent organization of The University Hospital (UH), New Jersey's premier Level I trauma center, located in Newark. UH-EMS is a hospital-based tiered service providing ALS and BLS coverage for Newark, Newark Liberty International Airport, Port Newark and Port Elizabeth, as well as primary ALS coverage for Orange and East Orange.

     In 2005, members of the UMDNJ cardiology department reviewed the department's procedures for STEMI patients, because their average door-to-balloon time was exceeding acceptable standards. They wanted a way to give cardiologists earlier notification of STEMI patients, and to consider the possibility of bringing recognized patients from the ambulance directly to the cath lab, bypassing the emergency department. "The name of the game is to open up the artery as soon as possible," says Vivek Dhruva, DO, who was the chief academic fellow of cardiology at the time the STAT-MI (for ST-segment Analysis using wireless Technology in acute Myocardial Infarction) project was proposed.

     Marc Klapholz, MD, FACC, FCSAI, director of cardiology, was the architect behind the program. After sketching out a process, he consulted every department to be involved: EMS, ED, information services and technology (IST), administration, cardiology, cath lab managers, regulatory affairs and the hospital's medical director. Medtronic/Physio-Control and Verizon Wireless were also consulted. Potential roadblocks were identified, such as an ongoing problem with bad or missing wires to connect cell phones to monitors to transmit EKGs.

     Regulatory compliance issues were a priority as well, especially if the ED was going to be bypassed. Completing the medical screening exam is an EMTALA requirement that had to be addressed. Other administrative issues included how to properly register patients and acquire appropriate consent in an expeditious manner. There was also consideration of what to do if the arteries were clear and no MI was present.

     The technology component was a challenge—how to efficiently transmit the EKG, and once it was sent, how to ensure it got to the cardiologists. What would be the best way to notify the paramedics about the patient's destination (cath lab vs. ED), not only during normal hours but after hours as well?

     The original plan included upgrading UMDNJ's LIFEPAK 12 monitors to allow wireless Bluetooth EKG transmission via pre-paired cell phones. An EKG receiving station (Medtronic's LIFENET software on a dedicated PC) was placed in the cath lab. "Smart" phones were issued to all cardiology fellows, several attending physicians and the chief of cardiology. These contained a PDF reader program to view EKGs. We then created e-mail accounts specific to each phone.

     The existing ED receiving station was reconfigured to transmit STEMI EKGs up to the cath lab's station. The cath lab station converts each EKG to a PDF and e-mails it to the smart phone accounts. It then pages designated pagers.