To Ensure That Patients with Signs and Symptoms of ST Elevation Myocardial Infarction (STEMI)

I. Purpose:

To ensure that patients with signs and symptoms of ST elevation myocardial infarction (STEMI) being managed at the paramedic level are transported to the most clinically appropriate facility II. Background and History Under EMS System Regulations (105 CMR 170.355), EMS Services are required to “transport a patient to an appropriate health care facility” which is interpreted by OEMS as being the “closest, by driving time, hospital emergency department.” In many cases this will be the most appropriate destination. Patients with particular clinical presentations have improved outcomes when transported to specialized facilities that are better equipped to manage their particular emergent conditions. Currently, there are Point-of-Entry plans for Trauma and Stroke patients. Published research and experience gained from existing Special Project Waivers within the Commonwealth (Boston, Cambridge, and Worcester), and from the medical literature, indicate that patients presenting with STEMI have better outcomes, than they do with thrombolysis, when they receive percutaneous coronary intervention (PCI) within 120 minutes (and possibly longer) after the onset of myocardial infarction. The Region recognizes that it is in the best interest for most STEMI patients to be transported to a facility that can perform PCI 24 hours a day, 7 days a week, even when such a transport takes longer than going to a closest facility that does not perform PCI. III. Definitions: Acute Coronary Syndrome (ACS) a spectrum of cardiac disease that includes unstable Angina, Non-Q wave MI, and Q Wave MI. Appropriate Health Care Facility 105 CMR 170.020 Closest Hospital Emergency Department – this is the facility that can be reached in the shortest driving time from the location of the incident. Medical Direction 105 CMR 170.020 On-line Medical Direction 105 CMR 130.1501 Patient 105 CMR 170.020 Percutaneous Coronary Intervention (PCI) a process using catheters to provide better blood flow through a blood vessel Point-of-Entry Plan 105 CMR 170.020 Special Project Waiver a process identified by O.E.M.S. that allows a service or a group of services to request a waiver of any existing regulation

Updated per OEMS: 6-26-2009 IV. Policy/Procedure:

1. Follow the Emergency Medical Services Pre-Hospital Treatment Protocols.

2. Appropriate evaluation of these patients should involve O-P-Q-R-S-T and obtaining a history using S-A-M-P-L-E. Identified life threats should be treated as indicated.

a) Special consideration in patients with ACS should include:

(1) Signs and Symptoms of Acute Pulmonary Edema

(2) Hypotension

3. Providers should consider the diagnosis of Acute Coronary Syndrome in patients presenting with any of the following symptoms:

b) Chest pain (squeezing; dull pressure or discomfort)

c) Pain radiating down the arms or jaw

d) Sudden onset of sweating [in itself a significant finding]

e) Difficulty breathing, anxiety or restlessness

f) Impending feeling of doom

g) Abnormal and/or irregular pulse rate

h) Abnormal blood pressure

i) Epigastric pain

j) Nausea/vomiting

For patients with possible ACS, the paramedic shall obtain and interpret a 12-Lead ECG as soon as possible. If there is uncertainty, the provider shall continue to follow procedure and contact medical control.

3. Complete a fibrinolytic checklist, if appropriate.

Updated per OEMS: 6-26-2009 4. Estimate your distance to the closest PCI center that is able to perform 24 hour a day/7 day a week PCI

5. Establish on-line medical control as per established protocols. In the event that the medical control facility is also the closest PCI hospital, additional medical control contact is not needed. Identification of the case as a possible STEMI as well as the anticipated travel time to the nearest PCI center should be provided early in the notification. Other pertinent data should include:

a) Results of your history and physical

b) 12 Lead results

c) Fibrinolytic Checklist results.

7. If more than one PCI center meets these criteria, take into consideration patient preference/history and established relationships

8. Transport – if transporting to a PCI hospital, notify it ASAP through C-MED – NOTE PCI centers are identified on the flowchart on Page 4 of this policy.

9. If a patient with an STEMI deteriorates while being transported to a PCI center, continued transport to the PCI center should be strongly considered, unless the patient’s airway is compromised.

10. A readable copy of the PCR and ECG demonstrating a STEMI must be sent to the State Medical Director and Regional Medical Director (the envelope should be labeled to indicate a STEMI for evaluation)

Dr. Jonathan Burstein State Medical Director Office of Emergency Medical Service Massachusetts Department of Public Health 2 Boylston Street, 3rd Floor, Boston, MA 02116

Dr. Charles Pozner Region IV Medical Director 25 B Street, Suite A Burlington, MA 01803

Updated per OEMS: 6-26-2009 Metropolitan Boston EMS Council (Region IV) STEMI Point of Entry for ALS Transported Patients1

Patient Presentation And 12 Lead EKG consistent with STEMI 2,3

Patient has any of the following: Lytic contraindications Or Severe CHF Or Hypotension

Yes No

Difference in EMS transport time Transport to identified between closest facility and PCI Hospital PCI Hospital 3,4,5,6 is < 30 minutes

Yes No

Notes 1. Patients with a compromised airway Transport to will go to the nearest facility 2. STEMI is defined as a 1 mm ST elevation in 2 or Closest more contiguous leads, typically with reciprocal Hospital changes 3. Ambiguous 12 Lead presentations should go to the nearest facility PCI Centers in Region IV Area 4. Receiving PCI center must be notified 5. Consider Patient preference/history and Beth Israel Deaconess Medical Center established relationships if multiple PCI centers Boston Medical Center are an option Brigham and Women's Hospital Caritas Good Samaritan Medical Center Caritas Norwood Hospital Caritas Saint Elizabeth's Medical Center Lahey Clinic Lowell General Hospital Massachusetts General Hospital Melrose-Wakefield Hospital MetroWest Medical Center - Framingham Mt. Auburn Hospital Saints Medical Center South Shore Hospital Tufts Medical Center

Updated per OEMS: 6-26-2009