Questions!

Prasugrel

What are other hospitals doing with prasugrel? We have been checking P2y12 assays and if inhibition is not greater than 50%, switching the patient to prasugrel. (However, we did have one patient who had 0 inhibition on the prasugrel as well.) I was wondering if anyone has come up with some type of protocol. The patient gets loaded with clopidogrel then gets a level checked. They are then changed to prasugrel if the level is low. Some physicians load the patient with 60 mg, but others do not. I was just curious to see how others are treating patients.

Annie Ruppert
Email: Annie.Ruppert@sharp.com
Cc: cathlabdigest@aol.com

Stocking the Impella

How many Impella 2.5 systems do you carry in stock? What is the minimum level you keep on hand at all times? Would you ever keep only 1 unit on site at all times? We have 5 rooms and we do approximately 4,800 procedures a year.

Scott Fylling, RCIS
Email: Scott.Fylling@bhsnet.org
Cc: cathlabdigest@aol.com

Data Collection, QI Position

We want to create a job in our cath lab that isolates data collection and quality improvement initiatives and does not require an RN. I can’t find any similar job descriptions online. Does a position like this even exist?

Erin
Email: erin.caruso@caritaschristi.org
Cc: cathlabdigest@aol.com

Panning Program

I had a small program that teaches staff and students to “pan the table” for the physician during a case. Since I have gotten my new computer, I cannot find it. Does anyone know where I could re-download this program? It is such an excellent tool to use for teaching panning. Everything is backwards and when better to study than sitting behind your computer screen, panning with your mouse?

Jason
Email: Itroje@aol.com
Cc: cathlabdigest@aol.com

Answered!

Post Recovery Situation

I am interested in knowing what the post recovery time is for patients that are being admitted to the hospital post cath or PCI. Currently, the lab I am working in requires the CCL to recover all patients being discharged from the CCL holding/recovery. We are a small facility with only 1 call team, which at this time is only one nurse. The nurse ends up staying 90 percent of the time. Should a STEMI come in, then the nurse has to transfer the patient to the ICU to continue the recovery time and discharge.

Mitzi Latour
Email: mlatourrn@yahoo.com
CC: cathlabdigest@aol.com

Mitzi,

In our facility, all of our emergent PCI post cath patients go directly to the ICU following their cath lab procedure. During off hours there are more staff and resources available in this setting; in addition, it is the highest level of care available. Our ICU adheres to a 1:2 nurse-patient ratio and caring for the post PCI patient is generally not a problem. With comprehensive post procedure assessment criteria in place, the ICU should be able to provide the level of care required by your organization.

William Rodgers, RN, MSN
Cardiovascular Clinician
Anderson Hospital
Maryville, IL
rodgersw@andersonhospital.org

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Optimizing D2B Times for STEMI Interventions: Time to Break Old Habits

Question:

My emergency room physicians are putting the breaks on sending a ST-elevation myocardial infarction (STEMI) to the cath lab unless the cath physician is physically on site. They feel the patient is their responsibility and don’t want to take a chance in the patient getting to the lab without a physician. We were assuring them that the physician had been notified before calling the emergency department (ED) to say we were ready, but that hasn’t been good enough. The ED docs want them there. Many hospitals I call are saying they aren’t waiting for that. What is the practice out there?

Mary Floyd, RN BSN CCRN RCIS
Director, Cardiac Catheterization Lab
Lewis Gale Medical Center

Answer:

It is a pity that your ED physicians are insisting on the cardiologist being in the cath lab before the STEMI patient is transported:

1. Although there is some validity to your ED physicians insisting on a physician being in the cath lab, you are almost certainly assured that you will not be able to achieve door-to-ballooon (D2B) times consistently. This is an enormous disservice to the patient.

2. Perhaps there needs to be a better triage of the STEMI patient before such a firm policy is incorporated by your ED physicians — most acute MI patients are clinically and hemodynamically stable for such transfers. For the situation with a truly unstable patient, which may not be often, the recommendation to have a physician in the cath lab is acceptable.

3. Several institutions, including Mercy Hospital in Miami, Florida (one of the 5 hospitals in the SINCERE database), have a bridge team in place, that includes the intensivist. In this situation, this bridge team provides urgent transportation and the intensivist signs off the patient to the interventional cardiologists. This is a very effective strategy — it provides seamless transition and improved quality of care. If your ED physicians are insistent, the bridge program may be a suitable option to consider.

4. Often, when ED or cath lab physicians have such important issues and discord on critical issues, regular STEMI meetings may help in building trust. Such a team should include the ED, cath lab, CCU and representation from administration.

5. At such meetings, each STEMI procedure may be reviewed and a collaborative strategy used to improve outcomes. In addition, such meetings should review both the D2B times and the rates of false alarms.1

A few related topics merit discussion here as well. Figures 1-2 (below) emphasize the importance of backward integration of STEMI decisions — in this suggested pathway, in order to consistently meet with D2B times, the decision for STEMI system alert must be backward integrated in a fashion that the system is activated by the earliest provider of STEMI care. Several institutions are struggling with this issue, along with the situation discussed above. Finally, there are two known methods for effective pre hospital triage and diagnosis — the first involves incorporating telemedicine in the ambulance; the second process used trained “advanced paramedics” that are able to reliably interpret the EKG and alert the STEMI system.

Questions about the STEMI process or the STEMI procedure? Email Dr. Mehta at cathlabdigest@aol.com.

Reference

1. Mehta S, Briceno R, Alfonso C, Bhatt M. Lessons from the Single Individual Community Experience Registry for Primary PCI (SINCERE) Database. In: Mehta S, ed. Textbook of STEMI Interventions. Malvern: HMP Communications; 2008: 95-110.