The Riverside STEMI Network (RSN) is a cooperative system of related Riverside providers, along with private and community owned providers. This network includes Riverside Medical Group physicians, Riverside acute care facilities in Newport News and Gloucester, local fire and rescue squads as well as Life Evac III medical air transport. Riverside STEMI Network members also work in collaboration with the Peninsulas Emergency Services Council (PEMS) to design and support emergency care protocols.
The goal of the Riverside STEMI Network is to improve the timely diagnosis (in the field and hospital environments), treatment and clinical outcomes for STEMI patients. STEMI or ST Elevated Myocardial Infarction is the most dangerous type of heart attack and is the result of a sudden blockage of one of the arteries that supply nutrient reach blood to the heart muscle. When blood flow is stopped for an extended period of time permanent damage to the heart muscle can occur. This condition can result in death or permanent disability to the individual. Riverside recognizes that rapid reperfusion or restoration of blood flow to the heart muscle is most important goal of any treatment plan and to that end works to reduce the critical time open blocked arteries using either mechanical (PTCA and/or stent) or thrombolytic (clot buster drugs). The national goal is to open blocked arteries in less than 90 minutes from arrival in the emergency center. This benchmark is often referred to as "door to balloon time" (D2B) and the Riverside goal is to meet this critical benchmark 100% of the time for all eligible patients.
Riverside physicians have adopted and/or developed protocols and order sets based on evidence based medicine guidelines to facilitate the diagnosis and treatment of STEMI patients.
The preferred method for reperfusion is the use of balloons or stents. This is preferred because the use of lytic or clot busting drugs does carry some risk in certain patient populations. Only certain hospitals can offer stent therapy and the American College of Cardiology / American Heart Association has defined guidelines for designating these hospitals. If PTCA is impractical due to weather or time constraints thrombolytic therapy will be delivered at the site of care most appropriate for the patient and conditions.
Diagnosis and treatment can starts in the field. Early use of 12 lead EKGs will help guide treatment plans and where patients should be transferred to fro treatment. Riverside supports PEMS and local first responders through on-going clinical education as well as monetary support to improve access to 12 lead EKG recordings. Riverside has made significant donations to local EMS agencies as well as the investment in the EKG receiving equipment at Riverside Regional Medical Center (RRMC). Riverside is committed to continue to work with PEMS to improve access to this technology as well as training and education for first responders.
Riverside physicians have adopted a policy for EKG reading for any field agency that transmits to RRMC. Riverside ER physicians will review the EKG and clinical history provided by EMS and determine if a STEMI emergency exists. If so Riverside physicians will assume medical control and authorize the launch of Life Evac III if the patient's location warrants air transport.
In the event that EKG transmission is not possible or reliable Riverside physicians will collaborate with field EMS personnel and will accept the paramedics opinion based on clinical signs and symptoms as well as the computer generated interpretation of the 12 lead EKG. Riverside will implement the STEMI CODE at the point even before the patient arrives at RRMC and begin the preparation for immediate transfer to the cath lab
For patients who bring themselves to the hospital or those transported by EMS (without field EKG) and complaints of chest pain or other sign and symptoms of heart attack the goal is a 12 lead EKG in < 10 minutes. If the EKG is positive for STEMI the STEMI CODE process is immediately implemented and the ER team implements the protocol for care of the patient as the cath lab is being prepped.
The Riverside STEMI code is a unique protocol (developed in 2004) that allows one call to notify and mobilize ALL Riverside team members necessary for the emergent care of the STEMI patient. This "one call does it call" process pages the cardiologist on call and the cath lab team as well as other clinical and administrative support. The cardiologist and cath lab team immediately report to the cath lab and prepare for the patients arrival. Response times of < 30 minutes is the goal for team members to arrive and begin their portion of the process.
For EMS and Air Transport patients time in the ER is limited to immediate medical evaluation and preparation for the cath lab.
The use of hypothermia therapy may be indicated in some cardiac arrest patients. Evidence suggests that early use of hypothermia therapy may reduce the morbidity and mortality associated with hypoxia during a STEMI event and improve cognitive function during and after recovery. Riverside supports the initiation of this therapy in the field and will continue this therapy in the ER, cath lab and critical care environments as determined by the attending physician
Each STEMI case is reviewed within 24 hours and several critical points are measured to determine any lapses in protocol and opportunities for improvement. Key measures include:
- Door to EKG
- EKG to MD review
- Review to calling STEMI CODE
- Arrival and readiness of cath lab
- Time to vascular access in cath lab
- Time to balloon inflation
All of these add up to the critical – door to balloon time.
2010 Statistics demonstrate that Riverside has met the critical door to balloon time measure in 100% of eligible STEMI patients.
The RSN is also available as resource to other acute care providers in the community and can be accessed by contacting the RRMC Emergency and Trauma Center or the Patient Transfer Center.