Thank you for viewing the Chest Pain MI Registry February case scenario for 2022 regarding metric 55 door-in door-out time, which is evaluating the percentage of acute STEMI or its equivalent patients with a time from ED arrival to ED discharge that is less than or equal to 30 minutes. A 78-year-old female presented to the emergency department at 10 p.m. via EMS from a senior living facility with no significant past medical history. She complained of chest tightness and dizziness. The initial ECG revealed ST elevation of 1.5 millimeters in leads V1 through V4 with a rate of 160 beats per minute. While obtaining initial labs, the patient became unresponsive at 10.15 p.m. with no signs of circulation. CPR ensued and ventricular fibrillation was noted on the telemetry monitor. The patient had a return of spontaneous circulation after one shock at 10.18 p.m. The ED physician had signed the STEMI equivalent ECG at 10.05 p.m., and it was transmitted at 10.07 p.m. to the receiving facility on-call cardiologist via secure text. The receiving facility cath lab team was subsequently activated. The patient was taken by air ambulance at 10.28 p.m. directly to the cath lab for primary PCI for ST. Our question is, is the patient included in the numerator for metric 55? Please take a few moments to review the scenario before making your selection. The answer is number two, yes. Metric 55 reviews the process of the referring facility. This patient had a denominator exception of cardiac arrest during less than or equal to 30 minutes of arrival. However, despite cardiac arrest occurring within 30 minutes of arrival, the patient was transferred out in 28 minutes. Having met the numerator criteria despite the incidence of cardiac arrest, the facility is given credit for the numerator performance. As the community strengthens its healthcare system, this is a very important piece of the puzzle. We understand the challenges each facility is facing. Quality improvements for institutions has made clinical toolkits to assist the facility's effort to improve overall cardiac care. It takes a whole village to achieve excellence, from the initial contact, whether it is ED or EMS service recognition of the STEMI ECG or its equivalent, to coordinating a quick transfer and simultaneously providing guideline-recommended therapies. Time is muscle. In the absence of contraindications, fibrinolytic therapy should be given to patients with STEMI and onset of ischemic symptoms within the previous 12 hours when it is anticipated that primary PCI cannot be performed less than or equal to 120 minutes from first medical contact. In this and like scenarios where reperfusion is anticipated to occur less than or equal to 120 minutes, then thrombolytic therapy may not be considered. When evaluating the treatment options for STEMI patients of non-PCI capable hospitals, timely fibrinolytic therapy needs to be considered when PCI is not feasible to be performed less than or equal to 120 minutes of first medical contact. When should the administration of thrombolytic therapy be considered? During inclement weather, when the patient condition prevents, such as being overweight for a helicopter, or traffic prevents timely primary PCI. Additionally, the limitations of the receiving facility's abilities need to be assessed. The ACC AHA guideline for the management of STEMI recommends that patients who present with STEMI to a non-PCI capable hospital should receive timely fibrinolytic therapy if inter-hospital timely transfer time for primary PCI is not feasible to achieve mechanical reperfusion in less than or equal to 120 minutes of first medical contact. Thank you for reviewing the Chest Pain MI Registry's February 2022 case scenario.

metric 55

door-in door-out time

acute STEMI

ED arrival to ED discharge

cardiac care