Thank you for viewing the Chest Pain MI Registry October case scenario regarding metric 56, time to primary PCI among transferred patients. In this scenario, a 53-year-old male with a past medical history of hypertension presented to a rural Hospital A at 10 o'clock for complaints of abdominal pain. While in the waiting room, he notified the triage nurse he was becoming short of breath and diaphoretic. An ECG revealed STEMI, and transport to the nearest PCI facility was arranged. However, EMS phoned the command center and reported an ETA of 25 minutes. Medevac was then called, who reported they were grounded due to weather. The patient left Hospital A at 11.23 via ambulance and arrived at Hospital B at 11.52. PCI was performed to a proximal LAD lesion at 12.14. Is this patient included in the numerator for metric 56, time to primary PCI among transferred patients? No or yes? Please take a moment to review to determine if this patient will be included in the numerator for metric 56, time to primary PCI among transferred patients. And the answer is number one, no. The patient is not included in the numerator for metric 56, time to primary PCI among transferred patients. We will review each denominator exclusion and exception on this slide to assure full understanding. In order to be excluded from the denominator, the patient would have had to receive a full dose of thrombolytics prior to arrival at Hospital B. In this scenario, that did not occur, therefore the exclusion was not met. The first denominator exception will remove patients from the measure when there is a patient-centered reason for delay in PCI and the time to first device activation time is longer than 120 minutes. While the time to first device activation time is longer than 120 minutes, there was no patient-centered reason for delay in PCI. Next, the patient was not enrolled in a clinical trial related to STEMI and reperfusion therapy to be considered for this exception. Next, there was no emergency medical services first medical contact non-system reason for delay as this patient arrived by car to Hospital A. Nor did the patient suffer any cardiac arrest to meet a denominator exception. And lastly, the transport time from Hospital A to Hospital B took less than 45 minutes. On receipt of this metrics value, part of evaluating next steps is to understand the patients that comprise the denominator so that an accurate assessment of next steps can be made. As the receiving facility, by creating and maintaining a regional system of STEMI care that includes assessment and continuous quality improvement of EMS and hospital-based activities, collaboration and timely feedback to the outside facility is a means to meet the Class I Level of Evidence Type B Guidelines recommendation. Noticing that system delays can be out of one's control allows for considering other means to identify and treat STEMI patients. A delay in ECG is common among patients who present with atypical symptoms of an acute coronary syndrome. A common rule of thumb includes performing an ECG, which is quick, easy, and low-cost on patients who complain of symptoms from the groin up. Additionally, system transport delays can be a time to review when it is appropriate and necessary to think about thrombolytics as a form of treatment. In the end, it is all about what is best for the patient, and reviewing outliers in metric performance can do just that. Thank you for viewing the Chest Pain MI Registry Monthly Case Scenario.

STEMI

transportation delays

primary PCI

exclusion criteria

system improvement