Harbor:Code STEMI

Background

Code STEMI is utilized to activate the cardiac catheterization team for consideration of emergent revascularization in the setting of ST-elevation myocardial infarction.

Harbor - UCLA is a STEMI Center, with 24/7 cardiac catheterization availability. STEMI activations are often called in from the field, and many patients are transferred from outside hospitals for STEMI treatment.

Accepting STEMI Transfers from Outside Hosptials

Not all hospitals in our area are STEMI receiving centers; a hospital that is not a STEMI Center may call you in the emergency department to request transfer of a STEMI via 911 EMS response. This countywide protocol allows hospitals that are not STEMI centers to call 911 to emergently transfer a patient in their Emergency Department (not inpatients) to a STEMI Center for emergent cardiac catheterization. The process for accepting a STEMI 911 IFT is as follows:

• Only Attending Base Hospital Physicians can accept a STEMI 911-IFT.
  
• Only STEMIs should be transferred by 911-IFT. This process should NOT be used for NSTEMIs or "concerning history"
  
• These calls should be answered on the recorded line in the Radio Room at (310) 328-1800. If you receive a STEMI transfer call to your Spectra phone, please ask the caller to call the Radio Room and go there to answer.
  
• The transferring hospital must transmit their ECG to you & there must be a Doc-to-Doc conversation to confirm that both of you see ST elevations on the ECG.
  
• If you don't see a STEMI, but the transferring physician reasonably believes that he/she does, please accept the patient and re-evaluate in our ED.
  
• If you do not see STEMI and the transferring physician reports concern for NSTEMI changes or troponin abnormalities, please advise them that we “would be happy to accept the patient for transfer via the Medical Alert Center; but at this time we are only supposed to accept STEMI 911-IFTs if they meet ECG criteria for emergent cardiac catheterization.”
  

More information on STEMI patients and Interfacility Transfer of STEMI patients can be found on the Harbor-UCLA Intranet under DEM Policies and Procedures.

(See also "TRANSFERS")

Dir OPS 1/9/17

Pre-Hospital Activation

If a STEMI is reported in from the field or from another hospital (911-IFT) the prehospital ECG should be printed by the MICN and brought to the Attending physician AND the physician should speak to the paramedics or transferring physician to get their clinical assessment.

If you agree that the transmitted ECG and clinical history are consistent with STEMI (see LA County Criteria for Pre-hospital Activation" (below), page out the STEMI as soon as possible. DO NOT wait for patient to arrive before placing the page, regardless of time of day. The Interventional Cardiologist on-call will review the ECG and cancel the STEMI activation if they disagree.

If the transferring hospital or reporting paramedic cannot or does not transmit the ECG, delay activation until the patient arrives and you have a chance to review the field or outside hospital ECG, or have performed one in our ED.

The Los Angeles County EMS Agency Prehospital Care Manual outlines the process for pre-hospital activation as follows:

Criteria for Contact/Transport to STEMI Receiving Center (SRC)

• Good-quality 12-lead ECG with >1mm ST-segment elevation in 2 or more contiguous leads, AND
• Computer analysis indicates ***ACUTE MI***or manufacturer equivalent, OR
• Paramedic concern for evolving ECG changes (i.e. hyperacute T waves in high risk patient)

Los Angeles County Criteria for Pre-hospital Activation of Code STEMI (abbreviated)

• Paramedic confident in STEMI impression
• ED physician agrees with STEMI impression
• Age 30-90
• Pain less than 12 hours
• Narrow QRS and Heart Rate <120
• Patient able to give informed consent

Procedure for Activating/Pre-Activating Code STEMI

Code STEMI pages can be placed by anyone; but are usually placed by a Clerk or MICN. Code STEMI pages should include, at a minimum:

• Patient age and sex
• Presenting complaint (e.g. Chest Pain, ROSC, ALOC, etc.)
• Patient location and/or ETA
• Phone number of Attending physician (full number including area code and Spectra extension)

In addition, if an ECG has been performed in our ED, please ask the MICN/Clerk to fax the ECG to the "STEMI Fax" number while placing the page. Cardiology must review the ECG themselves to activate the Cath lab.

If the Cardiology Attending decides to cancel the Code STEMI, they should call the ED Attending to discuss. This decision should not be relayed through the Cardiology Fellow. A calendar with the Cardiology Attending on call, including phone and pager numbers, is posted monthly in the ED Radio Room to facilitate communication.

See Also

• Harbor:Main
• Harbor:EKG STEMI Screening