12 Lead EKG Transmission - American Heart Association

Mission: Lifeline - South Dakota
EMS/Hospital Education - 12 Lead EKG Transmission
Travis Spier – RN, NREMT-P, CCEMT-P
Manager of Pre-hospital Care and Mobile Simulation
Sanford Health – Sioux Falls, SD

Disclosures
Travis Spier – Education – Mission: Lifeline SD

Objectives
• Identify the role of an EMS/facility provider
within the SD Mission: Lifeline project
• Identify the educational steps involved in
acquisition, transmission and arrival of a prehospital
12 lead EKG

Project Mission Statement
• AHA Mission Lifeline mission statement
▫ A collaborative multidisciplinary effort organized to
facilitate and develop processes for optimizing timely
access to, and delivery of, appropriate care for
STEMI patients that addresses a continuum from
home to hospital and subsequent outpatient follow
up.

Recognizing the Problem
• Time is Muscle
▫ South Dakota statistics
• According the Center’s for Disease Control, South
Dakota is in the Class 5 category for STEMI death
rates in the nation,
• Majority of heart muscle
damage occurs within
the first 2hrs of the crisis
• My study and results
of “T2B”

South Dakota – A Rural System of Care
• Establish a comprehensive STEMI system
linking EMS providers to receiving facilities and
interventional care centers
• Develop a successful and functional model for
other states and systems to replicate
• Working together as a healthcare team with a
focus in identifying, managing, correcting and
reporting on an acute cardiac emergency
(STEMI)

Pre-hospital (EMS) Goals
• A new and additional “ask” of EMS
• Improving the timeliness for evaluating,
treating, transporting a patient experiencing
an acute cardiac emergency (STEMI)
• Accurate lead placement to obtain an EKG
• Establishing steps to follow for transmitting
an EKG on the monitor
• Wires on for transport
• Contact the hospital following transmission

Hospital Receiving Center Goals
• Openly accept the EKG as it arrives from the
out-of-hospital environment
• Prompt decision making process of the EMS 12
lead EKG
• Preparation for receiving and referring the
patient
• Transport arrangements (ground vs. air)
• Treatment guidelines and order sets
• Report the information, movement of data

A Successful System –
Value/Role/Knowledge/Ownership
• Assists in the improvement of timely cardiac care and
management during a STEMI event
• Provides prompt care that originates in the home of a
patient who is experiencing an acute myocardial injury
(STEMI)

The Role of EMS
• Respond, care for and manage the cardiac
patient outside the walls of the hospital
• Demonstrate your role as a Physician Extender
• Serving as the hands, eyes and ears of the physician
medical director while caring for the cardiac patient
in your community
• Provide emergency care that meets the
standards established for cardiac care, adheres
to local guidelines and functions in the best
interest of the patient

SD Mission Lifeline – Remember “Mick”
• Opportunity to improve healthcare delivery and
management of the acutely ill patient
experiencing a cardiac emergency (STEMI) in
the pre-hospital environment
• Decreasing the time to STEMI management and
treatment

Implementation Process
• EMS/hospital startup in South Dakota
▫ Equipment acquisition and equipment specific
training (on-site in their community)
▫ Mission Lifeline orientation and 12 Lead Transmission
Training (onsite in their community)
▫ Participate in ongoing training and program
improvement strategies (onsite in their communities)
▫ Active participant in 12 lead acquisition and
transmitting guidelines (hook in water = fish)
▫ Ongoing training and skill maintenance that supports
sustainability (outreach education collaboration)

What we already had in place…
• Monthly EMS Education system
• Healthcare facility support and affiliation
• Benefit of being a small State
• Great people willing to help others

South Dakota
• Map of EMS and Hospitals

Theory of Practice
• Timely assessment of the patient and acquisition
of a 12 lead EKG by EMS providers.
• Early transmission of the pre-hospital EKG into
the emergency department’s receiving station
followed by on-line communication
• Early diagnosis and start of clinical care and
management of the of the acutely ill cardiac
patient.
• Providing prompt treatment and interventions
to prevent ischemic damage to the heart and
decrease mortality caused by STEMI events.

Education Material
EMS Agencies
• Product specific education
• MLSD STEMI Education
• AHA STEMI Textbook
• AHA Learn Rapid STEMI
• Sample EMS Protocol
• Sample EMS skill verification
form
• Education packet
• Quick reference card
• EMS Coach/Mentor
Hospitals
• Product education on
receiving software
• MLSD STEMI education
• AHA STEMI Textbook
• AHA Learn Rapid STEMI
• Education packet
• Lytic material
• Quick reference card
• Resource availability

Distribution of textbooks and key
codes
Telephone calls and emails
• Number of EMS providers at each agency
• Number of nurses at facilities
• Number of providers at facilities
• Books assigned to a location
• Key code attached to a textbook
• Roster logs participant and book

Setting up the Key Manager

Implementing the Process

Establishing a Guideline
Have a established guideline to assist an EMS
provider in determining when to obtain/transmit a
12 lead EKG
▫ Chest pain
▫ Shortness of breath
▫ Syncope or near syncope
▫ Weakness
▫ DKA
▫ Diaphoresis
▫ Respiratory failure
▫ Ventricular failure (CHF)
▫ Stroke
▫ Overdose
▫ Altered level of consciousness
▫ Suspected electrolyte
disturbances
▫ Pre and post cardio-version of
stable patients
▫ Post cardiac arrest with return
of spontaneous circulation
▫ Blunt chest trauma (only after
transport or more urgent care)
▫ Irregular rhythm
Non-discriminating or judgmental

Components for EMS Success
• Trained EMS providers
▫ Familiar with use and function of equipment
▫ Proficient in EKG lead placement
▫ Knowledgeable in the steps of transmitting a 12 lead
• Equipment capable of obtaining a 12 lead EKG
▫ Cardiac Monitor
• AED / Defibrillator / Monitor/ 12 Lead / Transmit capability
• Sync cardiovert / TCP / ETCO2 / NIBP / SpO2
▫ Capable of transmitting a 12 lead via established
wireless platform
• Transmission source to send the 12 lead EKG
▫ Utilizing cellular data technology

A Process that is Easy…
• What is common?

Community Based Education with
EMS
• Develop a basis for educational understanding
▫ Anatomy and physiology of the heart
▫ Evolution of a heart attack
▫ Lead placement
▫ Transmitting components
▫ Components of an EKG
▫ STEMI markers
▫ Hands on opportunities
▫ Ongoing practice

Lead Placement
• Emphasis on correct lead placement and
positioning of the patient

Transmitting the EKG
• Acquire and transmit EKG to the receiving
center along with follow-up communication
• Hospitals need time too…

Working Together as a Team
• Early access to diagnostic 12 lead EKG
• Early notification of treatment team at receiving
facility and tertiary center
• Initiate treatment plan by receiving facility
• Integrated data system merging information
with EMStat5 software
• Reporting capabilities and data collection
• Initial and ongoing educational opportunities

Community based education with
the hospital
• Pre-hospital system
• Value of the EMS 12 lead EKG
• Interpretation timeline
• The local STEMI patient
• STEMI management and practice
• Transfer arrangements
• Lytic utilization
• EKG acquisition in the ER
• Repeat EKG

A System for Assessing a 12 Lead
I
SEE
ALL
LEADS
Inferior Leads II, III, AVF
Septal Leads V1, V2
Anterior Leads V3, V4
Lateral Leads V5, V6, I, AVL
I
V1 V4
aVR
Lateral Septal Anterior
II aVL V2 V5
Inferior Lateral Septal Lateral
III aVF V3 V6
Inferior Inferior Anterior Lateral

AMI Localization
I
II
III
aVR
aVL
aVF
V1
V2
V3
V4
V5
V6
Anterior: V3, V4
Septal: V1, V2
Inferior: II, III, AVF
Lateral: I, AVL, V5, V6

Working Together
• American Heart Association
▫ Mission: Lifeline South Dakota
• Patient and Community Education
• EMS providers
• Receiving Facilities
• Tertiary PCI Cardiac Centers
• Mission: Lifeline South Dakota