Official Journal Of The Trinidad & Tobago Medical - the Trinidad and ...

3. Hospital Workshop (Moderators: Dr. Tricia Cummings
and Dr. Matthews Chacko)
Discussion and Recommendations
The conference participants all agreed that the hospital should
have the capabilities, including the personnel, expertise, and
facilities, to treat patients with STE myocardial infarction. Two
hospital models are possible. Each region would designate one
hospital which would receive patients whose lytic therapy was
deemed successful, as evidenced by amelioration of chest pain
and ST segment elevation (14). Those patients: (1) for whom
thrombolysis was deemed not successful; or (2) who experienced
complications during the treatment; or (3) while they were at
one of the regional hospitals, would be transferred to EWMSC
or San Fernando (when suitable training and facility are available
there) for aggressive investigation and intervention. Both hospital
models would contain Coronary Care Units for rhythm and
hemodynamic monitoring and for rapid defibrillation, the ability
to place and maintain temporary transvenous pacemakers, and
to initiate intravenous vasodilator and inotropic therapies. Both
models would also have the ability to perform echocardiograms
and stress testing. The higher level hospital would also have
the ability to perform coronary angiography, angioplasty,
placement of permanent pacemakers, cardio defibrillators and
intra-aortic balloon pumps, as well as performing cardiac surgery.
Attendees all agreed that hospitals caring for STE MI patients
would have expedited government approval for medicallyindicated
procedures and interventions and physician, nurse,
and technicians who are trained and experienced in performing
the indicated procedures noted above as well as the equipment
and supplies to do so.
The group also recognized the value of continuous improvement.
Two mechanisms to do so would be a requirement for physicians
and nurses caring for STE infarction patients to obtain relevant
continuing medical education credits, and for the hospital to
conduct regular morbidity and mortality conferences. It was
specifically mentioned, as well, that the proceedings of these
conferences be privileged vis-a-vis the legal system. In addition,
a registry would be implemented to track procedures, results,
complications, and clinical outcomes of STE MI patients during
their hospital admission. This information would be shared
with Accident and Emergency staff, and used for process
improvement and to inform subsequent resource allocation.
Survey Results
The highest clinical need and overall priority score (both 4.0)
was for a Coronary Care Unit in the major hospitals caring for
ST-elevation MI patients. This was followed by echocardiography
and stress testing facilities (3.9 for each in both categories) and
expedited approval for medically indicated procedures and
interventions (3.9 overall priority). Requirements for physician
and nurse qualifications both received high clinical needs score
(3.8 and 3.9) as did the need for mandatory CME (3.9), for
inter-disciplinary mortality and morbidity conferences (3.8) and
for tracking of most clinical outcomes (generally 3.8or higher).
The lowest score was for the clinical need for pulmonary artery
pressure monitoring (3.5).
4. Post-Discharge Workshop (Moderators: Dr. Rohan
Maharaj and Dr. Gary Gerstenblith)
Caribbean Medical Journal
ST-Elevation Myocardial Infarction: Best Practices and Implementation in Trinidad and Tobago
Discussion and Recommendations
Two major problems were identified from this workshop. The
first was the need for improved communication between the
hospital specialists and the family medicine physicians who
care for the patient in follow-up. The present practice is to give
the patient a letter akin to a discharge summary, which often
is not transmitted to any or all of the follow-up physicians. The
opinion was also expressed that a particular area for improvement
would be that between the public hospital and the private family
physician. The elements of the communication, which would
be sent directly to the patient-identified physicians responsible
for post-discharge care and with the patient’s permission, would
include details concerning the diagnoses, procedures, and results
of those procedures. There was an important need for
recommendations regarding follow-up medical therapy,
scheduled visits, what tests to perform, expected test results,
guidelines for risk factor management, and how to re-connect
with the specialist if there was any change in the patient’s
cardiac condition. It was also noted that patients are often
discharged on brand drugs and a request was made to include
in the communication information as to whether and when
patients might be switched to a generic formulation and then
assess the results of that switch. If patients required brand drugs,
it was suggested that forms be made available to family
physicians allowing their patients to receive these drugs through
the CDAP mechanism. In addition, smoking cessation aids
should be added to the CDAP list. The expedited communication
suggested would require services and personnel for transcription,
copying, and mailing of the communication and a mechanism
for STE MI patients to have access to expedited specialty
evaluation, if needed, following discharge.
The second major problem was the need for cardiac rehabilitation
centers for the purpose of supervised and monitored exercise,
patient education, and social interaction to aid the patient’s
return to work and increased activity. Patients would participate
for a one to two month period. These would require dedicated
nurses, space, exercise equipment and monitors, automatic
external defibrillators, and non-physician personnel trained in
cardiac education and rehabilitation. The opinion was also
expressed that these centers, in addition, provide cardiac followup
for these patients in terms of identifying new or recurrent
symptoms, cardiac exam, monitoring compliance, reviewing
and if needed changing medications, and with direct links back
to the specialist, hospital care team. This model would require
physician and nurse training in post-infarction management.
Advantages include concentration of resources, with specialized
personnel who would become expert in this one area.
Disadvantages would include the potential for fragmentation
of care for patients with multiple conditions, and the
inconvenience for these patients having to attend more than
one treatment entity.
Another aspect of post-discharge follow-up, which was not
extensively discussed but generally agreed upon was the
importance of obtaining follow-up clinical data for the purpose
of providing feedback to the hospital and consequent improved
care processes. Resources for construction of the data elements
and tools, and for personnel trained in the collection, analysis,
interpretation, and presentation of the results would have to be
identified.
27