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

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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
Caribbean Medical Journal ST-Elevation Myocardial Infarction: Best Practices and Implementation in Trinidad and Tobago Survey Results Assistance with follow-up of STE MI patients received the highest clinical need (4.0) and overall priority (4.0) scores. In particular, the participants rated protocols for ACE-inhibitor use (4.0), physical activity recommendations (3.9), secondary prevention goals (4.0), and cardiac rehabilitation (3.9) highly. A discharge letter to the primary care physician listing important diagnoses, procedures, and results during the hospitalization also received the highest clinical need score (4.0). Suitability of switching from brand to generic drugs (2.1), development of a polypill (2.0) and tracking of clinical outcome data (3.2) received relatively low clinical need scores. On the other hand, data collection for assessment of adherence to prescribed recommendations (4.0), lifestyle modifications, smoking cessation, medication adherence, and achievement of secondary prevention goals all received 4.0 clinical need scores. Proposed Pilot Demonstration Projects based on Recommendations of ST-EMI Working Groups It is anticipated that working committees will be formed to design and implement pilot/demonstration projects to assess the feasibility and preliminary effectiveness of interventions suggested by this conference to improve management of these patients 1. The following three pilot projects were also suggested: A. The first is to conduct, at the Arima District Health facility, a feasibility study of administering Tenecteplase to STelevation infarction patients, rather than wait to administer such therapy until they are transferred to a higher level of care. The lessons learned at Arima would be applicable to a decision regarding implementing such therapy at other District facilities. B. The second is establishing a registry of STEMI patients at San Fernando General Hospital, the Eric Williams Medical Sciences Complex, and Port of Spain General Hospital. Time from pain onset to different treatments, the types of procedures performed, complications, and outcomes would be recorded and analyzed. This would aid an understanding of the up-to-date clinical course of these patients and identify potential areas for improvement. C. The third would develop a tool to more effectively communicate to all of the follow-up physicians identified by the STEMI patient at the time of discharge, the diagnosis, the procedures performed during hospitalization and their results, and recommendations for subsequent treatment, follow-up, and re-connection with the specialized, in-hospital physicians if needed. The symposium has generated interest and recommended goals the participants believed were feasible and should be implemented in the country. Experts from diverse public, university and private sectors participated and it is recognized that no single entity has exclusive knowledge and experience to improve care for STE MI patients in Trinidad and Tobago. Further examination and modification of these goals are required, followed by the development of relevant protocols, identification of sites for 28 pilot, demonstration projects, personnel training, and purchase of equipment and supplies. This effort requires participation by Ministry of Health and Regional Health Authority experts, as well as EMS, Accident and Emergency, Medicine, cardiology, nursing, technology, statistical, and epidemiology expertise. Any protocol developed would serve as “guard rails,” not rigid guidelines, for health care providers. Protocols will have “expiration dates” and undergo periodic review by local experts and modified in accordance with the discovery and publication of new diagnostic and therapeutic strategies and interventions. Variation in the performance of the protocols is expected. Examination of the variations and the associated outcomes will also allow further refinement of the protocols. It is anticipated that the results of these efforts will result in improved care and outcomes, and lower total health care costs for patients with ST-Elevation myocardial infarction and that the results will have broad relevance not only to the national, but to international medical communities as well. REFERENCES [1] www.paho.org/hia/archivosvol2/paisesing/ Trinidad%20and%20Tobago%20English.pdf. Posted 2007; accessed 29 December 2009. [2] Thygesen K, Alpert JS, White HD on behalf of the Joint ESC/ACCF/AHA/WHF Task Force for the Redefinition of Myocardial Infarction. Universal definition of myocardial infarction. Eur Heart J 2007;28:2525-2538. [3] Antman EM, Anbe DT, Armstrong PW et al: ACC/AHA guidelines for the management of patients with ST-elevation myocardial infarction: Executive summary. Circulation 2004;110:588-636. [4] Kushner FG, Hand M, Smith SC Jr., et al: 2009 Focused updates: ACC/AHA guidelines for the management of patients with ST-elevation myocardial infarction (including the 2004 guideline and 2007 focused update) and ACC/AHA/SCAI guidelines on percutaneous coronary intervention (updating the 2005 guideline and 2007 focused update): a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines. Circulation 2009;120:2271-2306. [5] Gersh BJ, Stones GW, White HD, Holmes DH. Pharmacologic facilitation of primary percutaneous coronary intervention for acute myocardial infarction. Is the slope of the curve the shape of the future? JAMA 2005;293:979-986. [6] Khot UN, Johnson ML, Ramsey C, Khot MB, Todd R, Shaikh SR, Berg WJ. Emergency department activation of the catheterization laboratory and immediate transfer to an immediately available catheterization laboratory reduce door-to-balloon time in ST-elevation myocardial infarction. Circulation 2007;116:67-76. [7] Thomas CN, Williams DH, Hinds A, Ruyan DS, Ramrooop C, Nath CF, Crosy D. Stenting of partial and total coronary occlusions in Trinidad and Tobago. West Indian Med J 2001;50:22-26. [8] Cannon CP, Gibson CM, McCabe CH, Adgey AA, Schweiger MJ, Sequeira RF, Grollier G, Giugliano RP, Frey M, Mueller HS, Steingart RM, Weaver WD, Van der Werf F, Braunwald E. TNK-tissue plasminogen activator compared with front-loaded alteplase in acute myocardial infarction. Results of the TIMI 10B trial. Circulation 1998;98:2805-2814. [9] Mohan S, Lynch S, Cummings TA: Time equals myocardium: Are we in time? Unpublished data. [10] Chapman BL: Effect of coronary care on myocardial infarct mortality. British Heart J 1979:42:386-395. [11] Moss AJ, Zareba W, Hall WJ, Klein H, Wilber DJ, Cannom DS, Daubert JP, Higgins SL, Brown MW, Andrews ML. Prophylactic implantation of a defibrillator in patients with myocardial infarction and reduced ejection fraction. N Engl J Med 2002;346:877-883. [12] Goldberg R, Goff D, Cooper L, Luepker R, Zapka J, Bittner V, Osganian S, Lessard D, Cornell C, Meshack A, Mann C, Gilliland J, Feldman H. Age and sex differences in presentation of symptoms among patients with acute coronary disease. Coron Artery Dis 2000;11:399-407. [13] Zimetbaum PJ and Josephson ME: Use of the electrocardiogram in acute myocardial infarction. N Engl J of Med 2003;348:933-940.
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