We hear the overhead announcements all the time in the hospital … Code Blue … Code Red … and more recently, Code Trauma … Code STEMI … Code Stroke … and Code Sepsis. From the standpoint of risk and safety, these latter four are the “Codes” that practitioners and nurses must master in order to deliver the best possible care in the safest manner, thereby reducing risk to patients and clinicians alike. Previous blogs featured two time-sensitive emergencies: Code Stroke and Code Sepsis. Today I will highlight a third time-sensitive “code” — Code STEMI (ST-elevation MI.)
105 years ago in his landmark JAMA article, Dr. James Herrick of Chicago began by saying that “obstruction of a coronary artery or of any of its large branches has long been regarded as a serious accident. Several events contributed toward the prevalence of the view that this condition was almost always suddenly fatal.” Seven years later, his observations gained traction in the medical community, and he wrote more clearly that “the thought has been that with a certain artery obstructed there is a definite lesion in the heart muscle and if with that lesion there is a definite electrocardiogram, may we not be able to state with a reasonable degree of certainty that the patient has obstruction in a particular portion of the coronary system? May it perhaps be possible to localize a lesion in the coronary system with an accuracy comparable to that with which we locate obstructive lesions in the cerebral arteries?”
The Need for Speed
Despite the increased recognition of the role of the ECG in the diagnosis of acute MI in the days since Dr. Herrick, many decades passed until advances in treatment caught up. Unless the patient underwent prompt coronary bypass surgery, most acute therapy was directed at pain relief, rest and arrhythmia treatment. The options for definitive treatment were limited until fibrinolytic therapy for acute MI came along. The advent of fibrinolytics, followed by the adoption of percutaneous coronary intervention (PCI), ushered in a new age in which speed and communication became paramount in the care of the STEMI patient. As the evidence mounted that “time is muscle” and swift intervention was required to restore perfusion and reduce ischemic injury, hospitals developed an alert system that notified key personnel to the presence of a patient diagnosed with STEMI or its equivalent. Whether it is called “STEMI Alert,” “Code STEMI” or something else, this rapid notification system remains the cornerstone in the process of care for STEMI patients to this day.
No ECG, No STEMI: Know ECG, Know STEMI
The ECG serves as the trigger point for initiating a Code STEMI. Without an ECG, it is impossible to diagnose an “ST-elevation” MI. In our digital age, EMS can transmit their ECG to the ED or cardiologist, and the CODE STEMI alert system can be activated prior to patient arrival. To further speed the treatment process, some medical centers bypass the ED evaluation altogether and have the patient taken from the EMS vehicle directly to the cardiac cath lab for immediate evaluation and PCI. Regardless of your process, once a STEMI is already identified, it is critical to identify and eliminate any barriers to the immediate performance and interpretation of the ECG. Whether in triage or a treatment room, nurses must be empowered by a standing order to obtain an ECG immediately on any patient with chest pain or symptoms suggestive of an acute coronary event. A few cautions:
- Caution #1: The classic STEMI ECG is easy to interpret. Master the fine points of ECG interpretation to catch the subtle or uncommon findings.
- Caution #2: Beware the faulty or misleading computer-generated ECG interpretation. It is only as good as the person who programmed it.
- Caution #3: If the first ECG is not diagnostic, do another ECG if the clinical picture is concerning or the patient gets worse.
- Caution #4: Check an old ECG, as subtle ischemic changes may be new.
Code STEMI remains one of the most important and electrifying patient interactions in acute care medicine. “Time is muscle!” Your patients know this, their attorneys know this, the hospital knows this, and the folks looking at quality and writing the reimbursement checks know this. A missed MI is still high on the list in terms of average dollars spent on a med-mal case. Delays in the diagnosis and treatment of acute MI continue to be a major threat to patient safety. Be sure that you and everyone on your ED Department Team recognize that Code STEMI is a “seconds-to-minutes” emergency requiring your immediate attention and intervention in order to achieve the best outcome.