Hereford and Worcester Ambulance Service NHS Trust Model for Prehospital Thrombolysis.

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• Hereford and Worcester Ambulance Service NHS
  Trust Model for Pre-hospital Thrombolysis.

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FIRE PREVENTION!

• The infarcting heart can be likened to a burning
  building in our community the longer the fire is
  left unchecked, the more damage it will do.
  Previous methods of treatment have involved the
  Fire service arriving at the scene, loading the
  burning building onto a truck and then taking it
  back to the fire station to put the fire out.We
  now have the opportunity to put the fire out at
  the scene of the catastrophe, and should
  certainly be doing this Leif Svensson,
  cardiologist, Stockholm.

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APPLICATION TO THE NSF

• How can Pre-hospital Thrombolysis be delivered
  safely and effectively in the Community?
• What does the National Service Framework Require?

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NATIONAL SERVICE FRAMEWORKCORONARY HEART DISEASE

• Defibrillator available within 8 minutes of call
  for help (Std 5)
• Opiate and aspirin pre-hospital
• Thrombolysis within 60 minutes of calling for
  help (Standard 6) is this achievable?

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THE PROCEDURE IN HWAS DECISION SUPPORT

• Based on Swedish Decision Support
  Model(Karlsten, Uppsala County Hospital)
• Pre-hospital Thrombolysis governed by JRCALC
  Guidelines
• Procedure has been developed to provide Staff
  with Support
• Paramedic AND Technician fully trained
• Procedure has slight variations according to
  receiving hospital / local conditions.

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CARE OF THE PATIENT STEPS WITHIN THE PROCEDURE

• Initial Response
• Patient Assessment
• Initial Treatment
• Removal to Ambulance

• Further Treatment
• Assessment for Thrombolysis
• Informed Consent
• TNK Administration.

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INITIAL RESPONSE

• Aim to achieve 8 Minutes Response (NSF Std 5)
• (Ambulance carries Mobimed and TNK)
• TAKE TO PATIENT
• Oxygen
• Kit bag / Drugs
• Defibrillator.

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PATIENT ASSESSMENT

• ABC!
• ASSESS PAIN location, nature, duration, does
  anything change it
• Autonomic Disturbance?
• Previous medical history (brief).

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INITIAL TREATMENT

• Oxygen at high flow rate via non-rebreather mask
  90 approx.
• GTN
• Aspirin 300mg irrespective of patients own
  dose.

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REMOVAL TO AMBULANCE

• Remove the patient to the vehicle ASAP!
• Make them comfortable on stretcher
• Switch on Mobimed
• Tell them what you are going to do and why!
• Expose the Chest
• Apply ECG Electrodes, BP, SaO2. .

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FURTHER TREATMENT

• IV access
• Pain Relief
• Observe ECG, BP and Sao2..

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ASSESSMENT FOR THROMBOLYSIS

• Mobimed
• Examine ECG
• Patient assessment / ECG suggests AMI?
• Alert Hospital (MAU/CCU/AE) Receiving Unit
• JRCALC Questions / history
• Await Confirmation / Authorisation (Dr to respond
  within 3 Minutes).
• Text messages if required.

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JRCALC Restricted indications for thrombolysis
administered by Paramedics

• patients lt 75 years old
• symptoms (pain)
• typical distributiongt 15 mins
• lt 6 hours
• onset rapid but not abrupt
• not influenced by breathing

• signs
• heart rate 50140 bpm
• systolic blood pressure 80160 mmHg
• ECG
• ST elevation
• RBBB with S-T elevation

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JRCALC Extended contraindications for
thrombolysis administered by paramedics

• AV block gt 1st deg.
• pregnancy/delivery
• peptic ulcer
• stroke
• bleeding tendency
• warfarin

• surgical operation
• head injury/brain disorder
• prolonged CPR
• liver/renal failure.

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INFORMED CONSENT

• The patient has to be aware of the riskbenefit
  implications, so tell them..
• Your symptoms and the ECG suggest that you are
  having a heart attack. This has been confirmed
  by the hospital Doctor. We have a drug that can
  dissolve the clot causing the heart attack. This
  can considerably reduce its effects. There is a
  very small risk that this drug can cause internal
  bleeding, the worst of which can be a stroke.
  HOWEVER the benefits far outweigh the small risk
  do you wish to receive this drug?
• Consent can be verbal or non- verbal. It can
  only be given or refused by the patient. An
  optional signature box is provided on the form.
  Relatives / friends can witness but can neither
  consent nor refuse on patients behalf. (DoH, 12
  key points on consent).

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TNK ADMINISTRATION

• Prepare and draw up weight-adjusted dose of TNK
• Inform Hospital via Mobimed message of Patient
  weight- adjusted dosage - 1ml10kg
• Dr authorises administration via Mobimed
• TNK IV OVER 5 - 10 SECONDS
• FLUSH
• WEIGHT-ADJUSTED HEPARIN (New JRCALC Guidelines
  4,000 units.
• Apply Wristband Ive been Thrombolysed
• Pre-defined messages can be used.

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FACTORS AFFECTING CHOICE OF THROMBOLYTIC AGENT

• Ease of Administration
• Antigenicity
• Hypotension
• Recanalisation Efficacy
• Storage and Shelf Life
• Cost
• Major Bleeding Events.

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WHAT THEN?

• Be prepared for potential complications
• Reperfusion Arrhythmias, Minor Bleeds
• Inform hospital via Mobimed
• Remove to hospital ASAP
• Inform hospital of ETA with pre-defined Message
• Observe patient and Obs (Mobimed).

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COMMUNICATION/COLLABORATION AIDS TO PROGRESS

• Liaison between ambulance and acute trusts
• Training
• Shared guidelines
• Audit
• Champions

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TRAINING

• CCU and AE nurses attended the train the
  trainers day
• Nurses delivered some of the ECG sessions until
  paramedic trainers ready
• To attend joint Mobimed event so that
  communication can be improved further

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GUIDELINES

• Working to HWAST flow diagram at first site to go
  live
• Use of early experience informed development of
  full guidelines in both counties/ all 3 acute
  trust sites
• Shared by ambulance and acute trusts
• Mobimed user group continues

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AUDIT

• Regular review of transmissions
• Feedback queries from acute staff
• Investigate cases for ambulance staff
• Feedback on outcomes for crews
• Retrospective case-matched cohort study being
  written up

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RESULTS SO FAR

• At least 54 patients Thrombolysed to last week
• All went home
• Mean Call to Needle 41 mins (NSF Std 6)
• One VF arrest successful conversion to SR
• Where PHT not indicated, Door To Needle Times
  reduced at Hospital
• Staff enthusiastic now success achieved
• Other disciplines now on board.

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SUMMARY

• Thrombolysis in Hereford and Worcester has been
  shown to be feasible and successful in the
  pre-hospital setting. Barriers appear to be
  disappearing across the spectrum of disciplines,
  and Paramedics and Technicians are freely
  embracing the procedure despite initial
  scepticism. Patients are benefiting from Early
  Thrombolysis.