TIME IS LIFE

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TIME IS LIFE

• Update of diagnosis and
• treatment of
• Acute Coronary Syndromes (ACS)

DEPARTMENT OF VETERANS AFFAIRS Hudson Valley
Health Care System Montrose and Castle Point
Medical Centers
Stephanie Allen, MSN, MS, RN Nurse
Educator Doreen A. Mays, NP, MS, Program
Manager, Urgent Care Kathleen Smith, RN Case
Manager, Cardiology Kathleen Woods, RN, MSN, NP
Clinical Cardiology
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Objectives

• Apply knowledge to effectively identify and treat
  veterans with signs and symptoms of Acute
  Coronary Syndrome
• Increase knowledge of the VAs Time is Life Heart
  Attack Program in order to reinforce the
  education of patients in
• Recognizing signs and symptoms of a heart attack
• Calling 911
• Preparing an action plan in the case of a heart
  attack

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Objectives

• Recognize the importance of timely interventions
  for the diagnosis and treatment of ACS.

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Acute Coronary Syndrome

• Definition - ACS includes myocardial
  infarction (MI) and the various patterns of
  unstable angina new-onset angina, rest angina,
  or crescendo-pattern angina (more frequent,
  prolonged, or severe episodes in a patient with
  known angina).
• These entities should be identified quickly
  so that immediate treatment to prevent MI or
  salvage the myocardium can be initiated.

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Did You Know?

• 931,108 people died in 2001 from acute coronary
  syndrome (AHA, 2004)
• Mortality related to Acute Coronary Syndromes is
  divided almost equally between males and females
• More than half of these deaths occurred suddenly,
  within one hour of the onset of symptoms and
  outside of the hospital setting

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Study Reported in The New England Journal of
Medicine

• The VA contracted with researchers from the
  Harvard Medical School, Price Waterhouse Coopers,
  IBM, and the Lewin Group to evaluate outcomes of
  patients treated for heart attacks. The study
  used administrative data to compare mortality
  data for VA and Medicare patients who had
  suffered heart attacks.

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New England Journal StudyResults

• From 1997-1999, there was a statistically
  significant higher mortality rate among VA
  patients at 30 days after their heart attack
  and at 1, 2, and 3 year points.

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New England Journal StudyResults

• Veterans were less likely than Medicare
  patients to undergo invasive cardiac procedures
  such as angiography, angioplasty and surgery.
• On average, veterans traveled twice as far for
  VA cardiac care compared to Medicare patients.

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We can MAKE A DIFFERENCE !!!

• Goals for patients with
• Chest Pain
• 1. Immediate assessment of patients
• with chest pain.
• 2. Timely initiation of treatment.
• 3. Rapid determination of need for transfer to
  another facility.

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CBOC PATIENTS

• Call 911
• Obtain 12 lead EKG
• EMTs will administer medications and treatments
  per their protocol

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Orders for Immediate Treatment

• Determine cardiac rhythm on monitor.
• Labs CBC, SMA7, CK-MB, PT, PTT, U/A
• Troponin with results within 1 hour of draw
• Aspirin 325 mg chewable, if no ASA taken in
• past 3 hours.
• Nitroglycerine 0.4 mg sl if BP100 systolic.
• Repeat x 2 five minutes apart if
  needed.
• Insert saline lock.
• Monitor vital signs q 15 minutes.
• Morphine IV as per provider if chest pain not
  relieved by nitroglycerine.
• Beta blockers as per provider if deemed
  beneficial.

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If EKG shows ST
elevation or new LBBB

• Provider to call ER to obtain accepting
  physician
• Vassar- 454-8500 for Castle Point pts
• HVH- 737-9000 for Montrose pts
• Initiate immediate ACLS transport.
• Start lovenox 1mg/kg sq if no contraindications.

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If EKG shows - No ST elevation

• Determine TIMI Score
• Page cardiology at Castle Point for consultation
  or call Manhattan VA during WHEN hours.
• Determine disposition based on
  provider assessment, and TIMI score
  recommendations.

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What is a TIMI Score?

• TIMI is the Thrombolysis in Myocardial
  Infarction risk score. This score is a simple
  prognostic tool used to categorize a patients
  risk of death and ischemic events, and provides a
  basis for therapeutic decision-making.
•   Score Risk
  Factor
• 0-1
  4.7
• 2
  8.3
• 3
  13.2
• 4
  19.9
• 5
  26.2
• 6-7
  40.9

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TIMI Score

• ___ Age over 65
• ___ 3 or more risk factors for coronary disease
  
• ___ Established CAD
• ___ 2 or more angina events in past 24 hours
• ___ Use of ASA in past 7 days
• ___ Elevated enzymes
• ___ ST depression 0.5mm
•  
• Number of checks TIMI Score ______
• Risk Factors hypertension, cigarette smoking,
  obesity, physical inactivity, dislipidemia, DM,
  micro-albuminuria,
• GFR

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Time is Life Heart Attack Education Program

• This program was developed to assist
  clinicians in encouraging veterans to develop a
  personal acute myocardial infarction survival
  plan, and to seek medical attention as quickly as
  possible after symptoms first appear.

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Key Objectives of the Patient Education Program

• Recognize the signs and/or symptoms of a heart
  attack
• Call 911 for initiation of early treatment and
  emergency transport to the nearest hospital
  facility
• Develop a personal survival plan

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Recognize the Signs and/or Symptoms of a Heart
Attack

• Reinforce the common warning signs (chest
  pain/pressure/squeezing, neck/shoulder/ back/arm
  pain, chest discomfort with lightheadedness/fainti
  ng/ sweating/ nausea/vomiting/shortness of
  breath, or chest discomfort with feeling of doom
  or imminent death)
• Instruct that women may also experience fatigue,
  shortness of breath without chest pain, or lower
  chest pain

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Call 911 for theInitiation of Early Treatment

• If the patient is having signs/symptoms of a
  heart attack, instruct him/her
• Dont delay
• Call 911 immediately
• Tell the ambulance driver s/he is having chest
  pain
• Take 1 regular aspirin unless allergic
• Dont drive to the hospital

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Develop a Personal Survival Plan

• Emphasize the need for the patient to know the
  importance of
• Learning the heart attack warning signs
• Reducing the risks of heart attack
• Completing a Survival Plan Wallet Card
• Sharing the plan with family and friends

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Modalities of Patient Education

• Patients will have access to and be exposed to
  the Time is Life Education Program through
• Clinicians
• Combat Heart Attack and Survive Time is Life
  video
• Time is Life brochure, poster, and wallet card
• Risk Assessment Action Plan

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WE CAN MAKE A DIFFERENCE !!!

• Remember, for patients with chest pain
• Start oxygen, get a 12-lead EKG and have it read
  within 10 minutes!
• If ST changes are present, initiate immediate
  transfer to nearest private hospital.
• If no ST changes are present, include the TIMI
  score in determining disposition of the patient.
• Educate your patients on action to take if chest
  pain occurs.