19 CSR 30-40.790 - Transport Protocol for Stroke and ST-Segment Elevation Myocardial Infarction (STEMI) Patients

Current through Register Vol. 47, No. 7, April 1, 2022

PURPOSE: This rule establishes protocols for transporting suspected STEMI patients by severity and time of onset to the STEMI center where resources exist to provide appropriate care and suspected stroke patients by severity and time of onset to the stroke center where resources exist to provide appropriate care.

(1) All ground and air ambulances shall use the following state transport protocol for suspected stroke patients except in those circumstances listed in sections (3), (4), and (5) of this rule:
(A) Step 1-Assess for life threatening conditions (serious airway or respiratory compromise or immediate life threatening conditions that cannot be managed in the field).
1. If there are life threatening conditions, transport the patient to the nearest appropriate facility for stabilization prior to transport to a stroke center. Consider air/ground/facility options for timely and medically appropriate care (particularly in non-urban areas).
2. If there are no life threatening conditions, go to step 2 below in subsection (1)(B); and
(B) Step 2-Assess the duration of onset of symptoms (time last known well).
1. Group 1-If the patient is within the lytic/therapeutic window then transport to a level I, II, or III stroke center according to local and regional process. Consider the time for transport, the patient's condition, air/ground/hospital options for timely and medically appropriate care (particularly in non-urban areas), and the treatment windows. Continue to reassess the patient. If the patient's condition changes, then start back with subsection (1)(A) and follow the state stroke protocol outlined in section (1) starting from subsection (1)(A) and on according to the patient's condition. Consider out-of-state transport based on local and regional process for bi-state regions.
2. Group 2-If the patient is within the potential therapeutic window then transport to a level I stroke center or transport to a level I, II, or III stroke center according to local and regional process. Consider the time for transport, the patient's condition, air/ground/hospital options for timely and medically appropriate care (particularly in non-urban areas), and the treatment windows. Continue to reassess the patient. If the patient's condition changes then start back with subsection (1)(A) and follow the state stroke protocol outlined in section (1) starting from subsection (1)(A) and on according to the patient's condition. Consider out-of-state transport based on local and regional process for bi-state regions.
3. Group 3-If the patient is out of the lytic/therapeutic and potential therapeutic windows, then transport to a level I, II, III, or IV stroke center according to local and regional process. Consider the time for transport, the patient's condition, air/ground/hospital options for timely and medically appropriate care (particularly in non-urban areas), and the treatment windows. Continue to reassess the patient. If the patient's condition changes, then start back with subsection (1)(A) and follow the state stroke protocol outlined in section (1) starting from subsection (1)(A) and on according to the patient's condition. Consider out-of-state transport based on local and regional process for bi-state regions.
(2) All ground and air ambulances shall use the following state transport protocol for suspected STEMI patients except in those circumstances listed in sections (3), (4), and (5) of this rule:
(A) Step 1-Assess for life threatening conditions (serious airway or respiratory compromise or immediate life threatening conditions that cannot be managed in the field).
1. If there are life threatening conditions, then transport the patient to the nearest appropriate facility for stabilization prior to transport to a STEMI center. Consider air/ground/facility options for timely and medically appropriate care (particularly in non-urban areas).
2. If there are no life threatening conditions, then go on to step 2 below in subsection (2)(B) and assess vital signs and perform an electrocardiogram (ECG) if the ground or air ambulance has that capability. An electrocardiogram and electrocardiogram equipment are recommended;
(B) Step 2-Determine if the patient's vital signs and the electrocardiogram identifies the following:
1. ST-elevation in two (2) contiguous leads or new or presumed new left bundle branch block; and
2. The patient has two (2) of the following three (3) signs of cardiogenic shock:
A. Hypotension where systolic blood pressure is less than ninety millimeters of mercury (90 mmHG);
B. Respiratory distress where respirations are less than ten (10) or greater than twenty-nine (29) per minute; or
C. Tachycardia where the heart rate is greater than one hundred beats per minute (100 BPM);
3. If the patient has an electrocardiogram with ST-elevation in two (2) contiguous leads or new or presumed new left bundle branch block and two (2) of the three (3) signs of cardiogenic shock then transport to a level I STEMI center according to local and regional process. Consider the time for transport, the patient's condition, and the air/ground/hospital options for timely and medically appropriate care (particularly in non-urban areas);
4. If initial transport from the scene to a level I STEMI center is prolonged, then consider transporting to the nearest appropriate facility for stabilization prior to transport to a level I STEMI center;
5. Continue to reassess the patient. If the patient's condition changes, then start back at subsection (2)(A) above and follow the state STEMI protocol outlined in section (2) starting from subsection (2)(A) and on according to the patient's condition;
6. Consider out-of-state transport based on local and regional process for the bi-state region;
7. Communicate electrocardiogram findings to the hospital;
8. If the patient has a positive electrocardiogram but is negative for signs of cardiogenic shock, then go to step 3 in subsection (2)(C) below; and
(C) Step 3-Calculate the estimated time from STEMI identification with the patient to expected percutaneous coronary intervention (PCI) with the patient in order to determine whether the patient is within the percutaneous cornary intervention window. Communicate electrocardiogram findings to the hospital. If no ST-elevation or new or presumed new left bundle branch block then consider a fifteen-(15-) lead electrocardiogram, if available.
1. Group 1-If the patient is within the PCI window or the patient has had chest pain longer than twelve (12) hours or the patient is lytic/thrombolytic ineligible then transport to a level I or level II STEMI center according to local and regional process. Consider the time for transport, the air/ground/hospital options for timely and medically appropriate care (particularly in non-urban areas), the patient's condition, and all treatment windows. Consider the ischemic time and the potential role for lytics (within the lytic window) at an intervening STEMI center in route to the percutaneous coronary intervention center if approaching longer times within the percutaneous coronary intervention window. Continue to reassess the patient. If the patient's condition changes, then start back at subsection (2)(A) and follow the state STEMI protocol outlined in section (2) starting from subsection (2)(A) and on according to the patient's condition. Consider out-of-state transport based on local and regional process for bi-state regions.
2. Group 2-If the patient is outside the percutaneous coronary intervention window and within the lytic/therapeutic window, or outside both windows and the patient has no other known complications, then transport to the STEMI center (level I, II, III, or IV) according to local and regional process. Consider the time for transport, air/ground/hospital options for timely and medically appropriate care (particularly in non-urban areas), the patient's condition, and all the treatment windows. Consider the lytic window and the potential for STEMI center lytic administration when determining the destination(s). Continue to reassess the patient. If the patient's condition changes, then start back at subsection (2)(A) above and follow the state STEMI protocol outlined in section (2) starting from subsection (2)(A) and on according to the patient's condition. Consider out-of-state transport based on local and regional process for bi-state regions.
(3) When initial transport from the scene of illness or injury to a STEMI or stroke center would be prolonged, the STEMI or stroke patient may be transported to the nearest appropriate facility for stabilization prior to transport to a STEMI or stroke center.
(4) Nothing in this rule shall restrict an individual patient's right to refuse transport to a recommended destination. All ground and air ambulances shall have a written process in place to address patient competency and refusal of transport to the recommended destination.
(5) Ground and air ambulances are not required to use the state transport protocols in this rule when the ambulance is using a community-based or regional plan that has been approved by the department pursuant to section 190.200.3, RSMo, that waives the requirements of this rule. Copies of flow charts of an algorithm depicting the stroke and STEMI state transport protocols are available at the Health Standards and Licensure (HSL) office, online at the department's website www.health.mo.gov, or may be obtained by mailing a written request to the Missouri Department of Health and Senior Services, HSL, PO Box 570, Jefferson City, MO 65102-0570 or by calling (573) 751-6400.

Notes

19 CSR 30-40.790
AUTHORITY: sections 190.185 and 190.241, RSMo Supp. 2012.* Original rule filed Nov. 15, 2012, effective June 30, 2013.

*Original authority: 190.185, RSMo 1973, amended 1989, 1993, 1995, 1998, 2002 and 190.241, RSMo 1987, amended 1998, 2008.

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