New York City Direct Referral to Catheterization Lab

STEMI Notification & Transportation Protocol

04/18/23 ©2012, American Heart Association 2

What is Mission: Lifeline?

• Mission: Lifeline is the American Heart Association's systems-based approach to

improving emergency cardiac care for all Americans.

• M:L implements quality improvement strategies based on evidence-based guidelines

and forms partnerships across the system of care:

– community

– emergency medical service

– emergency department (referral and receiving centers)

– inpatient care

– post-discharge

Ideal System of Care

04/18/23 ©2012, American Heart Association 3

04/18/23 ©2010, American Heart Association 4

New York City Mission: Lifeline

TIMELINE

•New York City chosen as one of 20

sites nationwide to participate in pilot

project with Duke Clinical Research

Institute and the American Heart

Association

•Project Timeline:

July 2012-December 2013

PROJECT OBJECTIVES

•Establish regional standards for

emergency cardiovascular care

•Lower mortality by improving timely

treatment for STEMI patients

•Create sustainable system for treating

cardiovascular emergencies including

STEMI, cardiac arrest, stroke, aortic

dissection

04/18/23 ©2010, American Heart Association 5

Purpose of Protocol

Direct notification to receiving hospital ED and direct delivery of

certain STEMI patients to receiving hospital catheterization labs in order

to expedite PCI treatment and continue to provide the highest level of

care and transportation.

04/18/23 ©2010, American Heart Association 6

Direct to Cath Lab Criteria

INCLUSION CRITERIA

•Ongoing chest discomfort or upper body

discomfort felt to be ischemic in origin

•Symptom duration of <12 hours

•ST elevation of at least 2 mm in two or

more contiguous leads

•Absence of other issues believed to

require further evaluation and treatment

(see exclusions)

EXCLUSION CRITERIA

•LBBB

•Intubated

•Respiratory failure or CHF requiring

intubation

•Cardiac arrest

•DNR/DNI

•On-going Hospice care

•Obvious active severe bleeding

•Head or other serious trauma (meets

trauma center criteria)

04/18/23 ©2010, American Heart Association 7

Direct to Cath Lab Protocol

04/18/23 ©2010, American Heart Association 7

EMS

FDNY OLMC

Receiving Hospital ED(Meet, greet, and escort EMS)

Cath Lab

1. EMS transmits ECG to OLMC MD

2. OLMC MD confirms ST elevation and verifies direct referral criteria with EMS

3. OLMC notifies and transmits ECG and patient demographic info to PCI center ED

4. ED activates STEMI pager, including information that patient is Direct Referral to Cath Lab and ETA

5. Cath lab calls ED to confirm availability to proceed

6. Fellow, resident, or member of cath lab team greets EMS and patient at ED entrance and escorts them to cath lab

04/18/23 ©2010, American Heart Association 8

• FDNY will transmit the ECG and make a phone call (providing the necessary demographic

information to allow for preregistration) for all patients with ischemic type chest discomfort

and ST segment elevation >1mm.

• For all cases with >2 mm ST segment elevation who meet the agreed upon criteria for 

“direct referral to the cath lab” FDNY will use specific language stating that the patient

qualifies for “direct transport to the cath lab”.

• Hospitals will then preactivate the cath lab and follow their procedures on how to expedite

the patient to the cath lab.

Note: If the field ECG cannot be transmitted from the field to the hospital, FDNY will still call a

“direct referral to the cath lab” if the patient meets the criteria. (Note: the field EMS personnel

will still communicate verbally with FDNY On-Line Medical Control MDs who will make the

determination on the case).

Pre-Notification Protocol

8

04/18/23 ©2010, American Heart Association 9

• The hospital needs to escort EMS to the hospital’s Cath Lab on the EMS stretcher. EMS

will not take any patient directly from the field to a PCI Center’s cath lab. 

• Hospital staff must meet EMS within five minutes of arrival and the total time spent

awaiting an escort is not to exceed ten minutes.

• If no staff is available within 10 minutes, the patient shall be delivered to ED staff.

• With the availability of the transmitted field or hard copy ECG, time should not be wasted to

obtain an ECG at the time of arrival.

• If the cath lab is closed, the patient will then reside in the ED.

• Hospital “arrival time” is the time the patient is brought to the ED by EMS.

• If the field ECG cannot be transmitted, FDNY will still call a “direct referral to the cath

lab” if the patient meets the criteria.

Notes

04/18/23

Zainab Magdon-Ismail, Ed.M., MPH

Vice President, Quality Improvement Initiatives

American Heart Association

518-229-5483 (cell)

Zainab.Magdon@heart.org

Glenn Asaeda, MD

Chief Medical Director

Fire Department of New York

asaedag@fdny.nyc.gov

Questions?

10