A Pilot Project
Brought to you by Richard G. Lugar
Center for Rural Health
Joe Biggs, PH.D
Stephanie Laws , RN, BSN
Angela Powell, RN, BSN

Richard G. Lugar Center for Rural Health

“Advancing rural health through education, innovation, and collaboration”

• Rural Graduate Medical Education Network
• Telemedicine (LVI and Store-and-Forward)
• Pipeline / Recruitment
• Simulation Center (RHIC)
• Legislative & Regulatory Processes
• Rural Health Innovation Collaborative
• Interprofessional Education (IPE)
• IU School of Medicine Expansion (RMEP)
• School Based Mobile Telehealth (VPCHC)
• FQHC Planning Grant (Cork Medical Center)
• Upper Midwest Telehealth Resource Center

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Lugar Center Grants (Selected)
Grant Agency Amount Period
Telehealth Network
Grant Program
HRSA,
OAT
$612,575
09/10-
08/13
Simulation HRSA $99,000
09/10-
08/11
7

The Telemedicine
Network Grant Project promotes the development of telemedicine solutions to rural critical access facilities in order to provide access to specialized medical services and support evidence-based clinical outcomes at the community hospital level .

• August of 2010 Union Hospital’s Richard G. Lugar Center for
Rural Health was awarded the Telehealth Network Grant.
• Union Hospital is one of only eight recipients nationally of this competitive grant, awarded by Health Resources and Services
Administration (HRSA).
• The three year award will bring upwards of $600,000 in federal funds to the Wabash Valley.
• The grant allows Union Hospital and its partners to improve access to quality health care services in surrounding communities using telemedicine technologies

Wabash Valley Rural Telehealth
Network Partners
• Greene County General Hospital, Linton, IN
• Sullivan County Community Hospital,
Sullivan, IN
• St. Vincent Clay Hospital, Brazil, IN
• Putnam County Hospital, Greencastle, IN
• Paris Community Hospital, Paris, IL
• Crawford Memorial Hospital, Robinson, IL
• Union Hospital Clinton, Clinton, IN
• Union Hospital, Terre Haute, IN
• Hamilton Center, Inc., Sullivan, IN
• Hamilton Center, Inc., Linton, IN
• Hamilton Center, Inc., Bloomfield, IN
• Clay City Center for Family Medicine, Clay
City, IN
• Cork Medical Center, Marshall, IL
• Vermillion Parke Community Health Center,
Clinton, IN
• Vermillion Parke Community Health Center,
Cayuga, IN
• Federal Bureau of Prisons, Terre Haute, IN
• Vigo County Corrections Center, Terre
Haute, IN
• Parke County Emergency Medical
Services, Rockville, IN
• Vermillion County Emergency Medical
Services, Newport, IN

• Providence Medical Group Cardiology, Terre Haute, IN
• UAP Cardiology, Terre Haute, IN
• UAP Pulmonology, Terre Haute, IN
• Internal Medicine Nephrology, Terre Haute, IN
• Hamilton Center, Inc., Terre Haute, IN
• Vincennes Cardiovascular Consultants, Vincennes, IN
• Shriners Hospital for Children, Cincinnati, OH
• Shriners Hospital for Children, St. Louis, MO
• Union Hospital Center for Diabetes Education, Terre Haute, IN
• Union Hospital Respiratory Care Department, Terre Haute, IN
• Union Hospital Behavioral Health, Terre Haute, IN
• Dr. Charles Lewis, IU School of Dermatology, Indianapolis, IN

• Cardiology (hospital and clinic based)
• Pulmonology
• Hematology/Oncology
• Behavioral Health (Acute and Crisis Intervention)
• Child Psychiatry
• Routine Psychotherapy
• Dermatology
• Nephrology
• Chronic Disease Management (diabetes and respiratory)
• Pediatric Specialties with Shriner’s Hospital for Children
(Cincinnati and St. Louis)
• Rural EMS Pre-Hospital STEMI Care

• Primary Market Area- Parke and Vermillion
Counties
• Chest Pain Center Accredited
• 2 nd Largest Employer
• Designated HPSA and MUA
• Largely Agricultural

Cardiac Death Rates – Parke County

Good News ! We Can Make a Difference

• The broad goal of the project is to develop and implement a Field ST Elevation Myocardial
Infarction (STEMI) 12 Lead transmission process that will meet or exceed a target of “field
EKG to balloon time” of 90 minutes or less.
Protocols include pre-hospital BLS and ALS 12 lead EKG transmission to the local emergency department to initiate the one call “Code STEMI” process. Early initiation will facilitate timely patient transport to the receiving p ercutaneous coronary intervention (PCI) facility.

• The Centers for Medicare Services set the established best practice standard for a patient to arrive in the Cardiac Catheterization Suite within 90 minutes.
• Current best practice often will achieve a door to balloon times of less than 60 minutes.
• Dr. Michael Lemay of Ottawa Heart Institute published support for paramedic field transmission by demonstrating that “patients with blocked arteries that were fasttracked to angioplasty” demonstrated a
50% reduction in mortality (French and Koenig,
2009).

Local BLS Emergency Medical Services
Local Critical Access Hospital
Nearest PCI Facility
Citizens of Rural Communities
EMS Medical Directors
Cardiology Groups
Cardiac Catheterization Team
EMS Commission
Mission Lifeline – Indiana STEMI Project
Office for Advancement of Telehealth
(OAT)
Health Resources and Services
Administration (HRSA)

• Indiana Scope of BLS Providers
• Technological Challenges
• End User Skill Level
• Coordination of Education and Training
• Variations of Bandwidth across counties
• Different cellular providers with best coverage across the same County
• Cost of sustainability
• Creating buy in within the Rural Communities
• Ongoing support and Education of EMS

• Working within our 1 year waiver as granted by
Indiana EMS Commission
• Coordination among Emergency Medical Services
(EMS), dispatch, CAH facilities, admitting departments, ED physicians at the CAH and the receiving facility, emergency room nursing staff at the
CAH and the receiving facility, cardiac catheterization team and cardiologist
• Development of evidence-based Field STEMI 12
Lead EKG Transmission policies, protocols and procedures
• Training and staff development related to both equipment and process

EKG’s HavE CHanGEd OvEr tHE yEars…..

Collaborative effort
– Emergency Department CAH
– Emergency Department PCI
– EMS Medical Director
– Chest Pain Accreditation Team
– Hospital Administration
– EMS Commission for BLS Waiver

 Multiple Sessions
 Hands on approach
 Super-User Training
 Pocket guides sent with participants
 Case Studies
 Interactive skills assessment
 Protocols
 ER Staff

Chest Pain/Suspected
Acute Coronary
Syndrome Protocol
NOTE: This protocol applies to any patient complaining of chest discomfort , jaw pain, left arm pain, nausea, shortness of breath, dizziness or sweating.

Chest Pain/ Suspected Acute
Coronary Syndrome
1. Perform General Initial Medical Care, consider ALS care.
2. Administer four (4) 81 mg chewable aspirin for patient to chew and swallow if able to maintain airway and gag reflex is intact.
3. Acquire EKG via Physioglove within five minutes
4. Transmit to nearest receiving facility
5. Assist patient, family, or caregiver with the administration of the patient’s own sublingual or spray nitroglycerin

The Physioglove ES is a PC-based 12 Lead diagnostic resting
EKG system designed as an alternative to standard EKG devices. The system is comprised of three basic units:
A Physioglove
An electronics unit
Toughbook PC

To connect the PhysioGlove to the Preamplifier Unit
Plug the ECG cable plug from the PhysioGlove carefully but firmly into the
ECG cable plug socket at the end of the Preamplifier Unit.
Tighten both of the plug screws.

To connect the PhysioGlove to the computer
Take the USB cable (included in your product package) and connect it to the Electronic Unit and a PC USB port

Place the LA lead as high as possible in the armpit

Place the PhysioGlove over the patient's chest with the glove's centerline on the center of the sternum and electrodes V1 and V2 at the fourth intercostal space.

Position the LL electrode in the area of the pelvis close to the left leg, making sure the electrode makes skin contact.

• On the ECG tab, click the Run button

• Toughbook Laptop Technology
Built in wireless aircard
• Obtain tracing via Physioglove
• Transmit PDF file to FAX in the ER

EKG Obtained and converted to
PDF - Sent to
Email Server
0-4 Minutes
EKG sent by
Email to Fax solution
2-4 minutes
Fax Server forwards EKG to
Receiving
Hospital Fax
2-3 minutes

Initial field testing with wireless aircard
– Impedance from the ambulance disrupted device signal
– Challenges related to sporadic cellular coverage interrupted the transmission
– Dropped or lost transmissions due to transmit time
– Dropped or lost transmissions due to fax conversion software

 Eliminate Impedance of the Ambulance via
Wireless Booster Antenna
 Utilize server solution so that the EKG would not be crossing a intermediary Fax
 Transmit the EKG out of county as raw data and convert back to PDF at the server
 Send PDF from Server to Hospital Printer IP

ParKE COunty EKG’s – Rocky Fork Lake
Or…. FrOm tHE BiG rOCK

Initial Cellular Service with Wireless aircard fails in one of the pilot ambulances located in
Northern Vermillion County
For this truck only a MIFI mobile hotspot is utilized through another provioder

Age Sex Day Date EMS
Dispatch
Time
EMS
Scene
Time
EKG
Acquire
Time
EKG
Transmit
Time
Code
STEMI
CAH Door to
Transport
Protocol
Followed
Review by
Medical
Director

• Maintain data collection and analysis
• Facilitate development of long term sustainability plan with partners
• Report outcomes to grantors, Indiana EMS
Commission and IRB
• Evaluate feasibility of replication
• Collaborate with IRHA
• Share findings with Mission Lifeline
• Celebrate the efforts of our partners