Rokos, Ivan C. MD; Henry, Timothy D. MD; Weittenhiller, Ben MBA; Bjerke, Christine M. RN; Bates, Eric R. MD; French, William J. MD Author Information

HomeCirculation: Cardiovascular Quality and OutcomesVol. 4, No. 6Impact of Prehospital Electrocardiogram Protocol and Immediate Catheterization Team Activation for Patients With ST-Elevation–Myocardial Infarction Free AccessResearch ArticlePDF/EPUBAboutView PDFView EPUBSections ToolsAdd to favoritesDownload citationsTrack citationsPermissionsDownload Articles + Supplements ShareShare onFacebookTwitterLinked InMendeleyReddit Jump toSupplemental MaterialFree AccessResearch ArticlePDF/EPUBImpact of Prehospital Electrocardiogram Protocol and Immediate Catheterization Team Activation for Patients With ST-Elevation–Myocardial Infarction David M. Nestler, MD, MS, Roger D. White, MD, Charanjit S. Rihal, MD, MBA, Lucas A. Myers, NREMT-P, Christine M. Bjerke, RN, BSN, Ryan J. Lennon, MS, Jeffery L. Schultz, NREMT-P, Malcolm R. Bell, MBBS, FRACP, Bernard J. Gersh, MB, ChB, DPhil, David R. HolmesJr, MD and Henry H. Ting, MD, MBA David M. NestlerDavid M. Nestler From the Departments of Emergency Medicine (D.M.N.) and Anesthesiology (R.D.W.), the Division of Cardiovascular Diseases (C.S.R., C.M.B., M.R.B., B.J.G., D.R.H., H.H.T.), Mayo Medical Transport (L.A.M., J.L.S.), and the Department of Health Sciences Research, Division of Biomedical Statistics and Informatics (R.J.L.), Mayo Clinic College of Medicine, Rochester, MN. , Roger D. WhiteRoger D. White From the Departments of Emergency Medicine (D.M.N.) and Anesthesiology (R.D.W.), the Division of Cardiovascular Diseases (C.S.R., C.M.B., M.R.B., B.J.G., D.R.H., H.H.T.), Mayo Medical Transport (L.A.M., J.L.S.), and the Department of Health Sciences Research, Division of Biomedical Statistics and Informatics (R.J.L.), Mayo Clinic College of Medicine, Rochester, MN. , Charanjit S. RihalCharanjit S. Rihal From the Departments of Emergency Medicine (D.M.N.) and Anesthesiology (R.D.W.), the Division of Cardiovascular Diseases (C.S.R., C.M.B., M.R.B., B.J.G., D.R.H., H.H.T.), Mayo Medical Transport (L.A.M., J.L.S.), and the Department of Health Sciences Research, Division of Biomedical Statistics and Informatics (R.J.L.), Mayo Clinic College of Medicine, Rochester, MN. , Lucas A. MyersLucas A. Myers From the Departments of Emergency Medicine (D.M.N.) and Anesthesiology (R.D.W.), the Division of Cardiovascular Diseases (C.S.R., C.M.B., M.R.B., B.J.G., D.R.H., H.H.T.), Mayo Medical Transport (L.A.M., J.L.S.), and the Department of Health Sciences Research, Division of Biomedical Statistics and Informatics (R.J.L.), Mayo Clinic College of Medicine, Rochester, MN. , Christine M. BjerkeChristine M. Bjerke From the Departments of Emergency Medicine (D.M.N.) and Anesthesiology (R.D.W.), the Division of Cardiovascular Diseases (C.S.R., C.M.B., M.R.B., B.J.G., D.R.H., H.H.T.), Mayo Medical Transport (L.A.M., J.L.S.), and the Department of Health Sciences Research, Division of Biomedical Statistics and Informatics (R.J.L.), Mayo Clinic College of Medicine, Rochester, MN. , Ryan J. LennonRyan J. Lennon From the Departments of Emergency Medicine (D.M.N.) and Anesthesiology (R.D.W.), the Division of Cardiovascular Diseases (C.S.R., C.M.B., M.R.B., B.J.G., D.R.H., H.H.T.), Mayo Medical Transport (L.A.M., J.L.S.), and the Department of Health Sciences Research, Division of Biomedical Statistics and Informatics (R.J.L.), Mayo Clinic College of Medicine, Rochester, MN. , Jeffery L. SchultzJeffery L. Schultz From the Departments of Emergency Medicine (D.M.N.) and Anesthesiology (R.D.W.), the Division of Cardiovascular Diseases (C.S.R., C.M.B., M.R.B., B.J.G., D.R.H., H.H.T.), Mayo Medical Transport (L.A.M., J.L.S.), and the Department of Health Sciences Research, Division of Biomedical Statistics and Informatics (R.J.L.), Mayo Clinic College of Medicine, Rochester, MN. , Malcolm R. BellMalcolm R. Bell From the Departments of Emergency Medicine (D.M.N.) and Anesthesiology (R.D.W.), the Division of Cardiovascular Diseases (C.S.R., C.M.B., M.R.B., B.J.G., D.R.H., H.H.T.), Mayo Medical Transport (L.A.M., J.L.S.), and the Department of Health Sciences Research, Division of Biomedical Statistics and Informatics (R.J.L.), Mayo Clinic College of Medicine, Rochester, MN. , Bernard J. GershBernard J. Gersh From the Departments of Emergency Medicine (D.M.N.) and Anesthesiology (R.D.W.), the Division of Cardiovascular Diseases (C.S.R., C.M.B., M.R.B., B.J.G., D.R.H., H.H.T.), Mayo Medical Transport (L.A.M., J.L.S.), and the Department of Health Sciences Research, Division of Biomedical Statistics and Informatics (R.J.L.), Mayo Clinic College of Medicine, Rochester, MN. , David R. HolmesJrDavid R. HolmesJr From the Departments of Emergency Medicine (D.M.N.) and Anesthesiology (R.D.W.), the Division of Cardiovascular Diseases (C.S.R., C.M.B., M.R.B., B.J.G., D.R.H., H.H.T.), Mayo Medical Transport (L.A.M., J.L.S.), and the Department of Health Sciences Research, Division of Biomedical Statistics and Informatics (R.J.L.), Mayo Clinic College of Medicine, Rochester, MN. and Henry H. TingHenry H. Ting From the Departments of Emergency Medicine (D.M.N.) and Anesthesiology (R.D.W.), the Division of Cardiovascular Diseases (C.S.R., C.M.B., M.R.B., B.J.G., D.R.H., H.H.T.), Mayo Medical Transport (L.A.M., J.L.S.), and the Department of Health Sciences Research, Division of Biomedical Statistics and Informatics (R.J.L.), Mayo Clinic College of Medicine, Rochester, MN. Originally published1 Nov 2011https://doi.org/10.1161/CIRCOUTCOMES.111.961433Circulation: Cardiovascular Quality and Outcomes. 2011;4:640–646IntroductionGuidelines recommend implementing prehospital electrocardiograms (PH ECG) into systems of care for patients with suspected ST-elevation–myocardial infarction to reduce door-to-balloon time (DTB). We developed a PH ECG protocol with an affiliated emergency medical service, combining 4 features: (1) PH ECG acquisition; (2) emergency medical service interpretation without PH ECG transmission; (3) prehospital activation of the cardiac catheterization team; and (4) emergency department bypass. We compared data from June 1, 2006, to August 31, 2007 (preimplementation group, n=50), with data from October 1, 2007, to June 30, 2010 (postimplementation group, n=82), analyzing all patients with ST-elevation–myocardial infarction transported by an affiliated EMS and treated with primary percutaneous coronary intervention. PH ECGs were acquired in 33 (66%) and 67 (82%) patients in the preimplementation and postimplementation groups, respectively (P=0.041). Median DTB was 59 and 57 minutes for the preimplementation and postimplementation groups, respectively (P=0.28). In a prespecified subgroup analysis of postimplementation patients (n=38) who had prehospital activation of catheterization team and emergency department bypass, median DTB was 32 minutes (P<0.001 compared with preimplementation group). Our PH ECG protocol increased the frequency of PH ECG acquisition and decreased DTB for patients when all 4 features of our PH ECG protocol were carried out.Prehospital electrocardiograms (PH ECG) can decrease reperfusion times for patients with ST-elevation–myocardial infarction (STEMI) undergoing primary percutaneous coronary intervention (PCI).1–16 However, even when PH ECG are acquired, they may not be optimally utilized and integrated. A recent scientific statement by the American Heart Association (AHA) stated, "the central challenge for healthcare providers is not to simply perform PH ECG, but to use and integrate the diagnostic information from a PH ECG with systems of care."17The American College of Cardiology/AHA (ACC/AHA) guidelines for STEMI encourage a first medical contact-to-balloon time (FMCTB) within 90 minutes for patients undergoing primary PCI.18 These recommendations encourage an "as-soon-as-possible" strategy for primary PCI, citing improved survival for every 30-minute decrement in door-to-balloon time (DTB).19 Despite a class I recommendation for PH ECG acquisition, prehospital identification of STEMI, and prehospital activation of the cardiac catheterization laboratory for these patients, current studies show that PH ECG are performed on less than 30% patients with STEMI in the United States.5,8,20We developed and implemented a comprehensive PH ECG protocol for patients in Olmsted County, Minnesota, who were transported by Gold Cross Rochester (GCR), an affiliated emergency medical service (EMS). Our PH ECG protocol consisted of the following 4 features: (1) PH ECG acquisition; (2) PH ECG interpretation by paramedics without wireless transmission; (3) prehospital activation of the cardiac catheterization laboratory; and (4) patient bypass of the emergency department (ED). To test the hypothesis that our protocol would improve timeliness of reperfusion therapy for STEMI patients, we assessed time intervals preimplementation and postimplementation of the PH ECG protocol.MethodsStudy DesignA prospective, observational study design was used to collect demographic, prehospital, and in-hospital data on all patients transported by GCR EMS with STEMI and treated with primary PCI. All patients had a final hospital discharge diagnosis of STEMI, based on ECG findings, preintervention angiography, and reperfusion with primary PCI. The preimplementation group consisted of STEMI patients from June 1, 2006, to August 31, 2007, and the postimplementation group consisted of STEMI patients from October 1, 2007, to June 30, 2010. The month of September 2007 was designated the implementation and communication period. The primary end point is reperfusion time, measured as DTB and FMCTB, for all patients transported by GCR that had a final hospital diagnosis of STEMI during the preimplementation versus postimplementation time periods. For our primary end point, patients who had protocol exclusions and protocol violations and patients who did not have ST-elevation on PH ECG but developed ST-elevation on subsequent ECG in the ED were included in our analysis. In an attempt to learn the impact on DTB and FMCTB when the PH ECG protocol was fully executed, we also undertook a prespecified analysis of the preimplementation group versus the postimplementation subgroup who had all aspects of the PH ECG protocol performed, including prehospital activation of the catheterization laboratory and ED bypass. This study was conducted with institutional review board review approval.Setting and ParticipantsSaint Mary's Hospital is an academic tertiary care hospital and part of Mayo Clinic in Olmsted County, Minnesota (population, 141 360). We implemented the PH ECG protocol with GCR ambulance service, an affiliated EMS. GCR is an advanced cardiac life support (ACLS) ambulance service that provides services to Olmsted County, Minnesota, and employs approximately 67 Nationally Registered Emergency Medical Technician-Paramedics. There are other ambulance services based in outlying areas of or in proximity to Olmsted County that transported patients to Saint Mary's Hospital. They were excluded from this study because they represent a small percentage of our regional EMS coverage, only serve outlying areas of Olmsted County, and are staffed by basic life support personnel who frequently call for an ACLS intercept when transporting critically ill patients. Inclusion criteria included any patient during the study period that were transported by GCR EMS to Saint Mary's Hospital, who had a final clinical diagnosis of STEMI and was treated with primary PCI. Patients with STEMI transferred to Saint Mary's Hospital from a regional, STEMI-referral hospital were excluded from this analysis.InterventionIn September 2007, our PH ECG protocol (available in the online-only Data Supplement) was implemented, after receiving input from a multidisciplinary group consisting of physician and allied health members from Emergency Medicine, Cardiology, Cardiac Catheterization Laboratory, and EMS. Patients transported during this month were excluded from this analysis to allow for education of EMS personnel, communication to stakeholders, and protocol implementation.During the preimplementation phase, GCR personnel acquired PH ECG ad hoc, without any specific guidelines or protocols outlining when to acquire PH ECG, how to interpret, or how to utilize the information in the prehospital setting or at the hospital. Our PH ECG protocol included 4 features: (1) PH ECG acquisition; (2) PH ECG interpretation by paramedics without wireless transmission; (3) prehospital activation of the cardiac catheterization laboratory; and (4) patient bypass of the ED. We equipped 8 ambulances with Zoll M-Series monitor-defibrillators with 12-lead capability (Zoll Medical Corporation, Chelmsford, MA). All GCR paramedics underwent a 3-hour training session on the PH ECG protocol, including details of the protocol, PH ECG acquisition, and interpretation and were required to pass a test on the materials presented.According to the protocol, if the PH ECG computer algorithm interpretation displayed ***Acute Myocardial Infarction*** and GCR paramedics agreed that there was ≥1 mm of ST-segment elevation in 2 contiguous leads, then paramedics classified the PH ECG as a PH STEMI activation. If either the computer algorithm or the paramedic interpretation did not indicate STEMI, then the PH ECG was categorized as no PH STEMI activation. Our protocol did not involve wireless transmission to a central monitoring station for physician interpretation and over-read of the PH ECG.The PH ECG protocol included specific criteria for conditions when EMS should not activate the catheterization team or bypass the ED even when a STEMI is suspected in the prehospital setting. These included (1) left bundle-branch block on PH ECG; (2) need for head CT or neurological evaluation; (3) need for emergent intubation; (4) need for immediate hemodynamic stabilization; (5) chest trauma or motor vehicle collision victims; or (6) do-not-resuscitate status.The postimplementation group consisted of 2 subgroups: a PH STEMI activation subgroup when all 4 features of the PH ECG protocol were carried out (ie, PH ECG acquired, PH ECG interpreted as STEMI, catheterization team activated from the field, and patient bypassed the ED) and a no PH STEMI activation subgroup. To activate the catheterization laboratory, paramedics made a single call to the Saint Mary's Hospital Emergency Communications Center (ECC) to activate the cardiac catheterization laboratory team without needing approval by the ED or Cardiology physician. The ECC coordinates and dispatches ground and air ambulances for 30 regional hospitals in Minnesota, Wisconsin, and Iowa.21 The catheterization team was expected to arrive at the hospital and begin the procedure within 20 to 30 minutes of activation. The patient would bypass the ED and was transported directly to the cardiac catheterization laboratory. If the case occurred during off-hours and catheterization team members were still en route, the patient was transported to the Coronary Care Unit (CCU), which is across the hall from the catheterization laboratories on the Fourth floor of Saint Mary's Hospital, in an effort to avoid any unnecessary delays in the ED. The paramedics and CCU providers kept the patient on the ambulance gurney, and acute therapies including defibrillation and medications were immediately available. The paramedics and CCU providers cared for the patient until the catheterization team arrived. If the patient was in the "no PH STEMI activation" subgroup, the patient was taken to the ED for a standard evaluation.To encourage continuous quality improvement, we instituted feedback within 24–48 hours to all clinicians involved in each patient's care. The feedback, in the form of electronic mail, included DTB, FMCTB, specific time intervals, and a copy of the PH ECG for every prehospital STEMI activation. This document was also sent to all 67 GCR paramedics, regardless of whether they participated in the case, to foster learning from each case. A sample of the feedback electronic mail is shown in the online-only Data Supplement Figure.Variables and Data SourcesWe prospectively collected data on all patients transported by GCR to Saint Mary's Hospital who had STEMI and were treated with primary PCI. These data included time of ambulance arrival on scene (first medical contact time), time that PH ECG was acquired, length of time on scene, time of patient arrival at hospital (door time), and time of first device used to open the coronary artery, including balloon, stent, or thrombectomy device (balloon time).Statistical MethodsDiscrete data are summarized with frequency and group percentage and group comparisons are tested with Pearson χ2 test. GCR transport time intervals are summarized using median and innerquartile range and compared using a Mann-Whitney-Wilcoxon test. Kaplan-Meier methods are used to estimate time-to-balloon distributions, with group comparisons assessed using a log-rank test. Pairwise log-rank tests were adjusted for multiple tests using a permutation algorithm to simulate the test statistic distribution under the null hypothesis. Probability values <0.05 were considered statistically significant. All analyses were conducted using SAS 9.2 (SAS Institute, Cary, NC).ResultsParticipant Flow and Baseline Demographic DataWe identified a total of 135 STEMI patients who were transported by GCR to Saint Mary's Hospital and underwent primary PCI (Figure 1). Three were excluded because they refused consent for research use of their medical records, leaving 132 patients for analysis.Download figureDownload PowerPointFigure 1. Patient population. PH ECG indicates prehospital electrocardiogram; PH STEMI, prehospital ST-elevation–myocardial infarction.The preimplementation phase included 50 patients. Of these, 33 (66%) had a PH ECG performed. Because there was no PH ECG protocol in place and no plan for what to do with the PH ECG information, none of these patients had a "PH STEMI activation," and they were all taken to the ED for further treatment.The postimplementation phase included 82 patients with a final hospital diagnosis of STEMI, 67 (82%) of whom had a PH ECG performed (P=0.041 compared with the preimplementation group). Of these, 38 (46%) were classified as PH STEMI activation. Of the remaining 44 of 82 patients, who comprised the no PH STEMI activation group: (1) 15 patients did not have a PH ECG acquired. Of these, 12 had protocol exclusions including out-of-hospital cardiac arrest or shock, and 3 were protocol violations, as a PH ECG was not acquired; (2) 29 patients did have a PH ECG acquired. Of these, 14 patients did not have ST-elevation on their PH ECG but developed ST-elevation on a subsequent ECG in the ED; 6 patients had ST-elevation but the computer algorithm did not interpret as ***Acute Myocardial Infarction***; 5 patients had left bundle-branch block and were excluded; and 4 patients had a computer algorithm of ***Acute Myocardial Infarction*** but the paramedics failed to agree with the computer interpretation. During this same period, there were 4 false-positive activations. These were attributed to protocol violations, in which GCR activated the catheterization laboratory and bypassed the ED, but the computer interpretation did not read ***Acute Myocardial Infarction***, and the patient was not diagnosed with STEMI. These cases were not included in this analysis because we analyzed patients with a final hospital diagnosis of STEMI. Baseline demographic data for all STEMI patients in this analysis are presented in Table 1. Patient demographics were similar between all preimplementation and postimplementation patients, as well as between all preimplementation patients and the prespecified postimplementation PH STEMI activation group.Table 1. Baseline Demographic DataVariableAll Preimplementation (n=50)All Postimplementation (n=82)P ValuePostimplementation PH STEMI Activation (n=38)P Value†Age, y65.9±15.766.8±13.60.7467.0±11.60.73Male, n (%)36 (72)61 (74)0.7627 (71)0.92Hypertension, n (%)29 (58)54 (68)0.2726 (70)0.24Diabetes, n (%)9 (18)18 (22)0.569 (24)0.51Smoking status, n (%)0.950.57 Never19 (38)32 (40)14 (37) Former16 (32)23 (29)9 (24) Current15 (30)25 (31)15 (39)Hyperlipidemia, n (%)28 (56)52 (65)0.3023 (62)0.56History of CAD, n (%)19 (38)26 (32)0.4914 (37)0.91Cardiogenic shock,* n (%)8 (16)24 (29)0.089 (24)0.37Creatinine1.0±0.31.1±0.80.371.0±0.30.29PH STEMI indicates prehospital ST-elevation–myocardial infarction; CAD, coronary artery disease.*Cardiogenic shock, at or immediately after admission to the hospital, was defined as a persistent systolic blood pressure ≤85 mm Hg that was unresponsive to fluid administration and required vasopressors or placement of an intra-aortic balloon pump.†P value for comparing postimplementation PH-STEMI activation group versus all preimplementation group.Preimplementation Phase: Effect of PH ECG Acquisition on Reperfusion TimesDuring the preimplementation phase, we analyzed whether ad hoc acquisition of a PH ECG, without any formal protocol to guide its interpretation or use, led to a decrease in DTB or FMCTB. We found no difference in DTB or FMCTB between patients who did and did not receive a PH ECG during the preimplementation phase (Table 2). Median (interquartile range) DTB for patients with PH ECG acquired was 61 (49, 80) minutes, compared with 59 (43, 74) minutes for those without PH ECG acquired (P=0.61). Median (interquartile range) FMCTB for patients with PH ECG acquired was 90 (78, 111) minutes, compared with 91 (79, 112) minutes for those without PH ECG acquired (P=0.81).Table 2. Effect of PH ECG Acquisition on Reperfusion TimesPreimplementation With PH ECG Acquired (n=33)Preimplementation Without PH ECG Acquired (n=17)P ValueMedian DTB, min (interquartile range)61 (49, 80)59 (43, 74)0.61Median FMCTB, min (interquartile range)90 (78, 111)91 (79, 112)0.81PH ECG indicates prehospital electrocardiogram; DTB, door-to-balloon time; and FMCTB, first medical contact-to-balloon time.Postimplementation Phase: Effect of PH ECG Protocol on Reperfusion TimesThe median DTB was 59 (47, 76) minutes for the entire preimplementation group, compared with 57 (36, 72) minutes for the entire postimplementation group (P=0.28) (Table 3). The median FMCTB was 90 (78, 111) minutes for the preimplementation group compared with 88 (63, 114) minutes for the postimplementation group (P=0.87).Table 3. Effect of PH ECG Protocol on Reperfusion TimesAll Preimplementation (n=50)All Postimplementation (n=82)P Value*Postimplementation PH STEMI Activation (n=38)P Value†Median DTB, min (interquartile range)59 (47, 76)57 (36, 72)0.2832 (27, 55)<0.001Median FMCTB, min (interquartile range)90 (78, 111)88 (63, 114)0.8758 (51, 87)0.001PH ECG indicates prehospital electrocardiogram; PH STEMI, prehospital ST-elevation–myocardial infarction; DTB, door-to-balloon time; and FMCTB, first medical contact-to-balloon time.*Postimplementation versus pre-implementation comparison.†Postimplementation PH STEMI activation versus pre-implementation comparison.The postimplementation phase subgroup (n=38) who had PH STEMI activation had shorter median DTB 32 (27, 55) minutes compared with median DTB 59 (47, 76) minutes for the preimplementation group (P<0.001) (Table 3). Similarly, median FMCTB was 58 (51, 87) minutes for the postimplementation PH STEMI activation subgroup compared with 90 (78, 111) minutes for the preimplementation group (P=0.001). The median and variance for DTB and FMCTB for the preimplementation group, postimplementation group, and postimplementation PH STEMI activation subgroup are shown in Figure 2.Download figureDownload PowerPointFigure 2. Door-to-balloon time and first medical contact-to-balloon time by study group. PH STEMI indicates prehospital ST-elevation–myocardial infarction.DiscussionThe present study shows that our PH ECG protocol significantly reduced median DTB and FMCTB for patients with STEMI when all 4 features of our PH ECG protocol were carried out, including (1) PH ECG acquisition; (2) EMS interpretation without PH ECG transmission; (3) prehospital activation of the cardiac catheterization team; and (4) ED bypass. The median DTB decreased from 59 to 32 minutes (P<0.001) for patients with STEMI who had all 4 features of the PH ECG protocol performed.Although DTB has been the traditionally reported time metric for STEMI patients, this measure does not account for the time spent with medical personnel in the prehospital setting. In 2007, the guidelines called for a FMCTB of less than 90 minutes for patients with STEMI, with first medical contact being defined as EMS arrival for patients calling 911.18 As most centers have achieved DTB of 90 minutes in 75% of patients with STEMI,22 prehospital transport time and delay are gaining increasing importance and focus. To encourage rapid FMCTB, guidelines noted "an underutilized but effective strategy for improving systems of care for STEMI patients is to expand the use of prehospital 12-lead ECG programs by EMS that provide advanced life support."18 This study also demonstrated that median FMCTB decreased from a median of 90 to 58 minutes (P=0.001) when all 4 features of the PH ECG protocol were performed.Although there was no significant difference in the entire preimplementation and postimplementation comparison of DTB and FMCTB times, it should be noted that these analyses include all patients with a final hospital diagnosis of STEMI who were transported by GCR. Most of the postimplementation patients that did not have PH STEMI activation and ED bypass included protocol exclusions when the patient was too sick to acquire a PH ECG, patients who did not have ST elevation on the PH ECG but developed ST elevation after arrival to the ED, or cases in which there was no agreement by the paramedic and computer algorithm on the presence of ST elevation on the PH ECG. These situations contributed to the lack of significant difference in reperfusion times between the entire preimplementation and postimplementation groups.Several studies in the literature have shown improved reperfusion times in patients with STEMI when PH ECG is acquired.1–16 LeMay et al11 instituted a citywide protocol in Ottawa for STEMI management. They included paramedic interpretation, activation, and direct patient transport to the city's cardiac care center rather than any of the city's 4 hospital EDs, with a median DTB of 69 minutes. Rao et al15 published a report on a prehospital STEMI protocol using wireless transmission, in which the ED physician interpreted the ECG and activated the catheterization laboratory before patient arrival, and their median DTB was 60 minutes. Camp-Rogers et al3 reported a mean DTB of 49 minutes when paramedics reviewed electronic ECG interpretations and activated the laboratory in the prehospital setting, but they did not bypass the ED for any patients.Patients with STEMI who presented directly to Saint Mary's Hospital already have rapid DTB times of 67 minutes from 2004 to 2008.21 The Mayo PH ECG protocol extended these findings and integrated 4 key features, including (1) PH ECG acquisition; (2) EMS interpretation without PH ECG transmission; (3) prehospital activation of the cardiac catheterization team; and (4) ED bypass which resulted in a median DTB and FMCTB times of 32 minutes and 58 minutes, respectively. No other significant changes occurred with treatment of STEMI patients, either in the prehospital setting or in the ED, during this study period.For our protocol to be successful, we wanted several things to occur before the patient's arrival at the hospital. First, we wanted to increase the percentage of STEMI patients who had a PH ECG collected in the prehospital setting, and we wanted to have paramedics interpret that PH ECG without wireless transmission for physician overread. During the preimplementation phase, 66% patients with STEMI had PH ECG acquired without any protocol to guide how to use that diagnostic information. We found that DTB and FMCTB were similar for all patients in the preimplementation phase, regardless of whether a PH ECG was acquired. This is seemingly because we treated all patients similarly during this time period, regardless of whether they had a PH ECG collected. This highlights that acquiring a PH ECG is necessary but not sufficient to improve reperfusion times. Specific protocols must be implemented to integrate the diagnostic information from a PH ECG with downstream systems of care to decrease reperfusion times.To institute our protocol, we implemented a standardized training curriculum and competency examination for our paramedic staff that was required and completed over a half-day. In addition, we instituted feedback for all paramedics employed by our affiliated EMS, to encourage discussion and provide frequent reminders of our protocol. Also, we were able to avoid costly and complex technology, potential wireless transmission failures that have been reported as high as 20%, and physician staffing requirements that would otherwise be necessary if we instituted wireless PH ECG transmission.17,20,23,24 We believe that the training, competency examination, and protocol can be generalizable to larger populations with greater number of EMS personnel but may be limited to paramedic-level providers, given the complexity of decision-making.Once the PH ECG was collected and interpreted, we allowed paramedics to place a single call to activate the cardiac catheterization laboratory. A single-call paging system has been recommended by the D2B Alliance as a key strategy for hospitals to reduce DTB.25 We had already been using a single-call system for ED STEMI activations,21 and we simply enabled paramedics to call the same telephone number for prehospital activations. Finally, once the paramedics had activated the cardiac catheterization laboratory, the patient bypassed the ED entirely and went directly to the l

The clinical utility of new or "presumably new" left bundle branch block (LBBB) as an electrocardiographic criterion equivalent to ST-segment elevation myocardial infarction in contemporary practice is not well established. The aim of this study was to investigate the hypothesis that new or presumably new LBBB in symptomatic patients frequently leads to an overdiagnosis of acute myocardial infarction (AMI). A retrospective analysis of data from consecutive patients in the Mayo Clinic's ST-segment elevation myocardial infarction network from July 2004 to August 2009 was conducted among 892 patients, 36 (4%) of whom had new LBBB. The frequency, clinical characteristics, serum troponin levels, coronary angiographic findings, and outcomes of patients with new LBBB suspected of having AMI were evaluated. Compared with patients without LBBB (n = 856), those with new LBBB were older (64.5 vs 72.9 years, p < 0.001), had higher Thrombolysis In Myocardial Infarction (TIMI) risk scores (22.7 vs 31.0, p < 0.005), were less likely to undergo primary percutaneous coronary intervention (86% vs 22%, p < 0.001), and had longer door-to-balloon times. Only 14 patients (39%) had final diagnoses of acute coronary syndromes, of which 12 were AMI, while 13 (36%) had cardiac diagnoses other than acute coronary syndrome and 9 (25%) had noncardiac diagnoses. Of the patients with AMI, 5 had occluded culprit arteries, of which 2 involved the left anterior descending coronary artery. A Sgarbossa score ≥ 5 had low sensitivity (14%) but 100% specificity in diagnosing AMI in the presence of new LBBB. In conclusion, new or presumably new LBBB in patients suspected of having AMI identifies a high-risk subgroup, but only a small number have AMI. Two thirds of these patients are discharged from the hospital with alternative diagnoses. The Sgarbossa criteria appear to have limited utility in clinical practice because of their low sensitivity.

HomeCirculation: Cardiovascular Quality and OutcomesVol. 3, No. 1Using Prehospital Electrocardiograms to Improve Door-to-Balloon Time for Transferred Patients With ST-Elevation Myocardial Infarction Free AccessResearch ArticlePDF/EPUBAboutView PDFView EPUBSections ToolsAdd to favoritesDownload citationsTrack citationsPermissionsDownload Articles + Supplements ShareShare onFacebookTwitterLinked InMendeleyReddit Jump toSupplementary MaterialsFree AccessResearch ArticlePDF/EPUBUsing Prehospital Electrocardiograms to Improve Door-to-Balloon Time for Transferred Patients With ST-Elevation Myocardial InfarctionA Case of Extreme Performance Sridevi R. Pitta, MBBS, Lucas A. Myers, NREMT-P, Christine M. Bjerke, RN, Roger D. White, MD and Henry H. Ting, MD, MBA Sridevi R. PittaSridevi R. Pitta From the Knowledge and Encounter Research Unit (H.H.T.), Division of Cardiovascular Diseases (S.R.P., C.M.B., R.D.W., H.H.T.), and the Department of Emergency Medicine (L.A.M., R.D.W.), Mayo Clinic, Rochester, Minn. Search for more papers by this author , Lucas A. MyersLucas A. Myers From the Knowledge and Encounter Research Unit (H.H.T.), Division of Cardiovascular Diseases (S.R.P., C.M.B., R.D.W., H.H.T.), and the Department of Emergency Medicine (L.A.M., R.D.W.), Mayo Clinic, Rochester, Minn. Search for more papers by this author , Christine M. BjerkeChristine M. Bjerke From the Knowledge and Encounter Research Unit (H.H.T.), Division of Cardiovascular Diseases (S.R.P., C.M.B., R.D.W., H.H.T.), and the Department of Emergency Medicine (L.A.M., R.D.W.), Mayo Clinic, Rochester, Minn. Search for more papers by this author , Roger D. WhiteRoger D. White From the Knowledge and Encounter Research Unit (H.H.T.), Division of Cardiovascular Diseases (S.R.P., C.M.B., R.D.W., H.H.T.), and the Department of Emergency Medicine (L.A.M., R.D.W.), Mayo Clinic, Rochester, Minn. Search for more papers by this author and Henry H. TingHenry H. Ting From the Knowledge and Encounter Research Unit (H.H.T.), Division of Cardiovascular Diseases (S.R.P., C.M.B., R.D.W., H.H.T.), and the Department of Emergency Medicine (L.A.M., R.D.W.), Mayo Clinic, Rochester, Minn. Search for more papers by this author Originally published1 Jan 2010https://doi.org/10.1161/CIRCOUTCOMES.110.904219Circulation: Cardiovascular Quality and Outcomes. 2010;3:93–97A 45-year-old man was walking his dog at 5:30 am in June 2009 and developed crushing 10/10 substernal chest pain. He called 911 at 6:05 am after his symptoms persisted for 35 minutes. Emergency medical services (EMS) paramedics arrived at the scene at 6:09 am and obtained a brief history and examination showing a diaphoretic man, pulse of 92 bpm, blood pressure of 170/140 mm Hg, normal respiratory rate, and no rales or murmurs. Treatment was initiated including supplemental oxygen, sublingual nitroglycerin, and aspirin. A 12-lead prehospital (PH) ECG was acquired at the scene at 6:16 am and interpreted by paramedics as showing acute ST-elevation myocardial infarction (STEMI) (Figure 1). On the basis of the PH ECG, paramedics made a single phone call to the closest community hospital emergency department and activated the PH ECG STEMI protocol at 6:17 am. The closest community hospital was located within 5 miles and did not have capability for percutaneous coronary intervention (PCI). The STEMI protocol activation consisted of autolaunching helicopter transport to intercept the patient at the community hospital and alerting the cardiac catheterization team at the tertiary PCI center located 50 miles away with the estimated patient arrival time. The patient arrived at the community hospital emergency department (door 1) by ground ambulance at 6:26 am. Helicopter transport picked up the patient and departed the community hospital at 6:37 am with a door 1 in–to–door 1 out time of 11 minutes. The patient arrived at the tertiary PCI center (door 2) at 7:10 am and was transported directly to the cardiac catheterization laboratory. During transport from the helipad to the cardiac catheterization laboratory, the patient had ventricular fibrillation in the elevator, and a shock was delivered with 120 J of selected energy. Coronary angiography showed a thrombotic occlusion of the left anterior descending artery that was successfully treated with a drug eluting stent (Figure 2A and 2B). The time metrics from symptom onset to reperfusion with first PCI device are shown in Table 1. In summary, the door 1–to–first PCI device time was 61 minutes, first EMS contact–to–first PCI device time was 82 minutes, and symptom onset–to–first PCI device time was 117 minutes. The peak troponin level was 1.8 ng/mL, and ECG immediately after PCI is shown in Figure 3. There were no complications during the hospitalization, and cardiac MRI on hospital day 3 showed a large area of infarction involving the entire anterior wall and apex with a left ventricular ejection fraction of 39% and moderate delayed myocardial enhancement. The patient was discharged on hospital day 4 with referral to cardiac rehabilitation and the following medications: aspirin, clopidogrel, simvastatin, nicotine patch, lisinopril, and metoprolol. At 30-day follow-up, he was asymptomatic and compliant with his medications, and an echocardiogram showed left ventricular ejection fraction had improved to 52%. Download figureDownload PowerPointFigure 1. PH ECG obtained by EMS at the scene.Download figureDownload PowerPointFigure 2. A, Coronary angiography of proximal left anterior descending (LAD) total occlusion. B, Coronary angiography of proximal LAD after stent placement.Table 1. Time IntervalsDescriptionTimeTime Interval, minSymptom onset05:300911 call06:0535EMS on-scene06:094PH ECG acquired06:167STEMI protocol activation06:171Transport to local community hospital06:225Arrival at door 106:264Departure from door 106:3711Arrival at door 207:1033First PCI device07:2717Time intervals Door 1 in to door 1 out11 Door 2 to first PCI device17 Door 1 to first PCI device61 First EMS contact to first PCI Device82 Symptom onset to first PCI device117Download figureDownload PowerPointFigure 3. ECG after left anterior descending stent.Goals and Vision of the ProgramTimely reperfusion therapy with fibrinolytic therapy or primary PCI is the cornerstone of treatment to reduce infarct size and improve outcomes in patients with STEMI.1,2 Current guidelines recommend first medical contact–to–balloon times <90 minutes for both nontransferred and transferred patients with STEMI.3 However, recent analyses have demonstrated that fewer than 10% patients with STEMI who are transferred for primary PCI achieve this goal of <90 minutes.4,5Improving access to and timeliness of primary PCI for patients who require transfer to a STEMI receiving center has been the focus for the American Heart Association Mission Lifeline Initiative.6,7 PH ECG can provide earlier identification and triage of patients with STEMI8–11 and potentially improve access to and timeliness of primary PCI if the information from the PH ECG is integrated with downstream systems of care.12 Although PH ECG programs have been described for urban hospital networks,9,11 a “rural hybrid system” to coordinate prehospital triage and helicopter intercept for rural populations where STEMI referral hospitals and STEMI receiving centers are separated by long distances have not been reported. Current challenges for implementing PH ECG into systems of care have included: Low utilization of PH ECG among patients with acute coronary syndrome transported by EMS.Processes of care to enable rapid interpretation of PH ECG by EMS personnel or wireless transmission for remote physician interpretation.Coordinating downstream systems of care such as activating the cardiac catheterization laboratory while ambulance is en route, bypassing the emergency department, or bypassing non-PCI capable STEMI referral hospitals.Local Challenges in ImplementationWe implemented the PH ECG program at a 77-bed rural community hospital without PCI capability in February 2009. This STEMI referral hospital is located 50 miles from the STEMI receiving center (Saint Mary’s Hospital) and connected by a 2-lane rural road. This rural road system leads to delays in ground ambulance transport, particularly during winter and inclement weather. Historically, patients who were transferred to Saint Mary’s Hospital for primary PCI have an observed median door 1–to–first PCI device time of 116 minutes.13 The main challenges we sought to address included: Training EMS personnel to acquire and interpret PH ECG for STEMI.Developing a protocol for EMS personnel for what clinical situations to acquire a PH ECG.Developing a process for EMS personnel to activate the STEMI protocol that included autolaunching helicopter transport to intercept the patient and alerting the cardiac catheterization team at Saint Mary’s Hospital.Developing a diversion protocol for when it was and was not appropriate to bypass the emergency departments at the STEMI referral hospital and STEMI receiving center.Developing a process to minimize the door 1 in-to-door 1 out time at the STEMI-referral hospital.Developing a process to provide immediate feedback to all clinical providers.Design of the Mayo Prehospital ECG ProtocolThe Mayo PH ECG program for patients with STEMI transferred from rural community hospitals is distinct from the previously reported interhospital transfer approach.13 Before implementing the PH ECG program, paramedics were required to take a 1-day course on how to acquire and interpret PH ECG as well as to pass an examination to identify ST-elevation among 50 unknown ECG tracings. Ambulances were equipped with PH ECG equipment and were typically staffed by 1 paramedic and 1 intermediate-level EMS provider. A protocol was developed for what clinical situations to acquire a PH ECG for patients with suspected acute coronary syndrome (Appendix 1). The protocol limited the number of PH ECG to 2 attempts in order not to delay care or transport. The EMS personnel were educated to classify a PH ECG into 3 categories: Definite STEMI was defined as when EMS paramedics and computer interpretation were concordant for presence of acute ST elevation.Possible STEMI was defined as the presence of left bundle-branch block or when EMS paramedics and computer interpretation were discordant for acute ST elevation.Not STEMI was defined as when EMS paramedics and computer interpretation were concordant for the absence of acute ST elevation.In cases in which a definite STEMI was identified at the scene from a PH ECG, the paramedics were instructed to make a single phone call to the rural community hospital emergency department to activate the STEMI protocol. While the patient is en route by ground ambulance to the community hospital, helicopter transport has already been autolaunched to intercept the patient at the community hospital and the cardiac catheterization team at Saint Mary’s Hospital is alerted of the estimated patient arrival time. To achieve rapid door 1 in–to–door 1 out time at the STEMI referral hospital, the following processes were implemented: the patient was kept on the ambulance stretcher; the patient was not registered unless treatment was indicated; no emergency department evaluation, laboratory tests, repeat ECG, or other diagnostic tests were performed; adjunctive medications were administered by the paramedics and helicopter nurses; the patient was jointly monitored by the paramedic and emergency department nurses; and the patient was immediately transported to the STEMI receiving center when the helicopter arrived.The helicopter nurses transported the patient directly to the Saint Mary’s Hospital catheterization laboratory for emergent coronary angiography and bypassed the Saint Mary’s Hospital emergency department. However, if the patient was noted to have a diversion criterion, then full emergency department evaluation at the STEMI referral hospital or STEMI receiving center was performed. Standard diversion criteria were used by both paramedics and helicopter nurses, including respiratory distress requiring intubation, hemodynamic instability, suspected aortic dissection, suspected intracranial hemorrhage, or patients with “do not resuscitate” status (Appendix 2). In addition, EMS did not activate the STEMI protocol or helicopter autolaunch for patients with “do not resuscitate” status.A standardized process provided feedback to every provider (EMS, nurses, and physicians) involved in the clinical case within 24 to 48 hours, including all the time metrics shown in Table 1. Every PH ECG was reviewed for technical and clinical accuracy by a cardiologist (H.H.T.).Implementation of the InitiativeBefore implementation, multiple meetings were undertaken to achieve commitment and consensus from all stakeholders to implement the PH ECG program at the community hospital. A clear vision to improve access to and timeliness of primary PCI was defined and agreed on. Three critical pillars for success included having top leadership commitment, local clinical champions to sustain the momentum when barriers arose, and engagement of front-line staff who provided the actual patient care. These pillars needed to be aligned across all disciplines (cardiology, emergency medicine, nursing, and EMS). To implement major change initiatives, the organizational culture and readiness for change is equally or more important than the specific strategy.14During the first 6 months (February to August 2009) of the program, a total of 60 PH ECG were acquired for patients with suspected acute coronary syndrome; the time metrics for prehospital care are shown in Table 2. One patient was identified with a definite STEMI as reported in the clinical case and performance measures were provided to EMS personnel, nurses, and physicians involved in the case via electronic mail using the format shown in Table 1. The remaining 59 cases were categorized as not STEMI. Table 2. Time IntervalsTime IntervalsMedian (Quartile 1, Quartile 3), min911 call to EMS on scene5.0 (4.0, 9.0)EMS on scene to PH ECG acquired15.0 (7.9, 21.7)PH ECG acquired to door 19.5 (3.0, 18.2)Success of the InitiativeThe clinical case demonstrates a first medical contact-to-balloon time of 82 minutes and symptom onset to balloon time of 117 minutes, both of which are within ideal, guideline-recommended performance measures for a patient with STEMI transferred for primary PCI. The door 1 in–to–door 1 out time at the STEMI referral hospital was 11 minutes. An opportunity for improvement for EMS was the median on-scene–to–PH ECG acquired time of 15 minutes. This exceeded an analogous benchmark for door-to-ECG time <10 minutes for patients with suspected myocardial infarction who present directly to the emergency department. At 30-day follow-up, the patient did not have any adverse outcomes such as recurrent angina, readmission to any hospital, or death. His left ventricular function ejection fraction improved from 39% during the index event to 52% at 30-day follow-up. This improvement in left ventricular function probably reflects achieving a short total ischemic time from onset of symptoms to reperfusion therapy of <2 hours.Summary of the Experience, Future Directions, and ChallengesThis clinical case demonstrated that it is possible to achieve the guideline-recommended goal of first medical contact–to–balloon time of <90 minutes for patients transferred for primary PCI from a rural STEMI referral hospital located 50 miles from a STEMI receiving center. This high level of performance required educating EMS paramedics to acquire and interpret PH ECG, developing standard protocols for STEMI activation and transport, and optimizing transitions of care from ground ambulance to helicopter transport to cardiac catheterization laboratory.The potential for PH ECG to improve outcomes in patients with STEMI will hinge on integrating the PH ECG with downstream systems of care for urban and rural networks of STEMI referral hospitals and STEMI receiving centers. A rural hybrid system will require unique models for paramedics to coordinate prehospital triage as well as systems to integrate helicopter autolaunch and intercept at the STEMI referral hospital or en route. We are interested in evaluating whether the ground ambulance could bypass the rural community hospital and coordinate helicopter intercept of the ground ambulance while en route to the STEMI receiving center. This coordination of ground ambulance and helicopter intercept is currently being used for motor vehicle accident and trauma victims in the region.We plan to extend this “rural hybrid system” for prehospital triage and helicopter intercept to 30 STEMI referral hospitals located in rural Minnesota, Iowa, and Wisconsin that transfer patients with STEMI to Saint Mary’s Hospital (STEMI receiving center). Our evaluation will focus on precomparisons and postcomparisons of process and outcome measures15 for this system of care, which would include metrics such as first medical contact–to–balloon time, door 1 in–to–door 1 out time, door 1–to–needle time for instances when transfer for primary PCI is not possible due to weather, percentage of patients with STEMI treated with any reperfusion therapy, percentage of false alarms,16 prehospital delay time from symptom onset to hospital arrival, percentage of patients referred to cardiac rehabilitation, left ventricular ejection fraction, and mortality.The online-only Data Supplement is available with this article at http://circoutcomes.ahajournals.org/cgi/content/full/3/1/93/DC1.Sources of FundingThe study was supported by the Mayo Clinic Division of Cardiovascular Diseases.DisclosuresNone.FootnotesCorrespondence to Henry H. Ting, MD, Mayo Clinic, Division of Cardiovascular Diseases, 200 First St SW, Rochester, MN 55905. 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Brindis R and Krumholz H (2010) President’s Page: National Quality Initiatives Put ACC’s Mission Into Action, Journal of the American College of Cardiology, 10.1016/j.jacc.2010.09.004, 56:15, (1260-1262), Online publication date: 1-Oct-2010. January 2010Vol 3, Issue 1 Advertisement Article InformationMetrics https://doi.org/10.1161/CIRCOUTCOMES.110.904219PMID: 20123675 Originally publishedJanuary 1, 2010 Keywordselectrocardiogrammyocardial infarctionqualityangioplastyPDF download Advertisement SubjectsAcute Coronary SyndromesElectrocardiology (ECG)Ethics and PolicyMyocardial Infarction

BACKGROUND:Quality improvement efforts have focused on strategies to improve the timeliness of reperfusion therapy in ST-elevation myocardial infarction patients who present to hospitals with and without percutaneous coronary intervention (PCI) capability. We implemented and evaluated a protocol to optimize the timeliness of reperfusion therapy and to coordinate systems of care for a PCI center and 28 regional hospitals located up to 150 miles away across 3 states.METHODS AND RESULTS:The present study focused on a prospective, observational cohort of 597 patients who presented with ST-segment elevation and within 12 hours of symptom onset to Saint Marys Hospital and 28 regional hospitals up to 150 miles away between May 2004 and December 2006. The Mayo Clinic ST-elevation myocardial infarction protocol implemented strategies to improve timeliness of reperfusion therapy and to coordinate systems of care for transfer between hospitals. The study sample consisted of 258 patients who presented to Saint Marys Hospital and were treated with primary PCI (group A), 105 patients who presented to a regional hospital with symptom onset >3 hours and then were transferred for primary PCI (group B), and 131 patients who presented to a regional hospital with symptom onset <3 hours and were treated with full-dose fibrinolytic therapy (group C). For groups A and B, median door-to-balloon times were 71 and 116 minutes, respectively. Door-to-balloon time <90 minutes was achieved in 75% of group A and 12% of group B. Median door-to-needle time was 25 minutes for group C, and 70% had door-to-needle time <30 minutes.CONCLUSIONS:The Mayo Clinic ST-elevation myocardial infarction protocol demonstrates the feasibility of implementing strategies to optimize the timeliness of reperfusion therapy and the times that can be achieved through coordinated systems of care for ST-elevation myocardial infarction patients presenting to a PCI center (Saint Marys Hospital) and 28 regional hospitals without PCI capability located up to 150 miles away across 3 states.

Background— Quality improvement efforts have focused on strategies to improve the timeliness of reperfusion therapy in ST-elevation myocardial infarction patients who present to hospitals with and without percutaneous coronary intervention (PCI) capability. We implemented and evaluated a protocol to optimize the timeliness of reperfusion therapy and to coordinate systems of care for a PCI center and 28 regional hospitals located up to 150 miles away across 3 states. Methods and Results— The present study focused on a prospective, observational cohort of 597 patients who presented with ST-segment elevation and within 12 hours of symptom onset to Saint Marys Hospital and 28 regional hospitals up to 150 miles away between May 2004 and December 2006. The Mayo Clinic ST-elevation myocardial infarction protocol implemented strategies to improve timeliness of reperfusion therapy and to coordinate systems of care for transfer between hospitals. The study sample consisted of 258 patients who presented to Saint Marys Hospital and were treated with primary PCI (group A), 105 patients who presented to a regional hospital with symptom onset >3 hours and then were transferred for primary PCI (group B), and 131 patients who presented to a regional hospital with symptom onset <3 hours and were treated with full-dose fibrinolytic therapy (group C). For groups A and B, median door-to-balloon times were 71 and 116 minutes, respectively. Door-to-balloon time <90 minutes was achieved in 75% of group A and 12% of group B. Median door-to-needle time was 25 minutes for group C, and 70% had door-to-needle time <30 minutes. Conclusions— The Mayo Clinic ST-elevation myocardial infarction protocol demonstrates the feasibility of implementing strategies to optimize the timeliness of reperfusion therapy and the times that can be achieved through coordinated systems of care for ST-elevation myocardial infarction patients presenting to a PCI center (Saint Marys Hospital) and 28 regional hospitals without PCI capability located up to 150 miles away across 3 states.