Distant Early ECG Warning

     Each year coronary heart disease causes about 1.5 million Americans to suffer acute myocardial infarctions, resulting in about 500,000 deaths. Of the patients suffering these cardiac events, nearly 50% die before reaching a hospital.

     Hospital mortality from these cardiac events, however, has been profoundly reduced over the past five years. This is due to various evolving coronary interventions, or reperfusion strategies. These strategies are means to open the blood flow through coronary arteries, thereby preventing further heart muscle damage and death. The sooner the treatment, the better the outcome.

     A natural step in the evolution of electronic report writing seemed to be the capturing of 12-lead electrocardiograms for documentation purposes. A January 2006 report in the Journal of the American College of Cardiology determined, "Emergency medical services providers who administer advanced life support should include diagnostic 12-lead ECG programs as one of their services. Evidence demonstrates that this technology can be readily used by EMS providers to identify patients with ST-segment elevation myocardial infarction (STEMI) before the patient's arrival at a hospital emergency department. Earlier identification of STEMI patients leads to faster artery-opening treatment." TFR also wanted to incorporate a simple system for transmitting 12-leads from medic units in the field to local hospitals.

     When considering this, a couple of questions came to mind. Could the local tax base afford to pay for the technology? The JACC report stated that any cost analysis for providing this service must consider the demonstrated benefits of more rapid treatment of STEMI patients. Could the transmission of patient data from the field to the hospital-specifically 12-lead electrocardiogram tracings-really improve patient outcomes? In a relatively urban area with several medical centers and generally short transport times, TFR Rescue Chief Nick LoCicero thought it could.

     A primary goal in acquiring 12-leads from prehospital patients having cardiac problems would be to identify STEMIs. According to a March 2006 report in Circulation, nearly 400,000 patients experience STEMIs each year in the U.S. But only about 10% of EMS services in the U.S. use 12-lead ECGs in the ambulance. The number that transmit that data to hospitals is much smaller.

Developing the System
     The time was right for Tampa Fire Rescue to contemplate a 12-lead acquisition and transmission program.

     "The technology was coming of age, LoCicero says, "and there was a very aggressive medical group at one of the local hospitals that was interested in helping develop the whole system from the standpoint of street access and the quality of care right on through the hospital side.

     "In the past, the only treatment options were clotbusting drugs, and you either qualified for their use or you didn't. If your patient didn't qualify, care options were limited."

     With the introduction of percutaneous coronary interventions (PCIs) such as placing stents and cardiac catheterizations, the goal became to rapidly identify patients who were having cardiac problems. STEMI patients could benefit the most from PCIs. By having a system in place for rapid identification of such patients and fast-tracking them past the ED directly onto the cardiac catheterization table, lives would be saved.

     One of the concerns was how to get the 12-lead data from the rescue crews in the field to the hospital in a way that wasn't overly cumbersome.

     "We'd just gone from a three-lead ECG to a 12-lead system," LoCicero says, "and we didn't want to add more wires into the process."

     The department also didn't want to place fax-type devices in the backs of its ALS transport units. The goal was to make the records system electronic; a fax machine would just add more paper.

     "Another important concern," department Medical Director Catherine Carrubba, MD, notes, "was the quality of the 12-lead ECG transmission. We needed to have the right equipment to provide the receiving hospital with the best quality 12-lead tracing possible."

     Just as the department was beginning to transition from three leads to 12, ZOLL Data Systems introduced a device that could electronically package 12-lead ECG and patient data, such as vital sign trends, for transmission. It also developed software that could be loaded onto PDA/cell phone-type devices to allow data to be transferred to them. Transferring data packages to the PDAs without using wires was possible through short-range wireless Bluetooth technology. But once a data package was uploaded from the cardiac monitor to the PDA/cell phone, there had to be a way to get the information quickly and securely off to the hospital.

     Early in the program's development, city information technology services (ITS) specialists were brought on board. "We needed to clearly identify what we wanted to do," LoCicero says. "By defining the project, ITS would be able to tell us if we had the technology to support what we wanted to do."

     ITS helped identify potential pitfalls. Some involved patient information security. "A level of encryption would have to be built into the system," says Capt. Ken Licata, TFR's quality assurance officer. "It would have to be reasonably secure."

     It was decided that any transmissions to hospitals would be primarily identified by the rescue crews sending the information. Having limited personal patient information in the transmission would further protect patient privacy.

Moving Into the Electronic Age
     In 2005, Tampa Fire Rescue (TFR) responded to more than 53,000 EMS calls. The paperwork generated with this much workload can be overwhelming. That's why, eight years earlier, the department began a multiphase plan to develop a completely electronic run report system.

     The department's original run report system consisted of desktop terminals placed in fire stations and selected local hospitals. The primary challenge facing this type of system was staying connected to the main server. If paramedics delivered a patient to a hospital and the connection between the terminal in the ED and the main server was down, the medic would have to wait to get back to his station to complete his report. The medic crew, as required by law, would leave an abbreviated written report at the hospital with the patient. If, en route back to the station, the crew got another alarm, their report-writing would start to get backed up. A medic could be down several reports before finally having an opportunity to sit down at a terminal and complete them.

     The next generation of EMS report writing transitioned from terminals to handheld personal digital assistant (PDA) devices. PDAs were assigned to each of the department's 13 ALS transport units. These were standard PDAs with specialized EMS report-writing software. Run reports could be completed on them. At hospitals, medic crews utilized the infrared option to beam their reports from their PDAs to printers so paper reports could be left with patients. Back at the fire stations, the crews downloaded their reports into PCs, which then passed them to the main server for storage.

Acquiring the Technology
     Tampa Fire Rescue would need to purchase 13 ZOLL M-series Med Pro Plus 12-lead cardiac monitors-one for each of the city's ALS transport units. The total cost would be about $200,000. Additionally, upgraded PDAs/cell phones would be required, at a cost of about $6,000. The money came from EMS grants and the department's budget. As the system developed and new monitors and PDAs could be purchased, paramedic pumpers and ALS nontransport units would also be equipped.

     With the help of ZOLL and city ITS personnel, the basic system developed along the following lines: The ZOLL monitors would be used to obtain 12-lead ECGs. That information would then be wirelessly transferred to software on the handheld devices. Paramedic crews would have the option of entering other patient data before selecting the receiving hospital. The PDA, using its cell phone attributes, would then transfer the data to the city server. There the data package would be placed into a portable document format (PDF) file and forwarded via e-mail to the receiving hospital and TFR's QA officer and medical director. It would take less than two minutes for the data to pass from the PDA through the system and arrive as an e-mail at the hospital.

Trainging the Medics
     In about six months, 275 field paramedics had to be taught to properly acquire and interpret 12-leads. There would have to be classes on the technology and issues related to connectivity. "In the beginning," LoCicero says, "a lot of our paramedics didn't understand the benefits of a 12-lead ECG, nor did they understand what a STEMI was." The goal was to get them comfortable with all of it.

     The gist of the training was to show the paramedics how and when to use the new 12-lead technology. After the medics received their initial training at skills lab, the responsibility of monitoring whether they were using the training and equipment fell to the Quality Assurance office. The QA office monitored for patients who might have benefited from acquisition and transmission of 12-leads. Most of the time, it determined the medics were acquiring 12-leads and treating their patients appropriately; the only thing missing was the transmission. Each time a transmission mishap occurred, the medic provider was sent a QA report, along with the rules and policies for 12-lead transmission and troubleshooting literature. With this kind of reinforcement, the compliance rate increased greatly.

     For paramedics to maintain their acquisition, interpretation and transmission skills, they would have to practice them on a regular basis, so the department also put another training tool in place: The paramedics could acquire 12-leads on many patients suffering chest pain and other signs of cardiac problems. However, only a handful of those 12-leads would meet the criteria for transmission to the hospital. If a medic wanted to practice transmitting a 12-lead, the PDA has an option for it to be sent only to the QA office. The medic would get the practice of going through all the steps of sending it to a hospital, but the e-mail would only "land" with QA.

The System in Action
     In March 2006 Tampa Fire Rescue, the St. Joseph's ED and the hospital's Heart Institute combined their planning, training and technology to save the life of 46-year-old David Levine.

     Levine provides client support for a major financial services firm. On his lunch break each day, he would go out for a brief walk, but on this day, he couldn't do it. He was experiencing pain in his chest, left arm and jaw and "felt really lousy." Levine went to see his company's nurse, who called 9-1-1. Within a few minutes Tampa Fire Rescue Lt. Tim Hayes and paramedic Kelly McNatt were at his side. Even while Hayes attached the 12-lead ECG, Levine was insisting he just wanted to go home and rest. But Hayes noted changes in Levine's ECG that were indicative of a STEMI. Levine was persuaded to go to the hospital with the rescue crew. In addition to transmitting the ECG to the hospital (St. Joseph's), Hayes also applied standard chest pain care, including administration of morphine. The trip to the hospital took about 10 minutes in moderate traffic. While en route, Hayes took another 12-lead. "You could see obvious changes from the first one," he recalls. "I could see his problem was getting worse." So the second 12-lead was also transmitted.

The Hospitals' Role
     With all of this technology and training being put into place, there was still one component to be addressed: The hospitals needed to have a process in place to efficiently continue the care begun in the field.

     "With our system, for a hospital to participate, all it would need is a secure e-mail delivery location," LoCicero says. "As PCI becomes available at more hospitals throughout the community, they can be easily included."

     The Saint Joseph's Hospital Heart Institute is one of the most advanced and comprehensive centers for cardiovascular medicine in Florida. Its staff has performed more than 50,000 adult cardiac catheterizations over the past 25 years. Pamela Jones, the Institute's clinical cardiac outcomes coordinator, explains what happens there after the paramedics transmit the ECG: "Once the e-mail lands at the medical communications center, the technician opens the e-mail and immediately prints it out. The communication technician is then responsible for walking the printed 12-lead back into the emergency department and physically handing it to the on-duty physician. The physician is then responsible for reviewing the ECG to determine if a STEMI alert should be called."

     Once the physician in the ED signs off on the STEMI alert, the staff sends out a page. A representative of the cardiac and stroke team reports to the patient's bedside to function as a rapid triage nurse. This person facilitates packaging of the patient and expedites their transfer to the cardiac catheterization lab. The process is designed to get STEMI patients into the lab faster, so blockages in the blood vessels nourishing the heart can be found and opened with balloon angioplasty.

     "When such a blockage occurs, oxygen cannot flow to the heart muscles, and a wave of dying muscle cells begins to spread," explains Xavier Prida, MD, an interventional cardiologist at the Institute. "The faster the blockage is relieved, the less muscle is lost. Simply put, time is muscle. Muscle loss corresponds with death rates and disability."

     With the new 12-lead transmission technology, the eventual goal is to have patients go straight from the field to the cath lab without stopping in the ED at all. "Our hope," says Prida, "is that the new technology can slice as much as 20 minutes off the time it takes for the patient to reach the cath lab."

     National standards recommend that patients suffering STEMIs should be identified and treated by balloon angioplasty within 90 minutes of arriving at an emergency department. At St. Joseph's Hospital the average is about 82 minutes. According to a March 2006 report in Duke Medical News, "The national average 'door-to-perfusion' [time] is about 100 minutes." LoCicero would like to see that time frame include prehospital care, so that patients are in the cath lab within 90 minutes of paramedics arriving at their sides.

     Capt. Bill Wade has been with Tampa (FL) Fire Rescue since 1981 and has been involved with the fire and EMS profession since 1973. He has been a firefighter, paramedic and hazmat team member, as well as serving on TFR's tactical medic response team. For 10 years he has been the department's public information officer. He has also served as a faculty member for a local community college EMS program.

     While Levine lay on his stretcher in the back of the rescue car, he heard the paramedic crew say something about "e-mailing it now." He doesn't remember much else. Just as the rescue car reached St. Joseph's, his heart stopped. The rescue crew defibrillated Levine and got it beating again. He was rushed directly to the cath lab, where PCI opened his blocked cardiac arteries and got blood flowing to the heart muscle again.

     About three weeks after his heart attack, David Levine walked back into his office to a standing ovation from his coworkers.