Out-of-Hospital STEMI Alert

The October 2006 issue of EMS Magazine featured an article on out-of-hospital 12-lead ECG programs and EMS systems that have created pathways to reduce the time interval between scene arrival and balloon inflation in the cardiac catheterization lab for patients with ST segment-elevation myocardial infarction (STEMI).¹ This issue features an article on Tampa Fire Rescue's 12-lead acquisition and transmission program (see Distant Early ECG Warning, p. 43). Entities such as the Centers for Medicare and Medicaid Services (CMS), the Joint Commission on the Accreditation of Healthcare Organizations (JCAHO) and various physician professional societies are now mandating reductions in the time it takes emergency departments to obtain 12-lead ECGs for potential acute coronary syndrome patients and in door-to-balloon times for emergency cardiac catheterization.

     A landmark article published in the New England Journal of Medicine last November quantified average time savings at 365 hospitals that had implemented changes to reduce the interval from patient arrival in the ED to balloon inflation in the cardiac cath lab (see Door-to-Balloon Time-Saving Tips, page 54).² The current standard is 90 minutes, which is quite a difficult mark to achieve unless there's a focused internal marketing campaign and a large expenditure of money. Of the authors' six recommendations, EMS acquisition, interpretation and transmission of 12-lead ECGs was found to save more time (15.4 minutes) than any other intervention except requiring cath lab personnel to respond to the hospital within 20 minutes of being paged. The potential impact of this research was compared to the invention of CPR in terms of the lives that could be saved if the recommendations were acted upon.

     One of my favorite citations to point out how ridiculous it is that we still don't have widespread capability to diagnose patients with STEMIs, institute aggressive EMS care and move them toward cath labs is from the premiere episode of Emergency! This show depicted what was actually happening in the early 1970s as Los Angeles County implemented one of the first ALS systems in the country. If you listen carefully to the discussion between Gage and DeSoto during their tour of the new Squad 51 (paramedic responder/light rescue vehicle), there's distinct mention that the Datascope cardiac monitor is capable of acquiring and transmitting full 12-lead ECGs.

     This show was filmed in the fall of 1971 and aired in January 1972. It is now 35 years later, and the discussion about whether to expend money on 12-lead-capable monitors, transmission software/hardware and training so that paramedics can interpret basic emergency presentations on a cardiogram still occurs as if this topic were completely new to out-of-hospital care. In the EMS community, we take for granted the ability to identify, triage and risk-stratify patients with traumatic injuries who are candidates for immediate referral to accredited trauma centers. Statewide trauma plans, designated Level 1 and Level 2 (and sometimes Level 3) trauma centers and regional EMS system protocols for trauma care are now considered the rule rather than the exception. Ambulance crews have been calling "trauma alerts" for almost 20 years (more in some systems), and this is now considered routine practice in all metropolitan areas of the United States. Why not so for cardiac care?

What's the Holdup?
     What's the magic bullet for building an out-of-hospital STEMI alert capability? There is none. What makes EMS system medical oversight interesting for those of us who pursue it as a career is that solving these complex systems issues is challenging and exciting, not to mention that more lives are typically saved by instituting systemwide policies than by our individual actions as physicians at the scenes of emergencies. Here are several factors or systems issues that are frequently impediments to instituting up-to-date prehospital "cath alert" protocols.

     From the EMS perspective, several objectives must be met before a system can be built to reliably transfer patients with STEMIs directly to facilities with interventional cardiologists and cath labs that are ramped up and waiting. Alternatively, transport to facilities that can deliver thrombolytic therapy is acceptable if air transport to a cath lab is unavailable or impractical. The same provisos about time saved relative to infusion of the thrombolytic agent apply.

     First and foremost, a mandate needs to be set by both the system or service medical director and the operations chief that optimization of this process is essential. Of course, this requires an understanding by both of national standards regarding emergency cardiac care set forth by organizations such as the American Heart Association, American College of Cardiology, American College of Emergency Physicians, National Association of EMS Physicians, etc. The drive to get to this point may be led internally by EMS system personnel or externally by concerned citizens in the community, although the latter is less likely. EMS administrators and municipal authorities who focus on the financial bottom line need to understand that at present, performance of 12-lead ECGs and aggressive management of patients with STEMIs is an unfunded mandate, since Medicare bundles these costs into the ALS base rate-i.e., there is no "pay for performance" incentive.

     If the EMS system is not a true system but is composed of a host of independent agencies, this mandate for progress may be more difficult to achieve. Agency ego wars and the ability (or lack thereof) of regional EMS authorities to mediate differences, achieve consensus, develop protocols and bring hospital representatives to the table in a friendly manner may create a morass that hinders EMS system improvements. It has never been proven whether medical oversight by committee-the typical model in these areas-rather than by a designated medical director with unilateral authority helps or hurts the chances for successful policy development.

     Next, they must be familiar with the current emergency medicine and EMS literature relative to the subject. We do not have time or space to delve into the dozens of articles on this topic; suffice it to say that two things are clear: The peer-reviewed medical literature demonstrates without a doubt that in high-performance EMS systems that have optimized their approaches to emergency cardiac care (read this carefully-just putting 12-lead machines in a mediocre EMS system may not improve anything!) and deliver patients to hospitals that have worked together with these systems to achieve short door-to-balloon times, this can be achieved successfully. The data on mortality reduction is a little less clear, but this is likely because few systems have existed long enough to document this data using themselves as controls. Secondly, the 2004 ACC/AHA Guidelines for the Management of Patients With STEMI listed EMS 12-lead acquisition and interpretation as a Class IIa recommendation,3 meaning there was enough evidence at that time to suggest it was probably the right thing to do. Given that the data reviewed for a 2004 document was based on studies done up to five years prior, it is likely that the updated version of this practice guideline will upgrade the recommendation to a Class I (definitely should be done) status.

     Obviously, EMS personnel must be appropriately trained in the acquisition, interpretation and/or transmission of the 12-lead ECGs (which should take place in initial paramedic education courses) and must have the technology to do it all. As well, there must be a robust CQI system in place to identify and correct deficiencies in the system. While it only takes one sentence to describe the hardware and software packages necessary to spool up a cath alert process, this typically represents a 5-8-figure sum of money and 12-18 months of planning and implementation prior to a go-live date. Options for ECG interpretation include training paramedics to read the study on their own and make a diagnosis without physician backup (no transmission), diagnosing suspected acute MIs and transmitting only those to a base station for physician overread (selected transmission), or mandating transmission of every 12-lead ECG acquired without any paramedic interpretation. Intense education must also be focused on the concept of transport to the closest appropriate facility, not just the closest facility.

     Finally, from the EMS perspective, when you spend this kind of money and effort perfecting a system, the rank-and-file EMS providers must live and die by the sword-i.e., they need to get with the program, abide by the protocols and go the extra mile to look for all possible STEMIs, treat them aggressively and refer them to designated healthcare facilities. Thus, the net needs to be cast wide when deciding who needs a 12-lead ECG other than the standard patient who actually complains of chest pain. Patients who are also candidates include those with shortness of breath, abdominal pain, weakness and general ill feeling for which there is no obvious noncardiac explanation.

Hospital Considerations
     From the hospital perspective, construction of an out-of-hospital cath alert protocol has more to do with the institution's strategic plan and finding key physician advocates than it does with equipment and technology. In the big scheme of things, capital purchases of telemetry equipment are small potatoes, although one complicating factor occurs in areas without true EMS systems (see any repeating themes here?), where there is no standardization of purchasing for EMS capital equipment such as cardiac monitors. If hospitals perceive that there's no uniformity and sense of purpose in the EMS community (i.e., they need to buy ECG transmission equipment from Physio-Control, ZOLL and Philips because ambulance services do not pursue joint purchasing), they may be less likely to move forward on such a project.

     There are more individuals in the hospital who have to be positively influenced to create a successful out-of-hospital cath alert program than in the EMS system. First, the project needs to be recommended and approved by the chair or director, clinical-operations doc, head nurse and EMS director within the emergency department. Next, the cardiologists need to be on board and agree to develop a system that does not impede rapid processing of the patient from the out-of-hospital phase through the ED phase (some hospitals are now moving patients directly from the field to the cath lab and bypassing the ED completely).

     Additionally, since most EMS medical directors are staff physicians in emergency departments, they must be familiar with JCAHO mandates for early acquisition and interpretation of 12-lead ECGs for patients with complaints that could be consistent with acute coronary syndrome. The new standard is 10 minutes from the time the patient arrives in triage or at the ambulance entrance. It is almost impossible to meet this requirement in busy urban EDs unless the EMS providers can do it before they arrive. Other recommendations are available in the New England Journal of Medicine article referenced at this beginning of this editorial.

     Hospital administration needs to recognize the inherent public-relations, financial and customer-service value in optimizing this system and then agree to fund the costs associated with its implementation. You'd think this would be a no-brainer, especially given that the costs to implement one of the top recommendations to reduce door-to-balloon times (paramedic 12-lead ECGs) are almost all borne by EMS. Secondly, lack of compliance by hospitals will negatively impact reimbursement, community perceptions of quality of care, and confidence in the institution in the eyes of EMS providers.

     However, this is not necessarily the case. Many urban EDs are in crisis due to overworked staff members, staffing deficiencies, overcrowding, lack of emergency medicine-trained physicians and nurses credentialed as CENs, poor throughput and a host of other factors. Poor staff morale can create a culture of apathy and indifference that's counterproductive to attempts to improve patient care-something that requires effort on the part of every individual. I have witnessed paramedic-acquired ECGs thrown in the trash, detailed EMS reports of critically ill patients with potential STEMIs ignored and other hostile EMS/hospital interface issues.

Conclusion
     Ultimately, the tail wagging the dog is what may have to drive improvements in emergency medical care if the house of medicine fails to act. Hopefully, a national sense of urgency concerning issues such as these will push everyone involved in the delivery of emergency medicine, in both the out-of-hospital and in-hospital environments, to work together to achieve the most important goal: decreased morbidity and mortality. To those on their way to meeting this goal, EMS Magazine salutes you. For those who need some help, attend EMS EXPO 2007, where we will have a roundtable discussion on this topic and attempt to develop universal solutions you can take home to your local systems.

References

1. Sullivan B, Rosenbaum RA. Time is muscle. Emerg Med Serv 35(10):78-83, 2006.
   
2. Bradley EH, et al. Strategies for reducing the door-to-balloon time in acute myocardial infarction. New Engl J Med 355:2,308-20, 2006.
   
3. Pollack CV, et al. 2004 American College of Cardiology/American Heart Association guidelines for the management of patients with ST-elevation myocardiac infarction: Implications for emergency department practice. Ann Emerg Med 45:363-76, 2005.