Western Journal of Emergency Medicine: Integrating Emergency Care with Population Health

Introduction: We sought to determine the potential reduction in door-to-balloon time (DTB) byallowing paramedics to perform prehospital ST-Elevation Myocardial Infarction (STEMI) notificationusing brief communications via emergency medical services (EMS) 9-1-1 dispatchers as soon asthey saw a STEMI on 12-lead electrocardiogram (EKG). Our hypothesis was that earlier cardiaccatheterization lab (CCL) activation would improve overall DTB and avoid delays arising from onsceneissues or the time required to deliver a full report.

Methods: The study setting was a single suburban community teaching hospital, which is a regionalpercutaneous coronary intervention (PCI) center with more than 120,000 Emergency Department (ED)visits/year and is serviced by a single tiered-response, advanced life support (ALS) paramedic-levelagency. STEMI notifications from July 2009 to July 2012 occurred by either standard direct EMSto-physician notification or by immediate 9-1-1 dispatch notification. In the 9-1-1 dispatcher-aidednotification method, paramedics were asked to provide a brief one-sentence report using their lapelmicrophones upon immediate realization of a diagnostic EKG (usually within 1-2 minutes of patientcontact). This report to the 9-1-1 dispatcher included the patient’s sex, age, and cardiologist (if known).The dispatcher then called the emergency department attending and informed them that a STEMIwas being transported and that CCL activation was needed. We used retrospective chart review ofa consecutive sample of patients from an existing STEMI registry to determine whether there was astatistically significant difference in DTB between the groups.

Results: Eight hundred fifty-six total STEMI alert patients arrived by EMS during the study. Weexcluded 730 notifications due to events such as cardiac arrest, arrhythmia, death, resolution of EKGchanges and/or symptoms, cardiologist decision not to perform PCI, arrival as a transfer after priorstabilization at a referring facility or arriving by an EMS agency other than New Castle County EMS(NCC*EMS). Sixty-four (64) sequential patients from each group comprised the study sample. Theaverage DTB (SD) for the standard communication method was 57.6 minutes (17.9), while that fordispatcher-aided communication was 46.1 minutes (12.8), (mean difference 57.6-46.1 minutes=11.5minutes with a 95% CI [6.06,16.94]) p=0.0001. In the dispatcher-aided group, 92% of patients(59/64) met standards of ≤60 minute DTB time. Only 64% (41/64) met this goal in the standardcommunication group (p=0.0001).

Conclusion: Brief, early notification of STEMI by paramedics through 9-1-1 dispatchers achievesearlier CCL activation in a hospital system already using EMS-directed CCL activation. This practicesignificantly decreased DTB and yielded a higher percentage of patients meeting the DTB≤60minutes quality metric. [West J Emerg Med. 2015;16(3):472–480.]