The Lived Experience of Prehospital ECG in Rural Emergency Care. Ann Vreeland DNP, APRN, CNP, EMT-B Jason Lenz APRN, CNP

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1 The Lived Experience of Prehospital ECG in Rural Emergency Care Ann Vreeland DNP, APRN, CNP, EMT-B Jason Lenz APRN, CNP

2 Agency Hoyt Lakes Ambulance service in cooperation with the Northern Pines Medical Center located in northeastern Minnesota Professional team includes EMTs, ED staff (MD, RN, CNPs, and PAs), STEMI coordinator for Essentia Health, and Information Technology staff

3 Rural St. Louis County Basic Life Support Ambulance Service Critical Access Hospital within a healthcare system

4 Introduction Coronary heart disease: Leading cause of mortality in the United States ST-Elevated Myocardial Infarction (STEMI) accounts for 25-40%of Acute Coronary Syndrome (ACS) in the United States Timely administration of either angioplasty or a thrombolytic agent improves outcomes for patients

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9 Performance Measures Reperfusion therapy for patients with STEMI. The bold arrows and boxes are the preferred strategies. (ACC/AHA 2013)

10 Problem Summary Despite evidence that earlier time of treatment from onset reduces mortality, time-to-treatment remains prolonged Critical access hospitals meet optimal performance on the process measures for AMIs 91% of the time compared to non- CAHs which met this measure 97.8% of the time

11 Current Data

12 Literature Review Summary Utilizing prehospital emergency services to diagnose and triage STEMI patients as part of a system of care has been suggested to help improve time-to-treatment

13 Literature Review Summary Prehospital ECGs have been shown to shorten the time-to-reperfusion in patients experiencing STEMI Prehospital ECGs alone (not a part of system of care) are not as effective when compared with prehospital ECGs with early notification of the receiving hospital

14 Literature Review Summary The ability to transmit and accurately interpret the transmitted prehospital ECG is a feasible option for early notification Suggested that prehospital ECG may lower mortality and morbidity, more studies are required

15 Literature Review Summary Prehospital ECG recommended in the national guidelines from the American Heart Association Studies have shown that reductions in doorto-intervention times have been shown when prehospital ECG used to activate the catheterization laboratory while patient is enroute to the hospital despite this:

16 Literature Review Summary Prehospital ECGs were recorded in less than 10% of STEMI patients When used, the information is not translated into action or coordinated with a system of care to decrease delays in reperfusion therapy

17 Literature Review Summary Limited research has been done on the use of prehospital ECG by basic life support (BLS) providers Rural areas provide primarily BLS ambulance services, usually by volunteers supplemented by a relatively small number of advanced life support (ALS) providers

18 Recommendations: The American Heart Association 2013 All communities should create and maintain a regional system of STEMI care Performance of a 12-lead Electrocardiogram (ECG) by prehospital Emergency Medical Services (EMS) at the site of First Medical Contact (FMC) with symptoms of STEMI

19 Mission Statement Improve the care of the STEMI patient transported to the Northern Pines Medical Center by the Hoyt Lakes Ambulance Service by initiating the transmission of prehospital ECG.

20 IMPLEMENTATION & TRAINING

21 Key community leaders were informed and allowed input Medical Director Director of Nursing Ambulance service officers Tri-City Ambulance Medical Staff

22 Monitor with ECG and transmission capabilities Completion of the competency on the use of the MRx Heart Start monitor.

23 STEMI Training Attend STEMI Boot Camp sponsored by Essentia Health or on-site training by Jason Lenz APRN, CNP

24 The America Heart Association (AHA) course titled, Learn Rapid STEMI ID STEMI Training

25 Lead Placement All EMT s demonstrated correct lead placement on three different occasions on a live volunteer or manikin.

26 INDICATIONS Inclusion Criteria Patients 18 years of age or older with: Chest Pain Moderate or severe respiratory distress Symptoms similar to previous angina or myocardial infarction Syncope or near syncope As directed by medical control Exclusion Criteria Symptoms greater than 6 hours Trauma patients Patients who are: Unconscious Sedated Require cardiopulmonary resuscitation Transport time of 5 minutes or less Younger than 18

27 Possible STEMI patient Prehospital ECG ECG Transmitted to CAH from MRx via Bluetooth phone ECG received by (md, DON, project lead ECG prints at CAH nursing station ECG read by CAH MD YES STEMI? Notify PCI capable hospital and expedite patient transport to PCI hospital NO Treat at CAH

28

29 EVALUATION Three month evaluation period Evaluation included: Number of successful versus attempted ECG transmissions If the use of the prehospital ECG by the BLS service decreases door to intervention times in STEMI patients in a rural healthcare setting

30 EVALUATION 90% of eligible patients will have received a prehospital ECG transmitted successfully to the CAH Goal met when 12 of 13 eligible patients received a prehospital ECG transmitted successfully to the CAH (92%)

31 CASE STUDIES

32 STEMI 83 y/o female patient called 911 after 1 hour of chest pain 12-lead transmitted to CAH ER STEMI confirmed Bypassed rural hospitals EMS first medical contact to device time 98 minutes!

33 Findings EMT on the BLS ambulance service can identify the indications for a prehospital ECG Focus was on the importance of the prehospital ECG as part of a system of care EMTs had the ability to correctly place leads to complete an ECG in the field

34 Findings Successful transmission of the prehospital ECG Technically feasible Reduces time to primary percutaneous intervention Reliable in the diagnosis of STEMI May be more cost-effective than training of prehospital providers alone Benefit reaches beyond STEMI

35

36 Findings

37 This clinical project showed that even though cellular coverage areas are historically better in urban areas, transmission of a prehospital ECG is technically feasible in rural areas. Findings

38 Barriers/Unanticipated Events

39 QUESTIONS

40 References Adams, G., Abusaid, G., Lee, B., Maynard, C., Campbell, P., Wagner, G., et al. (2010). From theory to practice: Implementation of pre-hospital electrocardiogram transmission in ST-elevation myocardial infarction A multicenter experience. Journal of Invasive Cardiology, 22(11), Afolabi, B. A., Novaro, G. M., Pinski, S. L., Fromkin, K. R., & Bush, H. S. (2007). Use of the prehospital ECG improves door-to-balloon times in ST segment elevation myocardial infarction irrespective of time of day or day of week. Emergency Medicine Journal, 24, Retrieved from American College of Cardiology/American Heart Association Task Force on Practice Guidelines. (2013). ACC/AHA guidelines for the management of patients with STelevation myocardial infarction-executive summary: A report of the American College of Cardiology/American Heart Association task force on practice guidelines. Circulation: Journal of the American Heart Association, 127, Retrieved from Baliga, R. R. (2011). Quality of care and outcome in critical access rural hospitals. Cardiology Review,

41 Barbagelata, A., Perna, E. R., Clemmensen, P., Uretsky, B. F., Cimbaro Canella, J. P., Califf, R. M.,... Birnbaum, Y. (2007). Time to reperfusion in acute myocardial infarction. It is time to reduce it! Journal of Electrocardiology, 40, Retrieved from Brainard, A. H., Raynovich, W., Tandberg, D., & Bedrick, E. (2005). The prehospital 12- lead electrocardiogram s effect on time to initiation of reperfusion therapy: A systemic review and meta-analysis of existing literature. American Journal of Emergency Medicine, 23(3), Retrieved from Camp-Rogers, T., Dante, S., Kontos, M. C., Roberts, C. S., Kreisa, L., & Kurz, M. C. (2011). The impact of prehospital activation of the cardiac catheterization team on time to treatment for patients presenting with ST-segment-elevation myocardial infarction. American Journal of Emergency Medicine, 29, Retrieved from Curtis, J. P., Portnay, E. L., Wang, Y., McNamara, R. L., Herrin, J., Bradley, E. H.,... Krumholz, H. M. (2006). The pre-hospital electrocardiogram and time to reperfusion in patients with acute myocardial infarction, : Findings from the National Registry of Myocardial Infarction-4. Journal of the American College of Cardiology, 47(8), Retrieved from

42 Daudelin, D. H., Sayah, A. J., Kwong, M., Restuccia, M. C., Porcaro, W. A., Ruthazer, R.,... Selker, H. P. (2010, May). Improving use of prehospital 12-lead electrocardiography for early identification and treatment of acute coronary syndrome and ST-elevation myocardial infarction. Circulatory Cardiovascular Quality Outcomes, 3(3), Retrieved from Dhruva, V. N., Abdelhadi, S. I., Anis, A., Gluckman, W., Hom, D., Dougan, W.,... Klapholz, M. (2007). ST-segment analysis using wireless technology in acute myocardial infarction (STAT-MI) trial. Journal of the American College of Cardiology, 50(6), Retrieved from Gonzalez, M. A., Satler, L. E., Rodrigo, M. E., Gaglia, M. A., Ben-Dor, I., Maluenda, G.,... Waksman, R. (2011). Cellular video-phone assisted transmission and interpretation of prehospital 12-lead electrocardiogram in acute ST-segment elevation myocardial infarction. Journal of Interventional Cardiology, 24(2), Retrieved from Joynt, K. E., Harris, Y., Orav, E. J., & Jha, A. K. (2011). Quality of care and patient outcomes in critical access hospitals. Journal of the American Medical Association, 306(1), Larson, D. M., Sharkey, S. W., Unger, B. T., & Henry, T. D. (2005). Implementation of acute myocardial infarction guidelines in community hospitals. Academic Emergency Medicine, 12(6), Retrieved from

43 Lee, C. H., Van Gelder, C. M., & Cone, D. C. (2010). Early cardiac catheterization laboratory activation by paramedics with ST-segment elevation myocardial infarction on prehospital 12-lead electrocardiograms. Prehospital Emergency Care, 14, Retrieved from Lloyd-Jones, D., Adams, R., Carnethon, M., De Simone, G., Ferguson, T., Flegal, K.,... Go, A. (2009). Heart disease and stroke statistics-2009 update: A report from the American Heart Association Statistics Committee and Stroke Statistics Subcommittee. Circulation, 3(119), Retrieved from Minnesota Emergency Medical Services Regulatory Board. (2013). Home page. Retrieved from Mischke, K., Zarse, M., Perkuhn, M., Knackstedt, C., Markus, K., Koos, R.,... Schauerte, P. (2005). Telephonic transmission of 12-lead electrocardiograms during acute myocardial infarction. Journal of Telemedicine and Telecare, 11, Morrison, L. J., Brooks, S., Sawadsky, B., McDonald, A., & Verbeek, P. R. (2006). Prehospital 12-lead electrocardiography impact on acute myocardial infarction treatment times and mortality: A systemic review. Academic Emergency Medicine, 13(1), Retrieved from

44 Moyer, P., Ornato, J. P., Brady, W. J., Jr., Davis, L. L., Ghaemmaghami, C. A., Gibler, W. B.,... Zane, R. D. (2007). Development of systems of care for ST-elevation myocardial infarction patients: The emergency medical services and emergency department perspective. Circulation, 116, Retrieved from /CIRCULATIONAHA Patel, M., Dunford, J. V., Aquilar, S., Castillo, E., Patel, E., Fisher, R.,... Mahmud, E. (2012). Pre-hospital electrocardiography by emergency medical personnel. Journal of the American College of Cardiology, 60(9), Retrieved from / /j.jacc Pitta, S. R., Myers, L. A., Bjerke, C. M., White, R. D., & Ting, H. H. (2010). Using prehospital electrocardiograms to improve door-to balloon time for transferred patients with ST-elevation myocardial infarction: A case of extreme performance. Circulation Cardiovascular Quality and Outcomes: Journal of the American Heart Association, 3, Retrieved from Schoenbaum, M. (2011). Critical access hospitals: Hubs for rural health care. Minnesota Medicine, Schwab, B., Katalinic, A., Richardt, G., Kurowski, V., Kruger, D., & Mortensen, K., et al. (2006). Validation of 12-lead tele-electrocardiogram transmission in the real life scenario of acute coronary syndrome. Journal of Telemedicine and Telecare, 12,

45 Sillesen, M., Sejersten, M., Strange, S., Nielsen, S. L., Lippert, F., & Clemmensen, P. (2008). Referral of patients with ST-segment elevation acute myocardial infarction directly to the catheterization suite based on prehospital transmission of 12-lead electrocardiogram. Journal of Electrocardiology, 41(1), Retrieved from Strauss, D. G., Sprague, P. Q., Underhill, K., Maynard, C., Adams, G. L., Kessenich, A.,... Wagner, G. S. (2007). Paramedic transtelephonic communication to cardiologist of clinical and electrocardiographic assessment for rapid reperfusion of ST-elevation myocardial infarction. Journal of Electrocardiology, 40(3), Retrieved from Swor, R., Hegerberg, S., McHugh-McNally, A., Goldstein, M., & McEachin, C. C. (2006). Prehospital 12-lead ECG: Efficacy or effectiveness? Prehospital Emergency Care, 10(3), Retrieved from Terkelsen, C. J., Norgaard, B. L., Lassen, J. F., Gerdes, J. C., Ankersen, J. P., Romer, F.,... Andersen, H. R. (2002). Telemedicine used for remote prehospital diagnosing in patients suspected of acute myocardial infarction. Journal of Internal Medicine, 252,

46 Ting, H. H., Krumholz, H. M., Bradley, E. H., Cone, D. C., Curtis, J. P., Drew, B. J.,... Schuur, J. D. (2008). Implementation and integration of prehospital ECGs into systems of care for acute coronary syndrome: A scientific statement from the American Heart Association Interdisciplinary Council on Quality of Care and Outcomes Research, Emergency Cardiovascular Care Committee, Council on Cardiovascular Nursing, and Council on Clinical Cardiology. Circulation: Journal of the American Heart Association, 118, Retrieved from Welsh, R. C., Ornato, J., & Armstrong, P. W. (2003). Prehospital management of acute ST-elevation myocardial infarction: A time for reappraisal in North America. American Heart Journal, 1-8. Retrieved from Werman, H. A., Newland, R., & Cotton, B. (2011). Transmission of 12-lead electrocardiographic tracings by emergency medical technician-basics and emergency medical technician-intermediates: A feasibility study. The American Journal of Emergency Medicine, 29, Retrieved from

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