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Transmission of 12-lead electrocardiographic tracings by Emergency Medical Technician–Basics and Emergency Medical Technician–Intermediates: a feasibility study
American Journal of Emergency Medicine (2011) 29, 437–440
www.elsevier.com/locate/ajem
Brief Report
Transmission of 12-lead electrocardiographic tracings by Emergency Medical Technician–Basics and Emergency Medical Technician–Intermediates: a feasibility study☆ Howard A. Werman MD a,b,⁎, Robert Newland EMT-P c , Brad Cotton EMT-P, RN, MD c a
MedFlight, Columbus, OH 43235, USA Emergency Medicine, The Ohio State University, USA c Adena Regional Medical Center, USA b
Received 12 November 2009; revised 28 December 2009; accepted 21 January 2010
Abstract Introduction: Prehospital transmission of the electrocardiogram (ECG) in ST-elevation myocardial infarction patients has been shown to reduce door to treatment time and improve outcome. Acquisition of the ECG tracing is a paramedic skill, thus limiting the benefit of early ECG transmission to primarily urban areas. The purpose of this investigation was to determine whether prehospital ECGs could be transmitted by nonparamedic personnel. Methods: A prospective case series of consecutive patients with a chief complaint of chest pain was conducted. An ECG was transmitted on all eligible patients. Proper lead placement was verified, and the diagnostic quality of the ECG was assessed on emergency department arrival. Time on scene was recorded and compared with historical controls. Results: Ninety patients were enrolled in the study. An ECG was transmitted successfully in 89 (98.9%) of 90 patients. Accurate lead placement was noted in 89 (98.9%) of 90, and the ECG was of “diagnostic quality” in 85 (95.5%) of 89 patients. There was no increase in scene time during the study period. Conclusion: Prehospital transmission of diagnostic-quality ECG can be reliably performed by nonparamedic providers. © 2011 Elsevier Inc. All rights reserved.
1. Introduction Early diagnosis and subsequent treatment of ST-elevation myocardial infarction (STEMI) improve a patient's chances for a successful recovery and decrease mortality. Obtaining a ☆
Presented at the 2008 NAEMSP Annual Meeting, Phoenix, AZ, January 2008. ⁎ Corresponding author. MedFlight, Columbus, OH 43235, USA. Tel.: +1 614 734 8025. E-mail address: [email protected] (H.A. Werman). 0735-6757/$ – see front matter © 2011 Elsevier Inc. All rights reserved. doi:10.1016/j.ajem.2010.01.015
prehospital electrocardiogram (ECG) has emerged as a major strategy toward reducing “door to drug” and “door to balloon” time [1-5]. Fewer than 10% of STEMI patients have a prehospital ECG obtained [6,7]. This is particularly problematic in rural areas where Emergency Medical Services (EMS) care may be provided by Emergency Medical Technician–Basics (EMT-Bs) and Emergency Medical Technician–Intermediates (EMT-Is). The acquisition and transmission of a 12-lead ECG are not currently part of their current scope of practice. Current ECG technology allows digital transmission of the ECG image directly to the
438 receiving hospital [8,9]. In theory, any trained prehospital provider can be taught to obtain and transmit these images. The purpose of the current investigation was to determine whether the transmission of prehospital ECGs by rural EMTBs and EMT-Is was feasible.
H.A. Werman et al. quality of the field-transmitted ECG. The study protocol was reviewed and approved by the Medical Oversight Committee of the Ohio EMS Board within the Ohio Department of Public Safety.
3. Results 2. Methods 2.1. Study design This study was a prospective, unblinded case series of consecutive adult patients in a rural county in Ohio transported to the regional community hospital by designated EMS units. It is a 238-bed community hospital with cardiac catheterization and open-heart surgical capabilities operational 24 hours daily, every day of the year. The data were collected from July 1, 2005, to July 1, 2006. All patients with symptoms consistent with acute coronary syndrome including chest pain, chest discomfort, dyspnea, or other symptoms (nausea, diaphoresis, palpitations) and who had an expected transport time of greater than 10 minutes were eligible for inclusion. Five local volunteer EMS units were selected from the county EMS. A formal 4-hour training program on the study protocol was conducted with each of the volunteer services. Training included operation of the satellite telephone in conjunction with the monitor defibrillator, ECG lead placement using a template (see below), instructions in ECG transmission, inhospital verification procedures for proper lead placement, and training in the countywide chest pain protocols. No training on ECG interpretation was provided. A manufactured ECG lead placement system (Precordial Overlay System, CardioQuickSys, LLC, Sharonville, OH) was used to assist EMTs in proper lead placement. The EMS units used either LifePak-12 (Medtronic, Minneapolis, MN) or Zoll M Series (Zoll Medical Corp, Chelmsford, MA) monitor/defibrillators. The ECG was transmitted to a receiving unit. The automatic ECG impression function on the monitors was disabled for the study. The ECG leads remained on the patient until arrival in the ED. At that time, another ECG was completed and lead placement was assessed for accuracy by trained respiratory therapy staff or emergency department (ED) patient care coordinators. Other data were collected including time on scene, transport time, and diagnostic quality of transmitted 12-lead ECG. The diagnostic quality of transmitted image was graded as excellent, good, fair, or unsatisfactory by the receiving emergency physician or cardiologist; the quality was determined by comparing the field ECG to the ED ECG tracings.
2.2. Data analysis The primary outcome measures were time on scene, transport time, lead placement accuracy, and diagnostic
Fifty-five volunteer EMTs completed these training sessions for 12-lead ECG electrode and cable placement, use of cardiac monitors/defibrillators, and operation/use of satellite phones. Ninety consecutive adult patients with symptoms of acute coronary syndrome being transported to the hospital were included in the study. The average on scene time for the study period was 19.15 ± 14 minutes. This compares to an average on scene time of 19.60 ± 12 minutes during calendar year 2004 for the same EMS units before initiation of this project. The average transport time was 25.06 ± 9 minutes. Finally, the average time from ECG acquisition to transmission was 6.2 ± 5 minutes. With regard to the use of the ECG overlay system, the ECG electrodes were found to be accurately placed in 89 (99%) of 90 patients. In the one remaining patient, the ECG overlay system was removed before assessment of lead accuracy. In 83 patients (93%), all of the overlay electrodes were correctly placed. In 2 patients, lead V4 did not consistently display; in another patient, the arm limb leads were placed on the chest; and in 3 additional patients, leads V1 through V3 had poor skin contact due to moisture. Of the 90 patients enrolled in the study, a successful ECG transmission was achieved in 89 patients. In one case, the transmitting EMS unit accidentally (but successfully) transmitted the Patient Vital Summary Report. Eighty-five (95.5%) of the 89 successfully transmitted ECG tracings were rated as “readable diagnostic quality,” meaning that they received a rating of excellent, good, or fair. Eighty were rated as “excellent,” 2 were “good,” and 3 were rated as “fair” by the receiving emergency physician or cardiologist. Four tracings were felt to be “unsatisfactory,” meaning that the quality of the tracing was such that no diagnostic interpretation could be made.
4. Discussion In the United States, approximately 400 000 patients suffer from acute STEMI. These patients are at significant risk of death and disability. Transmission of the prehospital ECG has emerged as a major strategy in achieving a door to balloon time of 90 minutes or less [2,5] and is a class I recommendation from the American Heart Association [10]. Emergency care systems are being developed to extend the benefits of early percutaneous coronary intervention (PCI)
Transmission of 12-lead ECGs by EMT-Bs and EMT-Is and fibrinolysis to patients in more rural locations [11,12]. A unique limitation to full implementation is the provision of care by basic life support–trained providers who do not possess training in the use of ECG monitor/defibrillators as part of their normal scope of practice. We have demonstrated that, with minimal training, EMT-B and EMT-I personnel can be taught to transmit an ECG from the field to a PCI-capable facility reliably and with reasonable quality. Only one other study has focused on the ability of basiclevel providers to acquire an ECG tracing in the field [13]. This study was designed only to assess the increase in scene time as well as the appropriateness of the acquired prehospital ECG. These authors found that the mean scene time increased by 5 minutes (95% confidence interval, 3.66.4). They also found that the ECG was felt to be useful in 93.6% of cases. Our study found no difference in scene time, which may be explained by the fact that the ambulance units were capable of ECG transmission during transport via satellite technology. The ability to extend the benefits of prehospital ECG to more rural environments may help to reduce the documented disparity in health outcomes between rural and urban environments. Establishing a diagnosis of STEMI in the rural setting, however, is only one element of developing comprehensive solutions for providing rapid revascularization to eligible patients. Such strategies must consider time from symptom onset, duration of transport to closest PCIcapable and non–PCI-capable hospitals, and availability of advanced life support ground or air resources [14]. It should be noted that the average door to catheterization laboratory time for the 65 STEMI patients presenting to our ED was 74 minutes and the average door to balloon time was 99 minutes compared with 36 and 68 minutes, respectively, for 4 STEMI patients identified during our trial. There are barriers to implementation of ECG transmission capabilities by rural EMS. The first major limitation is technology failures. We found satellite technology to be very reliable in our pilot study. Other studies, however, have found a transmission failure rate that has been noted to be as high as 33% [15,16]. The second barrier is time. Simply stated, some rural areas are located too far from PCI centers to reliably achieve a reasonable transport time for mechanical thrombolysis [14]. In these settings, pharmacologic thrombolysis may be the more timely option. Transmission of an ECG may still be useful in making rapid treatment and transport decisions. A third barrier is training. An important component of successful ECG transmission is to use this technology for patients in whom there is a high clinical suspicion of ACS. Broad transmission of the ECG in low-risk patients is likely to result in a high false-positive activation of the invasive cardiologists. The specific training requirement for rural EMTs was not addressed in this study. The final barrier to implementation of a basic life support ECG transmission program is cost. The total cost for this study was $29 300.00 including an ECG transmission
439 station, ECG lead overlays, fax modems, and satellite telephones. This is a significant investment for many rural ambulance services. A cost-benefit analysis should be conducted before widespread implementation is considered. It is worth noting that because of the success of our demonstration project, the State of Ohio Division of Emergency Medical Services has enacted a change in the scope of practice for EMT-Bs, allowing them to acquire and transmit ECGs [17].
4.1. Limitations There are several limitations in interpretation of our findings. The most important was the fact that this study was conducted with active medical oversight. Therefore, the results of our analysis including the low rate of transmission failure, the quality of the transmitted ECG images, and the lack of extended scene times may not be reproduced under “real-world” conditions.
4.2. Conclusion Prehospital ECGs can reliably and accurately be transmitted by EMT-B and EMT-I personnel in a rural setting. These ECGs are of sufficient diagnostic quality on which to make clinical decisions. Prehospital ECG transmission by nonparamedic personnel could potentially extend the benefits of reduced door to drug or door to balloon time to rural environments. Further study is needed to validate this assumption.
References [1] Ferguson JD, Brady WJ, Perron AD, Kielar ND, Benner JP, Currance SB, et al. The prehospital 12-lead electrocardiogram: impact on management of the out-of-hospital acute coronary syndrome patient. Am J Emerg Med 2003;21:136-42. [2] Morrison LJ, Brooks S, Sawadsky B, McDonald A, Verbeek PR. Prehospital 12-lead electrocardiography impact on acute myocardial infarction treatment times and mortality: a systematic review. Acad Emerg Med 2006;13:84-9. [3] Brown JP, Mahmud E, Dunford JV, Ben-Yehuda O. Effect of prehospital 12-lead electrocardiogram on activation of the cardiac catheterization laboratory and door-to-balloon time in ST-segment elevation acute myocardial infarction. Am J Cardiol 2008;101:158-61. [4] Sejersten M, Sillesen M, Hansen PR, Nielsen SL, Nielsen H, Trautner S, et al. Effect of treatment delay of prehospital teletransmission of 12lead electrocardiogram to a cardiology for immediate triage and direct referral of patients with ST-segment elevation acute myocardial infarction to primary percutaneous coronary intervention. Am J Cardiol 2008;101:941-6. [5] Brainard AH, Raynovich W, Tandberg D, Bedrick EJ. The prehospital 12-lead electrocardiogram's effect on time to initiation of reperfusion therapy: a systematic review and meta-analysis of existing literature. Am J Emerg Med 2005;23:351-6. [6] Canto JG, Rogers WJ, Bowlby LJ, French WJ, Pearce DJ, Weaver WD. The prehospital electrocardiogram in acute myocardial infarction:
440
[7]
[8]
[9]
[10]
H.A. Werman et al. is its full potential being realized? National Registry of Myocardial Infarction 2 Investigators. J Am Coll Cardiol 1997;29:498-505. Curtis JP, Portnay EL, Wang Y, McNamara RL, Herrin J, Bradley EH, et al. The pre-hospital electrocardiogram and time to reperfusion in patients with acute myocardial infarction, 2000-2002: findings from the National Registry of Myocardial Infarction–4. J Am Coll Cardiol 2006;47:1544-52. Adams GL, Campbell PT, Adams JM, Strauss DG, Wall K, Patterson J, et al. Effectiveness of prehospital wireless transmission of electrocardiograms to a cardiologist via hand-held device for patients with acute myocardial infarction (from the Timely Intervention in Myocardial Emergency, NorthEast Experience [TIME-NE]). Am J Cardiol 2006;98:1160-4. Strauss DG, Sprague PQ, Underhill K, Maynard C, Adams GL, Kessenich A, et al. Paramedic transtelephonic communication to cardiologist of clinical and electrocardiographic assessment for rapid reperfusion of ST-elevation myocardial infarction. J Electrocardiol 2007;40:265-70. Guidelines 2000 for cardiopulmonary resuscitation and emergency cardiovascular care. Part 7: the era of reperfusion: section 1: acute coronary syndromes (acute myocardial infarction). The American Heart Prehospital 12-lead electrocardiogram 355 Association in
[11]
[12]
[13] [14] [15] [16]
[17]
collaboration with the International Liaison Committee on Resuscitation. Circulation 2000;102(8 Suppl):I172-I203. Henry TD, Unger BT, Sharkey SW, Lips DL, Pedersen WR, Madison JD, et al. Design of a standardized system for transfer of patients with ST-elevation myocardial infarction for percutaneous coronary intervention. Am Heart J 2005;150:373-84. Ting HH, Rihal CS, Gersh BJ, Haro LH, Bjerke CM, Lennon RJ, et al. Regional systems of care to optimize timeliness of reperfusion therapy for ST-elevation myocardial infarction: the Mayo Clinic STEMI protocol. Circulation 2007;116:729-36. Provo TA, Frascone RJ. 12-Lead electrocardiograms during basic life support care. Prehosp Emerg Care 2004;8:212-6. Ting HH, Yang EH, Rihal CS. Reperfusion strategies for ST-segment elevation myocardial infarction. Ann Int Med 2006;145:610-7. Whitbread M, Leah V, Bell T, Coats TJ. Recognition of ST elevation by paramedics. Emerg Med J 2002;19:66-7. Welsh RC, Travers A, Senaratne M, Williams R, Armstrong PW. Feasibility and applicability of paramedic-based prehospital fibrinolysis in a large North American center. Am Heart J 2006;152: 1007-14. Ohio revised code section 4765.37—authorized services by EMTBasic available at http://codes.ohio.gov/orc/4765.37.
www.elsevier.com/locate/ajem
Brief Report
Transmission of 12-lead electrocardiographic tracings by Emergency Medical Technician–Basics and Emergency Medical Technician–Intermediates: a feasibility study☆ Howard A. Werman MD a,b,⁎, Robert Newland EMT-P c , Brad Cotton EMT-P, RN, MD c a
MedFlight, Columbus, OH 43235, USA Emergency Medicine, The Ohio State University, USA c Adena Regional Medical Center, USA b
Received 12 November 2009; revised 28 December 2009; accepted 21 January 2010
Abstract Introduction: Prehospital transmission of the electrocardiogram (ECG) in ST-elevation myocardial infarction patients has been shown to reduce door to treatment time and improve outcome. Acquisition of the ECG tracing is a paramedic skill, thus limiting the benefit of early ECG transmission to primarily urban areas. The purpose of this investigation was to determine whether prehospital ECGs could be transmitted by nonparamedic personnel. Methods: A prospective case series of consecutive patients with a chief complaint of chest pain was conducted. An ECG was transmitted on all eligible patients. Proper lead placement was verified, and the diagnostic quality of the ECG was assessed on emergency department arrival. Time on scene was recorded and compared with historical controls. Results: Ninety patients were enrolled in the study. An ECG was transmitted successfully in 89 (98.9%) of 90 patients. Accurate lead placement was noted in 89 (98.9%) of 90, and the ECG was of “diagnostic quality” in 85 (95.5%) of 89 patients. There was no increase in scene time during the study period. Conclusion: Prehospital transmission of diagnostic-quality ECG can be reliably performed by nonparamedic providers. © 2011 Elsevier Inc. All rights reserved.
1. Introduction Early diagnosis and subsequent treatment of ST-elevation myocardial infarction (STEMI) improve a patient's chances for a successful recovery and decrease mortality. Obtaining a ☆
Presented at the 2008 NAEMSP Annual Meeting, Phoenix, AZ, January 2008. ⁎ Corresponding author. MedFlight, Columbus, OH 43235, USA. Tel.: +1 614 734 8025. E-mail address: [email protected] (H.A. Werman). 0735-6757/$ – see front matter © 2011 Elsevier Inc. All rights reserved. doi:10.1016/j.ajem.2010.01.015
prehospital electrocardiogram (ECG) has emerged as a major strategy toward reducing “door to drug” and “door to balloon” time [1-5]. Fewer than 10% of STEMI patients have a prehospital ECG obtained [6,7]. This is particularly problematic in rural areas where Emergency Medical Services (EMS) care may be provided by Emergency Medical Technician–Basics (EMT-Bs) and Emergency Medical Technician–Intermediates (EMT-Is). The acquisition and transmission of a 12-lead ECG are not currently part of their current scope of practice. Current ECG technology allows digital transmission of the ECG image directly to the
438 receiving hospital [8,9]. In theory, any trained prehospital provider can be taught to obtain and transmit these images. The purpose of the current investigation was to determine whether the transmission of prehospital ECGs by rural EMTBs and EMT-Is was feasible.
H.A. Werman et al. quality of the field-transmitted ECG. The study protocol was reviewed and approved by the Medical Oversight Committee of the Ohio EMS Board within the Ohio Department of Public Safety.
3. Results 2. Methods 2.1. Study design This study was a prospective, unblinded case series of consecutive adult patients in a rural county in Ohio transported to the regional community hospital by designated EMS units. It is a 238-bed community hospital with cardiac catheterization and open-heart surgical capabilities operational 24 hours daily, every day of the year. The data were collected from July 1, 2005, to July 1, 2006. All patients with symptoms consistent with acute coronary syndrome including chest pain, chest discomfort, dyspnea, or other symptoms (nausea, diaphoresis, palpitations) and who had an expected transport time of greater than 10 minutes were eligible for inclusion. Five local volunteer EMS units were selected from the county EMS. A formal 4-hour training program on the study protocol was conducted with each of the volunteer services. Training included operation of the satellite telephone in conjunction with the monitor defibrillator, ECG lead placement using a template (see below), instructions in ECG transmission, inhospital verification procedures for proper lead placement, and training in the countywide chest pain protocols. No training on ECG interpretation was provided. A manufactured ECG lead placement system (Precordial Overlay System, CardioQuickSys, LLC, Sharonville, OH) was used to assist EMTs in proper lead placement. The EMS units used either LifePak-12 (Medtronic, Minneapolis, MN) or Zoll M Series (Zoll Medical Corp, Chelmsford, MA) monitor/defibrillators. The ECG was transmitted to a receiving unit. The automatic ECG impression function on the monitors was disabled for the study. The ECG leads remained on the patient until arrival in the ED. At that time, another ECG was completed and lead placement was assessed for accuracy by trained respiratory therapy staff or emergency department (ED) patient care coordinators. Other data were collected including time on scene, transport time, and diagnostic quality of transmitted 12-lead ECG. The diagnostic quality of transmitted image was graded as excellent, good, fair, or unsatisfactory by the receiving emergency physician or cardiologist; the quality was determined by comparing the field ECG to the ED ECG tracings.
2.2. Data analysis The primary outcome measures were time on scene, transport time, lead placement accuracy, and diagnostic
Fifty-five volunteer EMTs completed these training sessions for 12-lead ECG electrode and cable placement, use of cardiac monitors/defibrillators, and operation/use of satellite phones. Ninety consecutive adult patients with symptoms of acute coronary syndrome being transported to the hospital were included in the study. The average on scene time for the study period was 19.15 ± 14 minutes. This compares to an average on scene time of 19.60 ± 12 minutes during calendar year 2004 for the same EMS units before initiation of this project. The average transport time was 25.06 ± 9 minutes. Finally, the average time from ECG acquisition to transmission was 6.2 ± 5 minutes. With regard to the use of the ECG overlay system, the ECG electrodes were found to be accurately placed in 89 (99%) of 90 patients. In the one remaining patient, the ECG overlay system was removed before assessment of lead accuracy. In 83 patients (93%), all of the overlay electrodes were correctly placed. In 2 patients, lead V4 did not consistently display; in another patient, the arm limb leads were placed on the chest; and in 3 additional patients, leads V1 through V3 had poor skin contact due to moisture. Of the 90 patients enrolled in the study, a successful ECG transmission was achieved in 89 patients. In one case, the transmitting EMS unit accidentally (but successfully) transmitted the Patient Vital Summary Report. Eighty-five (95.5%) of the 89 successfully transmitted ECG tracings were rated as “readable diagnostic quality,” meaning that they received a rating of excellent, good, or fair. Eighty were rated as “excellent,” 2 were “good,” and 3 were rated as “fair” by the receiving emergency physician or cardiologist. Four tracings were felt to be “unsatisfactory,” meaning that the quality of the tracing was such that no diagnostic interpretation could be made.
4. Discussion In the United States, approximately 400 000 patients suffer from acute STEMI. These patients are at significant risk of death and disability. Transmission of the prehospital ECG has emerged as a major strategy in achieving a door to balloon time of 90 minutes or less [2,5] and is a class I recommendation from the American Heart Association [10]. Emergency care systems are being developed to extend the benefits of early percutaneous coronary intervention (PCI)
Transmission of 12-lead ECGs by EMT-Bs and EMT-Is and fibrinolysis to patients in more rural locations [11,12]. A unique limitation to full implementation is the provision of care by basic life support–trained providers who do not possess training in the use of ECG monitor/defibrillators as part of their normal scope of practice. We have demonstrated that, with minimal training, EMT-B and EMT-I personnel can be taught to transmit an ECG from the field to a PCI-capable facility reliably and with reasonable quality. Only one other study has focused on the ability of basiclevel providers to acquire an ECG tracing in the field [13]. This study was designed only to assess the increase in scene time as well as the appropriateness of the acquired prehospital ECG. These authors found that the mean scene time increased by 5 minutes (95% confidence interval, 3.66.4). They also found that the ECG was felt to be useful in 93.6% of cases. Our study found no difference in scene time, which may be explained by the fact that the ambulance units were capable of ECG transmission during transport via satellite technology. The ability to extend the benefits of prehospital ECG to more rural environments may help to reduce the documented disparity in health outcomes between rural and urban environments. Establishing a diagnosis of STEMI in the rural setting, however, is only one element of developing comprehensive solutions for providing rapid revascularization to eligible patients. Such strategies must consider time from symptom onset, duration of transport to closest PCIcapable and non–PCI-capable hospitals, and availability of advanced life support ground or air resources [14]. It should be noted that the average door to catheterization laboratory time for the 65 STEMI patients presenting to our ED was 74 minutes and the average door to balloon time was 99 minutes compared with 36 and 68 minutes, respectively, for 4 STEMI patients identified during our trial. There are barriers to implementation of ECG transmission capabilities by rural EMS. The first major limitation is technology failures. We found satellite technology to be very reliable in our pilot study. Other studies, however, have found a transmission failure rate that has been noted to be as high as 33% [15,16]. The second barrier is time. Simply stated, some rural areas are located too far from PCI centers to reliably achieve a reasonable transport time for mechanical thrombolysis [14]. In these settings, pharmacologic thrombolysis may be the more timely option. Transmission of an ECG may still be useful in making rapid treatment and transport decisions. A third barrier is training. An important component of successful ECG transmission is to use this technology for patients in whom there is a high clinical suspicion of ACS. Broad transmission of the ECG in low-risk patients is likely to result in a high false-positive activation of the invasive cardiologists. The specific training requirement for rural EMTs was not addressed in this study. The final barrier to implementation of a basic life support ECG transmission program is cost. The total cost for this study was $29 300.00 including an ECG transmission
439 station, ECG lead overlays, fax modems, and satellite telephones. This is a significant investment for many rural ambulance services. A cost-benefit analysis should be conducted before widespread implementation is considered. It is worth noting that because of the success of our demonstration project, the State of Ohio Division of Emergency Medical Services has enacted a change in the scope of practice for EMT-Bs, allowing them to acquire and transmit ECGs [17].
4.1. Limitations There are several limitations in interpretation of our findings. The most important was the fact that this study was conducted with active medical oversight. Therefore, the results of our analysis including the low rate of transmission failure, the quality of the transmitted ECG images, and the lack of extended scene times may not be reproduced under “real-world” conditions.
4.2. Conclusion Prehospital ECGs can reliably and accurately be transmitted by EMT-B and EMT-I personnel in a rural setting. These ECGs are of sufficient diagnostic quality on which to make clinical decisions. Prehospital ECG transmission by nonparamedic personnel could potentially extend the benefits of reduced door to drug or door to balloon time to rural environments. Further study is needed to validate this assumption.
References [1] Ferguson JD, Brady WJ, Perron AD, Kielar ND, Benner JP, Currance SB, et al. The prehospital 12-lead electrocardiogram: impact on management of the out-of-hospital acute coronary syndrome patient. Am J Emerg Med 2003;21:136-42. [2] Morrison LJ, Brooks S, Sawadsky B, McDonald A, Verbeek PR. Prehospital 12-lead electrocardiography impact on acute myocardial infarction treatment times and mortality: a systematic review. Acad Emerg Med 2006;13:84-9. [3] Brown JP, Mahmud E, Dunford JV, Ben-Yehuda O. Effect of prehospital 12-lead electrocardiogram on activation of the cardiac catheterization laboratory and door-to-balloon time in ST-segment elevation acute myocardial infarction. Am J Cardiol 2008;101:158-61. [4] Sejersten M, Sillesen M, Hansen PR, Nielsen SL, Nielsen H, Trautner S, et al. Effect of treatment delay of prehospital teletransmission of 12lead electrocardiogram to a cardiology for immediate triage and direct referral of patients with ST-segment elevation acute myocardial infarction to primary percutaneous coronary intervention. Am J Cardiol 2008;101:941-6. [5] Brainard AH, Raynovich W, Tandberg D, Bedrick EJ. The prehospital 12-lead electrocardiogram's effect on time to initiation of reperfusion therapy: a systematic review and meta-analysis of existing literature. Am J Emerg Med 2005;23:351-6. [6] Canto JG, Rogers WJ, Bowlby LJ, French WJ, Pearce DJ, Weaver WD. The prehospital electrocardiogram in acute myocardial infarction:
440
[7]
[8]
[9]
[10]
H.A. Werman et al. is its full potential being realized? National Registry of Myocardial Infarction 2 Investigators. J Am Coll Cardiol 1997;29:498-505. Curtis JP, Portnay EL, Wang Y, McNamara RL, Herrin J, Bradley EH, et al. The pre-hospital electrocardiogram and time to reperfusion in patients with acute myocardial infarction, 2000-2002: findings from the National Registry of Myocardial Infarction–4. J Am Coll Cardiol 2006;47:1544-52. Adams GL, Campbell PT, Adams JM, Strauss DG, Wall K, Patterson J, et al. Effectiveness of prehospital wireless transmission of electrocardiograms to a cardiologist via hand-held device for patients with acute myocardial infarction (from the Timely Intervention in Myocardial Emergency, NorthEast Experience [TIME-NE]). Am J Cardiol 2006;98:1160-4. Strauss DG, Sprague PQ, Underhill K, Maynard C, Adams GL, Kessenich A, et al. Paramedic transtelephonic communication to cardiologist of clinical and electrocardiographic assessment for rapid reperfusion of ST-elevation myocardial infarction. J Electrocardiol 2007;40:265-70. Guidelines 2000 for cardiopulmonary resuscitation and emergency cardiovascular care. Part 7: the era of reperfusion: section 1: acute coronary syndromes (acute myocardial infarction). The American Heart Prehospital 12-lead electrocardiogram 355 Association in
[11]
[12]
[13] [14] [15] [16]
[17]
collaboration with the International Liaison Committee on Resuscitation. Circulation 2000;102(8 Suppl):I172-I203. Henry TD, Unger BT, Sharkey SW, Lips DL, Pedersen WR, Madison JD, et al. Design of a standardized system for transfer of patients with ST-elevation myocardial infarction for percutaneous coronary intervention. Am Heart J 2005;150:373-84. Ting HH, Rihal CS, Gersh BJ, Haro LH, Bjerke CM, Lennon RJ, et al. Regional systems of care to optimize timeliness of reperfusion therapy for ST-elevation myocardial infarction: the Mayo Clinic STEMI protocol. Circulation 2007;116:729-36. Provo TA, Frascone RJ. 12-Lead electrocardiograms during basic life support care. Prehosp Emerg Care 2004;8:212-6. Ting HH, Yang EH, Rihal CS. Reperfusion strategies for ST-segment elevation myocardial infarction. Ann Int Med 2006;145:610-7. Whitbread M, Leah V, Bell T, Coats TJ. Recognition of ST elevation by paramedics. Emerg Med J 2002;19:66-7. Welsh RC, Travers A, Senaratne M, Williams R, Armstrong PW. Feasibility and applicability of paramedic-based prehospital fibrinolysis in a large North American center. Am Heart J 2006;152: 1007-14. Ohio revised code section 4765.37—authorized services by EMTBasic available at http://codes.ohio.gov/orc/4765.37.