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The Lived Experience of
Prehospital ECG in Rural
Emergency Care
Ann Vreeland DNP, APRN, CNP, EMT-B
Jason Lenz APRN, CNP
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
Rural St. Louis County
Basic Life Support
Ambulance Service
Critical Access
Hospital within a
healthcare system
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
Performance MeasuresReperfusion therapy for patients with STEMI. The bold arrows and boxes are the preferred
strategies.
(ACC/AHA 2013)
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
Current Data
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
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
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
Literature Review Summary
Prehospital ECG recommended in the
national guidelines from the American Heart
Association
Studies have shown that reductions in door-
to-intervention times have been shown
when prehospital ECG used to activate the
catheterization laboratory while patient is
enroute to the hospital despite this:
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
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
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
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.
IMPLEMENTATION & TRAINING
Key community leaders were
informed and allowed input
Medical Director
Director of Nursing
Ambulance service
officers
Tri-City Ambulance
Medical Staff
Monitor with ECG
and transmission
capabilities
Completion of the
competency on
the use of the
MRx Heart Start
monitor.
STEMI Training
Attend STEMI Boot Camp
sponsored by Essentia Health or
on-site training by Jason Lenz
APRN, CNP
STEMI Training
The America
Heart
Association
(AHA) course
titled, Learn
Rapid STEMI
ID
Lead Placement
All EMT’s
demonstrated
correct lead
placement on three
different occasions
on a live volunteer
or manikin.
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
Possible
STEMI
patient
Prehospital
ECG
ECG
Transmitted
to CAH from
MRx via
Bluetooth
phone
ECG prints
at CAH
nursing
station
ECG
received by
e-mail(MD,
DON,
project lead
ECG
read by
CAH MD
STEMI?
NO
Treat at CAH
YES
Notify PCI
capable
hospital and
expedite
patient
transport to
PCI hospital
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
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%)
CASE STUDIES
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!
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
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
Findings
Findings
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.
Barriers/Unanticipated Events
QUESTIONS
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