Paramedics Read ECGs, Triage Patients to Specialty Hospital

While the general attitude among U.S. emergency physicians seems to be that paramedics should do less in the field, not more, across the border in Ottawa, Canada, EMTs trained in reading electrocardiograms have been making decisions on their own where to take heart attack patients. For the past year, the paramedics have chosen between the nearest hospital or a special unit of the University of Ottawa Heart Institute where primary percutaneous coronary interventions are performed. And the experiment seems to be paying off. Mortality among the patients taken directly to the specialty hospital was about 1.9 percent among the 108 heart attack patients transported to the unit, compared with 8.9 percent in-hospital mortality among 225 patients with ST-elevation myocardial infarction. “That difference was statistically significant,” said Michel Le May, MD, the director of the Coronary Care Unit Research Group at the University of Ottawa Heart Institute and an associate professor of medicine at the University of Ottawa. “There were 20 patients who died in the control group, and there were two patients who died in the paramedic group. We feel that these numbers are real.” Mortality among the patients taken to a specialty hospital was 1.9%, compared with 8.9% for patients taken to the nearest hospital The results have been sustained through 2006, Dr. Le May said, partly because of the program's simplicity. “Paramedics are bright young people, and they are quite willing to come up to the challenge and learn how to use the electrocardiogram,” he said. Dr. Le May also noted that the door-to-balloon times were cut in half from 125 minutes to 63 minutes. “This is important because we know that if we can reduce the door-to-balloon time, we can reduce mortality,” he said. “We know that time is myocardium.” The patients who were brought to the specialty hospital by the advanced care paramedics also stayed in the hospital for shorter periods of time, on average four days, than the patients who arrived in traditional fashion, who stayed for six days. “ST-elevation myocardial infarction is a type of heart attack that is truly life-threatening,” said Dr. Le May, explaining why the Ottawa medical establishment tried to find a better way to treat these patients. Because STEMI is most often caused by coronary artery clots, which can be successfully opened with primary angioplasty, Dr. Le May and colleagues concentrated on ways to get patients to the catheterization laboratory sooner. They took a page from European emergency treatment procedures, noting that in some countries there, physicians ride in ambulances to treat patients en route to a hospital. Reading the ECG Instead of putting doctors on the ambulance, the Ottawa group decided to train the paramedics to read a 12-lead electrocardiogram and to recognize STEMI. If they spotted that tracing on the electrocardiogram, the patient was taken directly to the Ottawa Heart Institute where an angioplasty team was alerted so it could be standing by when the patient arrived. “Traditionally there have been two methods in the past few years that we have been using to open up the artery, either clotbusters or angioplasty and stents,” Dr. Le May said when presenting his study at the 55th annual meeting of the American College of Cardiology. “STEMI is usually diagnosed in the hospital when the patient is transported to the hospital or walks into the emergency room,” he explained. “We know that the patients who call 9–1–1 are the patients who are a little bit sicker. We know that there is value in obtaining a prehospital electrocardiogram. “That electrocardiogram can be sent by telemedicine to a hospital center. The downside to that is that you can have transmission failures in about 20 percent of the cases. Plus you need somebody at the end of the line, somebody like a base hospital physician who is going to read the base electrocardiogram and then give you some feedback in order to tell you whether or not you should bring that patient to the specialized center for treatment.” In Ottawa, advanced care paramedics, similar to those in the United States who are trained in cardiac life support, were designated as the group to learn how to read electrocardiograms in the field. “We spent about a year training these people at reading the electrocardiograms, and we tested them and we found they had a positive accuracy of 82% and a negative accuracy of 99%,” Dr. Le May said. “What that means is that they will miss on the electrocardiograms from time to time and bring in patients with an ST-elevation on an electrocardiogram that doesn't turn out to be a heart attack, but the patient is still coming to the hospital. What we do know from the negative predictive value is that they rarely miss a heart attack. So those patients who have a heart attack are going to be brought to a specialized center where they can be treated.” Turf Battles After training the paramedics, the team then had to face its toughest struggles: changing local laws and eliminating turf battles. “Once we knew our paramedics were good at interpreting electrocardiograms,” Dr. Le May said, “we developed a STEMI program. In order to develop the STEMI program, we had to consult with our hospitals within the city. There is an ambulance act within Ontario that stipulates that you have to bring the heart attack patient to the nearest hospital. We had to have board meetings, we got our chiefs together, we got the CEOs, the cardiologists, the emergency physicians to all get in agreement that we should take all these heart attack patients to the heart institute and offer them all primary percutaneous coronary intervention.” Now that the program is in place, paramedics in the field obtain an electrocardiogram before they call the Ottawa Heart Institute. “We are doing this 24/7,” Dr. Le May said. “They notify the receptionist on a special dedicated phone. Once the receptionist knows the paramedics are coming in with a STEMI, she will ring a code. The STEMI code allows people to gather in the STEMI room, which is located in the cath lab. We will find a cardiologist who will be appointed to do the angiogram. Our success rate at angiography and doing angioplasty was 94 percent successful in these people.” Paul Douglass, MD, the chief of cardiology and the director of cardiovascular services at Atlanta Medical Center and a clinical assistant professor at the Morehouse School of Medicine, said the study shows that patients fare better when they receive treatment more quickly. “Here in Atlanta we have 20 different ambulances and to get them all to cooperate and to bring patients to hospitals that are equipped to deliver this type of service is a real challenge,” he said. Dr. Le May said the key to creating a successful model for transporting patients to the appropriate hospital requires that the champions of the proposal develop a consensus. “We can say that trained paramedics in the field can recognize patients having a heart attack,” he said. “You can develop a program where they independently identify that patient and decide to refer that patient to a specialized center. You can reduce your door-to-balloon time. The bottom line is you can reduce mortality.” Comments about this article? Write to EMN at[email protected].

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