264 Barriers to EMS Utilization During STEMI

Abstract

ST-segment elevation myocardial infarction (STEMI) remains a significant cause of mortality and morbidity. Despite documented benefits of Emergency Medical Services (EMS) transport to hospital for patients with STEMI, 40% still present via other methods and risk less timely care with poorer outcomes. Public service campaigns have targeted improving symptom awareness with limited effects on increasing EMS use in this population. This study sought to identify novel barriers to EMS use during STEMI using a unique study design. Fifty-eight sequential post-STEMI in-patients who met inclusion criteria were identified through the hospital STEMI registry (SMART-AMI - ethics board #02-245). Semi-structured interviews, with EMS users and non-EMS users, were conducted by non-medical personnel during the index hospital admission. Unstable patients or those unable to communicate were excluded. Barriers and facilitators of EMS use were identified from the transcripts and the rates of each were compared using the Fisher's exact test. Misinterpretation of symptoms was similar among EMS users and non-EMS users (55%, 53%). Self-rated severity of symptoms and presence of chest pain were not statistically different between the two groups. Perception that EMS would take longer than self-transport was evident in 53% of the non-EMS group and none of the EMS users (p=0.0001), and was the most frequent reason identified for non-EMS use. Perception that EMS was faster was noted in 46% of EMS users and 4% of non-EMS users (p=0.0002). We found that reluctance to be a burden on the health care system or to waste resources was endorsed by 35% of non-EMS users, compared to 3% of EMS users (p=0.0005). Embarrassment about EMS arriving to the office or home was common to both groups (19%, 17%; p=NS). Cost of EMS was not a prominent barrier with only 1 non-user endorsing. We identified several novel barriers to EMS use among the STEMI population, not previously targeted for intervention. Symptom identification has been previously described as a barrier, and has been the focus of past public campaigns, but this was not significantly different between EMS users and non-EMS users. Perception of the speed of EMS appears to have greatly impacted the decision to use EMS or self-transport. The concern over waste appears to be important and must be further explored. Public campaigns to address patient perception of EMS effectiveness and speed, as well as fear of wasting resources, may be effective in improving EMS utilization in the STEMI population.