31 * Ambulance triage of patients presenting urgently for permanent pacing

Abstract

Background: Previous retrospective audit of patients referred urgently for permanent pacing at our centre suggested that 60% of patients who were suitable for direct admission to a pacing centre could be identified at presentation with a saving of 4 bed days per patient, by eliminating admission to a non pacing centre first. Heart rate (HR) ≤50 bpm and/or atrioventricular block (AVB) were identified as triage criteria. Prospective evaluation of triage in the emergency department (ED) or emergency admission unit (EAU) in our referring hospital confirmed these findings, with 60 (60)% patients found suitable for direct referral in a year. We then tested whether these triage criteria could be applied by paramedics (rather than by doctors in the ED/EAU) called to patients subsequently referred for urgent pacing. Methods: The ambulance service paramedics agreed to use the system already in place for referring patient with ST elevation myocardial infarction for primary angioplasty. This includes sending a 12 lead ECG to the coronary care unit (CCU) of the pacing centre, and discussing the patient with the CCU coordinator by phone. For logistic reasons related to CCU beds, triage criteria were HR ≤50 bpm AND AVB, ratherthan the criteria tested before. Accepted patients were transferred directly to the pacing centre CCU; others were taken to the nearest ED. We evaluated this change in service prospectively. Results: 35 patients were accepted as urgent referrals for pacing in the first four months of this project. 19 were male, the mean age was 76.7 years. One patient was referred and accepted following a 999 call; he presented with syncope and an initial HR of 28 bpm, with complete AVB. 14 patients presented to primary care, and then to A&E or EAU. 9 of these had a HR ≤50 bpm. 13 patients were transported by the ambulance service; not all crews included paramedics. The table summarises the patient details. Only 26% of patients met the triage criteria, although 89% could be identifed at presentation as needing a pacemaker. Conclusions: Although we had predicted that 60% of patients presenting urgently for pacing could be identified at presentation, and 89% could have been identified in this cohort, only 1 was triaged by the ambulance service. The reasons for this were various: the triage criteria used were too strict, we underestimated the role of primary care in referring for urgent pacing, and triage was welcomed from one district only, and not from the whole of the region covered by ambulance service.