A Statewide Assessment of Prehospital Electrocardiography Approaches of Acquisition and Interpretation for ST-Elevation Myocardial Infarction Based on Emergency Medical Services Characteristics

Abstract

Background: The American Heart Association recommends acquiring and interpreting prehospital electrocardiograms (ECG) for patients transported by Emergency Medical Services (EMS) to the emergency department with symptoms highly suspicious of acute coronary syndrome. If interpreted correctly, prehospital ECGs have the potential to improve early detection of ST-elevation myocardial infarction (STEMI) and inform prehospital activation of the cardiac catheterization laboratory, thus reducing total ischemic time and improving patient outcomes. Standardized protocols for prehospital ECG interpretation methods are lacking due to variations in EMS system design, training, and procedures. Objectives: We aimed to describe approaches for prehospital ECG interpretation in EMS systems across North Carolina (NC), and examine potential differences among systems. Methods: A 35-item internet survey was sent to all NC EMS systems (n = 99). Questions pertaining to prehospital ECG interpretation methods included: paramedic, computerized algorithm (i.e., software interpretation), combined approaches, and/or transmission for physician interpretation, transmission capability, cardiac catheterization laboratory activation, and EMS system characteristics (e.g. rural versus urban). Data were summarized and compared. Results: A total of 96 EMS systems across NC responded to the survey (97% response rate); of these, 69% were rural. EMS medical directors (53%) or EMS administrative directors (42%) completed the majority of surveys. While 91% of EMS systems had a prehospital ECG interpretation protocol in place, only 61% had a written cardiac catheterization laboratory activation policy. More than half (55%) of systems reported paramedic interpretation of prehospital ECGs, followed by a combined paramedic and software interpretation approach (39%), physician interpretation (4%), or software interpretation only approach (2%). Nearly 80% of EMS systems transmitted prehospital ECGs to receiving hospitals (always or sometimes), regardless of interpretation method. All EMS systems had some paid versus non-paid EMS personnel and the majority (86%) had both basic and advanced life support capabilities. Conclusions: Most NC EMS systems had a paramedic only ECG interpretation or paramedic in combination with a computerized algorithm approach. Very few used a physician read approach following transmission, even in rural service areas.