EMS Strategies to Achieve Ideal

Updated:Jul 11,2013

Mission: Lifeline has defined strategies for the ideal EMS including:

Initial Contact

By an EMT Basic or Intermediate Provider

  • 911 operator trained to recognize potential acute cardiac symptoms and dispatch appropriate EMS resources to potential STEMI patient
  • ECG equipment and personnel dispatched to allow for 12 lead ECG within a total scene time of  less than  or equal to 15 minutes
  • ECG acquisition to be extended to basic providers including EMT basic and first responders
  • ECG obtained on all patients with chest discomfort suspected to be of ischemic origin
  • In the field ECG (to be interpreted by receiving physician on arrival or by transmission)
  • Documentation of symptom onset
  • Scene time of less than 15 minutes
  • Patient stays on ambulance stretcher for STEMI evaluation for hospitals that routinely transfer all or some patients by same ambulance
     

By an EMT-Paramedic

In addition to above:

  • Training to diagnose STEMI by symptoms and ECG
  • In the field ECG with a goal scene time of 15 minutes (An ECG machine should be dispatched to all potential STEMI calls to meet this 15 minute window)
  • Administer reperfusion checklist (See tools)
  • If patient is fibrinolytic ineligible, EMS notifies and diverts to a STEMI-Receiving hospital, as long as transportation time < 90 minutes
  • Early notification of the receiving hospital on all STEMI patients prior to arrival that includes direct communication with the physician capable of activating a reperfusion plan regarding symptom onset, ECG findings, and reperfusion checklist in addition to:
    o Patient Age, gender, and DNR status
    o Time of onset of symptoms
    o Primary physician/cardiologist
    o Whether patient taking wafarin
    o Past hx of MI, PCI/stent/CABG, renal failure, contrast allergy
  • Administer aspirin (162 to 325 mg chewed) to chest pain patients suspected of having STEMI unless contraindicated or an adequate dose of immediate-release aspirin can be verified as taken
  • EMS data elements collected, made available to receiving hospitals via run event sheet, and reviewed on a regular basis regarding symptom onset, time of 1st medical contact, ECG performance and findings, and transportation complications including arrest and death


Patient Transfer

Inter-hospital Transfer
  • STEMI patient for reperfusion has same priority as 911 call and trauma.
  • Patient stays on EMS stretcher for STEMI evaluation for inter-hospital transfer.
  • Transfer plan including preferred transport modality and backup transport modality is established.
  • Transport directly to catheterization laboratory when laboratory is staffed and available for PCI without reevaluation in the ED.
  • When possible, minimize or avoid continuous IV infusions such as nitroglycerin or heparin .
  • Transfer protocol should focus on rapid transport to catheterization laboratory rather than pain relief with medications.
  • Transfer patients to STEMI-Receiving hospital with similar consideration to patient registration, bed availability, and accepting physician as trauma patients (use of dummy registration numbers, acceptance of all STEMI patients regardless of bed availability, and reliance on a single accepting physician that is on call 24 hours per day / 7 days per week).
  • When transporting a patient treated with fibrinolysis who has continued chest pain and < 50% ST resolution (in the lead showing the worst initial elevation) after 90 minutes following the initiation of fibrinolysis, notify the receiving hospital about the potential need for rescue angioplasty. 
  • Hospital records should be faxed to the receiving catheterization laboratory so as not to delay patient pickup.
  • EMTALA/COBRA/medical necessity of transfer form should be completed as soon as possible after the decision to transfer.

Helicopter Transfer
 
In addition to above:
 

  • Local EMS should generally be used if available and 30 minute transportation time to destination hospital.
  • Whenever possible, helipad adjacent to emergency department
  • Helicopter capable of transporting patients on ten minutes notice 24/7; When not available, alternate transport options identified
  • Immediately activate helicopter transport during initial communication between referring hospital ED and receiving hospital regarding the need for reperfusion.
  • Establish a system whereby all patient transfers of any type can be specified as time critical within one hour versus diversion possible

 For ED:
 

  • Establish reperfusion checklists, standard pharmacological regimens and order sets
  • Establish clinical pathways
  • Use of single call activation systems