1. Very Rapid Treatment of STEMI: Utilizing Pre-Hospital ECGs to Bypass the Emergency Department Kenneth W. Baran, MD Medical Director for United Hospital’s Nasseff Heart Center Catheterization Lab

2. Very Rapid Treatment of STEMI Introduction PCI is the preferred treatment for acute STEMI when performed in a timely fashion.PCI is the preferred treatment for acute STEMI when performed in a timely fashion. The use of a 12 lead pre-hospital electrocardiogram (PH-ECG) has been proposed as a strategy to reduce EMS-to balloon (E2B) and door-to-balloon (D2B) times.The use of a 12 lead pre-hospital electrocardiogram (PH-ECG) has been proposed as a strategy to reduce EMS-to balloon (E2B) and door-to-balloon (D2B) times. Rapid identification of STEMI patients in the field facilitates transfer of patients directly to PCI capable hospitals.Rapid identification of STEMI patients in the field facilitates transfer of patients directly to PCI capable hospitals. In addition, early activation of the CV lab staff and the on-call interventional cardiologist may minimize delays in transporting patients from the ED to the CV lab.In addition, early activation of the CV lab staff and the on-call interventional cardiologist may minimize delays in transporting patients from the ED to the CV lab.

3. Very Rapid Treatment of STEMI Objectives We initiated a program to facilitate rapid transfer of STEMI patients from the pre-hospital setting to the CV lab by empowering EMS to interpret PH-ECGs and to activate the hospital CV lab staff prior to the patient’s arrival at our institution.We initiated a program to facilitate rapid transfer of STEMI patients from the pre-hospital setting to the CV lab by empowering EMS to interpret PH-ECGs and to activate the hospital CV lab staff prior to the patient’s arrival at our institution. A unique feature of our program was a time-saving strategy to transport patients from the pre-hospital setting directly to the CV lab, without stopping at any emergency department.A unique feature of our program was a time-saving strategy to transport patients from the pre-hospital setting directly to the CV lab, without stopping at any emergency department.

4. Very Rapid Treatment of STEMI Mechanisms Patients arrived at the CV lab via three different mechanismsPatients arrived at the CV lab via three different mechanisms  Direct transport from the pre hospital setting (home) to the CV lab  Transfer from referral hospital emergency department  Transport from emergency department at our institution

5. Very Rapid Treatment of STEMI Hypothesis We hypothesized that the accuracy of EMS interpretation of the PH-ECG, and therefore, the appropriateness of CV lab activation, would be comparable to the accuracy of ECG interpretation by MDs in the ED at our institution or by MDs at referral hospital EDs.We hypothesized that the accuracy of EMS interpretation of the PH-ECG, and therefore, the appropriateness of CV lab activation, would be comparable to the accuracy of ECG interpretation by MDs in the ED at our institution or by MDs at referral hospital EDs.

6. Very Rapid Treatment of STEMI Methods PARTICIPANTS EMS from 18 different organizations within a 45 mile radius of our institution participated in this pilot program.EMS from 18 different organizations within a 45 mile radius of our institution participated in this pilot program. 14 STEMI referral hospitals (SRH) without CV lab facilities also participated.14 STEMI referral hospitals (SRH) without CV lab facilities also participated. EMPOWERING EMS All participating EMS organizations had the ability to perform PH- ECGs, but several did not have fax transmission capabilities to have PH-ECGs over-read by ED MDs.All participating EMS organizations had the ability to perform PH- ECGs, but several did not have fax transmission capabilities to have PH-ECGs over-read by ED MDs. Therefore, we decided to empower EMS to interpret the PH-ECG and to activate the CV lab team when a STEMI was diagnosed.Therefore, we decided to empower EMS to interpret the PH-ECG and to activate the CV lab team when a STEMI was diagnosed. ED MD or cardiologist over-read or “prior approval” was not required.ED MD or cardiologist over-read or “prior approval” was not required.

7. Very Rapid Treatment of STEMI Methods SIMULTANEOUS ALERT SYSTEM A central paging system was used to simultaneously alert the on-call CV lab staff, on-call interventional cardiologist, our hospital ED and other hospital support personnel.A central paging system was used to simultaneously alert the on-call CV lab staff, on-call interventional cardiologist, our hospital ED and other hospital support personnel. BYPASSING THE ED Patients were transported directly to the CV lab without stopping at our ED if CV lab staff were on site and ready to receive the patient.Patients were transported directly to the CV lab without stopping at our ED if CV lab staff were on site and ready to receive the patient.

8. Very Rapid Treatment of STEMI Methods DIDACTIC AND REVIEW SESSIONS Numerous ECG interpretation didactic sessions were conducted for EMS by the authors.Numerous ECG interpretation didactic sessions were conducted for EMS by the authors. Accuracy of PH-ECG interpretation was adjudicated during weekly review sessions by a panel of up to 4 physicians including the authors and 2 non-interventional cardiologists.Accuracy of PH-ECG interpretation was adjudicated during weekly review sessions by a panel of up to 4 physicians including the authors and 2 non-interventional cardiologists. Accuracy rates for EMS, referring hospital EDs, our hospital ED and primary clinics are presented.Accuracy rates for EMS, referring hospital EDs, our hospital ED and primary clinics are presented.

9. Very Rapid Treatment of STEMI Results In a 24 month period from January 2007 to December 2008, the CV lab was activated 574 times: EMS 209, STEMI referral hospital EDs (SRH) 183, our STEMI referral center ED (SRC) 182.In a 24 month period from January 2007 to December 2008, the CV lab was activated 574 times: EMS 209, STEMI referral hospital EDs (SRH) 183, our STEMI referral center ED (SRC) 182.

10. Very Rapid Treatment of STEMI Patient Flow Diagram

11. Very Rapid Treatment of STEMI Results No significant differences were detected comparing the rates of accuracy of ECG interpretation among the groups (EMS 75%, SRH ED 81%, SRC ED 76%, p=0.24).No significant differences were detected comparing the rates of accuracy of ECG interpretation among the groups (EMS 75%, SRH ED 81%, SRC ED 76%, p=0.24).

12. Very Rapid Treatment of STEMI ECG Interpretation Accuracy Rates

13. Very Rapid Treatment of STEMI Results Door to balloon (D2B) time with EMS activation in the field (36 minutes) is significantly decreased compared to D2B time when the CV lab is activated through our ED (81 minutes) p<0.0001.Door to balloon (D2B) time with EMS activation in the field (36 minutes) is significantly decreased compared to D2B time when the CV lab is activated through our ED (81 minutes) p<0.0001. The ED bypass strategy reduced D2B more than 40 minutes regardless of time of presentation (daytime D2B 22 minutes v. 64 minutes, p<0.0001; after hours D2B 44 minutes v. 86 minutes, p<0.001)The ED bypass strategy reduced D2B more than 40 minutes regardless of time of presentation (daytime D2B 22 minutes v. 64 minutes, p<0.0001; after hours D2B 44 minutes v. 86 minutes, p<0.001)

14. Very Rapid Treatment of STEMI Mean Door to Balloon Times (D2B)

15. Very Rapid Treatment of STEMI Door to Balloon Times (Minutes)

16. Very Rapid Treatment of STEMI Results More patients in the EMS activation group received PCI within 90 minutesMore patients in the EMS activation group received PCI within 90 minutes Cumulative Door to Balloon (D2B) Rates

17. Very Rapid Treatment of STEMI Results 81% of patients in the EMS activation group had PCI performed within 90 minutes of EMS arrival at the pre-hospital setting81% of patients in the EMS activation group had PCI performed within 90 minutes of EMS arrival at the pre-hospital setting Cumulative Emergency Medical Services to Balloon (E2B) Rates

18. Very Rapid Treatment of STEMI Criteria for Emergency Medical Services Activation of Cardiac Catheterization Lab Acute onset of chest pain <6 hoursAcute onset of chest pain <6 hours Typical ST elevation >1mm in 2 contiguous leads; no wide QRS/LBBBTypical ST elevation >1mm in 2 contiguous leads; no wide QRS/LBBB Computerized ECG interpretation diagnosing acute MI helpful, but not mandatoryComputerized ECG interpretation diagnosing acute MI helpful, but not mandatory Nursing home patients should not be excluded; use clinical judgmentNursing home patients should not be excluded; use clinical judgment Age should not be an exclusionary factor; use clinical judgmentAge should not be an exclusionary factor; use clinical judgment Patient must be conscious, able to provide consent and reasonable historyPatient must be conscious, able to provide consent and reasonable history No obvious end stage diseaseNo obvious end stage disease

19. Very Rapid Treatment of STEMI Discussion Reducing time to treatment (E2B and D2B) requires a multifaceted effort to streamline the process of accurately diagnosing STEMI patients, rapidly transporting them to the CV lab, and performing PCI quickly. Pre-hospital diagnosis of STEMI with immediate activation of the CV lab team by EMS (without waiting for MD over-read of PH-ECG) has the potential to significantly reduce time to treatment. Delay in CV lab team readiness is minimized, especially after hours. Delegating the responsibility for ECG interpretation to EMS may result in increased rates of inaccurate diagnosis and unnecessary CV lab team activation. Our analysis, however, suggests that trained EMS personnel can accurately identify ECG patterns of STEMI at a rate comparable to ED MDs. Mean time to treatment (D2B) is significantly reduced when this strategy is utilized, resulting in a significantly higher percentage of patients who receive definitive treatment in less than 90 minutes.