A Simple Strategy Improves Prehospital Electrocardiogram Utilization and Hospital Treatment for Patients with Acute Coronary Syndrome (from the ST SMART Study)
Abstract:Although the American Heart Association recommends a prehospital electrocardiogram (ECG) be recorded for all patients who access the emergency medical system with symptoms of acute coronary syndrome (ACS), widespread use of prehospital ECG has not been achieved in the United States. A 5-year prospective randomized clinical trial was conducted in a predominately rural county in northern California to test a simple strategy for acquiring and transmitting prehospital ECGs that involved minimal paramedic training … Show more
“…140 By im plementation of a 12lead ECG from 5 electrodes and continuous STsegment monitoring transmitted via tele phone to the local EDs in northern California, patients (n=4219) with symptoms of ACS had a faster time to first intravenous drug; among patients with STEMI, there was a trend toward faster doortoballoon time and lower mortality risk. 141 In another prospective study of 678 patients with chest pain with suspected ACS, 26 patients had their therapy changed as a consequence of new injury or ischemia identified early through con tinuous STsegment monitoring. 142 It is reasonable to implement continuous ischemia monitoring with 12 leads to augment troponins in units with staff who are equipped with the appropriate education, protocol, and resources such as the ED and coronary care unit to improve early risk stratification for select patients with intermediate to high risk of ACS.…”
Background and Purpose:
This scientific statement provides an interprofessional, comprehensive review of evidence and recommendations for indications, duration, and implementation of continuous electro cardiographic monitoring of hospitalized patients. Since the original practice standards were published in 2004, new issues have emerged that need to be addressed: overuse of arrhythmia monitoring among a variety of patient populations, appropriate use of ischemia and QT-interval monitoring among select populations, alarm management, and documentation in electronic health records.
Methods:
Authors were commissioned by the American Heart Association and included experts from general cardiology, electrophysiology (adult and pediatric), and interventional cardiology, as well as a hospitalist and experts in alarm management. Strict adherence to the American Heart Association conflict of interest policy was maintained throughout the consensus process. Authors were assigned topics relevant to their areas of expertise, reviewed the literature with an emphasis on publications since the prior practice standards, and drafted recommendations on indications and duration for electrocardiographic monitoring in accordance with the American Heart Association Level of Evidence grading algorithm that was in place at the time of commissioning.
Results:
The comprehensive document is grouped into 5 sections: (1) Overview of Arrhythmia, Ischemia, and QTc Monitoring; (2) Recommendations for Indication and Duration of Electrocardiographic Monitoring presented by patient population; (3) Organizational Aspects: Alarm Management, Education of Staff, and Documentation; (4) Implementation of Practice Standards; and (5) Call for Research.
Conclusions:
Many of the recommendations are based on limited data, so authors conclude with specific questions for further research.
“…140 By im plementation of a 12lead ECG from 5 electrodes and continuous STsegment monitoring transmitted via tele phone to the local EDs in northern California, patients (n=4219) with symptoms of ACS had a faster time to first intravenous drug; among patients with STEMI, there was a trend toward faster doortoballoon time and lower mortality risk. 141 In another prospective study of 678 patients with chest pain with suspected ACS, 26 patients had their therapy changed as a consequence of new injury or ischemia identified early through con tinuous STsegment monitoring. 142 It is reasonable to implement continuous ischemia monitoring with 12 leads to augment troponins in units with staff who are equipped with the appropriate education, protocol, and resources such as the ED and coronary care unit to improve early risk stratification for select patients with intermediate to high risk of ACS.…”
Background and Purpose:
This scientific statement provides an interprofessional, comprehensive review of evidence and recommendations for indications, duration, and implementation of continuous electro cardiographic monitoring of hospitalized patients. Since the original practice standards were published in 2004, new issues have emerged that need to be addressed: overuse of arrhythmia monitoring among a variety of patient populations, appropriate use of ischemia and QT-interval monitoring among select populations, alarm management, and documentation in electronic health records.
Methods:
Authors were commissioned by the American Heart Association and included experts from general cardiology, electrophysiology (adult and pediatric), and interventional cardiology, as well as a hospitalist and experts in alarm management. Strict adherence to the American Heart Association conflict of interest policy was maintained throughout the consensus process. Authors were assigned topics relevant to their areas of expertise, reviewed the literature with an emphasis on publications since the prior practice standards, and drafted recommendations on indications and duration for electrocardiographic monitoring in accordance with the American Heart Association Level of Evidence grading algorithm that was in place at the time of commissioning.
Results:
The comprehensive document is grouped into 5 sections: (1) Overview of Arrhythmia, Ischemia, and QTc Monitoring; (2) Recommendations for Indication and Duration of Electrocardiographic Monitoring presented by patient population; (3) Organizational Aspects: Alarm Management, Education of Staff, and Documentation; (4) Implementation of Practice Standards; and (5) Call for Research.
Conclusions:
Many of the recommendations are based on limited data, so authors conclude with specific questions for further research.
“…Data for this retrospective analysis were obtained from the ST SMART (Synthesized Twelve-lead ST Monitoring and Real-time Tele-electrocardiography) Trial, a prospective randomized clinical trial in Santa Cruz County, California from 2003-2009 [12]. The primary aims of the ST SMART Trial were to compare patients with and without PH ECG ST-segment monitoring in paramedic scene time, hospital time to treatment, and survival over the period of the study.…”
Section: Methodsmentioning
confidence: 99%
“…Community assent was obtained by a front-page report in the county's newspaper ( Santa Cruz Sentinel, 2003) and by information posted on hospitals’ and EMS agencies’ websites [12]. Once study participants were comfortable and hemodynamically stable at the hospital, research nurses obtained written consent.…”
Section: Methodsmentioning
confidence: 99%
“…new onset shortness of breath not due to asthma or syncope not due to drug overdose or intoxication). Exclusion criteria were participants who were unwilling or unable to consent [12]. …”
Aims/Methods
We studied 735 patients who activated “911” for chest pain and/or anginal equivalent symptoms and received 12-lead ECG monitoring with specialized ischemia monitoring software in the ambulance. Prehospital electrocardiograms (PH ECG) were analyzed to determine the proportion of patients who present with completely normal PH ECG findings (absence of ischemia/infarction, arrhythmia, or any other abnormality) and to compare outcomes amongst patients with and without any PH ECG abnormality.
Results
Of 735 patients (mean age 70.5, 52.4% male), 68 (9.3%) patients had completely normal PH ECG findings. They experienced significantly less adverse hospital outcomes (12% vs 37%), length of stay (1.19 vs 3.86 days), and long-term mortality (9% vs 28%) than those with any PH ECG abnormality (p<.05).
Conclusion
Normal PH ECG findings are associated with better short and long-term outcomes in ambulance patients with ischemic symptoms. These findings may enhance early triage and risk stratification in emergency cardiac care.
“…At the opposite extreme are placed the grave cases that don't benefit in time about these kinds of centers. The mobile ECG platform provide in 1-2 minutes the main electrocardiograph shape, at home, and can alert the person if a dangerous situation is recorded, as emergency in cardiovascular diseases, (Drew, 2011).…”
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