Weekly Checks Improve Real-Time Prehospital ECG Transmission in Suspected STEMI

D’Arcy, Nicole; Bosson, Nichole; Kaji, Amy H.; Bui, Quang T.; French, William J.; Jue, Thomas; Elizarraraz, Yvonne; González, Natalia; García, José R.; Niemann, James T.

doi:10.1017/s1049023x18000341

Cited by 5 publications

(5 citation statements)

References 25 publications

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“…Table 3 shows the sensitivity, specificity, positive and negative likelihood radios, and AUC for each combination of the four criteria. The version of the algorithm using all four criteria (V1) had the highest positive likelihood ratio (95% CI, 210-595) and specificity (95% CI, 99.93-99.98), but the lowest sensitivity (95% CI, [11][12][13][14][15][16][17]. The AUC for this version was 0.57 (95% CI, 0.55-0.58; Figure 2).…”

Section: Resultsmentioning

confidence: 99%

“…11 Transmission of the ECG to a physician is a commonly applied solution, but this can be unreliable due to technical difficulties, such as poor wireless data signal. [12][13][14] Additionally, reliance on ED physician interpretation creates additional interruptions and increases physician workload, both of which are hypothesized to impact ED patient care. [15][16][17][18] Software algorithms are an easy solution, widely available on the cardiac monitor, and can be highly accurate.…”

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confidence: 99%

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A Novel Algorithm for Improving the Prehospital Diagnostic Accuracy of ST-Segment Elevation Myocardial Infarction

Goebel,

Westafer,

Ayala

et al. 2023

Prehosp. Disaster med.

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Introduction: Early detection of ST-segment elevation myocardial infarction (STEMI) on the prehospital electrocardiogram (ECG) improves patient outcomes. Current software algorithms optimize sensitivity but have a high false-positive rate. The authors propose an algorithm to improve the specificity of STEMI diagnosis in the prehospital setting. Methods: A dataset of prehospital ECGs with verified outcomes was used to validate an algorithm to identify true and false-positive software interpretations of STEMI. Four criteria implicated in prior research to differentiate STEMI true positives were applied: heart rate <130, QRS <100, verification of ST-segment elevation, and absence of artifact. The test characteristics were calculated and regression analysis was used to examine the association between the number of criteria included and test characteristics. Results: There were 44,611 cases available. Of these, 1,193 were identified as STEMI by the software interpretation. Applying all four criteria had the highest positive likelihood ratio of 353 (95% CI, 201-595) and specificity of 99.96% (95% CI, 99.93-99.98), but the lowest sensitivity (14%; 95% CI, 11-17) and worst negative likelihood ratio (0.86; 95% CI, 0.84-0.89). There was a strong correlation between increased positive likelihood ratio (r2 = 0.90) and specificity (r2 = 0.85) with increasing number of criteria. Conclusions: Prehospital ECGs with a high probability of true STEMI can be accurately identified using these four criteria: heart rate <130, QRS <100, verification of ST-segment elevation, and absence of artifact. Applying these criteria to prehospital ECGs with software interpretations of STEMI could decrease false-positive field activations, while also reducing the need to rely on transmission for physician over-read. This can have significant clinical and quality implications for Emergency Medical Services (EMS) systems.

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Section: Resultsmentioning

confidence: 99%

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confidence: 99%

A Novel Algorithm for Improving the Prehospital Diagnostic Accuracy of ST-Segment Elevation Myocardial Infarction

Goebel,

Westafer,

Ayala

et al. 2023

Prehosp. Disaster med.

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“…Previously identified barriers to ECG transmission include technical failures, such as failure of the monitor to connect to the wireless network; human error, such as failure of paramedic to select the correct receiving hospital; and protocol noncomplaince. 19 However, efforts directed specifically at improving ECG transmission have been shown to be effective. At a single center in LAC, a quality improvement initiative involving weekly ECG test transmissions resulted in 73% successful ECG transmission at that facility.…”

Section: Discussionmentioning

confidence: 99%

“…At a single center in LAC, a quality improvement initiative involving weekly ECG test transmissions resulted in 73% successful ECG transmission at that facility. 19 There are several possible explanations for the low rate of ED physician communication with paramedics. Feedback elicited from participating sites during the study reported that ED physicians found it impractical to take time away from caring for other ED patients to speak to the paramedics on the radio.…”

Section: Discussionmentioning

confidence: 99%

The Effect of Implementation of the American Heart Association Mission Lifeline PreAct Algorithm for Prehospital Cardiac Catheterization Laboratory Activation on the Rate of “False Positive” Activations

Tolles

Bosson

Kaji

et al. 2020

Prehosp. Disaster med.

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Hypothesis:Emergency Medical Services (EMS) systems have developed protocols for prehospital activation of the cardiac catheterization laboratory for patients with suspected ST-elevation myocardial infarction (STEMI) to decrease first-medical-contact-to-balloon time (FMC2B). The rate of “false positive” prehospital activations is high. In order to decrease this rate and expedite care for patients with true STEMI, the American Heart Association (AHA; Dallas, Texas USA) developed the Mission Lifeline PreAct STEMI algorithm, which was implemented in Los Angeles County (LAC; California USA) in 2015. The hypothesis of this study was that implementation of the PreAct algorithm would increase the positive predictive value (PPV) of prehospital activation.Methods:This is an observational pre-/post-study of the effect of the implementation of the PreAct algorithm for patients with suspected STEMI transported to one of five STEMI Receiving Centers (SRCs) within the LAC Regional System. The primary outcome was the PPV of cardiac catheterization laboratory activation for percutaneous coronary intervention (PCI) or coronary artery bypass graft (CABG). The secondary outcome was FMC2B.Results:A total of 1,877 patients were analyzed for the primary outcome in the pre-intervention period and 405 patients in the post-intervention period. There was an overall decrease in cardiac catheterization laboratory activations, from 67% in the pre-intervention period to 49% in the post-intervention period (95% CI for the difference, -14% to -22%). The overall rate of cardiac catheterization declined in post-intervention period as compared the pre-intervention period, from 34% to 30% (95% CI, for the difference -7.6% to 0.4%), but actually increased for subjects who had activation (48% versus 58%; 95% CI, 4.6%-15.0%). Implementation of the PreAct algorithm was associated with an increase in the PPV of activation for PCI or CABG from 37.9% to 48.6%. The overall odds ratio (OR) associated with the intervention was 1.4 (95% CI, 1.1-1.8). The effect of the intervention was to decrease variability between medical centers. There was no associated change in average FMC2B.Conclusions:The implementation of the PreAct algorithm in the LAC EMS system was associated with an overall increase in the PPV of cardiac catheterization laboratory activation.

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“…25,26 Meeting the ACC/AHA 90-min FMC to PCI goal is dependent on care processes at both EMS agencies and receiving hospitals. [27][28][29][30] Unsuccessful ECG transmission and delayed PCI center activation may negatively affect overall PCI time metrics, 5,[30][31][32][33] but it remains unclear how individual time intervals, such as FMC to ECG and scene time, are associated with mortality in patients cared for by rural EMS agencies. The primary objective of this study was to evaluate the association between FMC to PCI time and index hospitalization mortality in rural STEMI patients.…”

Section: Introductionmentioning

confidence: 99%

Delayed first medical contact to reperfusion time increases mortality in rural emergency medical services patients with ST‐elevation myocardial infarction

Stopyra,

Snavely,

Ashburn

et al. 2023

Academic Emergency Medicine

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BackgroundST‐elevation myocardial infarction (STEMI) guidelines recommend an emergency medical service (EMS) first medical contact (FMC) to percutaneous coronary intervention (PCI) time of ≤90 minutes. The primary objective of this study is to evaluate the association between FMC to PCI time and mortality in rural STEMI patients.MethodsWe conducted a cohort study of patients ≥18 years old with STEMI activations from January 2016 to March 2020. Data were obtained from a rural North Carolina (NC) Regional STEMI Data Registry, which included eight rural EMS agencies and three PCI centers, the National Cardiovascular Data Registry, and the EMS electronic health record. Prehospital and in hospital time intervals were digitally abstracted. The outcome of index hospitalization mortality was compared between patients who did and did not meet FMC to PCI time goal using Fisher's exact tests. Negative predictive value (NPV) for index hospitalization death was calculated with 95% confidence intervals. A receiver operating characteristic curve was constructed and an optimal FMC to PCI time goal was identified by maximizing NPV to prevent index hospitalization death.ResultsAmong 365 rural EMS STEMI patients, 30.1% (110/365) were female with a mean age of 62.5 ± 12.7 years. PCI was performed within the 90‐minute time goal in 60.5% (221/365) of patients. Among these patients, 3% (11/365) died during initial STEMI hospitalization, with 1.4% (3/221) mortality in the group that met the 90‐minute time goal compared to 5.6% (8/144) in patients exceeding the time goal (p=0.03). Meeting the 90‐minute time goal yielded a 98.6% (95%CI: 96.1‐99.7%) NPV for index death. A 78‐minute FMC to PCI time was the optimal cut point, yielding a NPV for index mortality of 99.3% (95%CI: 96.1‐100%).ConclusionDeath among rural patients with STEMI was four times more likely when they did not receive PCI within 90 minutes.

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Weekly Checks Improve Real-Time Prehospital ECG Transmission in Suspected STEMI

Cited by 5 publications

References 25 publications

A Novel Algorithm for Improving the Prehospital Diagnostic Accuracy of ST-Segment Elevation Myocardial Infarction

A Novel Algorithm for Improving the Prehospital Diagnostic Accuracy of ST-Segment Elevation Myocardial Infarction

The Effect of Implementation of the American Heart Association Mission Lifeline PreAct Algorithm for Prehospital Cardiac Catheterization Laboratory Activation on the Rate of “False Positive” Activations

Delayed first medical contact to reperfusion time increases mortality in rural emergency medical services patients with ST‐elevation myocardial infarction

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