The Lived Experience of

Prehospital ECG in Rural

Emergency Care

Ann Vreeland DNP, APRN, CNP, EMT-B

Jason Lenz APRN, CNP

Agency

Hoyt Lakes Ambulance service in

cooperation with the Northern Pines Medical

Center located in northeastern Minnesota

Professional team includes EMTs, ED staff

(MD, RN, CNPs, and PAs), STEMI

coordinator for Essentia Health, and

Information Technology staff

Rural St. Louis County

Basic Life Support

Ambulance Service

Critical Access

Hospital within a

healthcare system

Introduction

Coronary heart disease: Leading cause of

mortality in the United States

ST-Elevated Myocardial Infarction (STEMI)

accounts for 25-40%of Acute Coronary

Syndrome (ACS) in the United States

Timely administration of either angioplasty

or a thrombolytic agent improves outcomes

for patients

Performance MeasuresReperfusion therapy for patients with STEMI. The bold arrows and boxes are the preferred

strategies.

(ACC/AHA 2013)

Problem Summary

Despite evidence that earlier time of

treatment from onset reduces mortality,

time-to-treatment remains prolonged

Critical access hospitals meet optimal

performance on the process measures for

AMIs 91% of the time compared to non-

CAHs which met this measure 97.8% of the

time

Current Data

Literature Review Summary

Utilizing prehospital emergency services to

diagnose and triage STEMI patients as part

of a system of care has been suggested to

help improve time-to-treatment

Literature Review Summary

Prehospital ECGs have been shown to

shorten the time-to-reperfusion in patients

experiencing STEMI

Prehospital ECGs alone (not a part of

system of care) are not as effective when

compared with prehospital ECGs with early

notification of the receiving hospital

Literature Review Summary

The ability to transmit and accurately

interpret the transmitted prehospital ECG is

a feasible option for early notification

Suggested that prehospital ECG may lower

mortality and morbidity, more studies are

required

Literature Review Summary

Prehospital ECG recommended in the

national guidelines from the American Heart

Association

Studies have shown that reductions in door-

to-intervention times have been shown

when prehospital ECG used to activate the

catheterization laboratory while patient is

enroute to the hospital despite this:

Literature Review Summary

Prehospital ECGs were recorded in less

than 10% of STEMI patients

When used, the information is not translated

into action or coordinated with a system of

care to decrease delays in reperfusion

therapy

Literature Review Summary

Limited research has been done on the use

of prehospital ECG by basic life support

(BLS) providers

Rural areas provide primarily BLS

ambulance services, usually by volunteers

supplemented by a relatively small number

of advanced life support (ALS) providers

Recommendations:

The American Heart Association 2013

All communities should create and maintain

a regional system of STEMI care

Performance of a 12-lead Electrocardiogram

(ECG) by prehospital Emergency Medical

Services (EMS) at the site of First Medical

Contact (FMC) with symptoms of STEMI

Mission Statement

Improve the care of the STEMI patient

transported to the Northern Pines Medical

Center by the Hoyt Lakes Ambulance Service

by initiating the transmission of prehospital

ECG.

IMPLEMENTATION & TRAINING

Key community leaders were

informed and allowed input

Medical Director

Director of Nursing

Ambulance service

officers

Tri-City Ambulance

Medical Staff

Monitor with ECG

and transmission

capabilities

Completion of the

competency on

the use of the

MRx Heart Start

monitor.

STEMI Training

Attend STEMI Boot Camp

sponsored by Essentia Health or

on-site training by Jason Lenz

APRN, CNP

STEMI Training

The America

Heart

Association

(AHA) course

titled, Learn

Rapid STEMI

ID

Lead Placement

All EMT’s

demonstrated

correct lead

placement on three

different occasions

on a live volunteer

or manikin.

INDICATIONS

Inclusion Criteria

Patients 18 years of age or

older with:

Chest Pain

Moderate or severe

respiratory distress

Symptoms similar to

previous angina or

myocardial infarction

Syncope or near syncope

As directed by medical

control

Exclusion Criteria

Symptoms greater than 6

hours

Trauma patients

Patients who are:

Unconscious

Sedated

Require

cardiopulmonary

resuscitation

Transport time of 5

minutes or less

Younger than 18

Possible

STEMI

patient

Prehospital

ECG

ECG

Transmitted

to CAH from

MRx via

Bluetooth

phone

ECG prints

at CAH

nursing

station

ECG

received by

e-mail(MD,

DON,

project lead

ECG

read by

CAH MD

STEMI?

NO

Treat at CAH

YES

Notify PCI

capable

hospital and

expedite

patient

transport to

PCI hospital

EVALUATION

Three month evaluation period

Evaluation included:

– Number of successful versus attempted ECG

transmissions

– If the use of the prehospital ECG by the BLS

service decreases door to intervention times in

STEMI patients in a rural healthcare setting

EVALUATION

90% of eligible patients

will have received a

prehospital ECG

transmitted

successfully to the

CAH

Goal met when 12 of

13 eligible patients

received a prehospital

ECG transmitted

successfully to the

CAH (92%)

CASE STUDIES

STEMI

83 y/o female patient called 911 after 1 hour

of chest pain

12-lead transmitted to CAH ER

STEMI confirmed

Bypassed rural hospitals

EMS first medical contact to device time 98

minutes!

Findings

EMT on the BLS ambulance service can

identify the indications for a prehospital ECG

Focus was on the importance of the

prehospital ECG as part of a system of care

EMTs had the ability to correctly place leads

to complete an ECG in the field

Findings

Successful transmission of the prehospital

ECG

– Technically feasible

– Reduces time to primary percutaneous

intervention

– Reliable in the diagnosis of STEMI

– May be more cost-effective than training of

prehospital providers alone

– Benefit reaches beyond STEMI

Findings

Findings

This clinical project

showed that even though

cellular coverage areas

are historically better in

urban areas,

transmission of a

prehospital ECG is

technically feasible in

rural areas.

Barriers/Unanticipated Events

QUESTIONS

References

Adams, G., Abusaid, G., Lee, B., Maynard, C., Campbell, P., Wagner, G., et al. (2010).

From theory to practice: Implementation of pre-hospital electrocardiogram transmission

in ST-elevation myocardial infarction—A multicenter experience. Journal of Invasive

Cardiology, 22(11), 520-525

Afolabi, B. A., Novaro, G. M., Pinski, S. L., Fromkin, K. R., & Bush, H. S. (2007). Use of

the prehospital ECG improves door-to-balloon times in ST segment elevation myocardial

infarction irrespective of time of day or day of week. Emergency Medicine Journal, 24,

588-591. Retrieved from http://dx.doi.org/10.1136/emj.2007.047373

American College of Cardiology/American Heart Association Task Force on Practice

Guidelines. (2013). ACC/AHA guidelines for the management of patients with ST-

elevation myocardial infarction-executive summary: A report of the American College of

Cardiology/American Heart Association task force on practice guidelines. Circulation:

Journal of the American Heart Association, 127, 529-555. Retrieved from

http://dx.doi.org/10.1161/CIR.0b013e3182742c84.

Baliga, R. R. (2011). Quality of care and outcome in critical access rural hospitals.

Cardiology Review, 19-21.

Barbagelata, A., Perna, E. R., Clemmensen, P., Uretsky, B. F., Cimbaro Canella, J. P.,

Califf, R. M., . . . Birnbaum, Y. (2007). Time to reperfusion in acute myocardial infarction.

It is time to reduce it! Journal of Electrocardiology, 40, 257-264. Retrieved from

http://dx.doi.org/10.1016/j.electrocard.2007.01.007

Brainard, A. H., Raynovich, W., Tandberg, D., & Bedrick, E. (2005). The prehospital 12-

lead electrocardiogram’s effect on time to initiation of reperfusion therapy: A systemic

review and meta-analysis of existing literature. American Journal of Emergency

Medicine, 23(3), 351-356. Retrieved from http://dx.doi.org/10.1016/j.ajem.2005.02.004

Camp-Rogers, T., Dante, S., Kontos, M. C., Roberts, C. S., Kreisa, L., & Kurz, M. C.

(2011). The impact of prehospital activation of the cardiac catheterization team on time to

treatment for patients presenting with ST-segment-elevation myocardial infarction.

American Journal of Emergency Medicine, 29, 1117-1124. Retrieved from

http://dx.doi.org/10.1016/j.ajem.2010.08.005

Curtis, J. P., Portnay, E. L., Wang, Y., McNamara, R. L., Herrin, J., Bradley, E. H., . . .

Krumholz, H. M. (2006). The pre-hospital electrocardiogram and time to reperfusion in

patients with acute myocardial infarction, 2000-2002: Findings from the National Registry

of Myocardial Infarction-4. Journal of the American College of Cardiology, 47(8), 1544-

1552. Retrieved from http://dx.doi.org/10.1016/j.jacc.2005.10.077

Daudelin, D. H., Sayah, A. J., Kwong, M., Restuccia, M. C., Porcaro, W. A., Ruthazer,

R., . . . Selker, H. P. (2010, May). Improving use of prehospital 12-lead

electrocardiography for early identification and treatment of acute coronary syndrome

and ST-elevation myocardial infarction. Circulatory Cardiovascular Quality Outcomes,

3(3), 316-323. Retrieved from

http://dx.doi.org/doi:10.1161/CIRCOUTCOMES.109.895045

Dhruva, V. N., Abdelhadi, S. I., Anis, A., Gluckman, W., Hom, D., Dougan, W., . . .

Klapholz, M. (2007). ST-segment analysis using wireless technology in acute myocardial

infarction (STAT-MI) trial. Journal of the American College of Cardiology, 50(6), 509-513.

Retrieved from http://dx.doi.org/10.1016/j.jacc.2007.04.049

Gonzalez, M. A., Satler, L. E., Rodrigo, M. E., Gaglia, M. A., Ben-Dor, I., Maluenda, G., .

. . Waksman, R. (2011). Cellular video-phone assisted transmission and interpretation of

prehospital 12-lead electrocardiogram in acute ST-segment elevation myocardial

infarction. Journal of Interventional Cardiology, 24(2), 112-118. Retrieved from

http://dx.doi.org/10.1111/j.1540-8183.2010.00609.x

Joynt, K. E., Harris, Y., Orav, E. J., & Jha, A. K. (2011). Quality of care and patient

outcomes in critical access hospitals. Journal of the American Medical Association,

306(1), 45-52.

Larson, D. M., Sharkey, S. W., Unger, B. T., & Henry, T. D. (2005). Implementation of

acute myocardial infarction guidelines in community hospitals. Academic Emergency

Medicine, 12(6), 522-527. Retrieved from http://dx.doi.org/10.1197/j.aem.2005.01.008

Lee, C. H., Van Gelder, C. M., & Cone, D. C. (2010). Early cardiac catheterization

laboratory activation by paramedics with ST-segment elevation myocardial infarction on

prehospital 12-lead electrocardiograms. Prehospital Emergency Care, 14, 153-158.

Retrieved from http://dx.doi.org/doi:10.3109/10903120903537213

Lloyd-Jones, D., Adams, R., Carnethon, M., De Simone, G., Ferguson, T., Flegal, K., . . .

Go, A. (2009). Heart disease and stroke statistics-2009 update: A report from the

American Heart Association Statistics Committee and Stroke Statistics Subcommittee.

Circulation, 3(119), 480-486. Retrieved from

http://dx.doi.org/10.1161/CIRCULATIONAHA.108191259

Minnesota Emergency Medical Services Regulatory Board. (2013). Home page.

Retrieved from www.emsrb.state.mn.us

Mischke, K., Zarse, M., Perkuhn, M., Knackstedt, C., Markus, K., Koos, R., . . .

Schauerte, P. (2005). Telephonic transmission of 12-lead electrocardiograms during

acute myocardial infarction. Journal of Telemedicine and Telecare, 11, 185-190.

Morrison, L. J., Brooks, S., Sawadsky, B., McDonald, A., & Verbeek, P. R. (2006).

Prehospital 12-lead electrocardiography impact on acute myocardial infarction treatment

times and mortality: A systemic review. Academic Emergency Medicine, 13(1), 84-89.

Retrieved from http://dx.doi.org/10.1197/j.aem.2005.07.042

Moyer, P., Ornato, J. P., Brady, W. J., Jr., Davis, L. L., Ghaemmaghami, C. A., Gibler,

W. B., . . . Zane, R. D. (2007). Development of systems of care for ST-elevation

myocardial infarction patients: The emergency medical services and emergency

department perspective. Circulation, 116, 43-48. Retrieved from http://dx.doi.org/10.1161

/CIRCULATIONAHA.107.184047

Patel, M., Dunford, J. V., Aquilar, S., Castillo, E., Patel, E., Fisher, R., . . . Mahmud, E.

(2012). Pre-hospital electrocardiography by emergency medical personnel. Journal of the

American College of Cardiology, 60(9), 806-811. Retrieved from http://dx.doi.org

/10.1016/j.jacc.2012.03.071

Pitta, S. R., Myers, L. A., Bjerke, C. M., White, R. D., & Ting, H. H. (2010). Using

prehospital electrocardiograms to improve door-to balloon time for transferred patients

with ST-elevation myocardial infarction: A case of extreme performance. Circulation

Cardiovascular Quality and Outcomes: Journal of the American Heart Association, 3, 93-

97. Retrieved from http://dx.doi.org/10.1161/CIRCOUTCOMES.110.904219

Schoenbaum, M. (2011). Critical access hospitals: Hubs for rural health care. Minnesota

Medicine, 34-37.

Schwab, B., Katalinic, A., Richardt, G., Kurowski, V., Kruger, D., & Mortensen, K., et al.

(2006). Validation of 12-lead tele-electrocardiogram transmission in the real life scenario

of acute coronary syndrome. Journal of Telemedicine and Telecare, 12, 315-318.

Sillesen, M., Sejersten, M., Strange, S., Nielsen, S. L., Lippert, F., & Clemmensen, P.

(2008). Referral of patients with ST-segment elevation acute myocardial infarction

directly to the catheterization suite based on prehospital transmission of 12-lead

electrocardiogram. Journal of Electrocardiology, 41(1), 49-53. Retrieved from

http://dx.doi.org/10.1016/j.electrocard.2007.08.058

Strauss, D. G., Sprague, P. Q., Underhill, K., Maynard, C., Adams, G. L., Kessenich, A., .

. . Wagner, G. S. (2007). Paramedic transtelephonic communication to cardiologist of

clinical and electrocardiographic assessment for rapid reperfusion of ST-elevation

myocardial infarction . Journal of Electrocardiology, 40(3), 265-270. Retrieved from

http://dx.doi.org/10.1016/j.jelectrocard.2006.11.006

Swor, R., Hegerberg, S., McHugh-McNally, A., Goldstein, M., & McEachin, C. C. (2006).

Prehospital 12-lead ECG: Efficacy or effectiveness? Prehospital Emergency Care, 10(3),

374-377. Retrieved from http://dx.doi.org/10.1080/10903120600725876

Terkelsen, C. J., Norgaard, B. L., Lassen, J. F., Gerdes, J. C., Ankersen, J. P., Romer,

F., . . . Andersen, H. R. (2002). Telemedicine used for remote prehospital diagnosing in

patients suspected of acute myocardial infarction. Journal of Internal Medicine, 252, 412-

420.

Ting, H. H., Krumholz, H. M., Bradley, E. H., Cone, D. C., Curtis, J. P., Drew, B. J., . . .

Schuur, J. D. (2008). Implementation and integration of prehospital ECGs into systems of

care for acute coronary syndrome: A scientific statement from the American Heart

Association Interdisciplinary Council on Quality of Care and Outcomes Research,

Emergency Cardiovascular Care Committee, Council on Cardiovascular Nursing, and

Council on Clinical Cardiology. Circulation: Journal of the American Heart Association,

118, 1066-1079. Retrieved from

http://dx.doi.org/10.1161/CIRCULATIONAHA.108.190402

Welsh, R. C., Ornato, J., & Armstrong, P. W. (2003). Prehospital management of acute

ST-elevation myocardial infarction: A time for reappraisal in North America. American

Heart Journal, 1-8. Retrieved from http://dx.doi.org/10.1067/mhj.2003.47

Werman, H. A., Newland, R., & Cotton, B. (2011). Transmission of 12-lead

electrocardiographic tracings by emergency medical technician-basics and emergency

medical technician-intermediates: A feasibility study. The American Journal of

Emergency Medicine, 29, 437-440. Retrieved from

http://dx.doi.org/10.1016/j.ajem.2010.01.015