T r a n s m i s s i o n of p r e h o s p i t a l - a c q u i r e d 12-lead EKGs by m e a n s of cellular t e lephone from the
field directly to an e m e r g e n c y d e p a r t m e n t has now b e c o m e technical ly possible. Prehospital t r ea tmen t
of acu te myocardia l infarct ion wi th thrombolyt ic agen t s is a hotly deba ted topic in m a n y areas. Can this n e w prehospi ta l t echnology be u sed to decrease the t ime requi red to t reat a myocardial infarct ion and still avoid the problems and costs assoc ia ted wi th prehospi ta l admin i s t r a t ion of thrombolysis?
Correct p rehosp i t a l i n t e rp re t a t i on of 12-lead EKGs by a d v a n c e d life suppor t providers requires considerable t ime and expense for t ra ining. Medical c o m m a n d p h y s i c i a n s may be h e s i t a n t to order
admin i s t r a t ion of thrombolyt ics dur ing prehospi ta l care wi thout the benef i t of a clinical examina t ion on
their part. The LIFEPAK ® 11 acu te cardiac care sys tem
(Physio-Control Corporat ion, R e d m o n d , Wash.) (Figure 1) can provide a s imul t aneous readout of a 12-lead EKG to EMS personne l in the field and to the phys ic ian in the e m e r g e n c y depar tment . The un i t can be easily c o n n e c t e d to a cellular "bag-type" tele- phone via a coupl ing device and provides reliable t r ansmiss ion of EKGs in any area where cellular cov- erage is available. If al! icriteria are met, ~,MS person- ne l m a y p roceed wi th p a t i e n t prep"ar~tion for thrombolyt ic admin i s t r a t ion (starting IV 1"flfusions, prehospi ta l u se of aspirin, thrombolyt ic eligibility checklist blood sampling, and so on) while en route
to the e m e r g e n c y depar tment . When the pa t i en t arrives at the e m e r g e n c y depar tment , door-to-drug t ime can be dec reased considerably b e c a u s e EKG and v e n i p u n c t u r e have already b e e n obtained. Time
Figure 1 LIFEPAK® 11 monitor with phone. Photo by Dennis Collins. Used with permission of Physio-Control Corporation
Figure 2 RS 100 receiving station. Photo by Dennis Collins. Used with permission of Physio-Control Corporation.
delays usually assoc ia ted wi th ob ta in ing these diag- nost ic tes ts on arrival to the e m e r g e n c y d e p a r t m e n t can be el iminated.
Our facil i ty has e x p e r i e n c e d th rombo ly t i c admin i s t r a t ion "on arrival" to the e me r ge nc y depart - ment , e l imina t ing previous delays usually assoc ia ted
48 Volume 23, Number 1
Collins/JOURNAL OF EMERGENCY NURSING
FRICK HOSPITAL AND COMMUNITY HEALTH CENTER Mount Pleasant, Pennsylvania
Emergency Department Policy Manual Policy No. 3.11
SUBJECT: PILE-HOSPITAL CELLULAR EKG
EFFECTIVE DATE: December 10, 1 9 9 5 APPROVED BY:
REVISION DATES:
PURPOSE: To assure proper procedures are followed during transmission of 12 lead EKGs in a pre-hospital environment. To assure optimal patient care and compliance with existing EMS protocols.
EQUIPMENT REQUIRED:
1. 2. 3. 4.
Cellular EKG transmission unit (LPll) Interconnecting cables Cellular phone and cellular modem EKG electrodes
POLICY DETAIL:
1. Follow present chest pain protocol.
2. Attach patient to limb and precordial leads.
3. Attach an electrode for each lead.
4. Encourage the patient to remain as still as possible during the procedure.
Press "12 lead" one time to analyze and print the report, note the message status light on the monitor screen.
6. Press the transmit button.
7. Select the correct receive number.
Press "transmit" again and observe the on screen messages, take any actions noted on the screen to improve connection.
When the "transmission complete" indicator shows, press "exit" and turn off cellular phone.
Figure 3 Policy for us ing LIFEPAK ® 11. Used with permission of Frick Hospital and Communi ty Heal th Center.
w i t h d e f i n i t i v e m a n a g e m e n t of an a c u t e m y o c a r d i a l
in fa rc t ion . O n e p a t i e n t , a 47 -yea r -o ld m a n , w h o
r e p o r t e d only g a s t r i c b u r n i n g , s h o w e d a c u t e m y o c a r -
dial i n f a r c t i on c h a n g e s on h is EKG t r a c i n g w h i l e in
t r ans i t to t h e e m e r g e n c y d e p a r t m e n t . T h e p r e h o s p i -
tal 12- lead EKG w a s a d e t e r m i n i n g fac to r in p r o p e r
t r i a g e a n d s t a r t i n g u s e of a t h r o m b o l y t i c a g e n t w i t h -
in 6 m i n u t e s of h is arrival. T h e u n i t p r o v i d e s a n EKG
pr in tou t , i n c l u d i n g c o m p u t e r i z e d analys is , of a qua l i -
ty c o m p a r a b l e to EKGs o b t a i n e d in t h e hosp i ta l . We
h a v e n o t f o u n d t h a t a n y s p e c i a l t y p e of e l e c t r o d e is
n e e d e d to y ie ld a h i g h - q u a l i t y r ead ing .
T r a i n i n g r e q u i r e d for p r e h o s p i t a l ALS p r o v i d e r s
to co r r ec t l y a t t a c h t h e 12- lead m o n i t o r to a p a t i e n t is
m i n i m a l . Wi th p r a c t i c e , t h e l e a d s c a n b e p l a c e d in
l ess t h a n 30 s e c o n d s . T h e to ta l t i m e r e q u i r e d to
o b t a i n a n d t r a n s m i t a 12- lead EKG s h o u l d b e less
t h a n 3 m i n u t e s . P r e h o s p i t a l p r o v i d e r s w e r e ab le to
o b t a i n e x p e r i e n c e b y p e r f o r m i n g rou t i ne EKGs (in
t h e hospi ta l ) un t i l t he i r c o m p e t e n c y w a s e n s u r e d .
February 1997 49
JOURNAL OF EMERGENCY NURSING/Collins
The uni t f ea tu res an on -boa rd m e m o r y tha t can re ta in p h o n e n u m b e r s of local ED r ece iv ing units , pe rmi t t i ng the opera tor to a c c e s s the r ece ive r via a s p e e d dial a r r angemen t . Controls on the un i t pe rmi t qu ick ent ry of p a t i e n t data .
T ransmis s ion qual i ty is no t d e c r e a s e d by send- ing an EKG s igna l from a m o v i n g a m b u l a n c e provid- ed t h e a m b u l a n c e h a s a g o o d cel lular a n t e n n a sys tem. It is adv i sab le to per form t e s t t r an smi s s ions u s ing an EKG r h y t h m s imula tor from var ious uni ts in different loca t ions in t he se rv ice a rea before beg in - n ing ac tua l u se of the sys t em.
S t a r t - u p c o s t s for t h e s y s t e m i n c l u d e t h e LIFEPAK ® 11 ($16,000), the r ece iv ing un i t ($6,000), and t e l ephone coupler ($200, no t included) . However , cos t s vary wide ly wi th the vo lume and n u m b e r of un i t s pu rchased . Initial s e t u p a n d ins ta l la t ion of the rece iver requi re only a few hours. Old equ ipmen t , such as LIFEPAK ® 10s, m a y b e t r a d e d in to r e d u c e the p u r c h a s e price. One LIFEPAK ® 11 is r equ i red for e a c h mobi le unit , and one r ece iv ing s t a t ion for e ach facility. The t e l ephone coupler a n d cable m a y be car- r ied ins ide the p h o n e bag . Cos ts for cellular u s a g e vary wi th the a r ea and the a m o u n t of air t ime u s e d for e a c h t r ansmiss ion . We have found a mon th ly fee of app rox ima te ly $40 to b e average .
The uni t is a t t a c h e d to a s t a n d a r d cellular te le- p h o n e by a coup l ing device . For portabil i ty, t he te le- p h o n e and the LIFEPAK ® uni t are car r ied s epa ra t e ly and are a t t a c h e d at t he t ime of use. Like all par t s of the t r ansmiss ion , th is s e t u p requ i res only a few sec- onds. The w e i g h t of the uni t (25.2 pounds , c o m p a r e d wi th 20 p o u n d s for the s t a n d a r d LIFEPAK ® 10) m a k e s a ca r ry ing c a s e wi th shou lde r s t rap a des i rab le opt ion.
C o m m o n t r a n s m i s s i o n p rob l ems can inc lude a w e a k signal, w h i c h resul t s in t he r ece iv ing uni t fail- ing to pr in t out, and low b a t t e r i e s on e i ther t he cellu- lar p h o n e or t he LIFEP, AK ® unitl Bat te ry Prob lems can be m i n i m i z e d by regular m a i n t e n a n c e " a ~ d dai ly checks . The manufac tu r e r also has a battefy~*support cha rg ing s y s t e m avai lable t ha t can pro long ba t t e ry life by he lp ing to e l imina te t he m e m o r y usual ly asso- c i a t ed wi th r e c h a r g e a b l e ba t t e r i e s . In addi t ion , a 12- volt vehic le a d a p t e r is ava i lab le for LIFEPAK®-type ba t te r ies . S ignal p rob l ems can usual ly b e co r rec t ed by us ing an a n t e n n a ou t s i de t he a m b u l a n c e b e c a u s e t he a n t e n n a m o u n t e d on the cellular p h o n e m a y not p rov ide suff ic ient output . It is also impor t an t to m a k e sure tha t the a r ea from w h i c h the uni t is ope ra t ing has suff ic ient cellular coverage . A l t h o u g h cellular
c o v e r a g e is not usual ly a p rob lem in u r b a n se t t ings , th is can b e a major factor in rural areas. It is also pos - s ible to s e n d the s ignal over a regular t e l e p h o n e l ine from a p r iva te r e s i d e n c e by c o n n e c t i n g the un i t to t h e c o n v e n t i o n a l t e l e p h o n e l ines . Th is r e q u i r e s r e m o v i n g the t e ]ephone at the r e s i d e n c e from the c o n n e c t i n g wire and c o n n e c t i n g di rec t ly to the j ack on the unit .
In t he even t p rehosp i t a l med ica l c o m m a n d is c o n t a c t e d us ing the s a m e cellular t e lephone , i t will be n e c e s s a r y to m a i n t a i n a s e p a r a t e c on t a c t n u m b e r for r ece iv ing EKG t r ansmiss ions . Voice and EKG sig- nals c a n n o t be s en t over the s a m e cellular l ine s imul- taneously. A s e p a r a t e r ece iv ing line t ha t b y p a s s e s the r ece iv ing faci l i ty 's normal s w i t c h b o a r d p rov ides the m o s t t rouble- f lee per formance . The ED r e c e i v i n g uni t (Figure 2) should b e d i rec t ly c o n n e c t e d to th is d e d i c a t e d t e l ephone line.
Pol ic ies (Figure 3) should e m p h a s i z e fol lowing n o r m a l c h e s t p a i n t r e a t m e n t p ro toco l s be fo re a t t e m p t i n g EKG t ransmiss ion . Protocols should also inc lude s t e p s to be t a k e n in even t of t r a n s m i s s i o n failure or b u s y signal. We p re sen t ly con t inue to t rans- por t and p r e s e n t t he 12-lead EKG to the ED staff on arrival. Pe r fo rmance i m p r o v e m e n t s t ud i e s shou ld inc lude an aud i t of o n - s c e n e t ime so tha t any de lays EMS pe r sonne l m a y e xpe r i e nc e in s e t t i ng up an EKG t r a n s m i s s i o n can be d e t e c t e d and cor rec ted . The uni t is d e s i g n e d w i th an on -boa rd memory, pe rmi t - t ing s to red EKGs to b e p r in t ed at a la ter d a t e for r e c o r d k e e p i n g or pe r fo rmance i m p r o v e m e n t purpos - es. Spec ia l sof tware is avai lable from the manufac - turer to enab le s to red d a t a to b e t rans fe r red d i rec t ly to a pe r sona l c o m p u t e r for further study.
P rehosp i ta l 12-lead EKG t r a n s m i s s i o n can b e a powerfu l tool to d e c r e a s e overall t r e a t m e n t t i m e s for myoc a rd i a l infarction. Prov ided the b a s i c p r o c e d u r e s are followed, the s y s t e m can b e vir tual ly p rob lem- flee. We m a y e x p e c t to see p rehosp i t a l 12-lead EKG t r a n s m i s s i o n s b e c o m e the s t a n d a r d of care in t he near future, as th is t e c hno logy con t inues to deve lop and improve.
Cbntributions /6r this column shouM be sent to Connie J. Mattera, RN, MS, CEN, EMT-P, 6801 N. Olcott, Chicago, IL 60637; phone (773) 775-2260; or E. Marie Wilson, RN, MPA, 35 Chapman Mill Pored Rd., Westbrook, CT 06498; phone (860) 509- 7983.
