[NAEMSP Dialog] EMS Role in Reducing the Symptom to Reflow Interval for AMI

[Mic Gunderson]

From the time an AMI patient begins to have symptoms until they get
reflow through their coronary arteries restored, the 'time is muscle'
clock is ticking. This session of the NAEMSP Dialog is about the role
that EMS should (or could) play in keeping that symptom to reflow time
interval as short as possible. There are several important questions
that the EMS, ED and cardiology communities need to address in this
regard. Our intent is to facilitate discussion on these questions -
and thereby provide information that we can all use to help improve
care and guide further study in our respective systems.

I will get the conversation started by asking our invited participants
a few questions. That will help frame the issues we hope to address
and provide more specific items for you to reply to. So please, share
your viewpoints in this important discussion - and remember to 'sign'
your replies with your name and affilitation(s).

If you have any EMS, ED or cardiology colleagues you think should be
reading and/or participating in this discussion, please encourage them
to signup for Google Groups (http://groups.google.com) and the join
this NAEMSP Dialog group (ttp://groups.google.com/group/naemsp-
dialog).

Our invited participants for this session are:

Christopher Lee, MD - Chris is the lead author of the 'Early Cardiac
Cath Lab Activation by Paramedics for Patients with STEMI on
Prehospital 12 Lead ECGs' paper recently published in Prehospital
Emergency Care (see the 'Papers and Resources' section below). Chris
is a clinical instructor in emergency medicine at the Yale University
School of Medicine. He graduated from the University of Vermont
College of Medicine and completed his residency in emergency medicine
at Yale-New Haven Hospital. He is currently completing his fellowship
in EMS and pursing a PhD in investigative medicine at Yale.

Carin Van Gelder, MD - Carin is also one of the authors for the 'Early
Cardiac Cath Lab Activation by Paramedics for Patients with STEMI on
Prehospital 12 Lead ECGs' paper. She is an Assistant Professor in
emergency medicine at the Yale University School of Medicine, which is
where she also did her EM residency and EMS fellowship. She has had a
research focus on the heat physiology of firefighters and directs the
EMS Curriculum for the EM Residency at Yale - New Haven Hospital. She
also serves as the EMS Medical Director for the New Haven Sponsor
Hospital Program. Carin serves on the editorial board of Prehospital
Emergency Care.

David Cone, MD - Dave is another one of the authors for the paper
cited above. He serves as EMS Section Chief at the Yale University
School of Medicine, where he holds the rank of Associate Professor in
the departments of Emergency Medicine, and Epidemiology and Public
Health. He is the Immediate Past President of the National Association
of EMS Physicians, and Editor-in-Chief of Academic Emergency Medicine,
the journal of the Society for Academic Emergency Medicine. An active
EMS field provider since 1984, he has served as medical team manager
for two urban search and rescue task forces, is an active-duty
volunteer firefighter, and is the service chief of Connecticut’s only
physician response team.

Nick Nudell, REMT-P - Nick is has been involved in EMS for over 10
years, having worked as a volunteer EMT in rural EMS systems as well
as a paid paramedic in both rural and large urban systems. With more
than 15 years of experience in researching, supporting, and developing
emerging technologies, Nick is also a rising star in the field of
health care technology in the areas of data systems design and
analytics. Nick is the founder of the popular EKG Club online
discussion group. For the last few years, Nick has traveled the
country as a Senior Field Clinical Engineer for Angel Medical Systems
providing support services the cardiologists involved in clinical
trials of a medical device designed to detect precursors to acute
myocardial infarctions.

Tom Bouthillet, REMT-P - Tom is a Lieutenant / Paramedic with Hilton
Head Island Fire & Rescue. He has taught nationally in the University
of MAryland - Baltimore County's Critical Care Transport (CCEMT-P). He
also serves on the EMS Advisory Committee of the South Carolina
Chapter of the AHA's Mission: Lifeline, and is the editor of the
Prehospital 12 Lead ECG blog. His writings have been referenced in the
American Heart Journal, the Journal of the American College of
Cardiology: Cardiovascular Interventions, and the EP Lab Digest.

David Carter, RN, MBA - Dave is the Administrator for Sarasota
Memorial Healthcare System's freestanding Emergency Healthcare Center
in North Port, FL. In addition to a clinical background as a paramedic
and RN, he served as the EMS Director for FirstHealth of Carolinas,
based in Pinehurst, NC. He is also a site reviewer for the Society of
Chest Pain Centers.

Thanks,

--- Mic

Mic Gunderson
Editor / Moderator, NAEMSP Dialog;
President, IPS

--
You received this message because you are subscribed to the Google
Groups "NAEMSP Dialog" group.
To post to this group, send email to naemsp...@googlegroups.com
To unsubscribe from this group, send email to
naemsp-dialo...@googlegroups.com
For more options, visit this group at
http://groups.google.com/group/naemsp-dialog?hl=en
Visit NAEMSP at http://www.naemsp.org.

[Mic Gunderson]

Let me begin by asking our invited participants to jump right into one
of the questions that we hope to address over the next several weeks.
Has ECG transmission become the "million dollar solution to a 5 cent
problem"? Transmission can involve thousands of dollars of computer
equipment, expensive modems, recurring monthly subscriptions,
restrictive licensing agreements, and a lack of interoperability
between defibrillator/monitor and ePCR platforms. All of this is in an
age when a picture can be emailed around the globe in seconds from a
handheld device at a minimal cost.

Chris, Carin, Nick, Tom, Dave (Cone) and Dave (Carter) - what do you
think?

[medicnick]

Hi Mic,
I think it depends on the system and what it is intended to do. Does
the transmission of EKGs improve patient outcomes?

The equipment required to acquire a diagnostic quality 12 lead EKG is
not very complicated nor particularly expensive. What is complicated
and expensive are the platforms used to present the data for viewing
and archival. Many of today's popular platforms combine a number of
different sensors, therapies, and capabilities and are somewhat
sophisticated. There are even algorithms built into the devices that
do a decent job of interpreting the EKG for tell tale signs of STEMI.

In some areas of the country paramedics are required by protocol to
transmit the EKG for overreading while in other areas it is not
required. This is often a reflection of the local history of the
adoption of EMS initiated hospital protocols and specifically for
concerns with false positive/negative rates for paramedic
interpetation, computer interpretation, or a combination such as the
theme paper discusses.

Where transmission of the EKG is required, the cost of acquiring the
capability to transmit is a given. In areas where not required, as an
optional cost for the system, the capability may not purchased.
Requiring all system participants to use a single vendor reduces
competition and may increase the costs. Requiring all vendors to use a
common data and/or communications protocol may reduce costs and
improve interoperability.

Cheers,
Nick
medi...@gmail.com
(714) 699-3549

PS: My comments are mine and not the opinions of my employer.

[tbouthillet]

Compare our current situation to one of the solutions proposed for the European Union where ECGs are converted to DICOM format and transmitted to existing PACS systems already in place at the hospital. It's incomprehensible that a hospital should have to purchase 3 different computer systems to receive ECGs from Physio, ZOLL, and Philips (although General Devices CAREpoint can receive from multiple vendors and I have recently been made aware of a system in Texas where Physio-Control's LIFENET has been modified to allow ECGs from another vendor).

In Issue 4 of the STEMI Systems newsletter (2007) "Optimizing prehospital wireless ECG transmission: new data, new ideas" Landman, Rokos, et al. propsed the CAPTURE method (CAmera Phone Transmission and Universal Routing of prehospital Electrocardiograms) where paramedics simply take a photograph of a diagnostic quality 12-lead ECG and email it to a dedicated email account at the receiving hospital for the cost of a minimum cell phone data plan.

One the one hand, the paramedic profession has left itself open to exploitation by not embracing 12-lead ECGs fully in our scope of practice. There's still not broad agreement on what paramedics should be taught, or even what paramedics are capable of being taught. Clearly it's not enough to "recognize ST-elevation on the 12-lead ECG" as so many studies have measured, because false positives continue to be a problem. Having said that, a "false positive" can mean the ED physician canceled the STEMI Alert or it can also mean that the patient was cathed and had no culprit artery, so I think it's important to clarify what is meant when we speak about false positives.

I definitely see value in transmitting the ECG for expert consultation (although there is significant variability in physician interpretation) and I have personally witnessed occasions where the ED physician "stood down" the STEMI Alert after pulling an old ECG for comparison while the patient was still in the field. Even when paramedics are appropriately trained, I see nothing wrong with an extra set of "critical eyes" screening patients before the cardiac cath lab is activated. Diverting to a STEMI Receiving Center is another issue, and there are certainly times that marginal cases should probably be diverted even if the cath lab isn't activated while the patient is still in the field.

At a minimum, I think EMS and paramedic organizations and associations should promote the principles of interoperability (non-proprietary formats) and access to data at the local, regional, state, and national level. To answer the question, yes I think ECG transmission has become the "million dollar solution to the 5 cent problem" but I also think the monster has already been born. At this point our best hope may be to help steer the medical device industry in the direction we'd like them to go, and the top of that list needs to be interoperability so we're not locked into one vendor. Competition is good and monopolies are bad.

Tom

--

Tom Bouthillet

Lieutenant / Paramedic

Town of Hilton Head Island

Fire & Rescue Division

843-247-3453 (cell)

ems12lead.blogspot.com

[Mic Gunderson]

The recent paper in PEC by Lee, Van Gelder and Cone, 'Early Cardiac Cath Lab Activation by Paramedics for Patients with ST_Segment Elevation MI' brings up several questions - directly and indirectly.

In order to make good clinical decisions are on the basis of the interpretation of the prehospital ECG, the false positive and false negative rates need to be within some sort of acceptable limits. What are those acceptable limits? Are those acceptable limits the same for all decisions? For example, does an ambulance decision decision to bypass the closest ED in favor of a hospital with 24/7 PCI need the same level of false positives and false negatives as the decision to activate the cath lab?

The answers to those questions may help frame the question of who, how and when the ECG is interpreted.

Let me begin this line of discussion by asking Drs. Lee, Van Gelder and Cone for their perspectives on the acceptable limits for false positives and negatives and if those limits vary with type of decision.

--- Mic

Mic Gunderson 
Editor/Moderator, NAEMSP Dialog;
President, IPS

---

From: naemsp...@googlegroups.com [mailto:naemsp...@googlegroups.com] On Behalf Of tbouthillet
Sent: Saturday, May 01, 2010 8:06 AM
To: naemsp...@googlegroups.com
Subject: Re: [NAEMSP Dialog] Re: EMS Role in Reducing the Symptom to Reflow Interval for AMI

[Lee, Christopher]

I would first like to thank Mic Gunderson and NAEMSP for providing this opportunity to discuss a very important and contemporary issue in EMS.

As we all know, faster times to the cath lab in STEMI save lives. It is logical that if a STEMI is recognized by a paramedic in the field, earlier activation of the cath lab would translate to earlier time to coronary reperfusion. However, at many hospitals across the country, the cath lab is only activated once the patient arrives in the ED, despite proper recognition by EMS. Dave Cone, Carin Van Gelder, and myself, along with our cardiology colleagues, have used our research to support the implementation of EMS cath lab activation in our own hospital.

As Mic and Tom both mention, this leads to several questions:
1. Can paramedics even recognize STEMI on prehospital ECG?
2. If not, can we transmit the image to a physician, and then, is ECG image transmission the "million dollar solution to a 5 cent problem"?
3. What are acceptable false positive rates, and how do we define a false positive?
4. Should we worry about false negatives?

As pointed out, very real technological and financial limitations currently exist for the majority of EMS agencies to implement ECG image transmission to an emergency physician or cardiologist from the field. The "million dollar solution" may be irrelevant because the "5 cent problem" isn't actually the problem we should be focusing on. ECG image transmission should occur if paramedics can not reliably recognize STEMI, but the paper by Trivedi, Schuur, and Cone (Can Paramedics Read STEMI on Prehospital 12-Lead ECG? PEC, 2009;13(2):207-214) showed that paramedics in our system were able to recognize STEMI accurately and reliably. This certainly needs to be evaluated in each individual EMS system, and continuing education and training for rhythm recognition needs to be incorporated into any paramedic program.

I agree with Tom that there is definitely value in expert consultation and having "another set of eyes" read a difficult ECG. However, protocols to activate the cath lab should be established only for clear-cut cases of STEMI. If a paramedic is faced with a borderline or difficult ECG in the field, one can argue that by taking the patient to the ED without activating, then there is no change in clinical care than what is currently being done. If the ED physician activates the cath lab on EMS arrival, the system has simply defaulted to the system currently in place. This is what would occur during a false negative, and therefore isn't as concerning.

Mic and Tom also raise interesting points regarding false positives. Tom is absolutely correct that a false positive can mean one of two things: either an EMS activation that was cancelled by the ED physician, or a cath lab activation of a patient that ultimately was found to have clean coronaries. In discussions with our cardiology colleagues, it was established that a false positive rate of approximately 10% was acceptable and expected. It is understood that a false positive rate of 0% would imply that there are cases that are being missed. In other words, interventional cardiologists expect to find a certain number of clean coronaries in order to ensure capture of the largest number of occluded coronaries. Therefore, even if realistic image transmission were to occur, there would still be a 10% false positive rate. In our study, our false positive rate was comparable to the standard and deemed acceptable by our cardiologists.

Activation of the cath lab by EMS should not mean that EMS needs to recognize every single patient requiring reperfusion therapy. This is difficult without old ECGs and records to compare, and in the setting of more nuanced ECG interpretations such as a new left bundle branch block in a patient with chest pain. However, for patients who have a unequivocally recognized STEMI, EMS activation can save their lives. EMS activation doesn't have to capture "all or none" in order to be of benefit overall.

Chris

------------------------------------
Christopher H. Lee, MD
Clinical Instructor, Fellow - EMS and Disaster Medicine
Yale University Department of Emergency Medicine
464 Congress Avenue, Suite 260
New Haven, CT 06519
ph 203.785.4710

On May 3, 2010, at 1:31 PM, Mic Gunderson wrote:


The recent paper in PEC by Lee, Van Gelder and Cone, 'Early Cardiac Cath Lab Activation by Paramedics for Patients with ST_Segment Elevation MI' brings up several questions - directly and indirectly.


In order to make good clinical decisions are on the basis of the interpretation of the prehospital ECG, the false positive and false negative rates need to be within some sort of acceptable limits. What are those acceptable limits? Are those acceptable limits the same for all decisions? For example, does an ambulance decision decision to bypass the closest ED in favor of a hospital with 24/7 PCI need the same level of false positives and false negatives as the decision to activate the cath lab?


The answers to those questions may help frame the question of who, how and when the ECG is interpreted.


Let me begin this line of discussion by asking Drs. Lee, Van Gelder and Cone for their perspectives on the acceptable limits for false positives and negatives and if those limits vary with type of decision.

--- Mic

Mic Gunderson
Editor/Moderator, NAEMSP Dialog;
President, IPS

________________________________

From: naemsp...@googlegroups.com<mailto:naemsp...@googlegroups.com> [mailto:naemsp...@googlegroups.com] On Behalf Of tbouthillet

Sent: Saturday, May 01, 2010 8:06 AM

To: naemsp...@googlegroups.com<mailto:naemsp...@googlegroups.com>

Subject: Re: [NAEMSP Dialog] Re: EMS Role in Reducing the Symptom to Reflow Interval for AMI

Compare our current situation to one of the solutions proposed for the European Union where ECGs are converted to DICOM<http://en.wikipedia.org/wiki/Digital_Imaging_and_Communications_in_Medicine> format and transmitted to existing PACS<http://en.wikipedia.org/wiki/Picture_archiving_and_communication_system> systems already in place at the hospital. It's incomprehensible that a hospital should have to purchase 3 different computer systems to receive ECGs from Physio, ZOLL, and Philips (although General Devices CAREpoint can receive from multiple vendors and I have recently been made aware of a system in Texas where Physio-Control's LIFENET has been modified to allow ECGs from another vendor).

In Issue 4 of the STEMI Systems<http://stemisystems.com/> newsletter (2007) "Optimizing prehospital wireless ECG transmission: new data, new ideas" Landman, Rokos, et al. propsed the CAPTURE method (CAmera Phone Transmission and Universal Routing of prehospital Electrocardiograms) where paramedics simply take a photograph of a diagnostic quality 12-lead ECG and email it to a dedicated email account at the receiving hospital for the cost of a minimum cell phone data plan.

One the one hand, the paramedic profession has left itself open to exploitation by not embracing 12-lead ECGs fully in our scope of practice. There's still not broad agreement on what paramedics should be taught, or even what paramedics are capable of being taught. Clearly it's not enough to "recognize ST-elevation on the 12-lead ECG" as so many studies have measured, because false positives continue to be a problem. Having said that, a "false positive" can mean the ED physician canceled the STEMI Alert or it can also mean that the patient was cathed and had no culprit artery, so I think it's important to clarify what is meant when we speak about false positives.

I definitely see value in transmitting the ECG for expert consultation (although there is significant variability in physician interpretation) and I have personally witnessed occasions where the ED physician "stood down" the STEMI Alert after pulling an old ECG for comparison while the patient was still in the field. Even when paramedics are appropriately trained, I see nothing wrong with an extra set of "critical eyes" screening patients before the cardiac cath lab is activated. Diverting to a STEMI Receiving Center is another issue, and there are certainly times that marginal cases should probably be diverted even if the cath lab isn't activated while the patient is still in the field.

At a minimum, I think EMS and paramedic organizations and associations should promote the principles of interoperability (non-proprietary formats) and access to data at the local, regional, state, and national level. To answer the question, yes I think ECG transmission has become the "million dollar solution to the 5 cent problem" but I also think the monster has already been born. At this point our best hope may be to help steer the medical device industry in the direction we'd like them to go, and the top of that list needs to be interoperability so we're not locked into one vendor. Competition is good and monopolies are bad.

Tom

--
Tom Bouthillet
Lieutenant / Paramedic
Town of Hilton Head Island
Fire & Rescue Division
843-247-3453 (cell)

ems12lead.blogspot.com<http://ems12lead.blogspot.com/>

On Fri, Apr 30, 2010 at 5:22 PM, Mic Gunderson <mic.gu...@gmail.com<mailto:mic.gu...@gmail.com>> wrote:
Let me begin by asking our invited participants to jump right into one
of the questions that we hope to address over the next several weeks.
Has ECG transmission become the "million dollar solution to a 5 cent
problem"? Transmission can involve thousands of dollars of computer
equipment, expensive modems, recurring monthly subscriptions,
restrictive licensing agreements, and a lack of interoperability
between defibrillator/monitor and ePCR platforms. All of this is in an
age when a picture can be emailed around the globe in seconds from a
handheld device at a minimal cost.

Chris, Carin, Nick, Tom, Dave (Cone) and Dave (Carter) - what do you
think?

--- Mic

Mic Gunderson
Editor / Moderator, NAEMSP Dialog;
President, IPS

--
You received this message because you are subscribed to the Google
Groups "NAEMSP Dialog" group.

To post to this group, send email to naemsp...@googlegroups.com<mailto:naemsp...@googlegroups.com>

To unsubscribe from this group, send email to

naemsp-dialo...@googlegroups.com<mailto:naemsp-dialog%2Bunsu...@googlegroups.com>

For more options, visit this group at
http://groups.google.com/group/naemsp-dialog?hl=en

Visit NAEMSP at http://www.naemsp.org<http://www.naemsp.org/>.

--
You received this message because you are subscribed to the Google
Groups "NAEMSP Dialog" group.

To post to this group, send email to naemsp...@googlegroups.com<mailto:naemsp...@googlegroups.com>

To unsubscribe from this group, send email to

naemsp-dialo...@googlegroups.com<mailto:naemsp-dialo...@googlegroups.com>

For more options, visit this group at
http://groups.google.com/group/naemsp-dialog?hl=en

Visit NAEMSP at http://www.naemsp.org<http://www.naemsp.org/>.

--
You received this message because you are subscribed to the Google
Groups "NAEMSP Dialog" group.

To post to this group, send email to naemsp...@googlegroups.com<mailto:naemsp...@googlegroups.com>

To unsubscribe from this group, send email to

naemsp-dialo...@googlegroups.com<mailto:naemsp-dialo...@googlegroups.com>

For more options, visit this group at
http://groups.google.com/group/naemsp-dialog?hl=en

Visit NAEMSP at http://www.naemsp.org<http://www.naemsp.org/>.

[Mic Gunderson]

Thanks for your excellent reply Chris.

I'd now like to open the Dialog up to discussion with everyone's
participation. Please feel free to ask questions, offer your comments and
observations, or reply to previous questions. Our objective here is to tap
in the collective wisdom of all the people on the list and information in
the literature to pose and answer, as best as we can, the key questions that
we are now facing in advancing our policies and protocols to reduce the time
lag between the onset of symptoms and restoring coronary flow in patients
with AMI.

A couple of reminders:
- Include your name and affiliation in the 'signature' at the end of your
posts.
- Please keep the same subject line in your replies
- Because this list is moderated, expect a delay between submitting your
reply or comment and it being sent out to all list members. I will do my
best to keep those delays as short as possible.

Thanks,

--- Mic

Mic Gunderson
Editor / Moderator, NAEMSP Dialog;
President, IPS

--
You received this message because you are subscribed to the Google
Groups "NAEMSP Dialog" group.
To post to this group, send email to naemsp...@googlegroups.com

[Mic Gunderson]

The false positive rate for the field interpretation seems to be a
pivotal issue. Is there consensus around this definition? How do the
various EMS provider organizations and hospitals represented on this
listserv operational define false positives in their systems?

[Laurie Romig, MD, FACEP]

I would argue that from an EMS perspective, the false positive rate would
reflect those patients who are being declared EMS STEMI Alerts who don't go
to the cath lab and not necessarily those who have clean arteries on cath,
especially where patients don't go to the cath lab without overread of the
12 lead or a quick reevaluation upon arrival. Of course we know that there
are a number of reasons that candidate patients don't go to cath that don't
reflect that EMS has "wrongly" called a STEMI Alert and we have to expect
those. In our area (the supposed "Land of the Newly Wed and the Nearly
Dead") it's very common for ECG changes to be old or for patients and/or
families to decide against cath due to chronic illness, age and/or debility.
Even though we've been doing differential PCI transport since 2002, we're
still very much a STEMI System in evolution, utilizing 12 lead transmission,
relatively rarely going directly to the cath lab and only now beginning to
get detailed outcome info on our STEMI Alert patients. We rarely miss
calling a STEMI Alert on an EMS patient who goes to cath, but are still
working with about a 40% cath rate and are trying to sort out some of the
contributors that we can impact with education, medical control guidance and
quality management. The recent statement about 10% being a reasonable false
positive rate is the first I've heard of a potential benchmark to work
towards.

Laurie A. Romig, MD, FACEP
Medical Director
Pinellas County (FL) EMS

-----Original Message-----
From: naemsp...@googlegroups.com [mailto:naemsp...@googlegroups.com]
On Behalf Of Mic Gunderson
Sent: Wednesday, May 05, 2010 8:48 AM
To: NAEMSP Dialog
Subject: [NAEMSP Dialog] Re: EMS Role in Reducing the Symptom to Reflow
Interval for AMI

[Marc Berenson]

Out of curiosity Dr. Lee, did the 10% false positive rate come from the literature or the opinions of the Cardiologists that you spoke with? (I'm not necessarily negating the validity of that benchmark, but in the age of EBM it's hard - not impossible, but hard - to convince folks of anything that isn't supported concretely).
 
I think you all make excellent points regarding the necessity of reducing intervals to reperfusion. I personally am an advocate for Paramedic interpretation of 12 Lead EKGs and subsequent activation of the Cath Lab as appropriate. I actually think E2B times should be tracked along with D2B times and used as a performance benchmark.
 
Here's my question: If we really want to reduce reperfusion times, then designating STEMI receiving centers and bypassing non-PCI capable hospitals is imperative. However, not all areas have the luxury of having those facilities within a reasonable distance. Therefore, should be we consider using Medevac to bypass local facilities (where significant delays to PCI can occur) if the patient can not be driven there in a reasonable distance?
 
One other note: It is important to remember that while reducing E2B times are well within the abilities of EMS systems, reducing symptom onset to balloon time requires a much broader and more lateral approach that requires participation from the primary care, cardiology and public health communities. EMS can have an impact here too; although I'd venture a guess that most systems have not adopted a public health role as part of their operations.

 

--
Marc Berenson
MICU Paramedic
Holy Name EMS
Hackensack University Medical Center
beren...@gmail.com

[Paul Rostykus]

We are working to clearly define false positives and false negatives
for our STEMI system.

We define a false positive as when our STEMI protocol (requiring both
clinical and ECG criteria) is not met and the cath lab is activated by
the EMS radio call of "STEMI Activation", such as > 12 hours of
cardiac chest discomfort, no cardiac chest comfort (such as syncope or
nausea only), presence of a LBBB or a paced rhythm, or no ST
elevation. These are relatively easy to track.

In a similar fashion, a false negative is when our protocol criteria
are met and the cath lab is not activated by EMS. These, we find
harder to track.

About 97% of STEMI patients go to the cath lab. About 95% get PCI or
stent.

EMTs call "STEMI Activation" in the field - we do not transmit.

Paul S. Rostykus, MD, MPH
Jackson County (OR) EMS Supervising Physician

[Mic Gunderson]

(Posted on behalf of Marv Wayne, MD)

5 years of data have been reviewed in a system that does not transmit
EKG due to geography. Our worst year was 8% over call and 4% under.
Door to balloon time is actually shorter on EMS Cath Code
activations. Results continue to be excellent. Transmission is
helpful where it is cost effective but I think this shows medics can
be trained to read EKGs well. Just my 2$ (cents are worthless in
today’s economy)

Marv Wayne, MD
Associate Clinical Professor, University of Washington;
Attending Physician, Emergency Department, St Joseph Medical Center;
EMS Program Director, City of Bellingham, WA

[DW...@schertz.com]

Mic,

In San Antonio, we have struggled with this "definition" and we are
carrying forward a suggesting to adopt the following language:

1. TRUE: Patient met Pre-Hospital Heart Alert Criteria, hospital was
notified, patient went to cath lab (or didn't due to contra-indications)
2. FALSE: Patient DID NOT meet Pre-Hospital Heart Alert Criteria,
hospital was notified that they did, patient did not go to the cath lab
emergent
3. MISSED: Patient met Pre-Hospital Heart Alert Criteria, hospital WAS
NOT notified, patient went to cath lab (or didn't due to
contra-indications)

We feel the measurement we need to focus on is whether or not the
patient met the criteria in the pre-hospital environment that warranted
bringing in personnel to the cath lab (team and interventionalist). We
were getting all tangled up in the pre-hospital feedback on whether or
not the patient went to the cath lab and honestly, that is not purview
of the pre-hospital personnel. We look at it similarly to trauma, did
the patient meet our regions definition of "Trauma Alert" and if so, the
accuracy of the pre-hospital efforts should not be judged on whether or
not the patient was taken to surgery by the trauma surgeon.

A great example from my agency was a patient we had, female, atypical
ACS symptoms (sudden on set weakness) who was showing ST elevation in
M1-M4. A Heart Alert was initiated and the patient delivered to our PCI
center. By our definition, the outcome was TRUE for this case even
though the cardiologist and family opted NOT to take this patient to the
cath lab since she was 104 years old. (age is not an indicator for our
criteria).

Dudley

"Do not follow where the path may lead. Go instead where there is no
path and leave a trail" - Ralph Waldo Emerson

Dudley Wait
EMS Director
City of Schertz EMS
1400 Schertz Parkway
Schertz, TX 78154
210-619-1400 (O)
210-619-1499 (F)
210-488-4243 (C)

************Confidentiality Notice************
The information in this email may be confidential and/or privileged. If
you are not the intended recipient or an authorized representative of
the intended recipient, you are hereby notified that any review,
dissemination or copying of this email and its attachments, if any, or
the information contained herein is prohibited. If you have received
this email in error, please immediately notify the sender by return
email and delete this email from your computer system. Thank you.

-----Original Message-----
From: naemsp...@googlegroups.com
[mailto:naemsp...@googlegroups.com] On Behalf Of Mic Gunderson
Sent: Wednesday, May 05, 2010 7:48 AM
To: NAEMSP Dialog

Subject: [NAEMSP Dialog] Re: EMS Role in Reducing the Symptom to Reflow
Interval for AMI

[tbouthillet]

I think there are two take-home lessons here. First, we need to define exactly what we're talking about when we use the term "false positive". Second, we need to look at every single EMS-initiated "STEMI Alert" (or whatever you call it in your jurisdiction) and define exactly what caused the problem.

• Was it poor data quality or poor lead placement? This is extremely common.
• Was it an STE-mimic like LBBB, LVH, BER, or pericarditis? These are the best learning opportunities for a prehospital 12-lead ECG program.
• Did the patient not meet the clinical criteria? Certainly requiring a chief complaint of chest discomfort increases the specificity of EMS-initiated STEMI Alert, but are we missing atypical presentations? Should patients with abnormal neuro exams be excluded?
• Was the patient not cathed because they were a DNR or had an allergy to contrast dye (however, the ECG clearly showed acute STEMI). Does the prehospital criteria need to be modified?

It's also worth noting those situations where the patient did not meet the STEMI Alert criteria but ended up with a discharge diagnosis of STEMI or NSTEMI.

We have identified a handful of cases where an isolated posterior STEMI was missed, but the patient did not meet the "1 mm of ST-elevation (2 mm in leads V2 or V3) in 2 more more contiguous leads" criteria. In one case, the patient was not cathed until > 24 hours later and the discharge diagnosis was NSTEMI. One has to wonder how often that happens.

Additionally, I think we should attempt to identify patients who showed acute STEMI in the presence of LBBB or paced rhythm according to Sgarbossa's criteria (or the modified criteria that take into account the depth of the S-wave when measuring discordant ST-elevation) since those are high-risk patients.

I don't know if anyone saw Chang AM, Shofer FS, Tabas JA, et al. Lack of association between left bundle-branch block and acute myocardial infarction in symptomatic ED patients. Am J Emerg Med 2009;27:916-921 but "new LBBB" (previously undetected LBBB) may not be a particularly sensitive marker of AMI, and almost half of LBBB patients in the Larson study had no culprit artery.

Having said that, I worry about the "false negatives" that have marginal ECGs or baseline abnormalities that are triaged to non-PCI hospitals and end up receiving no reperfusion. These are very difficult to track.

I'm also not convinced that every patient who "receives a stent" in the cath lab is experiencing an acute thrombotic event in an epicardial coronary artery, but at some point you have to pick end point and there are some gray areas.

One thing I've suggested is that all the cards be placed on the table at our multi-disciplinary STEMI meetings. In other words, how many total patients (including walk-ins) were cathed and had no culprit artery? This is the only way to provide context for EMS-initiated STEMI Alerts. If 30% of patients fast-tracked to the cath lab by ED physicians have no culprit artery, then let's take that into account when we judge the number of "false positive" STEMI Alerts called by EMS.

I agree that a < 10% "false positive" rate for patients emergently cathed is a benchmark we should all be shooting for if we're defining "false positive" as "no culprit artery" but I suspect the actual number is much higher nationally.

I personally think the "false positive" rate for EMS-initiated STEMI Alerts that are canceled by the ED physician or cardiologist (patient is not emergently cathed) can and should be variable based on what the hospitals and physicians in a given locality are comfortable with.

One recent study from Southern California showed a 25.7% rate of "false positives" which sounds pretty bad, except that 22.9% were STEMI Alerts canceled by the ED physician. Only 2.8% had no culprit artery, which is pretty impressive, assuming there weren't a lot of missed STEMIs, which is not something the paper examined.

So if you look at it like a funnel where EMS puts potential STEMI patients in the pipeline and the ED physician acts as an additional filter, a 30% "false positive" rate might be perfectly acceptable.

In another community where the cath lab is being activated on nights, weekends, and holidays, and 30% of the time it's a false alarm (or a significantly higher rate of "no culprit artery" when compared to ED physicians) that could be a problem.

So I think we need robust data collection if we want to do apples-to-apples comparisons because every system is different and the devil's in the details.

Tom

--

Tom Bouthillet

Lieutenant / Paramedic

Town of Hilton Head Island

Fire & Rescue Division

843-247-3453 (cell)

--

[David Carter]

The question is not can a well trained Paramedic accurately recognize
STEMI or even an acute NSTEMI, it is dealing with the inconsistently
across America. The Society of Chest Pain Centers has accredited over
580 Chest Pain Centers in the US. Somewhere around 10% have EMS
activating the cath lab from the field, bypassing the closest and taking
the patient directly to a waiting cath lab team. Sadly, about 30%
(perhaps more) of EMS services lack 12 lead capabilities (my stats are a
SWAG). It's great if you live in a community that is in the top 10%
until you go on vacation..... As leaders of EMS we need to raise the
minimum acceptable level of care across the US.

-----Original Message-----
From: naemsp...@googlegroups.com
[mailto:naemsp...@googlegroups.com] On Behalf Of Mic Gunderson

Sent: Wednesday, May 05, 2010 4:02 PM
To: NAEMSP Dialog
Subject: [NAEMSP Dialog] Re: EMS Role in Reducing the Symptom to Reflow
Interval for AMI

[DW...@schertz.com]

The 2009 AHA EMS Survey showed that only 50% of EMS units across the
nation have 12-lead capability on at least 75% of their units. That is
very bothersome...especially where I like to vacation! :)

I agree with raising the minimum standard, and support that strongly,
however, I can tell you that within 60 minutes drive time from the 7th
largest city in the nation (San Antonio) there are EMS agencies that are
selling pancakes and sausage (not at the same time) just to put diesel
in the tanks. Asking them to have 12-lead capability when they have
this level of funding difficulty can get you some rather humorous looks
and comments.

We laugh in state meetings that there are trauma departments, cardiology
departments and neuro departments in hospitals and healthcare...yet when
someone is having chest pain, they do not get the "cardiac
ambulance"...they get the AMBULANCE. In our quest for better
reimbursement models, one of those has to be that agencies that invest
in these specific care issues must be able to be reimbursed at a higher
level than those that do not...and making it public like hospital core
measures probably wouldn't hurt either.

Dudley

"Do not follow where the path may lead. Go instead where there is no
path and leave a trail" - Ralph Waldo Emerson

Dudley Wait
EMS Director
City of Schertz EMS
1400 Schertz Parkway
Schertz, TX 78154
210-619-1400 (O)
210-619-1499 (F)
210-488-4243 (C)

[Launa Nielson]

I definately agree with you.
1) We need to raise the minimum standard of training for EMTs (yes,
volunteer too). The ones who usually complain the loudest are the fire/ems
agencies because they have to train in both fire and EMS. But a basic
firefighter class is 180 hr. EMT is 130 hrs. Something is wrong there.
Separate them so the EMTs CAN spend the extra time.
2) We are a rural paid volunteer agency (intermediate advanced) that reads
our 12 leads, calls the cath lab and bypasses our community hospital. We
sometimes goof and go straight to our local hospital if we aren't sure=1-2
hr delay. We are getting better however. The only reason we can do any of
this is because our medical director is extremely active in our agency.
Other agencies just laugh and say "our doc won't even come to one training a
year". He fights for us, trains us, and helps us with everything (for no
pay).
3) We have been very lucky and have been able to use the homeland security
grants for a number of purchases -- MANY EMS agencies aren't allowed any of
that federal money by their local law and fire departments.
4) EMS really needs the help of medical leaders. We are so busy with runs
and training we just don't have time for lobbying and "politicking". Yet I
know that is where we need to be.
5) We have had to fight so hard and long to be where we are today; EMS
agencies shouldn't have to fight to improve/advance, they should be
encouraged and helped.

Great information--thanks for having this discussion!
Launa Nielson
Wasatch County EMS
Heber City, UT

[Mic Gunderson]

(posted on behalf of David Carter)

If we were able to persuade CMS to increase reimbursement to an ALS 2
level for patients that received a medically necessary 12 lead, do you
think that would influence more services to acquire 12 lead capability
(and training)?

David Carter
Sarasota Memorial Health

[Launa Nielson]

Speaking for our agency and some other rural ones we have talked to, yes
there would be more interest if you could receive extra reimbursement for
doing a 12 lead. At the present time we supposedly cannot even bill for
them -- necessary or not--as we can't bill for reading them and we already
have a small fee for our cardiac monitor. We had to think long and hard
about spending the extra money for 12 leads when we can't even bill for
them. They ended up costing 9% of our annual budget (not including
training) BUT since we are all getting grey we decided it was worth cutting
some other areas. (-:

Can other areas of the country bill extra for doing and reading 12 leads? I
know the ED docs say they can't bill for reading them, only the
cardiologists get the money for that. Would that apply to us also? If
anybody knows how to legally and ethically bill for 12 leads we would
definately be interested.

Launa Nielson
Wasatch County EMS

----- Original Message -----
From: "Mic Gunderson" <mic.gu...@gmail.com>
To: "NAEMSP Dialog" <naemsp...@googlegroups.com>
Sent: Wednesday, May 05, 2010 7:30 PM
Subject: [NAEMSP Dialog] Re: EMS Role in Reducing the Symptom to Reflow
Interval for AMI

[Nick Nudell]

This is an excellent question and the discussion so far has been great.

 

With our intense focus on STEMI's and 12lead machines, we run the risk, as STEMI systems continue to develop, to lose sight of the big picture. What is important to the patient? 30% of them die every year before we get to talk to them, so perhaps our sample is biased?

 

Is the STEMI presentation (by 12 lead EKG alone) really the best that can be done? Are there other factors that could reduce the false +/- transports, tests, procedures, medications, etc?

 

These are questions I think about every day as some of you know. I'm interested in the thoughts of this distinguished group.

Cheers,

Nick

 

___________________
Nick Nudell
medi...@gmail.com
(714) 699-3549

[Mic Gunderson]

Given the financial barrier of purchasing 12 lead capable machines in
systems where funding for such technology is a REAL issue, is anyone aware
of places where STEMI screenings are being done with MCL leads as surrogates
for the V leads using the older 3 lead machines recording in 'diagnostic'
mode?

--- Mic

Mic Gunderson
Editor / Moderator, NAEMSP Dialog;
President, IPS

-----Original Message-----
From: naemsp...@googlegroups.com [mailto:naemsp...@googlegroups.com]

[Lee, Christopher]

I agree that maintaining (and expecting) a high standard of EMS care across the country is critical in advancing our specialty. Credibility in the public's eye and the potential for future financial reimbursement lies in our ability to provide standard "modern medicine" regardless of geographic location. However, this geographic fragmentation in medical care is not limited to EMS systems; a good recent example is therapeutic hypothermia for cardiac arrest survivors. Although the landmark studies for therapeutic hypothermia were published 8 years ago, only within the past year have many major medical centers finally started hypothermia protocols. This delay of close to 10 years seems to be typical for changing people's minds and behaviors, particularly in a traditional field such as medicine, which historically has been slow to accept change. Although many hospitals now have therapeutic hypothermia, any one of us may still be unlucky enough to vacation in a spot that simply doesn't have it...

Just as paramedics are now entrusted with the responsibility of ECG STEMI interpretation, it wasn't that long ago when cardiologists weren't so quick to give that responsibility to emergency physicians either. Times definitely change, albeit slowly.

In response to Marc's excellent question regarding a 10% false positive rate, this rate was not based in the literature. One of the reasons we approached our cardiology colleagues regarding this was that we simply did not know what an "acceptable" false positive rate would be. And they admitted as much that as a group, they came to the consensus that "around 10%" was going to be acceptable. Certainly this is very location specific. As we've seen in this discussion forum, the rates vary widely across our systems. Marc also brings up an excellent point that evidence based medicine will give us the most credibility when proposing protocol and patient care changes. Only by conducting sound scientific research can we legitimately advance EMS care and support multi-disciplinary early goal directed therapies (STEMI, sepsis, trauma, etc). My hope is that as we continue to collect data as a whole, a gold standard false positive rate can be identified.

I just saw the posting from Launa about ECG billing. I know that emergency physicians in our hospital definitely bill for ECG interpretation nor should this be limited to cardiologists. In fact we are often hounded for this very reason when we forget to sign the appropriate place for ECG interpretation in our charts...Whether or not paramedics can bill for interpretation is an excellent question that I would also be curious to know the answer.

Chris
------------------------------------
Christopher H. Lee, MD
Clinical Instructor, Fellow - EMS and Disaster Medicine
Yale University Department of Emergency Medicine
464 Congress Avenue, Suite 260
New Haven, CT 06519

ph 203.737.5090

[David Carter]

Currently EMS payments are limited to a all inclusive fee schedule.  CMS does not allow itemized charges such as 12 lead, thrombolitics, CPAP, ect.  Our revenue stream does not encourage good patient care.  Example, if you place a patient on CPAP and prevent an intubation, the patient wins and EMS looses:  Intubation=ALS 2, CPAP=ALS 1 a $150 loss of net revenue, the CPAP cost approximately $50 so the net loss is approximately $200...  The hospital wins by reducing the patients length of stay by approximately 2-3 days... We have multiple areas we need to address to affect culture shift and improve the overall system. 
 
There is a larger group becoming aware of issues such as the ones I described above.  As a group, EMS has a weak voice.  We need our hospitals, cardiologist, EM Doc's to help give us a voice.  Regional meetings with our hospitals is a excellent place to raise awareness.  Our state medical directors are another strong group we need to solicit help from.  They are in a pickle because they can not issue an unfunded mandate such as all ALS units must have 12 lead or CPAP capability.... 

---

Hotmail is redefining busy with tools for the New Busy. Get more from your inbox. See how.

[Cone, David]

Not to take this discussion off on a tangent, but I'm worried about this snippet from the below post:

"But a basic firefighter class is 180 hr. EMT is 130 hrs. Something is wrong there."

What do you mean?

Dave
--
David C. Cone, MD
EMS Section Chief
Yale Emergency Medicine
Editor-in-Chief
Academic Emergency Medicine
www.aemj.org

-----Original Message-----
From: naemsp...@googlegroups.com [mailto:naemsp...@googlegroups.com] On Behalf Of Launa Nielson
Sent: Wednesday, May 05, 2010 8:26 PM
To: naemsp...@googlegroups.com

[Launa Nielson]

The basic ff class is 180 hrs yet the basic EMT course is only 130 hrs.
Much of the pressure to shorten the basic EMT course came from national fire
groups because their volunteers didn't have time to take a longer EMS course
. I think its sad we currently think a house is more important than a
human life.

The new nationally recognized EMS levels (in my VERY humble opinion) blew it
also. They 'dummied' down the intermediate class. When you take your
vacation in rural America, chances are the highest level you will find in
the future is an extremely limited "advanced" EMT. Shouldn't we be
encouraging (pushing) increased education for volunteer EMS, not making it
easier just so other groups can easily obtain an ems certification too?

We are only an hour from a trauma one facility yet MANY areas in my state
are 6-7 hours away from one. I am referring to roads, not backpacking
areas. One frequently can not call a helicopter due to weather so you may
be with a volunteer crew for a long time. (3-4 hrs from ANY hospital is not
uncommon)

As volunteers we find it almost impossible to put in 1200 hrs of
training/education all at once. Yet we could do it if we could slowly build
on class after class. With the new levels that is impossible. Its pretty
tough to mandate 12 leads if EMTs are only taught to recognize v-fib,
v-tach, asystole, sinus brady and sinus tach. I am our agency's training
officer. While we do have a few who don't want to learn more, most eat it
up and beg for more. But it has to be doable (small amounts) with a family
and full time job.

Sorry for the long reply, as you can tell this is a sore spot with me.

Launa Nielson
Wasatch County EMS

[Mic Gunderson]

Dave and Launa,

I allowed the question from Dave and thank you Launa for the reply
below. This is off-topic, so let's leave this line of discussion off
here.

Thanks,

--- Mic

Editor / Moderator, NAEMSP Dialog;
President, IPS

[Gary....@memphistn.gov]

Thank you Mic since we all know that the National Standard Curriculum is developed by all stakeholders involved in EMS, not just fire organizations.
Gary Ludwig

----- Original Message -----
From: naemsp...@googlegroups.com <naemsp...@googlegroups.com>
To: NAEMSP Dialog <naemsp...@googlegroups.com>

Sent: Thu May 06 09:54:03 2010
Subject: [NAEMSP Dialog] Re: EMS Role in Reducing the Symptom to Reflow Interval for AMI

[Derek Isenberg]

How would the discussants response to those people who say that the cost of implementing 12-lead ECGs in the field is not cost efficient.

For example, if a system runs:
100,000 calls per year
2% of those calls are chest pain calls=2,000 calls a year and
1% of those calls are STEMIs-20 patients a year.

How do we justify the cost of the equipment and training of our medics for 20/100000 patients?

Sincerely,

Derek Isenberg, MD
EMS Medical Director
Mercy Fitzgerald EMS
Darby, PA

[Margaret Keavney]

Regrding billing extra for 12 lead application and interpretation:

A certain percentage of our patients are Medicare beneficiaries, and we would have to change the law to be allowed to bill for that.  Not impossible, but a very heavy lift.

In every commercial insurance contract I've ever seen for ambulance services, the insurance company takes an ancillary provider or physician contract, substitutes the work "ambulance" and plops in the HCPCS codes from the ambulance fee schedule with a rate.  In order to be able to bill those payors for those services, we need to change that model.  You can negotiate with an insurance company that they WILL pay for those services.  I imagine the conversation would go like this:

"When your member is having a STEMI, we can find out and bring them directly to the PCi hospital.  or, without this technology, we being them to the closest facility for a 12 lead.  When they find what we would have found in the field,they will discharge the patient and call another ambulance to take them to the STEMI hospital.  You will incur another ambulance bill AND an extra ED visit bill, including the physician and lab portions.  So, would you like to pay us for the field 12 lead?"

Margaret A. Keavney, Esq.
732-610-7100

www.njemslaw.com
Twitter: @keavneylaw
Ambulance Law Update: http://njemslaw.com/posts/