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Prehospital 12 lead ECG programs
Does your service perform prehospital 12 lead ECGs?
Does the prehospital 12 lead ECG help determine your transport destination?
Is the cath lab activated based on the prehospital 12 lead ECG?
Does your program rely on the paramedic interpretation of the 12 lead ECG? Does your program rely on computerized interpretation of the 12 lead ECG? Does your program rely on off-site interpretation of the 12 lead ECG by a physician? Does your program utilize a combination of these three methods?
If the prehospital 12 lead ECG is transmitted for off-site interpretation by a physician, what technology are you using? What is the failure rate? How is the data quality?
What was your initial education in 12 lead ECG interpretation?
Did it include a strong emphasis on STE-mimics (left bundle branch block, paced rhythm, left ventricular hypertrophy, benign early repolarization, pericarditis, hyperkalemia, etc.)?
Is there anything notable about your QA/QI process (regular multidisciplinary meetings at the hospital, data sharing, every 12 lead ECG reviewed by the Medical Control Physician, paramedics taken out of service and allowed to watch the cath procedure, etc.)?
Is your state involved in regionalizing STEMI care (similiar to trauma)?
How often are you called to the local community hospital for interhospital transfer of STEMI patients for primary PCI?
What has been the biggest barrier to the success of your prehospital 12 lead ECG program?
Does the prehospital 12 lead ECG help determine your transport destination?
Is the cath lab activated based on the prehospital 12 lead ECG?
Does your program rely on the paramedic interpretation of the 12 lead ECG? Does your program rely on computerized interpretation of the 12 lead ECG? Does your program rely on off-site interpretation of the 12 lead ECG by a physician? Does your program utilize a combination of these three methods?
If the prehospital 12 lead ECG is transmitted for off-site interpretation by a physician, what technology are you using? What is the failure rate? How is the data quality?
What was your initial education in 12 lead ECG interpretation?
Did it include a strong emphasis on STE-mimics (left bundle branch block, paced rhythm, left ventricular hypertrophy, benign early repolarization, pericarditis, hyperkalemia, etc.)?
Is there anything notable about your QA/QI process (regular multidisciplinary meetings at the hospital, data sharing, every 12 lead ECG reviewed by the Medical Control Physician, paramedics taken out of service and allowed to watch the cath procedure, etc.)?
Is your state involved in regionalizing STEMI care (similiar to trauma)?
How often are you called to the local community hospital for interhospital transfer of STEMI patients for primary PCI?
What has been the biggest barrier to the success of your prehospital 12 lead ECG program?
Tags: 12, STEMI, lead, prehospital
Views: 498
Replies to This Discussion
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Permalink Reply by ArcticKat on -
Hmmm, Yes, No, Yes, No, No, Yes, Yes, LP12 with digital cellular fax modem in vehicle, Nil, No, Yes, Yes, No, No, 10 - 15 per year, Not Applicable.
We started a 12 ECG transmitting program in 2001. They get faxed to the local hospital for the purpose of providing our doc an additional tool for determining the STEMI prior to our arrival and reducing the door to needle time. Ours is a small service and our ALS staff was trained long before prehospital 12 leads were available, so 12 lead interpretation skills were not significantly taught. It was only a minor orientation. Current paramedic training is significantly more involved in 12 lead interpretation.
When we got our LP12s in 2001 the medics took some remedial training with a 2 day course in 12 lead interpretation. These classes involved identification and location of STEMI, Right side and posterior ECGs, Various blocks, electrolyte imbalances, LVH, and causes of global ECG changes.
We have just added a new weapon to the arsenal by including the ability for our medics to conduct a blood test in the field for Troponin I, CK-MB, and Myoglobin. The blood test requires about 5 - 10 minutes for the results on a simple IVDD. This is a precursor to eventual thrombolytic therapy in the field. Our nearest cath lab is a 150 mile drive, the intent is to save a significant amount of time by treating with thrombolytics prehospitally and bypassing our local facility completely.
Hope this helps.
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Permalink Reply by Robert B on -
Both services that I work for in VT operate a STEMI protocol. We provide ALS services at the EMT-I level with medic intercepts if required. Intermediates (and Basics, if trained in house) will perform at least two 12 Leads in the field, and if the computerized analysis shows Acute MI or ST Elevation we will (potentially) change our transport destination to a hospital equipped with a 24Hr Cath Lab and let them know by radio or phone that we are declaring a STEMI alert. The hospital will then bring all necessary people to the ED and get the Cath Lab ready. Education for 12 Leads was mainly in house, with little content being included in the EMTI-03 protocol. Our receiving hospital carried out monthly Paramedic reviews (to which others are welcome), where all STEMI alert cases are reviewed.
I would say in general that the time I have used this it has worked very well and has positively affected patient outcomes. That said, I look forward to graduating my Medic program and having a greater depth of knowledge in Cardiology.
I hope this answers your question...
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Permalink Reply by stlmedic on -
Yes we have 12 lead written into our protocols very liberally. How it's done varies from medic to medic. We have several good hospitals in our area and so we're generally able to go to the hospital of patients choice. The only time really that the 12 lead would affect the transport decision would be when someone wants to pass one of our trauma centers to go to "their" hospital. Still most of our hospitals are within a pretty central corridor, so as long as their choice is within that corridor i'll try to accomodate for medical calls. And of course I won't take someone that I think will need the cath lab to one of the few "bandaid stations". Currently (and for anytime in the distant future) we do not have a way to send 12 lead to the receiving hospital. Interpretation is up to the medic, and I would hope that most of our medics don't rely on the machine interpretation however, there are some that I would prefer they use the machine. Sad, but our standards aren't the highest.
There's not much emphasis on learning 12 lead in medic school around here. In my class we spent just under and hour on 12 leads and only to determine where the infarct is. So after I had my license in hand, I went out and bought a Bob Page 12 lead book and self taught myself.
We typically don't do transfers, the private agencies around here handle all that. However, we do get called to various clinics for chest pain calls on a pretty regular basis. Sometimes legit, sometimes not.
Generally it's kind of up to us to police ourselves. We have a solid QA program, but after your 6 month probation it's not looked at near as much.
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Permalink Reply by Tom Bouthillet on -
ArcticKat - May I please know the make and model of your cell phone and digital cellular fax modem? Is it Bluetoothed?
Robert B - I think it's great that basics and intermediates are allowed to capture 12 lead ECGs at the point of patient contact. May I please know what determines the need for an ALS intercept?
stlmedic - Many services rely on the GE-Marquette 12SL interpretive algorithm, because the ***ACUTE MI SUSPECTED*** message has a high specificity (especially for chest pain patients with heart rates < 100 and good data quality).
Thanks for the comments!
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Permalink Reply by Jamie (Izer) Wieder on -
Wow, there are quite a few questions there....Our system has a great Stat cath program that starts in the field.
12 leads are performed here. This past summer, we had the Multi-lead medic course. (I'd recommend it). We're now jumping on the bandwagon of right sided and poseterior EKGs. The 12 lead does determine the transport decision; Williamsport Hospital has a cath lab. We also have a transfer arrangement for walk-ins to a community hospital about 20 minutes away. When the ER doc at that hospital recognizes STEMI pt, they call our transport service for an emergency transfer up to the cath lab. Whatever isn't done, we attempt to get done during transport (shaving, gown, labs, IVs etc).
We activate the cath lab based on our interpretation of the prehospital EKG.We do have the ability to transmit the EKG to the ER if we have the time and cell service. Transmission is easy and takes only a few minutes depending on quality of cell service. Data quality is good, they're able to read it just like it printed right out of the machine. It comes onto a computer and ER staff does have the ability to print it.
Transmission does help the cardiologist and ER physician know whats going on with the patient prior to our arrival. They usually have orders waiting there or the cath lab ready and we go straight upstairs. We call report with the pts name, birthdate, and cardiologist (if they have one) so the staff can get the pt registered and pull old EKGs/Charts PTA.
My initial training was in paramedic school through lectures, labs, and my own self-studies.
Every STEMI gets CQI'd by staff and on up the chain. We get feedback with every stat cath that we bring in. This feedback consists of times, arteries involved, and personal notes from our admin staff.
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Permalink Reply by Tom Bouthillet on
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Sounds like you guys have a great program, Jamie! I'm impressed that you guys even prep the patient (by "shaving" I'm assuming you mean you shave the groin). I see you transmit with cell technology. May I please know what kind of phone and modem you are using, and if it is Bluetoothed? Also, has anyone raised the issue of the "sunset" of Circuit Switch Data technology? I recently attended a meeting at my local hospital and the sales reps from Physio-Control told us that Verizon would be phasing out CSD technology within 2-6 years and they are recommending their web-based "STEMI Solution" that uses Internet Protocol (IP). If anyone is knowledgeable about this issue I would like to pick your brain. Thanks again!
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Permalink Reply by Trevor on -
We, in Austin have multiple "STEMI Centers" that we are able to bring our STEMIs to, obviously depending on what part of town we're in and where the patients cardiologist goes. We have LP12s and the capability (if time permits) to transmit a copy of the 12 lead to the receiving facility. When we determine that our patient is a "STEMI alert" we notify comm and tell them which hospital we will be transporting to, they call the receiving hospital and usually the cathlab is usually activated when we call a "STEMI alert". Frequently our medics will bring the patient DIRECTLY up to the cath suite. Only to stop at the ER for the ED MD and Cardiologist to look at the field ECG, the patient sometimes doesnt even get off our cot.
We have "CE session" 4x/year where we are "reassigned" off the truck for 2 days and go to the academy and receive CE. Every session we have STEMI and ECG reveiw (which includes reveiw of mimicers.)
A large share of our medics (myself included) went to Austin Comm. College for school and in that curriculum there is a Cardiology class which is a semester long.
Everytime we call a "stemi alert" we get feedback from our QA/QI dept. If the patient goes to the cathlab we usually get a "feedback" email stating which artery, how occluded, and outcome, sometimes they even send us fluroscopy pics from the cath.
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Permalink Reply by Tom Bouthillet on
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That's awesome! Thanks for the reply, Trevor. I've heard many good things about Austin-Travis County EMS, but I'm always happy to hear more!
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Permalink Reply by ArcticKat on
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Tom Bouthillet said:ArcticKat - May I please know the make and model of your cell phone and digital cellular fax modem? Is it Bluetoothed?
DO NOT GET BLUETOOTH IN YOUR LP12!!! Sorry, got my hackles up. I paid 1300 bucks to upgrade one of my LP12s to blue tooth, only to discover that the LP12 does not fax through bluetooth, it will only connect to my computer via bluetooth to do a data dump to the Lifenet software. Check closely with your cellular provider to determine if their cellular signal can conduct data transfers. Just because your cell phone is internet capable doesn't mean it can transfer LP12 data to a receiving station. I was able to bluetooth connect to my cell phone, and even though I could not fax, I could have sent data if my cellular company provided the service.
Now, on to the fax capability. We have the Motorola M800 mounted in our ambulance, but to be able to fax you will need to add a module that cost me about $1000,00 The LP12 has a standard phone cord connected to an internal modem, the phone cord plugs into the phone jack beside the monitor. I leave it unplugged until I plan to fax, because it tends to damage the cord when I grab the LP12 to go into the house and yank the cord out. :D. It can also be used at the scene in the same manner, just plug into the wall phone jack.
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Permalink Reply by Tom Bouthillet on
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But how do you feel about Bluetooth, Kat??? LOL! :) Our LP12s communicate with our cell phones via Bluetooth and then (somehow) transmit to the LIFENET Receiving Station at the hospital. However, as I mentioned before, we were recently notified by the Physio rep that it's "sunset" technology that will be phased out in 2-6 years.
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Permalink Reply by Robert B on
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It's really up to the individual provider to determine if they feel a Medic intercept is warranted, and that comes as much from the provider's own experience and comfort level. An intermediate with more experience may have an idea of what interventions a medic can perform and what they cannot. We can administer NTG, O2 and ASA as part of our CP protocol - if the 12 lead shows other dysrhythmias then a medic would be useful for an intervention, TCP or whatever. In other words, there's no set SOP on when/if a medic is called for a STEMI call.
Tom Bouthillet said:ArcticKat - May I please know the make and model of your cell phone and digital cellular fax modem? Is it Bluetoothed?
Robert B - I think it's great that basics and intermediates are allowed to capture 12 lead ECGs at the point of patient contact. May I please know what determines the need for an ALS intercept?
stlmedic - Many services rely on the GE-Marquette 12SL interpretive algorithm, because the ***ACUTE MI SUSPECTED*** message has a high specificity (especially for chest pain patients with heart rates < 100 and good data quality).
Thanks for the comments!
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Permalink Reply by Lee Meyer on
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Denver CO. All hospitals participate in a "cardiac alert" program. If a paramedic has a patient that is between 35-80 years of age, presents with signs and symptoms of ACS, has ECG ST changes of > 1mm or more in two or more continuous leads, and has a narrow complex QRS (no LBB, RBB etc.), then they meet the criteria. THe paramedic makes the call, no transmission of ECG etc. He/she calls the closest ER, or most appropriate ER and calls a "cardiac alert" for the patient. Upon arrival, x-ray, ECG, lab, cardiologist etc. will be waiting. The cath lab has been activated and is ready. Most hospitals have patients to the lab within 15 minutes of arrival. There are select handfull that have this process down to 5-10 minutes.
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