Oklahoma City and Tulsa have experienced one of the highest cardiac arrest survival rates in the country, but Oklahoma’s EMS leaders aren’t resting on their laurels. Instead, they’re planning a statewide ST-elevation myocardial infarction (STEMI) referral network in order to boost survival rates across Oklahoma’s urban and rural areas.
The plan involves implementing new statewide protocols, making 12-lead ECGs universal among EMS units, and having paramedics and EMTs transmit ECG data to hospitals in order to ascertain the best receiving facility.
A Fine Record
The metropolitan areas of Tulsa and Oklahoma City are covered by Emergency Medical Services Authority (EMSA), a public trust authority that’s Oklahoma’s largest EMS provider. When asked how EMSA achieved a 46% survival rate in bystander-witnessed ventricular fibrillation patients, EMSA Medical Director Jeffrey M. Goodloe, MD, FACEP, NREMT-P, says, “We have progressive cardiac arrest protocols, but we don’t do anything novel. Oklahoma has very clear and explicit medical treatment protocols, and there is buying in from all the EMTs and paramedics.”
What EMSA does differently is to have providers transmit every ECG so that an emergency department (ED) physician or cardiologist can prep for that patient. EMSA Director of Research and Clinical Development, T.J. Reginald, NREMT-P, says there’s good reason to include transmission as standard procedure. “The doctors and nurses who turn on the lights in the cath lab—they may be at home, but that transmission goes straight to their PDAs so they can head to the hospital when they receive it. That gives them 10 or 20 minutes lead time,” says Reginald. In fact, since 2008, it’s been standard practice when treating cardiac patients to acquire and transmit ECGs—a practice that leaders want to take to the state’s urban and rural areas.
Three organizations are focusing their efforts on improving cardiac care in the state: EMSA’s Medical Control Board, the Oklahoma State Department of Health’s Emergency Systems Division and the University of Oklahoma College of Medicine’s School of EMS.
The first step in the process was to distribute a survey about cardiac care to every EMS system in the state. The group received a 100% response rate. “We got a great snapshot of what happens to cardiac patients in Oklahoma,” says Goodloe. “There is tremendous enthusiasm for STEMI care in Oklahoma EMS. That’s going to make acute coronary care even more successful.”
Reginald explains that a lack of equipment or ability to transmit was the largest obstacle systems reported in the survey. “Many did not feel it was necessary; they did not want the expense, or they felt their paramedics were able to read the ECG themselves. Well, our paramedics are very good at reading ECGs too—but they still transmit every 12-lead. They don’t pick and choose which to transmit; we send them all and sort them out later,” he says.
Once Oklahoma has its referral network in place, the ECG transmission will be sent to an ED physician or cardiologist, who will make the call on whether it’s indicative of a STEMI and will dictate which facility the patient should be transported to. “This will give [EMS providers] better destination decision-making ability. They may drive longer to get to a hospital with a cath lab or cardiologist, but otherwise the patient may need to be transported again. EMS has done this for years with trauma,” Goodloe says. In fact, the STEMI referral network will be modeled from Oklahoma’s existing trauma system. Each hospital in the state will be classified as a percutaneous coronary intervention (PCI) center, a referral center or a fibrinolytic center.
Goodloe is working to update Oklahoma’s state protocols for 2011 with Timothy Cathey, MD, medical director for the Emergency Systems Division of the Oklahoma State Department of Health, and they hope that the new STEMI protocol will “encourage all paramedics and EMTs to acquire 12-lead ECGs.”
More importantly, Cathey points out, “The new protocol will be good for establishing timelines for STEMI care. For the first time, we’re going to force more continuity of care between EMS and hospitals by dictating the balloon time as 90 minutes, for example.”
Introducing the new protocol will lead to education on how to acquire and transmit 12-lead ECGs across the state. “Oklahoma is trying to create a statewide STEMI protocol, not just regional ones. We need to measure how this will work in rural areas, where the care is not as good because of the longer distances involved,” says Cathey.
It will likely take Oklahoma years to equip and train EMS units to emulate EMSA’s success with cardiac patients and even longer to get the STEMI referral network in place. But the leaders are on board, and EMS departments are eager to improve.
“This is an exciting time to be in EMS in Oklahoma. This [program] highlights the importance of EMS in patient care. If we can do this in Oklahoma, why can’t someone else do it in another state? There’s no reason,” says Goodloe.