Although a shortage of sound EMS field research remains in some areas, the fundamental EMS philosophy of doing the “right thing” continues to guide providers and medical directors alike to seek out better prehospital treatment options. These two groups have worked collaboratively with their hospital counterparts to identify assessment strategies and interventions to improve patient care in this unpredictable practice arena. One of the key changes to EMS practice that can improve patient care is the early identification and treatment of acute myocardial infarction (AMI).
Ageneral tenet of EMS is that faster care is better care. Since the beginning of modern EMS, studies have shown that a rapid response to out-of-hospital cardiac arrests is essential for patient survival.1 To maximize patient survival, discerning between ST-segment elevation myocardial infarction (STEMI) and other causes of chest pain is critical, as is early activation of such resources as the cardiac cath lab and the interventional cardiology team.
To that end, the National Heart Attack Alert Program Coordinating Committee, the National Heart, Lung and Blood Institute and the National Institutes of Health have all called for universal implementation of prehospital 12-lead ECG capability in EMS systems providing ALS care.
We now know that minimizing the time period from the onset of cardiac ischemia to the definitive treatment of opening the blocked artery with a balloon or with IV clot-dissolving medications will result in less myocardial damage and a better survival rate.2
In the late ’80s, a similar breakthrough, the use of IV “clot-busting” medications for the treatment of AMIs, also emphasized the relationship between treatment delay and outcome. Several large studies demonstrated that reducing the delay from onset of chest pain to emergency department (ED) arrival and subsequent cardiac reperfusion resulted in decreased cardiac damage and better survival. “Time is muscle” was the slogan of the decade.3
In the ’80s, and now 30 years later, EMS is in a pivotal position to improve patient outcomes. For EMS, the call for prehospital 12-leads is déjà vu.
Paramedics in Tucson, Ariz., have been trained in 12-lead recognition since 1974, despite not having portable ECG equipment available in the field. The discussions and planning that occurred prior to this implementation ensured the success of this standard-setting program. We believe strongly that any EMS service considering implementation of a field 12-lead ECG transmission program must first answer many of those same key questions.
Philosophy & Commitment
Is financial support to purchase and maintain the necessary equipment available? Initial purchase, maintenance and scheduled replacement must be planned. Group purchase plans may allow entire regions to share the cost burden.
Is there department-wide commitment to training and continuing education (CE) for paramedics? Initial training and regularly scheduled CE must include 12-lead analysis, equipment use, troubleshooting, patient assessment parameters and medical interventions.
Will a credible EMS medical director advocate for the department and paramedics? Although EMS may be at the forefront of change, it often receives the most criticism for what goes wrong with the patient. Does your agency have a medical director who’s willing to go to bat for EMS when the cardiologist is notified and the cath lab team activated based on an EMS 12-lead that’s inconclusive? This support is critical. Your medical director must be armed with system knowledge as well as the finesse to smooth ruffled feathers and ensure that your reputation stays intact.
Will paramedics be expected to interpret (or analyze) their findings? This may seem like an unusual question, but it’s one that must be answered. Paramedics can easily learn to analyze 12-lead ECGs, but the interpretation of 12-leads is more complex than just reading the tracing. No evidence-based number of ECG readings defines the attainment or maintenance of competence in 12-lead interpretation.4
In fact, there are so many complex variables that it takes years to master them. This can be demonstrated in any ED in the country where expert cardiologists and ED physicians discuss, debate and sometimes agree to disagree about the interpretation of the many variations found in an ECG.
During the early years of field 12-lead programs, the internal diagnostics of the monitors weren’t as accurate as the trained eye of an experienced paramedic. However, as time and technology has progressed, the diagnostic capability and sensitivity of the monitors has improved greatly. This improvement has come from many years of field testing and validation by cardiology and emergency medicine experts and those very same paramedics who began this advanced practice in the 1970s.
This question of whether to analyze or interpret the data comes fraught with opinion and bias. It must be discussed by paramedics and medical directors together, because the real answer lies not in who/what is better—the medic or machine—but what method provides the best patient advocacy and care.
After 22 years of field 12-leads, Tucson Fire Department has learned that the interpretive algorithm consistency of most modern 12-lead monitors can’t be matched in a static environment. However, the constantly changing EMS practice environment requires the knowledge and adaptability of an experienced paramedic to analyze the monitor findings, integrate that information with the patient presentation and use their critical-decision-making skills to provide the best patient care.
What outcome data will be collected and quality assurance (QA) completed to determine skill competency and appropriateness of interventions? Data has become the currency of EMS. Information related to prehospital care and treatment is a curious mixture of protected health information, statistics and reasoning for grant justification, and it’s the key to research dollars.
An individual or team of people must be responsible for crafting an objective QA plan, which should encompass dispatch and response, protocol compliance, skill proficiency, triage and transport and, whenever possible, patient outcome. Evaluating such targeted issues as STEMI may also aid in skills verification and critical decision-making processes.
Patient Care Questions
What patient care considerations must be made when implementing a field 12-lead program? Department, regional or statewide protocols should be in place to outline when to obtain a 12-lead; however, the autonomy and expertise of the paramedics can impact the door-to-balloon times. Are your providers expected to make treatment decisions based on pre-set algorithms? Do they contact online medical control, or do they follow practice guidelines that allow field decision making?
Designated cardiac receiving centers, STEMI centers and/or chest pain centers are now part of the specialty facility landscape. EMS agencies and regions must be familiar with these designations and understand any local service limitations. Bypassing, redirecting and diverting to any of them has the potential to affect the choices in EMS destinations. Having transport agreements with these specialty facilities may be necessary to ensure timely acceptance and transfer of care.
Now, determine which 12-lead monitor configurations, wireless connectivity options and printing methods will work best for your agency. Be aware that equipment, communication, connectivity and compatibility are never as simple as anticipated. Methods to receive and download the incoming 12-lead can include fax machines, fax servers or printers in the ED and/or on the paramedic unit.
Also, you should consider whether your crew will be able to provide an early notification to the receiving facility of a new-onset STEMI. Crews must obtain an online channel to present a brief medical report and convey a “STEMI alert” or provide telemetry to allow the hospital adequate preparation for a time-sensitive, monitored patient.
You must also plan for who will ensure uninterrupted data transmission, monitor and server functionality, troubleshoot system problems, archive data and facilitate record retention 24/7. Having a fully trained IT staff is desirable, but it’s not always practical. At least one or two EMS or administrative personnel should be well versed in the integration and use of the 12-lead monitor, transmission system and receiving hardware, and you’ll need this person to be on call at all times.
According to the “diffusion of innovations” theory, pioneered by Everett Rogers, people have different levels of readiness for adopting new innovations. Only 16% of adults can be counted as innovators or “early adopters,” and another 16% can be categorized as “laggards.”5
Knowing how adult learners adapt to change or adopt new practice strategies can be helpful in establishing a successful training program for both equipment competency and knowledge prior to the implementation of a prehospital 12-lead program.
Identify and utilize your own community experts in the program set up and training. Emergency physicians, registered nurses and cardiologists each offer a different skill set and teaching style. Choose these experts carefully to provide the best educational fit for your providers.
There will always be individuals ready to seek out new experiences and change their practice based on new information. There are others who’d rather stay with the tried and true, especially when faced with adopting new electronic or computer-based equipment or training venues. Several steps can ensure successful implementation.
Establish a time line. Implementation of a large education and technology-intensive program requires strategic planning with multiple groups and individuals.6
Identify super-users. Look to those top 16% in your agency to act as “super-users,” or field experts; include them in the program set up and implementation. Utilize their expertise, and let them drive the changes needed in the field. They’ll sell the ECG transmission program to the rest of the field personnel.
Enlist referent leaders. We all know who the real leaders are in our organization. Enlist these individuals when seeking a change in practice because their help can determine the success of any program. Employees identify with these leaders and use them as a positive frame of reference for accepting or blocking new approaches.7
Implement creative training solutions. Providing consistent CE, strip review and physician-guided case review can be time-consuming and resource-intensive for any fire or EMS department. Simulation labs, computer-based training and self-learning programs must be used creatively to produce the best educational experience for all learners.
After 22 years of field 12-lead use, the Tucson Fire Department has learned that detailed planning is critical to any program’s success, and the best patient care outcomes are a result of experienced paramedics equipped with state-of-the-art monitors and capable of critical decision-making. JEMS
This article originally appeared in August 2010 JEMS as “Leading the Pack: Correctly interpreting ECG data.”