Columns, Patient Care, Special Topics

Study Examines EMS’ Administration of Aspirin

Issue 5 and Volume 40.

The Research

Tataris KL, Mercer MP, Govindarajan P. Prehospital aspirin administration for acute coronary syndrome (ACS) in the USA: An EMS quality assessment using the NEMSIS 2011 database. Emerg Med J. Feb. 16, 2015. [Epub ahead of print.]

The Science

The authors of this study attempted to determine how often aspirin was administered by paramedics to patients with chest pain suspicious of acute coronary syndrome (ACS). They analyzed data from version 2 of the National EMS Information System (NEMSIS) database. Of the 198,232 eligible patients, only 45.5% (90,195) received aspirin from the prehospital provider.

Non-Hispanic blacks, Asians and Hispanics were more likely to receive aspirin as compared to non-Hispanic white patients. Patients living in the southern regions of the United States and those on Veterans Administration insurance were the least likely to receive aspirin. The age and sex of the patient didn’t appear to influence aspirin administration.

The authors concluded the administration of aspirin by EMS is low and proposed that the reasons and administration disparities discovered should be researched.

Medic Karen Wesley Comments

I found this to be a very interesting study. Not just because of the breakdown on who did and who didn’t receive aspirin, but because of the sheer numbers in general of those not receiving it.

Statistically, it seems significant to break this down in ethnicity and age, but the overall message remains that quality assurance measures aren’t recognizing nor addressing the failure to administer a medication known to be both time sensitive and of huge benefit to the patient. And if failures are observed, why haven’t measures been implemented to correct and educate providers?

It’s such a simple administration; I can only imagine there’s confusion on who should receive aspirin. Documentation elements should include the reason for the lack of administration.

This paper clearly makes the point that protocols and guidelines aren’t being met in patients with suspected ACS. The purpose of NEMSIS isn’t just to collect numbers–it’s meant to use the information to improve patient care. Perhaps it’s time providers, service directors and medical directors take a closer look at the quality assurance methods they’re using and develop policies and protocols to address this poor performance.

Doc Keith Wesley Comments

I’ll accept that EMS isn’t giving aspirin to every patient who deserves it. However, I don’t believe the rate is as low as this study reports. Version 2 of NEMSIS only accepted these answers: yes, no, not applicable, not recorded, not reporting, not known, or not available. It’d be interesting to know what percentage of those cases these authors categorized as “no” were in fact one of the “nots” listed above.

It didn’t report known qualifiers that would exclude aspirin administration such as already taken, anaphylaxis to aspirin and active gastrointestinal bleeding. That’s right, anaphylaxis. Not “allergy,” which most patients describe as gastric upset.

Almost every EMS agency that submits NEMSIS data does so by entering it into either their own service database and/or directly to their state EMS database, which then exports said data to NEMSIS. Not every state is providing NEMSIS with data consistent with the same version. In fact, since this study was performed, NEMSIS is now in version 3. This new version does accept the qualifiers I listed as to why aspirin wasn’t administered.

On the other hand, I believe there are many services that direct medics not to administer aspirin if the patient has already taken it, they have a history of peptic ulcer, or are on a blood thinner such as Coumadin (warfarin). Studies have shown that none of these are serious contraindications for the administration of a one-time aspirin dose of 240 mg.

So, before researchers attempt to reassess EMS aspirin use, I challenge all of you to examine your protocols and ensure that every patient with chest pain is given aspirin unless they clearly have a real contraindication.