Fifty years ago, the National Academy of Sciences highlighted the extremely poor on-scene care that existed for Americans who suffered from major trauma in its white paper, “Accidental Death and Disability: The neglected disease of modern society.” It shocked the nation by declaring a person was more likely to survive being injured on the battlefield than on a United States highway. This report paved the way for modern EMS by recommending the creation of standards for ambulance services, training and oversight in prehospital medicine.1
Legendary physician R Adams Cowley is credited with creating and popularizing the concept of a “golden hour” in trauma, underscoring the need for coordination from the moment trauma occurs to the time to definitive care. Deficiencies in trauma care were recognized and trauma systems of care were developed with EMS playing a central role.
As EMS evolved, so did the need to include EMS when developing systems of care for other time-sensitive emergencies. Cardiovascular disease, trauma, stroke and sepsis accounted for 925,000 deaths in the nation in 2014–equivalent to the population of Austin, Texas.2 As hospitals become specialized centers of excellence for ST elevation myocardial infarction (STEMI), stroke or sepsis, there are surrogate “golden hours”: door-to-needle in < 60 minutes for tPA treatment of stroke; door-to-puncture in < 90 minutes for endovascular treatment of large vessel occlusion (LVO) stroke; and door-to-balloon times of < 90 minutes for STEMI, and other time-driven goals in acute sepsis care.3—7 In each of these emergencies, rapid diagnosis, stabilization and transport to an appropriate facility is associated with improved care and outcomes.
MCHD’s multidisciplinary effort that leverages cutting-edge technology
will not only improve patient care for time-sensitive medical
emergencies such as sepsis, stroke and STEMI, but in the end for all patients.
In septic shock, every hour delay in getting antibiotics is associated with an 8% increase in mortality.4 Research demonstrated a doubling of survivors in STEMI when EMS made the decision to transport directly to a percutaneous coronary intervention (PCI)-capable hospital.7 EMS is involved in the care of 85% of stroke patients and is associated with an improvement in onset to treatment times (OTT).8,10 This is critical, as patient outcome in acute ischemic stroke improves with every 15-minute improvement in OTT.10
Although trauma, stroke, STEMI and sepsis differ in etiology, presentation and treatment priorities, common themes in best practices exist that can be incorporated into EMS systems to improve outcomes for patients experiencing any of these time-sensitive emergencies:3,4,14—16
- Prehospital notification;
- Patient data transmission (e.g., ECG, photos, last-known well times);
- Pertinent stroke/sepsis/trauma scores to define acuity;
- Transport to the most appropriate facility;
- Direct triage to vascular lab/CT scans when appropriate; and
- Prompt data feedback available to EMS.
The STEMI Example
One of the best examples of an effort to incorporate these practices and the idea of a holistic system of care is the American Heart Association’s (AHA) Mission: Lifeline. AHA launched Mission: Lifeline in 2007 and has championed the collaborative efforts by hospitals and EMS to provide timely reperfusion to STEMI patients in the U.S.14 The project studied the common practices in STEMI care and then provided a framework for developing a systematic approach to STEMI care for both in-hospital and prehospital care teams all the way from first medical contact in the field to discharge from the hospital, including all the stops in between. The principles have remarkable similarity to our best practices for time-sensitive emergencies:
- 15-minute scene time;
- Acquisition and interpretation of a 12-lead ECG;
- Transport destination decision (percutaneous coronary intervention (PCI)/non-PCI/closest facility);
- Electronic transmission of the ECG;
- Early hospital notification;
- Direct communication with a physician capable of activating a reperfusion plan; and
- Best practice recommendations for treatment protocols.
The Mission: Lifeline framework provides metrics for measuring and improving performance, guidelines for sharing outcomes, and data collection points to create a national cardiac data registry.
The data collected allows systems of care to identify barriers , including problems transmitting ECGs and other patient data, inadequate training in STEMI recognition, lack of buy-in from physicians and facilities, and inability to access patient outcome information across the system of care, specifically between hospitals and EMS.
As EMS evolved, so did the need to include EMS when developing
systems of care for other time-sensitive
emergencies such as sepsis and stroke.
It also allows EMS agencies to collaborate with their hospital partners to improve time to treatment, often yielding simple solutions that can improve patient outcomes, such as leaving the STEMI patient on the EMS stretcher while in the ED to facilitate rapid transfer to the cardiac catheterization lab. 5,7,13,14
There have been similar innovations documented for other time-sensitive emergencies such as stroke3,6,8—10,12,15 and trauma.16 Each one shows best practices for EMS in regard to timeframe, differential diagnosis, treatment, destination determination, and pre-arrival notification.
Yet, we still have a lot of room to improve, particularly in communication and coordination. For example, there are data to suggest that pre-arrival notification by EMS improves stroke therapy times, but this vital notification still occurs inconsistently and, in a quarter of cases, EMS failed to alert the hospital a stroke was en route.8 How can we communicate vital information, mobilize the correct resources and have accountability with transparency for all the members in the system of care?
Leveraging Mobile Technology
Current methods of communicating and coordinating care priorities often involve archaic technology such as radio, landline phones, faxes and pagers. Different combinations of these outdated modalities are used by multiple specialties including EMS, ED, radiology, trauma team, stroke team, cardiologists, cardiac catheterization lab, neuro-interventional suite and the ICU. The end result is different players trying to communicate complex information redundantly through an intermediary in high-stakes situations.
There are well-documented best practices for EMS,
yet how we develop a system of care that integrates these
practices in conjunction with regional hospital partners
is our most pressing challenge for the future.
The use of mobile technology to coordinate systems of care for time-sensitive medical emergencies is evolving with several technology solutions entering the market that are designed to close the loop of communication between EMS and our hospital partners, from transmission of prehospital ECGs and patient data, to pre-arrival notification20,21 and sharing outcomes in real time.22
Montgomery County Hospital District (MCHD), which provides EMS service in Montgomery County, Texas, just outside of Houston, recently began efforts to implement Pulsara, a novel mobile app that utilizes handheld iOS or Android devices to allow direct, real-time communication between EMS, the ED and the appropriate specialty and inpatient resources. Using the app, EMS providers in the field can enter information about a patient and activate a stroke or STEMI team with a few clicks. ED staff and members of the specialty teams–whether they’re in the hospital or on call from home–instantly receive the notification and can see the information entered in the field. They can also acknowledge they’ve received the alerts and send questions to the EMS team, all through the secure app.
Our research has demonstrated this improved communication method resulted in a 28—46% improvement in door-to-needle (DTN) therapy for stroke and a 22% improvement in door-to-balloon (DTB) in STEMI. Use of the app was further associated with a modest improvement in meeting the national benchmarks of DTN < 60 minutes in stroke and DTB < 90 minutes in STEMI.17—19
The app also follows best practice recommendations in stroke and STEMI by providing real-time feedback to EMS providers regarding the outcomes of their patients. This is a massive step forward for a fragmented healthcare system where communicating vital information between different agencies and entities is quite difficult and rarely occurs in real time.
In participating in Mission: Lifeline and by adopting the mobile app MCHD strives to improve communication with our local specialty centers and thus door-to-therapy times and patient outcomes. And we’re not stopping there. We’re also collecting data for the Validation of Integrating a Stroke Algorithm (VISA) study, which will evaluate our adoption of the Rapid Arterial Occlusion Evaluation (RACE) score in an attempt to better diagnose LVO strokes and facilitate rapid transport to regional comprehensive stroke centers. Potential sepsis patients are being evaluated using prehospital Quick Sequential Organ Failure Assessment (qSOFA) scores, and MCHD paramedics are providing hospitals with sepsis alerts in an effort to initiate sepsis bundles of care immediately upon arrival.
Conclusion
There are well-documented best practices for EMS, yet how we develop a system of care that integrates best practices in conjunction with regional hospital partners is our most pressing challenge for the future. MCHD’s multidisciplinary effort that leverages cutting-edge technology will not only improve patient care for time-sensitive medical emergencies such as sepsis, stroke and STEMI, but in the end for all patients.
EMS was envisioned as a critical component of the system of care that begins with the first 9-1-1 call and ends with definitive care. With new technologies, improved communication and relationships with our healthcare partners, and an emphasis on evidence-based interventions, that vision is finally being realized.
References
1. National Academy of Sciences and National Research Council. Accidental death and disability: The neglected disease of modern society. National Academies Press: Washington, D.C., 1966.
2. Kochanek KD, Murphy SL, Jiaquan Xu, et al. (June 30, 2016.) Deaths: Final data for 2014. CDC. Retrieved Nov. 15, 2016, from www.cdc.gov/nchs/data/nvsr/nvsr65/nvsr65_04.pdf.
3. English JD, Yavagal DR, Gupta R, et al. Mechanical thrombectomy-ready comprehensive stroke center requirements and endovascular stroke systems of care: Recommendations from the Endovascular Stroke Standards Committee of the Society of Vascular and Interventional Neurology (SVIN). Interv Neurol. 2016;4(3—4):138—150.
4. Kumar A, Roberts D, Wood KE, et al. Duration of hypotension before initiation of effective antimicrobial therapy is the critical determinant of survival in human septic shock. Crit Care Med. 2006;34(6):1589—1596.
5. Rathore SS, Curtis JP, Chen J, et al. Association of door-to-balloon time and mortality in patients admitted to hospital with ST elevation myocardial infarction: National cohort study. BMJ. 2009;338:b180.
6. Fonarow GC, Smith EE, Saver JL, et al. Timeliness of tissue-type plasminogen activator therapy in acute ischemic stroke: Patient characteristics, hospital factors, and outcomes associated with door-to-needle times within 60 minutes. Circulation. 2011;123(7):750—758.
7. LeMay MR, Wells GA, So DY, et al. Reduction in mortality as a result of direct transport from the field to a receiving center for primary percutaneous coronary intervention. J Am Coll Cardiol. 2012;60(14):1223—1230.
8. Lin CB, Peterson ED, Smith EE, et al. Emergency medical service hospital prenotification is associated with improved evaluation and treatment of acute ischemic stroke. Circ Cardiovasc Qual Outcomes. 2012;5(4):514—522.
9. Hussain M, Moussavi M, Korya D, et al. systematic review and pooled analyses of recent neurointerventional randomized controlled trials: Setting a new standard of care for acute ischemic stroke treatment after 20 years. Interv Neurol. 2016;5:39—50.
10. Saver JL, Fonarow GC, Smith EE, et al. Time to treatment with intravenous tissue plasminogen activator and outcome from acute ischemic stroke. JAMA. 2013;309(23):2480—2488.
11. O’ Gara PT, Kushner FG, Ascheim DD, et al. 2013 ACCF/AHA guideline for the management of ST-elevation myocardial infarction. J Am Coll Cardiol. 2013;61(4):e78—e140.
12. Mehta BP, Leslie-Mazwi TM, Chandra RV, et al. Reducing door-to-puncture times for intra-arterial stroke therapy: A pilot quality improvement project. J Amer Heart Assoc. 2014;3(6):e000963.
13. Jacobs AK, Antman EM, Faxon DP, et al. Development of systems of care for ST-elevation myocardial infarction patients: Executive summary. Circulation. 2007;116(2):217—230.
14. Mission: Lifeline Receiving Center. National report, Quarter 1 2010, Quarter 3, 2011 [quarterly report]. American Heart Association: 2011.
15. Casaubon LK, Boulanger JM, Blacquiere D, et al. Canadian stroke best practice recommendations: Hyperacute stroke care guidelines, update 2015. Int J Stroke. 2015;10(6):924—940.
16. Nathens AB, Jurkovich GJ, Cummings P, et al. The effect of organized systems of trauma care on motor vehicle crash mortality. JAMA. 2000;283(15):1990—1994.
17. Dickson R, Seupaul R, Nedelcut A, et al. STOP STEMI©–A novel medical application to improve the coordination of STEMI care: A brief report on door-to-balloon times after initiating the application. Crit Pathw Cardiol. 2014;13(3):85—88.
18. Dickson R, Nedelcut A. Stop Stroke©–A novel medical application to improve coordination of stroke care: A brief report on door to thrombolysis times after initiating the application. Stroke. 2015;46(Suppl 1):AWP207.
19. Dickson R, Sumathipala D, Reeves J. Stop Stroke© acute care coordination medical application: A brief report on post-implementation performance at a primary stroke center. J Stroke Cerebrovasc Dis. 2016;25(5):1275—1279.
20. Jaffe E, Blustein O, Rosenblat I, et al. (Aug. 22, 2016.) Building the infrastructure for the “EMS-to-balloon” era of STEMI treatment: Mobile app facilitates direct communication and ECG transmission between field paramedics and on-call cardiologists. JEMS. Retrieved Nov. 15, 2016, from www.jems.com/articles/2016/08/building-the-infrastructure-for-the-ems-to-balloon-era-of-stemi-treatment.html.
21. Borhcers C. (Oct. 17, 2013.) ‘Twiage’ app aims to relay info from ambulance to hospital. EMS1. Retrieved Nov. 15, 2016, from www.ems1.com/ems-products/technology/articles/1590138-Twiage-app-aims-to-relay-info-from-ambulance-to-hospital/.
22. Zavadsky M. (May 1, 2015.) Modern approaches to health information exchange will improve patient outcomes and decrease cost. JEMS. Retrieved Nov. 21, 2016, from www.jems.com/articles/supplements/special-topics/on-the-leading-edge/modern-approaches-to-health-information-exchange-will-improve-patient-outcomes-and-decrease-cost.html.
