Prehospital 12 lead ECG programs

I posted this series of questions today at JEMS Connect. Please feel free to respond here or there.

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?

9 Comments

  • ddonatto says:

    1. Does your service perform pre-hospital 12 lead ECGs?Response: Yes, every primary pre-hospital provider in Palm Beach County performs 12 lead ECGs.2. Does the prehospital 12 lead ECG help determine your transport destination?Response: Yes, every primary pre-hospital provider in Palm Beach County transports thier STEMI patients to facilities with PCI capabilities.3. Is the cath lab activated based on the prehospital 12 lead ECG?Response: Unfortunately, no. Some agencies are transmitting 12 lead ECGs and the hospitals will sometimes activate the Cath Lab based upon the transmitted 12 lead. Most hospitals use the “Cardiac Alert” notification to speed the 12 lead acquisition in the ER and then ED Doc activates. 4. Does your program rely on the paramedic interpretation of the 12 lead ECG? Response: Yes, every primary pre-hospital provider in Palm Beach County uses paramedic interpretation of 12 lead ECGs. Most consider the computerized interpretation in that process, but do not rely upon it. Some agencies are transmitting 12 lead ECGs and the hospitals will sometimes activate the Cath Lab based upon the transmitted 12 lead.5. Does your program rely on computerized interpretation of the 12 lead ECG? Response: See #46. Does your program rely on off-site interpretation of the 12 lead ECG by a physician? Response: See #47. Does your program utilize a combination of these three methods?Response: See #48. If the prehospital 12 lead ECG is transmitted for off-site interpretation by a physician, what technology are you using? Response: Varies by agency. Some use Physiocontrols system, some use Zoll system, and some (my agency) use fax modem in ECG to transmit over cellular.9. What is the failure rate? How is the data quality?Response: Low. Failures have been due to operator error in our experience. Two cases where onboard inverter failed to power cellular device. Data quality is good.10. What was your initial education in 12 lead ECG interpretation?Response: All paramedics who complete local college training program receive 12 hrs of 12 lead instruction. Our agency conducted 8 hr class for all medics about a year ago. We are scheduling 3 hrs of 12 lead training every quarter for every medic in 2009.11. Did it include a strong emphasis on STE-mimics (left bundle branch block, paced rhythm, left ventricular hypertrophy, benign early repolarization, pericarditis, hyperkalemia, etc.)?Response: No12. 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.)?Response: We followup on every STEMI patient and receive ED Diagnosis / ED Disposition and Cath Lab interventions if done as feedback. We review every ACS call for Aspirin Administration, NTG Administration, 12 lead tracing quality (BIG PROBLEM), 12 lead interpretation, time from pt. contact to 12 Lead, time from pt. contact to Cardiac Alert if applicable, time on scene if cardiac alert. Feedback provided to medic on call regarding all of above.13. Is your state involved in regionalizing STEMI care (similiar to trauma)?Response: No14. How often are you called to the local community hospital for interhospital transfer of STEMI patients for primary PCI?Response: We do not provide interfacility transport services.15. What has been the biggest barrier to the success of your prehospital 12 lead ECG program? Response: Our accuracy in 12 lead interpretation is lower than it should be; ED activation of Cath Lab only after ED gets own 12 Lead and ED MD reviews.Excellent Questions – thanks for asking.Darrel DonattoPalm Beach, FL

  • Tom B says:

    Thanks for the thorough reply, Darrel! Your QA/QI process sounds impressive. Our ED docs rarely activate the cath lab based on the prehospital 12 lead ECG, even when it’s a slam dunk STEMI. We also have problems with tracing quality (which is what I meant by data quality). The GE-Marquette 12SL interpretive algorithm isn’t bad for detecting STEMI, but “garbage in, garbage out” applies to computer algorithms! One can only assume that transmitting high quality 12 lead ECGs increases the odds of physician acceptance.I’d like to see some kind of 12 lead ECG certification for prehospital providers that includes all the STE-mimics.Tom

  • SoCal Medic says:

    Does your service perform pre-hospital 12 lead ECGs?Yes, all the ALS equiped rigs, whether it is Fire or EMS are required to have 12 Lead capabilities.2. Does the prehospital 12 lead ECG help determine your transport destination?It is a part of the report when trying to get a destination. 3. Is the cath lab activated based on the prehospital 12 lead ECG?Depends on the facility. The goal is to active based on paramedic intrepretation, however some relay on the computer itself. 4. Does your program rely on the paramedic interpretation of the 12 lead ECG? Oops, responded to early. See # 35. Does your program rely on computerized interpretation of the 12 lead ECG? Response: See #36. Does your program rely on off-site interpretation of the 12 lead ECG by a physician? Not yet, they are working on exploring the ability to transmit for ED consultation.7. Does your program utilize a combination of these three methods?Response: Just the computer and the paramedic.8. If the prehospital 12 lead ECG is transmitted for off-site interpretation by a physician, what technology are you using? still in an evaluation process.9. What is the failure rate? How is the data quality?10. What was your initial education in 12 lead ECG interpretation?Mine was done in another system out of my current state. It was a module based course taking roughly 12 hours. Currently they are presenting mandatory education that is 2 hours in length, with the ability to continue that at the individuals leisure.11. Did it include a strong emphasis on STE-mimics (left bundle branch block, paced rhythm, left ventricular hypertrophy, benign early repolarization, pericarditis, hyperkalemia, etc.)?Currently, no, not a strong emphasis in the required piece. There is in the additional piece that is optional.12. 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.)?Currently there are to many variables in play, some medics chose to do their documentation in the lab, if the patient is in there prior to them being placed back in service. QA/QI process is still being developed, it currently is soley between the Doctor and Paramedic at the ED, unless the ED feels more follow up is required.13. Is your state involved in regionalizing STEMI care (similiar to trauma)? There are different systems within the state, some work better with their neighbors than others. If there are plans within our County, I am not aware of them. To my knowledge, only one Medic was allowed to partcipate with the development of the STEMI program.14. How often are you called to the local community hospital for interhospital transfer of STEMI patients for primary PCI?I dont want to speculate on that because of the ALS or CCT Response. They have varying degrees of scope and medications, but are not within the same division. The CCT is soley and IFT unit, where as the ALS are 911 units pulled for IFT.15. What has been the biggest barrier to the success of your prehospital 12 lead ECG program? Ego, training, competancy.

  • Tom B says:

    Thanks, SoCal Medic! Two hours seems like an incredibly short period of time to learn 12 lead ECGs! If a 12 lead ECG certification for prehospital providers was available, do you think the EMS administrators in your area would be interested? Or would it be perceived as a needless additional expense?How many paramedics are in your system?Tom

  • SoCal Medic says:

    Tom, There is only one Engine I can think of that is not ALS, and only two Ladder Trucks that are not ALS out of our coverage area. Most of them all have more than one paramedic on them. With the recent chanve in protocols for Trauma Triage and the STEMI system, there was push back from the varies agencies becuase of the timeline to educate. Cost is a huge factor, especially with my agency being a private entitity. The original thought was 16 hours of education from the local governing body for protocols, it was reduced to 6 hours for those who did not have a program in place prior to July 1 of this year. Most of the systems that were grandfathered in, only had minimal education in place.

  • Tom B says:

    That’s too bad, Christopher! But I know you’re doing your part.

  • tbern says:

    Does your service perform prehospital 12 lead ECGs?Yes, we utilize 12-Lead ECGs using the Philips MRx monitors.Does the prehospital 12 lead ECG help determine your transport destination?Yes, we have three interventional facilities in the county. If the patient meets the criteria for a STEMI, the patient will be transported to one of those facilities.Is the cath lab activated based on the prehospital 12 lead ECG?Yes and no, as soon as we determine that we have a patient that meets the STEMI criteria based on the prehospital 12 Lead ECG, we immediately contact the interventional facilities emergency department via radio and advise them of the same. At that point, it’s the doctor’s preference in the ED as to either alert the cath lab based on the EMS report or wait until they assess the patient and review the ECG in the emergency department.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?In order for the patient to meet the STEMI criteria, the paramedic must interpret on the 12 Lead ECG that there is 1mm or greater ST elevation in contiguous leads and the computerized interpretation must show an ACUTE MI. We don’t utilize a method that allows for off-site ECG interpretation by a physician.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?Unfortunately, we don’t utilize a method that allows for off-site ECG interpretation by a physician.What was your initial education in 12 lead ECG interpretation?My initial education in 12 Lead ECG interpretation was done in paramedic school. I also had to take an 8 hour class on 12 Lead ECGs and pass a written exam that went along with the class. Did it include a strong emphasis on STE-mimics (left bundle branch block, paced rhythm, left ventricular hypertrophy, benign early repolarization, pericarditis, hyperkalemia, etc.)?We did cover those topics briefly in both the program and the class but not in any significant depth. 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.)?All 12 Lead ECGs that meet the STEMI criteria are reviewed by either our medical director, assistant medical director or medical services personnel that perform QA/QI on our patient care reports. If we transport a STEMI patient directly to the cath lab, we will typically remain with the patient and observe the procedure at the discretion of the crew and/or the staff running the lab.Is your state involved in regionalizing STEMI care (similar to trauma)?There are studies currently being performed at our interventional facilities on improving reperfusion times for STEMI patients. These studies utilize a combination of data from the transporting EMS system and the emergency departments receiving the patient. I know of similar programs with other systems in the state, some of which allow EMS to bypass the ER and take the patient directly to the cath lab. I’m not aware of a program that the state is currently running to improve STEMI care.How often are you called to the local community hospital for interhospital transfer of STEMI patients for primary PCI?We have four hospitals in the county that either do not provide or only provide limited interventions for STEMI patients. We are consistently summoned on a daily basis to transport these patients to one of the three interventional facilities for further care. The vast majority of these transports are handled by the EMS system in the county that does not have critical care services. What has been the biggest barrier to the success of your prehospital 12 lead ECG program?I feel that it stems between several components. The first being that we do not have the software or a program in place to transmit prehospital 12 Lead ECGs to interventional facilities. Next, the success rates of paramedics correctly interpreting these ECGs is currently to low, mainly due to lack of proper education and training. The last, just an overall lack of trust and commitment from the right people to allow EMS to begin providing these types of services. In my opinion, for being the largest city in the state of North Carolina, we are way behind in the times when it comes to STEMI care, it’s quite sad.

  • Tom B says:

    Thank you for that detailed reply, Tom! You wrote:”Yes and no, as soon as we determine that we have a patient that meets the STEMI criteria based on the prehospital 12 Lead ECG, we immediately contact the interventional facilities emergency department via radio and advise them of the same. At that point, it’s the doctor’s preference in the ED as to either alert the cath lab based on the EMS report or wait until they assess the patient and review the ECG in the emergency department.”I’m curious to know how often the EM physician does not activate the lab, and it turns out to not be a STEMI. Could you comment?Tom

  • tbern says:

    “I’m curious to know how often the EM physician does not activate the lab, and it turns out to not be a STEMI.” I can’t recall a time where the cath lab was not activated and it turned out to not be a STEMI. I wish I could say the same for the opposite. I’ve had more cases than I can recall where we’ve advised the ED physician that we had a patient that met the STEMI criteria, yet the cath lab was not activated based on our report. I truly wish we could get past this because in the end it only delays the time sensitive interventions that our patients need.

Leave a Reply

Your email address will not be published. Required fields are marked *