I’m going to share with you my thoughts on quality assurance of prehospital 12-lead ECG programs.
This is a excerpt from one of my posts in the current discussion called EMS Role in Reducing the Symptom to Reflow Interval for AMI at the National Association of EMS Physicians Dialog Group.
1.) Making sure that the patients who are supposed to be getting a 12-lead ECG are getting one.
2.) Making sure that the ECG is captured early on in the patient care encounter, preferably with the first set of vital signs and within 5 minutes of arriving at the patient’s side (unless there is a very good reason as opposed to an excuse).
3.) Making sure that the ECG is captured with *excellent* data quality! There is a lot of room for improvement here.
4.) Making sure that the appropriate actions are taken when the patient meets the stated criteria of the EMS system (whether that is a “STEMI Alert”, transmitting the ECG to a decision maker, or both).
5.) Making sure that serial ECGs are captured (one of which should be captured on arrival at the receiving hospital).
Sometimes asynchronous clocks can cause problems, but they are solvable problems. For example, we can mandate that the cardiac monitor be “powered on” when the EMS crew arrives at the patient’s side so we can calculate the “time to ECG”.
All of the rest can generally be QA/QI’d through retrospective case reviews or abstracted from ePCR. For example, patients who are diagnosed with ACS at the hospital and were transported by EMS but did not receive a 12-lead ECG in the field. We should find out why and use it as a learning opportunity.
We should also have regular meetings with the stakeholders on STEMI care so the people on the receiving end understand management’s expectations of patients who receiving a 12-lead ECG in the field (in other words, that they should be gowned and our approach is very standardized in the field).
Any STEMI Alerts that were called based on incorrect interpretation of the 12-lead ECG are learning opportunities and should be fed back to the line personnel as case reviews, along with tips for identifying that particular mimic in the future.
Often (but not always) what you’ll see is that poor data quality was a major factor. Sometimes it’s poor lead placement (limb leads on the chest) and sometimes it’s a very good mimic like an atypical strain pattern from left ventricular hypertrophy.
If the paramedics in the field are doing their part and the E2B/D2B times “fall out” then a problem on the hospital’s side of the fence. Sometimes there are legitimate reasons for this (marginal cases, an unstable patient, another STEMI patient already on the cath table) but our attention should be on system failures where EMS failed to act appropriately.
It doesn’t take long to figure out if the problems encountered are training-related versus compliance-related. If you have paramedics out there who just “don’t believe in 12-leads” or “don’t need a 12-lead to tell them who’s having a heart attack” you need to find that out and address it.
It also doesn’t take long to figure out who the problem physicians are. If you plot out all of your acute STEMI cases for a year on a time graph you might be surprised to see that the same ED physician was on duty for all of the “fall out” cases and a different ED physician was on duty for all of the D2B times < 60 minutes. That’s a problem that the hospital needs to address through peer review.
What are your thoughts?