Prehospital Electrocardiogram Transmission and Prehospital Scene Time: A Retrospective Cohort Study

Background: Telemedical transmission of prehospital electrocardiograms (ECGs) to a target clinic may improve clinical workflows and speed of intervention. However, whether ECG transmission delays prehospital workflows remains controversial. Therefore, we aimed to clarify whether ECG transmission prolongs prehospital scene time in patients diagnosed with acute coronary syndrome (ACS). Methods: We retrospectively included all patients diagnosed with ACS by prehospital emergency physicians from July 2016 to June 2019 at a single academic center. The primary endpoint was the effect of ECG transmission on prehospital scene time. The secondary endpoints were the effects of ECG diagnosis on prehospital scene time and quality of care. Multivariable regression was used to account for patients' age, physician specialty, completion of specialty training, and whether emergencies occurred throughout the day or night shifts as potential confounders. Results: A total of 1,106 cases were included, of which 154 ECG transmissions were performed. ECG transmission prolonged prehospital scene time by an average of 3 min: adjusted regression coefficient [95% confidence interval (95% CI)]: 3.24 (1.7-4.8), p < 0.001. Prehospital treatment time was not influenced by prehospital ECG-based diagnosis (ST-elevation myocardial infarction [STEMI] vs. non-ST-elevation ACS [NSTE-ACS]): adjusted regression coefficient (95% CI): 0.7 (-1.3 to 2.7), p = 0.490. Emergency physicians adhered to local standard operating procedures in 739 of 1,007 (73%) patients diagnosed with NSTE-ACS and 93 of 99 (94%) patients diagnosed with STEMI. A STEMI diagnosis compared with NSTE-ACS was associated with five times higher odds of adhering to standard operating procedures (odds ratio [95% CI]: 5.6 [2.7-14.6], p < 0.001). Conclusion: The observed delay of ∼3 min in the prehospital scene time by ECG transmission is clinically irrelevant. For patients prehospitally diagnosed with NSTE-ACS who do not meet STEMI criteria, adherence to standard operating procedures seems unjustifiably low and should be improved.

Temporal Trends in Reperfusion Delivery and Clinical Outcomes Following Implementation of a Regional STEMI Protocol – a 12 Year Perspective

Background

The Vancouver Coastal Health (VCH) ST-elevation myocardial infarction (STEMI) program aimed to increase access to primary percutaneous coronary intervention (PPCI) and reduce first-medical-contact-to-device times (FMC-DTs). We evaluated the long-term program impact on PPCI access and FMC-DT, and overall and reperfusion-specific in-hospital mortality.

Methods

We analyzed all VCH STEMI patients between June 2007 and November 2019. The primary outcome was the proportion of patients receiving PPCI over 4 program implementation phases over 12 years. We also evaluated overall changes in median FMC-DT and the proportion of patients achieving guideline-mandated FMC-DT, in addition to overall and reperfusion-specific in-hospital mortality.

Results

A total of 3138 of 4305 VCH STEMI patients were treated with PPCI. PPCI rates increased from 40.2% to 78.7% from 2007 to 2019 (P < 0.001). From phase 1 to 4, median FMC-DT improved from 118 to 93 minutes (percutaneous coronary intervention [PCI]-capable hospitals, P < 0.001) and from 174 to 118 minutes (non-PCI-capable hospitals, P < 0.001), with a concomitant increase in those achieving guideline-mandated FMC-DT (35.5% to 66.1%, P < 0.001). Overall in-hospital mortality was 9.0% (P = 0.20 across phases), with mortality differing significantly by reperfusion strategy (4.0% fibrinolysis, 5.7% PPCI, 30.6% no reperfusion therapy, P < 0.001). Mortality significantly decreased from phase 1 to phase 4 at non-PCI-capable centres (9.6% to 3.9%, P = 0.022) but not at PCI-capable centres (8.7% vs 9.9%, P = 0.27).

Conclusions

A regional STEMI program increased the proportion of patients who received PPCI and improved reperfusion times over 12 years. Although no statistically significant decrease occurred in overall regional mortality incidence, mortality incidence was decreased for patients presenting to non-PCI-capable centres.

Emergency Interhospital Transfer of Patients With ST‐Segment–Elevation Myocardial Infarction: Call 9‐1‐1—The American Heart Association Mission: Lifeline Program

ABSTRACT: The American Heart Association Mission: Lifeline program objectives are to improve the quality of care and outcomes for patients with ST‐segment–elevation myocardial infarction. Every minute of delay in treatment adversely affects 1‐year mortality. Transfer of patients safely and timely to hospitals with primary percutaneous coronary intervention capability is needed to improve outcomes. But treatment times continue to show delays, especially during interhospital transfers. A simple 3‐step process of an interhospital “Call 9‐1‐1” protocol may expedite this process. This STAT TRANSFER process uses a systems approach that considers diverse ways in which patients access care, how EMS responds and determines destinations, how referring hospital transfers are performed, urban and rural differences, and how receiving hospitals prepare for an incoming patient with ST‐segment–elevation myocardial infarction. This initiative suggests a strategy to reduce variability in interhospital transfer times using a STAT TRANSFER and a Call 9‐1‐1 process in a system of care that involves all stakeholders.

12导联穿戴心电设备在院前诊断急性ST段抬高型心肌梗死中的应用

OBJECTIVE

To assess the value of wearable 12-lead electrocardiogram (ECG) devices in pre-hospital diagnosis of acute ST segment elevation myocardial infarction (STEMI).

METHODS

This analysis was conducted among 441 patients selected from the''National ECG Network'', who used wearable 12-lead ECG device with critical situation warning of ST change between January 2019, and August, 2021.The general characteristics, response time and complaints of the patients with STEMI were analyzed.The accuracy of pre-hospital diagnosis of STEMI was compared between clinician's interpretation of ECGs and AI diagnosis by the wearable ECG device.

RESULTS

In 89 of the patients, a pre-hospital diagnosis of STEMI was made by physicians based on ECGs from the wearable devices, and 58 of them sought medical attention after online warning, with a referral rate of 65.17%.The average time for diagnostic assessment of the ECGs was 153.02 s, and the average time for confirmation of the diagnosis was 178.06 s.The sensitivity for pre-hospital diagnosis of STEMI by clinician's interpretation of the ECGs and by AI diagnosis was 100% and 88.37%, respectively, with a specificity of 95.40% and 79.31%, respectively.The pre-hospital diagnosis by clinicians and AI diagnosis of STEMI both showed a high consistency with the subsequent definite clinical diagnosis of STEMI.

CONCLUSION

Wearable 12-lead ECG devices can accurately record ECG characteristics of STEMI patients outside the hospital and allow immediate data uploading for an early diagnosis.The diagnoses of STEMI made based on AI technology are highly consistent with those by clinicians, demonstrating excellent clinical performance of the wearable ECG devices.

Impact of Helicopter Transport on Reperfusion Times and Long-Term Outcomes in Acute Myocardial Infarction Patients in Rural Areas: A Report From the Mie Acute Coronary Syndrome Registry

OBJECTIVE

Helicopter emergency medical services (HEMS) are effective for time-sensitive conditions, such as stroke and trauma. However, prognostic data on helicopter transport for acute myocardial infarction (AMI) patients are insufficient.

METHODS

We registered 2,681 AMI patients in the Mie Acute Coronary Syndrome Registry and enrolled 163 patients from rural areas to HEMS base hospitals with HEMS or ground emergency medical services (GEMS). They were categorized into 4 groups according to the transportation method for interhospital transfer (direct HEMS: n = 52, direct GEMS: n = 54, interhospital HEMS: n = 32, and interhospital GEMS: n = 25). The primary end point was the emergency medical services (EMS) call-to-balloon time. The secondary end point was 2-year major adverse cardiac and cerebrovascular events.

RESULTS

The direct HEMS group was younger than the direct GEMS group (P = .029). The EMS call-to-balloon time was shorter in the direct HEMS and interhospital HEMS groups than in each GEMS group (P = .015 and P = .046). The incidence of 2-year major adverse cardiac and cerebrovascular events tended to be lower in both HEMS groups than in each GEMS group.

CONCLUSION

Direct HEMS for AMI in rural areas shortens the time from the EMS call to reperfusion when the transport distance is expected to exceed 30 km, which may result in a better patient prognosis. In addition, prehospital diagnostic modalities, such as 12-lead electrocardiography and echocardiography, may shorten the duration from the EMS call to reperfusion.

The impact of pre-hospital 12-lead electrocardiogram and first contact by cardiologist in patients with ST-elevation myocardial infarction in Kanagawa, Japan

Background pre-hospital 12-lead electrocardiogram (ECG) by emergency medical service (EMS) personnel at the site of first medical contact (FMC) and the physician of first contact both play important roles in managing patients with ST-elevation myocardial infarction (STEMI). However, in Japan, pre-hospital 12-lead ECG is not routinely performed by EMS personnel at the site of FMC and the physician of first contact is not always a cardiologist. Methods from October 2015 to October 2019, 2035 consecutive STEMI patients transported from the field by ambulance were analyzed from the K-ACTIVE registry. Based on the presence (+) or absence (-) of pre-hospital 12-lead ECG / first contact by cardiologist, patients were divided into 4 groups (+/+, +/-, -/+, -/-). Patient characteristics, FMC to door time, door to device time and in-hospital mortality were compared. Results the numbers of patients in each group were as follows (+/+, n = 987; +/-, n = 211; -/+, n = 610; -/-, n = 227). For patient characteristics, there were significant differences in the prevalence of dyslipidemia and the presence of chest pain. The FMC to door time was similar (median value, +/+, 24 min; +/-, 25 min; -/+, 24 min; -/-, 24 min; p = 0.23). The door to device time was the shortest in the +/+ group (median value, +/+, 65 min; +/-, 80 min; -/+, 69 min; -/-, 88 min; p < 0.0001). Crude in-hospital mortality was the highest in the -/- group (+/+, 3.9%; +/-, 2.4%; -/+, 5.8%; -/-, 11.9%; p < 0.0001). After adjustment for age and sex, the adjusted odds ratios for in-hospital mortality were as follows [odds ratio (with 95% confidence interval) +/+, 0.33 [0.19-0.57]; +/-, 0.19 [0.07-0.52]; -/+, 0.49 [0.29-0.86]; -/-, 1 [reference)]. Conclusion pre-hospital 12-lead ECG and the physician of first contact had a significant impact on the door to device time and in-hospital mortality. Continuous efforts should be made to improve acute management of STEMI.

Prehospital tele-electrocardiographic triage improves the management of acute coronary syndrome in rural populations: A systematic review and meta-analysis

INTRODUCTION

Acute coronary syndrome (ACS) patients residing in rural areas are predisposed to higher risk of poor outcomes due to substantial delays in disease management, emphasising the importance of emerging telecardiology technologies in delivering emergency services in such settings. This meta-analysis aimed to investigate the impacts of prehospital telecardiology strategies on the clinical outcomes of rural ACS patients.

METHODS

A literature search was performed of articles published up to April 2020 through six databases. Included studies were assessed for bias risk using the ROBINS-I tool, and a random-effects model was utilised to estimate effect sizes. Certainty of evidence was assessed using the Grading of Recommendations Assessment, Development, and Evaluation (GRADE).

RESULTS

Twelve studies with a total of 3989 patients were included in this review. Prehospital telecardiology in the form of tele-electrocardiography (tele-ECG) enabled prompt diagnosis and triage, resulting in a decreased door-to-balloon (DTB) time (mean difference = -25.53 minutes, 95% confidence interval (CI) -36.08 to -14.97 minutes; I² = 98%), as well as lower in-hospital mortality (odds ratio (OR) = 0.57, 95% CI 0.36-0.92) and long-term mortality (OR = 0.52, 95% CI 0.39-0.69) rates, both with negligible heterogeneity (I² = 0%). GRADE assessment yielded very low to moderate certainty of evidence.Conclusion Prehospital tele-ECG appeared to be an effective and worthwhile approach in the management of rural ACS patients, as shown by moderate quality evidence on lower long-term mortality. Given the uncertainties of the evidence quality on DTB time and in-hospital mortality, future studies with a higher quality of evidence are required to confirm our findings.

Effects of Prehospital Traige and Diagnosis of ST Segment Elevation Myocardial Infarction on Mortality Rate

INTRODUCTION

Adverse outcomes and mortality associated with STEMI (ST segment elevation myocardial infarction) are associated with the management and diagnosis time. The aim of this study is to evaluate the outcomes of prehospital diagnosis of STEMI via emergency medical service (EMS) on mortality, in comparison to the patients who did not receive EMS.

METHODS

This retrospective study included STEMI patients, who underwent primary angioplasty. The patients were categorized as group A: referred without emergency service, group B: patients who did not receive PPCI and group C: patients referred via ambulance and received telecardiology. Medical records of these patients were evaluated for the diagnosis time, door-to-balloon time, in-hospital, six months, one year and three-year mortality, left ventricular ejection fraction and previous history of cardiovascular conditions and surgeries. The data were recorded and statistically analyzed using SPSS v21.

RESULTS

Of 424 patients studied, 79 were referred without emergency service (group A), 52 patients did not receive PPCI (group B) and 293 patients were referred via ambulance with telecardiology (group C). Door-to-balloon time was least in group C (57.78 min) compared to group A (141.70 min). In-hospital, six months, one year and three-year mortality was least in group C, however, the difference was not statistically significant. The left ventricular ejection fraction was significantly greater in group C.

CONCLUSION

The results of our study indicate that prehospital diagnosis and telecardiology significantly reduce door-to-balloon time in STEMI patients referred for percutaneous intervention and might have an influence on short-term and long-term mortality rates.

Electrocardiogram Interpretation Competency Among Paramedic Students

BACKGROUND

Electrocardiography is an essential emergency tool used in the pre-hospital setting. However, no studies have yet assessed electrocardiogram (ECG) interpretation among emergency medical services (EMS) students in Saudi Arabia. This study aimed to determine the ECG interpretation competency of paramedic students.

METHODOLOGY

Cross-sectional, single-center study, a pre-validated, self-administered, two-part questionnaire first created by Coll-Badell et al was used to assess the ECG interpretation competency of paramedic students at Prince Sultan College for Emergency Medical Services (PSCEMS) in King Saud University. Participant data were collected and analyzed to identify factors associated with improved competency.

RESULTS

All students of PSCEMS were included, and 137 of 248 paramedic students completed the questionnaire (55% response rate); 88 students (64.2%) scored >7.5 points, indicating competency in (ECG) interpretation. Factors such as grade point average (GPA) (>3.5) and enrollment in cardiology and advanced cardiac life support courses were found to be significantly associated with competency (p<0.001).

CONCLUSION

The majority of paramedic students were found to be competent in ECG interpretation. GPA and enrollment in cardiology and advanced cardiac life support courses were significantly associated with improved competency.

Community-Based Pre-Hospital Electrocardiogram Transmission Program for Reducing Systemic Time Delay in Acute ST-Segment Elevation Myocardial Infarction

Background and Objectives

In acute ST-segment elevation myocardial infarction (STEMI), on-site transmission of electrocardiogram (ECG) has been shown to reduce systemic time delay to reperfusion and improve outcomes. However, it has not been adopted in community-based emergency transport system in Korea.

Methods

Busan Regional Cardio-cerebrovascular Center and Busan Metropolitan City Fire and Safety Headquarters (BMFSH) jointly developed and conducted a pre-hospital ECG transmission program. Seven tertiary hospitals and 22 safety stations of BMFSH participated. Systemic time delay to reperfusion of STEMI patients in the program was compared with that of 95 patients transported by 119 emergency medical system (EMS) before the program was implemented.

Results

During the study period, 289 ECG transmissions were made by 119 EMS personnel, executed within 5 minutes in 88.1% of cases. Of these, 42 ECGs were interpreted as ST-segment elevation. Final diagnosis of STEMI was made in 20 patients who underwent primary percutaneous coronary intervention. With the program, systemic time delay to reperfusion was significantly reduced (median [interquartile range; IQR], 76.0 [62.2–98.7] vs. 90.0 [75.0–112.0], p<0.01). Significant reduction of door-to-balloon time was also observed (median [IQR], 45.0 [34.0–69.5] vs. 58.0 [51.0–68.0], p=0.03). The proportion of patients with systemic time delay shorter than 90 minutes rose (51.6% vs. 75.0%, p=0.08) with pre-hospital ECG transmission.

Conclusions

We developed and implemented a community-based pre-hospital ECG transmission program for expeditious triage of STEMI patients. Significant reductions of systemic time delay and door-to-balloon time were observed. The expanded use of pre-hospital ECG transmission should be encouraged to realize the full potential of this program.

The effect of prehospital telecardiology on the mortality and morbidity of ST-segment elevated myocardial infarction patients undergoing primary percutaneous coronary intervention: A cross-sectional study

OBJECTIVES

The sooner the primary percutaneous coronary intervention (PPCI) is performed, the better prognosis is expected in patients with acute myocardial infarction. The objective is to evaluate the effect of prehospital triage based on electrocardiogram (ECG) and telecardiology on the mortality and morbidity of ST-segment elevated myocardial infarction (STEMI) patients undergoing PPCI.

METHODS

This cross-sectional study was conducted based on the data extracted from the hospital information system (HIS) of one general hospital, which had the capability of performing PPCI 24 h a day, 7 days a week. All patients with STEMI who undergone PPCI during 1 year, transferred by emergency medical service (EMS) and their data were registered in the HIS were eligible. Besides the baseline characteristics, first medical contact (FMC)-to-balloon time was recorded. Morbidity based on predischarge left ventricular ejection fraction (LVEF) and mortality based on Global Registry of Acute Cardiac Events (GRACE) score were also recorded. Patients who were referred to the hospital by EMS with prehospital ECG and telecardiology were compared with those without prehospital ECG.

RESULTS

Totally, 298 patients with STEMI were enrolled, of whom 183 patients (61.4%) had prehospital ECG (telecardiology), and 115 patients (38.6%) had not. The means of predischarge LVEF of the patients in the first and the second groups were 40.7 ± 10.4 and 40.6 ± 11.2, respectively (P = 0.946). The mean of the probability of 6-month mortality based on GRACE score in the first group was significantly less than that of the second group (P = 0.004). Analyses of multivariable ordinal logistic regression showed that 6-month mortality severity risk in the second group was 1.5 times more than the first group (95% confidence interval 0.8-2.6), although this difference was not statistically significant (P = 0.199).

CONCLUSIONS

It is likely that prehospital telecardiology, with shortening FMC to balloon time result in reducing probability 6-month mortality in STEMI patients who undergone PPCI. However, the process of telecardiology had no effect on predischarge LVEF in the current study.

Comparison between urban and rural mortality in patients with acute myocardial infarction: a nationwide longitudinal cohort study in South Korea

OBJECTIVES

This study investigated the risk associated with interhospital transfer of patients with acute myocardial infarction (AMI) and clinical outcomes according to the location of the patient' residence.

DESIGN

A nationwide longitudinal cohort.

SETTING

National Health Insurance Service database of South Korea.

PARTICIPANTS

This study included 69 899 patients with AMI who visited an emergency centre from 2013 to 2015, as per the Korea National Health Insurance Service database.

PRIMARY OUTCOME MEASURE

The clinical outcome of a patient with AMI was defined as mortality within 7 days, 30 days and 1 year.

RESULTS

Clinical outcomes were analysed and compared with respect to the location of the patient's residence and occurrence of interhospital transfer. We concluded that the HR of mortality within 7 days was 1.49 times higher (95% CI 1.18 to 1.87) in rural patients than in urban patients not subjected to interhospital transfer and 1.90 times higher (95% CI 1.13 to 3.19) in transferred rural patients than in non-transferred urban patients.

CONCLUSIONS

To reduce health inequality in rural areas, a healthcare policy considering regional characteristics, rather than a central government-led, catch-all approach to healthcare policy, must be formulated. Additionally, a local medical emergency delivery system, based on allocation of roles between different medical facilities in the region, must be established.

Characteristics of Prehospital Electrocardiogram Use in North Carolina Using a Novel Linkage of Emergency Medical Services and Emergency Department Data

Objective: Prehospital electrocardiography (ECG) is recommended for patients with suspected acute coronary syndrome (ACS), yet only 20-80% of chest pain patients receive a prehospital ECG. Less is known about prehospital ECG use in patients with less common complaints (e.g., fatigue) suspicious for ACS who are transported by emergency medical services (EMS). The aims of this study were to determine: (1) the proportion of patients with chest pain and less typical complaints, and (2) patient characteristics associated with prehospital ECG use in patients transported by EMS to emergency departments across North Carolina. Methods: A novel linked database was created between prehospital and emergency department (ED) patient care data from the North Carolina Prehospital Medical Information System and the North Carolina Disease Event Tracking and Epidemiologic Collection Tool. Institutional review board approval and a data use agreement were received prior to the start of the study. Patients ≥21 transported during 2010-14 by EMS with select variables were included. We examined patients' complaints (symptoms), characteristics (e.g., race, ethnicity, final hospital diagnosis), and prehospital ECG use (yes/no). Analysis included descriptive statistics and mixed logistic regression. Results: During 2010-14, there were 1,967,542 patients with linked EMS-ED data (mean age: 56.9 [SD: 22.2], 43.2% male, 63.7% White). Of these, 643,174 (32.6%) received a prehospital ECG. Patients with prehospital ECG presented with the following complaints: 20% chest pain; 10% shortness of breath; 6% abdominal pain/problems; 6% altered level of consciousness; 5% syncope/dizziness; 4% palpitations; 12% other complaints; and 37% missing. Patients' presenting complaints were the strongest predictor of prehospital ECG use, adjusting for age, sex, race, ethnicity, urbanicity, and date and time of EMS dispatch. Conclusions: Patients with chest pain were significantly more likely to receive a prehospital ECG compared to those with less typical but suspicious complaints for ACS. Patients with less common presentations remain disadvantaged for early triage, risk stratification, and intervention prior to the hospital.

The VITAL study and overall pooled analysis with the VIPS non-invasive stroke detection device

INTRODUCTION

Effective triage of patients with emergent large vessel occlusion (ELVO) to endovascular therapy capable centers may decrease time to treatment and improve outcome for these patients. Here we performed a derivation study to evaluate the accuracy of a portable, non-invasive, and easy to use severe stroke detector.

METHODS

The volumetric impedance phase shift spectroscopy (VIPS) device was used to assign a bioimpedance asymmetry score to 248 subjects across three cohorts, including 41 subjects presenting as acute stroke codes at a major comprehensive stroke center (CSC), 79 healthy volunteers, and 128 patients presenting to CSCs with a wide variety of brain pathology including additional stroke codes. Diagnostic parameters were calculated for the ability of the device to discern (1) severe stroke from minor stroke and (2) severe stroke from all other subjects. Patients with intracranial hardware were excluded from the analysis.

RESULTS

The VIPS device was able to differentiate severe stroke from minor strokes with a sensitivity of 93% (95% CI 83 to 98), specificity of 92% (95% CI 75 to 99), and an area under the curve (AUC) of 0.93 (95% CI 0.85 to 0.97). The device was able to differentiate severe stroke from all other subjects with a sensitivity of 93% (95% CI 83 to 98), specificity of 87% (95% CI 81 to 92), and an AUC of 0.95 (95% CI 0.89 to 0.96).

CONCLUSION

The VIPS device is a portable, non-invasive, and easy to use tool that may aid in the detection of severe stroke, including ELVO, with a sensitivity of 93% and specificity of 92% in this derivation study. This device has the potential to improve the triage of patients suffering severe stroke.

Emergency Medical Services Utilization and Outcomes of Patients with ST-Elevation Myocardial Infarction in Lebanon

BACKGROUND

Arrival of patients with ST-elevation myocardial infarction (STEMI) by Emergency Medical Services (EMS) results in shorter reperfusion times and lower mortality in developed countries.

OBJECTIVES

This study examines EMS use by STEMI patients in Lebanon and associated clinical outcomes.

METHODS

A retrospective observational study with chart review was carried out for STEMI patients arriving to the Emergency Department of a tertiary care center in Lebanon between January 1, 2013 and August 31, 2016. A descriptive analysis was done and followed by a bivariate analysis comparing two groups of patients (EMS vs. Non-EMS).

RESULTS

A total of 280 patients were included in the study. They were mostly male (71.8%). Mean age was 65.1 years (95% confidence interval [CI] 63.4-66.9). Only 12.5% (95% CI 8.6-16.4) presented by EMS. Chest pain (81.1%) was the most common presenting symptom. Anterior myocardial infarction was the most common electrocardiogram (ECG) diagnosis (51.4%). Most patients were admitted (98.2%), and 72.0% of these patients were treated with primary percutaneous coronary intervention. Cardiogenic shock was the most frequent in-hospital complication (6.2%). The mortality rate was 7.1%. Mean door-to-ECG and door-to-balloon times were 10.8 (95% CI 7.1-14.4) min and 106.2 (95% CI 95.9-116.6) min, respectively. Patients' characteristics, presenting symptoms, outcomes, and performance metrics were similar between the two groups.

CONCLUSION

EMS is underutilized by STEMI patients in Lebanon and is not associated with improvement in clinical outcomes. Medical oversight and quality initiatives focusing on outcomes of patients with timely sensitive emergencies are needed to advance the prehospital care system in Lebanon.

Ambulance use, distance and outcomes in patients with suspected cardiovascular disease: a registry-based geographic information system study

BACKGROUND

Despite guideline recommendations, the majority of patients with symptoms suggestive of acute coronary syndrome do not use emergency medical services to reach the emergency department (ED). The aim of this study was to investigate the factors associated with EMS utilisation and subsequent patient outcomes.

METHODS

Using administrative data, all patients who presented to an ED in the metropolitan areas of Edmonton and Calgary in the years of 2007-2013 with main ED diagnosis of acute coronary syndrome, stable angina or chest pain were included. The travel distance was estimated using the geographic information system method to approximate the distance between the ED and patient home. The clinical endpoints were the 7-day and 30-day all-cause events (death, re-hospitalisation and repeat ED visit).

RESULTS

Of 50,881 patients, 30.5% presented by emergency medical services. Patients with older age, female sex, ED diagnosis of acute coronary syndrome, more comorbidities and lower household income were more likely to use emergency medical services to reach the hospital. Longer travel distance was associated with higher emergency medical services use (odds ratio 1.09, 95% confidence interval 1.09-1.10), but it was not a predictor of clinical events. After adjustment for covariates and inverse propensity score weighting, emergency medical services use was associated with a higher risk of 7-day and 30-day clinical events.

CONCLUSION

Several demographic and clinical features were associated with higher emergency medical services use including geographical variation. Although longer travel distance was shown to be linked to higher emergency medical services use, it was not an independent predictor of patient outcome. This has implications for the design of emergency medical services systems, triage and early diagnosis and treatment options.

Pre-hospital detection of acute ischemic stroke secondary to emergent large vessel occlusion: lessons learned from electrocardiogram and acute myocardial infarction

Currently, there is no device capable of detecting acute ischemic stroke (AIS) secondary to emergent large vessel occlusion (ELVO) in the pre-hospital setting. The inability to reliably identify patients that would benefit from primary treatment with endovascular thrombectomy remains an important limitation to optimizing emergency medical services (EMS) triage models and time-to-treatment. Several clinical grading scales that rely solely on clinical examination have been proposed and have demonstrated only moderate predictive ability for ELVO. Consequently, a technology capable of detecting ELVO in the pre-hospital setting would be of great benefit. An analogous scenario existed decades ago, in which pre-hospital detection of acute myocardial infarction (AMI) was unreliable until the emergence of the 12-lead ECG and its adoption by EMS providers. This review details the implementation of pre-hospital ECG (PHECG) for the detection of AMI and explores how early experience with PHECG may be applied to ELVO detection devices, once they become available.