Gender Differences in Scene Time, Transport Time, and Total Scene to Hospital Arrival Time Determined by the Use of a Prehospital Electrocardiogram in Patients with Complaint of Chest Pain

Ambulance service recognition of health inequalities and activities for reduction: An evidence and gap map of the published literature

Background

Emergency medical services (EMS) are often patients' first point of contact for urgent and emergency care needs. Patients are triaged over the phone and may receive an ambulance response, with potential conveyance to the hospital. A recent scoping review suggested disparities in EMS patient care in the United States. However, it is unknown how health inequalities impact EMS care in other developed countries and how inequalities are being addressed.

Objectives

This rapid evidence map of published literature aims to map known health inequalities in EMS patients and describe interventions reducing health inequalities in EMS patient care.

Methods

The search strategy consisted of EMS synonyms and health inequality synonyms. The MEDLINE/PubMed database was searched from 1 January 2010 to 26 July 2022. Studies were included if they described empirical research exploring health inequalities within ambulance service patient care. Studies were mapped on to the EMS care interventions framework and Core20PLUS5 framework. Studies evaluating interventions were synthesised using the United Kingdom Allied Health Professions Public Health Strategic Framework.

Results

The search strategy yielded 771 articles, excluding duplicates, with two more studies added from hand searches. One hundred studies met the inclusion criteria after full-text review. Inequalities in EMS patient care were predominantly situated in assessment, treatment and conveyance, although triage and response performance were also represented. Studies mostly explored EMS health inequalities within ethnic minority populations, populations with protected characteristics and the core issue of social deprivation. Studies evaluating interventions reducing health inequalities (n = 5) were from outside the United Kingdom and focused on older patients, ethnic minorities and those with limited English proficiency. Interventions included community paramedics, awareness campaigns, dedicated language lines and changes to EMS protocols.

Conclusions

Further UK-based research exploring health inequalities of EMS patients would support ambulance service policy and intervention development to reduce health inequality in urgent and emergency care delivery.

Exploring factors influencing time from dispatch to unit availability according to the transport decision in the pre-hospital setting: an exploratory study

BACKGROUND

Efficient resource distribution is important. Despite extensive research on response timings within ambulance services, nuances of time from unit dispatch to becoming available still need to be explored. This study aimed to identify the determinants of the duration between ambulance dispatch and readiness to respond to the next case according to the patients' transport decisions.

METHODS

Time from ambulance dispatch to availability (TDA) analysis according to the patients' transport decision (Transport versus Non-Transport) was conducted using R-Studio™ for a data set of 93,712 emergency calls managed by a Middle Eastern ambulance service from January to May 2023. Log-transformed Hazard Ratios (HR) were examined across diverse parameters. A Cox regression model was utilised to determine the influence of variables on TDA. Kaplan-Meier curves discerned potential variances in the time elapsed for both cohorts based on demographics and clinical indicators. A competing risk analysis assessed the probabilities of distinct outcomes occurring.

RESULTS

The median duration of elapsed TDA was 173 min for the transported patients and 73 min for those not transported. The HR unveiled Significant associations in various demographic variables. The Kaplan-Meier curves revealed variances in TDA across different nationalities and age categories. In the competing risk analysis, the 'Not Transported' group demonstrated a higher incidence of prolonged TDA than the 'Transported' group at specified time points.

CONCLUSIONS

Exploring TDA offers a novel perspective on ambulance services' efficiency. Though promising, the findings necessitate further exploration across diverse settings, ensuring broader applicability. Future research should consider a comprehensive range of variables to fully harness the utility of this period as a metric for healthcare excellence.

Factors associated with prolonged on-scene time in ambulance transportation among patients with minor diseases or injuries in Japan: a population-based observational study

BACKGROUND

Prolonged prehospital time is a major global problem in the emergency medical system (EMS). Although factors related to prolonged on-scene times (OSTs) have been reported in patients with trauma and critical medical conditions, those in patients with minor diseases or injuries remain unclear. We examined factors associated with prolonged OSTs in patients with minor diseases or injuries.

METHODS

This population-based observational study used the ambulance transportation and request call record databases of the Higashihiroshima Fire Department, Japan, between January 1, 2016, and December 31, 2022. The participants were patients with minor diseases or injuries during the study period. We performed a multivariable logistic regression analysis with robust error variance to examine the association between patient age, sex, severity, accident type, date and time of ambulance call, and the coronavirus disease 2019 (COVID-19) pandemic with prolonged OSTs. Prolonged OST was defined as ≥ 30 min from the ambulance arrival at the scene to departure.

RESULTS

Of the 60,309 people transported by ambulance during the study period, 20,069 with minor diseases or injuries were included in the analysis. A total of 1,241 patients (6.2%) experienced prolonged OSTs. Fire accidents (adjusted odds ratio [aOR]: 7.77, 95% confidence interval [CI]: 3.82-15.79), natural disasters (aOR: 28.52, 95% CI: 2.09-389.76), motor vehicle accidents (aOR: 1.63, 95% CI: 1.30-2.06), assaults (aOR: 2.91, 95% CI: 1.86-4.53), self-injuries (aOR: 5.60, 95% CI: 3.37-9.32), number of hospital inquiries ≥ 4 (aOR: 77.34, 95% CI: 53.55-111.69), and the COVID-19 pandemic (aOR: 2.01, 95% CI: 1.62-2.50) were associated with prolonged OSTs. Moreover, older and female patients had prolonged OSTs (aOR: 1.18, 95% CI: 1.01-1.36 and aOR: 1.12, 95% CI: 1.08-1.18, respectively).

CONCLUSIONS

Older age, female sex, fire accidents, natural disasters, motor vehicle accidents, assaults, self-injuries, number of hospital inquiries ≥ 4, and the COVID-19 pandemic influenced prolonged OSTs among patients with minor diseases or injuries. To improve community EMS, we should reconsider how to intervene with potentially modifiable factors, such as EMS personnel performance, the impact of the presence of allied services, hospital patient acceptance systems, and cooperation between general emergency and psychiatric hospitals.

Assessment of Gender Bias During Paramedic-Physician Handoffs

Objective Gender bias against female physicians has been frequently demonstrated and associated with negative feelings toward their careers. Gender bias has also been demonstrated in prehospital clinical care. However, potential gender bias during paramedic-physician handoffs has not been studied. This study aimed to identify gender bias during interactions between prehospital personnel and emergency physicians at the time of patient handoff. Methods An observational study was conducted at an urban academic emergency department. Observers were trained to record information from paramedic-physician handoffs but were blind to the nature of the study. The primary outcome was to whom paramedics initially directed the focus of their handoff report based on physician gender, with secondary outcomes of to whom paramedics directed most of their report and whether they asked about further questions based on physician gender. Results There were 784 observed handoffs. There was no significant association between the gender of the physician and which physician received first attention (χ2 {1, N = 782} = 0.9736, p = 0.3238) or majority attention (χ2 {1, N = 780} = 1.9414, p = 0.1635). Paramedics were more likely to ask questions to male attendings than female attendings (χ2 {1, N = 784} = 4.4319, p = 0.0353). Conclusion We identified limited differences in communication based on gender between paramedics and physicians during emergency department patient handoffs.

Disparities in Emergency Medical Services Care Delivery in the United States: A Scoping Review

BACKGROUND

Emergency medical services (EMS) often serve as the first medical contact for ill or injured patients, representing a critical access point to the health care delivery continuum. While a growing body of literature suggests inequities in care within hospitals and emergency departments, limited research has comprehensively explored disparities related to patient demographic characteristics in prehospital care.

OBJECTIVE

We aimed to summarize the existing literature on disparities in prehospital care delivery for patients identifying as members of an underrepresented race, ethnicity, sex, gender, or sexual orientation group.

METHODS

We conducted a scoping review of peer-reviewed and non-peer-reviewed (gray) literature. We searched PubMed, CINAHL, Web of Science, Proquest Dissertations, Scopus, Google, and professional websites for studies set in the U.S. between 1960 and 2021. Each abstract and full-text article was screened by two reviewers. Studies written in English that addressed the underrepresented groups of interest and investigated EMS-related encounters were included. Studies were excluded if a disparity was noted incidentally but was not a stated objective or discussed. Data extraction was conducted using a standardized electronic form. Results were summarized qualitatively using an inductive approach.

RESULTS

One hundred forty-five full-text articles from the peer-reviewed literature and two articles from the gray literature met inclusion criteria: 25 studies investigated sex/gender, 61 studies investigated race/ethnicity, and 58 studies investigated both. One study investigated sexual orientation. The most common health conditions evaluated were out-of-hospital cardiac arrest (n = 50), acute coronary syndrome (n = 36), and stroke (n = 31). The phases of EMS care investigated included access (n = 55), pre-arrival care (n = 46), diagnosis/treatment (n = 42), and response/transport (n = 40), with several studies covering multiple phases. Disparities were identified related to all phases of EMS care for underrepresented groups, including symptom recognition, pain management, and stroke identification. The gray literature identified public perceptions of EMS clinicians' cultural competency and the ability to appropriately care for transgender patients in the prehospital setting.

CONCLUSIONS

Existing research highlights health disparities in EMS care delivery throughout multiple health outcomes and phases of EMS care. Future research is needed to identify structured mechanisms to eliminate disparities, address clinician bias, and provide high-quality equitable care for all patient populations.

Variation in on-scene time of emergency medical services and the extent of the difference of on-scene time between genders: a retrospective population-based registry study in Riyadh Province, Saudi Arabia

OBJECTIVES

To identify the intergender variation of on-scene time (OST) for highly urgent emergency cases conveyed by emergency medical services (EMS) in Saudi Arabia and to assess other predictors of OST and hypothesise for possible factors delaying OST.

DESIGN

A retrospective population-based registry study.

SETTING

Riyadh Province is the largest province in terms of population and the second in terms of geographical area.

PARTICIPANTS

All highly urgent transported patients from the scene to emergency departments, be they medical emergencies or trauma emergencies during 2018.

OUTCOME MEASURE

OST difference between men and women transported by EMS.

RESULTS

In total, 21 878 patients were included for analysis: 33.9% women and 66.1% men. The median OST for women was 22 min (IQR 15-30) and 18 min (IQR 11-26) for men (p<0.001); for medical cases, median OST was 23 min (IQR 16-31) for women compared with 20 min (IQR 13 - 29) for men (p<0.001); for trauma cases, the median OST of both sexes was equal. We found the following additional predictors of OST: factors of emergency type, sex, age category, geographical areas, type of ambulance vehicle and hospital type were all significantly associated with OST in the crude or adjusted analyses. Factors of emergency type, sex, age category, geographical areas, type of ambulance vehicle and hospital type were also significantly associated with the odds of OST of more than 15 min in the crude and adjusted regression analyses.

CONCLUSIONS

The median OST was longer than 15 min for more than half of transported cases. For medical cases, women had a longer median OST than men. Additional predictors associated with prolonged OST were the patient's age, area (ie, urban vs rural), type of ambulance vehicle and season. These findings are hypothesis generating and require further studies.

Delays to Hospital Presentation in Women and Men with ST-Segment Elevation Myocardial Infarction: A Multi-Center Analysis of Patients Hospitalized in New York City

Purpose

Previous studies have shown longer delays from symptom onset to hospital presentation (S2P time) in women than men with acute myocardial infarction. The aim of this study is to understand the reasons for delays in seeking care among women and men presenting with an ST-Segment Elevation Myocardial Infarction (STEMI) through a detailed assessment of the thoughts, perceptions and patterns of behavior.

Patients/Methods and Results

A total of 218 patients with STEMI treated with primary angioplasty at four New York City Hospitals were interviewed (24% female; Women: 68.7 ± 13.1 years and men: 60.7 ± 13.8 years) between January 2009 and August 2012. A significantly larger percentage of women than men had no chest pain (62% vs 36%, p<0.01). Compared to men, a smaller proportion of women thought they were having a myocardial infarction (15% vs 34%, p=0.01). A larger proportion of women than men had S2P time >90 minutes (72% of women vs 54% of men, p= 0.03). Women were more likely than men to hesitate before seeking help, and more women than men hesitated because they did not think they were having an AMI (91% vs 83%, p=0.04). Multivariate regression analysis showed that female sex (Odds Ratio: 2.46, 95% CI 1.10–5.60 P=0.03), subjective opinion it was not an AMI (Odds Ratio 2.44, 95% CI 1.20–5.0, P=0.01) and level of education less than high school (Odds ratio 7.21 95% CI 1.59–32.75 P=0.01) were independent predictors for S2P >90 minutes.

Conclusion

Women with STEMI have longer pre-hospital delays than men, which are associated with a higher prevalence of atypical symptoms and a lack of belief in women that they are having an AMI. Greater focus should be made on educating women (and men) regarding the symptoms of STEMI, and the importance of a timely response to these symptoms.

Gender differences, inequalities and biases in the management of Acute Coronary Syndrome

OBJECTIVE

The approach to Acute Coronary Syndrome from a gender perspective is relatively recent. Research is extensive at epidemiological and clinical levels. However, available evidence, besides neglecting the social dimensions of the disease, has made women invisible. The objective of this review was to analyze the inequalities and gender biases in Acute Coronary Syndrome, from the beginning of the disease process to the final resolution.

METHODS

An exhaustive review of the literature of the entire health care process, from risk factors to rehabilitation and recovery, was carried out. The search for articles on gender, gender inequalities, or gender bias was conducted in indexed journals of social and health sciences. Also, a specific search was performed for each stage of the process, such as risk factors, prehospital phase, diagnosis, treatment, and rehabilitation.

RESULTS

Results showed the presence of gender biases throughout the entire health care process in Acute Coronary Syndrome. It is shown gender inequalities in the access to medical care, including a poor recognition among women themselves as well as among health professionals; longer prehospital delays; inadequate diagnoses and treatments; or less assistance to cardiac rehabilitation programmes. These biases occurred at the different levels of the health services involved. Finally, this review included recommendations proposed or arising from the revised papers.

CONCLUSIONS

Reducing gender biases in Acute Coronary Syndrome implies developing strategies to raise awareness among women, improve training of professionals serving at the different levels of health services, reduce delays, develop health management measures, and promote a research agenda.

Disparities in Emergency Medical Services Time Intervals for Patients with Suspected Acute Coronary Syndrome: Findings from the North Carolina Prehospital Medical Information System

Background

Timely emergency medical services (EMS) response, management, and transport of patients with suspected acute coronary syndrome (ACS) significantly reduce delays to emergency treatment and improve outcomes. We evaluated EMS response, scene, and transport times and adherence to proposed time benchmarks for patients with suspected ACS in North Carolina from 2011 to 2017.

Methods and Results

We conducted a population‐based, retrospective study with the North Carolina Prehospital Medical Information System, a statewide electronic database of all EMS patient care reports. We analyzed 2011 to 2017 data on patient demographics, incident characteristics, EMS care, and county population density for EMS‐suspected patients with ACS, defined as a complaint of chest pain or suspected cardiac event and documentation of myocardial ischemia on prehospital ECG or prehospital activation of the cardiac care team. Descriptive statistics for each EMS time interval were computed. Multivariable logistic regression was used to quantify relationships between meeting response and scene time benchmarks (11 and 15 minutes, respectively) and prespecified covariates. Among 4667 patients meeting eligibility criteria, median response time (8 minutes) was shorter than median scene (16 minutes) and transport (17 minutes) time. While scene times were comparable by population density, patients in rural (versus urban) counties experienced longer response and transport times. Overall, 62% of EMS encounters met the 11‐minute response time benchmark and 49% met the 15‐minute scene time benchmark. In adjusted regression analyses, EMS encounters of older and female patients and obtaining a 12‐lead ECG and venous access were independently associated with lower adherence to the scene time benchmark.

Conclusions

Our statewide study identified urban–rural differences in response and transport times for suspected ACS as well as patient demographic and EMS care characteristics related to lower adherence to scene time benchmark. Strategies to reduce EMS scene times among patients with ACS need to be developed and evaluated.

Gender Disparities in Cardiac Catheterization Rates Among Emergency Department Patients With Chest Pain

BACKGROUND

Previous studies have noted differences in rates of cardiac testing based on gender of patients. We evaluated cardiac catheterization rates for men and women presenting to the emergency department (ED) with chest pain, particularly among patients without a history of myocardial infarction (MI) or recent positive stress test.

METHODS

We performed a prospective evaluation of patients presenting to an urban, academic medical center for assessment of chest pain. We recorded baseline information, testing, and outcomes related to ED, observation unit, and inpatient stay. Primary outcomes included gender differences in cardiac catheterization and stenting rates among patients without an MI or positive stress test.

RESULTS

Over the 5.5 year study period, 2242 ED patients with chest pain participated in the study (45% male). Men and women had similar rates of cardiac stress testing (16.7% vs. 15.2%, P = 0.317) as well as similar rates of positive cardiac stress testing (2.9% vs. 1.9%, P = 0.116). Men were more likely to undergo cardiac catheterization (10.4% vs. 4.9%, P < 0.001). Men who had neither MI nor positive stress test were more likely than women to undergo cardiac catheterization: 5.8% versus 3.3%, P = 0.010. Similarly, men in this group were more likely to experience stent placement: 2.1% versus 0.7%, P = 0.003.

CONCLUSIONS

Similar to previous studies, we noted disparities in cardiac testing by gender. Men were more likely to go to cardiac catheterization without an MI or a positive stress test. This disparity in a more aggressive strategy of cardiac catheterization in men may result in higher stenting rates in this group.

Comparison of pre-hospital emergency services time intervals in patients with heart attack in Arak, Iran

Background:

After cardiac arrest, the possibility of death or irreversible complications will highly increase in the absence of cardiac resuscitation within 4 to 6 minutes. Accordingly, measuring the pre-hospital services time intervals is important for better management of emergency medical services delivery. The purpose of this study then was to investigate pre-hospital time intervals for patients with heart attack in Arak city, based on locations and time variables.

Methods:

This is a retrospective descriptive cross-sectional study, which was conducted at the Arak Emergency Medical Services (EMS) during 2017-2018. Data were analyzed by SPSS version 13.

Results:

The total number of heart attack patients registered in Arak emergency medical services was 2,659 of which 51% of patients were males. Six percent of patients were under 25 and about 49 percent were between 46 and 65 years old. The average of activation, response, on-scene, transportation, recovery and total time intervals were 3:30, 7:56, 15:15, 13:34, 11:07, 12:11, and 41:25, respectively. In the city area, the shortest and longest average response time intervals were in spring and winter, respectively. In out of the city area, the shortest average response time interval was in summer and the longest one in autumn. The shortest and the longest average response time intervals in the city area were in June and March, respectively, and in out of the city area, the shortest average response time interval was in June and the longest one in April.

Conclusions:

The shorter response and delivery time interval compared to the other studies may indicate improvement in the provision of EMS. Special attention should be paid to the facilities and equipment of vehicles during cold seasons to be in the shortest possible time. Also, training and informing the staff more about the code of cardiac patients along with general public education can help improve these intervals.

Factors associated with emergency medical service delays in suspected ST-elevation myocardial infarction in Victoria, Australia: A retrospective study

OBJECTIVE

To assess the effect of patient and system characteristics on emergency medical service (EMS) delays prior to arrival at hospital in suspected ST-elevation myocardial infarction (STEMI).

METHODS

This was a retrospective observational study of 1739 patients who presented with suspected STEMI to the EMS in Melbourne, Australia between October 2011 and January 2014. Our primary outcome measure was call-to-hospital time, defined as the time in minutes from emergency call to hospital arrival. We examined the association of patient and system characteristics on call-to-hospital time using multivariable linear regression.

RESULTS

The mean call-to-hospital time was 60.1 min (standard deviation 20.5) and the median travel distance was 13.0 km (interquartile range 7.2-23.1). In the multivariable model, patient characteristics associated with longer call-to-hospital time were age ≥75 years (2.3 min; 95% confidence interval [CI] 0.6-4.0), female sex (1.9 min; 95% CI 0.3-3.4), pre-existing mental health disorder (4.0 min; 95% CI 1.9-6.1) or musculoskeletal disease (2.7 min; 95% CI 1.0-4.4), absence of chest pain (3.0 min; 95% CI 1.1-4.8), and presentation with clinical complications. System factors associated with call-to-hospital time include lower dispatch priority (12.7 min; 95% CI 9.0-16.5) and non-12-lead electrocardiography (ECG) capable ambulance first on scene (4.5 min; 95% CI 3.1-5.8). Patients who were not initially attended by a 12-lead capable ambulance were less likely to receive a 12-lead ECG within 10 min (18.5% vs 71.0%, P < 0.001).

CONCLUSION

A range of patient and system factors may influence EMS delays in STEMI. However, optimising dispatch prioritisation and widespread availability of prehospital 12-lead ECG could lead to substantial reduction in time to treatment.

Few with ST-segment elevation myocardial infarction are diagnosed within 10 minutes from first medical contact, and women have longer delay times than men

Background

Previous reports have questioned the feasibility and gender equality of obtaining a prehospital ECG within 10 minutes of ambulance arrival for patients with ST-segment elevation myocardial infarction (STEMI). The main objective of this study was to investigate the proportion of STEMI patients with a prehospital ECG within 10 minutes of ambulance arrival. The secondary objective was to study the gender differences in delay times in prehospital STEMI care.

Methods

This study was a retrospective study based on 539 patients with STEMI at the investigating hospital. Ambulance and medical charts, as well as the national quality registry “SWEDEHEART”, were reviewed for each patient for demographics and time information.

Results

A prehospital ECG was obtained within 10 minutes of ambulance arrival for 99 (29%) of the men and 19 (14%) of the women, p = 0.001. Women had a 2 minutes longer delay between ambulance arrival and prehospital ECG (95% CI 0–4 min, p = 0.018) than men. Women also had a significantly longer patient delay. None of the other time intervals differed among men and women.

Conclusions

Only for a minority of patients is a prehospital ECG taken within the recommended ten minutes from ambulance arrival. Women have longer patient delay times, as well as delay times to the acquisition of a prehospital ECG than men. Improvements of prehospital ECG acquisition and adjustments of the guidelines are warranted.

Review article: Impact of 12-lead electrocardiography system of care on emergency medical service delays in ST-elevation myocardial infarction: A systematic review and meta-analysis

To assess the impact of prehospital 12-lead electrocardiography (PH ECG) on emergency medical service (EMS) delay in patients with ST-elevation myocardial infarction (STEMI), we systematically searched five online electronic databases, including MEDLINE, Embase, Emcare, Cochrane Library and CINAHL, between 1990 and August 2017. Controlled trials and observational studies comparing EMS time delays with and without PH ECG in STEMI patients were eligible. Two reviewers independently screened studies for eligibility, extracted data and appraised study quality. The primary outcome was the time elapsed between scene arrival and hospital arrival. The secondary outcomes were response time, scene time, transport time and emergency call-to-hospital arrival time. Random effects models were used to pool weighted mean differences in EMS delay. Seven moderate-quality studies (two controlled trials and five observational) involving 81 005 participants were included in the data synthesis. The primary treatment strategy was in-hospital thrombolysis and percutaneous coronary intervention in four and three studies, respectively. PH ECG was associated with a 7.0 min increase in scene arrival-to-hospital arrival time (three studies; n = 80 628; 95% CI 6.7-7.2; I² = 0.0%) and a 2.9 min increase in scene time (four studies; n = 377; 95% CI 1.2-4.6; I² = 0.0%). PH ECG had no effect on transport or call-to-hospital intervals, although both measures showed evidence of heterogeneity. In patients with STEMI, PH ECG is associated with a modest increase in EMS delays. Measurement and improvement of EMS system delays may help to expedite treatment for STEMI.

Race and sex disparities in prehospital recognition of acute stroke

OBJECTIVES

The objective of this study was to examine prehospital provider recognition of stroke by race and sex.

METHODS

Diagnoses at emergency department (ED) and hospital discharge from a statewide database in California were linked to prehospital diagnoses from an electronic database from two counties in Northern California from January 2005 to December 2007 using probabilistic linkage. All patients 18 years and older, transported by ambulances (n = 309,866) within the two counties, and patients with hospital-based discharge diagnoses of stroke (n = 10,719) were included in the study. Logistic regression was used to analyze the independent association of race and sex with the correct prehospital diagnosis of stroke.

RESULTS

There were 10,719 patients discharged with primary diagnoses of stroke. Of those, 3,787 (35%) were transported by emergency medical services providers. Overall, 32% of patients ultimately diagnosed with stroke were identified in the prehospital setting. Correct prehospital recognition of stroke was lower among Hispanic patients (odds ratio [OR] = 0.77, 95% confidence interval [CI] 0.61 to 0.96), Asians (OR = 0.66, 95% CI 0.55 to 0.80), and others (OR = 0.71, 95% CI = 0.53 to 0.94), when compared with non-Hispanic whites, and in women compared with men (OR = 0.82, 95% CI = 0.71 to 0.94). Specificity for recognizing stroke was lower in females than males (OR = 0.84, 95% CI = 0.78 to 0.90).

CONCLUSIONS

Significant disparities exist in prehospital stroke recognition.

Association between prehospital electrocardiogram use and patient home distance from the percutaneous coronary intervention center on total reperfusion time in ST-segment-elevation myocardial infarction patients: a retrospective analysis from the national cardiovascular data registry

BACKGROUND

Current guidelines recommend ≤90 minutes from first medical contact to percutaneous coronary intervention (FMC2B) for ST-segment-elevation myocardial infarction (STEMI) patients. We evaluated the relationship between patient home distance from a percutaneous coronary intervention (PCI) center, prehospital electrocardiogram (ECG) use, and FMC2B time among patients with STEMI.

METHODS

We performed a retrospective cohort study including all STEMI patients in the ACTION-Get With The Guidelines registry from July 1, 2008, to September 30, 2012, who were transported by ambulance to a PCI center. Patient home distance was defined as the driving distance from the patient's home zip code to the PCI center address. Distance was classified into tertiles, and linear regression was used to characterize the interaction between prehospital ECG use and patient home distance with respect to FMC2B time.

RESULTS

Of the 29,506 STEMI patients, 19,690 (67%) received a prehospital ECG. The median patient home distance to the PCI center was 11.0 miles among patients with and 9.9 miles among those without a prehospital ECG. Prehospital ECGs were associated with a 10-minute reduction in the FMC2B time (P < .0001), which was consistent across distance tertiles (11 vs 11 vs 10 minutes). The association between prehospital ECGs and shorter FMC2B was attenuated by 0.8 minute for every 10-mile increase in distance (interaction P = .0002).

CONCLUSIONS

Prehospital ECGs are associated with a 10-minute reduction in the FMC2B time. However, patient home distance from a PCI center does not substantially change this association.

Factors associated with longer time to treatment for patients with suspected acute coronary syndromes: a cohort study

BACKGROUND

Rapid treatment of acute coronary syndromes (ACS) is important; causes of delay in emergency medical services care of ACS are poorly understood.

METHODS AND RESULTS

We performed an analysis of data from IMMEDIATE (Immediate Myocardial Metabolic Enhancement during Initial Assessment and Treatment in Emergency Care), a randomized controlled trial of emergency medical services treatment of people with symptoms suggesting ACS, using hierarchical multiple regression of elapsed time. Out-of-hospital ECGs were performed on 54,230 adults calling 9-1-1; 871 had presumed ACS, 303 of whom had ST-segment elevation myocardial infarction and underwent percutaneous coronary intervention. Women, participants with diabetes mellitus, and participants without previous cardiovascular disease waited longer to call 9-1-1 (by 28 minutes, P<0.01; 10 minutes, P=0.03; and 6 minutes, P=0.02, respectively), compared with their counterparts. Time from emergency medical services arrival to ECG was longer for women (1.5 minutes; P<0.01), older individuals (1.3 minutes; P<0.01), and those without a primary complaint of chest pain (3.5 minutes; P<0.01). On-scene times were longer for women (2 minutes; P<0.01) and older individuals (2 minutes; P<0.01). Older individuals and participants presenting on weekends and nights had longer door-to-balloon times (by 10, 14, and 11 minutes, respectively; P<0.01). Women and older individuals had longer total times (medical contact to balloon inflation: 16 minutes, P=0.01, and 9 minutes, P<0.01, respectively; symptom onset to balloon inflation: 31.5 minutes for women; P=0.02).

CONCLUSIONS

We found delays throughout ACS care, resulting in substantial differences in total times for women and older individuals. These delays may impact outcomes; a comprehensive approach to reduce delay is needed.