Primary Care Paramedics Independently Triaging Patients for Primary Percutaneous Angioplasty in Acut

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Primary Care Paramedics Independently Triaging
Patients for Primary Percutaneous Angioplasty in
Acute ST-SegmentElevation Myocardial Infarction

• A. Alrajhi, MD, MBA, FRCPC
• Ottawa Base Hospital Program

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Co - authors

• Dr. Richard Dionne
• Dr. Justin Maloney
• Dr. Badr Al Jasir
• Dr. Micheal Le May
• Dr. Mohammed Al Sultan
• Ed Ouston, ACP
• John Trickett, RN

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Disclosure

• I do not have an affiliation (financial or
  otherwise) with any commercial organization that
  may have a direct or indirect connection to the
  content of my presentation.
• ? I have/had an affiliation (financial or
  otherwise) with a commercial organization that
  may have a direct or indirect connection to the
  content of my presentation.

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Background

• More than half of acute STEMI patients initially
  receive care from out-of-hospital emergency
  medical services (EMS) paramedics ¹
• Rapid access to percutaneous coronary
  intervention for patients presenting with STEMI
  significantly reduces morbidity and mortality ²

• So Dy et. al. Am J Cardiol. 200697458-461
• McNamara RL et. al. J Am Coll Cardiol.
  2006472180-2186

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Background

• Paramedics could be trained to accurately
  interpret prehospital electrocardiograms (ECGs)
  for the detection of ST-segment elevation
  myocardial infarction ¹

• M. Le May et. al. Am J Cardiol. 2006981329-1333

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Background

• Guideline door-to-balloon-times were more often
  achieved when trained paramedics independently
  triaged and transported patients directly to a
  designated primary PCI center than when patients
  were referred from emergency departments ¹

• M. Le May et. al. N Engl J Med 2008358231-40

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Objective

• Ambulances in Ottawa are staffed with 1
  Advanced Care Paramedic (70)
• Primary Care Paramedics (PCPs) with no advanced
  life support training (30)

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Objective

• Measure the accuracy of Primary Care Paramedics
  (PCPs) interpretations of 12-lead ECGs in
  patients with chest pain for acute STEMI and
  independently activate a bypass protocol for
  primary PCI

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Methods

• A standardized review of consecutive ambulance
  call records
• All patients with chest pain who were transported
  by dual crew PCPs
• A twelve-lead ECG was done and interpreted, in
  the field, by PCPs

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Methods

• PCPs took a two days training course in
  interpreting ECGs
• Paramedics were required to pass a written
  certification examination for the recognition of
  STEMI

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Methods

• Diagnosis of STEMI was made if
• Chest pain 30 min onset 12 hrs
• and
• 1mm ST- segment elevation in 2 contiguous
  limb leads
• Or
• 2mm ST- segment elevation in 2 contiguous
  precordial leads

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Methods

• As a gold standard, two blinded emergency
  physicians independently reviewed prehospital
  health records and the ECGs for STEMI, using same
  explicit criteria
• If MDs disagreed, a third blinded emergency
  physician will make the final decision

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Methods

• Same ECGs were interpreted by two independent,
  blinded Advanced Care Paramedics (ACPs) for the
  presence of STEMI
• If ACPs disagreed, the EKG was considered as
  STEMI

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Methods

• Data was used to measure the accuracy of PCPs in
  diagnosing STEMI by calculating
• Sensitivity
• Specificity
• PPV
• NPV
• Kappa value

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Results

• Patients transported over 12 months period (Jan
  1st 2007 and Dec 31st 2007)
• 878 patients met the inclusion criteria
• Chest pain
• Transported by dual crew PCPs
• ECG done and interpreted by PCPs
• 755 patients post exclusion

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Patients flow
878 Patients
93 Incomplete/poor quality ECGs
123 Patients excluded
30 Missing ECGs
755 Patients
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Demographics
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Results
20 FP
10 FN
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Results

• Detecting acute STEMI by PCPs
• Sensitivity 89.6 (95 CI 79.7-95.7)
• Specificity 97.8 (95 CI 96.4-98.8)
• PPV 80 (95 CI 69.2-88.4)
• NPV 98.9 (95 CI 98.2-99.7)
• Accuracy of 97

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Results

• The kappa coefficient for agreement between PCPs
  and emergency physicians
• Kappa 0.82 (95 CI 0.75 0.89)

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Results
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Results
Sensitivity 71 Specificity 97
Safety and feasibility of Prehospital
Thrombolysis Carried Out by Paramedics P.
Keeling et. al , BMJ 200332727-28 (5 July),
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Results

• Training Primary Care Paramedics (PCPs) to
  independently triage and transport patients with
  STEMI to Primary PCI centers is feasible

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Conclusions

• With proper training, PCPs can accurately
  diagnose acute STEMI and independently triage
  patients for Primary PCI, thus, potentially
  reducing delays to reperfusion

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Thank You
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