Moving Care Forward
2010; Lippincott Williams & Wilkins; Volume: 122; Issue: 15 Linguagem: Inglês
10.1161/circulationaha.110.982033
ISSN1524-4539
Autores Tópico(s)Heart Failure Treatment and Management
ResumoHomeCirculationVol. 122, No. 15Moving Care Forward Free AccessEditorialPDF/EPUBAboutView PDFView EPUBSections ToolsAdd to favoritesDownload citationsTrack citationsPermissions ShareShare onFacebookTwitterLinked InMendeleyReddit Jump toFree AccessEditorialPDF/EPUBMoving Care ForwardPrehospital Emergency Cardiac Systems James G. Jollis, MD, FACC James G. JollisJames G. Jollis From the Division of Cardiology, Duke University, Durham, NC. Originally published27 Sep 2010https://doi.org/10.1161/CIRCULATIONAHA.110.982033Circulation. 2010;122:1443–1445Other version(s) of this articleYou are viewing the most recent version of this article. Previous versions: September 27, 2010: Previous Version 1 In 1967, the modern era of prehospital emergency cardiac care began with Dr Frank Pantridge's publication of "A mobile intensive-care unit in the management of myocardial infarction."1 Recognizing that myocardial infarction mortality could be reduced by interventions prior to hospital arrival, Dr Pantridge developed a specialized ambulance system in Belfast, Ireland to stabilize and transport patients with suspected acute myocardial infarction to the Royal Victoria Hospital. Within 3 years, Dr Pantridge's system was being replicated in the United States, first in Haywood County, NC and subsequently in Pittsburgh, Pa, Seattle, Wash, Miami, Fla, and Los Angeles, Calif. Dr Pantridge recognized the importance of collecting performance data and setting time standards, including a goal of 15 minutes from dispatch to patient arrival. His initial publication documented an improvement in the percentage of calls meeting this goal from 20% to 78%.Article see p 1464Over 40 years later, prehospital emergency cardiac care has expanded in scope to provide rapid coronary artery reperfusion for ST-segment elevation myocardial infarction (STEMI). The essential elements include prehospital diagnosis and in-the-field catheterization laboratory activation. In the Acute Coronary Treatment and Intervention Outcomes Network (ACTION) registry, the 27% of patients with a prehospital ECG underwent faster coronary reperfusion (median time to primary percutaneous coronary intervention [PCI]: 61 minutes versus 75 minutes, P<0.0001; fibrinolysis:19 minutes versus 29 minutes, P=0.003) and had a trend toward lower mortality (adjusted odds ratio: 0.80, 95% confidence interval: 0.63 to 1.01).2 When the prehospital ECG is used to activate catheterization laboratories, treatment times are remarkably fast. Rokos and colleagues highlighted 10 regional STEMI systems that combined paramedic diagnosis with hospital activation resulting in half of patients undergoing coronary intervention within 60 minutes of hospital arrival.3 Recognizing the importance of prehospital care, both US and European guidelines establish primary PCI time standards from "first medical contact."4,5 In the United States, first medical contact is defined as when the emergency medical service (EMS) arrives on scene, with a PCI goal of 90 minutes.In this issue of Circulation, Jonathan Studnek and colleagues describe ST elevation myocardial infarction care in the Mecklenburg County, NC EMS Agency or Medic, one of the premier emergency medical systems in the United States.6 While the guidelines recognize the importance of prehospital care, they provide minimal advice on the implementation of this care in terms of components or time standards. In a fashion typical of this system, MEDIC has raised the bar for treatment, starting the clock at the earlier time point of the 9-1-1 call rather than scene time while maintaining a 90 minute overall goal to device deployment. Studnek and colleagues examine the ability of MEDIC to reach this 90 minute goal according to a number of systematic time intervals, including 9-1-1 call to scene arrival, arrival to 12-lead ECG acquisition, total scene time, ECG time to hospital notification, and scene departure to cardiac catheterization laboratory table. By incorporating measurable EMS tasks and time intervals into an analysis of reperfusion speed, this study provides unique and much-needed guidance to emergency medical systems about the successful implementation of rapid reperfusion.The work found three of these intervals to be most associated with 90 minute treatment times: 9-1-1 call to scene time of less than 10 minutes, total scene time of less than 15 minutes, and scene to table time of less than 30 minutes. The first of these time intervals, call to scene, may be improved with better dispatch organization, including early routing of calls to medical dispatchers, having dispatchers trained to recognize symptoms of potential myocardial infarction and direct paramedics and ECG equipment to the scene, and deployment of paramedic units and 12-lead ECG equipment across the EMS service area to reach patients in a timely manner. The second interval, short scene time, may be reduced by protocols and training. Scene times can be shortened by training paramedics to execute chest pain and STEMI protocols in an expedient fashion ("diagnose, activate, load, and go") and training first responders to obtain 12-lead ECGs.The third interval, scene to table time, is largely a function of travel time, a systematic element that is difficult to alter. The finding that 90% of patients who could be transported within 30 minutes were treated within 90 minutes, while only 56% of patients requiring transport over 30 minutes achieved this goal addresses the question of "how far is too far" to transport. Taking into account dispatch time and the time for transport from an ambulance bay to the catheterization laboratory, the data suggest patients transported longer than 30 to 35 minutes cannot reliably undergo PCI within 90 minutes of first medical contact. EMS diversion from a closer hospital that lacks interventional facilities to a PCI hospital is not supported for longer travel times, unless the patient has other features that favor PCI such as contraindications to fibrinolysis or cardiogenic shock.7 Helicopter transport seems unlikely to overcome the ground transport obstacle, as air medical dispatch, patient "packaging," and two separate take-offs and landings are likely consume at least 30 to 35 minutes. Conversely, these findings suggest that patients with ST elevation myocardial who are within 30 to 35 minutes of a PCI hospital should be diverted to such facilities. Routine diversion to proximate PCI centers represents a national standard of care for all urban areas.The article by Studnek et al highlights all of the elements of MEDIC that make it a superior system: an algorithm-based medical dispatch triage system, on-scene ECGs for all patients with possible symptoms of acute myocardial infarction, paramedic and machine ECG interpretation, direct catheterization laboratory activation from the field, collaboration and coordination by two competing hospital systems and multiple competing physician groups, strong medical leadership, dedicated STEMI system coordinators, and ongoing data collection encompassing EMS and hospital records.The data efforts deserve particular note as probably the single most important element of prehospital emergency care. Studnek and colleagues link the early processes in EMS response to hospital reperfusion to understand which are most important for success. While the MEDIC data appear routine, they actually represent a standard far above the capabilities of many EMS agencies and hospitals. Prehospital emergency systems can only be implemented with data that span the entire episode of care. These data need to be available at hospital arrival, routinely incorporated into the hospital record, contain elements relevant to acute myocardial infarction, follow formats common to all EMS systems, and have the ability to be combined, analyzed, and reported in an aggregate fashion. In reality, paramedics often leave the hospital without providing records as their "run sheets" are completed electronically after return to service. If run sheets or ECGs are left with the patient, they may fail to be incorporated into the hospital record due to lack of registration information or a system by which to include the data. The leading standard for uniform data, the National EMS Information System, has just added elements that identify ST elevation myocardial infarction to the most recent release, and these elements will not be included in the Health Level 7 standard until 2012.8 Years may pass before STEMI elements are incorporated into EMS records as data collection is left to the discretion of state and local EMS agencies.Dr Pantridge developed prehospital care in a place and time far removed from the Health Insurance Portability and Accountability Act of 1996. The Standards for Privacy of Individually Identifiable Health Information established by this act both guide and hinder efforts to combine and analyze data for emergency care that crosses EMS and hospital boundaries.9 This rule creates boundaries around health care operations beyond which data sharing is subject to complex regulations. The privacy rule specifically allows hospitals, physicians, and other health care providers to share protected health information across institutions as long as "each entity either has or had a relationship with the individual who is the subject of the protected health information." In practice, most health care professionals are unlikely to have read or fully comprehend the 101-page Administrative Simplification of the Health Insurance Portability and Accountability Act (HIPAA) privacy rule pertinent to data sharing. Rather than risk censure, job loss, or fines, a common default position for all information requests tends to be "I can't give you the information because it would be a HIPAA violation."Emergency cardiac care systems require the coordination of multiple EMS agencies and hospitals in a given region. HIPAA defines a number of data elements critical to prehospital care including times, dates, and geographic locations as protected health information subject to privacy rules. Again, the HIPAA privacy rule provides at least two formats for collecting and analyzing these data from participating agencies and hospitals: a "limited data set" and an "organized health care arrangement." The limited data set allows for the sharing of indirect identifiers including times, dates, and location among institutions as long as "data use agreements" are executed by each institution and no attempt is made to contact any subjects. This approach has two notable limitations. Firstly, the prohibition of patient contact prevents systems from assessing long term outcomes once the patient leaves the hospital. A second limitation involves the administrative burden of data use agreements. In the North Carolina state STEMI system in which MEDIC participates, over 100 hospital and 500 EMS agency data use agreements have to be implemented in order to combine EMS and hospital data.10 A further 600 "business associate agreements" must be implemented if contractors such as the National Cardiovascular Disease Registry are employed to assemble or analyze these data. Expanding such agreements and the limited data set approach to over 15 000 EMS agencies and 5 000 hospitals nationwide is not practical or affordable. A more direct approach to data collection and analyses involves the formation of a HIPAA-recognized entity, the "organized health care arrangement." This arrangement is defined by the privacy rule as "an organized system of health care in which more than one covered entity participates and in which the participating covered entities hold themselves out to the public as participating in a joint arrangement and participate in joint activities that include quality assessment and improvement activities." This framework permits the disclosure and use of protected health information for "health care operations" of the organization. Thus, the HIPAA privacy rule specifically permits regional emergency cardiac systems that meet the definition of organized health care arrangement to collect and share protected health information in a manner consistent with other health care providers without the need for additional consents or data use agreements. By establishing regional systems like MEDIC and meticulously analyzing performance data, we can achieve the full potential of Dr Pantridge's initial foray beyond the hospital door to the scene of a critically ill cardiac patient.DisclosuresDr Jollis has received research support from the Kate B. Reynolds Foundation, Sanofi-Aventis, Philips, and the Medtronic Foundation.FootnotesThe opinions expressed in this article are not necessarily those of the editors or of the American Heart Association.Correspondence to James G. Jollis, Professor of Medicine and Radiology, Duke University, Box 3254 DUMC, Durham, NC, 27710. E-mail james.[email protected]eduReferences1. Pantridge JF, Geddes JS. A mobile intensive-care unit in the management of myocardial infarction. Lancet. 1967; 2:271–273.CrossrefMedlineGoogle Scholar2. Diercks DB, Kontos MC, Chen AY, Pollack CV, Wiviott SD, Rumsfeld JS, Magid DJ, Gibler WB, Cannon CP, Peterson ED, Roe MT. 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Circulation. 2004; 110:588–636.MedlineGoogle Scholar8. National Emergency Medical Services Information System. NEMSIS Data Dictionary. http://www.nemsis.org/media/pdf/NEMSISDataDictionaryV3.0Final.pdf. Accessed September 2, 2010.Google Scholar9. U.S. Department of Health and Human Services Office for Civil Rights. HIPAA Administrative Simplification. http://www.hhs.gov/ocr/privacy/hipaa/administrative/privacyrule/adminsimpregtext.pdf. Accessed September 2, 2010.Google Scholar10. Jollis JG, Roettig ML, Aluko AO, Anstrom KJ, Applegate RJ, Babb JD, Berger PB, Bohle DJ, Fletcher SM, Garvey JL, Hathaway WR, Hoekstra JW, Kelly RV, Maddox WT, Shiber JR, Valeri FS, Watling BA, Wilson BH, Granger CB. Reperfusion of Acute Myocardial Infarction in North Carolina Emergency Departments (RACE) investigators. implementation of a statewide system for coronary reperfusion for ST-segment elevation myocardial infarction. JAMA. 2007; 298:2371–2380.CrossrefMedlineGoogle Scholar Previous Back to top Next FiguresReferencesRelatedDetailsCited By Seblova J, Cimpoesu D, Khoury A, Revue E and Trenkler S (2018) Prehospital emergency care systems in Europe – EuSEM prehospital section survey 2016, European Journal of Emergency Medicine, 10.1097/MEJ.0000000000000553, 25:6, (446-447), Online publication date: 1-Dec-2018. Long B, Serrano L, Cabanas J and Bellolio M (2016) Opportunities for Emergency Medical Services (EMS) Care of Syncope, Prehospital and Disaster Medicine, 10.1017/S1049023X16000376, 31:4, (349-352), Online publication date: 1-Aug-2016. Malamed S and Orr D (2015) Acute Myocardial Infarction Medical Emergencies in the Dental Office, 10.1016/B978-0-323-17122-9.00028-7, (456-474), . 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October 12, 2010Vol 122, Issue 15 Advertisement Article InformationMetrics © 2010 American Heart Association, Inc.https://doi.org/10.1161/CIRCULATIONAHA.110.982033PMID: 20876431 Originally publishedSeptember 27, 2010 KeywordselectrocardiographyEditorialsmyocardial reperfusionemergency medical servicesPDF download Advertisement SubjectsCardiopulmonary Resuscitation and Emergency Cardiac CareElectrocardiology (ECG)Ethics and PolicyMyocardial Infarction
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