Evaluation of a primary care paramedic STEMI bypass guideline

Safety and Adverse Events During Primary Care Paramedic Interfacility Transfer of Stable STEMI Patients

OBJECTIVE

Current guidelines recommend that patients presenting with ST-elevation myocardial infarction (STEMI) to hospitals not capable of performing primary percutaneous coronary intervention (PCI) be transferred to a PCI-capable hospital if reperfusion can be accomplished within 120 min. Most STEMI patients are accompanied by an advanced care paramedic (ACP, equivalent to EMT-P), nurse, or physician who can manage complications should they arise. In our region, stable STEMI patients are transported by primary care paramedics (PCPs, similar scope of practice to advanced EMT) in cases where a nurse, physician, or ACP paramedic is not available. Our goal was to describe adverse events and need for advanced interventions among initially stable STEMI patients during interfacility transfer by PCPs.

METHODS

We reviewed ambulance and hospital records of initially stable STEMI patients (as determined by first set of vital signs documented by paramedics) transferred to a PCI-capable hospital by PCPs between March 1, 2014, and December 31, 2019. We identified whether pre-determined adverse clinical events occurred during the transport as well as the potential need for advanced care interventions not within the PCP scope of practice. Adverse events upon arrival in the PCI lab were also identified.

RESULTS

Of 346 STEMI patients transferred, 179 met inclusion criteria. The mean age of included patients was 61 years (SD 12.1) and 74.9% (134/179) were male. Median transport interval was 36 min (IQR 3.0). During transport, 47/179 (26.0%) patients experienced pre-defined adverse events; for 16/47 (34%), one or more adverse events was major. Three patients met criteria for ACP interventions. One patient suffered a cardiac arrest and was promptly resuscitated with defibrillation by the PCPs.

CONCLUSIONS

We found PCP-interfacility transport of initially stable STEMI patients was safe and associated with a moderate proportion of adverse events, the majority of which did not require an advanced care intervention. These findings may help decision-making to avoid delays transferring stable patients to PCI-capable centers.

Safety and clinically important events in PCP-initiated STEMI bypass in Ottawa

What is known about the topic?

Transport of STEMI patients directly to the cath lab (STEMI bypass) by advanced care paramedics (ACPs) is common practice. The safety of this practice with primary care paramedics (PCPs) is unknown.

What did this study ask?

What is the prevalence and breakdown of events during PCP STEMI bypass?

What did this study find?

Clinically important events are common in STEMI bypass patients. A smaller proportion of events would be addressed differently by ACP compared to PCP protocols.

Why does this study matter to clinicians?

This study adds to the evidence that PCP STEMI bypass is safe.

Clinical adverse events in prehospital patients with ST-elevation myocardial infarction transported to a percutaneous coronary intervention centre by basic life support paramedics in a rural region

CLINICIAN’S CAPSULE

What is known about the topic?

ST-elevation myocardial infarction (STEMI) patients transported by ambulance are at risk for adverse events.

What did this study ask?

What is the impact of transport time on the occurrence of adverse events in the presence of basic life support paramedics?

What did this study find?

Transport time is not associated with a higher risk of adverse events.

Why does this study matter to clinicians?

Largest investigation of adverse events in a Canadian cohort of STEMI patients transported by ambulance.