Clinical pathway: helicopter scene STEMI protocol to facilitate long-distance transfer for primary PCI

Risk of Delayed Percutaneous Coronary Intervention for STEMI in the Southeast United States

Background

Emergent reperfusion by percutaneous coronary intervention (PCI) within 90 minutes of first medical contact (FMC) is indicated in patients with ST-segment elevation myocardial infarction (STEMI). However, long transport times in rural areas in the Southeast US make meeting this goal difficult. The objective of this study was to determine the number of Southeast US residents with prolonged transport times to the nearest 24/7 primary PCI (PPCI) center.

Methods

A cross-sectional study of residents in the Southeastern US was conducted based on geographical and 2022 5-Year American Community Survey data. The geographic information system (GIS) ArcGIS Pro was used to estimate Emergency Medical Services (EMS) transport times for Southeast US residents to the nearest PPCI center. All 24/7 PPCI centers in North Carolina, South Carolina, Georgia, Florida, Mississippi, Alabama, and Tennessee were included in the analysis, as well as nearby PPCI centers in surrounding states. To identify those at risk of delayed FMC-to-device time, the primary outcome was defined as a >30-minute transport time, beyond which most patients would not have PCI within 90 minutes. A secondary outcome was defined as transport >60 minutes, the point at which FMC-to-device time would be >120 minutes most of the time. These cutoffs are based on national median EMS scene times and door-to-device times.

Results

Within the Southeast US, we identified 62,880,528 residents and 350 PPCI centers. Nearly 11 million people living in the Southeast US reside greater than 30 minutes from a PPCI center (17.3%, 10,866,710, +/- 58,143), with 2% (1,271,522 +/- 51,858) living greater than 60 minutes from a PPCI hospital. However, most patients reside in short transport zones; 82.7% (52,013,818 +/- 98,741). Within the Southeast region, 8.4% (52/616) of counties have more than 50% of their population in a long transport zone and 42.3% (22/52) of those have more than 90% of their population in long transport areas.

Conclusions

Nearly 11 million people in the Southeast US do not have access to timely PCI for STEMI care. This disparity may contribute to increased morbidity and mortality.

The Development of Helicopter Emergency Medical Services in the Republic of Ireland

Helicopter emergency medical services (HEMS) have formed an integral component of the Irish health care system for the past decade; yet, the factors leading their commencement, their evolutions over this time, and the current model of service delivery have not been widely published. Aeromedical service provision may vary significantly from country to country and may also vary regionally within countries. A health system's necessities; capacity and maturity; the level of state, corporate, private, or community investment; and the capacity of the contracted service provider are all factors that influence the service provision. This research article describes the historic factors leading to a military and health system collaboration to HEMS during an era of health care reform. Over the past decade, the Irish health system has undergone significant reconfiguration and centralization of services, leading to increased demands on emergency medical ground and air medical services. Future advancements in aeromedical service provision require an innate understanding of the current model. This article adds to the knowledge base, informs policy makers, and supports decision making surrounding HEMS provision and the potential to explore military and health system collaborations and enhanced overall service provision.

Helicopter EMS and rapid transport for ST-elevation myocardial infarction: The HEARTS study

Background: Helicopter emergency medical services (HEMS) and ground EMS (GEMS) are both integral parts of out-of-hospital transport systems for patients with ST-elevation myocardial infarction (STEMI) undergoing emergency transport for primary percutaneous coronary intervention (PPCI). There are firm data linking time savings for PPCI transports with improved outcome. A previous pilot analysis generated preliminary estimates for potential HEMS-associated time savings for PPCI transports. Methods: This non-interventional multicenter study conducted over the period 2012–2014 at six centers in the USA and in the State of Qatar assessed a consecutive series of HEMS transports for PPCI; at one center consecutive GEMS transports of at least 15 miles were also assessed if they came from sites that also used HEMS (dual-mode referring hospitals). The study assessed time from ground or air EMS dispatch to transport a patient to a cardiac center, through to the time of patient arrival at the receiving cardiac unit, to determine proportions of patients arriving within accepted 90- and 120-minute time windows for PPCI. Actual times were compared to “route-mapping” GEMS times generated using geographical information software. HEMS' potential time savings were calculated using program-specific aircraft characteristics, and the potential time savings for HEMS was translated into estimated mortality benefit. Results: The study included 257 HEMS and 27 GEMS cases. HEMS cases had a high rate of overall transport time (from dispatch to receiving cardiac unit arrival) that fell within the predefined windows of 90 minutes (67.7% of HEMS cases) and 120 minutes (91.1% of HEMS cases). As compared to the calculated GEMS times, HEMS was estimated to accrue a median time saving of 32 minutes (interquartile range, 17–46). The number needed to transport for HEMS to get one additional case to PPCI within 90 minutes was 3. In the varied contexts of this multicenter study, the number of lives saved by HEMS, solely through time savings, was calculated as 1.34 per 100 HEMS PPCI transports. Conclusions: In this multicenter study, HEMS PPCI transport was found to be appropriate as defined by meeting predefined time windows. The overall estimate for lives saved through time savings alone was consistent with previous pilot data and was also generally consistent with favorable cost-effectiveness. Further research is necessary to confirm these findings, but judicious HEMS deployment for PPCI transports is justified by these data.

A review of enhanced paramedic roles during and after hospital handover of stroke, myocardial infarction and trauma patients

BACKGROUND

Ambulance paramedics play a critical role expediting patient access to emergency treatments. Standardised handover communication frameworks have led to improvements in accuracy and speed of information transfer but their impact upon time-critical scenarios is unclear. Patient outcomes might be improved by paramedics staying for a limited time after handover to assist with shared patient care. We aimed to categorize and synthesise data from studies describing development/extension of the ambulance-based paramedic role during and after handover for time-critical conditions (trauma, stroke and myocardial infarction).

METHODS

We conducted an electronic search of published literature (Jan 1990 to Sep 2016) by applying a structured strategy to eight bibliographic databases. Two reviewers independently assessed eligible studies of paramedics, emergency medical (or ambulance) technicians that reported on the development, evaluation or implementation of (i) generic or specific structured handovers applied to trauma, stroke or myocardial infarction (MI) patients; or (ii) paramedic-initiated care processes at handover or post-handover clinical activity directly related to patient care in secondary care for trauma, stroke and MI. Eligible studies had to report changes in health outcomes.

RESULTS

We did not identify any studies that evaluated the health impact of an emergency ambulance paramedic intervention following arrival at hospital. A narrative review was undertaken of 36 studies shortlisted at the full text stage which reported data relevant to time-critical clinical scenarios on structured handover tools/protocols; protocols/enhanced paramedic skills to improve handover; or protocols/enhanced paramedic skills leading to a change in in-hospital transfer location. These studies reported that (i) enhanced paramedic skills (diagnosis, clinical decision making and administration of treatment) might supplement handover information; (ii) structured handover tools and feedback on handover performance can impact positively on paramedic behaviour during clinical communication; and (iii) additional roles of paramedics after arrival at hospital was limited to 'direct transportation' of patients to imaging/specialist care facilities.

CONCLUSIONS

There is insufficient published evidence to make a recommendation regarding condition-specific handovers or extending the ambulance paramedic role across the secondary/tertiary care threshold to improve health outcomes. However, previous studies have reported non-clinical outcomes which suggest that structured handovers and enhanced paramedic actions after hospital arrival might be beneficial for time-critical conditions and further investigation is required.