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James M. McCabe, MD

James M. McCabe, MD Ehrin J. Armstrong MD, Sonia Garg MD, Ateet Patel MD, Kurt S. Hoffmayer MD, Prashant Bhave MD, John S. MacGregor MD PhD, John Stein MD, Scott Kinlay MBBS PhD, Peter Ganz MD.

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James M. McCabe, MD

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  1. James M. McCabe, MD Ehrin J. Armstrong MD, Sonia Garg MD, Ateet Patel MD, Kurt S. Hoffmayer MD, Prashant Bhave MD, John S. MacGregor MD PhD, John Stein MD, Scott Kinlay MBBS PhD, Peter Ganz MD EFFECT OF AMBULANCE USE ON THE TRIAGE OF PATIENTS WITH ST-ELEVATION MYOCARDIAL INFARCTIONS BY EMERGENCY PHYSICIANS

  2. Background • Preferred therapy for an ST-elevation myocardial infarction (STEMI) is opening blocked artert in the catheterization lab; faster is better • Increasing autonomy among Emergency Room physicians to “activate” the cath lab team for a possible STEMI • Emergency Room (ER) systems and ER physician performance largely un-evaluated

  3. Current National STEMI Databases Insufficient to Evaluate ER Performance Most national STEMI databases enroll patients after they’ve undergone catheterization These databases may not include patients inaccurately diagnosed in the ER – not all ST elevations are heart attacks Unbiased evaluation of ER performance requires evaluation of all ER STEMI diagnoses

  4. The Activate-SF Registry • Urban trauma center and tertiary care hospital • All possible STEMI referrals to the cath lab through central paging systems • Permanent record of all STEMI activations by the ER irrespective of outcome

  5. The Process for STEMI Care Out of Hospital Emergency Room Catheterization Lab • Ambulance Transport • 199 pts • 113 got ECG • 86 no ECG Reperfusion (“balloon”) Time Arrival at Hospital (Door Time) Inciting ECG Cath lab Activation Time 356 pts Cath Lab Arrival 326 pts (30 declined) Self- Presented 157 pts Lab to Balloon ECG to Activation Door to Activation Door to Lab Door to Balloon

  6. Baseline Demographics Between those Self-Presenting and Those Taking Ambulance are Similar

  7. ECGs Between those Self-Presenting and Those Taking Ambulance Similar An ECG is the principle test for diagnosing a STEMI

  8. No Difference in Percent of Actual STEMIs, Coronary Artery Involved, Between Those Self-Presenting and Those Taking Ambulance

  9. Ambulance Patients More Critically Ill, Requiring Care & Potentially Slowing Transit Through the ER

  10. Ambulance Use and Pre-hospital ECGs Expedite Treatment in the ER • Ambulance use and pre-hospital ECG each associated with significant reductions in ER time prior to cath lab activation (unadjusted data)

  11. Benefits of Ambulance Use on ER Efficiency based on Pre-hospital ECG • Taking an ambulance to the hospital shortens times in the ER and total Door to Balloon time • This effect is entirely driven by acquisition of a pre-hospital ECG • In San Francisco, ECGs are not forwarded to destination hospitals and Cardiology team not ‘activated’ by EMS personnel; benefit could even be greater • Pre-hospital ECG shortens ER times irrespective of age, gender, race, critical condition, history of CAD, typical risk factors (DM, HTN, dyslipidemia & active tobacco use), chief complaint at presentation, millimeters of ST elevation on inciting ECG, the number of leads with ST elevation on ECG

  12. Pre-hospital ECG Shortens All Time Intervals in the Emergency Room Without Effect on Procedural Times Squares are magnitude of change, error bars are 95% confidence intervals (95%CI). Any 95%CI that crosses the 0 line is non-significant

  13. Asian Race Associated with Slower Door to Cath Lab Activation Times • Diverse, urban cohort: 36% Caucasian • Asian race the 2nd largest demographic: 27% • Bad News: Asian race associated with 65% slower door to cath lab activation time • Good News: no difference in any ER times among Black or Hispanic cohorts

  14. Delays Among Asians Due to Translator Requirements - Unavailable in Ambulances • 47% of Asian subjects required a translator • No delays through the ER for those of Asian race who do not require a translator

  15. Summary 44% of STEMI referrals to the cath lab self-present to the hospital Ambulance use shortens transit of STEMI patients through the ER and shortens door to balloon times The beneficial effects of ambulance use on ER efficiency are derived from a pre-hospital ECG 43% of STEMI referrals presenting by ambulance do not get a pre-hospital ECG, some due to language barriers Pre-hospital ECGs are associated with significant decreases in time spent in the emergency room despite more critical illness among ambulance users requiring initial stablization

  16. Summary Asian race is associated with delays in the ER for those requiring a translator but not with significant differences in total time to reperfusion No delays seen for other racial groups

  17. Looking Forward Broadening indications for pre-hospital ECG use and targeting language barriers are areas for potential improvement Benefits of pre-hospital ECG likely further maximized by remote forwarding to destination hospital

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