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Decision making between nurses and paramedics in reperfusion of ST elevation myocardial infarction
  1. SM Mclean,
  2. ADF Flapan
  1. The Edinburgh Heart Centre, Edinburgh, UK

Abstract

Introduction To describe a reperfusion programme in ST elevation myocardial infarction (STEMI) based around prehospital decision-making between coronary care unit (CCU) nurses and ambulance paramedics.

Methods Experience began in 2004 with nurses and paramedics discussing 12-lead electrocardiograms (ECG) transmitted from the ambulance to the CCU. This programme involved CCU nurses providing support to paramedics considering prehospital thrombolysis (PHT). The programme evolved in 2006 to include primary percutaneous coronary intervention (PCI). Based on a 90-minute diagnosis-to-PCI balloon time, nurses and paramedics now make a joint decision on whether patients with STEMI should recieve either PHT or primary PCI, based on clinical history, ECG findings, travel time from hospital and availability of PCI facilities.

Results Between 1 December 2006 and 31 August 2008 primary PCI was the treatment for 70% of patients (526/751), with PHT administered to 1.5% (11/751) and inhospital thrombolysis to 5.9% (44/751). The mean length of hospital stay was 3.5 days for primary PCI patients and 5.9 days for all comers. Although non-randomised data, inhospital and 30-day mortality are significantly reduced in the primary PCI group at 3.2% and 4.7%, respectively. The 90-minute diagnosis-to-PCI balloon inflation was achieved in 64% of primary PCI cases (77% in in-hours cases and 45% out-of-hours). The median door-to-PCI balloon time was 53 minutes. No reperfusion therapy was administered to 14.2% of patients (107/751) with a discharge diagnosis of STEMI over the 21 months of the optimal reperfusion programme. This compares favourably with 141/487 (29%) in the first 12 months of the PHT programme, 89/438 (20%) in the second 12 months of the PHT programme and with the GRACE registry, which reported sustained rates of no-reperfusion in up to 29% of patients with STEMI. The on-call team were called for primary PCI on three occasions in which the patient did not undergo primary PCI. All three of these patients had widespread coronary disease with no occlusive thrombus. None had normal coronary arteries.

Conclusions Using prehospital 12-lead ECG transmission, CCU nurses and ambulance paramedics can safely and effectively decide on the most appropriate reperfusion therapy for patients with STEMI. There are no other reported data of nurses and paramedics operating in this way and despite the single-centre observational nature of the data, this system of care appears to have a positive predictive value worth further exploration.

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