title: Paramedic decision making: prehospital thrombolysis and beyond.
abstract: BACKGROUND
  Mortality from acute myocardial infarction is influenced by the speed at which reperfusion therapy is delivered. In the U.K., prehospital thrombolysis (PHT), administered by paramedics, has been developed to improve call to needle (CTN) times. Recently, it has been shown in randomised trials that mortality can be further reduced by primary percutaneous coronary intervention (PPCI). This project was developed to assess current ST-elevation myocardial infarction practice in a district general hospital and to prepare paramedics for PPCI.
  
  
  METHODS
  Data were collected prospectively over a 12-month period for all patients who received thrombolysis for a presumed myocardial infarct. The primary outcome measures for each case were who delivered the thrombolysis, either the paramedic crew or the hospital, and if the patient did not receive PHT the reason why not. Secondary outcome measures included the CTN time.
  
  
  RESULTS
  153 patients received thrombolysis over the time period (99 men, 54 women, mean age 66 ± 15 years). Of this group, 55 patients received PHT (35.9%) with a median CTN time of 36 min (inter-quartile range (IQR) 30-42 min). The commonest reason for exclusion from receiving PHT was that the patient's history did not fit the eligibility criteria (25% of cases).
  
  
  CONCLUSIONS
  Paramedics are able to deliver PHT promptly and safely. With the focus now on PPCI, it is anticipated that not only will paramedics be able to select patients for delivery to a heart attack centre for PPCI, they will be selecting many more patients for this treatment than have up to now received PHT.
authors.affiliation: Chesterfield Royal Hospital NHS Foundation Trust, Chesterfield, UK.
authors.forename: Alyson M
authors.initials: AM
authors.lastname: Smith
authors.forename: Pamela J
authors.initials: PJ
authors.lastname: Hardy
authors.forename: David A
authors.initials: DA
authors.lastname: Sandler
authors.forename: Justin
authors.initials: J
authors.lastname: Cooke
mesh_terms: D000368:Aged; D000369:Aged, 80 and over; D002983:Clinical Competence; D003657:Decision Making; D004632:Emergency Medical Services / Q000379:methods* / Q000592:standards; D004634:Emergency Medical Technicians; D005260:Female; D006801:Humans; D008297:Male; D008875:Middle Aged; D009203:Myocardial Infarction / Q000175:diagnosis / Q000628:therapy*; D011446:Prospective Studies; D015912:Thrombolytic Therapy; D013997:Time Factors; D006113:United Kingdom