title: Assessment of the safety and effectiveness of emergency department STEMI bypass by defibrillation-only emergency medical technicians/primary care paramedics.
abstract: BACKGROUND
  The American Heart Association (AHA) suggests emergency medical service (EMS) providers transporting ST-segment elevation myocardial infarction (STEMI) patients to a percutaneous coronary intervention (PCI) center require advanced life support (ALS) skills.
  
  
  OBJECTIVE
  To evaluate the potential safety and time savings effectiveness of defibrillation-only emergency medical technician/primary care paramedic (EMT-D/PCP) EMS transport to a PCI center in a system where only emergency medical technician-paramedics/advanced care paramedics (EMT-Ps/ACPs) are authorized to bypass non-PCI hospitals.
  
  
  METHODS
  We reviewed 89 consecutive patients meeting STEMI criteria transported by EMT-Ds/PCPs per protocol by one of three paths: 1) closest non-PCI center emergency department (ED) with secondary transfer by EMT-Ps/ACPs to a PCI lab, 2) rendezvous with EMT-Ps/ACPs and diversion to a PCI lab, and 3) PCI center ED if it was closest. Actual transport times to the PCI center ED were compared to predicted transport times determined by mapping software had EMT-Ds/PCPs followed a direct path. Lastly, we recorded predefined clinically important events and advanced care interventions.
  
  
  RESULTS
  Twenty-seven, 51, and 11 patients followed paths 1, 2, and 3 respectively. Median transport times for path 1 were 6 (IQR 5) minutes to reach the nearest non-PCI center ED and 66 (IQR 45) minutes to the PCI center ED compared to a median predicted 13 (IQR 7) minutes to a PCI center ED had EMT-Ds/PCPs followed a direct path. Median transport time for path 2 was 12 (IQR 8) minutes compared to a median predicted time of 11 (IQR 6) minutes had no EMT-P/ACP rendezvous occurred. Median transport time for path 3 was 7 minutes (IQR 5). Three patients experienced prehospital cardiac arrest; 1 required dopamine, and 4 others received a saline bolus for hypotension.
  
  
  CONCLUSIONS
  Substantial time savings may occur if EMT-Ds/PCPs bypass non-PCI center EDs with only a small predicted increase (about 7 minutes) in the transport time to the PCI center ED. EMT-P/ACP rendezvous does not appear to substantially increase transport time. Given the relatively low occurrence of clinically important events, our findings suggest that EMT-D/PCP bypass to a PCI center ED may be safe and effective for selected STEMI patients.
authors.forename: Garry
authors.initials: G
authors.lastname: Ross
authors.forename: Thamir
authors.initials: T
authors.lastname: Alsayed
authors.forename: Linda
authors.initials: L
authors.lastname: Turner
authors.forename: Chris
authors.initials: C
authors.lastname: Olynyk
authors.forename: Adam
authors.initials: A
authors.lastname: Thurston
authors.forename: P Richard
authors.initials: PR
authors.lastname: Verbeek
mesh_terms: D000368:Aged; D000488:Allied Health Personnel; D004554:Electric Countershock / Q000379:methods*; D004632:Emergency Medical Services / Q000379:methods*; D004634:Emergency Medical Technicians; D004636:Emergency Service, Hospital; D005260:Female; D006801:Humans; D008297:Male; D009203:Myocardial Infarction / Q000628:therapy*; D010360:Patient Transfer; D062645:Percutaneous Coronary Intervention; D011320:Primary Health Care; D013997:Time Factors; D014481:United States
keywords: ST-segment elevation myocardial infarction; emergency medical services; percutaneous coronary intervention; prehospital emergency care; triage