title: Using EMS Dispatch to Trigger STEMI Alerts Decreases Door-to-Balloon Times.
abstract: BACKGROUND
  We sought to determine the potential reduction in door-to-balloon time (DTB) by allowing paramedics to perform prehospital ST-Elevation Myocardial Infarction (STEMI) notification using brief communications via emergency medical services (EMS) 9-1-1 dispatchers as soon as they saw a STEMI on 12-lead electrocardiogram (EKG). Our hypothesis was that earlier cardiac catheterization lab (CCL) activation would improve overall DTB and avoid delays arising from on-scene issues or the time required to deliver a full report.
  
  
  METHODS
  The study setting was a single suburban community teaching hospital, which is a regional percutaneous coronary intervention (PCI) center with more than 120,000 Emergency Department (ED) visits/year and is serviced by a single tiered-response, advanced life support (ALS) paramedic-level agency. STEMI notifications from July 2009 to July 2012 occurred by either standard direct EMS-to-physician notification or by immediate 9-1-1 dispatch notification. In the 9-1-1 dispatcher-aided notification method, paramedics were asked to provide a brief one-sentence report using their lapel microphones upon immediate realization of a diagnostic EKG (usually within 1-2 minutes of patient contact). This report to the 9-1-1 dispatcher included the patient's sex, age, and cardiologist (if known). The dispatcher then called the emergency department attending and informed them that a STEMI was being transported and that CCL activation was needed. We used retrospective chart review of a consecutive sample of patients from an existing STEMI registry to determine whether there was a statistically significant difference in DTB between the groups.
  
  
  RESULTS
  Eight hundred fifty-six total STEMI alert patients arrived by EMS during the study. We excluded 730 notifications due to events such as cardiac arrest, arrhythmia, death, resolution of EKG changes and/or symptoms, cardiologist decision not to perform PCI, arrival as a transfer after prior stabilization at a referring facility or arriving by an EMS agency other than New Castle County EMS (NCC*EMS). Sixty-four (64) sequential patients from each group comprised the study sample. The average DTB (SD) for the standard communication method was 57.6 minutes (17.9), while that for dispatcher-aided communication was 46.1 minutes (12.8), (mean difference 57.6-46.1 minutes=11.5 minutes with a 95% CI [6.06,16.94]) p=0.0001. In the dispatcher-aided group, 92% of patients (59/64) met standards of ≤60 minute DTB time. Only 64% (41/64) met this goal in the standard communication group (p=0.0001).
  
  
  CONCLUSIONS
  Brief, early notification of STEMI by paramedics through 9-1-1 dispatchers achieves earlier CCL activation in a hospital system already using EMS-directed CCL activation. This practice significantly decreased DTB and yielded a higher percentage of patients meeting the DTB≤60 minutes quality metric.
authors.affiliation: Christiana Care Health System, Department of Emergency Medicine, Newark, Delaware.
authors.forename: Justin C
authors.initials: JC
authors.lastname: Stowens
authors.affiliation: Christiana Care Health System, Value Institute, Newark, Delaware.
authors.forename: Seema S
authors.initials: SS
authors.lastname: Sonnad
authors.affiliation: State of Delaware Office of Emergency Medical Services and Health Preparedness, Christiana Care Health System, Department of Emergency Medicine, Newark, Delaware.
authors.forename: Robert A
authors.initials: RA
authors.lastname: Rosenbaum
mesh_terms: D000488:Allied Health Personnel; D015906:Angioplasty, Balloon, Coronary / Q000379:methods; D019985:Benchmarking; D006328:Cardiac Catheterization / Q000379:methods; D004636:Emergency Service, Hospital / Q000458:organization & administration*; D006801:Humans; D008487:Medical History Taking; D009203:Myocardial Infarction / Q000175:diagnosis / Q000628:therapy*; D062645:Percutaneous Coronary Intervention / Q000379:methods*; D019114:Remote Consultation / Q000458:organization & administration*; D012189:Retrospective Studies; D013689:Telephone; D061665:Time-to-Treatment / Q000458:organization & administration / Q000706:statistics & numerical data; D014187:Transportation of Patients / Q000379:methods*; D014481:United States / Q000453:epidemiology