William Koenig

Integration of pre-hospital electrocardiograms and ST-elevation myocardial infarction receiving center (SRC) networks: impact on Door-to-Balloon times across 10 independent regions.

OBJECTIVES The aim of this study was to evaluate the rate of timely reperfusion for ST-elevation myocardial infarction (STEMI) with primary percutaneous coronary intervention (PPCI) in regional STEMI Receiving Center (SRC) networks. BACKGROUND The American College of Cardiology Door-to-Balloon (D2B) Alliance target is a >75% rate of D2B <or=90 min. Independent initiatives nationwide have organized regional SRC networks that coordinate universal access to 9-1-1 with the pre-hospital electrocardiogram (PH-ECG) diagnosis of STEMI and immediate transport to a SRC (designated PPCI-capable hospital). METHODS A pooled analysis of 10 independent, prospective, observational registries involving 72 hospitals was performed. Data were collected on all consecutive patients with a PH-ECG diagnosis of STEMI. The D2B and emergency medical services (EMS)-to-balloon (E2B) times were recorded. RESULTS Paramedics transported 2,712 patients with a PH-ECG diagnosis of STEMI directly to the nearest SRC. A PPCI was performed in 2,053 patients (76%) with an 86% rate of D2B <or=90 min (95% confidence interval: 84.4% to 87.4%). Secondary analyses of this cohort demonstrated a 50% rate of D2B <or=60 min (n = 1,031), 25% rate of D2B <or=45 min (n = 517), and an 8% rate of D2B <or=30 min (n = 155). A tertiary analysis restricted to 762 of 2,053 (37%) cases demonstrated a 68% rate of E2B <or=90 min. CONCLUSIONS Ten independent regional SRC networks demonstrated a combined 86% rate of D2B <or=90 min, and each region individually surpassed the American College of Cardiology D2B Alliance benchmark. In areas with regional SRC networks, 9-1-1 provides entire communities with timely access to quality STEMI care.

Emergency Medical Services System Changes Reduce Pediatric Epinephrine Dosing Errors in the Prehospital Setting

OBJECTIVE. The goal was to describe the change in the rate of epinephrine dosing errors in the treatment of pediatric patients in prehospital cardiopulmonary arrest after the Los Angeles County Emergency Medical Services Agency instituted a program in which paramedics were required to use the Broselow tape and to report color zone categories to the base station and base stations were given and instructed formally in the use of the color-coded drug dosing chart. METHODS. An observational analysis of a natural experiment was performed. Children ≤12 years of age who were determined to be in prehospital cardiopulmonary arrest and who received prehospital epinephrine treatment by paramedics, in the periods of 1994 to 1997 and 2003 to 2004, were included in the study. RESULTS. In the 1994 to 1997 cohort, we identified 104 subjects in prehospital cardiopulmonary arrest who received epinephrine with a documented weight and route of administration. Only 29 of 104 subjects in the 1994 to 1997 cohort received the correct dose, whereas 46 of 104 subjects received a first dose within 20% of the correct dose. In the 2003 to 2004 cohort, we identified 41 children ≤12 years of age who were in cardiopulmonary arrest and received prehospital epinephrine treatment but 4 children were excluded, leaving 37 subjects. Twenty-one of 37 subjects received the correct dose, whereas 24 of 37 subjects received a dose within 20%. The odds ratio for obtaining the correct epinephrine dose after the system changes versus before was 3.0, and that for obtaining a dose within 20% of the correct dose was 2.5. CONCLUSIONS. The program seems to have resulted in reduction of the rate of epinephrine dosing errors in the prehospital treatment of children in cardiopulmonary arrest in Los Angeles County.

The Effectiveness of a Novel, Algorithm-Based Difficult Airway Curriculum for Air Medical Crews Using Human Patient Simulators

Introduction. Airway management is one of the most important skills possessed by flight crews. However, few data exist about the efficacy of various educational approaches. Traditional models for airway training, including cadaver labs, operating room exposure, andclinical apprenticeships, are scarce andoffer variable educational quality. The objective of this analysis was to evaluate the effectiveness of a simulator-based difficult airway curriculum in a large, aeromedical company. Methods. Simulation training was integrated into existing airway training for all crew members; an original difficult airway algorithm was used to guide scenarios. To evaluate its effectiveness, rapid sequence intubation (RSI) success before andafter curriculum implementation was determined. In addition, crew members rated their confidence with various aspects of airway management before andafter exposure to the airway workshops. Results. First attempt andoverall ETI success improved from 71.3% and89.3% before (n = 261) to 87.5% and94.6% after (n = 504) implementation of the algorithm andsimulation training, whereas the incidence of hypoxic arrests during RSI decreased from 2.7% to 0.2% (p < 0.01 for all comparisons). Crew members reported improvements in confidence with regard to all aspects of airway management following participation in the simulation workshops. Conclusions. A novel, integrated airway management curriculum using treatment algorithms andsimulation appeared to be effective for improving RSI success among air medical crews in this program.

Effect of Prehospital Cardiac Catheterization Lab Activation on Door-to-Balloon Time, Mortality, and False-Positive Activation

Abstract Background. Reperfusion of ST elevation myocardial infarction (STEMI) is most effective when performed early. Notification of the cardiac catheterization laboratory (cath lab) prior to hospital arrival based on paramedic-performed ECGs has been proposed as a strategy to decrease time to reperfusion and mortality. The purpose of this study was to compare the effects of cath lab activation prior to patient arrival versus activation after arrival at the emergency department (ED). Methods. We performed a retrospective cohort study (n = 1933 cases) using Los Angeles County STEMI database from May 1, 2008 through August 31, 2009. The database includes patients arriving at a STEMI Receiving Center (SRC) by ambulance who were diagnosed with STEMI either before or after hospital arrival. We compared the cohort of patients with prehospital cath lab activation to those activated from the ED within 5 minutes of first ED ECG. Outcomes measured were mortality, door-to-balloon time, percent door-to-balloon time <90 min, and percentage of false-positive activations. Results. Prehospital cath lab activations had mean door-to-balloon times 14 minutes shorter (95% CI 11–17), in-hospital mortality 1.5% higher (95% CI −1.0–5.2), and false-positive activation 7.8%, (95% CI 2.7–13.3) higher than ED activation. For prehospital activation, 93% (95% CI 91–94%) met a door-to-balloon target of 90 minutes versus 85% (95% CI 80–88%) for ED activations. Conclusion. Prehospital cath lab activation based on the prehospital ECG was associated with decreased door-to-balloon times but did not affect hospital mortality. False-positive activation was common and occurred more often with prehospital STEMI diagnosis.

Survival and Neurologic Outcome after Out-of-Hospital Cardiac Arrest: Results One Year after Regionalization of Post-Cardiac Arrest Care in a Large Metropolitan Area

Abstract Background. Post-resuscitation care of cardiac arrest patients at specialized centers may improve outcome after out-of-hospital cardiac arrest (OOHCA). This study describes experience with regionalized care of resuscitated patients. Methods. Los Angeles (LA) County established regionalized cardiac care in 2006. Since 2010, protocols mandate transport of nontraumatic OOHCA patients with field return of spontaneous circulation (ROSC) to a STEMI Receiving Center (SRC) with a hypothermia protocol. All SRC report outcomes to a registry maintained by the LA County Emergency Medical Services (EMS) Agency. We report the first years data. The primary outcome was survival with good neurologic outcome, defined by a Cerebral Performance Category (CPC) score of 1 or 2. Results. The SRC treated 927 patients from April 2011 through March 2012 with median age 67; 38% were female. There were 342 patients (37%) who survived to hospital discharge. CPC scores were unknown in 47 patients. Of the 880 patients with known CPC scores, 197 (22%) survived to hospital discharge with a CPC score of 1 or 2. The initial rhythm was VF/VT in 311 (34%) patients, of whom 275 (88%) were witnessed. For patients with an initial shockable rhythm, 183 (59%) survived to hospital discharge and 120 (41%) had survival with good neurologic outcome. Excluding patients who were alert or died in the ED, 165 (71%) patients with shockable rhythms received therapeutic hypothermia (TH), of whom 67 (42%) had survival with good neurologic outcome. Overall, 387 patients (42%) received TH. In the TH group, the adjusted OR for CPC 1 or 2 was 2.0 (95%CI 1.2–3.5, p = 0.01), compared with no TH. In contrast, the proportion of survival with good neurologic outcome in the City of LA in 2001 for all witnessed arrests (irrespective of field ROSC) with a shockable rhythm was 6%. Conclusion. We found higher rates of neurologically intact survival from OOHCA in our system after regionalization of post-resuscitation care as compared to historical data.

Paramedic and Emergency Medical Technicians Views on Opportunities and Challenges When Forgoing and Halting Resuscitation in the Field

OBJECTIVES The objective was to assess paramedic and emergency medical technicians (EMT) perspectives and decision-making after a policy change that allows forgoing or halting resuscitation in prehospital atraumatic cardiac arrest. METHODS Five semistructured focus groups were conducted with 34 paramedics and 2 EMTs from emergency medical services (EMS) agencies within Los Angeles County (LAC), 6 months after a policy change that allowed paramedics to forgo or halt resuscitation in the field under certain circumstances. RESULTS Participants had an overwhelmingly positive view of the policy; felt it empowered their decision-making abilities; and thought the benefits to patients, family, EMS, and the public outweighed the risks. Except under certain circumstances, such as when the body was in public view or when family members did not appear emotionally prepared to have the body left on scene, they felt the policy improved care. Assuming that certain patient characteristics were present, decisions by paramedics about implementing the policy in the field involve many factors, including knowledge and comfort with the new policy, family characteristics (e.g., agreement), and logistics regarding the place of arrest (e.g., size of space). Paramedic and EMT experiences with and attitudes toward forgoing resuscitation, as well as group dynamics among EMS leadership, providers, police, and ED staff, also play a role. CONCLUSIONS Participants view the ability to forgo or halt resuscitation in the field as empowering and do not believe it presents harm to patients or families under most circumstances. Factors other than patient clinical characteristics, such as knowledge and attitudes toward the policy, family emotional preparedness, and location of arrest, affect whether paramedics will implement it.

Implementation of specialty centers for patients with ST-segment elevation myocardial infarction.

Background. Early percutaneous coronary intervention (PCI) has been shown to be superior to fibrinolytic therapy andis associated with reduced morbidity andmortality for patients with ST-segment elevation myocardial infarction (STEMI). Objective. To determine the performance of a regional system with prehospital 12-lead electrocardiogram (ECG) identification of STEMI patients anddirect paramedic transport to STEMI receiving centers (SRCs) for provision of primary PCI. Methods. This was a prospective study evaluating the first year of implementation of a regional SRC network to determine the key time intervals for patients identified with STEMI in the prehospital setting. Results. During the 12-month study period, 1,220 patients with a suspected STEMI were identified on prehospital 12-lead ECG, of whom 734 (60%) underwent emergency PCI. A door-to-balloon time of 90 minutes or less was achieved for 651 (89%) patients, and459 (62.5%) had EMS–patient contact-to-balloon times ≤ 90 minutes. Transport of suspected STEMI patients to an SRC resulted in ambulance diversion from a closer ED for 31% of patients anda median increase in transport time of 3.8 minutes. Conclusion. Door-to-balloon times within the 90-minute benchmark were achieved for almost 90% of STEMI patients transported by paramedics after implementing our regionalized SRC system

Developing an ST-elevation myocardial infarction system of care in Dallas County

BACKGROUND The American Heart Association Caruth Initiative (AHACI) is a multiyear project to increase the speed of coronary reperfusion and create an integrated system of care for patients with ST-elevation myocardial infarction (STEMI) in Dallas County, TX. The purpose of this study was to determine if the AHACI improved key performance metrics, that is, door-to-balloon (D2B) and symptom-onset-to-balloon times, for nontransfer patients with STEMI. METHODS Hospital patient data were obtained through the National Cardiovascular Data Registry Action Registry-Get With The Guidelines, and prehospital data came from emergency medical services (EMS) agencies through their electronic Patient Care Record systems. Initial D2B and symptom-onset-to-balloon times for nontransfer primary percutaneous coronary intervention (PCI) STEMI care were explored using descriptive statistics, generalized linear models, and logistic regression. RESULTS Data were collected by 15 PCI-capable Dallas hospitals and 24 EMS agencies. In the first 18 months, there were 3,853 cases of myocardial infarction, of which 926 (24%) were nontransfer patients with STEMI undergoing primary PCI. D2B time decreased significantly (P < .001), from a median time of 74 to 64 minutes. Symptom-onset-to-balloon time decreased significantly (P < .001), from a median time of 195 to 162 minutes. CONCLUSION The AHACI has improved the system of STEMI care for one of the largest counties in the United States, and it demonstrates the benefits of integrating EMS and hospital data, implementing standardized training and protocols, and providing benchmarking data to hospitals and EMS agencies.

Developing Quality Indicators for the Appropriateness of Resuscitation in Prehospital Atraumatic Cardiac Arrest

Objective. The vast majority of out-of-hospital cardiac arrest victims do not survive or suffer severe neurological impairment. We sought to develop a set of straightforward clinical indicators that paramedics could use to better match resuscitation attempts to those most likely to benefit. Methods. In partnership with the Los Angeles County Emergency Medical Services, we used the RAND/UCLA appropriateness method of quantifying expert opinion regarding the risks andbenefits of medical procedures. We presented available scientific evidence related to potential indicators of the quality of resuscitative care to stakeholder-nominated experts. Forty-one candidate indicators incorporated key variables, including initial rhythm, patient preferences, presence of witnesses, andplace of arrest. Nine panelists, including palliative care andemergency medical specialists, rated the appropriateness of paramedic use of each indicator by using a 1–9 scale. An indicator was considered appropriate if the potential benefits outweighed the potential harm to the patient or their family. Indicators were retained if median score was ≥7. Results. The expert panel voted to retain 28 quality indicators. Three addressed signs of irreversible death (e.g., dependent lividity), 8 addressed patient preferences (e.g., inquiring about DNR status), andthe remainder addressed combinations of initial rhythm andother prognostic signs (e.g., “If initial rhythm is asystole andpatient is known by apparent surrogate decision maker to have a terminal illness, then forgo resuscitation.”). Our experts recommended a series of much more liberal criteria for forgoing resuscitation than is currently practiced. This includes ascertaining andhonoring patient preferences, either through written documents or family members, andcombinations of clinical criteria that predict poor neurological outcome, such as asystole, terminal illness, age greater than 70, andresponse time greater than 15 minutes. Conclusions. These quality indicators expand on the previously limited circumstances in which paramedics might forgo field resuscitation andimplementation could reduce future harm from such procedures among seriously ill patients. Our current efforts focus on using these indicators to aid implementation of a new resuscitation policy for seriously ill patients in our county.

Treatment and Outcomes of ST Segment Elevation Myocardial Infarction and Out-of-Hospital Cardiac Arrest in a Regionalized System of Care Based on Presence or Absence of Initial Shockable Cardiac Arrest Rhythm

The aim of this study was to evaluate the treatment and outcomes of patients with ST-segment elevation myocardial infarctions complicated by out-of-hospital cardiac arrest in a regional system of care. In this retrospective study, the effect of the absence of an initial shockable arrest rhythm was analyzed. The primary end point of survival with good neurologic outcome in patients with and without an initial shockable arrest rhythm was adjusted for age, witnessed arrest, bystander cardiopulmonary resuscitation, and treatment with therapeutic hypothermia and percutaneous coronary intervention. One-hundred sixty-eight of 348 patients (49%) survived to hospital discharge. Patients with a shockable initial rhythm were more likely to receive therapeutic hypothermia (48% vs 37%, risk ratio 1.2, 95% confidence interval [CI] 1.0 to 1.5) and to be treated in the cardiac catheterization laboratory (80% vs 43%, risk ratio 2.8, 95% CI 2.0 to 3.8). The likelihood of survival with good neurologic outcome in patients with a shockable initial rhythm compared with those presenting without a shockable rhythm was 4.8 (95% CI 2.7 to 8.7). In patients who underwent percutaneous coronary intervention, the likelihood of survival with good neurologic outcome was higher (risk ratio 2.7, 95% CI 1.1 to 6.8) in those with a shockable rhythm. In conclusion, the absence of an initial shockable rhythm in patients with ST-segment elevation myocardial infarctions plus out-of-hospital cardiac arrest is associated with significantly worse survival and neurologic outcome. These differences persist despite application of therapies including therapeutic hypothermia and percutaneous coronary intervention within a regionalized system of care.