Coronary artery disease
Effect on Treatment Delay of Prehospital Teletransmission of 12-Lead Electrocardiogram to a Cardiologist for Immediate Triage and Direct Referral of Patients With ST-Segment Elevation Acute Myocardial Infarction to Primary Percutaneous Coronary Intervention

https://doi.org/10.1016/j.amjcard.2007.11.038Get rights and content

Prehospital electrocardiogram (ECG) transmission to hospitals was shown to reduce time to treatment in patients with acute myocardial infarction. However, new technologies allow transmission directly to a mobile unit so an attending physician can respond irrespective of presence within or outside the hospital. The primary study purpose was to determine whether delays could be decreased in an urban area by transmitting a prehospital 12-lead ECG directly to the attending cardiologist’s mobile telephone for rapid triage and transport to a primary percutaneous coronary intervention (PCI) center, bypassing local hospitals and emergency departments. A secondary purpose was to describe whether transport would be safe despite longer transport times. During a 2-year period, patients with acute nontraumatic chest pain had their prehospital ECG transmitted directly to a cardiologist’s mobile telephone. Time to treatment was compared with historic controls. After ECG evaluation, 168 patients (30%) were referred directly for PCI, and 146 of these (87%) underwent emergent catheterization. In referred patients, median time from 911 call to PCI was significantly shorter than in the control group (74 vs 127 minutes; p <0.001). Accordingly, door-to-PCI time was 63 minutes shorter for referred patients versus controls (34 vs 97 minutes; p <0.001). During transport, 7 patients (4%) experienced ventricular fibrillation; 3 patients (2%), ventricular tachycardia; and 1 patient (0.5%), pulseless electrical activity, including 2 deaths (1%) caused by treatment-resistant arrhythmia. In conclusion, transmission of a prehospital 12-lead ECG directly to the attending cardiologist’s mobile telephone decreased door-to-PCI time by >1 hour when patients were transported directly to PCI centers, bypassing local hospitals. Ambulance transport seems safe despite longer transport times.

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Methods

Patients in urban Copenhagen (600,000 inhabitants), Denmark, requesting ambulance assistance for acute nontraumatic chest pain were eligible for inclusion from October 27, 2003, to October 31, 2005. Two PCI centers and 4 local hospitals were involved. Patients with STEMI from Copenhagen City were referred to PCI center 1 (maximal transport distance 10 km), whereas those from Copenhagen County were directed to PCI center 2 (maximal transport distance 22 km). All ambulances were manned with

Results

Of 565 included patients, the EMT-basic ambulances enrolled 243 (43%). A total of 184 patients were admitted to a PCI center. Most (n = 168; 91%) were referred directly to PCI based on their prehospital 12-lead ECG, but only 146 of these (87%) underwent emergent catheterization. Sixteen patients (4% of EMT-transported vs 2% of MD-transported; p = 0.1) were referred for PCI after initial triage resulted in admission to the nearest local hospital, where new ECG changes occurred. The remaining 381

Discussion

The present study showed that prehospital 12-lead ECG transmission directly to a cardiologist’s mobile telephone with immediate triage and referral of patients with STEMI directly to a catheterization suite was extremely efficient and for the first time showed door-to-PCI time decreased by >1 hour. More than one third of all ambulances in Europe and the United States carry equipment for recording and transmission of prehospital 12-lead ECGs.1 However, triage delays ensue when attending

Acknowledgment

We appreciate the time and effort put into this study by Falck A/S, Tårnby, Denmark, The Mobile Emergency Care Unit, Copenhagen, Denmark, participating local hospitals, research nurses, attending cardiologists, and PCI operators.

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This work was supported by Carl og Katy Kajsings Legat, Copenhagen, Denmark; C.C. Klestrup og hustru Henriette Klestrups Mindelegat, Copenhagen, Denmark; Danske Lægers Forsikring under Codan/SEB Pension, Copenhagen, Denmark; Direktør Emil Hertz og hustru Inger Hertz’ Fond, Copenhagen, Denmark; Eva og Henry Frænkels Mindefond, Copenhagen, Denmark; Købmand Sven Hansen og hustru Ina Hansens Fond, Sorø, Denmark; Lippmann Fonden, Copenhagen, Denmark; and Physio-Control Inc., a division of Medtronic, Redmond, Washington.

Dr. Trautner served on government committees on emergency medicine and prehospital care in Denmark and is medical director of an ambulance service, Falck A/S, Copenhagen, Denmark; Dr. Hampton is a former employee of Physio-Control, Inc., Redmond, Washington, and a current employee of Medtronic, Inc., Redmond, Washington; Dr. Wagner has research grants from Welch Allyn, Beaverton, Oregon, Cierra, Redwood City, California, Boehringer-Ingelheim, Ridgefield, Connecticut, and Medtronic Physio-Control, Inc., Redmond, Washington; and Dr. Clemmensen has research grants from and is a consultant for Medtronic, Inc., Redmond, Washington.

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