D'Arcy Nicole T, Bosson Nichole, Kaji Amy H, Bui Quang T, French William J, Thomas Joseph L, Elizarraraz Yvonne, Gonzalez Natalia, Garcia Jose, Niemann James T
1Harbor-UCLA Medical Center and Los Angeles Biomedical Institute,Torrance,California USA;David Geffen School of Medicine at UCLA,Los Angeles,CaliforniaUSA.
Prehosp Disaster Med. 2018 Jun;33(3):245-249. doi: 10.1017/S1049023X18000341. Epub 2018 Apr 30.
IntroductionField identification of ST-elevation myocardial infarction (STEMI) and advanced hospital notification decreases first-medical-contact-to-balloon (FMC2B) time. A recent study in this system found that electrocardiogram (ECG) transmission following a STEMI alert was frequently unsuccessful.HypothesisInstituting weekly test ECG transmissions from paramedic units to the hospital would increase successful transmission of ECGs and decrease FMC2B and door-to-balloon (D2B) times.
This was a natural experiment of consecutive patients with field-identified STEMI transported to a single percutaneous coronary intervention (PCI)-capable hospital in a regional STEMI system before and after implementation of scheduled test ECG transmissions. In November 2014, paramedic units began weekly test transmissions. The mobile intensive care nurse (MICN) confirmed the transmission, or if not received, contacted the paramedic unit and the department's nurse educator to identify and resolve the problem. Per system-wide protocol, paramedics transmit all ECGs with interpretation of STEMI. Receiving hospitals submit patient data to a single registry as part of ongoing system quality improvement. The frequency of successful ECG transmission and time to intervention (FMC2B and D2B times) in the 18 months following implementation was compared to the 10 months prior. Post-implementation, the time the ECG transmission was received was also collected to determine the transmission gap time (time from ECG acquisition to ECG transmission received) and the advanced notification time (time from ECG transmission received to patient arrival).
There were 388 patients with field ECG interpretations of STEMI, 131 pre-intervention and 257 post-intervention. The frequency of successful transmission post-intervention was 73% compared to 64% prior; risk difference (RD)=9%; 95% CI, 1-18%. In the post-intervention period, the median FMC2B time was 79 minutes (inter-quartile range [IQR]=68-102) versus 86 minutes (IQR=71-108) pre-intervention (P=.3) and the median D2B time was 59 minutes (IQR=44-74) versus 60 minutes (IQR=53-88) pre-intervention (P=.2). The median transmission gap was three minutes (IQR=1-8) and median advanced notification time was 16 minutes (IQR=10-25).
Implementation of weekly test ECG transmissions was associated with improvement in successful real-time transmissions from field to hospital, which provided a median advanced notification time of 16 minutes, but no decrease in FMC2B or D2B times. D'ArcyNT, BossonN, KajiAH, BuiQT, FrenchWJ, ThomasJL, ElizarrarazY, GonzalezN, GarciaJ, NiemannJT. Weekly checks improve real-time prehospital ECG transmission in suspected STEMI. Prehosp Disaster Med. 2018;33(3):245-249.
引言
ST段抬高型心肌梗死（STEMI）的现场识别及提前通知医院可缩短首次医疗接触至球囊扩张（FMC2B）时间。该系统近期的一项研究发现，STEMI警报发出后的心电图（ECG）传输常常不成功。
假设
安排护理人员每周向医院进行心电图测试传输，可提高心电图的成功传输率，并缩短FMC2B及门球时间（D2B）。
方法
这是一项自然实验，观察在区域STEMI系统中，预定的心电图测试传输实施前后，连续的现场确诊STEMI患者被转运至一家具备经皮冠状动脉介入治疗（PCI）能力的医院的情况。2014年11月，护理人员开始每周进行测试传输。移动重症护理护士（MICN）确认传输情况，若未收到，则联系护理人员及科室的护士教育者以识别并解决问题。按照全系统协议，护理人员传输所有经STEMI解读的心电图。接收医院将患者数据提交至单一登记处，作为持续的系统质量改进的一部分。将实施后的18个月内心电图成功传输的频率及干预时间（FMC2B和D2B时间）与之前的10个月进行比较。实施后，还收集了心电图传输被接收的时间，以确定传输间隔时间（从心电图采集到心电图传输被接收的时间）及提前通知时间（从心电图传输被接收到患者到达的时间）。
结果
共有388例现场心电图解读为STEMI的患者，其中131例在干预前，257例在干预后。干预后成功传输的频率为73%，而干预前为64%；风险差异（RD）=9%；95%置信区间，1 - 18%。在干预后时期，FMC2B时间中位数为79分钟（四分位间距[IQR]=68 - 102），而干预前为86分钟（IQR=71 - 108）（P = 0.3），D2B时间中位数为59分钟（IQR=44 - 74），干预前为60分钟（IQR=53 - 88）（P = 0.2）。传输间隔时间中位数为3分钟（IQR=1 - 8），提前通知时间中位数为16分钟（IQR=10 - 25）。
结论
每周进行心电图测试传输与现场至医院实时传输成功率的提高相关，提前通知时间中位数为16分钟，但FMC2B或D2B时间未缩短。
D'Arcy NT、Bosson N、Kaji AH、Bui QT、French WJ、Thomas JL、Elizarraraz Y、Gonzalez N、Garcia J、Niemann JT。每周检查可改善疑似STEMI患者的院前心电图实时传输。《院前灾难医学》。2018；33(3)：245 - 249。
