Davis Paul, Howie Graham J, Dicker Bridget, Garrett Nicholas K
Clinical Audit and Research Team, St John Ambulance Service, Auckland, New Zealand.
Department of Paramedicine, School of Clinical Sciences, Auckland University of Technology, Auckland, New Zealand.
J Thorac Dis. 2019 May;11(5):1819-1830. doi: 10.21037/jtd.2019.05.45.
In regions of New Zealand without coronary catheterisation laboratory (CCL) facilities, patients presenting with ST-elevation myocardial infarction (STEMI) are often subjected to prolonged delays before receiving primary percutaneous coronary intervention (PPCI) if it is the chosen reperfusion strategy. Therefore, we aimed to trial a new process of paramedic-initiated helivac of STEMI patients from the field directly to the CCL.
Utilising a prospective observational approach, over a 48-month period, paramedics identified patients with a clinical presentation and electrocardiogram features consistent with STEMI and transported them directly to the regional air ambulance base for helivac to the CCL (flight time 30-35 minutes). These patients were compared to two historic STEMI cohorts either transported by paramedics to the region's local hospital or self-presenting, prior to helivac. The primary outcome measures were: first medical contact-to-balloon (FMCTB) time and accuracy of paramedic diagnosis. Secondary outcome measures were mortality at 30 days and six months, and hospital length of stay (LOS).
A total of 92 patients underwent helivac for PPCI (mean age of 64 years, SD ±10.3). Median FMCTB time was 155 minutes (IQR 27) for the historic cohorts (n=57), versus 102 minutes (IQR 16) for the experimental cohort (n=35, P<0.001). Paramedic diagnosis showed a sensitivity of 97% (95% CI: 85 to 99) and a specificity of 100% (95% CI: 84 to 100) with no inappropriate CCL activations. No significant difference was observed between groups in terms of 30 day and 6-month mortality. Hospital LOS was significantly shorter among the experimental cohort (P=0.01).
Paramedic-initiated helivac of STEMI patients from the field directly to the CCL for PPCI is safe and feasible and can significantly improve time-to-treatment to within benchmark timeframes, resulting in reduced hospital LOS.
在新西兰没有冠状动脉导管插入实验室（CCL）设施的地区，如果选择直接经皮冠状动脉介入治疗（PPCI）作为再灌注策略，出现ST段抬高型心肌梗死（STEMI）的患者在接受该治疗前往往会经历长时间延误。因此，我们旨在试验一种新流程，即由护理人员启动将STEMI患者从现场直接空运至CCL的直升机转运。
采用前瞻性观察方法，在48个月期间，护理人员识别出临床表现和心电图特征符合STEMI的患者，并将他们直接转运至地区空中救护基地，以便直升机转运至CCL（飞行时间30 - 35分钟）。将这些患者与两个历史STEMI队列进行比较，这两个队列在直升机转运之前，要么由护理人员转运至该地区的当地医院，要么自行前往医院。主要结局指标为：首次医疗接触至球囊扩张（FMCTB）时间和护理人员诊断的准确性。次要结局指标为30天和6个月时的死亡率以及住院时间（LOS）。
共有92例患者接受直升机转运以进行PPCI（平均年龄64岁，标准差±10.3）。历史队列（n = 57）的FMCTB时间中位数为155分钟（四分位间距27），而试验队列（n = 35，P < 0.001）为102分钟（四分位间距16）。护理人员诊断的敏感性为97%（95%置信区间：85至99），特异性为100%（95%置信区间：84至100），且没有不适当的CCL激活情况。在30天和6个月死亡率方面，各队列之间未观察到显著差异。试验队列的住院时间显著更短（P = 0.01）。
由护理人员启动将STEMI患者从现场直接空运至CCL进行PPCI是安全可行的，并且可以显著缩短治疗时间至基准时间范围内，从而缩短住院时间。
