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Evaluation of a primary care paramedic STEMI bypass guideline

  • Jonathan L. Kwong (a1), Garry Ross (a2), Linda Turner (a2), Chris Olynyk (a3), Sheldon Cheskes (a4) (a2), Adam Thurston (a3) and P. Richard Verbeek (a2) (a5)...

Abstract

Objective

Limited evidence supports primary care paramedic (PCP) direct transport of ST-segment elevation myocardial infarction (STEMI) patients for percutaneous coronary intervention (PCI). The goal of this study was to evaluate an urban-based PCP STEMI bypass guideline.

Methods

We reviewed consecutive Toronto Paramedic Services call reports between April 7, 2015, and May 31, 2016, regarding STEMI patients identified by PCPs. The primary outcome was patient assignment (stable versus unstable) according to guideline criteria. Secondary outcomes were the proportion of PCP-transported patients who had an indication for an advanced care intervention (ACI) or who received an ACI when PCPs rendezvoused with an advanced care paramedic (ACP). Lastly, we reviewed prehospital outcomes of cardiac arrest patients and calculated the difference in transport intervals between direct PCP bypass and a PCI-centre and predicted transport interval to the closest emergency department (ED).

Results

Of 361 patients, 232 were PCP transports and 129 were ACP-rendezvous transports. There was a significant difference in the distribution of stable and unstable patients between PCPs and ACPs (p<0.001). For PCP patients, 21/232 (9.1%) had indications for an ACI, whereas 34/129 (26.4%) ACP patients received an ACI. Eleven patients experienced cardiac arrest; 10 were successfully resuscitated (5 of these by PCPs). The median difference between direct PCP bypass and a PCI-centre versus transport to the closest ED was 5.53 minutes (IQR=6.71).

Conclusions

We found a significant difference in the distribution of stable and unstable patients and fewer patients with indications for an ACI in PCP patients. This PCP STEMI bypass guideline appears feasible.

Contexte

Il existe peu de données étayant le transport direct, par les ambulanciers paramédicaux - soins primaires (PSP), de patients ayant subi un infarctus du myocarde avec sus-décalage du segment ST (STEMI) vers un centre en vue d’une intervention coronarienne percutanée (ICP).

Objectif

L’étude visait à évaluer une directive sur le transport direct, par les PSP, de patients ayant subi un STEMI vers un centre d’ICP, en milieu urbain.

Méthode

Nous avons passé en revue tous les rapports d’appels consécutifs, reçus par les Toronto Paramedic Services, entre le 7 avril 2015 et le 31 mai 2016, sur des patients ayant subi un STEMI reconnu par les PSP. Le principal critère d’évaluation était l’état du patient (stable ou instable) selon les critères de la directive. Le critère secondaire, lui, consistait en la proportion de patients transportés par les PSP et ayant une indication d’intervention en soins avancés (ISA) ou ayant subi une ISA au lieu de rencontre avec l’ambulancier paramédical - soins avancés (PSA). Enfin, nous avons examiné les résultats des arrêts cardiaques en phase préhospitalière, et calculé les écarts de temps entre le transport direct de patients, par les PSP, vers un centre d’ICP et le temps prévu de transport de patients vers le service des urgences (SU) le plus près.

Résultats

Sur 361 patients, 232 ont été transportés par des PSP et 129, transportés vers un lieu de rencontre avec un PSA. Il y avait un écart significatif dans la répartition des patients stables et des patients instables entre les PSP et les PSA (p<0,001). Parmi les patients transportés par les PSP, 21/232 (9,1 %) avaient une indication d’ISA contre 34/129 (26,4 %) pour les patients transportés par les PSA et soumis à une ISA. Par ailleurs, 11 patients ont fait un arrêt cardiaque et 10 ont été réanimés, dont 5 par les PSP. L’écart médian du temps écoulé entre le transport direct de patients, par les PSP, vers un centre d’ICP et le transport de patients vers le SU le plus près était de 5,53 minutes (écart interquartile=6,71).

Conclusions

Un écart significatif a été relevé dans la répartition des patients stables et des patients instables, et il y avait moins de patients ayant une indication d’ISA chez les patients transportés par les PSP. La directive sur le transport direct, par les PSP, de patients ayant subi un STEMI vers un centre spécialisé semble donc applicable.

Copyright

Corresponding author

Correspondence to: Dr. P. Richard Verbeek, Sunnybrook Centre for Prehospital Medicine, 77 Brown’s Line, Suite 100, Toronto, ON M8W 3S2; Email: richard.verbeek@sunnybrook.ca

References

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