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The Effect of Implementation of the American Heart Association Mission Lifeline PreAct Algorithm for Prehospital Cardiac Catheterization Laboratory Activation on the Rate of “False Positive” Activations

Published online by Cambridge University Press:  20 May 2020

Juliana Tolles Open the ORCID record for Juliana Tolles [Opens in a new window] ,
Nichole Bosson ,
Amy H. Kaji ,
Timothy D. Henry ,
William J. French ,
Marianne Gausche-Hill ,
Kevin Andruss ,
Nathan McNeil ,
Eric C. Nakkim  and
Gregory S. Thomas
...Show all authors
Juliana Tolles*
Affiliation:
Harbor-UCLA Medical Center, Torrance, CaliforniaUSA David Geffen School of Medicine at UCLA, Torrance, CaliforniaUSA
Nichole Bosson
Affiliation:
Harbor-UCLA Medical Center, Torrance, CaliforniaUSA David Geffen School of Medicine at UCLA, Torrance, CaliforniaUSA Los Angeles County Emergency Medical Services Agency, Los Angeles, CaliforniaUSA
Amy H. Kaji
Affiliation:
Harbor-UCLA Medical Center, Torrance, CaliforniaUSA David Geffen School of Medicine at UCLA, Torrance, CaliforniaUSA
Timothy D. Henry
Affiliation:
The Christ Hospital, Cincinnati, OhioUSA
William J. French
Affiliation:
Harbor-UCLA Medical Center, Torrance, CaliforniaUSA David Geffen School of Medicine at UCLA, Torrance, CaliforniaUSA
Marianne Gausche-Hill
Affiliation:
Harbor-UCLA Medical Center, Torrance, CaliforniaUSA David Geffen School of Medicine at UCLA, Torrance, CaliforniaUSA Los Angeles County Emergency Medical Services Agency, Los Angeles, CaliforniaUSA
Kevin Andruss
Affiliation:
PIH Health Hospital Whittier, Whittier, CaliforniaUSA
Nathan McNeil
Affiliation:
Cedars-Sinai Medical Center, Los Angeles, CaliforniaUSA
Eric C. Nakkim
Affiliation:
Torrance Memorial Medical Center, Torrance, CaliforniaUSA
Gregory S. Thomas
Affiliation:
Memorial Care, Long Beach Medical Center, Long Beach, CaliforniaUSA
Michael R. Gunderson
Affiliation:
Center for Systems Improvement, Lakeland, FloridaUSA Department of Emergency Health Services, University of Maryland, College Park, MarylandUSA
Roger J. Lewis
Affiliation:
Harbor-UCLA Medical Center, Torrance, CaliforniaUSA David Geffen School of Medicine at UCLA, Torrance, CaliforniaUSA
*
Juliana Tolles, MD, MHS, Department of Emergency Medicine, Harbor-UCLA Medical Center, 1000 West Carson Street Box #21, Torrance, California90502USA, E-mail: jtolles@emedharbor.edu
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Abstract

Hypothesis:

Emergency Medical Services (EMS) systems have developed protocols for prehospital activation of the cardiac catheterization laboratory for patients with suspected ST-elevation myocardial infarction (STEMI) to decrease first-medical-contact-to-balloon time (FMC2B). The rate of “false positive” prehospital activations is high. In order to decrease this rate and expedite care for patients with true STEMI, the American Heart Association (AHA; Dallas, Texas USA) developed the Mission Lifeline PreAct STEMI algorithm, which was implemented in Los Angeles County (LAC; California USA) in 2015. The hypothesis of this study was that implementation of the PreAct algorithm would increase the positive predictive value (PPV) of prehospital activation.

Methods:

This is an observational pre-/post-study of the effect of the implementation of the PreAct algorithm for patients with suspected STEMI transported to one of five STEMI Receiving Centers (SRCs) within the LAC Regional System. The primary outcome was the PPV of cardiac catheterization laboratory activation for percutaneous coronary intervention (PCI) or coronary artery bypass graft (CABG). The secondary outcome was FMC2B.

Results:

A total of 1,877 patients were analyzed for the primary outcome in the pre-intervention period and 405 patients in the post-intervention period. There was an overall decrease in cardiac catheterization laboratory activations, from 67% in the pre-intervention period to 49% in the post-intervention period (95% CI for the difference, -14% to -22%). The overall rate of cardiac catheterization declined in post-intervention period as compared the pre-intervention period, from 34% to 30% (95% CI, for the difference -7.6% to 0.4%), but actually increased for subjects who had activation (48% versus 58%; 95% CI, 4.6%-15.0%). Implementation of the PreAct algorithm was associated with an increase in the PPV of activation for PCI or CABG from 37.9% to 48.6%. The overall odds ratio (OR) associated with the intervention was 1.4 (95% CI, 1.1-1.8). The effect of the intervention was to decrease variability between medical centers. There was no associated change in average FMC2B.

Conclusions:

The implementation of the PreAct algorithm in the LAC EMS system was associated with an overall increase in the PPV of cardiac catheterization laboratory activation.

Keywords

cardiac catheterizationmyocardial infarctionprehospital emergency care
Type
Original Research
Information
Prehospital and Disaster Medicine , Volume 35 , Issue 4 , August 2020 , pp. 388 - 396
Copyright
© World Association for Disaster and Emergency Medicine 2020

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