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Underuse of prehospital strategies to reduce time to reperfusion for ST-elevation myocardial infarction patients in 5 Canadian provinces

Published online by Cambridge University Press:  21 May 2015

Michael J. Schull
Affiliation:
Institute for Clinical Evaluative Sciences, Toronto, Ont. the Division of Emergency Medicine, Department of Medicine, University of Toronto, Toronto, Ont. Sunnybrook Health Sciences Centre, Toronto, Ont.
Samuel Vaillancourt
Affiliation:
the Division of Emergency Medicine, Department of Medicine, University of Toronto, Toronto, Ont.
Linda Donovan
Affiliation:
Institute for Clinical Evaluative Sciences, Toronto, Ont.
Lucy J. Boothroyd
Affiliation:
Agence d'évaluation des technologies et des modes d'intervention en santé, Montréal, Que.
Dug Andrusiek
Affiliation:
Institute for Clinical Evaluative Sciences, Toronto, Ont. Emergency and Health Services Commission, Vancouver, BC
John Trickett
Affiliation:
Base Hospital Program, Ottawa Hospital, Ottawa, Ont.
Sunil Sookram
Affiliation:
the Department of Emergency Medicine, University of Alberta, Calgary, Alta.
Andrew Travers
Affiliation:
Emergency Health Services, Halifax, NS
Marian J. Vermeulen
Affiliation:
Institute for Clinical Evaluative Sciences, Toronto, Ont.
Jack V. Tu
Affiliation:
Institute for Clinical Evaluative Sciences, Toronto, Ont. Agence d'évaluation des technologies et des modes d'intervention en santé, Montréal, Que. Department of Medicine, University of Toronto, Toronto, Ont.

Abstract

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Objective:

Timely reperfusion therapy for ST-elevation myocardial infarction (STEMI) is an important determinant of outcome, yet targets for time to treatment are frequently unmet in North America. Prehospital strategies can reduce time to reperfusion. We sought to determine the extent to which emergency medical services (EMS) use these strategies in Canada.

Methods:

We carried out a cross-sectional survey in 2007 of ground EMS operators in British Columbia, Alberta, Ontario, Quebec and Nova Scotia. We focused on the use of 4 prehospital strategies: 1) 12-lead electrocardiogram (ECG), 2) routine expedited emergency department (ED) transfer of STEMI patients (from a referring ED to a percutaneous coronary intervention [PCI] centre), 3) prehospital bypass (ambulance bypass of local EDs to transport patients directly to PCI centres) and 4) prehospital fibrinolysis.

Results:

Ninety-seven ambulance operators were surveyed, representing 15 681 paramedics serving 97% of the combined provincial populations. Of the operators surveyed, 68% (95% confidence interval [CI] 59%–77%) had ambulances equipped with 12-lead ECGs, ranging from 40% in Quebec to 100% in Alberta and Nova Scotia. Overall, 47% (95% CI 46%-48%) of paramedics were trained in ECG acquisition and 40% (95% CI 39%–41%) were trained in ECG interpretation. Only 18% (95% CI 10%–25%) of operators had prehospital bypass protocols; 45% (95% CI 35%–55%) had protocols for expedited ED transfer. Prehospital fibrinolysis was available only in Alberta. All EMS operators in British Columbia, Alberta and Nova Scotia used at least 1 of the 4 prehospital strategies, and one-third of operators in Ontario and Quebec used 0 of 4. In major urban centres, at least 1 of the 3 prehospital strategies 12-lead ECG acquisition, bypass or expedited transfer was used, but there was considerable variation within and across provinces.

Conclusion:

The implementation of widely recommended prehospital STEMI strategies varies substantially across the 5 provinces studied, and relatively simple existing technologies, such as prehospital ECGs, are underused in many regions. Substantial improvements in prehospital services and better integration with hospital-based care will be necessary in many regions of Canada if optimal times to reperfusion, and associated outcomes, are to be achieved.

Type
Original Research • Recherche originale
Copyright
Copyright © Canadian Association of Emergency Physicians 2009

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