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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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References

O’Gara, PT, Kushner, FG, Ascheim, DD, et al. 2013 ACCF/AHA guideline for the management of ST-elevation myocardial infarction: a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines. J Am Coll Cardiol. 2013;61(4):e78–140.Google Scholar
Brodie, BR, Hansen, C, Stuckey, TD, et al.Door-to-balloon time with primary percutaneous coronary intervention for acute myocardial infarction impacts late cardiac mortality in high-risk patients and patients presenting early after the onset of symptoms. J Am Coll Cardiol. 2006;47(2):289–295.CrossRefGoogle ScholarPubMed
Keeley, EC, Boura, JA, Grines, CL.Primary angioplasty versus intravenous thrombolytic therapy for acute myocardial infarction: a quantitative review of 23 randomized trials. Lancet (London, England). 2003;361(9351):13–20.CrossRefGoogle Scholar
Zijlstra, F, Hoorntje, JCA, de Boer, M-J, et al.Long-term benefit of primary angioplasty as compared with thrombolytic therapy for acute myocardial infarction. N Eng J Med. 1999;341(19):1413–1419.CrossRefGoogle ScholarPubMed
Terkelsen, CJ, Jensen, LO, Tilsted, HH, et al.Health care system delay and heart failure in patients with ST-segment elevation myocardial infarction treated with primary percutaneous coronary intervention: follow-up of population-based medical registry data. Ann Intern Med. 2011;155(6):361–367.CrossRefGoogle ScholarPubMed
De Luca, G, Suryapranata, H, Ottervanger, JP, Antman, EM.Time delay to treatment and mortality in primary angioplasty for acute myocardial infarction: every minute of delay counts. Circulation. 2004;109(10):1223–1225.CrossRefGoogle ScholarPubMed
Terkelsen, CJ, Sorensen, JT, Maeng, M, et al.System delay and mortality among patients with STEMI treated with primary percutaneous coronary intervention. JAMA. 2010;304(7):763–771.CrossRefGoogle ScholarPubMed
Krumholz, HM, Herrin, J, Miller, LE, et al.Improvements in door-to-balloon time in the United States, 2005 to 2010. Circulation. 2011;124(9):1038–1045.CrossRefGoogle ScholarPubMed
Shavadia, JS, Roe, MT, Chen, AY, et al.Association between cardiac catheterization laboratory pre-activation and reperfusion timing metrics and outcomes in patients with ST-segment elevation myocardial infarction undergoing primary percutaneous coronary intervention: a report from the ACTION Registry. JACC Cardiovasc Interv. 2018;11(18):1837–1847.CrossRefGoogle ScholarPubMed
Squire, BT, Tamayo-Sarver, JH, Rashi, P, Koenig, W, Niemann, JT.Effect of prehospital cardiac catheterization lab activation on door-to-balloon time, mortality, and false-positive activation. Prehosp Emerg Care. 2014;18(1):1–8.CrossRefGoogle ScholarPubMed
Eckstein, M, Koenig, W, Kaji, A, Tadeo, R.Implementation of specialty centers for patients with ST-segment elevation myocardial infarction. Prehosp Emerg Care. 2009;13(2):215–222.CrossRefGoogle ScholarPubMed
Bosson, N, Kaji, AH, Niemann, JT, et al.The utility of prehospital ECG transmission in a large EMS system. Prehosp Emerg Care. 2015;19(4):496–503.CrossRefGoogle Scholar
Team RC. R: a language and environment for statistical computing. R Foundation for Statistical Computing. 2016. https://www.R-project.org/. Accessed November 2019.Google Scholar
McManus, DD, Gore, J, Yarzebski, J, Spencer, F, Lessard, D, Goldberg, RJ.Recent trends in the incidence, treatment, and outcomes of patients with STEMI and NSTEMI. Am J Med. 2011;124(1):40–47.CrossRefGoogle ScholarPubMed
Ward, MJ, Kripalani, S, Zhu, Y, et al.Incidence of emergency department visits for ST-elevation myocardial infarction in a recent six-year period in the United States. Am J Cardiol. 2015;115(2):167–170.CrossRefGoogle Scholar
Barnes, GD, Katz, A, Desmond, JS, et al.False activation of the cardiac catheterization laboratory for primary PCI. Am J Manag Care. 2013;19(8):671–675.Google ScholarPubMed
Potter, BJ, Matteau, A, Mansour, S, et al.Sustained performance of a “physicianless” system of automated prehospital STEMI diagnosis and catheterization laboratory activation. Can J Cardiol. 2017;33(1):148–154.CrossRefGoogle ScholarPubMed
Adams, G, Abusaid, G, Lee, B, et al.From theory to practice: implementation of pre-hospital electrocardiogram transmission in ST-elevation myocardial infarction - a multicenter experience. J Invasive Cardiol. 2010;22(11):520–525.Google ScholarPubMed
D’Arcy, NT, Bosson, N, Kaji, AH, et al.Weekly checks improve real-time prehospital ECG transmission in suspected STEMI. Prehosp Disaster Med. 2018;33(3):245–249.CrossRefGoogle ScholarPubMed
Goebel, M, Vaida, F, Kahn, C, Donofrio, JJ.A novel algorithm for improving the diagnostic accuracy of prehospital ST-elevation myocardial infarction. Prehosp Disaster Med. 2019;34(5):489–496.CrossRefGoogle ScholarPubMed
Baran, KL, Lange, D, Ajoku, A, et al.Prospective assessment of the mission: Lifeline PreAct-STEMI algorithm to reduce false activation of the cardiac catheterization laboratory. J Am Coll Cardiol. 2018;71(11):A1171.CrossRefGoogle Scholar
Sanko, S, Eckstein, M, Bosson, N, et al.15 Accuracy of out-of-hospital automated ST segment elevation myocardial infarction detection by LIFEPAK 12 and 15 devices: the Los Angeles experience. Ann Emerg Med. 2016;16(4):S6–S7.Google Scholar
Inovise Medical. Inovise 12L Interpretive Algorithm Statement of Validation and Accuracy. Technical Report No. 1. https://api.zoll.com/-/media/uploadedfiles/public_site/products/x_series/mistatementofaccuracy_v5.ashx. Accessed November 2019.Google Scholar
Gershlick, AH, Khan, JN, Kelly, DJ, et al.Randomized trial of complete versus lesion-only revascularization in patients undergoing primary percutaneous coronary intervention for STEMI and multivessel disease: the CvLPRIT trial. J Am Coll Cardiol. 2015;65(10):963–972.CrossRefGoogle ScholarPubMed
Wald, DS, Morris, JK, Wald, NJ, et al.Randomized trial of preventive angioplasty in myocardial infarction. N Eng J Med. 2013;369(12):1115–1123.CrossRefGoogle ScholarPubMed
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