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Implementation and Integration of Prehospital ECGs Into Systems of Care for Acute Coronary Syndrome

A Scientific Statement From the American Heart Association Interdisciplinary Council on Quality of Care and Outcomes Research, Emergency Cardiovascular Care Committee, Council on Cardiovascular Nursing, and Council on Clinical Cardiology
Originally publishedhttps://doi.org/10.1161/CIRCULATIONAHA.108.190402Circulation. 2008;118:1066–1079

Clinical case: A 58-year-old woman called 9-1-1 with acute onset of chest pain that had persisted for 30 minutes. She had a history of hypertension, hyperlipidemia, and type 2 diabetes mellitus but no previous history of myocardial infarction or heart failure. Her medications included aspirin, atorvastatin, lisinopril, and metoprolol. Paramedics were dispatched, and a prehospital ECG demonstrated 3- to 4-mm ST-segment elevation in leads I, aVL, and V2 through V6 (Figure 1). Her examination revealed a regular pulse of 90 bpm, a blood pressure of 100/60 mm Hg, clear lungs, and normal heart sounds with no murmurs. Paramedics interpreted the prehospital ECG and activated the catheterization laboratory en route to the hospital. On hospital arrival, the patient was transported directly to the catheterization laboratory. Coronary angiography demonstrated an occluded proximal left anterior descending artery, which was successfully treated with balloon angioplasty and a stent. The pertinent time intervals were as follows: paramedic dispatch to balloon time, 56 minutes; paramedic arrival at the scene to balloon time, 46 minutes; hospital door to balloon time, 23 minutes. Her biomarkers revealed a peak troponin T of 2.42 ng/mL and a peak creatine kinase muscle-brain isoenzyme of 26.8 ng/mL. An echocardiogram demonstrated normal left ventricular ejection fraction of 55%, with mild anterior hypokinesis, and the patient was discharged on hospital day 3.

Figure 1. Prehospital ECG.

Current Guidelines for Prehospital ECGs Among Patients With ST-Segment–Elevation Myocardial Infarction

American Heart Association national guidelines,1–3 as well as other consensus and scientific statements,4–11 recommend that emergency medical services (EMS) acquire and use prehospital ECGs to evaluate patients with suspected acute coronary syndrome. Despite these recommendations, prehospital ECGs are used in fewer than 10% of patients with ST-segment–elevation myocardial infarction (STEMI),12,13 and this rate has not substantially changed since the mid-1990s. Furthermore, even when a prehospital ECG is acquired, the information is often not effectively translated into action and coordinated with hospital systems of care to decrease delays in reperfusion therapy.13 The purpose of this article is to summarize evidence concerning the benefits of using prehospital ECGs, review barriers and challenges to routine use, and recommend approaches to enhance their effectiveness for improving quality of care for patients with acute coronary syndromes.

What Are the Benefits of Using Prehospital ECGs in Patients With STEMI?

Multiple studies have demonstrated the benefits of prehospital ECGs for decreasing door-to-drug time and door-to-balloon time in patients with STEMI.12–30 The direction and magnitude of the time savings are clinically relevant, resulting in an approximately 10-minute decrease in door-to-drug time and 15- to 20-minute decrease in door-to-balloon time.12,13 However, these time savings may not reflect the full potential of prehospital ECGs to decrease delays in reperfusion therapy. In fact, studies have shown further reductions in door-to-balloon time when prehospital ECGs are used to activate the catheterization laboratory while the patient is en route to the hospital.31–37

For patients transported by EMS without prehospital ECG, delay from symptom onset to reperfusion therapy, which reflects the overall period of ischemic injury, can be divided into 4 time intervals: (1) symptom onset to EMS arrival, (2) EMS arrival to hospital arrival, (3) hospital arrival to ECG, and (4) ECG to reperfusion. Prehospital ECG programs, if effectively implemented and coordinated with hospital systems of care, would be expected to decrease the latter 3 time intervals (Figure 2). The second interval is composed of time from first medical contact by EMS to hospital door, and EMS personnel may behave with more urgency if a diagnosis of STEMI has been made in the field. The third interval is essentially eliminated with a prehospital ECG. The fourth interval can be decreased by advanced notification of the hospital to receive and evaluate the patient, to activate the catheterization laboratory while the patient is en route, or to bypass the emergency department and transport the patient directly to the catheterization laboratory. Scholz and colleagues reported the impact of prehospital ECGs on these time intervals from 114 patients with STEMI treated within an integrated system of care.38 The system consisted of acquiring a prehospital ECG by emergency responders (in Germany, this was generally a physician), transmitting the prehospital ECG to a fax machine at the percutaneous coronary intervention (PCI) hospital cardiac intensive care unit, activating the catheterization laboratory en route if STEMI was diagnosed, and bypassing the emergency department when the catheterization laboratory team was on-site. Pertinent time intervals were collected for 1 year. Comparing performance in the last quarter of implementing this system with the first quarter (reference group), the time spent at the scene decreased from 25 to 19 minutes, time spent in the emergency department decreased from 14 to 3 minutes, time from arterial access to balloon decreased from 21 to 11 minutes, door-to-balloon time decreased from 54 to 26 minutes, and first medical contact to balloon time decreased from 113 to 74 minutes. The authors also concluded that systematic, quarterly feedback on performance to cardiology, emergency department, and EMS stakeholders was an important component in improving prehospital and hospital processes of care.38

Figure 2. Reperfusion time goals for patients with ST-segment–elevation myocardial infarction.

Can EMS Providers Acquire Prehospital ECGs?

A survey found that 90% of EMS systems serving the 200 largest cities in the United States had 12-lead ECG equipment available in their ambulance systems.39 EMS providers can rapidly acquire diagnostic-quality prehospital ECGs with an average increase of 5 to 6 minutes in the on-scene time interval.14–16,28,40–49 To acquire diagnostic-quality prehospital ECGs, a valuable strategy is to educate EMS providers about the importance of careful patient positioning and lead placement. Movement artifact, lead misplacement, and poor skin contact can result in poor-quality tracing that can be misinterpreted by algorithms or EMS providers.

One study, which used data from the National Registry of Myocardial Infarction between 1994 and 1996, found that patients with prehospital ECGs had time intervals that were 20 minutes longer from symptom onset to hospital arrival.12 This finding was difficult to interpret, however, as there was no measure of how long the prehospital ECG required and potential selection bias in who received a prehospital ECG. For example, patients who had a longer transport distance may have received a higher rate of prehospital ECGs as compared with those with a shorter transport distance. An analysis of the National Registry of Myocardial Infarction between 2000 and 2002 found that patients with prehospital ECGs did not have longer times from symptom onset to hospital arrival.13

Can EMS Providers Reliably Interpret or Communicate Prehospital ECGs?

Several studies have examined the feasibility of EMS providers identifying STEMI using prehospital ECGs with or without wireless transmission.20,36,50–58 The pros and cons for computer algorithm interpretation, paramedic interpretation, and wireless transmission for physician interpretation of prehospital ECGs are summarized in Table 1. There are no data to compare the effectiveness of these different approaches for diagnostic accuracy or quality of reperfusion therapy delivered to patients with STEMI. The choice of which option to use may also be limited by the specific resources available in the community or its local geography.

‘Table 1. Models for interpreting Prehospital ECGs

Method of Interpreting Prehospital ECGProsCons
EMS indicates emergency medical services.
Computer algorithm interpretationRapid, easyFalse-positive and false-negative rates higher than physician interpretation
No wireless network or technology requirements
Paramedic interpretationRapid, easy No wireless network or technology requirementsRequires intensive education and quality assurance program
More complex in communities with multiple EMS providers and agencies
Wireless transmission and physician interpretationTheoretically, lowest rate of false-positives and false-negativesNew technology requirement for EMS providers and hospital
Medical oversight can provide guidance on destination hospital and treatment en route    Reliable wireless network Transmission unit on ambulance
    Receiver station unit at hospital
    Smartphones for physicians
Requires system to ensure immediate interpretation by physician
Transmission failures

Studies have also shown that paramedics with specific ECG training can reliably interpret prehospital ECGs without transmitting to a hospital or physician. Trained paramedics can identify STEMI with sensitivity ranging from 71% to 97% and specificity ranging from 91% to 100%,15,16,59–65 and with good agreement between paramedics and emergency department physicians (κ ranging from 0.59 to 0.73).20,60,64 The sensitivity (97%) and specificity (91%) of trained paramedics to interpret prehospital ECGs and diagnose STEMI was particularly high in one study, which included a 2-day training seminar.62 A study of this issue, conducted in the United States with 151 patients with suspected acute myocardial infarction transported by a large urban EMS system, found that trained paramedics had 80% sensitivity and 97% specificity in diagnosing STEMI with prehospital ECGs, with good agreement between paramedics and emergency physicians (κ=0.73).64

Alternatively, prehospital ECGs can be transmitted by EMS for physician interpretation to drive decision making, but this approach has been limited by technology requirements for rapid and reliable transmission of prehospital ECGs. Two pilot studies have demonstrated that wireless transmission of prehospital ECG is feasible.36,55 In the Timely Intervention in Myocardial Emergency–Northeast Experience (TIME-NE) conducted in Concord, NC, 24 patients with STEMI had successful wireless transmission of prehospital ECGs to a hospital receiving station and the on-call cardiologist’s smartphone.55 The on-call cardiologist then decided whether to activate the catheterization laboratory on the basis of the prehospital ECG. Median door-to-balloon time decreased in this study to 50 minutes as compared with 101 minutes for historical controls; however, there were 19 patients with STEMI who experienced failed wireless transmission. In the ST-Segment Analysis Using Wireless Technology in Acute Myocardial Infarction (STAT-MI) study conducted in Newark, NJ, 80 patients had prehospital ECGs transmitted using a wireless cellular phone network to a secure hospital central server and to the on-call cardiologist’s smartphone.36 This model had no transmission failures; median time from prehospital ECG acquisition to availability on the remote server was 2 minutes and on the smartphone was 4 minutes. The door-to-balloon time was 80 minutes with use of prehospital ECGs, as compared with 146 minutes for historical controls without use of prehospital ECGs. In geographic regions with reliable wireless network coverage, wireless transmission of prehospital ECG for physician interpretation is feasible and reliable; however, current wireless networks can fail to transmit or encounter significant delays in up to 20% to 44% of cases as a result of wireless “dead zones” in a moving ambulance or in rural areas with sparse coverage.50,55,62,66,67

Wireless transmission prehospital ECG systems are commercially available from Medtronic36,57 (Minneapolis, Minn), Welch Allyn55 (Beaverton, Ore), Zoll Medical30 (Chelmsford, Mass), and Phillips Healthcare (Andover, Mass). These systems acquire the prehospital ECG and automatically transmit the data using Bluetooth protocol to a nearby cellular phone. The cellular phone functions as a router to transmit the data to a central receiving station and smartphones via a wireless cellular network or wireless local area network (IEEE 802.11).68–71 A novel approach using camera phones with multimedia messaging service has been proposed and tested in 10 patients.72 A camera phone obtains a digital picture of the prehospital ECG paper printout and wirelessly transmits the picture to an e-mail account, and the ECG image can be viewed on any multimedia messaging service–capable device, such as a computer or smartphone. This approach may be a simple, low-cost, and innovative technology73 to communicate diagnostic image data and warrants further study for feasibility in real-world practices.

Can EMS and Hospitals Organize Systems to Effectively Use Prehospital ECGs?

EMS and hospitals should organize efficient systems of care for patients with STEMI from the prehospital phase of care to hospital arrival and reperfusion therapy in the hospital phase of care. The typical current process2 for emergency cardiac care initiated by a 9-1-1 call is contrasted with the ideal process in Figure 3. Historically, EMS providers have been trained to follow these steps in evaluating patients with chest pain in the field: (1) assess airway, breathing, circulation, and vital signs; (2) obtain focused history and examination; (3) assess cardiac rhythm; (4) initiate treatment with oxygen, aspirin, nitroglycerin, and morphine and insert intravenous line; (5) recommended: acquire 12-lead prehospital ECG at the scene, after the patient is transferred to the ambulance, or while en route to the hospital. Because the 12-lead ECG represents the critical data for diagnosis and decision making in patients with chest pain, it should be prioritized and performed as early as possible at the scene. If a STEMI is identified on the prehospital ECG, then scene times should be minimized, with expedited transport to the hospital. Moreover, if the prehospital ECG is communicated to the destination hospital shortly after first medical contact with EMS providers, then the hospital will have more time to prepare for the patient.

Figure 3. Current versus ideal processes to integrate prehospital ECGs into systems of care.

The information from a prehospital ECG and advanced notification should lead to efficient action by hospital systems of care to deliver prompt reperfusion therapy, including preparing to receive and evaluate the patient, activating the catheterization laboratory while the patient is en route, or bypassing the emergency department and transporting the patient directly to the catheterization laboratory.32,37,74 If patients are evaluated in the emergency department, the evaluation should be streamlined by having a physician and necessary resources (eg, translators, nurses) ready before patient arrival, following a standard protocol for treatment, and minimizing physical movement, such as transferring between stretchers. Although bypassing the emergency department may be intuitively faster, concerns have been raised about processes for obtaining informed consent, patient safety, and consideration of alternative diagnoses (eg, aortic dissection, intracranial hemorrhage) or other false-positives that may account for the ST-segment elevation on the ECG in up to 10% to 15% of patients.75–77 Furthermore, during off hours,78,79 the catheterization team may not have arrived at the hospital before the ambulance, and the patient will need to be observed in a critical care setting until the catheterization laboratory is ready to receive the patient.

Can Regional Networks of Hospitals Organize Systems to Effectively Use Prehospital ECGs?

Patients with STEMI who require interhospital transfer experience substantial delays with a median first hospital door-to-balloon time of 180 minutes.80 In the United States, regional networks of hospitals and systems of care have been implemented and evaluated to improve time to reperfusion therapy for patients who initially present to a community hospital without on-site PCI capability.35,81–83 Similar, but broader systems of optimizing reperfusion therapy across populations have also been in place in Europe for several years.24,84,85 European systems often have a physician in the ambulance, a central dispatch center for ambulances, and highly organized regional prehospital care, which stands in contrast to the disorganized, competitive environment in the United States.

Prehospital ECGs can play an important role for triage of patients in a regional network of hospitals, and the two models proposed include prehospital triage versus interhospital transfer.3,11,74,86–89 The prehospital triage model transports patients with STEMI to the closest PCI center and bypasses hospitals without PCI capability. The interhospital transfer model focuses on advanced notification and efficient transfer of patients from non-PCI hospitals to PCI centers.11 Several key factors, including distance, urban versus rural location, collaborative versus competitive relationships between hospitals, and variability of EMS providers, influence which model is best suited for specific regional populations. An analysis of the US Census Survey and the American Hospital Association Annual Survey showed that 80% of the adult population live within 60 minutes of a PCI-capable hospital, and only 5% live farther than 90 minutes from one.90 However, there are still 20% of the adult population and large geographic areas that do not meet this standard. One model of regionalized STEMI care does not preclude the other. Both can coexist within a single network and are often driven by specific resources available within a community and local geography. No data comparing the models exist, and potential unintended consequences, such as exceptionally long delays to reperfusion, should be monitored.10,91

How Have Prehospital ECGs Been Incorporated Into Existing Systems of Care?

Many communities are implementing prehospital ECG programs that are in varying stages of development, and Boston, Los Angeles, North Carolina, and Ottawa (Canada) provide important contrasts (Table 2). The Boston EMS program, one of the country’s first, involves municipal paramedics trained to interpret and categorize prehospital ECGs as definite STEMI, possible STEMI, or nondiagnostic.9,64,92 Patients with definite STEMI or possible STEMI are triaged to the closest PCI hospital, and the former are brought directly to the catheterization laboratory and the latter are evaluated in the emergency department. The emergency physician decides whether to activate the catheterization laboratory on the basis of the paramedic interpretation while the patient is en route to the hospital. The Boston EMS program covers a relatively small geographic area (<50 square miles) with 60 to 70 municipal paramedics, and private EMS providers do not participate in the program.

Table 2. Comparison of Existing Prehospital ECG Programs

LocationPrehospital ECG InterpretationActivate Catheterization Lab en Route to HospitalBypass Non-PCI Hospitals
PCI indicates percutaneous coronary intervention; MI, myocardial infarction; and STEMI, ST-segment–elevation myocardial infarction.
Boston64,92Paramedic interpretationYes (activation by emergency department physician based on paramedic interpretation)Yes (for all patients with “definite STEMI” or “possible STEMI”)
Los Angeles County76,87Computer algorithm interpretationYes (activation by emergency department physician based on computer algorithm interpretation)Yes (for all patients with acute MI)
North Carolina83Mixed (used computer algorithm interpretation, paramedic interpretation, or wireless transmission)Mixed (activation by paramedics or emergency department physician)Mixed (paramedics occasionally diverted patients with STEMI to nearest PCI hospital)
Ottawa65,96Paramedic interpretationYes (activation by paramedic through a central page operator)Yes (for all patients with STEMI)

In contrast, the Los Angeles County EMS program includes all EMS providers, an area of >4000 square miles with approximately 2500 paramedics working for 27 agencies.76,87 The variability and sheer numbers of EMS providers to train in ECG interpretation were considered an insurmountable obstacle. The Los Angeles County EMS program therefore relies on computer algorithm interpretation that identifies ***ACUTE MI*** to prompt EMS transport of patients to the closest PCI center (or STEMI receiving center). The emergency physician decides whether to activate the catheterization laboratory on the basis of the computer algorithm interpretation while the patient is en route to the hospital. A few hospitals in Los Angeles County have started to pilot the feasibility of transmitting prehospital ECGs for physician interpretation. Both the Boston and Los Angeles programs are undergoing formal evaluation. There are also ongoing clinical trials in other parts of the United States evaluating the effectiveness of prehospital ECGs to decrease first medical contact to balloon/drug times.93–95

The Reperfusion of Acute Myocardial Infarction in North Carolina Emergency Departments (RACE) Investigators implemented a statewide approach to improve timeliness of reperfusion therapy for patients with STEMI.83 The use of prehospital ECGs was high, and prehospital ECGs were acquired in 61% and 43% of patients with STEMI transported by EMS to PCI hospitals and non-PCI hospitals, respectively. However, the RACE program did not have standardized procedures for when to acquire a prehospital ECG, who would interpret the prehospital ECG, and how to integrate the prehospital ECG with systems of care. Each hospital and region decided how to interpret and integrate the prehospital ECG based on available resources, geography, and decisions by regional leadership.

The Ottawa citywide system, which included 1 PCI center and 4 non-PCI hospitals located within 7 miles of the PCI center, reported their 1-year experience in 344 patients with STEMI.96 The first hospital door-to-balloon time was 69 minutes when paramedics acquired and interpreted a prehospital ECG and bypassed non-PCI hospitals as compared with 123 minutes when a prehospital ECG was not performed and the patient was initially brought to a non-PCI hospital and required interhospital transfer for primary PCI.

What Are the Barriers to Implementing Successful Prehospital ECG Programs?

What Are the Costs and Benefits for Prehospital ECG Programs?

Currently, there are no cost-effectiveness models to evaluate this diagnostic technology from the different perspectives of patients, hospitals, payors, and society.97 One study reported that the incremental cost to upgrade prehospital ECG equipment to wireless capability was $16 100, which consisted of $11 000 for a receiving station, $600 for cell phones, and $4500 for data cables.57 The direct cost for prehospital ECG equipment with monitoring and defibrillation capability ranges from $9000 to $25 000, but this does not take into account other direct and indirect costs for training, quality assurance, and organizing complex EMS and hospital systems.8,98 Developing and implementing STEMI systems require substantial investment of resources that impact on the value of acquiring and using the information provided by prehospital ECGs. Comparative cost models for efficiently acquiring, interpreting, and transmitting prehospital ECGs within the context of STEMI systems will be informative and valuable. Additionally, it will be important to compare the development of STEMI systems of care with other healthcare priorities, both in cardiovascular medicine and other disciplines.

What Training and Maintenance of Competency Do EMS Providers Need?

In the United States, EMS providers are trained to several competency levels. Although the federal government (http://www.nhtsa.dot.gov/portal/site/nhtsa/menuitem.2a0771e91 315babbbf30811060008a0c/) has defined a standard curricula for each of 4 levels (first responder, emergency medical technician [EMT]–basic, EMT-intermediate, and EMT-paramedic),99 many states use definitions and regulations that vary significantly between states as well as within a single state (rural versus urban areas). The National Registry of EMTs (www.nremt.org), the nation’s de facto “board” for certification, currently certifies EMS personnel at the first responder, EMT-basic, EMT-intermediate/1985, EMT-intermediate/1999, and EMT-paramedic levels.

First responder roles are often provided by firefighters or law enforcement officers.9 EMT-basic personnel provide basic life support, including first aid, cardiopulmonary resuscitation, oxygen, and early defibrillation. EMT-intermediate and EMT-paramedic personnel provide advanced life support, including intubation and intravenous medications. Prehospital ECG acquisition has historically been limited to EMT-paramedic. The current EMT-paramedic national standard curriculum99 includes the following objectives intended to provide paramedics with a basic understanding of the pathophysiology and ECG features of acute myocardial infarction:

5–2.9 Identify the arterial blood supply to any given area of the myocardium.

5–2.22 Discuss the pathophysiology of cardiac disease and injury.

5–2.34 Relate the cardiac surfaces or areas represented by the ECG leads.

5–2.48 Recognize the changes on the ECG that may reflect evidence of myocardial ischemia and injury.

5–2.78 Identify the ECG changes characteristically seen during evolution of an acute myocardial infarction.

The National Association of EMS Educators (www.naemse.org) is presently revising all of the existing national standard curricula for EMS with new standards. The initial draft of this document, released in June 2007, includes 12-lead ECG interpretation as a required competency for paramedics. Currently, no standards exist regarding how much initial and subsequent periodic education is required to achieve and maintain competency in prehospital ECG interpretation. Also, there are no standard protocols for when and what patient subsets to obtain a prehospital ECG, as well as what to do with the data.

It has been proposed that prehospital ECG acquisition be extended to EMT-basic and EMT-intermediate levels.9 A preliminary study showed that EMT-basic personnel could acquire, but not interpret, ECGs in a comparable amount of time as compared with EMT-paramedics.100 Although rural geographic areas without paramedic coverage could benefit by extending prehospital ECG acquisition skills to EMT-basic personnel, this would require significant changes in current curriculum, training, protocols, and policy.

EMS systems vary substantially with regard to configuration and structure, each using some combination of EMS providers to deliver emergency medical care for rural, suburban, or urban communities. Physician oversight also varies, with only a small number of large EMS systems having full-time physician medical directors. Given the challenges with EMS training, maintenance of competency,101–103 quality management, and medical oversight, there is no “one size fits all” or even “one size fits most” solution.

How Will Patients With Acute Coronary Syndromes Use EMS?

The reluctance of patients with acute coronary syndromes to call 9-1-1 is a major obstacle to realization of the full public health benefits of prehospital ECGs and organizing systems of care. Prior studies have shown that 10% to 59% of patients with chest pain use EMS104–111 and less than half of patients with STEMI use EMS versus self-transport to the hospital.8,110 Studies have demonstrated that patients with STEMI arriving by ambulance receive faster reperfusion therapy than those who arrive by self-transport, particularly in busy, overcrowded emergency departments.112,113 Unfortunately, educational and media efforts to increase EMS use have had limited success.114 Conversely, if substantially more patients with chest pain call 9-1-1, EMS and emergency department systems may need to grow to provide adequate access and capacity.113,115–117 Efforts to increase the reach of prehospital ECG programs will need to address the limited use of EMS by patients with STEMI and the need to expand EMS capacity to meet increased demand.

What Areas of Future Research Need to Be Addressed?

How Will the Use of Prehospital ECGs Be Measured and Assessed?

For the most part, current measures for assessing the use and timeliness of reperfusion therapy in STEMI (eg, door-to-balloon time) are hospital-based and therefore inadequate for evaluating the effectiveness of prehospital ECGs. To evaluate the incremental benefit of this technology, current hospital-based measures (door-to-balloon time) would need to evolve to patient-centered measures, such as first medical contact to reperfusion or symptom onset to reperfusion. Current STEMI guidelines recommend that the pertinent metric for quality of reperfusion therapy are first medical contact to balloon <90 minutes and first medical contact to drug <30 minutes.3 Furthermore, we need to assess patient responsiveness after onset of symptoms, appropriate use of EMS and EMS responsiveness, EMS scene time to acquire prehospital ECGs, and effective communication of this data to destination hospitals and its use in decision making about reperfusion therapy. There needs to be careful analysis of the denominator or eligible population who should have received a prehospital ECG versus those who actually received a prehospital ECG. For providers to adopt the technology, an improved understanding of how potential gains in rapid reperfusion translate into improved clinical outcomes would be ideal, as well as an understanding of the frequency of false alarms and other unintended consequences. Real-world examples are particularly helpful in this regard, given the wide-ranging approaches that different types of healthcare systems—for example, urban versus rural—may require. These examples would also be important for assessing the overall value of this technology relative to the financial investment in equipment, training, and organizing STEMI systems.

How Will Prehospital ECGs Be Performed and in Whom Should They Be Used?

There remains a poor understanding of who will acquire and interpret prehospital ECGs and in whom these tests should be performed. A direct comparison of diagnostic accuracy and times for ECG interpretation by computer algorithm, paramedics, and emergency physicians or cardiologists would be valuable. Most regions that use prehospital ECGs have standard protocols for what types of symptoms should prompt acquisition of the test, but the false-positive and false-negative rates have been poorly characterized in general. It would be valuable to understand the frequency of ST-segment elevation from other causes,118 such as early repolarization, left ventricular hypertrophy, left bundle-branch block, pericarditis, hyperkalemia, atrial flutter, Brugada syndrome, pulmonary embolism, and Prinzmetal angina, as prehospital ECG programs are implemented.

It has been reported that approximately 5% of patients with chest pain who are evaluated by EMS have STEMI.59,76 The incremental value of this technology when the number needed to treat is 20 for 1 patient who benefits needs to be verified and elucidated in patients with more atypical symptoms, such as shortness of breath, dizziness, or other atypical symptoms.

How Will Prehospital ECGs Be Integrated Into Practice Without Unintended Consequences?

An important area of investigation is how the prehospital ECGs can optimize decision making to triage patients to destination hospitals with and without PCI capability. The broad and diverse population of the United States poses several challenges to establishing effective systems of care for incorporating prehospital ECGs into routine clinical practice. It is apparent that a one-size-fits-all approach is neither practical nor ideal. The use of this technology requires a careful assessment of the local needs and resources within each community, with the overarching goal to improve patient care and access, timeliness of reperfusion therapy, and the proportion of eligible patients who receive reperfusion.

A better understanding of the precise role of different providers in the design of systems that use prehospital ECGs is needed. How will the roles of EMS and emergency physicians evolve for activating the catheterization laboratory? How will safeguards be established so that patients with other life-threatening conditions that may mimic or complicate STEMI are not missed and care is not delayed? Investigators should be encouraged to explore both the benefits and pitfalls of implementing a prehospital ECG program. There may be unintended deleterious effects to patients, such as longer scene times and overall longer time from symptom onset to reperfusion.

What Policy Measures Should Be Adopted to Encourage Use of Prehospital ECGs?

The healthcare system within the United States is not currently organized in a way that encourages the adoption of prehospital ECGs or regional systems of care for STEMI.90,119,120 Numerous providers in the prehospital and hospital settings make it challenging to foster cooperation. For example, in many regions, there are several private, for-profit EMS that are responsible for evaluating and transporting patients. Successful implementation will require the inclusion of these providers and may necessitate that prehospital ECGs are required by regulation and are reimbursed. Currently, EMS reimbursement is typically based on 2 levels of care as well as distances traveled, but EMS is not reimbursed for specific services delivered, including a prehospital ECG. However, it also is unclear whether expansion of reimbursement for prehospital ECGs may lead to overuse and misuse.

Issues surrounding reimbursement are also fundamental to hospitals. Cardiac patients are seen as lucrative, given the high rate of invasive procedures associated with these conditions, and represent prestigious service lines for the institution.121 Encouraging EMS systems to use prehospital ECGs as part of protocols that divert patients from community hospitals to STEMI destination hospitals will be challenging, because the loss of profitable cardiac patients may impact the financial viability of a rural, critical access hospital. EMS providers, emergency physicians, and cardiologists will need to engage and work together to implement an ideal, integrated prehospital ECG system of care for patients with acute coronary syndrome.

Additionally, it is unclear what regulatory oversight is needed to assess quality of prehospital ECG programs. These issues raise the concern of accountability after their establishment. Much of the daily work required for these systems will be done at the local healthcare system level, with groups of expert providers from the community participating in the design and implementation of these programs. However, authority and funding for these programs may need to come from higher levels of government, such as county, state, or regional health agencies. Increasingly, health agencies at these regulatory levels are recognizing the importance of timely therapy for patients with STEMI and categorizing them similar to trauma patients. This emphasis on rapid treatment and the expansion of primary PCI to more hospitals may allow for funding of programs for prehospital ECGs to be tied in as well.

Summary

Prehospital ECG programs have the potential to improve the way care is delivered to patients with STEMI in the United States. Current American Heart Association guidelines recommend that paramedics perform and evaluate a prehospital ECG routinely on patients with chest pain suspected of having STEMI (Class IIa, Level of Evidence B).1,3 The central challenge for healthcare providers is not to simply perform a prehospital ECG, but to use and integrate the diagnostic information from a prehospital ECG with systems of care. The potential savings in time from first medical contact to reperfusion therapy by integrating prehospital ECGs with hospital systems of care are considerable and clinically relevant. However, the gaps between use under ideal circumstances and in routine practice remain substantial (Table 3). There are many logistic barriers, including the need for increased patient use of EMS; increased EMS capacity; improved education and quality assurance for EMS providers; improved collaboration among EMS, emergency departments, and cardiology; improved organization of hospital systems and providers; and improved coordination of regional hospital networks to provide the ideal patient care rather than optimize market share. It also is apparent that several financial barriers, including reimbursement and cost-effectiveness of this diagnostic technology, will need to be overcome for prehospital ECGs to gain widespread support across payors, providers, and healthcare systems. But these barriers are not insurmountable and can be overcome with dedicated efforts to improving systems of care. Future investigations and policy measures are needed to encourage EMS, hospitals, and healthcare systems to adopt and maximize the full potential of this technology, as well as monitor unintended consequences.

Table 3. Requirements for an Integrated Prehospital ECG System of Care

EMT indicates emergency medical technician.
EMS
    Training and ongoing quality assurance for EMS providers and medical control physicians
    Acquiring prehospital ECG as early as possible during initial scene evaluation
    Minimize scene time when STEMI is diagnosed
    Advanced notification of destination hospital
    Activation of catheterization laboratory by EMS providers or emergency physician while patient is en route to hospital
PCI Hospital
    Organize reliable wireless networks and technologies
    Advanced preparation to receive and evaluate patient
    Activation of catheterization laboratory by emergency physician while patient is en route to hospital
    Streamline emergency department evaluation or bypass emergency department
    Prehospital triage for regional hospital networks to bypass non-PCI hospitals
Research and Quality Assurance
    Monitor quality measures, including first medical contact to drug/balloon
    Monitor false-positive and false-negative rates
    Evaluate whether EMT-basic and EMT-intermediate can acquire prehospital ECG reliably and efficiently
    Promote systematic and routine feedback of performance to all stakeholders, including EMS, emergency department, and cardiology

Many of the barriers to the widespread implementation of prehospital ECGs are being addressed by the American Heart Association’s Mission: Lifeline, a national initiative launched in 2007 to improve systems of care for patients with STEMI.11 Mission: Lifeline’s initial phase includes Emergency Medical Services System Assessment and Improvement. Working in collaboration with EMS organizations on national and local levels, Mission: Lifeline is conducting a comprehensive survey to determine EMS capability, policy, infrastructure, and resources, including prehospital ECG capability and protocols for care of patients with STEMI. On the basis of the above assessment, the American Heart Association plans to build and evaluate the appropriate infrastructure to ideally serve patients with STEMI that is tailored at the local, regional, or state level. The implementation phase will address funding, training, the potential for overuse of STEMI services or procedures, and identification of underserved populations and development of strategies to mitigate disparities in access to care, as well as evaluation of existing process measures and patient outcomes.91

The American Heart Association makes every effort to avoid any actual or potential conflicts of interest that may arise as a result of an outside relationship or a personal, professional, or business interest of a member of the writing panel. Specifically, all members of the writing group are required to complete and submit a Disclosure Questionnaire showing all such relationships that might be perceived as real or potential conflicts of interest.

This statement was approved by the American Heart Association Science Advisory and Coordinating Committee on July 2, 2008. A single reprint is available by calling 800-242-8721 (US only) or by writing the American Heart Association, Public Information, 7272 Greenville Ave, Dallas, TX 75231-4596. Ask for reprint No. 71-0454. A copy of the statement is also available at http://www.americanheart.org/presenter.jhtml?identifier=3003999 by selecting either the “topic list” link or the “chronological list” link. To purchase additional reprints, call 843-216-2533 or e-mail [email protected].

Expert peer review of AHA Scientific Statements is conducted at the AHA National Center. For more on AHA statements and guidelines development, visit http://www.americanheart.org/presenter.jhtml?identifier=3023366.

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Disclosures

Writing Group Disclosures

NameEmploymentResearch GrantOther Research SupportSpeakers’ Bureau/HonorariaOwnership InterestConsultant/ Advisory BoardOther
Henry H. TingMayo ClinicACC*; Mayo Foundation for Medical Education and Research*NoneNoneNoneNoneNone
Elizabeth H. BradleyYale UniversityNHLBINoneNoneVHA*NoneNone
David C. ConeYale UniversityNoneNoneNoneNoneNoneNone
Jeptha P. CurtisYale UniversityCO Foundation for Medical Care*NoneNoneNoneNoneNone
Barbara J. DrewUCSFNoneMedtronic Emergency Response Systems*GE Healthcare*; Phillips Medical*NoneGE Healthcare*None
John M. FieldPenn State UniversityNoneNoneNoneNoneSenior Science Editor, AHA-ECCNone
William J. FrenchUCLANoneNoneNoneNoneNoneNone
W. Brian GiblerUniversity of CincinnatiAbbott/iSTAT+O7NoneNoneAudicor*; Siloam*NoneEducational grant support from Abbott; Biosite; Bristol-Myers Squibb; Daiichi Sankyo Lilly; Otsuka; Sanofi-Aventis; Schering-Plough; The Medicines Company
David C. GoffWake Forest UniversityNoneNoneNoneNoneNoneNone
(Continued)

Continued

NameEmploymentResearch GrantOther Research SupportSpeakers’ Bureau/HonorariaOwnership InterestConsultant/ Advisory BoardOther
This table represents the relationships of writing group members that may be perceived as actual or reasonably perceived conflicts of interest as reported on the Disclosure Questionnaire, which all members of the writing group are required to complete and submit. A relationship is considered to be “significant” if (a) the person receives $10 000 or more during any 12-month period, or 5% or more of the person’s gross income; or (b) the person owns 5% or more of the voting stock or share of the entity, or owns $10 000 or more of the fair market value of the entity. A relationship is considered to be “modest” if it is less than “significant” under the preceding definition.
*Modest.
†Significant.
Alice K. JacobsBoston Medical CenterNoneNoneNoneNoneNoneNone
Harlan M. KrumholzYale UniversityNoneNoneNoneNoneNoneNone
Brahmajee K. NallamothuUniversity of MichiganAHRQNoneNoneNoneNoneNone
Robert E. O'ConnorUniversity of Virginia Health SystemNoneNoneNoneNoneNoneNone
Jeremiah D. SchuurVAMC and Yale UniversityNoneNoneNoneNoneNoneNone

Reviewer Disclosures

ReviewerEmploymentResearch GrantOther Research SupportSpeakers’ Bureau/HonorariaExpert WitnessOwnership InterestConsultant/Advisory BoardOther
This table represents the relationship of reviewers that may be perceived as actual or reasonably perceived conflicts of interest as reported on the Disclosure Questionnaire, which all reviewers are required to complete and submit.
Elliott M. AntmanBrigham and Women’s HospitalNoneNoneNoneNoneNoneNoneNone
Eric BatesUniversity of MichiganNoneNoneNoneNoneNoneNoneNone
James V. DunfordUniversity of California, San DiegoNoneNoneNoneNoneNoneNoneNone

References

  • 1 Antman EM, Anbe DT, Armstrong PW, Bates ER, Green LA, Hand M, Hochman JS, Krumholz HM, Kushner FG, Lamas GA, Mullany CJ, Ornato JP, Pearle DL, Sloan MA, Smith SC Jr, Alpert JS, Anderson JL, Faxon DP, Fuster V, Gibbons RJ, Gregoratos G, Halperin JL, Hiratzka LF, Hunt SA, Jacobs AK. ACC/AHA guidelines for the management of patients with ST-elevation myocardial infarction–executive summary: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Writing Committee to Revise the 1999 Guidelines for the Management of Patients With Acute Myocardial Infarction). Circulation. 2004; 110: 588–636.LinkGoogle Scholar
  • 2 ECC Committee, Subcommittees and Task Forces of the American Heart Association. 2005 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. Circulation. 2005; 112 (suppl IV): IV-1–IV-203.LinkGoogle Scholar
  • 3 Antman EM, Hand M, Armstrong PW, Bates ER, Green LA, Halasyamani LK, Hochman JS, Krumholz HM, Lamas GA, Mullany CJ, Pearle DL, Sloan MA, Smith SC Jr; 2004 Writing Committee Members, Anbe DT, Kushner FG, Ornato JP, Jacobs AK, Adams CD, Anderson JL, Buller CE, Creager MA, Ettinger SM, Halperin JL, Hunt SA, Lytle BW, Nishimura R, Page RL, Riegel B, Tarkington LG, Yancy CW. 2007 Focused Update of the ACC/AHA 2004 Guidelines for the Management of Patients With ST-Elevation Myocardial Infarction: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines: developed in collaboration with the Canadian Cardiovascular Society, endorsed by the American Academy of Family Physicians: 2007 Writing Group to Review New Evidence and Update the ACC/AHA 2004 Guidelines for the Management of Patients With ST-Elevation Myocardial Infarction, Writing on Behalf of the 2004 Writing Committee. Circulation. 2008; 117: 296–329.LinkGoogle Scholar
  • 4 Emergency department: rapid identification and treatment of patients with acute myocardial infarction: National Heart Attack Alert Program Coordinating Committee, 60 Minutes to Treatment Working Group. Ann Emerg Med. 1994; 23: 311–329.CrossrefMedlineGoogle Scholar
  • 5 Dracup K, Alonzo AA, Atkins JM, Bennett NM, Braslow A, Clark LT, Eisenberg M, Ferdinand KC, Frye R, Green L, Hill MN, Kennedy JW, Kline-Rogers E, Moser DK, Ornato JP, Pitt B, Scott JD, Selker HP, Silva SJ, Thies W, Weaver WD, Wenger NK, White SK. The physician’s role in minimizing prehospital delay in patients at high risk for acute myocardial infarction: recommendations from the National Heart Attack Alert Program: Working Group on Educational Strategies to Prevent Prehospital Delay in Patients at High Risk for Acute Myocardial Infarction. Ann Intern Med. 1997; 126: 645–651.CrossrefMedlineGoogle Scholar
  • 6 Hutter AM Jr, Weaver WD. 31st Bethesda Conference: emergency cardiac care: task force 2: acute coronary syndromes: section 2A: prehospital issues. J Am Coll Cardiol. 2000; 35: 846–853.MedlineGoogle Scholar
  • 7 Crocco TJ, Sayre MR, Aufderheide TP; National Association of EMS Physicians. Prehospital triage of chest pain patients. Prehosp Emerg Care. 2002; 6: 224–228.CrossrefMedlineGoogle Scholar
  • 8 Garvey JL, MacLeod BA, Sopko G, Hand MM; National Heart Attack Alert Program (NHAAP) Coordinating Committee; National Heart, Lung, and Blood Institute (NHLBI); National Institutes of Health. Pre-hospital 12-lead electrocardiography programs: a call for implementation by emergency medical services systems providing advanced life support. J Am Coll Cardiol. 2006; 47: 485–491.CrossrefMedlineGoogle Scholar
  • 9 Moyer P, Ornato JP, Brady WJ Jr, Davis LL, Ghaemmaghami CA, Gibler WB, Mears G, Mosesso VN Jr, Zane RD. Development of systems of care for ST-elevation myocardial infarction patients: the emergency medical services and emergency department perspective. Circulation. 2007; 116: e43–e48.LinkGoogle Scholar
  • 10 Nallamothu BK, Krumholz HM, Ko DT, LaBresh KA, Rathore S, Roe MT, Schwamm L. Development of systems of care for ST-elevation myocardial infarction patients: gaps, barriers, and implications. Circulation. 2007; 116: e68–e72.LinkGoogle Scholar
  • 11 Jacobs AK, Antman EM, Faxon DP, Gregory T, Solis P. Development of systems of care for ST-elevation myocardial infarction patients: executive summary. Circulation. 2007; 116: 217–230.LinkGoogle Scholar
  • 12 Canto JG, Rogers WJ, Bowlby LJ, French WJ, Pearce DJ, Weaver WD. The prehospital electrocardiogram in acute myocardial infarction: is its full potential being realized? National Registry of Myocardial Infarction 2 Investigators. J Am Coll Cardiol. 1997; 29: 498–505.CrossrefMedlineGoogle Scholar
  • 13 Curtis JP, Portnay EL, Wang Y, McNamara RL, Herrin J, Bradley EH, Magid DJ, Blaney ME, Canto JG, Krumholz HM. The pre-hospital electrocardiogram and time to reperfusion in patients with acute myocardial infarction, 2000-2002: findings from the National Registry of Myocardial Infarction-4. J Am Coll Cardiol. 2006; 47: 1544–1552.CrossrefMedlineGoogle Scholar
  • 14 Karagounis L, Ipsen SK, Jessop MR, Gilmore KM, Valenti DA, Clawson JJ, Teichman S, Anderson JL. Impact of field-transmitted electrocardiography on time to in-hospital thrombolytic therapy in acute myocardial infarction. Am J Cardiol. 1990; 66: 786–791.CrossrefMedlineGoogle Scholar
  • 15 Weaver WD, Cerqueira M, Hallstrom AP, Litwin PE, Martin JS, Kudenchuk PJ, Eisenberg M. Prehospital-initiated vs hospital-initiated thrombolytic therapy: the Myocardial Infarction Triage and Intervention Trial. JAMA. 1993; 270: 1211–1216.CrossrefMedlineGoogle Scholar
  • 16 Foster DB, Dufendach JH, Barkdoll CM, Mitchell BK. Prehospital recognition of AMI using independent nurse/paramedic 12-lead ECG evaluation: impact on in-hospital times to thrombolysis in a rural community hospital. Am J Emerg Med. 1994; 12: 25–31.CrossrefMedlineGoogle Scholar
  • 17 Millar-Craig MW, Joy AV, Adamowicz M, Furber R, Thomas B. Reduction in treatment delay by paramedic ECG diagnosis of myocardial infarction with direct CCU admission. Heart. 1997; 78: 456–461.CrossrefMedlineGoogle Scholar
  • 18 Selker HP, Zalenski RJ, Antman EM, Aufderheide TP, Bernard SA, Bonow RO, Gibler WB, Hagen MD, Johnson P, Lau J, McNutt RA, Ornato J, Schwartz JS, Scott JD, Tunick PA, Weaver WD. Prehospital ECG. Ann Emerg Med. 1997; 29: 20–24.CrossrefGoogle Scholar
  • 19 Myers RB. Prehospital management of acute myocardial infarction: electrocardiogram acquisition and interpretation, and thrombolysis by prehospital care providers. Can J Cardiol. 1998; 14: 1231–1240.MedlineGoogle Scholar
  • 20 Ioannidis JP, Salem D, Chew PW, Lau J. Accuracy and clinical effect of out-of-hospital electrocardiography in the diagnosis of acute cardiac ischemia: a meta-analysis. Ann Emerg Med. 2001; 37: 461–470.CrossrefMedlineGoogle Scholar
  • 21 Morrow DA, Antman EM, Sayah A, Schuhwerk KC, Giugliano RP, deLemos JA, Waller M, Cohen SA, Rosenberg DG, Cutler SS, McCabe CH, Walls RM, Braunwald E. Evaluation of the time saved by prehospital initiation of reteplase for ST-elevation myocardial infarction: results of the Early Retavase-Thrombolysis in Myocardial Infarction (ER-TIMI) 19 trial. J Am Coll Cardiol. 2002; 40: 71–77.CrossrefMedlineGoogle Scholar
  • 22 Ferguson JD, Brady WJ, Perron AD, Kielar ND, Benner JP, Currance SB, Braithwaite S, Aufderheide TP. The prehospital 12-lead electrocardiogram: impact on management of the out-of-hospital acute coronary syndrome patient. Am J Emerg Med. 2003; 21: 136–142.CrossrefMedlineGoogle Scholar
  • 23 Pedley DK, Bissett K, Connolly EM, Goodman CG, Golding I, Pringle TH, McNeill GP, Pringle SD, Jones MC. Prospective observational cohort study of time saved by prehospital thrombolysis for ST elevation myocardial infarction delivered by paramedics. BMJ. 2003; 327: 22–26.CrossrefMedlineGoogle Scholar
  • 24 Terkelsen CJ, Lassen JF, Nørgaard BL, Gerdes JC, Poulsen SH, Bendix K, Ankersen JP, Gøtzsche LB, Rømer FK, Nielsen TT, Andersen HR. Reduction of treatment delay in patients with ST-elevation myocardial infarction: impact of pre-hospital diagnosis and direct referral to primary percutanous coronary intervention. Eur Heart J. 2005; 26: 770–777.CrossrefMedlineGoogle Scholar
  • 25 Björklund E, Stenestrand U, Lindbäck J, Svensson L, Wallentin L, Lindahl B; the RIKS-HIA Investigators. Prehospital diagnosis and start of treatment reduces time delay and mortality in real-life patients with STEMI. J Electrocardiol. 2005; 38 (suppl 1): 186.CrossrefMedlineGoogle Scholar
  • 26 Brainard AH, Raynovich W, Tandberg D, Bedrick EJ. The prehospital 12-lead electrocardiogram’s effect on time to initiation of reperfusion therapy: a systematic review and meta-analysis of existing literature. Am J Emerg Med. 2005; 23: 351–356.CrossrefMedlineGoogle Scholar
  • 27 Hankins DG, Luke A. Emergency medical service aspects of emergency cardiac care. Emerg Med Clin North Am. 2005; 23: 1219–1231.CrossrefMedlineGoogle Scholar
  • 28 Morrison LJ, Brooks S, Sawadsky B, McDonald A, Verbeek PR. Prehospital 12-lead electrocardiography impact on acute myocardial infarction treatment times and mortality: a systematic review. Acad Emerg Med. 2006; 13: 84–89.CrossrefMedlineGoogle Scholar
  • 29 Amsterdam EA, Miles P, Turnipseed S, Diercks D. The prehospital ECG: a simple (and effective) tool for a complex problem. Crit Pathw Cardiol. 2007; 6: 64–66.CrossrefMedlineGoogle Scholar
  • 30 Brown JP, Mahmud E, Dunford JV, Ben-Yehuda O. Effect of prehospital 12-lead electrocardiogram on activation of the cardiac catheterization laboratory and door-to-balloon time in ST-segment elevation acute myocardial infarction. Am J Cardiol. 2008; 101: 158–161.CrossrefMedlineGoogle Scholar
  • 31 Bradley EH, Roumanis SA, Radford MJ, Webster TR, McNamara RL, Mattera JA, Barton BA, Berg DN, Portnay EL, Moscovitz H, Parkosewich J, Holmboe ES, Blaney M, Krumholz HM. Achieving door-to-balloon times that meet quality guidelines: how do successful hospitals do it? J Am Coll Cardiol. 2005; 46: 1236–1241.CrossrefMedlineGoogle Scholar
  • 32 Bradley EH, Herrin J, Wang Y, Barton BA, Webster TR, Mattera JA, Roumanis SA, Curtis JP, Nallamothu BK, Magid DJ, McNamara RL, Parkosewich J, Loeb JM, Krumholz HM. Strategies for reducing the door-to-balloon time in acute myocardial infarction. N Engl J Med. 2006; 355: 2308–2320.CrossrefMedlineGoogle Scholar
  • 33 Bradley EH, Curry LA, Webster TR, Mattera JA, Roumanis SA, Radford MJ, McNamara RL, Barton BA, Berg DN, Krumholz HM. Achieving rapid door-to-balloon times: how top hospitals improve complex clinical systems. Circulation. 2006; 113: 1079–1085.LinkGoogle Scholar
  • 34 Swor R, Hegerberg S, McHugh-McNally A, Goldstein M, McEachin CC. Prehospital 12-lead ECG: efficacy or effectiveness? Prehosp Emerg Care. 2006; 10: 374–377.CrossrefMedlineGoogle Scholar
  • 35 Gross BW, Dauterman KW, Moran MG, Kotler TS, Schnugg SJ, Rostykus PS, Ross AM, Weaver WD. An approach to shorten time to infarct artery patency in patients with ST-segment elevation myocardial infarction. Am J Cardiol. 2007; 99: 1360–1363.CrossrefMedlineGoogle Scholar
  • 36 Dhruva VN, Abdelhadi SI, Anis A, Gluckman W, Hom D, Dougan W, Kaluski E, Haider B, Klapholz M. ST-Segment Analysis Using Wireless Technology in Acute Myocardial Infarction (STAT-MI) trial. J Am Coll Cardiol. 2007; 50: 509–513.CrossrefMedlineGoogle Scholar
  • 37 Nallamothu BK, Bradley EH, Krumholz HM. Time to treatment in primary percutaneous coronary intervention. N Engl J Med. 2007; 357: 1631–1638.CrossrefMedlineGoogle Scholar
  • 38 Scholz KH, Hilgers R, Ahlersmann D, Duwald H, Nitsche R, von Knobelsdorff G, Volger B, Möller K, Keating FK. Contact-to-balloon time and door-to-balloon time after initiation of a formalized data feedback in patients with acute ST-elevation myocardial infarction. Am J Cardiol. 2008; 101: 46–52.CrossrefMedlineGoogle Scholar
  • 39 Williams DM. 2006 JEMS 200-city survey: EMS from all angles. JEMS. 2007; 32: 38–46.Google Scholar
  • 40 Grim P, Feldman T, Martin M, Donovan R, Nevins V, Childers RW. Cellular telephone transmission of 12-lead electrocardiograms from ambulance to hospital. Am J Cardiol. 1987; 60: 715–720.CrossrefMedlineGoogle Scholar
  • 41 Grim PS, Feldman T, Childers RW. Evaluation of patients for the need of thrombolytic therapy in the prehospital setting. Ann Emerg Med. 1989; 18: 483–487.CrossrefMedlineGoogle Scholar
  • 42 Aufderheide TP, Hendley GE, Thakur RK, Mateer JR, Stueven HA, Olson DW, Hargarten KM, Laitinen F, Robinson N, Preuss KC, Hoffman RG. The diagnostic impact of prehospital 12-lead electrocardiography. Ann Emerg Med. 1990; 19: 1280–1287.CrossrefMedlineGoogle Scholar
  • 43 Kudenchuk PJ, Ho MT, Weaver WD, Litwin PE, Martin JS, Eisenberg MS, Hallstrom AP, Cobb LA, Kennedy JW. Accuracy of computer-interpreted electrocardiography in selecting patients for thrombolytic therapy: MITI Project Investigators. J Am Coll Cardiol. 1991; 17: 1486–1491.CrossrefMedlineGoogle Scholar
  • 44 Gibler WB, Kereiakes DJ, Dean EN, Martin L, Anderson L, Abbottsmith CW, Blanton J, Blanton D, Morris JA, Gibler CD, Erb RE, Teichman SL. Prehospital diagnosis and treatment of acute myocardial infarction: a north-south perspective: the Cincinnati Heart Project and the Nashville Prehospital TPA Trial. Am Heart J. 1991; 121: 1–11.CrossrefMedlineGoogle Scholar
  • 45 Aufderheide TP, Keelan MH, Hendley GE, Robinson NA, Hastings TE, Lewin RF, Hewes HF, Daniel A, Engle D, Gimbel BK, Bortin KR, Clardy DJ, Schmidt DH, Bajwa T, Holzhauer P, Dabrowski RC, Schuchard GH, Teichman S. Milwaukee prehospital chest pain project: phase I: feasibility and accuracy of prehospital thrombolytic candidate selection. Am J Cardiol. 1992; 69: 991–996.CrossrefMedlineGoogle Scholar
  • 46 Aufderheide TP, Hendley GE, Woo J, Lawrence S, Valley V, Teichman SL. A prospective evaluation of prehospital 12-lead ECG application in chest pain patients. J Electrocardiol. 1992; 24 (suppl): 8–13.CrossrefMedlineGoogle Scholar
  • 47 Aufderheide TP, Haselow WC, Hendley GE, Robinson NA, Armaganian L, Hargarten KM, Olson DW, Valley VT, Stueven HA. Feasibility of prehospital r-TPA therapy in chest pain patients. Ann Emerg Med. 1992; 21: 379–383.CrossrefMedlineGoogle Scholar
  • 48 Weaver WD. Time to thrombolytic treatment: factors affecting delay and their influence on outcome. J Am Coll Cardiol. 1995; 25 (suppl 1): 3S–9S.CrossrefMedlineGoogle Scholar
  • 49 Kudenchuk PJ, Maynard C, Cobb LA, Wirkus M, Martin JS, Kennedy JW, Weaver WD. Utility of the prehospital electrocardiogram in diagnosing acute coronary syndromes: the Myocardial Infarction Triage and Intervention (MITI) Project. J Am Coll Cardiol. 1998; 32: 17–27.CrossrefMedlineGoogle Scholar
  • 50 Massel D, Dawdy JA, Melendez LJ. Strict reliance on a computer algorithm or measurable ST segment criteria may lead to errors in thrombolytic therapy eligibility. Am Heart J. 2000; 140: 221–226.CrossrefMedlineGoogle Scholar
  • 51 Terkelsen CJ, Nørgaard BL, Lassen JF, Gerdes JC, Ankersen JP, Rømer F, Nielsen TT, Andersen HR. Telemedicine used for remote prehospital diagnosing in patients suspected of acute myocardial infarction. J Intern Med. 2002; 252: 412–420.CrossrefMedlineGoogle Scholar
  • 52 Campbell PT, Patterson J, Cromer D, Wall K, Adams GL, Albano A, Corey C, Fox P, Gardner J, Hawthorne B, Lipton J, Sejersten M, Thompson A, Thompson A, Wilfong S, Maynard C, Wagner G. Prehospital triage of acute myocardial infarction: wireless transmission of electrocardiograms to the on-call cardiologist via a handheld computer. J Electrocardiol. 2005; 38: 300–309.CrossrefMedlineGoogle Scholar
  • 53 Clemmensen P, Sejersten M, Sillesen M, Hampton D, Wagner GS, Loumann-Nielsen S. Diversion of ST-elevation myocardial infarction patients for primary angioplasty based on wireless prehospital 12-lead electrocardiographic transmission directly to the cardiologist’s handheld computer: a progress report. J Electrocardiol. 2005; 38 (suppl 1): 194–198.CrossrefMedlineGoogle Scholar
  • 54 Young D, Barbagelata A, Wagner G. Have we made progress in reducing time to reperfusion in the management of acute myocardial infarction? A last decade overview: the potential key role of wireless electrocardiographic transmission. J Electrocardiol. 2005; 38 (suppl 1): 94–95.CrossrefMedlineGoogle Scholar
  • 55 Adams GL, Campbell PT, Adams JM, Strauss DG, Wall K, Patterson J, Shuping KB, Maynard C, Young D, Corey C, Thompson A, Lee BA, Wagner GS. Effectiveness of prehospital wireless transmission of electrocardiograms to a cardiologist via hand-held device for patients with acute myocardial infarction (from the Timely Intervention in Myocardial Emergency, NorthEast Experience [TIME-NE]). Am J Cardiol. 2006; 98: 1160–1164.CrossrefMedlineGoogle Scholar
  • 56 Vaught C, Young DR, Bell SJ, Maynard C, Gentry M, Jacubowitz S, Leibrandt PN, Munsey D, Savona MR, Wall TC, Wagner GS. The failure of years of experience with electrocardiographic transmission from paramedics to the hospital emergency department to reduce the delay from door to primary coronary intervention below the 90-minute threshold during acute myocardial infarction. J Electrocardiol. 2006; 39: 136–141.CrossrefMedlineGoogle Scholar
  • 57 Davis DP, Graydon C, Stein R, Wilson S, Buesch B, Berthiaume S, Lee DM, Rivas J, Vilke GM, Leahy DR. The positive predictive value of paramedic versus emergency physician interpretation of the prehospital 12-lead electrocardiogram. Prehosp Emerg Care. 2007; 11: 399–402.CrossrefMedlineGoogle Scholar
  • 58 Strauss DG, Sprague PQ, Underhill K, Maynard C, Adams GL, Kessenich A, Sketch MH Jr, Berger PB, Marcozzi D, Granger CB, Wagner GS. Paramedic transtelephonic communication to cardiologist of clinical and electrocardiographic assessment for rapid reperfusion of ST-elevation myocardial infarction. J Electrocardiol. 2007; 40: 265–270.CrossrefMedlineGoogle Scholar
  • 59 Weaver WD, Eisenberg MS, Martin JS, Litwin PE, Shaeffer SM, Ho MT, Kudenchuk PJ, Hallstrom AP, Cerqueira MD, Copass MK, Kennedy JW, Cobb LA, Ritchie JL. Myocardial Infarction Triage and Intervention project: phase 1: patient characteristics and feasibility of prehospital initiation of thrombolytic therapy. J Am Coll Cardiol. 1990; 15: 925–931.CrossrefMedlineGoogle Scholar
  • 60 Hill R, Heller M, Rosenau A, Melanson S, Pronchik D, Patterson J, Gulick H. Paramedic interpretation of prehospital lead-II ST-segments. Prehosp Disaster Med. 1997; 12: 141–144.MedlineGoogle Scholar
  • 61 Brinfield K. Identification of ST elevation AMI on prehospital 12 lead ECG: accuracy of unaided paramedic interpretation. J Emerg Med. 1998; 16: 22S.Google Scholar
  • 62 Whitbread M, Leah V, Bell T, Coats TJ. Recognition of ST elevation by paramedics. Emerg Med J. 2002; 19: 66–67.CrossrefMedlineGoogle Scholar
  • 63 Keeling P, Hughes D, Price L, Shaw S, Barton A. Safety and feasibility of prehospital fibrinolysis carried out by paramedics. BMJ. 2003; 327: 27–28.CrossrefMedlineGoogle Scholar
  • 64 Feldman JA, Brinsfield K, Bernard S, White D, Maciejko T. Real-time paramedic compared with blinded physician identification of ST-segment elevation myocardial infarction: results of an observational study. Am J Emerg Med. 2005; 23: 443–448.CrossrefMedlineGoogle Scholar
  • 65 Le May MR, Dionne R, Maloney J, Trickett J, Watpool I, Ruest M, Stiell I, Ryan S, Davies RF. Diagnostic performance and potential clinical impact of advanced care paramedic interpretation of ST-segment elevation myocardial infarction in the field. CJEM. 2006; 8: 401–407.CrossrefMedlineGoogle Scholar
  • 66 Giovas P, Papadoyannis D, Thomakos D, Papazachos G, Rallidis M, Soulis D, Stamatopoulos C, Mavrogeni S, Katsilambros N. Transmission of electrocardiograms from a moving ambulance. J Telemed Telecare. 1998; 4 (suppl 1): 5–7.CrossrefMedlineGoogle Scholar
  • 67 Papouchado M, Cox H, Bailey J, White W, Spreadbury T. Early experience with transmission of data from moving ambulances to improve the care of patients with myocardial infarction. J Telemed Telecare. 2001; 7 (suppl 1): 27–28.CrossrefGoogle Scholar
  • 68 Selker HP, Zalenski RJ, Antman EM, Aufderheide TP, Bernard SA, Bonow RO, Gibler WB, Hagen MD, Johnson P, Lau J, McNutt RA, Ornato J, Schwartz JS, Scott JD, Tunick PA, Weaver WD. An evaluation of technologies for identifying acute cardiac ischemia in the emergency department: executive summary of a National Heart Attack Alert Program Working Group report. Ann Emerg Med. 1997; 29: 1–12.CrossrefMedlineGoogle Scholar
  • 69 Selker HP, Zalenski RJ, Antman EM, Aufderheide TP, Bernard SA, Bonow RO, Gibler WB, Hagen MD, Johnson P, Lau J, McNutt RA, Ornato J, Schwartz JS, Scott JD, Tunick PA, Weaver WD. An evaluation of technologies for identifying acute cardiac ischemia in the emergency department: a report from a National Heart Attack Alert Program Working Group. Ann Emerg Med. 1997; 29: 13–16.CrossrefMedlineGoogle Scholar
  • 70 Lau J, Ioannidis JPA, Balk EM, Milch C, Terrin N, Chew PW, Salem D. Diagnosing acute cardiac ischemia in the emergency department: a systematic review of the accuracy and clinical effect of current technologies. Ann Emerg Med. 2001; 37: 453–460.CrossrefMedlineGoogle Scholar
  • 71 Landman A, Rokos IC, French WJ, Gross B. Optimizing prehospital wireless ECG transmission: new data, new ideas. STEMI Systems[serial online]. 2007;4:2–5. Available at: http://stemisystems.org/. Accessed May 1, 2008.Google Scholar
  • 72 Ohtsuka M, Uchida E, Nakajima T, Yamaguchi H, Takano H, Komuro I. Transferring images via the wireless messaging network using camera phones shortens the time required to diagnose acute coronary syndrome. Circ J. 2007; 71: 1499–1500.CrossrefMedlineGoogle Scholar
  • 73 Christensen CM. The Innovator’s Dilemma: When New Technologies Cause Great Firms to Fail. Boston, Mass: Harvard Business School Press; 1997.Google Scholar
  • 74 Ortolani P, Marzocchi A, Marrozzini C, Palmerini T, Saia F, Serantoni C, Aquilina M, Silenzi S, Baldazzi F, Grosseto D, Taglieri N, Cooke RM, Bacchi-Reggiani ML, Branzi A. Clinical impact of direct referral to primary percutaneous coronary intervention following pre-hospital diagnosis of ST-elevation myocardial infarction. Eur Heart J. 2006; 27: 1550–1557.CrossrefMedlineGoogle Scholar
  • 75 Barbagelata A, Ware DL. Denying reperfusion or falsely declaring emergency: the dilemma posed by ST-segment elevation. J Electrocardiol. 2006; 39 (suppl 1): S73–S74.CrossrefMedlineGoogle Scholar
  • 76 Youngquist ST, Kaji AH, Lipsky AM, Koenig WJ, Niemann JT. A Bayesian sensitivity analysis of out-of-hospital 12-lead electrocardiograms: implications for regionalization of cardiac care. Acad Emerg Med. 2007; 14: 1165–1171.CrossrefMedlineGoogle Scholar
  • 77 Larson DM, Menssen KM, Sharkey SW, Duval S, Schwartz RS, Harris J, Meland JT, Unger BT, Henry TD. “False-positive” cardiac catheterization laboratory activation among patients with suspected ST-segment elevation myocardial infarction. JAMA. 2007; 298: 2754–2760.CrossrefMedlineGoogle Scholar
  • 78 Magid DJ, Wang Y, Herrin J, McNamara RL, Bradley EH, Curtis JP, Pollack CV Jr, French WJ, Blaney ME, Krumholz HM. Relationship between time of day, day of week, timeliness of reperfusion, and in-hospital mortality for patients with acute ST-segment elevation myocardial infarction. JAMA. 2005; 294: 803–812.CrossrefMedlineGoogle Scholar
  • 79 Afolabi BA, Novaro GM, Pinski SL, Fromkin KR, Bush HS. Use of the prehospital ECG improves door-to-balloon times in ST segment elevation myocardial infarction irrespective of time of day or day of week. Emerg Med J. 2007; 24: 588–591.CrossrefMedlineGoogle Scholar
  • 80 Nallamothu BK, Bates ER, Herrin J, Wang Y, Bradley EH, Krumholz HM; NRMI Investigators. Times to treatment in transfer patients undergoing primary percutaneous coronary intervention in the United States: National Registry of Myocardial Infarction (NRMI)-3/4 analysis. Circulation. 2005; 111: 761–767.LinkGoogle Scholar
  • 81 Ting HH, Rihal CS, Gersh BJ, Haro LH, Bjerke CM, Lennon RJ, Lim CC, Bresnahan JF, Jaffe AS, Holmes DR, Bell MR. Regional systems of care to optimize timeliness of reperfusion therapy for ST-elevation myocardial infarction: the Mayo Clinic STEMI protocol. Circulation. 2007; 116: 729–736.LinkGoogle Scholar
  • 82 Henry TD, Sharkey SW, Burke MN, Chavez IJ, Graham KJ, Henry CR, Lips DL, Madison JD, Menssen KM, Mooney MR, Newell MC, Pedersen WR, Poulose AK, Traverse JH, Unger BT, Wang YL, Larson DM. A regional system to provide timely access to percutaneous coronary intervention for ST-elevation myocardial infarction. Circulation. 2007; 116: 721–728.LinkGoogle Scholar
  • 83 Jollis JG, Roettig ML, Aluko AO, Anstrom KJ, Applegate RJ, Babb JD, Berger PB, Bohle DJ, Fletcher SM, Garvey JL, Hathaway WR, Hoekstra JW, Kelly RV, Maddox WT Jr, Shiber JR, Valeri FS, Watling BA, Wilson BH, Granger CB; Reperfusion of Acute Myocardial Infarction in North Carolina Emergency Departments (RACE) Investigators. Implementation of a statewide system for coronary reperfusion for ST-segment elevation myocardial infarction. JAMA. 2007; 298: 2371–2380.CrossrefMedlineGoogle Scholar
  • 84 Terkelsen CJ, Nørgaard BL, Lassen JF, Andersen HR. Prehospital evaluation in ST-elevation myocardial infarction patients treated with primary percutaneous coronary intervention. J Electrocardiol. 2005; 38 (suppl 1): 187–192.Google Scholar
  • 85 Kalla K, Christ G, Karnik R, Malzer R, Norman G, Prachar H, Schreiber W, Unger G, Glogar HD, Kaff A, Laggner AN, Maurer G, Mlczoch J, Slany J, Weber HS, Huber K; Vienna STEMI Registry Group. Implementation of guidelines improves the standard of care: the Viennese registry on reperfusion strategies in ST-elevation myocardial infarction (Vienna STEMI registry). Circulation. 2006; 113: 2398–2405.LinkGoogle Scholar
  • 86 Jacobs AK, Antman EM, Ellrodt G, Faxon DP, Gregory T, Mensah GA, Moyer P, Ornato J, Peterson ED, Sadwin L, Smith SC; American Heart Association’s Acute Myocardial Infarction Advisory Working Group. Recommendation to develop strategies to increase the number of ST-segment-elevation myocardial infarction patients with timely access to primary percutaneous coronary intervention. Circulation. 2006; 113: 2152–2163.LinkGoogle Scholar
  • 87 Rokos IC, Larson DM, Henry TD, Koenig WJ, Eckstein M, French WJ, Granger CB, Roe MT. Rationale for establishing regional ST-elevation myocardial infarction receiving center (SRC) networks. Am Heart J. 2006; 152: 661–667.CrossrefMedlineGoogle Scholar
  • 88 Rathore SS, Epstein AJ, Nallamothu BK, Krumholz HM. Regionalization of ST-segment elevation acute coronary syndromes care: putting a national policy in proper perspective. J Am Coll Cardiol. 2006; 47: 1346–1349.CrossrefMedlineGoogle Scholar
  • 89 Henry TD, Atkins JM, Cunningham MS, Francis GS, Groh WJ, Hong RA, Kern KB, Larson DM, Ohman EM, Ornato JP, Peberdy MA, Rosenberg MJ, Weaver WD. ST-segment elevation myocardial infarction: recommendations on triage of patients to heart attack centers: is it time for a national policy for the treatment of ST-segment elevation myocardial infarction? J Am Coll Cardiol. 2006; 47: 1339–1345.CrossrefMedlineGoogle Scholar
  • 90 Nallamothu BK, Bates ER, Wang Y, Bradley EH, Krumholz HM. Driving times and distances to hospitals with percutaneous coronary intervention in the United States: implications for prehospital triage of patients with ST-elevation myocardial infarction. Circulation. 2006; 113: 1189–1195.LinkGoogle Scholar
  • 91 Peterson ED, Ohman EM, Brindis RG, Cohen DJ, Magid DJ. Development of systems of care for ST-elevation myocardial infarction patients: evaluation and outcomes. Circulation. 2007; 116: e64–e67.LinkGoogle Scholar
  • 92 Moyer P, Feldman J, Levine J, Beshansky J, Selker HP, Barnewolt B, Brown D, Cardoza JP, Grossman SA, Jacobs A, Kerman BJ, Kimmelstiel C, Larson R, Losordo D, Pearlmutter M, Pozner C, Ramirez A, Rosenfield K, Ryan T, Zane R, Cannon C. Implications of the mechanical (PCI) vs thrombolytic controversy for ST segment elevation myocardial infarction on the organization of emergency medical services: the Boston EMS experience. Crit Pathw Cardiol. 2004; 3: 53–61.CrossrefMedlineGoogle Scholar
  • 93 Drew BJ, Dempsey ED, Joo TH, Sommargren CE, Glancy JP, Benedict K, Krucoff MW. Pre-hospital synthesized 12-lead ECG ischemia monitoring with trans-telephonic transmission in acute coronary syndromes: pilot study results of the ST SMART trial. J Electrocardiol. 2004; 37 (suppl 1): 214–221.CrossrefMedlineGoogle Scholar
  • 94 Drew BJ, Pelter MM, Lee E, Zegre J, Schindler D, Fleischmann KE. Designing prehospital ECG systems for acute coronary syndromes: lessons learned from clinical trials involving 12-lead ST-segment monitoring. J Electrocardiol. 2005; 38 (suppl 1): 180–185.CrossrefMedlineGoogle Scholar
  • 95 Merla R, Adams G, Birnbaum Y, Uretsky B, Wagner G, Barbagelata A. Wireless electrocardiogram in early diagnosis and triaging of ST-elevation myocardial infarction: the TIME study. J Electrocardiol. 2007; 40 (suppl 1): S39–S41.CrossrefMedlineGoogle Scholar
  • 96 Le May MR, So DY, Dionne R, Glover CA, Froeschl MP, Wells GA, Davies RF, Sherrard HL, Maloney J, Marquis JF, O'Brien ER, Trickett J, Poirier P, Ryan SC, Ha A, Joseph PG, Labinaz M. A citywide protocol for primary PCI in ST-segment elevation myocardial infarction. N Engl J Med. 2008; 358: 231–240.CrossrefMedlineGoogle Scholar
  • 97 Eisenstein EL. Conducting an economic analysis to assess the electrocardiogram’s value. J Electrocardiol. 2006; 39: 241–247.CrossrefMedlineGoogle Scholar
  • 98 Aufderheide TP, Kereiakes DJ, Weaver WD, Gibler WB, Simoons ML. Planning, implementation, and process monitoring for prehospital 12-lead ECG diagnostic programs. Prehosp Disaster Med. 1996; 11: 162–171.CrossrefMedlineGoogle Scholar
  • 99 National Highway Traffic Safety Administration. Part IV medical cardiology declarative. Section VE 3.a. EMT-paramedic national standard. Washington, DC; 1999: 15.Google Scholar
  • 100 Provo TA, Frascone RJ. 12-lead electrocardiograms during basic life support care. Prehosp Emerg Care. 2004; 8: 212–216.MedlineGoogle Scholar
  • 101 Usatch BR, Cone DC. Automated external defibrillator training and skill retention at a ski patrol. Prehosp Emerg Care. 2002; 6: 325–329.CrossrefMedlineGoogle Scholar
  • 102 Riegel B, Nafziger SD, McBurnie MA, Powell J, Ledingham R, Sehra R, Mango L, Henry MC; PAD Trial Investigators. How well are cardiopulmonary resuscitation and automated external defibrillator skills retained over time? Results from the public access defibrillation (PAD) trial. Acad Emerg Med. 2006; 13: 254–263.CrossrefMedlineGoogle Scholar
  • 103 Woollard M, Whitfield R, Newcombe RG, Colquhoun M, Vetter N, Chamberlain D. Optimal refresher training intervals for AED and CPR skills: a randomised controlled trial. Resuscitation. 2006; 71: 237–247.CrossrefMedlineGoogle Scholar
  • 104 Kereiakes DJ, Gibler WB, Martin LH, Pieper KS, Anderson LC. Relative importance of emergency medical system transport and the prehospital electrocardiogram on reducing hospital time delay to therapy for acute myocardial infarction: a preliminary report from the Cincinnati heart project. Am Heart J. 1992; 123: 835–840.CrossrefMedlineGoogle Scholar
  • 105 Meischke H, Eisenberg MS, Larsen MP. Prehospital delay interval for patients who use emergency medical services: the effect of heart-related medical conditions and demographic variables. Ann Emerg Med. 1993; 22: 1597–1601.CrossrefMedlineGoogle Scholar
  • 106 Goff DC Jr, Feldman HA, McGovern PG, Goldberg RJ, Simons-Morton DG, Cornell CE, Osganian SK, Cooper LS, Hedges JR. Prehospital delay in patients hospitalized with heart attack symptoms in the United States: the REACT trial: Rapid Early Action for Coronary Treatment (REACT) Study Group. Am Heart J. 1999; 138: 1046–1057.CrossrefMedlineGoogle Scholar
  • 107 Brown AL, Mann NC, Daya M, Goldberg R, Meischke H, Taylor J, Smith K, Osganian S, Cooper L. Demographic, belief, and situational factors influencing the decision to utilize emergency medical services among chest pain patients: Rapid Early Action for Coronary Treatment (REACT) study. Circulation. 2000; 102: 173–178.LinkGoogle Scholar
  • 108 Siepmann DB, Mann N, Hedges JR, Daya M. Association between prepayment systems and emergency medical services use among patients with acute chest discomfort syndrome: for the Rapid Early Action for Coronary Treatment (REACT) study. Ann Emerg Med. 2000; 35: 573–578.CrossrefGoogle Scholar
  • 109 Faxon D, Lenfant C. Timing is everything: motivating patients to call 9-1-1 at onset of acute myocardial infarction. Circulation. 2001; 104: 1210–1211.LinkGoogle Scholar
  • 110 Canto JG, Zalenski RJ, Ornato JP, Rogers WJ, Kiefe CI, Magid D, Shlipak MG, Frederick PD, Lambrew CG, Littrell KA, Barron HV; National Registry of Myocardial Infarction 2 Investigators. Use of emergency medical services in acute myocardial infarction and subsequent quality of care: observations from the National Registry of Myocardial Infarction 2. Circulation. 2002; 106: 3018–3023.LinkGoogle Scholar
  • 111 Moser DK, Kimble LP, Alberts MJ, Alonzo A, Croft JB, Dracup K, Evenson KR, Go AS, Hand MM, Kothari RU, Mensah GA, Morris DL, Pancioli AM, Riegel B, Zerwic JJ. Reducing delay in seeking treatment by patients with acute coronary syndrome and stroke: a scientific statement from the American Heart Association Council on Cardiovascular Nursing and Stroke Council. Circulation. 2006; 114: 168–182.LinkGoogle Scholar
  • 112 Kereiakes DJ, Weaver WD, Anderson JL, Feldman T, Gibler B, Aufderheide T, Williams DO, Martin LH, Anderson LC, Martin JS, McKendall G, Sherrid M, Greenberg H, Teichman SL. Time delays in the diagnosis and treatment of acute myocardial infarction: a tale of eight cities: report from the Pre-hospital Study Group and the Cincinnati Heart Project. Am Heart J. 1990; 120: 773–780.CrossrefMedlineGoogle Scholar
  • 113 Weiss SJ, Derlet R, Arndahl J, Ernst AA, Richards J, Fernández-Frackelton M, Schwab R, Stair TO, Vicellio P, Levy D, Brautigan M, Johnson A, Nick TG. Estimating the degree of emergency department overcrowding in academic medical centers: results of the national ED overcrowding study (NEDOCS). Acad Emerg Med. 2004; 11: 38–50.CrossrefMedlineGoogle Scholar
  • 114 Luepker RV, Raczynski JM, Osganian S, Goldberg RJ, Finnegan JR Jr, Hedges JR, Goff DC Jr, Eisenberg MS, Zapka JG, Feldman HA, Labarthe DR, McGovern PG, Cornell CE, Proschan MA, Simons-Morton DG. Effect of a community intervention on patient delay and emergency medical service use in acute coronary heart disease: the Rapid Early Action for Coronary Treatment (REACT) trial. JAMA. 2000; 284: 60–67.CrossrefMedlineGoogle Scholar
  • 115 Schull MJ, Vermeulen M, Slaughter G, Morrison L, Daly P. Emergency department crowding and thrombolysis delays in acute myocardial infarction. Ann Emerg Med. 2004; 44: 577–585.CrossrefMedlineGoogle Scholar
  • 116 Magid DJ, Asplin BR, Wears RL. The quality gap: searching for the consequences of emergency department crowding. Ann Emerg Med. 2004; 44: 586–588.CrossrefMedlineGoogle Scholar
  • 117 Wilper AP, Woolhandler S, Lasser KE, McCormick D, Cutrona SL, Bor DH, Himmelstein DU. Waits to see an emergency department physician: U.S. trends and predictors, 1997–2004. Health Aff (Millwood). 2008; 27: w84–w95.CrossrefMedlineGoogle Scholar
  • 118 Wang K, Asinger RW, Marriott HJ. ST-segment elevation in conditions other than acute myocardial infarction. N Engl J Med. 2003; 349: 2128–2135.CrossrefMedlineGoogle Scholar
  • 119 Nallamothu BK, Taheri PA, Barsan WG, Bates ER. Broken bodies, broken hearts? Limitations of the trauma system as a model for regionalizing care for ST-elevation myocardial infarction in the United States. Am Heart J. 2006; 152: 613–618.CrossrefMedlineGoogle Scholar
  • 120 Solis P, Amsterdam EA, Bufalino V, Drew BJ, Jacobs AK. Development of systems of care for ST-elevation myocardial infarction patients: policy recommendations. Circulation. 2007; 116: e73–e76.MedlineGoogle Scholar
  • 121 Nallamothu BK, Wang Y, Cram P, Birkmeyer JD, Ross JS, Normand SLT, Krumholz HM. Acute myocardial infarction and congestive heart failure outcomes at specialty cardiac hospitals. Circulation. 2007; 116: 2280–2287.LinkGoogle Scholar

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