2013 STEMI Guidelines: EMS is Accountable

On Monday, the American College of Cardiology Foundation and the American Heart Association released the 2013 Guidelines for the Management of ST-Elevation Myocardial Infarction. Their last updates to these guidelines were in 2004 and 2006, so this is an important milestone.

If you have been following our blog and podcast, most of the changes will not be earth shattering. We have long been advocates of evidence based STEMI care, which has put us at the bleeding edge as the guidelines take time to catch up. What does this mean for you, our readers?

Our readers have been ahead of the game! We're constantly impressed by your breadth and depth of knowledge.

The 2013 guidelines makes these changes, which we've covered before, to the identification of STEMI:

The honest answer is we probably would not have written a post about these guidelines if it were not for the following gem, buried on page 10 in the section on Regional Systems of Care (emphasis mine):

"For patients who call 9-1-1, direct care begins with FMC, defined as the time at which the EMS provider arrives at the patient’s side. EMS personnel should be accountable for obtaining a prehospital ECG, making the diagnosis, activating the system, and deciding whether to transport the patient to a PCI-capable or non–PCI capable hospital."

Folks, a joint task force of cardiologists has just placed the responsibility for the diagnosis and activation of a STEMI in the hands of EMS providers!

Many systems are already ahead of the game when it comes to STEMI care, but others lag behind.

We've taken responsibility for the care of cardiac arrest victims and now is the time we acknowledge the critical role we play in STEMI care.

  • Does your system acknowledege paramedic diagnosis of STEMI?
  • Are you ready to take on the responsibility of diagnosis and activation of STEMI?

10 Comments

  • it is neat news, and it’s nice to have the responsibility. but there are plenty of crews who still know next to nothing about 12-leads, and the false STEMI activations we see in reviews are plentiful and sometimes unbelievably stupid.

    furthermore, establishing PCI hospital transport guidelines can make it too hasty of a decision. it’s too all or nothing, with no consideration for borderline cases, where non-PCI hospitals don’t want to see patients diverted to PCI hospitals, which in my experience, creates a big ol’ fight among all the stakeholders. non-PCI hospitals always complained when crews brought patients to PCI hospitals “just in case.” they hate it even more when crews were wrong.

    many subtle cases develop over time, and even the physicians and specialist discuss and debate over hours before going to PCI. in such cases, to expect a correct transport decision from an ambulance crew, no matter how good they are with 12-leads, is asking too much.

  • Training_Chief says:

    We've been making STEMI field diagnosis and prehospital cath lab activation for several years in my area of NC. We have found that in some cases our false activation rates are comparable, if not lower than ED physicians. Our systems have found great benefit in having a destination triage policy for STEMI candidates, it works and it saves time.
    It requires training, training and more training to keep medics fresh on ECG interpretation. It requires a working relationship with your PCI centers and regular feedback on cases, a dedicated quality improvement program and proactive EMS/hospital leaders. It does work

  • Robert says:

    Chris, how am I supposed to have any 12 lead ECG secrets if you post them all on this site?!?!?! :)
    I've been seeing a significant increase in 12 lead ecg knowledge in Vegas. We are able to activate the cath lab in the field w/ comparable percentage rates of the ED physicians. 

  • burned-out,

    I'm a bit biased being from North Carolina, where like Training_Chief we have been doing this for a while. We have a Statewide system which mandates local systems evaluate their destinations and have a plan in place for their providers. This makes most destination questions moot.

    If I hadn't seen this sort of system work first hand I would agree with most of your comments, but it can work and does work. Our statewide false positive rate for EMS is ~15%, which is wonderful. A decent amount of overtriage is necessary to make sure tough cases don't fall through the cracks.

    It does require a lot of coordination and cross-cutting relationships between dispatchers, first responders, transport units, ED's, cath lab teams, and interventionalists. But once you do it, you'll never want to do it another way!

    I think the educational side is the easiest to fix. We have a wonderful STEMI coordinator in our area who ensures crews receive QA/QI within 24-48 hours for every activation. They get non-punitive feedback when they're wrong and continuing education is pretty aggressive to help keep us sharp.

    The way I look at it is if South Dakota can get an entire State onboard and if North Carolina can get an entire State onboard, obviously everyone (but California) can do it!

  • based on first-hand experience, in front of and behind the scenes, over the past 7-8 years, those were just a couple of the things that people bickered about endlessly in and out of unbelievably painful meetings. non-PCI destinations were always unhappy about overtriage. (money.) even PCI destinations were unhappy about overtriage as well. (money too.) i suppose you can legitimately muse that the hospitals are never happy with anything anyway.
    i'd like to think that these dozens of stakeholders can agree on most important things in a perfect world, but they don't even agree on what the important things are.
    and we haven't even begun to talk about the crews yet.
    i'm not saying it doesn't work, but it's not quite as pretty as it sounds on paper.

  • brand says:

    Great Info! But Im having some trouble trying to load your blog. I have read it many times before and never gotten something like this, but now when I try to load something it just takes a little while (5-10 minutes ) and then just stops. I hope i dont have spyware or something. Does anyone know what the problem could be?

  • Scott says:

    Chris,
     
    Where in the guidelines is this new list of STEMI equivalents. The only thing I found is the introductory definition of STEMI section where the language is quite wishy-washy. Am I missing something. Please email direct as well.

  • Christopher says:

    Scott,

    Good catch! A second read shows they only meant to provide "suggestions" for modifications to the ACCF/AHA Third Universal Definition of Myocardial Infarction (came out in August 2012). They put some of those recommendations into their actual guidelines when discussing thrombolytic usage, otherwise yep they were pretty wishy-washy.

    I guess I was just excited to see them acknowledge an evidence based definition of a STEMI!

    Guidelines: can't activate with them, can't activate without them.

  • Scott says:

    Yeah, I am baffled by this. Everyone I know assoc. with these guidelines said that new LBBB would disappear with this update but instead the STEMI guidelines say nothing definitive and that new 3rd universal definition document is riddled with new LBBB signifying AMI.

  • Medic1030 says:

    We have been doing EMS STEMI dx and activation of the PCI team with direct transport to the cath lab at the closest cardiac centre for a few years now at my service in southern Ontario, Canada.  It has been working phenomenally well. We have false activation rates equall to or better than the ER docs and our EMS-contact-to-balloon-inflation times are actually better than the door-to-balloon times for walk-in patients in the same hospital. As part of the protocol we also get to speak directly to the interventional cardiologist on call in order to discuss borderline or unusual cases and seek direction on whether a direct-to-PCI bypass is appropriate or whether the closest ER or ER at the PCI centre are more appropriate in these specific cases.  A 12-lead is also acquired 10 mins post return of circulation on all sudden cardiac arrest patients and these are also eligible for direct-to-PCI transport. So far so good with this program in all regards.

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