At 01:00 PM 15/07/00 +0100, you wrote:
Our local hospital has started a system which allows the ambulance crews to
request direct admission to CCU for obvious or suspected cardiac conditions.
Basically the admission criteria is any patient where the crew have, or
would have, administered Aspirin.
The door to needle times have come down dramatically.
Unfortunately I have not got the figures to hand, but if memory serves
correct, D to N time through A&E was about 60 mins and through direct
admission, 15 mins. The unit reports that the ambulance crews have been very
good at recognising cardiac conditions and only a handful of patients have
been referred to another ward.
New monitoring equipment in the hospital which uses telemetry means that a
patient arriving and being given an ECG in A&E can also be monitored in CCU.
A small portable device also allows a patient to be monitored anywhere in
the hospital.
With new digital radio systems being introduced in the ambulances which will
allow for data transmissions there is no reason, given the funding, that
ECGs could not be sent ahead and a decision made about admission while the
patient is still en-route.
Someone else mentioned moving the patient on Blues & Twos. Sorry but I think
you will find that this rarely happens. We are always taught to try and keep
the patient calm. They may use the blues but the aim is to give the pt a
smooth comfortable journey so as not to worsen their condition.

Nick Sentance
Paramedic
Lincs.


The North American prehospital experience in 12 lead EKGs is well engaged.

It is both strange & ironic that the first prehosp. 12s studies all 
pinpointed towards improved door to needle times ! ? My question at the 
time was why have prehospital fix an essentially A & E  performance problem 
? The answer is clear... because it works. Will these studies need to be 
reassessed once the ERs get on line with more aggressive triage ? 
(Aggressive Triage Nursing protocols O2, NTG, EKG, notification, IV lines, 
Thrombolysis set-up, etc.)
Read here: Triage nurses may need to operate more like Paramedics ?

As for the medics… well anything to improve Pt outcome.
12 leads have gotten cheaper & better (& so have the medics… same price 
though !)
Medics, electronic interpretation & telemetry are all valid interpretation 
approaches.
Thrombolysis has generally been excluded from the Urban medics pharmacopia
This might be reassessed with easier thrombolysis modalities ! ?
Although I see no great impetus in doing so due to proximity of hospital.
Perhaps appropriate in the context of AMI transports to specialized care 
(longer transport) ?
Emergency TCPA would be the main argument in favor of this but I would 
surmise also an interest in treating in high volume specialized wards.
Otherwise the Suburb & rural area are appropriate venue for prehosp 
Fibrinolysis.
Paradoxically that is where there’s an experience/knowledge gap need to be 
filled the most.

The initial concern that 12leads would add on scene times has not panned 
out (less than 5 min average added scene time) To be noted, since the 
advent of thrombolysis (circa 1985) most EMS have set a benchmark of MAX 20 
min. on scene with a suspected AMI (in the EMS context this does not 
translate into a pious wish but are measured, documented & medics are 
answerable to abnormal delays)

This is a good example here of the malleability of EMT-P
Where medical control is properly run… these changes are applied overnight.
Not quite so possible with in the greater context of every day medical practice
(Just try to successfully implement a 10 min trauma scene time)

As for AVERAGE door to needle times.
Good A & Es brag of 20 min averages
30 min is accepted
Some will embarrassingly admit to 40 min
As for the 60 min ? door to needle…
Well t’would be just an argument in favor of prehospital thrombolysis.

Local solution:
They have started a Cardiac event registry here in Canada
Participating hospital are required to report benchmark times & treatments.
Removes the guesstimating of the whole process.
And allow a structured outcome analysis
And process analysis. (Studied the breakdown of the delays)

Triage seem sto be the hos point
Nurse have to Fastrack of Fastreat these Pt
O2, 12 lead, NTG (when appropriate), notification, IV access etc

Common snags  (from memory)
Delay in MD EKG reading
Waiting for EKG technician
Registering
Routine triage evaluation & then on to delayed access to Pt stretcher
Cardiologist consult.
Delay because thrombolysis needed to be done in ITU

Perhaps you may obtain further information with CAEP ?
Canadian Association of Emergency Physician
http://www.caep.ca/caep/plsql/get?page=index3.html
Medical education, MI letter


Charles Brault EMT-P



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