Chest pain is one of the most common symptoms for patients presenting to the emergency department (ED).1 In fact, in the United States, more than 6 million patients present to the ED annually with complaints of chest pain, which is suggestive of acute coronary syndrome (ACS). According to the U. S. Department of Health and Human Services, Centers for Disease Control and Prevention’s National Center for Health Statistics, during the reporting period of 2007-2008, 35% of chest pain patients were admitted, transferred, or died.2
In Corazon’s experience, the number of patients admitted through the ED with chest pain is in the 50–60% range of those who present. And among those, 25–30% have experienced an acute myocardial event or ST-segment elevation myocardial infarction (STEMI), which means they are candidates for emergent catheterization to determine treatment options.
Depending on the hospital’s status as a community or regional referral center, between 50% and 75% of the cardiac admissions may arise from the ED.3 Statistically, the percentage of ACS or myocardial infarction (MI) cases with ST elevation varies in differing regions and tracking databases, mainly due to the age of patients included and the type of surveillance used, as well as the differing data definitions for the databases. For example, the National Registry of Myocardial Infarction-4 (NRMI-4) indicates that 29% of MI patients are STEMI patients; the Global Registry of Acute Coronary Events (GRACE), which includes US patient populations, reports 35%; while the second Euro Heart Survey on ACS (EHS-ACSII) reports 47%.
Over the years, the American Heart Association has worked to educate the public to seek medical care when experiencing the signs or symptoms suggestive of a heart attack. One of the key instructions has been to activate 9-1-1, or their local EMS provider. The mantra is “Time is Muscle,” meaning that the sooner these patients seek evaluation and intervention, the better their outcomes will be. EMS involvement is a significant component of the equation.
For this reason, we believe it is critically important for the hospital and Emergency Medical Service (EMS) agencies to have a collaborative, integrated approach to patient care. Such an arrangement can lead to increased access to lifesaving care, along with better quality outcomes for patients with ACS and/or STEMI.
The activation of EMS when experiencing chest pain provides the advantage of commencing important therapies such as oxygen and aspirin administration, cardiac monitoring, administration of pain control medication based on patient assessment and indication, and administration of antiarrhythmic medications as necessary. EMS also has the ability to notify the ED, which can subsequently lead to activation of the catheterization laboratory prior to the patient’s arrival, which will allow for a decreased door-to-balloon time. EMS personnel are quickly able to initiate resuscitation efforts should the patient suffer a cardiac arrest.4 Interestingly, however, studies show that only about 25–50% of chest pain patients activate EMS when they experience chest pain.5,6 This proves that more outreach is necessary in order to better streamline pre-hospital care.
These compelling statistics demonstrate the impact that AMI/STEMI has on the patient population and the resultant impact on healthcare organizations. Frequently, EMS personnel are the first medical interaction patients receive. No doubt EMS agencies are valuable components of the healthcare delivery team. These providers are trained to administer basic and advanced life support during emergency situations and to transport patients to the closest, most appropriate hospital. EMS involvement also helps decrease reperfusion time, with the goal of opening a blocked coronary artery within 60 minutes from first medical contact. As a result of delays in activating EMS and the transport times to the hospital, organizations start the clock from the time the patient arrived in the ED until reperfusion. This process has until now been the norm — but wouldn’t it be nice to be able to start the clock sooner? If we start the clock with first contact with medical providers, does this include EMS? Should it?
Hospitals should understand the importance of ED/EMS relations and strategize about ways to improve upon these relationships. The call-out above outlines the high-level strategies that can be used to enhance EMS relations.
Any organization that is seeking accreditation as a Chest Pain Center through the Society of Chest Pain Centers is aware that Key Element #17 is emergency department integration with the EMS. This element of the accreditation process has been put in place to help hospitals understand the importance of EMS as an extension of the clinical care team. As part of the accreditation process, the hospital must be able to adequately demonstrate how they have established and maintained their relationship with the local EMS provider/s.
The American Heart Association has an initiative in process called “Mission: Lifeline.” Lifeline Certification Programs will acknowledge STEMI Systems, EMS, Non-PCI/STEMI Referral Centers, and PCI/STEMI Receiving Centers for their efforts to improve quality of care for STEMI patients. One of the relevant points is that EMS should have prearranged destination protocols for STEMI patients, including bypassing non-PCI hospital/STEMI Referral Centers and transporting their patients directly to a primary PCI hospital/ STEMI Receiving Center for patients with anticipated short transport times (e.g. < 30 minutes in an urban/suburban setting) so as to achieve primary PCI within 90 minutes.
Many states have already passed legislation (or are in the process of developing regulatory guidelines) that requires EMS providers transport patients with signs and symptoms that are highly suspicious of an acute MI to hospitals that offer cardiac catheterization/angioplasty, with or without cardiac surgery on site. And, for patients experiencing a neurologic emergency, EMS is required to transport these patients to a hospital that, at minimum, is a designated primary stroke center.
In some instances, EMS districts/ regions and agencies have developed protocols related to STEMI and acute stroke patient receiving facilities with input from their medical directors. These agencies understand the importance these organizations offer and have elected to self-regulate, rather than wait for direction from legislature.
In Corazon’s experience working with hospitals to develop or reengineer cardiovascular and neuroscience programs, we include the local EMS agencies in the “dry run” — an evaluation process performed prior to a program going live. Having the EMS personnel involved demonstrates the organization’s commitment to excellence from pre- to post-hospital care, and helps everyone to better understand the changes that are coming and how they will be impacted.
EMS agencies can play a major role when it comes to deciding transport destinations for patients suffering from an ACS or neurologic events, as well as a host of other conditions. This emphasizes the importance of providing EMS personnel a clear understanding of the organization’s clinical capabilities, as it can impact where patients are transported, consequently affecting patient volumes and accompanying revenue.
In addition to the regulatory requirements focusing on improving patient care and providing direction about when patients should be transported to what hospital, EMS agencies want to partner with hospitals. EMS personnel are required to obtain continuing education requirements in specific disease areas in order to maintain their certification/credentials, and will look to the hospital to help them obtain this training. By including these providers in the hospital’s education/certification programs (ACLS, PALS, etc.), the EMS providers will feel like they are truly an extension of the care team through this more inclusive approach.
There are many reasons why hospitals should collaborate with EMS agencies, and many ways to do so. The primary reason to enhance collaboration and foster a team-oriented environment is the potential for improved clinical quality and more streamlined operations.
EMS personnel are trained to function in emergency situations, and work to transport patients to the closest, most appropriate healthcare facility. While there are policies and regulations in place for EMS providers regarding which facility the patients should be transported to, collaborating with them will continue to demonstrate that EMS is a valuable part of the healthcare delivery team.
Only with a truly collaborative and team-oriented approach will major strides be made in pre-hospital care delivery. Streamlining care before the patient even reaches the hospital can do much to improve the patient experience through the full continuum of care.
Kevin Miracle can be contacted at firstname.lastname@example.org.
- Pitts SR, Niska RW, Xu J, et al. National Hospital Ambulatory Medical Care Survey: 2006 emergency department summary. Natl. Health Stat Report 2008;7:1–38.
- Bhuiya FA, Pitts SR, McCaig LF. Emergency Department Visits for Chest Pain and Abdominal Pain: United States, 1999–2008. NCHS Data Brief #43. September 2010. Available online at www.cdc.gov/nchs/ data/databriefs/db43.pdf. Accessed June 21, 2011.
- Johnson J. Getting to the heart of it: proven strategies to bypass the competition in cardiovascular services. Pittsburgh, PA: Corazon Consulting, LP; 2003.
- Canto JG, Zalenski RJ, Ornato JP, et al. 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(24):3018–3023.
- Hutchings CB, Mann NC, Daya M, et al. Rapid early action for coronary treatment study. Patients with chest pain calling 9-1-1 or self transporting to reach definitive care: which mode is quicker? American Heart J 2004;147(1):35–41.
- Brown AL, Mann NC, Daya M, et al. 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(2):173–178.
- Society of Chest Pain Centers. Available online at http://www.scpcp.org. Accessed June 21, 2011.