What does EMS look like in the ideal STEMI and Cardiac Resuscitation system of care?
Before answering that question, it is important to remember that there is no "one-size-fits-all" answer. A city swelling with residents presents different issues than a region where there is more wildlife or livestock than people. Providing emergency medical services to someone at the crest of a Colorado mountain poses obstacles unlike those of transporting a STEMI or cardiac resuscitation patient from one Hawaiian isle to another for percutaneous coronary intervention (PCI).
Through Mission: Lifeline®, the American Heart Association provides a set of guidelines that equip STEMI and cardiac resuscitation systems of care across the nation to improve timely access to appropriate medical treatment, ultimately saving lives. Although early activation of the 911 Emergency Medical System is important in the chain of survival for both the Mission: Lifeline STEMI and the Cardiac Resuscitation programs, community preparation and involvement are necessary to improve the outcomes for victims of out of hospital cardiac arrest. The relationship between the community and the local EMS service can serve as a catalyst for increasing community awareness of the need for CPR, organizing and conducting community CPR classes, and identifying the needs for public Automated External Defibrillator (AED) placement and use.
In the ideal system for EMS and emergency departments, standardized point of entry protocols (created by state-based coalitions of EMS personnel, emergency physicians and cardiologists, and supported by payers and administrators) for both STEMI and cardiac resuscitation systems of care would establish which patients are transported to the nearest hospital, a referral center, and which patients are transported to the nearest receiving center. This will be based in part on the timely acquisition, interpretation and pre-arrival notification of a positive 12-lead electrocardiogram (ECG). With the patient who experiences out of hospital cardiac arrest, there is a high index of suspicion of a STEMI also occurring; especially in those patients who experienced signs and symptoms consistent with acute coronary syndrome prior to the arrest and for those patients with known cardiovascular disease. Once spontaneous return of circulation has returned to the cardiac arrest patient, timely acquisition of a 12 lead ECG is critical to the destination transport decision.
When an ECG indicates STEMI, with or without the additional insult of a cardiac arrest, the catheterization laboratory team would be activated by EMS personnel in the field or by emergency physicians after receiving the notification of the positive ECG. Patients transported to a referral hospital by EMS would remain on the stretcher with EMS personnel in attendance until the decision about whether to transport to a Receiving hospital is rendered. For STEMI patients who transport themselves to a referral center and require primary PCI, activation of EMS via a 9-1-1 system would occur in order to expedite the transfer process. An ideal system would also foster a coordinated curriculum to teach EMS providers and ED staff to care for STEMI patients and to provide feedback on performance and compliance with guidelines. For a more detailed understanding of how EMS effectively operates within a system of care, navigate to the strategies of an ideal EMS.