Ways to improve prehospital care
Next time a myocardial infarction patient arrives in your ED, you may find that the 12-lead electrocardiogram (ECG) has already been done in the field. This is only one example of a wide array of new approaches for prehospital care outlined in new guidelines for emergency cardiovascular care, says Rebecca L. Stark-Johnson, CRNA, APNP, anesthesia manager at Fort Atkinson (WI) Memorial Health Services and a regional faculty instructor for the Dallas-based American Heart Association’s (AHA’s) Advanced Cardiac Life Support (ACLS) Program.
"The guidelines emphasize that ACLS issues do indeed start in the field and not just at the ED entrance," she says.
3 minutes to defibrillation
Here are ways to improve prehospital care, according to the guidelines:
• Set a goal for rapid defibrillation.
The guidelines emphasize early defibrillation using first responders and automated external defibrillators (AEDs), says John M. Field, MD, FACC, FACEP, associate professor of medicine and surgery at Pennsylvania State University College of Medicine in Hershey, and ACLS science editor at AHA. "The goal is three minutes to defibrillation in unmonitored areas of the hospital and campus sites."
For patients in cardiac arrest, rapid defibrillation is a high-priority goal, says Stark-Johnson. "Community and in-hospital ACLS must be supported by a well-established basic life support program that can provide immediate emergency CPR."
The guidelines recommend that health care providers with a duty to respond to cardiac arrest should be educated, equipped, and authorized to perform automated external defibrillation, she says.
The AHA offers a training program, the Heartsaver AED Course, which is only four hours in length, says Bradley. "It is excellent training for all levels of people from layperson without any experience or knowledge, to even health care workers."
The program offers hands-on training with AEDs, says Bradley. "There are scenarios built into the program that allow participants to be very comfortable with the equipment and their skill level," she adds. "I highly recommend this program as a trainer for people new to the concept of AEDs."
• Rapidly triage patients to an appropriate intervention site.
Many rural areas do not have the ability to provide ACLS skills in the field, notes Stark-Johnson. "But they may have the ability to send a 12-lead ECG for the ED physician to [evaluate]," she says. "This is a timesaving factor."
The more rapid entry into the ACLS mode, the greater the opportunity to minimize the extent of damage or maximize the ability to convert an arrhythmia, explains Stark-Johnson.
• Know benefits of a prehospital 12-lead ECG.
There has been a continued shift to the prehospital arena for early identification of myocardial infarction, reports Darlene Bradley, RN, MSN, MAOM, CCRN, CEN, director of emergency/trauma services at UCI Medical Center at University of California-Irvine.
"Recommendations are now provided for paramedics to complete a 12-lead ECG in the field and transmit the information to an ED that is immediately equipped to provide fibrinolytic therapy," she explains.
For patients with acute coronary syndromes, the guidelines recommend a prehospital 12-lead ECG, notes Stark-Johnson. "This improves diagnosis, reduces time to treatment, identifies patients requiring reperfusion, contributes to mortality reduction, and facilitates triage to cardiac centers."
• Consider prehospital fibrinolytic therapy.
If there is a prolonged transfer time to a receiving facility, EMS agencies may want to consider administration of this drug prior to arrival in the ED, says Bradley.
"The goal of care is to reduce the door-to-drug time," she stresses. "Nurses should be in a state of readiness with emergency equipment, 12-lead ECG, and medications immediately available."
"This is beneficial when the transport of patients with acute infarction from home to the hospital is prolonged," says Stark-Johnson.
Stark-Johnson recommends that if the total of the following exceeds 60 minutes, you should consider prehospital fibrinolytics: Onset of chest pain to contact of ACLS personnel with patient, and arrival of ACLS at the patient’s side to arrival at the hospital.
Angioplasty is an alternative to fibrinolytic therapy in centers with high volume and experienced operators, says Stark-Johnson. "Patients in cardiogenic shock who are less than [age] 75 need transport to cardiac interventional centers," she says.
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