Improving STEMI outcomes starts with building trust

Ada County Paramedics, a three-time Mission: Lifeline recipient, describes their collaborations with hospitals and doctors to improve STEMI care

By Hadley Mayes

Ada County Paramedics is regularly asked by other EMS agencies for advice on achieving this important level of care and recognition.

Ada County Paramedics, located in Boise, Idaho, has provided BLS and ALS pre-hospital health care since 1975. The agency ran approximately 26,000 calls in 2015. Ada County Paramedics has 133 employees, running 911 dispatched calls from 13 stations across the county which includes the cities of Boise, Meridian, Eagle, Star, Garden City and parts of Kuna.

For Ada County Paramedics and its two major hospital systems — partners in the entire process — hinged on building trust among providers.
For Ada County Paramedics and its two major hospital systems — partners in the entire process — hinged on building trust among providers. (Photo/Courtesy of Saint Alphonsus Regional Medical Center, Level II Trauma Center, Boise, Idaho)

For Ada County Paramedics and its two major hospital systems — partners in the entire process — hinged on building trust among providers. Here is how we used to respond to STEMI and how we developed a Mission: Lifeline award winning program.

History: Opportunity to improve

Before the improvement process began when a STEMI was recognized after performing a 12-lead EKG in the field, the process was long and somewhat disjointed. With obvious protocol gaps and a process that had yet to be established or streamlined, Ada County Paramedics were eager to define the process and help ensure it was the same, across the board, no matter to which hospital or location paramedics delivered a patient.

In the past, the STEMI protocol often looked like this:

  • Paramedic crew manually called the hospital to alert and activate cath lab preparation.
  • Medics arrived at the emergency department with the patient.
  • Emergency physician screened patient and field reports and confirmed the paramedics’ STEMI diagnosis.
  • After roughly a half hour or more, the patient was then taken to the cath lab.

The above process differed from facility to facility and even from physician to physician. Seeing that there were not only inefficiencies in the process, but inconsistencies, Ada County Paramedics sought out key players in both hospital systems to discuss how it could be improved. Ada County Paramedics met with the local cardiologist groups, emergency department groups and STEMI coordinators.

Series of important changes

Harry Eccard, Deputy Chief Ada County Paramedics, who led the STEMI process overhaul, began with looking at the agency's data and how it compared to national criteria and best practices, including guidelines from Society of Chest Pain Centers and the American Heart Association. About four years ago, Eccard presented these national benchmarks to hospital leadership to illustrate the opportunity for a process change.

One simple, yet monumental change was the way the hospitals were alerted of an incoming STEMI patient.

"We started transmitting the EKGs in-field, to the hospital with the push of a button," Eccard said. "With this in place, we no longer needed to call the hospital, which could take precious time and attention away from our patients."

Another big change Ada County Paramedics and the hospitals implemented was diverting STEMI patients from the emergency department directly to the cath lab. This significantly decreased the time from onset of patient symptoms to the patient physically being in the cath lab.

Photo/Courtesy of Saint Alphonsus Regional Medical Center, Level II Trauma Center, Boise, Idaho

"We had to look at it from the perspective, that just because it may have been done a certain way in the past, it was perhaps no longer serving the patient as well as it could," Eccard said. "Instead of dominos falling, and each person waiting on someone else before they could start preparations for their own job, one transmission would go out to each necessary medical professional so that each employee could begin their jobs simultaneously."

Skipping the emergency department entirely turned out to benefit the patient more.

"As soon as the button-push transmission is activated, cath lab preparations are underway," Eccard said, "And if it’s outside of regular cath lab hours, key players are immediately paged back to their respective hospitals."

Now, each Monday, the hospital’s STEMI Coordinators receive a list of all the STEMI calls Ada County Paramedics received in the past seven days. Having a report of the first medical contact to EKG time, transmission time to arrival at the hospital and on-scene time helps the collaborators stay focused on the same goal — a speedier process to mobilize the cath lab so when the patient arrives, they’re ready.

"The more time we can give on the front end to get everyone mobilized to the cath lab, the better," Eccard said.

The final change that was perhaps one of the more difficult to implement in the new STEMI process was no longer requiring an emergency physician to confirm the STEMI as diagnosed by paramedics in the field.

"There was a lot of learning and trusting one another that needed to take place," Eccard said. "This whole thing really hinged on trust."

Maintaining Mission: Lifeline recognition

Ada County Paramedics found the newly implemented changes in each hospital’s STEMI protocol were somewhat difficult at first, as processes that had been agreed upon weren’t necessarily adhered to. But strong data proved the new process worked better than what had been done historically.

Because Ada County Paramedics is the only EMS transport agency in the county, the agency has a good amount of say over processes. Healthy working relationships between paramedics and the hospitals have also helped maintain this AHA-recognized status.

"We have representatives sitting on each hospital systems’ cardiac care and STEMI committees," Eccard said. "The Regional Interagency Committee on EMS meets monthly. There’s a lot of open, honest communication between us and STEMI Coordinators. We work together, that’s what this is all about."

Because of their success in STEMI protocol processes, Ada County Paramedics frequently receive calls and inquiries from other agencies asking how to achieve Mission: Lifeline recognition.

In addition to urging the agencies to approach their hospital systems, Ada County Paramedics have another simple recommendation.

"Just sit down, have the conversation and be honest and respectful of one another," Eccard said. "Remember that everyone's end goal is the same. We all want what’s best for our patients."

About Ada County Paramedics

Hadley Mayes is the Ada County Paramedics PIO and marketing coordinator. Ada County (Idaho) Paramedics has provided exceptional medical care and superior service since 1975. Our expertise and genuine concern for our patients are just a few of the many things that shape our philosophy, which is based on integrity, trust, humanity, stewardship and excellence.

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