Prehospital Identification of Underlying Coronary Artery Disease by Community Paramedics.

There is a lack of definitive evidence that preventative, in-home medical care provided by highly trained community paramedics reduces acute health care utilization and improves the overall well-being of patients suffering from chronic diseases. The Expanding Paramedicine in the Community (EPIC) trial is a randomized controlled trial designed to investigate the use of community paramedics in chronic disease management (ClinicalTrials.gov ID: NCT02034045). This case of a patient randomized to the intervention arm of the EPIC study demonstrates how the added layer of frequent patient contact by community paramedics and real-time electronic medical record (EMR) correspondence between the paramedics, physicians and other involved practitioners prevented possible life-threatening complications. The visiting community paramedic deduced the need for an electrocardiogram, which prompted the primary care physician to order a stress test revealing abnormalities and thus a coronary artery bypass graft was performed without emergency procedures, unnecessary financial expenditure or further health degradation such as a myocardial infarction.

Prehospital diagnosis and triage of ST-elevation myocardial infarction by paramedics without advanced care training.

BACKGROUND: Prehospital triage of ST-elevation myocardial infarction (STEMI) for primary percutaneous coronary intervention (PCI) reduces treatment times. Prehospital triage and transport of STEMI patients have traditionally been undertaken in emergency medical service systems with Advanced Care Paramedics (ACPs). However, ACPs are not available in many regions. A pilot study was conducted to determine the feasibility of prehospital STEMI triage in a region with only Primary Care Paramedics. METHODS: Hemodynamically stable patients with chest pain and suspected STEMI were brought directly to a catheterization laboratory for primary PCI. End points included accuracy of prehospital STEMI identification, complications during transfer, and treatment times. RESULTS: One hundred thirty-four consecutive patients with suspected STEMI were triaged for primary PCI. Only 1 patient developed complications during transport (rapid atrial flutter) that required ACP skills. One hundred thirty-three patients underwent urgent angiography, and 105 patients underwent PCI. Based on physician interpretation of the prehospital electrocardiogram, there was agreement with triage decision for 121 (90%) of the 134 cases. The final diagnosis based on the angiogram and cardiac markers was true STEMI for 106 patients and false positive for 28 patients. The median first medical contact to balloon time was 91 (81-115) minutes. CONCLUSIONS: Hemodynamically stable patients with suspected STEMI can be safely and effectively transported directly for primary PCI by paramedics without advanced care training. Prehospital STEMI triage for primary PCI can be extended to regions that have few or no paramedics with advanced care training.

Implementation trial of the basic life support termination of resuscitation rule: reducing the transport of futile out-of-hospital cardiac arrests.

BACKGROUND: The basic life support (BLS) termination of resuscitation (TOR) rule recommends transport and continued resuscitation when cardiac arrest is witnessed by EMT-Ds, or there is a return of spontaneous circulation, or a shock is given, and prior studies have suggested the transport rate should fall to 37%. METHODS AND RESULTS: This real-time prospective multi-center implementation trial evaluated the BLS TOR rule for compliance, transport rate and provider and physician comfort. Both provider and physician noted their decision-making rationale and ranked their comfort on a 5-point Likert scale. Functional survival was measured at discharge. Of 2421 cardiac arrests, 953 patients were eligible for the rule, which was applied correctly for 755 patients (79%) of which 388 were terminated. 565 patients were transported resulting in a reduction of the transport rate from 100% (historical control) to 59% (p<0.001). The BLS TOR rule was not followed in 198 eligible patients (21%) and they were all transported despite meeting the criteria to terminate. Providers cited 241 reasons for non-compliance: family distress, short transport time interval, younger age and public venue. All 198 transported patients, non-compliant with the rule, died. Both providers and physicians were comfortable with using the rule to guide TOR (median [IQR] of 5 [4,5]; p<0.001). CONCLUSIONS: This implementation trial confirmed the accuracy of the BLS TOR rule in identifying futile out-of-hospital cardiac arrest (OHCA) resuscitations, significantly reduced the transport rate of futile OHCA and most providers and physicians were comfortable following the rule's recommendations.

Expanding Paramedicine in the Community (EPIC): study protocol for a randomized controlled trial.

BACKGROUND: The incidence of chronic diseases, including diabetes mellitus (DM), heart failure (HF) and chronic obstructive pulmonary disease (COPD) is on the rise. The existing health care system must evolve to meet the growing needs of patients with these chronic diseases and reduce the strain on both acute care and hospital-based health care resources. Paramedics are an allied health care resource consisting of highly-trained practitioners who are comfortable working independently and in collaboration with other resources in the out-of-hospital setting. Expanding the paramedic's scope of practice to include community-based care may decrease the utilization of acute care and hospital-based health care resources by patients with chronic disease. METHODS/DESIGN: This will be a pragmatic, randomized controlled trial comparing a community paramedic intervention to standard of care for patients with one of three chronic diseases. The objective of the trial is to determine whether community paramedics conducting regular home visits, including health assessments and evidence-based treatments, in partnership with primary care physicians and other community based resources, will decrease the rate of hospitalization and emergency department use for patients with DM, HF and COPD. The primary outcome measure will be the rate of hospitalization at one year. Secondary outcomes will include measures of health system utilization, overall health status, and cost-effectiveness of the intervention over the same time period. Outcome measures will be assessed using both Poisson regression and negative binomial regression analyses to assess the primary outcome. DISCUSSION: The results of this study will be used to inform decisions around the implementation of community paramedic programs. If successful in preventing hospitalizations, it has the ability to be scaled up to other regions, both nationally and internationally. The methods described in this paper will serve as a basis for future work related to this study. TRIAL REGISTRATION: ClinicalTrials.gov: NCT02034045. Date: 9 January 2014.