Only in a minority of STEMI-patients do we achieve our goal of PCI in less 90 minutes from them entering the ED. Despite the guidelines clearly recommending a door-to-ballon-time (D2B) of less than 90 minutes.
All the stuff we do in the ED from getting the ECG, making the call, making the phone calls, to getting the PCI staff in place takes time and it always seems to take more than the 90 minutes we aim for.
One obvious solution to this problem is to activate the cathlab already prehospitally. Most of the things that delay us in the ED can be done during the time the patient is transported. Then, ideally the patient could be rolled through the ED and directly to the cathlab for reperfusion.
Sounds simple enough, but as a prehospital doc I’ve lost count of the times I have requested to have the cath lab on standby on our arrival only to see us lose all momentum when we arrive in an ED where no-one knew we were on our way.
I won’t go into the reasons for this here but it is obvious to me solid logistics and operating protocols need to be in place for prehospital activation of the cath lab to work every time.
But what is to gain if we had the logistics in place? These guys do have the framework for it and they looked at the accuracy of prehospital activation of the cathlab and how it affects the relevant timings.
They compared their old procedure of having the ED physiscian activating the cath lab with a new system where a solid framework allowed the EMS personell to requesting the cath lab activated. Their numbers were low but the results nevertheless interesting.
All relevant timings were improved by prehospital activation.
Dispatch to reperfusion time improved by 20 minutes.
Recognition to reperfusion time improved 20 minutes.
Door-to balloon time improved by 18 minutes.
As for accuracy they achieved a sensitivity of 79,5 and a specificity of 99,7%. This means the EMS crews missed a few STEMIS that should have gone to cath lab. However, given that they still treated and transported the patients without delay, we are still a lot better of than with ED activation given the improved timings for correctly identified patients.
So, it is time to start taking this seriously.