Coronary artery disease is the second leading cause of death in Canada. Time to treatment in ST-elevation myocardial infarction (STEMI) is directly related to morbidity and mortality. Thrombolysis is the primary treatment for STEMI in many regions of Canada because of prolonged transport times to percutaneous coronary intervention-capable centres. To reduce time from first medical contact (FMC) to thrombolysis, some emergency medical services (EMS) systems have implemented prehospital thrombolysis (PHT). PHT is not a novel concept and has a strong evidence base showing reduced mortality.
Here, we describe a quality improvement initiative to decrease time from FMC to thrombolysis using PHT and aim to describe our methods and challenges during implementation. We used a quality improvement framework to collaborate with hospitals, EMS, cardiology, emergency medicine and other stakeholders during implementation. We trained advanced care paramedics to administer thrombolysis in STEMI with remote cardiologist support and aimed to achieve a guideline-recommended median FMC to needle time of <30 min in 80% of patients.
Overall, we reduced our median FMC to needle time by 70%. Our baseline patients undergoing in-hospital thrombolysis had a median time of 84 min (IQR 62–116 min), while patients after implementation of PHT had a median time of 25 min (IQR 23–39 min). Patients treated within the guideline-recommended time from FMC to needle of <30 min increased from 0% at baseline to 61% with PHT. Return on investment analysis showed $2.80 saved in acute care costs for every $1.00 spent on the intervention.
While we did not achieve our goal of 80% compliance with FMC to needle time of <30 min, our results show that the intervention substantially reduced the FMC to needle time and overall cost. We plan to continue with ongoing implementation of PHT through expansion to other communities in our province.
- quality improvement
- ST elevation myocardial infarction
- emergency medical services
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Contributors All authors made substantial contributions to the conception or design of the work, or the acquisition, analysis or interpretation of data. SD is the guarantor of the study and accepts full responsibility for the finished work and/or the conduct of the study, had access to the data, and controlled the decision to publish. SD, AG, NG, CC, SCP, RG and JH were involved in conception of the work. AG, NG, CC, CH, JH, SD and SCP were involved in the analysis and interpretation of the data. All authors were involved in drafting the work or revising it critically for important intellectual content. AG, NG, CC, JH and SCP were involved in initial drafting. All authors critically revised the work. All authors approved the version submitted and agreed to be accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are addressed.
Funding Funding was provided by British Columbia Emergency Health Services, Interior Health and the Specialist Services Committee of BC (award number HSR2019-7). No specific grant/award numbers are available for Interior Health or British Columbia Emergency Health Services funding.
Competing interests None declared.
Ethics No institutional ethical approval was required for this quality improvement initiative from a research ethics board, but ethical considerations were discussed with the working group and Health Authority. The initiative was approved through Interior Health with completion of a thorough privacy impact assessment to ensure patient confidentiality and safety. An ethical dilemma included insuring voluntary participation through informed consent. As a result, patients were informed of their participation in a pilot trial, and each patient appropriately consented to treatment in the prehospital setting using our verbal informed consent script (online supplemental appendices 1 and 3). Lastly, to ensure anonymity of participants, data were collected on a secure network drive that was password protected. Only deidentified patient data were shared with the rest of the study team.
Provenance and peer review Not commissioned; externally peer reviewed.
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