By now, the value of EMS sending 12-lead EKGs ahead to hospitals is well established. It can speed the diagnosis and confirmation of patients’ ST-elevation myocardial infarctions (STEMIs), and help save valuable minutes toward activating cath labs and clearing their blockages.
The new BR Med-Connect system in East Baton Rouge Parish, Louisiana, allows that, and is showing early promise for cutting door-to-balloon times. Its potential next step—adding video telemedicine capabilities to parish ambulances—could go even farther toward merging the knowledge of ED docs with the skills of providers in the field.
With telemedicine, says Assistant Administrator Chad Guillot, “It’s not just about those few minutes you see a physician when you drop off a patient. The entire time you’re on a call, you can work more closely as a team, because you’re able to share all this information together. That’s what we want to see.”
The video element of BR Med-Connect will rely on a planned upgrade to a 4G wireless network in Baton Rouge; the area’s current 3G network leaves video transmission too choppy and vulnerable to dead spots. But the service has the equipment ready to go in a pair of ambulances, pending that improvement and its own rollout process.
Meanwhile, the current network is fine for data such as 12-leads, and all the service’s trucks can send those. The BR Med-Connect system, supplied by New Jersey-based General Devices, allows bidirectional voice and data among all system partners, including hospitals—“We saw it as a link between everybody,” says Guillot, “not just an EMS unit and a particular hospital.” It consists of the company’s Rosetta-DS laptop/tablet data solution in ambulances; CAREpoint Workstations to receive and integrate information in area EDs; e-Bridge mobile telemedicine components to allow hospital-to-hospital connections; and an e-Net Messenger system for exchanging voice, text and data among all players.
In sending the 12-leads, Rosetta-DS works over digital radios, cellular air cards and cell phones, and can switch among carriers as needed. It sends to any standard PC or PDA, and when using CAREpoint Workstations and e-Net Messenger, can tell senders when their reports get to their destinations. East Baton Rouge medics use it on laptops to send data from their ZOLL monitors, which is received, displayed, archived and reviewed on CAREpoints in the area’s five hospital emergency departments (Our Lady of the Lake, Ochsner, Lane, and Baton Rouge General’s Bluebonnet and Mid City campuses). The local office of emergency preparedness also has one for disaster use. ED staff use the CAREpoints to manage all EMS activities. The 12-leads, after physician review, are forwarded by e-Net Messenger to cath labs and elsewhere. On their cath lab arrival, an audio/visual alert notifies personnel; ED staff are in turn notified when the report is opened, or if it isn’t.
The BR Med-Connect system began operating in February, and there’s not yet been time to amass enough data for conclusions about its success. But there’s at least some early anecdotal evidence that the interval to definitive care for STEMI patients is being squeezed down.
“I know in our hospital, since April, we’ve only had, I believe, 9 or 10 patients with STEMIs, and not all of those had EKGs sent in,” says Cullen Hebert, MD, medical director for East Baton Rouge Parish EMS and a physician at Our Lady of the Lake. “But we have used it, and we’ve been watching the trends very closely. In some cases we’re getting down into the 50- to 60-minute range for door-to-balloon times.”
“I’ve spoken to nurses in the cath labs at some of the hospitals,” says Guillot, “and they’ve told me that on several occasions now, because they’ve been alerted earlier with 12-leads from the field, they’ve been able to make their way down to the ER to receive the patient, in some cases even before we get there. That’s happened several times. And that’s kind of the idea. It’s going to take some time, but it at least gets people thinking in the mode of, Do we really need to wait for this? Maybe we can start moving more quickly.”
The system also provides a benefit to quality review. Previously, medics would drop off the traditional static paperwork with patients, which couldn’t always capture everything that happened on a call. Now docs get detailed electronic records, plus audio recordings of interactions between crews and doctors/nurses. “What’s really neat is that if you have a question, you can go back and listen,” says Hebert. “Did the patient get aspirin? Yes, they said it right there: ‘Patient gets aspirin.’ So it’s another way for checks and balances to happen.”
What’s more, tying the prehospital data electronically in to hospital records also goes a long way toward legitimizing it as part of the care continuum. It’s a rare EMS provider who hasn’t been frustrated by having their reports and assessments underappreciated at the ED. BR Med-Connect ties it institutionally into the record.
“Many times, ERs would run their own tests and things once we got there,” says Guillot, “and what we did in the field wasn’t looked at real well. This gives us an opportunity to better share that data and make it more meaningful to patient care.”
The next step involves collecting data from all the hospitals to quantify the benefit of BR Med-Connect across the community. Besides the STEMIs, it’s being used to facilitate treatment of patients with cardiac arrhythmias (v-tach, v-fib), and work is ongoing to expand it to stroke evaluations.
With any big innovation that changes the equilibrium between field and ED, there can be growing pains. In at least a few cases in Baton Rouge, the ingrained habit of obtaining separate EKGs in the ED has been one that’s died hard. But of course, spending that time on STEMI patients negates much of the value of the prehospital EKG.
“One of the problems we’re going to have in each hospital is changing the culture,” says Hebert. “In our emergency room, they’ve still been getting the EKG when the patient arrives. Sometimes that’s warranted, and sometimes it’s not, so we have to drill down and find out exactly what’s happening with that thought process. We know the transmitted EKGs were excellent in their configuration. So I think it’s just going to be a culture change. Our chest pain committee has now mandated that if they get a valid EKG from EMS, they’re not going to waste time waiting for another to be done at the bedside. That was a huge step.”
A lesson about such changes is to painstakingly work out details and establish all-important buy-in on the front end. In the case of BR Med-Connect, it took some time to get traction. Hospitals’ point people were initially “kind of hit and miss” in their approach, Guillot says, and EMS leaders had to press administrators for the kind of full-fledged commitment necessary to fully integrate the system, train users and maximize its benefit.
Accomplishing that “was really important to the whole thing,” Guillot says. “Once we had those key people in place, they were able to work together, and we didn’t always have mixed messages going on. Having those people communicating is really important in this kind of process.” That includes the whole range of stakeholders: ED staff, administrators, cardiology staff, IT folks, etc.
“This isn’t like going to Best Buy and picking up a computer and saying ‘OK, we’ll make this work,’” Hebert says. “It’s very sophisticated, and it takes a lot of teamwork and time invested. You have to have the protocols done and all the partial questions answered, then you jump in with both feet and bring the protocols to life. You make them living documents, and be prepared to have your knees scraped and a few pats on the back.”