Digital EMS Point of Care Innovation to Improve Rural STEMI Outcomes

项目概要/摘要 美国农村发生ST段抬高型心肌梗死（STEMI）的可能性是普通人群的八分之一， 比城市居民得到及时的治疗。这种差异即使在经皮 冠状动脉介入治疗（PCI）时间根据到医院的距离进行调整， 发病率和死亡率。及时提供农村STEMI护理的一个主要障碍是缺乏可用的辅助工具 护理人员为院前STEMI提供一致的循证方法。我们的建议将 将基于证据的农村紧急医疗服务（EMS）STEMI最佳实践转化为多方面的， 数字化临床决策支持工具来解决这一障碍。这项研究建立在我们团队的基础上， 混合方法研究确定了（i）以前量化不佳的农村EMS STEMI护理复杂性， (ii)及时护理的障碍;（iii）改进的机会。农村STEMI应用将是 使用开发的开源、跨平台的移动的应用程序开发、实施和完善 我们的团队内部。最初，我们将在北部农村开发和测试农村STEMI应用程序的可用性 卡罗莱纳县EMS机构，以提高院前提供者的能力，以减少首次医疗接触（FMC）， 再灌注（PCI或溶栓）时间。这将是第一个智能设备应用程序，提供实时， 针对STEMI EMS患者的循证、指南驱动、患者特异性治疗援助。我们 预计最终的应用程序将包含特定的实时数据，包括EMS到达现场，ECG时间， 附近急诊室、导管室和导管室的地图集成 空房的这种新颖的数字工具将通过提供现场时间倒计时、医院 激活指标倒计时，以及EMS特定的路线导航帮助，以进一步减少FMC， 再灌注时间因此，我们的应用程序将纳入预测FMC所需的关键参数， 再灌注时间，并确定用初始溶栓治疗而不是 PCI。通过在另外七个农村EMS机构分阶段实施农村STEMI应用程序，我们将 评价其缩短FMC至再灌注时间的可行性和初步效果。此应用程序将 还通过提供自动生成的 向所有关键利益相关者提交STEMI反馈报告。最后，这项拟议的研究将是第一个应用混合 方法的方法来描述农村EMS机构之间的实施促进者和障碍， 他们为STEMI患者提供的护理。通过让实地提供者参与半结构化访谈，研究将 强调质量改进工作、EMS管理支持和跨学科合作， 护理患有STEMI的EMS患者。该提案直接解决了如何改进 农村的院前FMC可以缩短再灌注时间，这反过来又会减少发病率和死亡率的差异。我们 随后将在大型多系统混合有效性实施试验中测试农村STEMI应用程序。

Project Summary/Abstract Rural Americans experiencing an ST-Elevation Myocardial Infarction (STEMI) are eight times less likely to receive timely definitive treatment than their urban counterparts. This disparity exists even after percutaneous coronary intervention (PCI) times are adjusted for distance to the hospital and exposes rural patients to excess morbidity and mortality. A major obstacle to timely rural STEMI care is a lack of tools available to assist paramedics in providing a consistent evidence-based approach to prehospital STEMI. Our proposal will translate evidenced-based rural Emergency Medical Services (EMS) STEMI best practices into a multifaceted, digital, clinical decision support tool to address this obstacle. This study builds on our team’s foundational mixed methods research that identified (i) previously poorly quantified complexities of rural EMS STEMI care, (ii) barriers to timely care, and (iii) opportunities for improvement. The Rural STEMI Application will be developed, implemented, and refined using an open-source, cross-platform mobile application developed internally by our team. Initially, we will develop and test the usability of the Rural STEMI App in a rural North Carolina County EMS agency to improve prehospital providers’ ability to reduce first medical contact (FMC) to reperfusion (PCI or thrombolytic) times. This will be the first smart device application to provide real-time, evidence-based, guideline-driven, patient-specific treatment assistance for EMS patients with STEMI. We anticipate that the final App will incorporate specific real-time data, including EMS arrival on scene, ECG time, map integrations of nearby emergency departments and catheterization labs, and catheterization lab availability. This novel digital tool will assist the EMS team by providing a scene time countdown, hospital activation metric countdowns, and EMS-specific route navigation assistance to further decrease FMC to reperfusion time. Thus, our application will incorporate critical parameters needed to predict FMC to reperfusion time and identify patients that are better treated with initial thrombolytic administration instead of PCI. Through phased implementation of the Rural STEMI App in seven additional rural EMS agencies, we will evaluate its feasibility and preliminary effectiveness to reduce FMC to reperfusion time. This application will also address the need for improved STEMI encounter communication by providing an automatically generated STEMI feedback report to all key stakeholders. Finally, this proposed study will be the first to apply a mixed methods approach to characterize implementation facilitators and barriers among rural EMS agencies in the care they provide to STEMI patients. By engaging field providers in semi-structured interviews, the study will emphasize quality improvement efforts, EMS administration support, and interdisciplinary collaboration in the care of EMS patients with STEMI. This proposal directly addresses a critical gap regarding how to improve rural prehospital FMC to reperfusion times, which in turn will reduce disparities in morbidity and mortality. We will subsequently test the Rural STEMI App in a large multisystem hybrid effectiveness-implementation trial.