Digital EMS Point of Care Innovation to Improve Rural STEMI Outcomes

项目总结/文摘

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.