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Decision Making In a Time Sensitive Setting: Can Paramedics Identify St-Elevation Myocardial Infarction on a Pre-Hospital Electrocardiogram? A Literature Review

Author: Truc Baccan, BS

Primary Advisor: Juliana Brixey, PhD, MPH, MSN, RN

Committee Members: Paul Rowan, PHD, MPH

Masters thesis, The University of Texas Health Science Center School of Health Information Sciences at Houston.


Background: Coronary artery disease is the most common type of cardiovascular disease, accounting for 1 of every 6 deaths. In a time sensitive setting of a pre-hospital case of an acute myocardial infarction, where time is muscle and every minute counts, paramedics often make clinical decisions with limited information while faced with multitude of interplay factors and distractions; thus, emergency setting requires a different way of approaching and resolving clinical problems. Furthermore, as first medical responders, paramedics provide emergency and nonemergency care to patients with diverse complex medical conditions and injuries, the level of clinical competence expected and scope of practice has grown; therefore, it is important to evaluate the judgment, decision-making, and competence of paramedics.

Methods: Medline, PsycINFO, and PubMed databases were searched for published English language studies that evaluated paramedics ability to identify ST-elevation myocardial infarction on a pre-hospital electrocardiogram. The Mixed Methods Appraisal Tool (MMAT) was selected to provide a measure of methodological quality of included studies. The MMAT served as a checklist with template of key questions to assist in the critical appraisal of studies included in systematic mixed studies reviews.

Results: Sixteen studies were reviewed. All studies were quantitative. Fifteen were nonrandomized and one was randomized. Study quality scores ranged from 25% to 100%. One was excluded from the final review due to low quality scores for inclusion in the literature review. A total of 11 articles were identified as studies assessing the diagnostic performance of paramedics. Of those, five studies were of paper-based clinical scenarios and six studies were of actual scenarios or in the field with chest pain patient who required an ECG. A total of five studies were identified as assessing the clinical impact of pre-hospital ECGs obtained and interpreted by paramedics. Across the studies, there were two types of outcomes: short-term clinical impacts, and long-term outcomes. The observed clinical impacts were: (1) time saving, comprised of door to balloon time, first medical contact to needle time, door to needle time, or treatment of thrombolytic time. The second observed set of clinical impacts was: (2) hospital mortality, length of hospital stay, and long term mortality.

Conclusions: The purpose of this paper was to undertake a literature review examining the ability of paramedics to identify ST-elevation myocardial infarction on pre-hospital electrocardiograms. There were consistence evidences supporting paramedics’ role as interpreters and decision makers. Additionally, favorable beneficial effects on short-term and long-term were noted in studies evaluating clinical impact of pre-hospital ECGs obtained and interpreted by paramedics.