Toronto’s cardiac care system is evolving to become one of the most comprehensive in the world. A significant part of that evolution is a new city-wide program involving Toronto EMS where STEMI (ST-Segment Elevation Myocardial Infarction) patients will receive reperfusion therapies in the shortest possible time.
The ability for Toronto’s Level III Paramedics to perform in-field 12-lead electrocardiogram (ECG) acquisition is the first step in a series of required changes to improve the outcome for STEMI patients.
In addition to the patients EMS encounters on 911 emergency calls, Toronto EMS will play a central role in managing patients who arrive at community hospital emergency departments where definitive care may not available.
Implementation of the system will occur in four phases:
Phase One – from January 2008 to early April 2008:
Level III paramedics will acquire a 12-lead ECG for any patient with symptoms suggestive of cardiac ischemia.
If the Zoll monitor reports an “Acute MI” on the ECG print-out, the paramedic will complete a thrombolysis eligibility checklist, notify the closest ED and transport the patient.
The patient will continue to receive on-scene ALS interventions such as oxygen, nitroglycerine, morphine, and ASA.
Phase Two – April 2008:
Toronto EMS will start diverting STEMI patients within a pre-defined area of south-central Toronto directly to the PCI (Percutaneous Coronary Intervention) lab at St. Michael’s Hospital, much as we do today for major trauma.
Patients outside this geographical zone will continue to be taken to the closest appropriate local ED.
Phase Three – April or May 2008:
Toronto EMS will launch a partnership with St. Joseph’s Health Centre to transport STEMI patients from St. Joseph’s ED to St. Michael’s PCI lab. These patients will normally be those who have walked into the St. Joseph’s ED or who were brought there by Level I Paramedic crews.
Level III Paramedic crews will be dispatched to St. Joseph’s ED on a Delta basis to ensure these patients receive the fastest possible access to St. Michael’s PCI services while being well cared for en route.
This process will be called a STAT (STEMI ALS Transport) call.
Phase Four – Early to mid-2009:
City-wide Level III Paramedic direct transport to an on-call PCI lab for all STEMI patients.
Level III Paramedic provisional diagnosis of MI using manual 12-lead interpretation in addition to the interpretation provided by the monitor.
Level III Paramedic administration of medications on scene and en route in preparation for PCI.
24-hour access to three PCI sites (St. Michael’s, Sunnybrook, and UHN General Site).
City-wide STAT program introduced hospital-by-hospital as each facility becomes ready to participate.
Paramedics
