Paramedic myocardial infarction care with fibrinolytics: a process map and hazard analysis

Despite the supporting published evidence for prehospital fibrinolysis (PHF) for ST-elevation myocardial infarction (STEMI) patients by paramedics, the complexity of the process has not been rigorously explored in a stepwise approach. The objectives of this study were to (1) map the process of care that occurs during EMS management of STEMI with administration of PHF from 911 call to transfer of care to the emergency department and (2) to identify steps that could adversely affect patient safety or clinical outcome.

A Health Care Failure Mode and Effect Analysis was conducted. Steps were identified and organized into major call phases. Each step was categorized as a decision, technical skill, or task. The role required to perform each was identified: emergency medical dispatcher (EMD) or primary (PCP) or advanced care paramedic (ACP). The map was validated against a video-taped STEMI scenario. Once finalized, the steps with potential for risk to safety or outcome (hazard modes (HMs)) were identified. HMs were scored by study team consensus for probability to occur and likely severity of impact to the patient (minimum = 2, maximum = 16, ≥8 considered high risk).

The map consisted of 18 phases and 167 steps, of which 37 (22.2%) were decisions, 67 (40.1%) were technical skills, and 63 (37.7%) were tasks. Ten steps could be completed by an EMD (6.0%), 76 (45.5%) by a PCP, and 81 (48.5%) by an ACP. The phases with the most steps were initial treatment, n = 31 steps (18.0%), and reperfusion therapy, n = 30 steps (18.0%). Sixty-eight HMs were identified, mean score 4.54 (SD 2.32), five of which scored eight or above (7.3%). The highest scoring HMs were history-taking, obtaining 12-lead, and transmitting 12-lead (all scores = 12). The phases with the most HMs were initial treatment (n = 12 HMs) and reperfusion therapy (n = 12 HMs).

In this mapping study of STEMI calls in which paramedics administer fibrinolytics, the process was found to be complex, containing many steps, but relatively few individual steps were highly hazardous to patient care or safety. This study has enabled specific actions to target the highest scoring hazard modes, in an effort to improve paramedic practice and patient safety for EMS STEMI patients. Key words: emergency medical services; myocardial infarction; fibrinolytic agents; ambulances; process map.