Effect of Real-Time Physician Oversight of Prehospital STEMI Diagnosis on ECG-Inappropriate and False Positive
Laurie-Anne Boivin-Proulx1,2, Alexis Matteau1,2, Christine Pacheco3
1Centre de Recherche du Centre Hospitalier de l'Université de Montréal (CRCHUM), Montréal, Québec, Canada.
Insights
Physician oversight in prehospital ST-elevation myocardial infarction diagnosis may reduce inappropriate activations but delays treatment. Further research is needed to balance diagnostic accuracy and timely interventions in emergency cardiac care.
Area of Science:
- Cardiology
- Emergency Medicine
- Health Services Research
Background:
- Prehospital diagnosis of ST-elevation myocardial infarction (STEMI) and early cardiac catheterization laboratory (CCL) activation are crucial for reducing ischemic time.
- Physician oversight in prehospital STEMI diagnosis systems is being evaluated for its impact on diagnostic accuracy and treatment delays.
Purpose of the Study:
- To determine if physician oversight improves diagnostic performance in a prehospital STEMI diagnosis and CCL activation system.
- To assess the effect of physician reinterpretation on treatment delays in STEMI patients.
Main Methods:
- A study analyzed 428 prehospital electrocardiograms (ECGs) for STEMI diagnosis in two Montreal catchment areas (2012-2015).
- Patients received either automated CCL activation or physician reinterpretation of ECGs before CCL activation.
- System performance was measured by false positive rates, inappropriate activations (IA), and time from first medical contact (FMC) to device deployment.
Main Results:
- Physician oversight showed a trend towards decreasing inappropriate activations (7% vs 3%, P=0.062).
- However, physician oversight was associated with a significantly lower proportion of patients achieving the target FMC-to-device time (76% vs 60%, P<0.001).
- No significant difference in false positive activation rates was observed between automated and physician-oversight groups.
Conclusions:
- Real-time physician oversight may reduce inappropriate STEMI activations but can negatively impact time-to-treatment.
- Identifying predictors for inappropriate activations could optimize system performance by guiding the need for physician oversight.
- Larger clinical studies are required to further investigate and validate these findings.
Background:
ST-elevation myocardial infarction diagnosis at first medical contact (FMC) and prehospital cardiac catheterization laboratory (CCL) activation are associated with reduced total ischemic time and therefore have become the dominant ST-elevation myocardial infarction referral method in primary percutaneous coronary intervention systems. We sought to determine whether physician oversight was associated with improved diagnostic performance in a prehospital CCL activation system and what effect the additional interpretation has on treatment delay.
Methods:
Between 2012 and 2015, all patients in 2 greater Montreal catchment areas with a chief symptom of chest paint or dyspnea had an in-the-field electrocardiogram (ECG). A machine diagnosis of "acute myocardial infarction" resulted either in automatic CCL (automated cohort without oversight) or transmission of the ECG to the receiving centre emergency physician for reinterpretation before CCL activation. System performance was assessed in terms of the proportion of false positive and inappropriate activations (IA), as well as the proportion of patients with FMC-to-device times ≤ 90 minutes.
Results:
Four hundred twenty-eight (428) activations were analyzed (311 automated; 117 with physician oversight). Physician oversight tended to decrease IAs (7% vs 3%; P = 0.062), but was also associated with a smaller proportion of patients achieving target FMC-to-device (76% vs 60%; P < 0.001). There was no significant effect on the proportion of false positive activation.
Conclusions:
Real-time physician oversight might be associated with fewer IAs, but also appears to have a deleterious effect on FMC-to-device performance. Identifying predictors of IA could improve overall performance by selecting ECGs that merit physician oversight and streamlining others. Larger clinical studies are warranted.
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