Door-to-balloon time in primary percutaneous coronary intervention for patients with ST-Segment Elevation Myocardial Infarction

Introduction: Over the past years Primary Percutaneous Coronary Intervention (PCI) has emerged as an effective treatment strategy for acute ST-Elevation Myocardial Infarction (STEMI).1 The survival rate with Primary PCI however is dependent on the time to treatment,2 thus, given the time dependency of survival in patient with STEMI undergoing Primary PCI, the American College of Cardiology and American Heart Association (ACC/AHA) in their management guidelines of acute myocardial infarction also endorsed by European Society of Cardiology (ESC) have established a door- to-balloon time of 90 minutes as a gold standard for Primary PCI.4 The aim of this audit is to measure and compare this key performance measurement for quality of care of patients with STEMI in the Maltese Islands. Methods: This audit was conducted at the only PCI-capable hospital in Malta – Mater Dei Hospital. All the patients coming in through the Accident and Emergency Department with an ST-elevation Myocardial Infarction or a new onset Left Bundle Branch Block (LBBB), thus eligible for a Primary PCI, were included in this audit. This was a prospective audit between January 2012 and December 2012 and using a proforma, data was collected primarily to map out the Door-to-Ballon times for Primary PCI during that period. This data was also used to pinpoint areas were time delays occur when dealing with STEMI cases. Door-to-Balloon times from pre-hospital diagnosis of STEMI using the MRX was also audited and compared to times of in-hospital STEMI diagnosis. Results: During the 12 months duration of the audit, 157 patients were recorded in the CathLab Database as having had an Emergency Primary PCI. Recorded in the audit were 135 patients of which 123 were STEMI patients eligible for a Primary PCI and 12 STEMI patients not eligible for Primary PCI and thus not included in the audit. The Mean Door-to- Balloon times of all 123 patients was found to be 101.45 minutes. Data analysis showed that the times during 'Office Hours' (8am to 5pm) were statistically significantly less than those of 'After hours' (5pm to 8am) (N=123, p<0.001) and those with a Door-to- Balloon time of more than 90 minutes, data analysis showed the number of such cases were statistically significantly less during 'Office Hours' (N=36, p=0.02). With pre-hospital ECG diagnosis of STEMI, data analysis showed that with MRX, Door-to-Ballon times are significantly less when compared to those during 'Office Hours' and 'After Hours' (N=57, p=0.003 and N=66, p<0.001 respectively). Conclusion: From the results obtained, local achievement to remain well within the standards suggested by the ACC/AHA and ESC of Primary PCI ? 90 minutes for STEMI was not reached, however several factors contributing to delays and strategies to minimize delay were pointed out in order to further improve the local practice and thus lowering mortality rates associated with STEMI.peer-reviewe

Cardiac arrest recognition and telephone CPR by emergency medical dispatchers

Emergency Medical Service (EMS) systems annually encounters about 275 000 out-of-hospital cardiac arrest (OHCA) patients in Europe and approximately 420,000 cases in the United States.1 Survival rates have been reported to be poor with approximately 10% survival to hospital discharge.2 The chance of surviving from an OHCA is highly associated with Emergency Medical Dispatchers’ (EMD) recognition of cardiac arrest, early bystander cardiopulmonary resuscitation (CPR), and early defibrillation.3-6 This study was a simulation based study. All emergency nurses who were eligible by training to answer 112 calls and activate the EMS were included in this study. The simulations were run by two experienced ED nurses who followed predefined scripts. The two key questions that the authors were after included ascertaining patient responsiveness and breathing status. EMDs who offered telephone assisted CPR (tCPR) were noted and observed. The mean percentage recognition of out of hospital cardiac arrest by the Maltese EMDs was 67%. 28% of EMDs who recognized cardiac arrest asked both questions regarding patient’s responsiveness and breathing whilst only 8% of EMDs who did not recognize cardiac arrest asked both questions. The mean percentage of telephone assisted CPR was 58%. Conclusion: When compared to other European countries, OHCA recognition by Maltese EMDs needs to improve. However, given that the local EMDs have no formal guidelines or algorithms for their use during 112 calls, results are encouraging to say the least especially in telephone assisted CPR. With educatiopeer-reviewe

CPR performance in lay people with telephone assisted CPR instructions : a prospective manikin-based observational study

Background: It is reported that Emergency Medical Services (EMS) in Europe, annually encounter about 275,000 out-of-hospital cardiac arrests (OHCA) whilst in the United States (US) this number rises to 420,000. The chance of survival from an OHCA is dependent on recognition of cardiac arrest by Emergency Medical Dispatchers’ (EMDs), early bystander cardiopulmonary resuscitation (CPR), and early defibrillation. Telephone assisted CPR (TCPR) by EMDs (also known as dispatcher assisted CPR – DA-CPR) has been shown to double the frequency of bystander CPR so much so that it has now obtained a key position in the 2015 European Resuscitation Council guidelines. --- Method: This was a prospective, manikin-based observational study conducted in Malta between July 2018 and July 2019. The aim of this study was to test a set of TCPR instructions in Maltese on lay people with no previous knowledge of CPR. The primary endpoint was to check for understanding and correct execution of such instructions vis-à-vis hand positioning during chest compression, compressions depth and rate. Participants were recruited from 10 localities around Malta. Data was collected using Laerdal’s Resus Annie® QCPR manikin and SkillReporterTM (PC) software. --- Results: One hundred fifty-five participants were included in the study. Approximately 7 out of 10 participants performed compressions with correct hand position. Approximately 6 out of 10 participants performed a compression rate between 100 – 120/min and 2 out of 10 rescuers achieved the recommended 50-60mm compression depth. --- Conclusion: In our study we found that in Malta, laypeople with no previous CPR training can understand and execute our proposed chest compression only TCPR instructions in Maltese. The introduction of a standard operating procedure and training of EMDs on policy, expectations and performance is vital if we need to improve bystander CPR and survival rates locally. Training coupled with quality improvement projects such as call collection for review, analysis and feedback is the way forward.peer-reviewe

EFSUMB Clinical Practice Guidelines for Point-of-Care Ultrasound:Part One (Common Heart and Pulmonary Applications) SHORT VERSION

Aims To evaluate the evidence and produce a summary and recommendations for the most common heart and lung applications of point-of-care ultrasound (PoCUS). Methods We reviewed 10 clinical domains/questions related to common heart and lung applications of PoCUS. Following review of the evidence, a summary and recommendation were produced, including assignment of levels of evidence (LoE) and grading of the recommendation, assessment, development, and evaluation (GRADE). 38 international experts, the expert review group (ERG), were invited to review the evidence presented for each question. A level of agreement of over 75 % was required to progress to the next section. The ERG then reviewed and indicated their level of agreement regarding the summary and recommendation for each question (using a 5-point Likert scale), which was approved if a level of agreement of greater than 75 % was reached. A level of agreement was defined as a summary of “strongly agree” and “agree” on the Likert scale responses. Findings and Recommendations One question achieved a strong consensus for an assigned LoE of 3 and a weak GRADE recommendation (question 1). The remaining 9 questions achieved broad agreement with one assigned an LoE of 4 and weak GRADE recommendation (question 2), three achieving an LoE of 3 with a weak GRADE recommendation (questions 3–5), three achieved an LoE of 3 with a strong GRADE recommendation (questions 6–8), and the remaining two were assigned an LoE of 2 with a strong GRADE recommendation (questions 9 and 10). Conclusion These consensus-derived recommendations should aid clinical practice and highlight areas of further research for PoCUS in acute settings