Vol 28, No 1 (2021)
Original Article
Published online: 2019-07-15

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Paramedic versus physician-staffed ambulances and prehospital delays in the management of patients with ST-segment elevation myocardial infarction

Artur Borowicz1, Klaudiusz Nadolny123, Kamil Bujak4, Daniel Cieśla5, Mariusz Gąsior4, Bartosz Hudzik46
Pubmed: 31313273
Cardiol J 2021;28(1):110-117.


Background: Time delays to reperfusion therapy in ST-segment elevation myocardial infarction (STEMI) still remain a considerable drawback in many healthcare systems. Emergency medical service (EMS) has a critical role in the early management of STEMI. Under investigation herein, was whether the use of physician-staffed ambulances leads to shorter pre-hospital delays in STEMI patients.

Methods: This was an observational and retrospective study, using data from the registry of the Silesian
regional EMS system in Katowice, Poland and the Polish Registry on Acute Coronary Syndromes
(PL-ACS) for a study period of January 1, 2013 to December 31, 2016. The study population (n = 717)
was divided into two groups: group 1 (n = 546 patients) — physician-staffed ambulances and group 2
(n = 171 patients) — paramedic-staffed ambulances.

Results: Responses during the day and night shifts were similar. Paramedic-led ambulances more
often transmitted 12-lead electrocardiogram (ECG) to the percutaneous coronary intervention centers.
All EMS time intervals were similar in both groups. The type of EMS dispatched to patients (physicianstaffed vs. paramedic/nurse-only staffed ambulance) was adjusted for ECG transmission, sex had no impact on in-hospital mortality (odds ratio [OR] 1.41; 95% confidence interval [CI] 0.79–1.95;
p = 0.4). However, service time exceeding 42 min was an independent predictor of in-hospital mortality
(OR 4.19; 95% CI 1.27–13.89; p = 0.019). In-hospital mortality rate was higher in the two upper
quartiles of service time in the entire study population.

Conclusions: These findings suggest that both physician-led and paramedic-led ambulances meet the
criteria set out by the Polish and European authorities. All EMS time intervals are similar regardless
of the type of EMS unit dispatched. A physician being present on board did not have a prognostic impact
on outcomes.

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  1. Widimsky P, Wijns W, Fajadet J, et al. Reperfusion therapy for ST elevation acute myocardial infarction in Europe: description of the current situation in 30 countries. Eur Heart J. 2010; 31(8): 943–957.
  2. De Luca G, Suryapranata H, Ottervanger JP, et al. Time delay to treatment and mortality in primary angioplasty for acute myocardial infarction: every minute of delay counts. Circulation. 2004; 109(10): 1223–1225.
  3. Kristensen SD, Laut KG, Fajadet J, et al. Reperfusion therapy for ST elevation acute myocardial infarction 2010/2011: current status in 37 ESC countries. Eur Heart J. 2014; 35(29): 1957–1970.
  4. Ibanez B, James S, Agewall S, et al. 2017 ESC Guidelines for the management of acute myocardial infarction in patients presenting with ST-segment elevation: The Task Force for the management of acute myocardial infarction in patients presenting with ST-segment elevation of the European Society of Cardiology (ESC). Eur Heart J. 2018; 39(2): 119–177.
  5. Beygui F, Castren M, Brunetti ND, et al. Pre-hospital management of patients with chest pain and/or dyspnoea of cardiac origin. A position paper of the Acute Cardiovascular Care Association (ACCA) of the ESC. Eur Heart J Acute Cardiovasc Care. 2015 [Epub ahead of print].
  6. Haner A, Örninge P, Khorram-Manesh A. The role of physician–staffed ambulances: the outcome of a pilot study. J Acute Dis. 2015; 4(1): 63–67.
  7. Böttiger BW, Bernhard M, Knapp J, et al. Influence of EMS-physician presence on survival after out-of-hospital cardiopulmonary resuscitation: systematic review and meta-analysis. Crit Care. 2016; 20: 4.
  8. Hagihara A, Hasegawa M, Abe T, et al. Physician presence in an ambulance car is associated with increased survival in out-of-hospital cardiac arrest: a prospective cohort analysis. PLoS One. 2014; 9(1): e84424.
  9. Polonski L, Gasior G, Gierlotka M, et al. Polish Registry of Acute Coronary Syndromes (PL-ACS). Characteristics, treatments and outcomes of patients with acute coronary syndromes in Polan. Kardiol Pol. 2007; 65(8): 861–872.
  10. Steg PhG, James SK, Atar D, et al. ESC Guidelines for the management of acute myocardial infarction in patients presenting with ST-segment elevation. Eur Heart J. 2012; 33(20): 2569–2619.
  11. McGinn AP, Rosamond WD, Goff DC, et al. Trends in prehospital delay time and use of emergency medical services for acute myocardial infarction: experience in 4 US communities from 1987-2000. Am Heart J. 2005; 150(3): 392–400.
  12. Goldstein P, Lapostolle F, Steg G, et al. Lowering mortality in ST-elevation myocardial infarction and non-ST-elevation myocardial infarction: key prehospital and emergency room treatment strategies. Eur J Emerg Med. 2009; 16(5): 244–255.
  13. Savage ML, Poon KKC, Johnston EM, et al. Pre-hospital ambulance notification and initiation of treatment of ST elevation myocardial infarction is associated with significant reduction in door-to-balloon time for primary PCI. Heart Lung Circ. 2014; 23(5): 435–443.
  14. Curtis JP, Portnay EL, Wang Y, et al. The pre-hospital electrocardiogram and time to reperfusion in patients with acute myocardial infarction, 2000-2002: findings from the National Registry of Myocardial Infarction-4. J Am Coll Cardiol. 2006; 47(8): 1544–1552.
  15. Morrison LJ, Brooks S, Sawadsky B, et al. Prehospital 12-lead electrocardiography impact on acute myocardial infarction treatment times and mortality: a systematic review. Acad Emerg Med. 2006; 13(1): 84–89.
  16. O'Donnell D, Mancera M, Savory E, et al. The availability of prior ECGs improves paramedic accuracy in recognizing ST-segment elevation myocardial infarction. J Electrocardiol. 2015; 48(1): 93–98.
  17. Brunetti ND, De Gennaro L, Correale M, et al. Pre-hospital electrocardiogram triage with telemedicine near halves time to treatment in STEMI: A meta-analysis and meta-regression analysis of non-randomized studies. Int J Cardiol. 2017; 232: 5–11.
  18. Brunetti ND, Bisceglia L, Dellegrottaglie G, et al. Lower mortality with pre-hospital electrocardiogram triage by telemedicine support in high risk acute myocardial infarction treated with primary angioplasty: Preliminary data from the Bari-BAT public Emergency Medical Service 118 registry. Int J Cardiol. 2015; 185: 224–228.
  19. Zimoch WJ, Kosowski M, Tomasiewicz B, et al. Impact of pre-hospital electrocardiogram teletransmission on time delays in ST segment elevation myocardial infarction patients: a single-centre experience. Postepy Kardiol Interwencyjnej. 2015; 11(3): 212–217.
  20. Kleinrok A, Płaczkiewicz DT, Puźniak M, et al. Electrocardiogram teletransmission and teleconsultation: essential elements of the organisation of medical care for patients with ST segment elevation myocardial infarction: a single centre experience. Kardiol Pol. 2014; 72(4): 345–354.
  21. Kawecki D, Gierlotka M, Morawiec B, et al. Direct Admission Versus Interhospital Transfer for Primary Percutaneous Coronary Intervention in ST-Segment Elevation Myocardial Infarction. JACC Cardiovasc Interv. 2017; 10(5): 438–447.
  22. Nakatsuma K, Shiomi H, Morimoto T, et al. Inter-Facility transfer vs. Direct admission of patients with ST-segment elevation acute myocardial infarction undergoing primary percutaneous coronary intervention. Circ J. 2016; 80(8): 1764–1772.
  23. Le May MR, Wells GA, So DY, et al. Reduction in mortality as a result of direct transport from the field to a receiving center for primary percutaneous coronary intervention. J Am Coll Cardiol. 2012; 60(14): 1223–1230.
  24. Chan AW, Kornder J, Elliott H, et al. Improved survival associated with pre-hospital triage strategy in a large regional ST-segment elevation myocardial infarction program. JACC Cardiovasc Interv. 2012; 5(12): 1239–1246.
  25. Henry TD, Sharkey SW, Burke MN, et al. A regional system to provide timely access to percutaneous coronary intervention for ST-elevation myocardial infarction. Circulation. 2007; 116(7): 721–728.
  26. Wöhrle J, Desaga M, Metzger C, et al. Impact of transfer for primary percutaneous coronary intervention on survival and clinical outcomes (from the HORIZONS-AMI Trial). Am J Cardiol. 2010; 106(9): 1218–1224.
  27. Busk M, Maeng M, Rasmussen K, et al. The Danish multicentre randomized study of fibrinolytic therapy vs. primary angioplasty in acute myocardial infarction (the DANAMI-2 trial): outcome after 3 years follow-up. Eur Heart J. 2008; 29(10): 1259–1266.