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Investigation of paramedics' compliance with clinical practice guidelines for the management of chest pain
Ken Figgis, Oliver Slevin and J Brian Cunningham Emerg Med J 2010 27: 151-155

doi: 10.1136/emj.2008.064816

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Prehospital care

Investigation of paramedics compliance with clinical practice guidelines for the management of chest pain
Ken Figgis,1 Oliver Slevin,2 J Brian Cunningham2
1 Emergency Department, Mayo General Hospital, Castlebar, UK 2 Faculty of Life and Health Sciences, University of Ulster, Newtownabbey, UK

Correspondence to K Figgis, Emergency Department, Mayo General Hospital, Castlebar, Co Mayo, UK; kggis@hotmail.com Accepted 8 March 2009

ABSTRACT Background Acute coronary syndromes remain a leading cause of preventable early deaths. However, previous studies have indicated that paramedics compliance with chest pain protocols is suboptimal and that many patients do not receive the benets of appropriate prehospital treatment. Aims To evaluate paramedics level of compliance with national clinical practice guidelines and to investigate why, in certain circumstances, they may deviate from the clinical guidelines. Setting The Health Service Executive Mid-Western Regional Ambulance Service which serves a mixed urban and rural population across three counties in the west of Ireland. Method A retrospective review of completed ambulance Patient Care Report Forms was conducted for all adult patients with non-traumatic chest pain treated between 1 December 2007 and 31 March 2008. During the same study period, paramedics were asked to complete a prospective questionnaire survey investigating the rationale behind their treatment decisions, their estimation of patient risk and their attitudes towards the clinical practice guidelines and training. Results 382 completed Patient Care Report Forms were identied for patients with chest pain, of whom 84.8% received ECG monitoring, 75.9% were given oxygen, 44.8% were treated with sublingual glyceryl trinitrate (GTN) and 50.8% were treated with aspirin. Only 20.4% of patients had a prehospital 12-lead ECG recorded. 58 completed questionnaires were returned (response rate 15%); 64% of respondents said they had received insufcient training to identify ECG abnormalities. Conclusions Prehospital treatment with oxygen, aspirin, sublingual GTN and ECG monitoring remains underused by paramedics, even though only a small number of patients had documented contraindications to their use. The small number of patients who received a prehospital 12-lead ECG is a cause of particular concern and suggests that incomplete patient assessment may contribute to undertreatment. Further provision of training and equipment is necessary to enable paramedics to more accurately assess and treat patients with acute coronary syndromes.

Cardiovascular disease is the single largest cause of death in Ireland, with heart disease accounting for approximately 23% of all deaths.1 It is estimated that one-third of all patients with acute myocardial infarction die before arrival at hospital.2 While developments in treatment introduced over the last two decades have signicantly reduced in-hospital mortality and improved long-term survival for patients who survive long enough to reach hospital, attempts to reduce out-of-hospital mortality in the
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early stages of acute myocardial infarction have met with only marginal success. As a result, overall mortality gures have remained relatively static.3 The aims of prehospital treatment are to provide optimal resuscitation and begin infarct-limiting treatment as early as possible in order to improve patients outcome following acute myocardial infarction. The Pre-Hospital Emergency Care Council, which is the statutory organisation responsible for determining training standards and standards of care for pre-hospital care providers in Ireland, has produced clinical practice guidelines (CPGs) for the management of patients with ischaemic chest pain.4 These guidelines recommend that all patients with ischaemic chest pain should receive a 12-lead ECG, continuous ECG monitoring, supplemental oxygen, aspirin and sublingual glyceryl trinitrate (GTN) unless contraindicated. As sudden cardiac arrest is the most common preventable cause of death during the early phase of myocardial infarction, the CPGs recommend that paramedics should use continuous ECG monitoring to enable the early detection and early debrillation of life-threatening arrhythmias. In the UK this has contributed to a signicant reduction in deaths following out-of-hospital cardiac arrests.2 5 Oxygen has been used in the treatment of acute myocardial infarction for many years, as it was widely thought to relieve myocardial ischaemia and symptoms of heart failure. Recently this established wisdom has been questioned by the argument that, through autoregulation, hyperoxaemia causes localised vasoconstriction and actually reduces myocardial blood ow. To date, the evidence from clinical trials underpinning both sides in this debate remains weak, and large randomised controlled trials are needed to determine if the routine use of oxygen therapy in acute myocardial infarction is harmful or indeed benecial.6 It is therefore questionable whether oxygen should be administered to all patients with suspected myocardial infarction as recommended in the current CPGs, or only to those with evidence of hypoxia. Aspirin is recommended in the CPGs as it is safe, inexpensive, easy to administer and has signicant benets in reducing mortality and other vascular complications following myocardial infarction.7 8 A multicentre study of 922 patients with acute myocardial infarction showed that patients who received aspirin before arrival at hospital had a signicantly lower mortality rate than those given aspirin following admission, both at 7 days (2.4% vs 7.3%, respectively) and at 30 days (4.9% vs 11.1%, respectively), as well as a lower incidence of serious complications including pulmonary oedema, cardiogenic shock and cardiac arrest.9
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Nitrates are also recommended in the CPGs as they relieve the symptoms of ischaemic chest pain and have some benecial haemodynamic effects.10 11 However, a large multicentre randomised trial involving over 58 000 patients with suspected myocardial infarction showed that their use has no signicant effect in reducing mortality.12 Although the benet of performing a prehospital 12-lead ECG has not been proved conclusively, a meta-analysis of earlier studies showed that the use of a 12-lead ECG by paramedics in conjunction with an alert call to the emergency department before arrival led to a reduction in the mean door-to-needle time of 36.1 min for patients with acute myocardial infarction without leading to signicantly longer on-scene times.13 Furthermore, the acquisition of a prehospital 12-lead ECG may assist in the early recognition and treatment of patients presenting with atypical symptoms of coronary ischaemia. Although the CPGs exist as a national standard, evidence from previous studies conducted in the UK and the USA suggests that paramedics frequently do not comply with their EMS (Emergency Medical Service) systems protocols. An audit conducted across nine ambulance services in England and Wales found that the proportion of patients with chest pain who were given aspirin varied widely between services from 11% to 74%.14 A retrospective study conducted across four EMS services in Pennsylvania reviewed the ambulance records of 300 patients with chest pain and found that 96% of patients were given oxygen, 91% received ECG monitoring, 73% were given GTN and only 49% were given aspirin.15 In a similar study undertaken in Denver, Colorado, investigators reviewed the records of 453 patients with non-traumatic chest pain, of whom 232 were identied as having ischaemic chest pain. Although 169 patients had no contraindication to aspirin, only 92 (54%) received it.16 In a prospective study designed to investigate why paramedics did not follow their service protocols, 13 of 52 (33%) paramedics reported that the patients chest pain was not thought to be cardiac in origin, 10 (26%) reported that the patient had already taken aspirin, 3 (9%) reported that the patient was already painfree and 6 (15%) cited insufcient training as the reason for not giving aspirin.17 It is important to understand why paramedics do not adhere to chest pain protocols in order to reduce the incidence of errors occurring through omission of treatment, and ensure that the maximum possible number of patients receive the benets of appropriate early treatment. The objectives of this study were to evaluate paramedics level of compliance with the CPGs and to investigate why, in certain circumstances, they may have deviated from the guidelines. a retrospective review of completed ambulance Patient Care Report (PCR) forms was conducted to determine the number of patients who received ECG monitoring, oxygen, aspirin and sublingual GTN and who had a 12-lead ECG recorded by the attending paramedics. The PCR form is a standardised report form completed for every patient, containing information about the ambulance response time, the patients presenting complaint, their medical history and treatment. Data from the PCR was used to compile a complete data set for the entire study population, as well as determining the response rate and detecting any reporting bias in the questionnaire responses. Second, paramedics were asked to complete a prospective questionnaire survey. Questionnaires were placed in each ambulance station at the start of the study period and paramedics were asked to complete a questionnaire form for each patient they treated with chest pain. The questionnaires asked if the paramedics had administered each of the treatment interventions in the chest pain CPGs and, if not, to state the reason why (eg, the patient refused, had a history of adverse reaction or other relevant contraindication). The questionnaire also asked about the paramedics level of training and experience, their assessment of the patients risk of suffering a myocardial infarction and their attitudes towards the CPGs and training. This methodology was chosen to allow paramedics participating in the study to remain anonymous, thus enabling them to feel less inhibited about describing why they may have decided to deviate from the CPGs and not administer a particular treatment.

RESULTS Patient Care Report (PCR) forms

During the study period, 13 580 calls were received to the regional ambulance service, including emergency calls and requests for patient transfers. A search of all completed PCR forms found that 382 emergency calls were received for patients with chest pain. Tables 1e5 show the percentage of patients with chest pain who received ECG monitoring, oxygen, sublingual GTN, aspirin and a 12-lead ECG, respectively, and the reasons documented why each treatment intervention was not given. Although the CPGs recommend that a 12-lead ECG should be recorded and transmitted to the receiving hospital, it was not possible to determine from the PCR forms whether a 12-lead ECG was recorded or recorded and transmitted. The results shown in table 5 should be assumed to mean that a 12-lead ECG was recorded only.

Questionnaire responses
Fifty-eight completed questionnaires were returned (response rate 15%). Fifty-six paramedics (96.6%) said that they monitored the patients ECG rhythm; 54 (93.1%) said that they gave the patient oxygen; 38 (65.5%) said that they gave the patient GTN and 41 (70.7%) said that they gave the patient aspirin. Four paramedics (6.9%) said that they recorded and transmitted

METHODS Setting and study population

The Health Service Executive Mid-Western Regional Ambulance Service serves a mixed urban and rural population of over 339 000 across three counties in the west of Ireland. Ethical approval for the study was obtained through the University of Ulster s research ethics lter committee. Access was granted by the Health Service Executive National Ambulance Service. The study population included all adult patients (aged 18 years and over) with non-traumatic chest pain. Patients with other acute coronary syndromes (such as arrhythmias or acute heart failure) who did not present with chest pain were not included, as the CPG specically refers to the management of chest pain.4

Table 1 Number of patients with chest pain who received ECG monitoring
Number of patients Patients received ECG rhythm monitoring No; No; No; No; chest pain not cardiac in origin patient refused patient pain-free reason not specied 324 9 5 1 43 Percentage 84.8% 2.4% 1.3% 0.3% 11.3%

Study design
The study used two approaches to gather data during the study period (1 December 2007 to 31 March 2008). First,
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Table 2 Number of patients with chest pain who received oxygen
Number of patients Patients given oxygen No; chest pain not cardiac in origin No; patient refused No; patient pain-free No; reason not specied 290 14 9 5 64 Percentage 75.9% 3.7% 2.4% 1.3% 16.8% Patients given aspirin No; chest pain not cardiac in origin No; already given by GP No; peptic ulcer/history of adverse reaction No; altered level of consciousness No; already taken unspecied dose of aspirin No; patient already taken 75 mg aspirin No; patient refused No; patient pain-free No; reason not specied

Table 4 Number of patients with chest pain who received aspirin

Number of patients 194 31 27 9 2 3 8 8 3 92 Percentage 50.8% 8.1% 7.1% 2.4% 0.5% 0.8% 2.1% 2.1% 0.8% 24.1%

a 12-lead ECG. The responses to the questionnaires indicate that the number of patients given each treatment intervention was considerably higher than was actually documented in the PCR forms, as shown in gure 1. Despite emails distributed through their supervisors and visits to the ambulance stations to encourage paramedics to participate in the study, the response rate remained poor (15%). This may have been because ambulance crews are frequently under pressure from a demanding workload and are inclined to view research activities as being relatively unimportant compared with providing patient care.18 However, the low response rate combined with the very positive responses to questions about compliance with the CPG suggest that many of the paramedics may not have completed questionnaires in cases where they did not give most treatment interventions because of fear of disciplinary action or litigation being taken against them. When asked in the questionnaires why they had not transmitted a 12-lead ECG to the receiving hospital, 26 paramedics (44.8%) identied an equipment problem either in the ambulance or at the receiving hospital and 16 (27.6%) said that they had not received sufcient training to record a 12-lead ECG. In response to a series of Likert items designed to assess paramedic attitudes towards the CPGs and training, 47 (81%) agreed that the CPGs reect best evidence-based practice while only 5 (9%) said that the CPGs were unclear. Thirty-nine paramedics (67%) said that they felt that they had received appropriate training to assess and manage patients with chest pain; however, 37 (64%) said that they had received insufcient training to identify ECG abnormalities.

DISCUSSION
It is important to understand why paramedics do not adhere to chest pain protocols in order to reduce the incidence of errors occurring through omission of treatment and ensure that the maximum possible number of patients receive the benets of appropriate early treatment. However, understanding noncompliance is complicated: rst, because it is often unclear what proportion of patients are suffering from ischaemic chest pain, especially in the prehospital environment; and, second, because the fact that a treatment has not been given does not necessarily Table 3 Number of patients with chest pain who received sublingual glyceryl trinitrate (GTN)
Number of patients Patients given sublingual GTN spray No; chest pain not cardiac in origin No; already self-administered or given by GP No; low BP/history of adverse reaction No; patient refused No; patient pain-free No; reason not specied 171 33 29 11 9 11 118 Percentage 44.8% 8.6% 7.6% 2.9% 2.4% 2.9% 30.9%

indicate that an error has occurred but may be because a valid contraindication exists. The limitations of undertaking a retrospective chart review such as this is that incomplete documentation may have affected the selection of appropriate patients for inclusion and resulted in the under-reporting of cases where treatments were given or contraindications were present but not documented. More patients received oxygen and ECG monitoring than aspirin and GTN. This is not surprising as oxygen and ECG monitoring are supportive interventions used in the management of other conditions that present with chest pain such as pulmonary embolism, and are not specic to the management of acute coronary syndromes. The number of patients who were not treated with sublingual GTN or aspirin because the treatment was refused, contraindicated or unnecessary was surprisingly small. Ninety-three (24.3%) patients were not given GTN and 88 (23%) were not given aspirin because they refused, had already received it, were pain-free, had a contraindication or had chest pain that was not thought to be cardiac in origin. These gures may have been under-reported if the relevant information was not documented on the PCR form. The large number of patients who did not receive treatment interventions for unspecied reasons is a cause for concern. Forty-three patients (11.3%) did not receive ECG monitoring, 64 patients (16.8%) did not receive oxygen, 118 (30.9%) did not receive GTN and 92 patients (24.1%) did not receive aspirin for reasons that were not documented in the PCR form. The poor response rate to the questionnaire survey (15%) meant that this did not provide any signicant insight into why so many patients were undertreated. The comparison of compliance rates for each treatment intervention between the PCR and questionnaire data sets shown in gure 1 strongly suggests an element of reporting bias in the questionnaire responses. It is harder to assess whether the research study actually inuenced the behaviour of paramedics and therefore whether the compliance rates reported in the PCR data were exaggerated by a Hawthorne effect. If so, it is doubtful Table 5 Number of patients with chest pain who had a 12-lead ECG recorded
Number of patients 12-lead ECG recorded No; chest pain not cardiac in origin No; patient refused No; reason not specied 78 29 6 269 Percentage 20.4% 7.6% 1.6% 70.4%

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100 90 80 70 60 50 40 30 20 10 0 Moni tor O xyge n Aspi ri n GTN 12-l e ad ECG
PCR Data Q ue sti onnai re Data

Tre atme nts gi ve n

Figure 1 Variations in percentage of patients who received treatment interventions according to data collection source. GTN, glyceryl trinitrate; PCR, Patient Care Report Form. if this could have been eliminated. Even if a researcher had been placed in the emergency department of each of the three hospitals to interview paramedics after they brought in patients with chest pain instead of placing the questionnaires in the ambulance stations beforehand, paramedics would have quickly become aware of the purpose of the study. Just over 20% of patients had a prehospital 12-lead ECG recorded. In most cases the reason why a 12-lead ECG was not recorded was not specied in the PCR form. When asked in the questionnaire survey why they had not transmitted a 12-lead ECG to the receiving hospital, 26 paramedics (44.8%) identied an equipment problem either in the ambulance or at the receiving hospital and 16 (27.6%) said that they had not received sufcient training to record a 12-lead ECG. Thirty-seven paramedics (64%) said that they had received insufcient training to identify ECG abnormalities. While it could be argued that the acquisition of a prehospital 12-lead ECG is unnecessary if paramedics are not trained to perform thrombolysis, a meta-analysis of earlier studies demonstrated that the use of a prehospital 12lead ECG by paramedics in conjunction with a pre-arrival alert call to the emergency department led to a reduction in the mean door-to-needle time of 36.1 min for patients with acute myocardial infarction without leading to signicantly longer onscene times.13 Furthermore, since failure to correctly diagnose and treat acute coronary syndromes is a major cause of errors in emergency medicine practice and is associated with poor patient outcomes,19e21 the acquisition of a prehospital 12-lead ECG may assist in the early recognition of patients presenting with atypical symptoms, leading to an overall improvement in prehospital management and enhanced compliance. Thirty-three patients (8.6%) were not given GTN and 31 patients (8.1%) were not given aspirin because their chest pain was not thought to be cardiac in origin. While it is to be expected that some patients will present with chest pain of different aetiologies, this gure is questionable as only three patients within this group had a 12-lead ECG recorded to exclude coronary ischaemia. It is worrying that others within this group had several documented risk factors for coronary heart disease, yet they were still treated as non-cardiac chest pain without having a 12-lead ECG recorded. Conversely, the number of patients who had non-cardiac chest pain may have been higher than the gure
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reported. If treatment was withheld because the paramedics thought that the patients chest pain was not cardiac in origin but this was not documented, this would have simply been reported as Not givendreason unspecied. A further concern regarding the underutilisation of 12-lead ECGs by paramedics is that patients presenting with a silent myocardial infarction are not being adequately recognised and treated. Earlier studies suggest that more than 8% of all patients with conrmed myocardial infarction present with no chest pain and consequently are at high risk of initially being misdiagnosed and incorrectly treated.22 Because the accurate identication of these patients from completed PCR forms created a considerable methodological difculty and since the CPGs specically refer to the management of cardiac chest pain, patients presenting with arrhythmias or acute heart failure who did not have documented chest pain were not included in our study. Had they been included, it is likely that the percentage of patients receiving each treatment intervention would have been lower than that reported. Although the current CPGs from the Pre-Hospital Emergency Care Council for the management of cardiac chest pain are broadly consistent with current international guidelines,10 23 acute myocardial infarction is an area of intensive research and the CPGs should be updated frequently to remain in line with developments in evidence-based practice. In view of our studys ndings in relation to the poor utilisation of 12-lead ECG, we believe that the CPGs should be revised so that a prehospital 12lead ECG is recommended for all adults with non-traumatic chest pain and that exceptions based on the patients age, duration of pain and journey time to hospital should be deleted from the current edition of the guidelines.4 While the current controversy in the scientic literature surrounding the routine use of oxygen in uncomplicated myocardial infarction remains unresolved, it may be prudent to amend the CPGs so that oxygen is only recommended for patients who show signs of hypoxia. Furthermore, we would recommend that consideration be given to the inclusion of oral clopidogrel in the CPGs, since aspirin remains the only treatment intervention recommended in the current guidelines that has been proved to have a directly benecial effect in reducing the incidence of mortality and major adverse coronary events.

CONCLUSION
Early recognition and effective prehospital treatment is necessary to reduce mortality and morbidity among patients with acute coronary syndromes. However, the ndings from this and previous studies suggest that paramedics compliance with their services CPGs remains suboptimal. Further research is necessary to understand why, since it is likely that poor compliance and errors originate not from a single cause but from a combination of sources.24 25 Further training is needed to enable paramedics to use 12-lead ECG to more accurately assess patients risk of suffering myocardial ischaemia. This is likely to become even more important in the future as paramedics take on an increasingly important role in providing prehospital thrombolysis and in selecting patients suitable for transfer to specialist centres for primary percutaneous coronary intervention.
Acknowledgements The authors thank the staff of the Health Service Executive Mid-Western Regional Ambulance Service for their cooperation and assistance in conducting this research study. Competing interests None declared. Ethics approval This study was conducted with the approval of the University of Ulsters research ethics lter committee. Provenance and peer review Not commissioned; externally peer reviewed. Emerg Med J 2010;27:151e155. doi:10.1136/emj.2008.064816

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