Investigation of paramedics' compliance with clinical practice guidelines for the management of chest pain

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 benefits 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 identified 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 insufficient 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.