Prehospital ST-Elevation Myocardial Infarction Activation and Door-to-Catheterization Time Using a Tele-ECG Communication Platform: A Quality Improvement Review

Prompt activation of the Cardiac Catheterization Lab (Cath Lab) remains a cornerstone in the treatment of ST Elevation Myocardial Infarction (STEMI) and is critical for early cardiac reperfusion. Prehospital STEMI recognition and Cath Lab activation can reduce delays; however, this process can be limited by emergency medical services (EMS) provider level, electrocardiogram (ECG) interpretation, and communication failures. We conducted a Quality Improvement (QI) review of cardiac cases and ECGs transmitted via TigerConnect, a secure prehospital communication platform, in order to evaluate the association between STEMI activation and door-to-Cath Lab times.

We reviewed all cardiac cases/ECGs transmitted by 12 EMS agencies to an on-call emergency department (ED) physician at an academic ED from 9/1/2024-11/28/2025. Cases were categorized as non-STEMI, STEMI with prehospital Cath Lab activation via TigerConnect, or STEMI without prehospital activation but subsequently activated after ED arrival. For cases meeting STEMI criteria, ED and Cath Lab arrival times were abstracted. Door-to-Cath Lab times were compared between groups using a t-test for mean difference. Physician reviewer comments were qualitatively analyzed to identify potential factors contributing to missed activations.

A total of 316 prehospital cardiac cases/ECGs were transmitted through TigerConnect, of which 20 (6.3%) met STEMI criteria. Of these, 15 (75%) received prehospital Cath Lab activation, while 5 (25%) were activated after ED arrival. Median door-to-Cath Lab time was 18.5 (IQR 13.3-40.3) minutes for patients with prehospital activation, compared to 48.0 (IQR 27.0-50.0) minutes for those activated after ED arrival (mean difference -13.0 minutes; 95% CI: -31.9 to 5.9; p=0.18). All cases without prehospital activation had documented workflow or data-quality barriers, including transmission of ECG readouts rather than strips (n=2, 40%), missing patient identifiers (n=1, 20%), poor ECG image quality (n=1, 20%), and cardiology request for ED evaluation (n=1, 20%).

Prehospital ECG transmission and ED physician review were associated with shorter door-to-Cath Lab times, though this study was underpowered for statistical significance. Missed activations were primarily due to modifiable communication and data-quality barriers, rather than failure to recognize STEMI.