A Qualitative Analysis of Barriers to Evidence-Based Care in the Prehospital Management of Patients with Suspected Acute Coronary Syndrome

Abstract

Objectives

Prehospital electrocardiogram (ECG) and administration of aspirin are evidence-based strategies for patients with acute coronary syndrome (ACS). However, emergency medical services (EMS) compliance in patients with suspected ACS varies widely. We sought to understand the barriers to prehospital ECG acquisition and aspirin administration for patients with suspected ACS.

Methods

In this qualitative study, we interviewed EMS clinicians at three geographically diverse United States (U.S.)-based EMS agencies. We interviewed practicing clinicians and quality and operations leaders at these agencies. Based on the Reach, Effectiveness, Adoption, Implementation, and Maintenance (RE-AIM) framework, interviews were recorded, transcribed, and analyzed using a grounded qualitative approach with open coding. The Systems Engineering Initiative for Patient Safety (SEIPS) framework and a constant comparison technique were used to identify and refine themes.

Results

Twenty-five paramedics and 20 additional agency personnel participated. Median age was 41 (IQR: 34–51) years and 13 (29%) were female. Themes were organized using SEIPS and longitudinally through four phases of an EMS call. During the pre-arrival phase, staffing challenges, training quality, and dispatch may anchor EMS clinicians on a diagnosis. During the diagnosis and treatment phase, safety and communication barriers may take priority over care delivery. Additionally, EMS clinicians must allocate assets (e.g. whether to send an advanced life support unit) and financial resources; veteran EMS clinicians identified their experience whereas newer clinicians cited their recent education when making these decisions. Also, diagnostic uncertainty due to increasing patient complexity and atypical presentations contributed to diagnostic errors. During the response and transport phase, the scope of practice limits the use and interpretation of the ECG, with clinicians reporting that liberal use of ECG led to more rapid decision-making. Finally, in the after phase, personnel reported the “psychologically taxing” nature of the job contributing to biases, bad habits, and burnout. Performance feedback was desired for personal development, though currently perceived as infrequent and punitive.

Conclusions

Multiple, interrelated themes underscored the complexities of delivering evidence-based care to prehospital patients with ACS. Education in ECG interpretation, resource allocation, bias, and enhancing feedback may serve as strategies to address the identified barriers.

Introduction

Recognizing that “time is muscle” in cardiac emergencies (1–4), substantial efforts have focused on developing systems of care, like the American Heart Association’s (AHA) Mission: Lifeline initiative (5), to prioritize the safe and efficient management of patients with ST-elevation myocardial infarction (STEMI) from the prehospital setting through coronary reperfusion. Beyond timely care, there are two actions that Emergency Medical Services (EMS) can perform that are evidence-based for the prehospital management of patients with STEMI. The ISIS-2 trial established the mortality benefit of giving aspirin early, and administration of aspirin to patients with suspected Acute Coronary Syndrome (ACS) in the prehospital setting is the standard of care (6). Studies also demonstrated that prehospital electrocardiograms (ECG) are associated with a reduction in door-to-balloon time (7) and mortality (8). Recognizing EMS’s critical role in ACS care, the AHA recommended obtaining prehospital ECGs to improve the chain of survival (9). With increased recognition of the essential role of EMS in the chain or survival, the appropriate administration of aspirin and use of ECG are priorities for prehospital clinicians caring for patients with suspected ACS. However, there is substantial variability in the performance of this care. An ECG is performed in the prehospital setting between 20% and 80% of the time in patients with suspected ACS and aspirin is given only 45% and 58% of the time to patients with acute myocardial ischemia and/or suspected ACS (10–12). Reasons for variability may be due to atypical presentations of ACS, time of day, female sex, younger age, Black, Hispanic, and those with more comorbidities, and rurality of the calls (10,13,14).

Despite the critical role for the care of prehospital patients with suspected ACS, there is limited research examining reasons for this variability, particularly amongst United States (U.S.)-based EMS systems. In an abstract from the United Kingdom about the performance of ECGs, focus groups reported that decision-making was impacted by patient characteristics (e.g., age, sex, ethnicity, privacy), clinician training, and systemic barriers like equipment availability, distance to the percutaneous coronary intervention center, guidelines, and organizational pressures (15). A study of Hong-Kong EMS clinicians examining ECG performance cited patient privacy concerns and patients’ desire to forgo ECG to not further delay transport to the hospital (16). In a Chinese study, interviewees identified a theme of capacity limitations and disjointed care leading to STEMI treatment delay (17). In Sub-Saharan Africa, coronary care networks were identified as fragmented secondary to delayed STEMI recognition, systems delays, and lack of regionalized care (18). In a single qualitative study from the U.S., EMS clinicians identified that communication barriers, lack of supplies, protocol changes, and experience all impact timely prehospital STEMI care (19).

While emerging data paints a complex portrayal of the barriers to ECG use in the prehospital setting, important gaps in understanding this variability in US-based EMS systems of care remain. To address these gaps, we sought to use qualitative methods to understand a diverse set of perspectives on this challenge using EMS clinician and stakeholder (operational leadership, education, and quality assurance leaders) perspectives with the goal of identifying potentially modifiable targets for future intervention studies.

Methods

We used a qualitative approach with semi-structured interviews to understand EMS and stakeholders’ perceptions of barriers to the use of evidence-based guidelines in the prehospital care of patients with suspected ACS.

Setting and Selection of Participants

We partnered with ESO, Inc. as part of a larger National Institutes of Health study on prehospital ACS care to conduct interviews at three heterogenous prehospital agencies. We recruited three EMS agencies from the South, Mid-Atlantic, and Northwest regions of the US to participate via convenience sampling of agencies already using ESO. Their annual call volumes and staffing varied from 25,000–106,000 calls and from 130–600 staff members. Within the selected agencies, EMS clinicians and stakeholders were recruited through local champions, email notifications, and snowball recruiting techniques through other participants.

Study participants included EMS clinicians from each agency. Clinicians were included if they worked at least one clinical shift in the preceding month with at least one EMS call for a patient with chest pain. Additional stakeholders included clinical and operational leaders at the organizations with previous EMS field experience and supervisory roles in feedback and compliance, including local training officers, medical directors, and local administrative leadership. These stakeholders were not required to be from one of the three EMS agencies so that we could enhance broader representation of the stakeholder perspectives. This study was approved by the Vanderbilt University Medical Center Institutional Review Board, as exempt as it was minimal risk.

Data Collection

One-on-one semi-structured interviews were conducted virtually by two study personnel including one coauthor (MR) using an interview guide (Table 1) based on the Reach, Effectiveness, Adoption, Implementation, and Maintenance (RE-AIM) framework to assess the reach, effectiveness, adoption, implementation, and maintenance of a public health intervention like prehospital ECG and aspirin in suspected ACS (20,21). Interview guides were developed and tailored to each group of respondents. EMS clinicians were asked questions about attitudes, norms, and potential motivators of behavior change, specifically 1) barriers of guideline recommended care; 2) potential incentives to address gaps in care; and 3) context, including EMS workflow and processes in the care of suspected ACS patients. Stakeholders were asked questions about the characteristics of practice setting and environment surrounding feedback and quality review, specifically 1) potential site variability for guideline recommended care and 2) existing approaches to feedback. In addition to planned prompts in the interview guide, participants were asked follow-up questions to clarify responses and elicit further detail.

Table 1. Summary of EMS clinician and stakeholder interview guides.

Context, including workflow and processes	Please describe your general responsibilities Please describe your work setting and the types of patients and complaints typically seen Please describe how many patients you care for in a typical shift Please describe how you use the electronic health record tablet while you’re on shift What resources do you currently have that help you when you’re working a shift
Barriers to guideline concordant care	Describe your experience with caring for patients with chest pain Please describe how to decide whether to administer aspirin Please describe how to decide whether to perform an electrocardiogram Describe any benefit these two actions may have for prehospital patients with chest pain Please describe the role guidelines for chest pain care play in performing these two actions How would learning about your actions and patient outcomes influence your practice Why do you think others may or may not perform these actions
User requirements, including delivery modality, engagement strategies, timing of feedback, and response to a novel design feedback system	Describe any feedback on patient outcomes and clinical performance you currently receive Please review the following sample feedback report, what information does this convey to you What would be the best way to deliver this through the existing EHR platform
Potential site variability for guideline concordant care (stakeholders)	Please describe any challenge in delivering guideline concordant chest pain care (aspirin and electrocardiogram) in the prehospital setting What are some reasons for variability in performance of guideline concordant care for chest pain in prehospital setting What is the benefit of these two actions in prehospital patients with chest pain How would learning about patient outcomes and clinical care delivery influence guideline concordant chest pain care in the prehospital setting
Existing approach to feedback (stakeholders)	Please describe your use of reporting tools or metrics (quality or otherwise) as they relate to acute cardiac care in your role, if any Describe any feedback on patient outcomes and clinical performance you currently deliver about acute cardiac care What resources are available to help you in reviewing performance of an EMS provider

Interviewers planned to pilot the interview guide with up to 10 participants and these pilot interviews were recorded and reviewed by a qualitative methods expert. All interviews were conducted virtually by a trained interviewer (MR) at a time convenient to the participant to minimize interference with clinical work. Interviews were targeted to last approximately 30 min, recorded using Microsoft Teams (Redmond, WA), transcribed and de-identified by a transcriptionist (Home Row, Inc., Henderson, NV), and stored securely with a unique participant number. Once the interviewer was trained and interview guide finalized, the pilot was completed and we planned to review interview findings after 3–5 interviews to evaluate for thematic and content saturation, the point at which no new information is learned (22). We then reviewed every 3–5 interviews until thematic saturation was reached by consensus with the study team.

Analysis

We used the Systems Engineering Initiative for Patient Safety (SEIPS) model to analyze the interview transcripts. The SEIPS model is a patient safety framework to help explain how system design can impact both patient safety and outcomes of employees, patient, and the organization (23). Applied to the prehospital setting, the SEIPS model facilitates an examination of the patient through their prehospital care journey focusing on how people, environment, tasks, technology, processes, feedback, and outcomes influence health care quality and patient safety. We reasoned that this framework best suited the objective of this research to examine patients with suspected ACS, as they experience multiple phases of care in the prehospital setting that rely on many interrelated factors related to people (patients and clinicians), environments, tasks, and processes.

A hierarchical coding system was developed and refined using an iterative, grounded, inductive qualitative approach guided by the SEIPS model. In developing the coding system, we identified 29 major themes that were further subdivided into subthemes. Transcripts were then coded by an open coding approach using Dedoose (Los Angeles, CA).

After thematic saturation was achieved, we calculated the frequencies of each code to examine the distribution of quotes. The codes were then cross-referenced with quotes to identify themes and to identify representative quotes of potential barriers to evidence-based care. These themes were presented and analyzed by the research team in an iterative process to further refine the themes and subthemes along the EMS continuum of care, beginning at EMS dispatch and ending after the delivery of the patient to the health care facility. Transcripts, quotation, and codes were all managed using Microsoft Teams and Excel (Microsoft Inc., Redmond, WA), and Dedoose (Manhattan Beach, CA). This research adheres to the Consolidated Criteria for Reporting Qualitative Research (COREQ) guidelines for qualitative research (24).

Results

A total of 45 interviews were conducted. Twenty-five paramedics and 20 clinical and operational stakeholders were interviewed. Their demographics are presented in Table 2. The median age of EMS clinicians was 34 (interquartile range [IQR] 31.5–48.5) years, the median years of service was 17 (IQR 12–23.5), and 7 (28%) were female. All clinicians were paramedics, and one was also a nurse. Among stakeholders, two were quality officers (10%), six were medical directors (30%), four were EMS/fire chiefs (20%), two were STEMI coordinators (10%), and six were EMS consultants/lawyers/executive directors (30%). The median age of stakeholders was 49 (IQR 38.8–58.8), and 6 (30%) were female.

Table 2. Characteristics of interview participants.

	EMS clinicians (N = 25)	EMS stakeholders (N = 20)
Age, years, median (IQR)	34 (31.5 − 48.5)	49 (38.8 − 58.8)
EMS experience, years, median (IQR)	17 (12 − 23.5)
Role, N (%)
Quality officer		2 (10)
Medical directors		6 (30)
EMS/fire chiefs		4 (20)
STEMI coordinators		2 (10)
Other		6 (30)
Male sex, N (%)	18 (72)	14 (70)
Race, N (%)^*,#
Asian	1 (4)	2 (10)
Black	3 (12)	0 (0)
Hispanic	2 (8)	0 (0)
White	18 (72)	14 (70)
Practice settings, N (%)^#
Urban	24 (96)	12 (60)
Suburban	8 (48)	11 (55)
Rural	6 (24)	4 (20)

* Interviewees could opt not to select a race identifier.

^# Interviewees could self-select multiple race categories and practice settings.

Qualitative results are organized by intervals along the EMS care continuum, with several themes noted during each interval. The discrete time intervals used were 1) pre-arrival/en route to a call, 2) the diagnosis/treatment phase, 3) the response/transport phase, and 4) after the call phase. The pre-arrival/en route phase begins when the patient activates 9-1-1 until EMS arrives on scene. It also includes any education or training that the clinician may have received prior to the call. The diagnosis/treatment phases begins when the clinician encounters the patient and lasts until transport to the hospital begins. The response/transport phase includes the interval between scene departure and handing over care at the hospital. The phase of care after the call includes documentation, emotional response, and feedback/follow-up on patient care. The salient themes are visually represented throughout the course of an EMS call in Figure 1.

Figure 1. Summary of themes and subthemes from 45 interviews with EMS clinicians and stakeholders organized by phase of the EMS call (x-axis) and the SEIPS framework domains (y-axis).

Pre-Arrival/En Route Phase

Prior to being activated for a potential ACS call, the training, agency protocols, availability of staffing, and type of information provided by telecommunicators impact the delivery of care once upon scene. First, interviewees discussed how variable involvement from their medical directors may delay or outright prevent updates in prehospital protocols.

Some of your younger doctors or more progressive doctors are constantly doing research. So, they might be titrating their protocols regularly […] as new research comes out. Versus your veteran doctor, who – can’t teach an old dog new tricks. […] They don’t like change, and their protocols probably reflect that same demeanor. – Paramedic 24

Additionally, interviewees cited how staffing and capacity issues frequently made it difficult to provide the level of care that they would like to.

Currently we’re struggling with is staffing, which all agencies are struggling with that right now. […] But if we don’t have enough paramedics come to work during the day for our shift, we might have to make those ambulances that would’ve been in advanced life support, a basic life support. – Stakeholder 16, STEMI coordinator

Additionally, some clinicians referenced how dispatch’s communications can potentially anchor a responding team on a diagnosis and its severity, but that when they receive new or conflicting information, they must be able to pivot their decision making and diagnosis.

We have a high amount of stimulant and drug use, also. So, […] you have to be careful about being led down the wrong path and just assuming it’s just a drug overdose. – Stakeholder 10, Assistant Fire Chief

Diagnosis and Treatment Phase

The diagnosis and management of a patient on scene with suspected ACS can be complex, delaying definitive diagnosis and prompt treatment. Interviewees cited multiple challenges including communication barriers, complex and atypical presentations of potentially life-threatening illnesses, how clinician experience impacts care activities performed while on scene and the need to allocate resources while caring for the patient.

First, when on scene, a recurring theme was the challenge of obtaining a history, gathering information, and building a rapport with the patient.

The number one thing would be any kind of communication barrier […] If the patient’s unresponsive already, then obviously it makes it harder to provide care. If the patient speaks different languages, it makes it harder to provide care because we have to go through our language line and […] there’s always some errors in translation and there’s some time barriers. – Stakeholder 4, Medical Director

Communication barriers further compounded prompt care when patients did not comprehend the potential severity of their illness.

Willingness to be helped makes it easier on me. We run into a lot of patients that are not willing to go to the hospital. Even if you’re telling them, "You’re having a heart attack," and they’re like, "No, I don’t want to go.”–Stakeholder 11, Associate Chief Medical Officer

In addition, paramedics and stakeholders frequently referenced how patient presentations have become more complex and it is difficult to deal with making decisions in uncertainty.

Chest pain, or what people think is chest pain, isn’t always chest pain. So, your elderly, female diabetics, they don’t have chest pain all the times when they’re having a heart attack. – Paramedic 24

Increased experience was identified as motivating prompt care while on scene.

When you walk into a bedroom, you look at a person, are they sick or not? […] and it’s until you start running those and get that real world experience that you can literally walk in and go, "They are sick." Like, I don’t even need their vital signs to tell you they’re not good. – Paramedic 5

Clinicians also cited how once they were on scene that they are often tasked with not only caring for the patient, but also the allocation of resources and triaging of assets due to resource limitations. They spoke about the need to make decisions related to whether to transport to a catheterization lab capable center, to use an ALS unit, and whether to drive with the use of lights and sirens.

We were supposed to be dispatched to a patient, care first for that patient and then bring them to the hospital, rather than necessarily having to decide what level of resources are appropriate for their care. But the reality is because of the constraints of resources that we face, we have to make such decisions. – Stakeholder 20, EMS Systems Consultant

Response and Transport Phase

The response and transport phase includes the transportation of the patient to the hospital. Impacting the use of aspirin and ECG were the perceived attitudes about their use, and scope of practice under the clinician’s license. Specifically, interviewees referenced how clinical management varies from patient to patient, but that more liberal use of ECG and aspirin were warranted.

I generally perform 12-leads on just about everybody. If they have an issue going from their belly button all the way up to their head, anything that I think is neurological or cardiac or pulmonary, or if they are nausea or chest pain, I get a 12-lead. Some medics do not. – Stakeholder 8, Quality Assurance Officer

I would say the bar is pretty low if they don’t have an allergy to [aspirin]. We tend to be pretty liberal with it simply because, from what I understand, it’s one of the medications we have that really does show mortality benefit. – Stakeholder 20, EMS Systems Consultant

Additionally, depending on the level of the clinician, some tools, such as ECG, may not be available or they may not be able to interpret the readings based on their scope of practice.

Or they might not even […] have the tools. You know, […] like our BLS providers, they don’t have the capability […] to perform or to interpret 12-lead EKGs. So […] if they just think, oh, this person just has, like, a, you know, like a stomach flu or something like that, they’ll just transport the patient to the closest hospital. – Paramedic 11

After Phase

In the phase following the EMS encounter, the quality and timing of feedback along with the emotional toll of the job were recognized as taxing. These factors impact how EMS clinicians prepare for the next response, their emotional state when they do so, and potential biases that may arise.

Interviewees discussed how they wanted more feedback on their patients’ outcomes at the hospital, and how the quality of feedback that they receive was often lacking. They discussed how feedback is essential for education and growth.

At an agency level, if paramedics don’t hear back that they activated a STEMI alert, and it wasn’t a STEMI, they don’t know that they’re doing something wrong. So, that could lead to differences in care for sure. And I've done some work on that, actually, just showing that the feedback that individual people get in EMS is so poor that there’s no way for them to learn, in essence, right? They can’t learn from their mistakes or their successes because they never hear back. – Paramedic 18

So, for me looking at those reports, it’s really to be able to help the patient, you know, identify if I'm doing good job, if our agency’s doing a good job. And if I see faults in something, I can obviously let my supervisors know and push that up the chain of command and if they identify that I'm right, they would work on fixing it because their goal is just like mine, good patient care. – Stakeholder 16, STEMI Coordinator

In addition, clinicians also discussed how it can be psychologically taxing to do the job of EMS, and how the constant stress of the job wears on clinicians and may lead to biases about the patient population they care for.

We have to be the duck. If you ever see a duck floating on the water, he looks calm and relaxed. But if you look at his feet under the water, those little feet are going a mile a minute to keep him relaxed, you know? And that’s, you know, inside our brain is going a mile a minute, but outside we have to be the duck. We have to be just calm all times. – Paramedic 5

We all have bias of some type. But if we choose to let that bias affect how we deliver our care – and that bias can be something as simple as race. Something as simple as somebody having an accent that you just don’t understand, or just somebody that you may typically run on a lot, even an individual that you know. […] So, not having that bias. I won’t say, "not having it," but not letting it affect you doing a good patient assessment and providing good and competent care, I think is really key – Stakeholder 10, Assistant Fire Chief

Discussion

Interviews of EMS clinicians and stakeholders illustrated how EMS clinicians work in a complex system that is often resource constrained, time-pressured, and mentally challenging. Major themes emerged that impact the use of evidence-based care in suspected ACS patients, including: training, availability of staffing, dispatch anchoring, atypical clinical presentations, communication barriers, the role of experience in recognizing illness severity, triaging resources, attitudes about the use of evidence-based care, scope of practice license, the dearth of quality feedback, and the psychological stress of working in EMS.

The revealed themes regarding challenges of providing evidence-based care to patients with suspected cardiovascular emergencies in the prehospital environment are grounded in prior research. Delivery of evidence-based care is complicated by staffing shortages and hospital capacity issues. This has likely become more prevalent in recent years as greater attention is paid to the high rate of turnover in the EMS workforce (25), and how to address the EMS workforce crisis (26, 27). Additionally, participants discussed the important role of medical directors in updating protocols to deliver evidence-based care. Carey et al. (28) interviewed prehospital clinicians and identified similar findings that direct medical oversight facilitates guideline concordant care, while ambiguous protocols hinder evidence-based care.

Once on scene, the environment, patients and their families, and task management create further complexity. In our interviews, paramedics discussed how difficulties in overcoming communication challenges and quickly establishing rapport hindered their ability to deliver evidence-based care. A retrospective analysis quantified language barriers in prehospital care delays in Minnesota, and found that while small, language barriers were identified in 3.3 out of every 1,000 patient encounters (29). Further and consistent with our findings, patients with multiple chronic medical comorbidities did not receive approximately 20% of guideline recommendations (30). Groups that do not present with typical ACS symptoms were also less likely to receive evidence-based care (14,31–33).

Clinicians identified that during the treatment and response phase of care, liberal use of ECGs was necessary to prevent missed cardiac emergencies. They also noted that dispatching the wrong level of ambulance or incorrectly triaging the severity of a patient meant that the EMS clinician transporting the patient may not even have the ability to perform and/or interpret an ECG based on their scope of practice. This is consistent with current recommendations that do not include a monitor capable of obtaining a 12-lead ECG on basic life support ambulances (34).

In the final phase after the EMS call, EMS clinicians in our study often cited their desire for more robust feedback. This is consistent with prior studies that found that more than 97% of EMS clinicians desired more feedback, up to one third did not receive any feedback in the previous thirty days, and that clinicians universally thought that receiving feedback was either “essential” or “beneficial” (35,36). The EMS clinicians also reported in our interviews that the stress of the job contributed to burnout, fatigue, and bad habits in their care of prehospital ACS patients. This is supported by researching highlighting the mental burden of working in EMS, with findings indicating that EMS clinicians have signs of posttraumatic stress syndrome, depression, higher sick day usage, and thoughts about leaving their job or the profession (37–40).

These interviews underscore the relevance and challenges of these systemic factors in the relatively brief time periods for the delivery of prehospital care for patients with suspected ACS. Using the identified themes and representative quotes, we identified two potential interventions to address some of these barriers. First is the use of education and training to mitigate the experience gaps, unique patient populations, communication barriers, and different patient backgrounds that may generate biases. Prior research showed that quality improvement programs that inform continuing education and targeted educational interventions are effective strategies to improve performance (41,42). The second strategy is the delivery of targeted and systemic feedback to clinicians about care processes and patient outcomes. Multiple studies have shown that audit and feedback improve outcomes and guideline adherence (41–45) and may be protective against burnout (40). However, providing feedback effectively and in a sustainable manner is difficult and rarely done well. It should be timely, actionable, non-punitive, and delivered in a non-group setting (44,45). Within large EMS agencies, it can be difficult to scale this type of feedback to enhance adoption effectively. One potential approach to provide this feedback is through information exchange between hospitals and EMS agencies as there is more widespread adoption of electronic health records (46). However, the design, delivery, context, and timeliness of such feedback remain important considerations in any feedback system (47).

While feedback is an essential component of quality improvement and continuing education, a recent systematic review underscored the need for more rigorous study on the impact of EMS clinician feedback (48). In the future, these studies will inform best practices for improving guideline adherence. These findings inform the design of tools and interventions to address the training and feedback gaps identified. However, they will need to be vetted through rigorous effectiveness implementation trials to examine their adoption, use, and effectiveness in real world settings.

Limitations

While our study represents perspectives from three distinct EMS agencies and stakeholders, generalizability beyond these settings is limited. Further, the clinician perspectives were all paramedics, without Basic Life Support (BLS) clinician perspectives represented. Further, these interviews represent perspectives of individuals and while attempts have been made to mitigate potential biases by the qualitative investigators through use of accepted qualitative methods, the potential remains for bias to exist. Finally, since interviewees were informed that they were being interviewed regarding guideline adherence in suspected ACS their responses may have been impacted by recall bias and social desirability bias. As a result, EMS clinician and stakeholder responses may not reflect actual practice nor the relative ranking of these opinions.

Conclusions

There are numerous barriers to use of aspirin and ECG use for patients with suspected ACS in the prehospital setting. Through interviews with EMS clinicians and key stakeholders, this study identified potential barriers to the evidence-based care of prehospital patients with suspected ACS as: staffing and capacity issues, varying medical director involvement, dispatch anchoring, difficulty managing the scene, patient complexity and diagnostic uncertainty, varying levels of experience and training, resource management, clinical decision making, practice scope, lack of high-quality feedback, and clinician burnout. Potential interventions to address these barriers include targeted education and regular use of non-punitive, individualized feedback.

Declaration of Generative AI in Scientific Writing

The authors did not use a generative artificial intelligence (AI) tool or service to assist with preparation or editing of this work. The author(s) take full responsibility for the content of this publication.

Acknowledgments

None.

Disclosure Statement

The authors report there are no competing interests to declare.

Additional information

Funding

This work was supported by the National Heart, Lung, and Blood Institute of the National Institutes of Health under award number R34HL155400.