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The barriers associated with emergency medical service use for acute coronary syndrome: the awareness and influence of an Australian public mass media campaign
  1. Susie Cartledge1,2,
  2. Judith Finn1,3,
  3. Lahn Straney1,
  4. Phillip Ngu2,4,
  5. Dion Stub1,2,4,5,
  6. Harry Patsamanis6,
  7. James Shaw1,2,
  8. Janet Bray1,2,3
  1. 1 Department of Epidemiology and Preventive Medicine, Monash University, Victoria, Australia
  2. 2 Alfred Health, Victoria, Australia
  3. 3 School of Nursing, Midwifery and Paramedicine, Curtin University, Bentley, Western Australia, Australia
  4. 4 Baker IDI Heart and Diabetes Institute, Victoria, Australia
  5. 5 Western Health, Victoria, Australia
  6. 6 National Heart Foundation of Australia, Victoria, Australia
  1. Correspondence to Ms Susie Cartledge, Department of Epidemiology and Preventive Medicine, Monash University, The Alfred Centre, Level 6, 99 Commercial Road, Melbourne, Victoria 3004, Australia; susie.cartledge{at}


Background Emergency medical services (EMS) transport to hospital is recommended in acute coronary syndrome (ACS) guidelines, but only half of patients with ACS currently use EMS. The recent Australian Warning Signs campaign conducted by the Heart Foundation addressed some of the known barriers against using EMS. Our aim was to examine the influence of awareness of the campaign on these barriers in patients with ACS.

Methods Interviews were conducted with patients admitted to an Australian tertiary hospital between July 2013 and April 2014 with a diagnosis of ACS. Patient selection criteria included: aged 35–75 years, competent to provide consent, English speaking, not in residential care and medically stable. Multivariable logistic regression was used to examine factors associated with EMS use.

Results Only 54% of the 199 patients with ACS interviewed used EMS for transport to hospital. Overall 64% of patients recalled seeing the campaign advertising, but this was not associated with increased EMS use (52.0%vs56.9%, p=0.49) or in the barriers against using EMS. A large proportion of patients (43%) using other transport thought it would be faster. Factors associated with EMS use for ACS were: age >65 years, ST-elevation myocardial infarction, a sudden onset of pain and experiencing vomiting.

Conclusion In medically stable patients with ACS, awareness of the Australian Warning Signs campaign was not associated with increased use of EMS or a change in the barriers for EMS use. Future education strategies could emphasise the clinical role that EMS provide in ACS.

  • Acute coronary syndrome
  • emergency medical services
  • ambulance
  • decision making

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Key messages

What is already known on this subject?

  • Less than half of patients with acute coronary syndrome (ACS) present to hospital by emergency medical services (EMS). Identified barriers to EMS use include a perception of speed, underestimating the seriousness of symptoms, embarrassment or thinking EMS transport is not necessary.

  • No study to date has examined the influence of an intervention (eg, mass media campaign) on these barriers.

What this study adds?

  • This study found no association between awareness of the Australian Heart Foundation’s Warning Sign campaign and EMS use, or a difference in the known barriers, in a cohort of patients with ACS. Patients often perceived self-transport as faster or symptoms as not serious enough to warrant EMS use.

  • Future public interventions could highlight the rationale for EMS use in ACS.


Acute coronary syndrome (ACS) can be a life-threatening condition.1 Patient outcomes can be improved with revascularisation therapies,2 3 but the effectiveness of these treatments is time dependant and requires rapid presentation to hospital—preferably by emergency medical services (EMS).

EMS transport to hospital is recommended in international ACS guidelines.4–6 Paramedics are trained to detect and provide emergency treatment for ACS, and for the potentially life-threatening complications associated with this condition, such as cardiac arrhythmias and cardiac arrest. Transport by EMS also ensures suspected patients with ACS present to hospitals with revascularisation capabilities. In addition, some EMS are able to initiate intravenous reperfusion (ie, thrombolysis) to a subset of patients with ACS.7 However, across a number of international settings, a large proportion of patients with ACS are still transporting themselves to hospital (40%–50%).8–10 Identified barriers against EMS use include a perception of speed, with many thinking other forms of transport are faster, underestimating the seriousness of symptoms or thinking EMS transport is not necessary, and not wanting to be embarrassed if they are wrong.11 12

In 2009, to address these barriers and to improve awareness of symptoms and reduce prehospital delay in ACS, the Heart Foundation of Australia launched the ‘Warning Signs of Heart Attack’ strategy.13 The strategy included mass media and digital advertising campaigns with a primary focus on the lesser known warning signs of ACS and the importance of acting quickly by calling EMS, and a secondary focus on barriers of embarrassment and perceived seriousness. This campaign ran periodically across the state of Victoria, Australia, between 2009 and 2012, with an intense campaign in the city of Melbourne for 4 months in 2013.13 14 We have previously reported an association between awareness of this campaign and shorter times in presenting to hospital in patients with ACS.13 A more recent report found an increase in the number of calls to EMS for chest pain during the period in which campaign activity took place; however, it is unknown if these users had ACS14 or if the campaign had an impact on the factors that prevent the use of EMS.14 Therefore, the aims of this study are to investigate the effect of awareness of the 2013 Warning Signs campaign on EMS use and the associated barriers among patients with ACS .


Design and setting

We conducted a prospective, single-centre survey of patients with ACS13 examining awareness of the campaign, EMS use and reason for choice of transport. This study was approved by the Monash University Human Ethics Research Committee (CF13/3743-2013001917) and the Alfred Hospital Human Ethics Committee (235/13).

The study was undertaken at the Alfred Hospital which is located in metropolitan Melbourne in the state of Victoria, Australia. The hospital is a major tertiary teaching centre with specialist cardiology and cardiovascular services including a helipad to receive rural patients. The state of Victoria is serviced by a single EMS, in which the user pays unless the service is covered under private health insurance or EMS subscription.

2013 campaign

The Warning Signs campaign is described in detail elsewhere.13 14 In brief, the campaign had strong messages for patients with acute symptoms of ACS to use EMS for transport to hospital. The main two television and radio advertisements featured: (1) a 45 s advertisement featuring a deceased patient reliving his prehospital experience ("I wish I could have my heart attack again") and (2) 15 s advertisement featuring a cardiologist explaining the importance of using EMS even if patients are unsure they are having a heart attack ("It’s ok to call").15 The campaign also addressed known barriers to calling EMS such as concerns that symptoms are not ACS or serious enough ("The operator will work out if you need an ambulance, if it’s a false alarm, well that’s the best thing that could happen"). The campaign ran intermittently in Melbourne between 2009 and 2013, with a fully paid advertising campaign running from May to August in 2013.

Study population

We included consecutive, hospital-admitted patients who had a confirmed primary admission diagnosis of ACS aged 35–75 years (campaign target population). Patients were recruited and interviewed within 3 days of hospital admission. Because of a change in study staffing, recruitment occurred across two time periods (July to November 2013 and February to April 2014). All subtypes of ACS were included: ST-elevation myocardial infarction (STEMI), non-ST-elevation myocardial infarction (NSTEMI) and unstable angina (UA). Patients were identified from daily screening of cardiology admission lists. All patients provided informed consent and were medically stable at the time of interview.

Data collection

We collected quantitative and qualitative data from medical records and face-to-face semistructured interviews with hospitalised patients with ACS. The interview tool (see online supplementary appendix 1)13 included questions from the modified Response to Symptoms Questionnaire16 17 and specific questions about awareness of the campaign, mode of transport to hospital and rationale for not using EMS (open-ended question with multiple answers allowed).

Supplementary Material

Supplementary appendix 1

Patient’s awareness of the Warning Signs campaign was assessed unprompted (Prior to this hospitalisation, had you seen any of television commercials and/or advertising about heart attacks?) and then prompted using two video stills from the television advertising (Prior to this hospitalisation, had you seen any of the following television commercials and/or advertising?).

Data analysis

The sample is described using proportions for categorical variables, and median and IQR for continuous variables. We compared groups (used EMS vs did not use EMS and barriers to EMS by campaign awareness) by χ2 and Mann-Whitney tests.

We used a multivariable logistic regression to identify the factors associated with EMS use. Factors with a p value <0.1 in the univariate analysis were included in the multivariable regression analysis. Symptoms that have been identified in previous studies12 17 as having an effect on EMS use were also analysed at the univariate level and included in the multivariable analysis if they satisfied the criteria. Categories of variables were as follows: age ≤65 vs >65 years; male versus female; born in English-speaking country no versus yes; completed secondary school or higher no versus yes; prior medical or first aid training no versus yes; EMS insurance no versus yes; prior risk factors no versus yes; symptoms present no versus yes; ACS subtype (UA vs STEMI or NSTEMI); and a perceived sense of control over symptoms (not all or mildly vs moderate to extremely). Significance levels were set at 0.05 and analysis was performed using Stata V.14.0.


Patient characteristics

As previously reported,13 323 patients with ACS were admitted and screened for the study. Of these, 109 were ineligible (age n=77, non–English speaking n=15, medically unstable n=8, inpatient event n=5, cognitive impairment n=3, and previously interviewed and readmitted n=1) and 214 were eligible, with 199 (93%) patients consenting and 15 declining to participate. Included patients were similar in sex and ACS subtype to excluded patients.

The median age of interviewed participants was 62 years (IQR 53–68), and the sample consisted of predominantly male patients (68%), those born in an English-speaking country (67%) and those with EMS insurance (via health insurance or subscription) (70%) (table 1). The most common subtype of ACS was NSTEMI (44%), followed by UA (35%) and STEMI (21%).

Table 1

Characteristics of patients and a comparison by EMS use

Transport to hospital

In almost two-thirds of cases, the need to present to hospital was determined by the patient (61%). In other cases, the decision was made by a trained healthcare professional (medical doctor, Nurse-on-Call advice line, EMS) or first aid officer (27%), with only a small proportion made by the patient’s family, friends or coworkers (12%). Patients identified multiple reasons in their decision to go to hospital: the type of symptoms (n=81), advice from someone else (n=63), the severity of symptoms (n=61), symptoms did not improve or worsened (n=47) and medication or symptoms did not improve with rest (n=5).

Overall, only half (n=107, 54%) of patients used EMS to get to hospital, with eight of these patients travelling in a car first and calling EMS when symptoms worsened. Other modes of transport to hospital included car (38%), walking (3%), taxi (3%) and public transport (2%). EMS use was highest in patients with STEMI (69%), followed by NSTEMI (52%) and UA (47%) (table 1).

Campaign awareness and impact on EMS use

Overall, 127 (64%) patients recalled seeing or hearing the Australian Heart Foundation's ‘Warning Signs of Heart Attack’ campaign (prompted and unprompted).13 EMS use was not associated with campaign awareness (52% vs 56.9%, p=0.49) (figure 1) or in those who stated the campaign influenced their behaviour (56% vs 53%, p=0.78). There was also no difference in EMS use when examined in those with prompted (54% vs 54%, p=0.95) or unprompted (51% vs 57%, p=0.46) recall of the campaign.

Figure 1

The proportion of patients who recalled seeing the National Heart Foundation Warning Signs of Heart Attack campaign (n=127, total x axis) and those who used EMS (n=107, total y axis). EMS, emergency medical services.

Factors associated with EMS use

The univariate analysis found that those patients who used EMS tended to be older (median age 65 years vs 59 years, p=0.003); have had no prior first aid or medical training (57% vs 38%, p=0.01); and be more likely to have experienced a sudden onset of pain (70% vs 53%, p=0.02) or vomiting (13% vs 2%, p=0.005). There was no association with EMS use and having EMS insurance (68% vs 72%, p=0.59).

In the multivariable analysis, increased EMS use was seen in older patients (adjusted OR (AOR) 2.90, 95% CI 1.45 to 5.80, p=0.003), those with STEMI (relative to UA) (AOR 2.63, 95% CI 1.00 to 6.91, p=0.05) and those experiencing a sudden onset of symptoms (AOR 2.01, 95% CI 1.01 to 4.01, p=0.05) or vomiting (AOR 5.47, 95% CI 1.07 to 27.97, p=0.04) (table 2).

Table 2

Multivariable analysis of factors associated with EMS use (n=199)

When asked why they did not use EMS, the majority of patients thought it would be faster to take another form of transport (n=40, 43%) or that their symptoms were not serious enough (n=25, 27%) (table 3). These reasons were not statistically different when examined by campaign awareness.

Table 3

Barriers to using EMS in those choosing other transport (multiple answers allowed) and comparison by campaign awareness (n=92)


Awareness of the campaign in our sample, of medically stable patients with ACS who were capable of being interviewed, was relatively good and comparable to other international mass media ACS campaigns.18 19 However, awareness of the campaign was not associated with increased EMS use or changes in the known barriers to EMS use. This may in part be due to the fact that the campaign did not invest as heavily in addressing barriers to EMS use, and instead focused on raising awareness of the lesser known warning signs and the importance of acting quickly.

Internationally, the use of mass media campaigns to educate the public and influence prehospital behaviour for ACS has shown varying results. The largest study conducted to date, the REACT Trial20 which included 20 communities who were randomised to a large multifaceted intervention strategy, showed no effect on prehospital delay, but an increase in EMS use. This finding is in contrast to our study, and studies of other international mass media campaigns,18 21–23 which have shown a reduction in prehospital delay times, but no impact on EMS use. This may in part be due to differences in the cohort studied, which in our study was limited to patients who were middle aged, medically stable and English speaking. However, other randomised controlled trials targeting patients with coronary heart disease24 or a provisional diagnosis of ACS25 with personalised education sessions have also shown no increase in EMS use.

In another study in population, the Warning Signs campaign was associated with an increase in calls to EMS for chest pain of between 7% and 15%.14 However, it remains unknown if this increase in calls was for true cardiac emergencies, but our results suggest that it may not. However, this requires confirmation in a larger sample. We are currently undertaking a study linking EMS calls for chest pain to hospital diagnosis to examine this issue.

The fact that mass media campaigns and targeted education interventions have generally failed to improve EMS use demonstrates the complexity of decision making for patients when deciding to use EMS. The factors considered in this decision-making process are diverse, and include consideration of time, seriousness and cost. In most of Australia, private health insurance or an EMS subscription is required to cover EMS costs. Although, the majority of our sample (70%) had EMS insurance or subscriptions, cost was a consideration in a small proportion (8%) of patients. We demonstrated, as others have, that older age8 26 and experiencing STEMI9 17 were associated with an increase in the likelihood of EMS use for ACS. We also had a similar direction of effect by sex, with more female patients using EMS.8 27 Unlike other reports,9 experiencing severe pain did not increase the odds of EMS use in our population; however, sudden onset of pain and vomiting were significantly associated with increased odds of EMS use.17 A previous report suggests that patients only come to hospital via EMS if they feel very unwell,9 and this was also seen in our study in which patients arriving by other means viewed their symptoms as not serious enough to warrant using EMS.

Also consistent with other studies, our respondents perceived self-transport as a faster form of transport to hospital,9 10 12 17 which may relate to the proximity to hospital as the majority of patients (80%) were metropolitan residents and the hospital is located within 4 km of the central business district. Previous research has found lower rates of EMS use in those with shorter travel times to hospital.28 This finding may also explain why patients who recognised their symptoms as heart related were not more likely to use EMS. Attention needs to be directed towards highlighting the importance of using EMS beyond a means of transport. EMS provide medical care, such as pain relief, thrombolysis and ALS in the event of ACS escalating to a cardiac arrest. Patients and the community also need to be aware that EMS will consider the most appropriate hospital to treat the condition, such as the availability of cardiac interventions. Such education needs to be targeted at groups who do not use EMS, such as men and those under 65 years of age, and may be best informed by first understanding the public’s existing perceptions and expectations of EMS.


Our study has some limitations. First, recall bias must be considered as patients were asked to give responses to the questionnaire retrospectively 2–3 days after the ACS event. Second, data were collected at only one site, which is located close to the central business district. Although our hospital also receives rural patients, which made up 20% of patients in our sample, proximity to hospital and socio-economic status were not collected. Measures of these should be considered in future studies. Third, our sample excluded patients who died (prehospital or inhospital), were elderly (not the target of campaign) and were unable to be interviewed (eg, non-English speaking, medically unstable or cognitively impaired). It is possible that EMS use is different in these groups, therefore our results may not apply to these cohorts. However, a recently published study has found the Warning Signs campaign to be associated with a decrease in the incidence of out-of-hospital cardiac arrest29—possibly related to patients with ACS acting earlier on symptoms. Furthermore, the profile of our sample was similar to patients in the ‘ACS snapshot’—an audit of 4398 patients with ACS admitted to 286 Australian and New Zealand hospitals in 2012.30

In conclusion, we found no association between having seen the National Heart Foundation Warning Signs campaign and EMS use in our cohort of patients with ACS. Barriers such as EMS response times or not thinking symptoms were serious enough remain highly prevalent among our population despite the campaign’s targeted campaign messages.


We thank Dr Jathushan Palasubramaniam for his assistance with data collection and Alyse Lennox for assistance with data entry.



  • Contributors JB, SC, DS, JS and JF conceived and designed the study, and contributed to the ethics committee (Institutional Review Board) application. JB and JF supervised the overall study. SC and PN collected all data. SC and JB cleaned and formatted the data. SC, JB and LS undertook the data analysis. All authors contributed to interpretation of the results, and drafting and revision of the manuscript. JB takes responsibility for the paper as a whole.

  • Funding This study was commissioned by the Heart Foundation. The Heart Foundation was not involved in the data collection or statistical analysis. JB, JF and SC receive salary support from the National Health and Medical Research Council (NHMRC) Centre for Research Excellence: Australian Resuscitation Outcomes Consortium (no 1029983). JB and DS are supported by a cofunded NHMRC/Heart Foundation Research Fellowships. JF receives salary support from St John Ambulance Western Australia. JS has no funding to declare.

  • Competing interests JB, DS and JF provide unpaid consultation to the Heart Foundation. HP is employed by the Heart Foundation. JS has no conflicts to declare.

  • Provenance and peer review Not commissioned; externally peer reviewed.