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Kummerow Broman K, Ward MJ, Poulose BK, Schwarze ML. Surgical Transfer Decision Making: How Regional Resources are Allocated in a Regional Transfer Network. Jt Comm J Qual Patient Saf 2018; 44:33-42. [PMID: 29290244 PMCID: PMC5751937 DOI: 10.1016/j.jcjq.2017.07.005] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2017] [Revised: 07/25/2017] [Accepted: 07/26/2017] [Indexed: 01/23/2023]
Abstract
BACKGROUND Tertiary care centers often operate above capacity, limiting access to emergency surgical care for patients at nontertiary facilities. For nontraumatic surgical emergencies there are no guidelines to inform patient selection for transfer to another facility. Such decisions may be particularly difficult for gravely ill patients when the benefits of transfer are uncertain. METHODS To characterize surgeons' decision-making strategies for transfer, a qualitative analysis of semistructured interviews was conducted with 16 general surgeons who refer and accept patients within a regional transfer network. Interviews included case-based vignettes about surgical patients with high comorbidity, multisystem organ failure, and terminal conditions. An inductive coding strategy was used, followed by performance of a higher-level analysis to characterize important themes and trends. RESULTS Surgeons at outlying hospitals seek transfer when the resources to care for patients' surgical needs or comorbid conditions are unavailable locally. In contrast, surgeons at the tertiary center accept all patients regardless of outcome or resource considerations. Bed availability at the tertiary care center restricts transfer capacity, harming patients who cannot be transferred. Surgeons sometimes transfer dying patients in order to exhaust all treatment options or appease families, but they are conflicted about the value of transfer, which displaces patients from their local communities and limits access to tertiary care for others. CONCLUSION Decisions to transfer surgical patients are complex and require comprehensive understanding of local capacity and regional resources. Current decision-making strategies fail to optimize patient selection for transfer and can inappropriately allocate scarce tertiary care beds.
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Bosson N, Baruch T, French WJ, Fang A, Kaji AH, Gausche-Hill M, Rock A, Shavelle D, Thomas JL, Niemann JT. Regional "Call 911" Emergency Department Protocol to Reduce Interfacility Transfer Delay for Patients With ST-Segment-Elevation Myocardial Infarction. J Am Heart Assoc 2017; 6:JAHA.117.006898. [PMID: 29275369 PMCID: PMC5779010 DOI: 10.1161/jaha.117.006898] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND We evaluated the first-medical-contact-to-balloon (FMC2B) time after implementation of a "Call 911" protocol for ST-segment-elevation myocardial infarction (STEMI) interfacility transfers in a regional system. METHODS AND RESULTS This is a retrospective cohort study of consecutive patients with STEMI requiring interfacility transfer from a STEMI referring hospital, to one of 35 percutaneous coronary intervention-capable STEMI receiving centers (SRCs). The Call 911 protocol allows the referring physician to activate 911 to transport a patient with STEMI to the nearest SRC for primary percutaneous coronary intervention. Patients with interfacility transfers were identified over a 4-year period (2011-2014) from a registry to which SRCs report treatment and outcomes for all patients with STEMI transported via 911. The primary outcomes were median FMC2B time and the proportion of patients achieving the 120-minute goal. FMC2B for primary 911 transports were calculated to serve as a system reference. There were 2471 patients with STEMI transferred to SRCs by 911 transport during the study period, of whom 1942 (79%) had emergent coronary angiography and 1410 (73%) received percutaneous coronary intervention. The median age was 61 years (interquartile range [IQR] 52-71) and 73% were men. The median FMC2B time was 111 minutes (IQR 88-153) with 56% of patients meeting the 120-minute goal. The median STEMI referring hospital door-in-door-out time was 53 minutes (IQR 37-89), emergency medical services transport time was 9 minutes (IQR 7-12), and SRC door-to-balloon time was 44 minutes (IQR 32-60). For primary 911 patients (N=4827), the median FMC2B time was 81 minutes (IQR 67-97). CONCLUSIONS Using a Call 911 protocol in this regional cardiac care system, patients with STEMI requiring interfacility transfers had a median FMC2B time of 111 minutes, with 56% meeting the 120-minute goal.
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Affiliation(s)
- Nichole Bosson
- The Los Angeles County Emergency Medical Services Agency, Los Angeles, CA .,Harbor-UCLA Medical Center and Los Angeles Biomedical Institute, Torrance, CA.,David Geffen School of Medicine at UCLA, Los Angeles, CA
| | | | - William J French
- Harbor-UCLA Medical Center and Los Angeles Biomedical Institute, Torrance, CA.,David Geffen School of Medicine at UCLA, Los Angeles, CA
| | | | - Amy H Kaji
- Harbor-UCLA Medical Center and Los Angeles Biomedical Institute, Torrance, CA.,David Geffen School of Medicine at UCLA, Los Angeles, CA
| | - Marianne Gausche-Hill
- The Los Angeles County Emergency Medical Services Agency, Los Angeles, CA.,Harbor-UCLA Medical Center and Los Angeles Biomedical Institute, Torrance, CA.,David Geffen School of Medicine at UCLA, Los Angeles, CA
| | | | - David Shavelle
- The Keck School of Medicine of the University of Southern California, Los Angeles, CA
| | - Joseph L Thomas
- Harbor-UCLA Medical Center and Los Angeles Biomedical Institute, Torrance, CA.,David Geffen School of Medicine at UCLA, Los Angeles, CA
| | - James T Niemann
- Harbor-UCLA Medical Center and Los Angeles Biomedical Institute, Torrance, CA.,David Geffen School of Medicine at UCLA, Los Angeles, CA
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Association Between Hospital Practices and Door-in-door-out Time in ST-segment Elevation Myocardial Infarction. Crit Pathw Cardiol 2017; 15:165-168. [PMID: 27846009 DOI: 10.1097/hpc.0000000000000093] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Current guidelines suggest a "door-in-door-out" (DIDO) time of 30 minutes or shorter for patients with ST-segment elevation myocardial infarction (STEMI) who arrive at a STEMI referral hospital and are transferred to a STEMI-receiving center for primary percutaneous coronary intervention. Experts previously identified 18 system practices as critical for reducing DIDO times. The objective of this study was to describe how frequently these critical practices are used and to determine whether their use was associated with shorter DIDO times. METHODS We surveyed 18 STEMI referral hospitals for 4 STEMI-receiving centers regarding their use of these 18 practices. The median number used was 14 practices (interquartile range 12-15). We then evaluated their association with DIDO times in all patients (n = 93) transferred from these STEMI referral hospitals to the 4 STEMI-receiving centers for primary percutaneous coronary intervention. RESULTS In univariate linear regression analyses, system-wide quality improvement programs with leaders in the emergency medical services agencies and STEMI referral hospitals were associated with shorter DIDO times (P < 0.001 for all). Overall use of system practices was not associated with DIDO times (P = 0.143). The majority (76%, 95% confidence interval: 66%-85%) of DIDO times did not meet the 30-minute goal. CONCLUSIONS These findings highlight the difficulty in achieving the 30-minute DIDO goal and the need for continued focus on strategies for reducing DIDO time, including system-wide quality improvement programs.
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Jneid H, Addison D, Bhatt DL, Fonarow GC, Gokak S, Grady KL, Green LA, Heidenreich PA, Ho PM, Jurgens CY, King ML, Kumbhani DJ, Pancholy S. 2017 AHA/ACC Clinical Performance and Quality Measures for Adults With ST-Elevation and Non-ST-Elevation Myocardial Infarction: A Report of the American College of Cardiology/American Heart Association Task Force on Performance Measures. J Am Coll Cardiol 2017; 70:2048-2090. [PMID: 28943066 DOI: 10.1016/j.jacc.2017.06.032] [Citation(s) in RCA: 131] [Impact Index Per Article: 18.7] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
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Rosell-Ortiz F, Mellado Vergel FJ, García del Águila J. Estrategias de reperfusión en hospitales sin intervención coronaria percutánea primaria. Rev Esp Cardiol (Engl Ed) 2017. [DOI: 10.1016/j.recesp.2017.05.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
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56
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Jneid H, Addison D, Bhatt DL, Fonarow GC, Gokak S, Grady KL, Green LA, Heidenreich PA, Ho PM, Jurgens CY, King ML, Kumbhani DJ, Pancholy S. 2017 AHA/ACC Clinical Performance and Quality Measures for Adults With ST-Elevation and Non–ST-Elevation Myocardial Infarction: A Report of the American College of Cardiology/American Heart Association Task Force on Performance Measures. Circ Cardiovasc Qual Outcomes 2017; 10:HCQ.0000000000000032. [DOI: 10.1161/hcq.0000000000000032] [Citation(s) in RCA: 50] [Impact Index Per Article: 7.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
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57
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Schneider MA, McMullan JT, Lindsell CJ, Hart KW, Deimling D, Jump D, Davis T, Hinckley WR. Reducing Door-in Door-out Intervals in Helicopter ST-segment Elevation Myocardial Infarction Interhospital Transfers. Air Med J 2017; 36:244-247. [PMID: 28886785 DOI: 10.1016/j.amj.2017.04.004] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2017] [Accepted: 04/06/2017] [Indexed: 06/07/2023]
Abstract
BACKGROUND Many health systems rely on helicopter EMS (HEMS) to transfer ST-elevation myocardial infarction (STEMI) patients for percutaneous coronary intervention (PCI) to a hospital with a catheterization laboratory. Mortality rates increase with the time to reperfusion, so reducing delays is imperative. For interhospital STEMI transfers, the time spent in the initial hospital from arrival until departure (door-in to door-out interval or DIDO) should be minimized. OBJECTIVE To evaluate the impact of a series of process improvements to reduce DIDO intervals for STEMI patients transferred via a hospital based HEMS program. METHODS Changes made to the STEMI transfer protocol in March 2011 were: (a) allowing transferring facilities to request HEMS before identifying an accepting cardiologist or hospital, with one hospital serving as a default PCI center in the case of delays, (b) limiting continuous infusions to those absolutely necessary for the transfer flights and (c) training flight crews to minimize time at bedside. Trained dual abstractors conducted structured medical record reviews for all STEMI patients 18 years and older, transferred to a PCI facility by HEMS from March 2011 to December 2012. Discrepancies were adjudicated. We compared DIDO intervals to a historical control cohort from 2007. We used the Mann-Whitney U test to compare times, and calculated differences with 95% confidence intervals. RESULTS Of 244 patients identified, six were excluded due to incomplete data. The historical cohort included 179 cases. Mean age was 59 (SD 14) years, 81% were white and 66% male. There were no differences in patient characteristics or door to EKG times between the cohorts. Median door-in to door-out interval decreased from 83 minutes (IQR 43) to 68 minutes (IQR 31) (difference 15 minutes, 95% CI 8 to 21, P <.0001). EKG to HEMS request decreased 21 minutes (95% CI 17 to 25, P <.0001), and HEMS ground time decreased 3 minutes (95% CI 2 to 4, P <.0001). There was a 32% absolute increase in the proportion of patients with EKG to helicopter request interval <35 minutes (83% vs 51%, difference 32%, 95% CI 24% to 41%, P <.0001). CONCLUSION HEMS-focused process improvements can significantly reduce the DIDO interval times for STEMI patients transferred for PCI.
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Affiliation(s)
| | - Jason T McMullan
- Department of Emergency Medicine, University of Cincinnati College of Medicine, Cincinnati, OH
| | - Christopher J Lindsell
- Department of Clinical Research, University of Cincinnati College of Medicine, Cincinnati, OH
| | - Kimberly W Hart
- Department of Emergency Medicine, University of Cincinnati College of Medicine, Cincinnati, OH
| | - Diana Deimling
- Department of Air Care & Mobile Care, University of Cincinnati College of Medicine, Cincinnati, OH
| | - Debra Jump
- Department of Air Care & Mobile Care, University of Cincinnati College of Medicine, Cincinnati, OH
| | - Todd Davis
- Department of Emergency Medicine, University of Washington Medicine Valley Medical Center, Renton, WA
| | - William R Hinckley
- Department of Emergency Medicine, University of Cincinnati College of Medicine, Cincinnati, OH
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Ho CK, Chen FC, Chen YL, Wang HT, Lee CH, Chung WJ, Lin CJ, Hsueh SK, Hung SC, Wu KH, Liu CF, Kung CT, Cheng CI. Using a Cloud Computing System to Reduce Door-to-Balloon Time in Acute ST-Elevation Myocardial Infarction Patients Transferred for Percutaneous Coronary Intervention. BIOMED RESEARCH INTERNATIONAL 2017; 2017:2963172. [PMID: 28900621 PMCID: PMC5576394 DOI: 10.1155/2017/2963172] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/06/2017] [Accepted: 07/18/2017] [Indexed: 11/21/2022]
Abstract
BACKGROUND This study evaluated the impact on clinical outcomes using a cloud computing system to reduce percutaneous coronary intervention hospital door-to-balloon (DTB) time for ST segment elevation myocardial infarction (STEMI). METHODS A total of 369 patients before and after implementation of the transfer protocol were enrolled. Of these patients, 262 were transferred through protocol while the other 107 patients were transferred through the traditional referral process. RESULTS There were no significant differences in DTB time, pain to door of STEMI receiving center arrival time, and pain to balloon time between the two groups. Pain to electrocardiography time in patients with Killip I/II and catheterization laboratory to balloon time in patients with Killip III/IV were significantly reduced in transferred through protocol group compared to in traditional referral process group (both p < 0.05). There were also no remarkable differences in the complication rate and 30-day mortality between two groups. The multivariate analysis revealed that the independent predictors of 30-day mortality were elderly patients, advanced Killip score, and higher level of troponin-I. CONCLUSIONS This study showed that patients transferred through our present protocol could reduce pain to electrocardiography and catheterization laboratory to balloon time in Killip I/II and III/IV patients separately. However, this study showed that using a cloud computing system in our present protocol did not reduce DTB time.
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Affiliation(s)
- Chi-Kung Ho
- Department of Public Health, Kaohsiung Medical University, Kaohsiung, Taiwan
| | - Fu-Cheng Chen
- Emergency Department, Kaohsiung Chang Gung Memorial Hospital, Kaohsiung, Taiwan
- Chang Gung University College of Medicine, Kaohsiung, Taiwan
| | - Yung-Lung Chen
- Chang Gung University College of Medicine, Kaohsiung, Taiwan
- Division of Cardiology, Department of Internal Medicine, Kaohsiung Chang Gung Memorial Hospital, Kaohsiung, Taiwan
| | - Hui-Ting Wang
- Emergency Department, Kaohsiung Chang Gung Memorial Hospital, Kaohsiung, Taiwan
- Chang Gung University College of Medicine, Kaohsiung, Taiwan
| | - Chien-Ho Lee
- Chang Gung University College of Medicine, Kaohsiung, Taiwan
- Division of Cardiology, Department of Internal Medicine, Kaohsiung Chang Gung Memorial Hospital, Kaohsiung, Taiwan
| | - Wen-Jung Chung
- Chang Gung University College of Medicine, Kaohsiung, Taiwan
- Division of Cardiology, Department of Internal Medicine, Kaohsiung Chang Gung Memorial Hospital, Kaohsiung, Taiwan
| | - Cheng-Jui Lin
- Chang Gung University College of Medicine, Kaohsiung, Taiwan
- Division of Cardiology, Department of Internal Medicine, Kaohsiung Chang Gung Memorial Hospital, Kaohsiung, Taiwan
| | - Shu-Kai Hsueh
- Chang Gung University College of Medicine, Kaohsiung, Taiwan
- Division of Cardiology, Department of Internal Medicine, Kaohsiung Chang Gung Memorial Hospital, Kaohsiung, Taiwan
| | - Shin-Chiang Hung
- Emergency Department, Kaohsiung Chang Gung Memorial Hospital, Kaohsiung, Taiwan
- Chang Gung University College of Medicine, Kaohsiung, Taiwan
| | - Kuan-Han Wu
- Emergency Department, Kaohsiung Chang Gung Memorial Hospital, Kaohsiung, Taiwan
- Chang Gung University College of Medicine, Kaohsiung, Taiwan
| | - Chu-Feng Liu
- Emergency Department, Kaohsiung Chang Gung Memorial Hospital, Kaohsiung, Taiwan
- Chang Gung University College of Medicine, Kaohsiung, Taiwan
| | - Chia-Te Kung
- Emergency Department, Kaohsiung Chang Gung Memorial Hospital, Kaohsiung, Taiwan
- Chang Gung University College of Medicine, Kaohsiung, Taiwan
| | - Cheng-I Cheng
- Chang Gung University College of Medicine, Kaohsiung, Taiwan
- Division of Cardiology, Department of Internal Medicine, Kaohsiung Chang Gung Memorial Hospital, Kaohsiung, Taiwan
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Abstract
Reperfusion therapy decreases myocardium damage during an acute coronary event and consequently mortality. However, there are unmet needs in the treatment of acute myocardial infarction, consequently mortality and heart failure continue to occur in about 10% and 20% of cases, respectively. Different strategies could improve reperfusion. These strategies, like generation of warning sign recognition and being initially assisted and transferred by an emergency service, could reduce the time to reperfusion. If the first electrocardiogram is performed en route, it can be transmitted and interpreted in a timely manner by a specialist at the receiving center, bypassing community hospitals without percutaneous coronary intervention capabilities. To administer thrombolytic therapy during transport to the catheterization laboratory could reduce time to reperfusion in cases with expected prolonged transport time to a percutaneous coronary intervention center or to a center without primary percutaneous coronary intervention capabilities with additional expected delay, known as pharmaco-invasive strategy. Myocardial reperfusion is known to produce damage and cell death, which defines the reperfusion injury. Lack of resolution of ST segment is used as a marker of reperfusion failure. In patients without ST segment resolution, mortality triples. It is important to note that, until recently, reperfusion injury and no-reflow were interpreted as a single entity and we should differentiate them as different entities; whereas no-reflow is the failure to obtain tissue flow, reperfusion injury is actually the damage produced by achieving flow. Therefore, treatment of no-reflow is obtained by tissue flow, whereas in reperfusion injury the treatment objective is protection of susceptible myocardium from reperfusion injury. Numerous trials for the treatment of reperfusion injury have been unsuccessful. Newer hypotheses such as “
controlled reperfusion”, in which the interventional cardiologist assumes not only the treatment of the culprit vessel but also the way to reperfuse the myocardium at risk, could reduce reperfusion injury.
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Affiliation(s)
- Alejandro Farah
- Interventional Cardiology Department, San Bernardo Hospital, Salta, Argentina
| | - Alejandro Barbagelata
- Universidad Católica de Buenos Aires, Buenos Aires, Argentina.,Department of Medicine, Duke University School of Medicine, Durham, NC, USA
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60
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Rosell-Ortiz F, Mellado Vergel FJ, García Del Águila J. Reperfusion Strategies in Hospitals Without Primary Percutaneous Coronary Intervention. ACTA ACUST UNITED AC 2017; 70:887. [PMID: 28705530 DOI: 10.1016/j.rec.2017.05.031] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2017] [Accepted: 05/03/2017] [Indexed: 10/19/2022]
Affiliation(s)
- Fernando Rosell-Ortiz
- Servicio de Emergencias 061, Empresa Pública de Emergencias Sanitarias de Andalucía, Almería, Spain.
| | | | - Javier García Del Águila
- Servicio de Emergencias 061, Empresa Pública de Emergencias Sanitarias de Andalucía, Almería, Spain
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61
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Russo J, Le May MR. Time to Treatment: Focus on Transfer in ST-Elevation Myocardial Infarction. Interv Cardiol Clin 2017; 5:427-437. [PMID: 28581993 DOI: 10.1016/j.iccl.2016.06.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
In the modern ST-elevation myocardial infarction (STEMI) system, the use of electrocardiogram by emergency medical services (EMS) personnel and the option to bypass emergency departments on route to a PCI-capable hospital is of particular importance. Through training and a standardized referral process, EMS personnel can now accurately diagnose and refer STEMI patients directly to the catheterization laboratory of a percutaneous coronary intervention-capable hospital. Regional STEMI models have been implemented successfully across North America, resulting in palpable reductions in door-to-balloon time, morbidity, and mortality.
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Affiliation(s)
- Juan Russo
- Division of Cardiology, University of Ottawa Heart Institute, 40 Ruskin Street, Ottawa K1Y 4W7, Canada
| | - Michel R Le May
- Division of Cardiology, University of Ottawa Heart Institute, 40 Ruskin Street, Ottawa K1Y 4W7, Canada.
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Fabris E, van’t Hof A, Hamm C, Lapostolle F, Lassen J, Goodman S, ten Berg J, Bolognese L, Cequier A, Chettibi M, Hammett C, Huber K, Janzon M, Merkely B, Storey R, Zeymer U, Cantor W, Rousseau H, Vicaut E, Montalescot G. Impact of presentation and transfer delays on complete ST-segment resolution before primary percutaneous coronary intervention: insights from the ATLANTIC trial. EUROINTERVENTION 2017; 13:69-77. [DOI: 10.4244/eij-d-16-00965] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
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63
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Maddox TM, Albert NM, Borden WB, Curtis LH, Ferguson TB, Kao DP, Marcus GM, Peterson ED, Redberg R, Rumsfeld JS, Shah ND, Tcheng JE. The Learning Healthcare System and Cardiovascular Care: A Scientific Statement From the American Heart Association. Circulation 2017; 135:e826-e857. [DOI: 10.1161/cir.0000000000000480] [Citation(s) in RCA: 67] [Impact Index Per Article: 9.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
The learning healthcare system uses health information technology and the health data infrastructure to apply scientific evidence at the point of clinical care while simultaneously collecting insights from that care to promote innovation in optimal healthcare delivery and to fuel new scientific discovery. To achieve these goals, the learning healthcare system requires systematic redesign of the current healthcare system, focusing on 4 major domains: science and informatics, patient-clinician partnerships, incentives, and development of a continuous learning culture. This scientific statement provides an overview of how these learning healthcare system domains can be realized in cardiovascular disease care. Current cardiovascular disease care innovations in informatics, data uses, patient engagement, continuous learning culture, and incentives are profiled. In addition, recommendations for next steps for the development of a learning healthcare system in cardiovascular care are presented.
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Saseendran A, Ally K, Gangadevi P, Banakar PS. Effect of supplementation of lecithin and carnitine on growth performance and nutrient digestibility in pigs fed high-fat diet. Vet World 2017; 10:149-155. [PMID: 28344396 PMCID: PMC5352838 DOI: 10.14202/vetworld.2017.149-155] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2016] [Accepted: 01/03/2017] [Indexed: 11/16/2022] Open
Abstract
Aim: To study the effect of dietary supplementation of lecithin and carnitine on growth performance and nutrient digestibility in pigs fed high-fat diet. Materials and Methods: A total of 30 weaned female large white Yorkshire piglets of 2 months of age were selected and randomly divided into three groups allotted to three dietary treatments, T1 - Control ration as per the National Research Council nutrient requirement, T2 - Control ration plus 5% fat, and T3 - T2 plus 0.5% lecithin plus 150 mg/kg carnitine. The total dry matter (DM) intake, fortnightly body weight of each individual animal was recorded. Digestibility trial was conducted toward the end of the experiment to determine the digestibility coefficient of various nutrients. Results: There was a significant improvement (p<0.01) observed for pigs under supplementary groups T2 and T3 than that of control group (T1) with regards to growth parameters studied such as total DM intake, average final body weight and total weight gain whereas among supplementary groups, pigs reared on T3 group had better intake (p<0.01) when compared to T2 group. Statistical analysis of data revealed that no differences were observed (p>0.05) among the three treatments on average daily gain, feed conversion efficiency, and nutrient digestibility during the overall period. Conclusion: It was concluded that the dietary inclusion of animal fat at 5% level or animal fat along with lecithin (0.5%) and carnitine (150 mg/kg) improved the growth performance in pigs than non-supplemented group and from the economic point of view, dietary incorporation of animal fat at 5% would be beneficial for improving growth in pigs without dietary modifiers.
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Affiliation(s)
- Arathy Saseendran
- Department of Animal Nutrition, College of Veterinary and Animal Sciences, Kerala Veterinary and Animal Sciences University, Mannuthy, Thrissur - 680 651, Kerala, India
| | - K Ally
- Department of Animal Nutrition, College of Veterinary and Animal Sciences, Kerala Veterinary and Animal Sciences University, Mannuthy, Thrissur - 680 651, Kerala, India
| | - P Gangadevi
- Department of Animal Nutrition, College of Veterinary and Animal Sciences, Kerala Veterinary and Animal Sciences University, Mannuthy, Thrissur - 680 651, Kerala, India
| | - P S Banakar
- Department of Animal Nutrition, College of Veterinary and Animal Sciences, Kerala Veterinary and Animal Sciences University, Mannuthy, Thrissur - 680 651, Kerala, India
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65
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STEMI Care in Poland and the United States: Both Have Some Distance Yet to Travel. JACC Cardiovasc Interv 2017; 10:448-450. [PMID: 28216220 DOI: 10.1016/j.jcin.2017.01.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/04/2017] [Accepted: 01/05/2017] [Indexed: 10/20/2022]
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66
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Yiadom MYAB, Baugh CW, McWade CM, Liu X, Song KJ, Patterson BW, Jenkins CA, Tanski M, Mills AM, Salazar G, Wang TJ, Dittus RS, Liu D, Storrow AB. Performance of Emergency Department Screening Criteria for an Early ECG to Identify ST-Segment Elevation Myocardial Infarction. J Am Heart Assoc 2017; 6:JAHA.116.003528. [PMID: 28232323 PMCID: PMC5523988 DOI: 10.1161/jaha.116.003528] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Abstract
Background Timely diagnosis of ST‐segment elevation myocardial infarction (STEMI) in the emergency department (ED) is made solely by ECG. Obtaining this test within 10 minutes of ED arrival is critical to achieving the best outcomes. We investigated variability in the timely identification of STEMI across institutions and whether performance variation was associated with the ED characteristics, the comprehensiveness of screening criteria, and the STEMI screening processes. Methods and Results We examined STEMI screening performance in 7 EDs, with the missed case rate (MCR) as our primary end point. The MCR is the proportion of primarily screened ED patients diagnosed with STEMI who did not receive an ECG within 15 minutes of ED arrival. STEMI was defined by hospital discharge diagnosis. Relationships between the MCR and ED characteristics, screening criteria, and STEMI screening processes were assessed, along with differences in door‐to‐ECG times for captured versus missed patients. The overall MCR for all 7 EDs was 12.8%. The lowest and highest MCRs were 3.4% and 32.6%, respectively. The mean difference in door‐to‐ECG times for captured and missed patients was 31 minutes, with a range of 14 to 80 minutes of additional myocardial ischemia time for missed cases. The prevalence of primarily screened ED STEMIs was 0.09%. EDs with the greatest informedness (sensitivity+specificity−1) demonstrated superior performance across all other screening measures. Conclusions The 29.2% difference in MCRs between the highest and lowest performing EDs demonstrates room for improving timely STEMI identification among primarily screened ED patients. The MCR and informedness can be used to compare screening across EDs and to understand variable performance.
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Affiliation(s)
| | | | | | - Xulei Liu
- Vanderbilt University, Nashville, TN
| | - Kyoung Jun Song
- Department of Emergency Medicine, University of California at Davis, Sacramento, CA
| | - Brian W Patterson
- Department of Emergency Medicine, University of Wisconsin at Madison, WI
| | | | - Mary Tanski
- Department of Emergency Medicine, Oregon Health & Sciences University, Portland, OR
| | - Angela M Mills
- Department of Emergency Medicine, University of Pennsylvania, Philadelphia, PA
| | - Gilberto Salazar
- Department of Emergency Medicine, University of Texas Southwestern, Dallas, TX
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Breuckmann F, Hochadel M, Voigtländer T, Haude M, Schmitt C, Münzel T, Giannitsis E, Mudra H, Heusch G, Schumacher B, Barth S, Schuler G, Hailer B, Walther D, Senges J. On versus off-hour care of patients with acute coronary syndrome and persistent ST-segment elevation in certified German chest pain units. EUROPEAN HEART JOURNAL-ACUTE CARDIOVASCULAR CARE 2016; 6:3-9. [PMID: 26714975 DOI: 10.1177/2048872615624845] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Regional healthcare projects improve the off-hour care of patients with acute coronary syndromes and persistent ST-segment elevation myocardial infarction (STEMI). To analyse differences in quality of care between on and off-hour care of STEMI patients admitted to certified German chest pain units. METHODS A total of 1107 STEMI patients from the German chest pain unit registry were enrolled. Analyses comprised critical time intervals (symptoms to first medical contact (FMC), FMC to admission, symptoms to admission, symptoms to balloon, FMC to balloon, door to balloon times) and major adverse cardiac and cerebrovascular events at follow-up. RESULTS 54.8% of patients were admitted off-hours. Symptoms to admission (2:28 (1:28-5:20 h) vs. 3:16 h (1:35-8:06 h), P<0.001), symptoms to FMC (1:15 h (0:33-3:00 h) vs. 2:00 h (0:40-6:46 h), P<0.001) and FMC to admission intervals (0:45 h (0:30-1:20 h) vs. 0:52 h (0:32-1:35 h), P=0.09) were shorter during off-hours. Percutaneous revascularisation rates were high and without difference between on and off-hours (95.5% vs. 96.8%, P=0.30). Door to balloon times were significantly less during on-hours (0:32 h (0:18-1:06 h) vs. 0:44 h (0:23-1:20 h), P<0.01) without negative impact on the proportion of patients with a door to balloon time of <60 min (72.6% vs. 68.4%, P=0.19), symptoms to balloon (3:49 h (2:12-10:46 h) vs. 3:30 h (2:04-7:41 h), P=0.08) or FMC to balloon times (1:26 h (0:56-2:22 h) vs. 1:30 h (1:03-2:29 h), P=0.14). Major adverse cardiac and cerebrovascular event rates did not differ significantly between on and off-hours (log-rank test P=0.36). CONCLUSIONS The German chest pain unit network ensures rapid and structured preclinical and in-hospital care independent from the circadian variation of admission. Slower door to balloon times off-hours are compensated by faster symptoms to admission or symptoms to FMC intervals. Further efforts should focus on patient awareness programmes on-hours and STEMI alarming tracks off-hours.
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Affiliation(s)
| | | | | | | | - Claus Schmitt
- 5 Clinic for Cardiology and Angiology, Municipal Hospital Karlsruhe, Germany
| | - Thomas Münzel
- 6 2nd Department of Medicine, Johannes Gutenberg-University Mainz, Germany
| | | | - Harald Mudra
- 8 Department of Cardiology, Pneumology, Internal Intensive Care Medicine, Städtisches Klinikum München GmbH, Germany
| | - Gerd Heusch
- 9 Institute for Pathophysiology, University Duisburg-Essen, Germany
| | | | - Sebastian Barth
- 11 Department of Cardiology, Herz- und Gefäß-Klinik GmbH, Germany
| | | | - Birgit Hailer
- 13 Department of Cardiology, Catholic Clinics Essen-Northwest, Germany
| | - Dirk Walther
- 14 2nd Department of Medicine, HELIOS Kreiskrankenhaus Gotha/Ohrdruf, Germany
| | - Jochen Senges
- 2 Institute for Myocardial Infarction Research, Germany
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Dharma S, Andriantoro H, Purnawan I, Dakota I, Basalamah F, Hartono B, Rasmin R, Isnanijah H, Yamin M, Wijaya IP, Pratama V, Gunawan TB, Juwana YB, Suling FRW, Witjaksono AMO, Lasanudin HF, Iskandarsyah K, Priatna H, Tedjasukmana P, Wahyumandradi U, Kosasih A, Budhiarti IA, Pribadi W, Wirianta J, Lubiantoro U, Pramesti R, Widowati DR, Aminda SK, Basalamah MA, Rao SV. Characteristics, treatment and in-hospital outcomes of patients with STEMI in a metropolitan area of a developing country: an initial report of the extended Jakarta Acute Coronary Syndrome registry. BMJ Open 2016; 6:e012193. [PMID: 27580835 PMCID: PMC5013359 DOI: 10.1136/bmjopen-2016-012193] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
OBJECTIVE We studied the characteristics of patients with ST segment elevation myocardial infarction (STEMI) after expansion of a STEMI registry as part of the STEMI network programme in a metropolitan city and the surrounding area covering ∼26 million inhabitants. DESIGN Retrospective cohort study. SETTING Emergency department of 56 health centres. PARTICIPANTS 3015 patients with acute coronary syndrome, of which 1024 patients had STEMI. MAIN OUTCOME MEASURE Characteristics of reperfusion therapy. RESULTS The majority of patients with STEMI (81%; N=826) were admitted to six academic percutaneous coronary intervention (PCI) centres. PCI centres received patients predominantly (56%; N=514) from a transfer process. The proportion of patients receiving acute reperfusion therapy was higher than non-reperfused patients (54% vs 46%, p<0.001), and primary PCI was the most common method of reperfusion (86%). The mean door-to-device (DTD) time was 102±68 min. In-hospital mortality of non-reperfused patients was higher than patients receiving primary PCI or fibrinolytic therapy (9.1% vs 3.2% vs 3.8%, p<0.001). Compared with non-academic PCI centres, patients with STEMI admitted to academic PCI centres who underwent primary PCI had shorter mean DTD time (96±44 min vs 140±151 min, p<0.001), higher use of manual thrombectomy (60.2% vs13.8%, p<0.001) and drug-eluting stent implantation (87% vs 69%, p=0.001), but had similar use of radial approach and intra-aortic balloon pump (55.7% vs 67.2%, and 2.2% vs 3.4%, respectively). In patients transferred for primary PCI, TIMI risk score ≥4 on presentation was associated with a prolonged door-in to door-out (DI-DO) time (adjusted OR 2.08; 95% CI 1.09 to 3.95, p=0.02). CONCLUSIONS In the expanded JAC registry, a higher proportion of patients with STEMI received reperfusion therapy, but 46% still did not. In developing countries, focusing the prehospital care in the network should be a major focus of care to improve the DI-DO time along with improvement of DTD time at PCI centres. TRIAL REGISTRATION NUMBER NCT02319473.
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Affiliation(s)
- Surya Dharma
- Department of Cardiology and Vascular Medicine, Faculty of Medicine, University of Indonesia, National Cardiovascular Center Harapan Kita, Jakarta, Indonesia
| | - Hananto Andriantoro
- Department of Cardiology and Vascular Medicine, Faculty of Medicine, University of Indonesia, National Cardiovascular Center Harapan Kita, Jakarta, Indonesia
| | - Ismi Purnawan
- Chairman, Indonesian Heart Association, Jakarta Branch, Jakarta, Indonesia
| | - Iwan Dakota
- Department of Cardiology and Vascular Medicine, Faculty of Medicine, University of Indonesia, National Cardiovascular Center Harapan Kita, Jakarta, Indonesia
| | | | - Beny Hartono
- Binawaluya Cardiac Center, East Jakarta, Indonesia
| | - Ronaly Rasmin
- Budhi Asih General Hospital, East Jakarta, Indonesia
| | | | - Muhammad Yamin
- Division of Cardiology, Department of Internal Medicine, Faculty of Medicine, University of Indonesia, Cipto Mangunkusumo General Hospital, Central Jakarta, Indonesia
| | - Ika Prasetya Wijaya
- Division of Cardiology, Department of Internal Medicine, Faculty of Medicine, University of Indonesia, Cipto Mangunkusumo General Hospital, Central Jakarta, Indonesia
| | - Vireza Pratama
- Department of Cardiology, Gatot Soebroto Army Central Hospital, Central Jakarta, Indonesia
| | - Tjatur Bagus Gunawan
- Department of Cardiology, Dr Mintohardjo Hospital, Indonesian Naval Hospital, Central Jakarta, Indonesia
| | | | - Frits R W Suling
- Department of Cardiology, Christian University of Indonesia General Hospital, East Jakarta, Indonesia
| | - A M Onny Witjaksono
- Department of Cardiology, St Carolus General Hospital, Central Jakarta, Indonesia
| | | | | | | | | | | | | | | | - Wisnoe Pribadi
- Esnawan Antariksa Indonesian Air Force Hospital, East Jakarta, Indonesia
| | | | | | - Rini Pramesti
- Fatmawati General Hospital, South Jakarta, Indonesia
| | | | | | | | - Sunil V Rao
- Section Chief, Department of Cardiology, Duke University Medical Center, Durham VA Medical Center, Durham, North Carolina, USA
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Ward MJ, Kripalani S, Zhu Y, Storrow AB, Wang TJ, Speroff T, Munoz D, Dittus RS, Harrell FE, Self WH. Role of Health Insurance Status in Interfacility Transfers of Patients With ST-Elevation Myocardial Infarction. Am J Cardiol 2016; 118:332-7. [PMID: 27282834 PMCID: PMC4949088 DOI: 10.1016/j.amjcard.2016.05.007] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/16/2016] [Revised: 05/05/2016] [Accepted: 05/05/2016] [Indexed: 11/20/2022]
Abstract
Lack of health insurance is associated with interfacility transfer from emergency departments for several nonemergent conditions, but its association with transfers for ST-elevation myocardial infarction (STEMI), which requires timely definitive care for optimal outcomes, is unknown. Our objective was to determine whether insurance status is a predictor of interfacility transfer for emergency department visits with STEMI. We analyzed data from the 2006 to 2011 Nationwide Emergency Department Sample examining all emergency department visits for patients age 18 years and older with a diagnosis of STEMI and a disposition of interfacility transfer or hospitalization at the same institution. For emergency department visits with STEMI, our multivariate logistic regression model included emergency department disposition status (interfacility transfer vs hospitalization at the same institution) as the primary outcome, and insurance status (none vs any [including Medicare, Medicaid, and private insurance]) as the primary exposure. We found that among 1,377,827 emergency department STEMI visits, including 249,294 (18.1%) transfers, patients without health insurance (adjusted odds ratio 1.6, 95% CI 1.5 to 1.7) were more likely to be transferred than those with insurance. Lack of health insurance status was also an independent risk factor for transfer compared with each subcategory of health insurance, including Medicare, Medicaid, and private insurance. In conclusion, among patients presenting to United States emergency departments with STEMI, lack of insurance was an independent predictor of interfacility transfer. In conclusion, because interfacility transfer is associated with longer delays to definitive STEMI therapy than treatment at the same facility, lack of health insurance may lead to important health disparities among patients with STEMI.
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Affiliation(s)
- Michael J Ward
- Department of Emergency Medicine, Vanderbilt University School of Medicine, Nashville, Tennessee.
| | - Sunil Kripalani
- Section of Hospital Medicine, Division of General Internal Medicine and Public Health, Center for Clinical Quality and Implementation Research, Vanderbilt University School of Medicine, Nashville, Tennessee
| | - Yuwei Zhu
- Department of Biostatistics, Vanderbilt University School of Medicine, Nashville, Tennessee
| | - Alan B Storrow
- Department of Emergency Medicine, Vanderbilt University School of Medicine, Nashville, Tennessee
| | - Thomas J Wang
- Division of Cardiology, Vanderbilt University School of Medicine, Nashville, Tennessee
| | - Theodore Speroff
- Geriatric Research, Education, and Clinical Center, Department of Medicine, VA Tennessee Valley Healthcare System, Nashville, Tennessee
| | - Daniel Munoz
- Division of Cardiology, Vanderbilt University School of Medicine, Nashville, Tennessee
| | - Robert S Dittus
- Geriatric Research, Education, and Clinical Center, Department of Medicine, VA Tennessee Valley Healthcare System, Nashville, Tennessee; Department of Medicine, Institute for Medicine and Public Health, Vanderbilt University School of Medicine, Nashville, Tennessee
| | - Frank E Harrell
- Department of Biostatistics, Vanderbilt University School of Medicine, Nashville, Tennessee
| | - Wesley H Self
- Department of Emergency Medicine, Vanderbilt University School of Medicine, Nashville, Tennessee
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Sankey CB, McAvay G, Siner JM, Barsky CL, Chaudhry SI. "Deterioration to Door Time": An Exploratory Analysis of Delays in Escalation of Care for Hospitalized Patients. J Gen Intern Med 2016; 31:895-900. [PMID: 26969311 PMCID: PMC4945556 DOI: 10.1007/s11606-016-3654-x] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/25/2015] [Revised: 09/23/2015] [Accepted: 02/19/2016] [Indexed: 10/22/2022]
Abstract
BACKGROUND Timely escalation of care for patients experiencing clinical deterioration in the inpatient setting is challenging. Deterioration on a general floor has been associated with an increased risk of death, and the early period of deterioration may represent a time during which admission to the intensive care unit (ICU) improves survival. Previous studies examining the association between delay from onset of clinical deterioration to ICU transfer and mortality are few in number and were conducted more than 10 years ago. OBJECTIVE We aimed to evaluate the impact of delays in the escalation of care among clinically deteriorating patients in the current era of inpatient medicine. DESIGN AND PARTICIPANTS This was a retrospective cohort study that analyzed data from 793 patients transferred from non-intensive care unit (ICU) inpatient floors to the medical intensive care unit (MICU), from 2011 to 2013 at an urban, tertiary, academic medical center. MAIN MEASURES "Deterioration to door time (DTDT)" was defined as the time between onset of clinical deterioration (as evidenced by the presence of one or more vital sign indicators including respiratory rate, systolic blood pressure, and heart rate) and arrival in the MICU. KEY RESULTS In our sample, 64.6 % had delays in care escalation, defined as greater than 4 h based on previous studies. Mortality was significantly increased beginning at a DTDT of 12.1 h after adjusting for age, gender, and severity of illness. CONCLUSIONS Delays in the escalation of care for clinically deteriorating hospitalized patients remain frequent in the current era of inpatient medicine, and are associated with increased in-hospital mortality. Development of performance measures for the care of clinically deteriorating inpatients remains essential, and timeliness of care escalation deserves further consideration.
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Affiliation(s)
- Christopher B Sankey
- Section of General Medicine, Department of Internal Medicine, Yale University School of Medicine, Harkness Hall A, Room 306, 367 Cedar St., New Haven, CT, 06510, USA. .,Yale-New Haven Hospital, New Haven, CT, USA.
| | - Gail McAvay
- Section of Geriatric Medicine, Department of Internal Medicine, Yale University School of Medicine, New Haven, CT, USA
| | - Jonathan M Siner
- Section of Pulmonary, Critical Care and Sleep Medicine, Department of Internal Medicine, Yale University School of Medicine, New Haven, CT, USA
| | - Carol L Barsky
- Patient Safety and Quality, Hackensack University Medical Center, Hackensack, NJ, USA
| | - Sarwat I Chaudhry
- Section of General Medicine, Department of Internal Medicine, Yale University School of Medicine, Harkness Hall A, Room 306, 367 Cedar St., New Haven, CT, 06510, USA.,Yale-New Haven Hospital, New Haven, CT, USA
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71
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Broman KK, Poulose BK, Phillips SE, Ehrenfeld JM, Sharp KW, Pierce RA, Holzman MD. Unnecessary Transfers for Acute Surgical Care: Who and Why? Am Surg 2016. [DOI: 10.1177/000313481608200823] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Interhospital transfers for acute surgical care occur commonly, but without clear guidelines or protocols. Transfers may subject patients and delivery systems to significant burdens without clear clinical benefit. The incidence and factors associated with unnecessary transfers are not well described. We conducted a retrospective cohort study of patient transfers within a regional referral network to a tertiary center for nontrauma acute surgical care from 2009 to 2013. Clinically unnecessary transfers were defined as transfers that resulted in no intervention (operation, endoscopy, or interventional radiology procedure) and discharge to home within 72 hours. We performed bivariate and multivariate logistic regression analyses. The study population included 2177 patient transfers, 19 per cent of which were determined to be clinically unnecessary. After adjustment, clinically unnecessary transfers were more commonly performed for patient request (odds ratio = 2.52, 95% confidence interval = 1.60–3.99), continuity of care (1.87, 1.44–2.42), and care by urologic (1.50, 1.06–2.13) and vascular services (1.44, 1.03–2.01). Patients with higher comorbidity and severity of illness scores were less likely to have unnecessary transfers. The burden of unnecessary transfers could be mitigated by identifying appropriate transfer candidates through mutually developed guidelines, interfacility collaboration, and increased use of remote care to provide surgical subspecialty consultation and maintain continuity.
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Affiliation(s)
- Kristy Kummerow Broman
- Departments of Surgery Vanderbilt University Medical Center, Nashville, Tennessee
- Geriatric Research Education and Clinical Center, Veterans Affairs Medical Center, Tennessee Valley Healthcare System
| | - Benjamin K. Poulose
- Departments of Surgery Vanderbilt University Medical Center, Nashville, Tennessee
| | - Sharon E. Phillips
- Departments of Biostatistics Vanderbilt University Medical Center, Nashville, Tennessee
| | - Jesse M. Ehrenfeld
- Departments of Surgery Vanderbilt University Medical Center, Nashville, Tennessee
- Departments of Anesthesiology Vanderbilt University Medical Center, Nashville, Tennessee
- Departments of Bioinformatics Vanderbilt University Medical Center, Nashville, Tennessee
- Departments of Health Policy, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Kenneth W. Sharp
- Departments of Surgery Vanderbilt University Medical Center, Nashville, Tennessee
| | - Richard A. Pierce
- Departments of Surgery Vanderbilt University Medical Center, Nashville, Tennessee
| | - Michael D. Holzman
- Departments of Surgery Vanderbilt University Medical Center, Nashville, Tennessee
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Ting R, Tejpal A, Finken L, Fisher M, Lefkowitz C, Parthasarathy H, Fallis B, Fosbol EL, Al-Shehri M, Kutryk M, Buller CE, Fam N, Graham JJ, Cheema AN, Bagai A. Repatriation to referral hospital after reperfusion of STEMI patients transferred for primary percutaneous coronary intervention: Insights of a Canadian regional STEMI care system. Am Heart J 2016; 177:145-52. [PMID: 27297860 DOI: 10.1016/j.ahj.2016.04.017] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/01/2015] [Accepted: 04/26/2016] [Indexed: 11/24/2022]
Abstract
BACKGROUND In regional systems of ST-segment elevation myocardial infarction (STEMI) care, patients presenting to hospitals without percutaneous coronary intervention (PCI) are transferred to PCI-capable hospitals for primary PCI. Repatriation, a practice whereby such patients are transferred back to non-PCI referral hospitals after reperfusion is prevalent in many jurisdictions, yet little is known of this practice and its safety. METHODS We studied 979 consecutive STEMI patients transported from the emergency department and catchment area of two non-PCI hospitals in Ontario, Canada to a regional PCI-hospital for primary PCI between January 2008 and June 2014. Logistic regression modeling was performed to determine factors associated with delayed repatriation beyond 24 hours and to evaluate the association between repatriation and index-admission mortality. RESULTS Eight hundred and fifteen (83.2%) patients were repatriated with 524 (65.2%) patients repatriated within 24 hours. Factors independently associated with delayed repatriation included systolic blood pressure (OR 1.03 per 5 mmHg decrease, 95% CI 1.01-1.06, P= .04), requirement for mechanical ventilation (OR 24.9, 95% CI 5.4-115.3, P< .0001), ventricular arrhythmia (OR 3.0, 95% CI 1.3-6.6, P= .01), infarct-related artery (P= .03), final TIMI flow grade (P= .01) and access-site complications (OR 2.36, 95% CI 1.04-5.4, P= .04). After repatriation, 9 (1.3%) patients returned to the PCI-hospital for urgent care, and 16 (2.0%) died during index-admission. After adjustment, repatriation was not associated with increase in index-admission mortality (adjusted OR 0.46, 95% CI 0.16-1.32, P= .15). CONCLUSIONS In a regional STEMI care system in Ontario, Canada, patients are routinely repatriated to non-PCI hospitals after primary PCI. This practice was associated with very low and acceptable rate of return to the PCI-hospital during index-admission without an adverse impact on short-term outcomes.
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Nakatsuma K, Shiomi H, Morimoto T, Furukawa Y, Nakagawa Y, Ando K, Kadota K, Yamamoto T, Suwa S, Horie M, Kimura T. Inter-Facility Transfer vs. Direct Admission of Patients With ST-Segment Elevation Acute Myocardial Infarction Undergoing Primary Percutaneous Coronary Intervention. Circ J 2016; 80:1764-72. [PMID: 27350014 DOI: 10.1253/circj.cj-16-0204] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
BACKGROUND Inter-facility transfer for primary percutaneous coronary intervention (PCI) from referring facilities to PCI centers causes a significant delay in treatment of ST-segment elevation acute myocardial infarction (STEMI) patients undergoing primary PCI. However, little is known about the clinical outcomes of STEMI patients undergoing inter-facility transfer in Japan. METHODS AND RESULTS In the CREDO-Kyoto acute myocardial infarction (AMI) registry that enrolled 5,429 consecutive AMI patients in 26 centers in Japan, the current study population consisted of 3,820 STEMI patients who underwent primary PCI within 24 h of symptom onset. We compared long-term clinical outcomes between inter-facility transfer patients and those directly admitted to PCI centers. The primary outcome measure was a composite of all-cause death or heart failure (HF) hospitalization. There were 1,725 (45.2%) inter-facility transfer patients, and 2,095 patients (54.8%) with direct admission to PCI centers. The cumulative 5-year incidence of death/HF hospitalization was significantly higher in the inter-facility transfer patients than in those with direct admission (26.9% vs. 22.2%; log-rank P<0.001). After adjusting for potential confounders, the risk for death/HF hospitalization was significantly higher (adjusted hazard ratio: 1.22, 95% confidence interval: 1.07-1.40, P<0.001) in the inter-facility transfer patients than in those directly admitted. CONCLUSIONS Inter-facility transfer was associated with significantly worse long-term clinical outcomes for patients with STEMI undergoing primary PCI. (Circ J 2016; 80: 1764-1772).
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Affiliation(s)
- Kenji Nakatsuma
- Department of Cardiovascular Medicine, Graduate School of Medicine, Kyoto University
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Pfister R, Lee S, Kuhr K, Baer F, Fehske W, Hoepp HW, Baldus S, Michels G. Impact of the Type of First Medical Contact within a Guideline-Conform ST-Elevation Myocardial Infarction Network: A Prospective Observational Registry Study. PLoS One 2016; 11:e0156769. [PMID: 27258655 PMCID: PMC4892676 DOI: 10.1371/journal.pone.0156769] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2016] [Accepted: 05/19/2016] [Indexed: 12/31/2022] Open
Abstract
Aims The impact of type of first medical contact (FMC) in the setting of a guideline conform metropolitan ST-elevation myocardial infarction (STEMI) network providing obligatory primary percutaneous coronary intervention (PCI) is unclear. Methods and Results 3,312 patients were prospectively included between 2006 and 2012 into a registry accompanying the “Cologne Infarction Model” STEMI network, with 68.4% primarily presenting to emergency medical service (EMS), 17.6% to non-PCI-capable hospitals, and 14.0% to PCI-capable hospitals. Median contact-to-balloon time differed significantly by FMC with 89 minutes (IQR 72–115) for EMS, 107 minutes (IQR 85–148) for non-PCI- and 65 minutes (IQR 48–91) for PCI-capable hospitals (p < 0.001). TIMI-flow grade III and in-hospital mortality were 75.7% and 10.4% in EMS, 70.3% and 8.6% in non-PCI capable hospital and 84.4% and 5.6% in PCI-capable hospital presenters, respectively (p both < 0.01). The association of FMC with in-hospital mortality was not significant after adjustment for baseline characteristics, but risk of TIMI-flow grade < III remained significantly increased in patients presenting to non-PCI capable hospitals. Conclusion Despite differences in treatment delay by type of FMC in-hospital mortality did not differ significantly. The increased risk of TIMI-flow grade < III in patients presenting to non PCI-capable hospitals needs further study.
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Affiliation(s)
- Roman Pfister
- Department III of Internal Medicine, University of Cologne, Cologne, Germany
- * E-mail:
| | - Samuel Lee
- Department III of Internal Medicine, University of Cologne, Cologne, Germany
| | - Kathrin Kuhr
- Institute of Medical Statistics, Informatics and Epidemiology, University of Cologne, Cologne, Germany
| | | | | | - Hans-Wilhelm Hoepp
- Department III of Internal Medicine, University of Cologne, Cologne, Germany
| | - Stephan Baldus
- Department III of Internal Medicine, University of Cologne, Cologne, Germany
| | - Guido Michels
- Department III of Internal Medicine, University of Cologne, Cologne, Germany
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Interhospital transfer for acute surgical care: does delay matter? Am J Surg 2016; 212:823-830. [PMID: 27381817 DOI: 10.1016/j.amjsurg.2016.03.004] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2015] [Revised: 03/03/2016] [Accepted: 03/10/2016] [Indexed: 11/21/2022]
Abstract
BACKGROUND Delays to definitive care are associated with poor outcomes after trauma and medical emergencies. It is unknown whether inter-hospital transfer delays affect outcomes for nontraumatic acute surgical conditions. METHODS We performed a retrospective cohort study of patient transfers for acute surgical conditions within a regional transfer network from 2009 to 2013. Delay was defined as more than 24 hours from presentation to transfer request and categorized as 1 or 2+ days. The primary outcome was post-transfer death or hospice. Bivariate and multivariable logistic regression were performed. RESULTS The cohort included 2,091 patient transfers. Delays of 2 or more days were associated with death or hospice in unadjusted analyses, but there was no difference after adjustment. Predictors of post-transfer death or hospice included older age, higher comorbidity scores, and greater severity of illness. CONCLUSIONS Delays in transfer request were not associated with post-transfer mortality or discharge to hospice, suggesting effective triage of nontraumatic acute surgical patients.
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Anderson LL, French WJ, Peng SA, Vora AN, Henry TD, Roe MT, Kontos MC, Granger CB, Bates ER, Hellkamp A, Wang TY. Direct Transfer From the Referring Hospitals to the Catheterization Laboratory to Minimize Reperfusion Delays for Primary Percutaneous Coronary Intervention: Insights From the National Cardiovascular Data Registry. Circ Cardiovasc Interv 2016; 8:e002477. [PMID: 26338881 DOI: 10.1161/circinterventions.114.002477] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND For patients with ST-segment-elevation myocardial infarction (STEMI) requiring interhospital transfer for primary percutaneous coronary intervention, direct transfer from the STEMI referral hospital to the catheterization laboratory (cath lab) at the STEMI receiving hospital may expedite reperfusion, but can be logistically challenging. METHODS AND RESULTS We studied 33,901 STEMI patients transferred for primary percutaneous coronary intervention in the Acute Coronary Treatment and Intervention Outcomes Network Registry-Get With The Guidelines from July 2008 to December 2012. The majority of patients were transferred directly to the cath lab (26,510 [78.2%]), and 7391 patients (21.8%) were transferred first to the hospital emergency department/ward. We observed significant interhospital variation in transfer patterns; only 21% of STEMI receiving hospitals routinely transferred >90% of STEMI patients to the cath lab directly. Compared with patients transferred first to the emergency department/ward, STEMI patients transferred to the cath lab had significantly lower first door-to-balloon times (median 191 versus 116 minutes, P<0.0001). After multivariable logistic regression, patients transferred directly to the cath lab also had lower adjusted mortality risk (odds ratio 0.58, 95% confidence interval 0.51-0.66, P<0.0001). Cardiogenic shock, heart failure signs/symptoms, and nonsystem reasons for reperfusion delay were present in 11%, 15%, and 28% of patients transferred first to the emergency department/ward, respectively. The association of direct cath lab transfer with lower mortality persisted after excluding patients with these reasons for delay to primary percutaneous coronary intervention (adjusted odds ratio 0.62, 95% confidence interval 0.46-0.84, P=0.002). CONCLUSIONS Direct transfer of STEMI patients to the cath lab for primary percutaneous coronary intervention was associated with significantly faster reperfusion and lower mortality risk compared with transfer first to the emergency department/ward.
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Affiliation(s)
- Lindsay L Anderson
- From the Department of Medicine (L.L.A., A.N.V., M.T.R., C.B.G., T.Y.W.) and Department of Biostatistics (S.A.P., A.H.), Duke Clinical Research Institute, Duke University Medical Center, Durham, NC; Department of Medicine, Harbor-UCLA Medical Center, Torrance, CA (W.J.F.); Department of Medicine, Minneapolis Heart Institute Foundation at Abbott Northwestern Hospital, Minneapolis, MN (T.D.H.); Department of Medicine, Virginia Commonwealth University, Richmond, VA (M.C.K.); and Department of Medicine, University of Michigan, Ann Arbor, MI (E.R.B.)
| | - William J French
- From the Department of Medicine (L.L.A., A.N.V., M.T.R., C.B.G., T.Y.W.) and Department of Biostatistics (S.A.P., A.H.), Duke Clinical Research Institute, Duke University Medical Center, Durham, NC; Department of Medicine, Harbor-UCLA Medical Center, Torrance, CA (W.J.F.); Department of Medicine, Minneapolis Heart Institute Foundation at Abbott Northwestern Hospital, Minneapolis, MN (T.D.H.); Department of Medicine, Virginia Commonwealth University, Richmond, VA (M.C.K.); and Department of Medicine, University of Michigan, Ann Arbor, MI (E.R.B.)
| | - S Andrew Peng
- From the Department of Medicine (L.L.A., A.N.V., M.T.R., C.B.G., T.Y.W.) and Department of Biostatistics (S.A.P., A.H.), Duke Clinical Research Institute, Duke University Medical Center, Durham, NC; Department of Medicine, Harbor-UCLA Medical Center, Torrance, CA (W.J.F.); Department of Medicine, Minneapolis Heart Institute Foundation at Abbott Northwestern Hospital, Minneapolis, MN (T.D.H.); Department of Medicine, Virginia Commonwealth University, Richmond, VA (M.C.K.); and Department of Medicine, University of Michigan, Ann Arbor, MI (E.R.B.)
| | - Amit N Vora
- From the Department of Medicine (L.L.A., A.N.V., M.T.R., C.B.G., T.Y.W.) and Department of Biostatistics (S.A.P., A.H.), Duke Clinical Research Institute, Duke University Medical Center, Durham, NC; Department of Medicine, Harbor-UCLA Medical Center, Torrance, CA (W.J.F.); Department of Medicine, Minneapolis Heart Institute Foundation at Abbott Northwestern Hospital, Minneapolis, MN (T.D.H.); Department of Medicine, Virginia Commonwealth University, Richmond, VA (M.C.K.); and Department of Medicine, University of Michigan, Ann Arbor, MI (E.R.B.)
| | - Timothy D Henry
- From the Department of Medicine (L.L.A., A.N.V., M.T.R., C.B.G., T.Y.W.) and Department of Biostatistics (S.A.P., A.H.), Duke Clinical Research Institute, Duke University Medical Center, Durham, NC; Department of Medicine, Harbor-UCLA Medical Center, Torrance, CA (W.J.F.); Department of Medicine, Minneapolis Heart Institute Foundation at Abbott Northwestern Hospital, Minneapolis, MN (T.D.H.); Department of Medicine, Virginia Commonwealth University, Richmond, VA (M.C.K.); and Department of Medicine, University of Michigan, Ann Arbor, MI (E.R.B.)
| | - Matthew T Roe
- From the Department of Medicine (L.L.A., A.N.V., M.T.R., C.B.G., T.Y.W.) and Department of Biostatistics (S.A.P., A.H.), Duke Clinical Research Institute, Duke University Medical Center, Durham, NC; Department of Medicine, Harbor-UCLA Medical Center, Torrance, CA (W.J.F.); Department of Medicine, Minneapolis Heart Institute Foundation at Abbott Northwestern Hospital, Minneapolis, MN (T.D.H.); Department of Medicine, Virginia Commonwealth University, Richmond, VA (M.C.K.); and Department of Medicine, University of Michigan, Ann Arbor, MI (E.R.B.)
| | - Michael C Kontos
- From the Department of Medicine (L.L.A., A.N.V., M.T.R., C.B.G., T.Y.W.) and Department of Biostatistics (S.A.P., A.H.), Duke Clinical Research Institute, Duke University Medical Center, Durham, NC; Department of Medicine, Harbor-UCLA Medical Center, Torrance, CA (W.J.F.); Department of Medicine, Minneapolis Heart Institute Foundation at Abbott Northwestern Hospital, Minneapolis, MN (T.D.H.); Department of Medicine, Virginia Commonwealth University, Richmond, VA (M.C.K.); and Department of Medicine, University of Michigan, Ann Arbor, MI (E.R.B.)
| | - Christopher B Granger
- From the Department of Medicine (L.L.A., A.N.V., M.T.R., C.B.G., T.Y.W.) and Department of Biostatistics (S.A.P., A.H.), Duke Clinical Research Institute, Duke University Medical Center, Durham, NC; Department of Medicine, Harbor-UCLA Medical Center, Torrance, CA (W.J.F.); Department of Medicine, Minneapolis Heart Institute Foundation at Abbott Northwestern Hospital, Minneapolis, MN (T.D.H.); Department of Medicine, Virginia Commonwealth University, Richmond, VA (M.C.K.); and Department of Medicine, University of Michigan, Ann Arbor, MI (E.R.B.)
| | - Eric R Bates
- From the Department of Medicine (L.L.A., A.N.V., M.T.R., C.B.G., T.Y.W.) and Department of Biostatistics (S.A.P., A.H.), Duke Clinical Research Institute, Duke University Medical Center, Durham, NC; Department of Medicine, Harbor-UCLA Medical Center, Torrance, CA (W.J.F.); Department of Medicine, Minneapolis Heart Institute Foundation at Abbott Northwestern Hospital, Minneapolis, MN (T.D.H.); Department of Medicine, Virginia Commonwealth University, Richmond, VA (M.C.K.); and Department of Medicine, University of Michigan, Ann Arbor, MI (E.R.B.)
| | - Anne Hellkamp
- From the Department of Medicine (L.L.A., A.N.V., M.T.R., C.B.G., T.Y.W.) and Department of Biostatistics (S.A.P., A.H.), Duke Clinical Research Institute, Duke University Medical Center, Durham, NC; Department of Medicine, Harbor-UCLA Medical Center, Torrance, CA (W.J.F.); Department of Medicine, Minneapolis Heart Institute Foundation at Abbott Northwestern Hospital, Minneapolis, MN (T.D.H.); Department of Medicine, Virginia Commonwealth University, Richmond, VA (M.C.K.); and Department of Medicine, University of Michigan, Ann Arbor, MI (E.R.B.)
| | - Tracy Y Wang
- From the Department of Medicine (L.L.A., A.N.V., M.T.R., C.B.G., T.Y.W.) and Department of Biostatistics (S.A.P., A.H.), Duke Clinical Research Institute, Duke University Medical Center, Durham, NC; Department of Medicine, Harbor-UCLA Medical Center, Torrance, CA (W.J.F.); Department of Medicine, Minneapolis Heart Institute Foundation at Abbott Northwestern Hospital, Minneapolis, MN (T.D.H.); Department of Medicine, Virginia Commonwealth University, Richmond, VA (M.C.K.); and Department of Medicine, University of Michigan, Ann Arbor, MI (E.R.B.).
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De Luca G, Petrelli A, Landriscina T, Gnavi R, Giammaria M, Costa G. Geographic and socioeconomic differences in access to revascularization following acute myocardial infarction. Eur J Public Health 2016; 26:760-765. [PMID: 27221608 DOI: 10.1093/eurpub/ckw062] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Geographic and socioeconomic barriers may hinder fair access to healthcare. This study assesses geographic and socioeconomic disparities in access to reperfusion procedures in acute myocardial infarction (AMI) patients residing in Piedmont (Italy). METHODS Coronary Care Units (CCUs) were geocoded with a geographic information system (GIS) and the shortest drive time from CCUs to patients' residence was computed and categorized as 0 to <20, 20 to <40 and ≥40 min. Using data on AMI emergency hospitalizations in 2004-2012, we employed a log-binomial regression model to evaluate the relation between drive time and use of Percutaneous Transluminal Coronary Angioplasty (PTCA) occurring within 2 days after a hospitalization for an episode of AMI, and whether this relation varied depending on the period of hospitalization. RESULTS A total of 29% of all cases with a diagnosis of AMI (n = 66 097), were revascularized within 2 days from the index admission. The further AMI patients lived from CCUs, the less likely they were to receive revascularization: compared with distance <20 min, RRs were respectively 0.84 [95% CI 0.80-0.88] and 0.78 [95% CI 0.71-0.86]. Findings also showed that less educated people had a lower relative risk of being revascularized compared to more educated people (RR = 0.78; 95% CI = 0.74-0.82). Both inequalities have reduced in recent years. CONCLUSION This study provides evidence of reduced geographical and socioeconomic differences in revascularization use over time. Geography and socioeconomic status should not determine the type of treatment received for life-threatening conditions such as AMI.
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Affiliation(s)
- Giuliana De Luca
- Department of Economics, Statistics and Finance, University of Calabria, Rende (CS), Italy
| | - Alessio Petrelli
- Epidemiology Unit, ASL TO3, Piedmont Region, Grugliasco, Italy.,National Institute for Health, Migration and Poverty (INMP), Rome, Italy
| | | | - Roberto Gnavi
- Epidemiology Unit, ASL TO3, Piedmont Region, Grugliasco, Italy
| | | | - Giuseppe Costa
- Epidemiology Unit, ASL TO3, Piedmont Region, Grugliasco, Italy.,Department of Clinical and Biological Science, University of Turin, Turin, Italy
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78
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Khot UN, Johnson-Wood ML, VanLeeuwen R, Ramsey C, Khot MB. A hospital-wide system to ensure rapid treatment time across the entire spectrum of emergency percutaneous intervention. Catheter Cardiovasc Interv 2015; 88:678-689. [PMID: 26700212 PMCID: PMC5132092 DOI: 10.1002/ccd.26372] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/12/2015] [Accepted: 11/27/2015] [Indexed: 11/11/2022]
Abstract
OBJECTIVES This study's aim was to describe a hospital-wide system to deliver rapid door-to-balloon time across the entire spectrum of emergency percutaneous intervention. BACKGROUND Many patients needing emergency PCI are excluded from door-to-balloon public reporting metric; these groups do not achieve door-to-balloon times ≤90 min and have increased mortality rates. METHODS We prospectively implemented a protocol for patients with STEMI or other emergency indication for catheterization mandating (1) emergency department physician or cardiologist activation of the catheterization lab and (2) immediate patient transfer to an immediately available catheterization lab by an in-house nursing transfer team. RESULTS From September 1, 2005 to December 31, 2008, 526 consecutive patients underwent emergency PCI. Median door-to-balloon time was 68 min with 85.7% ≤90 min overall. Important subgroups included primary emergency department (62.5 min), cardiorespiratory arrest (71 min), cardiogenic shock (68 min), need for temporary pacemaker or balloon pump (67 min), initial ECG without ST-elevation (66.5 min), transfer from another ED (84 min), in-hospital (70 min), and activation indications other than STEMI (68 min). Patients presenting to primary ED and in transfer were compared to historical controls. Treatment ≤90 min increased (28%-85%, P < 0.0001). Mean infarct size decreased, as did hospital length-of-stay and admission total hospital costs. Acute myocardial infarction all-cause 30-day unadjusted mortality and risk-standardized mortality ratios were substantially lower than national averages. CONCLUSION A hospital-wide systems approach applied across the entire spectrum of emergency PCI leads to rapid door-to-balloon time, reduced infarct size and hospitals costs, and low myocardial infarction 30-day all-cause mortality. © 2015 Wiley Periodicals, Inc.
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Affiliation(s)
- Umesh N Khot
- Cleveland Clinic Department of Cardiovascular Medicine, Cleveland, Ohio
| | | | | | | | - Monica B Khot
- Cleveland Clinic Department of Cardiovascular Medicine, Cleveland, Ohio
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79
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Park JH, Ahn KO, Shin SD, Cha WC, Ryoo HW, Ro YS, Kim T. The first-door-to-balloon time delay in STEMI patients undergoing interhospital transfer. Am J Emerg Med 2015; 34:767-71. [PMID: 26926589 DOI: 10.1016/j.ajem.2015.12.058] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2015] [Revised: 12/18/2015] [Accepted: 12/20/2015] [Indexed: 11/27/2022] Open
Abstract
BACKGROUND Interhospital transfer delays for ST-elevation myocardial infarction (STEMI) patients requiring primary percutaneous coronary intervention (PCI) may be shortened by improved regional care systems. We evaluated the transfer process and first door-to-balloon (D1toB) time in STEMI patients who underwent interhospital transfer for primary PCI. METHODS AND RESULTS We evaluated the D1toB time in 1837 patients who underwent interhospital transfer for primary PCI from the Cardiovascular Disease Surveillance program in Korea. Only 29.3% of patients had a D1toB time less than 120 minutes, as recommended by the American College of Cardiology Foundation/American Heart Association guidelines for the management of STEMI. After adjusting for potential confounders, chest pain at presentation (adjusted odds ratio [AOR], 2.06; 95% confidence interval [CI], 1.18-3.83), transfer to a PCI center with an annual PCI volume greater than 200 (AOR, 1.35; 95% CI, 1.04-1.74), and higher urbanization level (AOR, 2.01 [95% CI, 1.40-2.91], for urban areas; AOR, 3.70 [95% CI, 2.59-3.83], for metropolitan areas) showed beneficial effects on reducing the D1toB time. The median length of stay in the referring hospital (D1LOS) and interhospital transport time were 50 (interquartile range [IQR], 30-100) minutes and 32 (IQR, 20-51) minutes, respectively. The median time interval from the door of the receiving hospital to balloon insertion was 55 (IQR, 40-79) minutes. CONCLUSIONS Patients with STEMI undergoing interhospital transfer did not receive definite care within the recommended therapeutic time window. Delays in the transfer process (length of stay in the referring hospital and interhospital transport time) were major contributors to the delay in the D1toB time.
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Affiliation(s)
- Jeong Ho Park
- Laboratory of Emergency Medical Service, Seoul National University Hospital Biomedical Research Institute, Seoul, Korea; Department of Emergency Medicine, Seoul National University College of Medicine, Seoul National University Hospital, Seoul, Korea.
| | - Ki Ok Ahn
- Laboratory of Emergency Medical Service, Seoul National University Hospital Biomedical Research Institute, Seoul, Korea.
| | - Sang Do Shin
- Laboratory of Emergency Medical Service, Seoul National University Hospital Biomedical Research Institute, Seoul, Korea; Department of Emergency Medicine, Seoul National University College of Medicine, Seoul National University Hospital, Seoul, Korea.
| | - Won Chul Cha
- Laboratory of Emergency Medical Service, Seoul National University Hospital Biomedical Research Institute, Seoul, Korea; Department of Emergency Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea.
| | - Hyun Wook Ryoo
- Laboratory of Emergency Medical Service, Seoul National University Hospital Biomedical Research Institute, Seoul, Korea; Department of Emergency Medicine, Kyungpook National University College of Medicine, Daegu, Korea.
| | - Young Sun Ro
- Laboratory of Emergency Medical Service, Seoul National University Hospital Biomedical Research Institute, Seoul, Korea.
| | - Taeyun Kim
- Laboratory of Emergency Medical Service, Seoul National University Hospital Biomedical Research Institute, Seoul, Korea; Department of Emergency Medicine, Seoul National University College of Medicine, Seoul National University Bundang Hospital, Seongnam, Korea.
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80
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Ward MJ, Baker O, Schuur JD. Association of Emergency Department Length of Stay and Crowding for Patients with ST-Elevation Myocardial Infarction. West J Emerg Med 2015; 16:1067-72. [PMID: 26759656 PMCID: PMC4703176 DOI: 10.5811/westjem.2015.8.27908] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2015] [Accepted: 08/14/2015] [Indexed: 11/23/2022] Open
Abstract
Introduction With the majority of U.S. hospitals not having primary percutaneous coronary intervention (pPCI) capabilities, the time spent at transferring emergency departments (EDs) is predictive of clinical outcomes for patients with ST-elevation myocardial infarction (STEMI). Compounding the challenges of delivering timely emergency care are the known delays caused by ED crowding. However, the association of ED crowding with timeliness for patients with STEMI is unknown. We sought to examine the relationship between ED crowding and time spent at transferring EDs for patients with STEMI. Methods We analyzed the Centers for Medicare and Medicaid Services (CMS) quality data. The outcome was time spent at a transferring ED (i.e., door-in-door-out [DIDO]), was CMS measure OP-3b for hospitals with ≥10 acute myocardial infarction (AMI) cases requiring transfer (i.e., STEMI) annually: Time to Transfer an AMI Patient for Acute Coronary Intervention. We used four CMS ED timeliness measures as surrogate measures of ED crowding: admitted length of stay (LOS), discharged LOS, boarding time, and waiting time. We analyzed bivariate associations between DIDO and ED timeliness measures. We used a linear multivariable regression to evaluate the contribution of hospital characteristics (academic, trauma, rural, ED volume) to DIDO. Results Data were available for 405 out of 4,129 hospitals for the CMS DIDO measure. These facilities were primarily non-academic (99.0%), non-trauma centers (65.4%), and in urban locations (68.5%). Median DIDO was 54.0 minutes (IQR 42.0,68.0). Increased DIDO time was associated with longer admitted LOS and boarding times. After adjusting for hospital characteristics, a one-minute increase in ED LOS at transferring facilities was associated with DIDO (coefficient, 0.084 [95% CI [0.049,0.119]]; p<0.001). This translates into a five-minute increase in DIDO for every one-hour increase in ED LOS for admitted patients. Conclusion Among patients with STEMI presenting to U.S. EDs, we found that ED crowding has a small but operationally insignificant effect on time spent at the transferring ED.
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Affiliation(s)
- Michael J Ward
- Vanderbilt University, Department of Emergency Medicine, Nashville, Tennessee
| | - Olesya Baker
- Brigham and Women's Hospital, Department of Emergency Medicine, Boston, Massachusetts
| | - Jeremiah D Schuur
- Brigham and Women's Hospital, Department of Emergency Medicine, Boston, Massachusetts
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Steglich-Arnholm H, Krieger DW. Carotid stent-assisted thrombectomy in acute ischemic stroke. Future Cardiol 2015; 11:615-32. [PMID: 26406551 DOI: 10.2217/fca.15.54] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
Acute carotid occlusion or near-occlusion with concomitant intracranial embolism cause severe acute ischemic strokes in patients. These concomitant occlusions have suggested poor response to intravenous thrombolysis and complicate endovascular treatment. Nevertheless, endovascular stent-assisted thrombectomy may improve outcome in patients but the treatment is not without concerns. Required antiplatelet therapy to prevent stent thrombosis may increase the rate of intracranial hemorrhage, especially after recent thrombolysis. Furthermore, technical difficulties in access of the intracranial vasculature may cause adverse events, even in the hands of experienced interventionalists. These concerns currently defy the treatment in being recommended for general use and only on a compassionate basis. However, recent patient series have suggested reasonable safety and efficacy for carotid stent-assisted thrombectomy.
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Affiliation(s)
| | - Derk W Krieger
- Department of Neurology, Rigshospitalet, Blegdamsvej 9, Copenhagen 2100, Denmark.,Faculty of Health & Medical Science, University of Copenhagen, Blegdamsvej 3B, København N 2200, Denmark
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Windecker S, Kolh P, Alfonso F, Collet JP, Cremer J, Falk V, Filippatos G, Hamm C, Head SJ, Jüni P, Kappetein AP, Kastrati A, Knuuti J, Landmesser U, Laufer G, Neumann FJ, Richter DJ, Schauerte P, Sousa Uva M, Stefanini GG, Taggart DP, Torracca L, Valgimigli M, Wijns W, Witkowski A. 2014 ESC/EACTS guidelines on myocardial revascularization. EUROINTERVENTION 2015; 10:1024-94. [PMID: 25187201 DOI: 10.4244/eijy14m09_01] [Citation(s) in RCA: 211] [Impact Index Per Article: 23.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Affiliation(s)
- Stephan Windecker
- Cardiology, Bern University Hospital, Freiburgstrasse 4, CH-3010 Bern, Switzerland
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Pre-hospital ticagrelor in ST-segment elevation myocardial infarction: Ready for prime time? Int J Cardiol 2015; 194:41-3. [PMID: 26011263 DOI: 10.1016/j.ijcard.2015.05.064] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/24/2015] [Revised: 04/26/2015] [Accepted: 05/09/2015] [Indexed: 11/21/2022]
Abstract
In ST-segment elevation myocardial infarction (STEMI) patients undergoing primary percutaneous coronary intervention (PCI) peri-procedural P2Y12 antagonism - although of great importance - is often suboptimal, even with the novel oral antiplatelet agents prasugrel and ticagrelor. The concept of pre-hospital ticagrelor loading, investigated in the recently published Administration of Ticagrelor in the Cath Lab or in the Ambulance for New ST Elevation Myocardial Infarction to Open the Coronary Artery (ATLANTIC) trial, appears quite a promising strategy to optimize peri-procedural platelet inhibition and potentially clinical outcome. Implementation of such an approach when treating low risk STEMI patients in 'real life' practice might prove even more beneficial than expected from the ATLANTIC results, given the reported delays from first medical contact to primary PCI performance.
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85
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Dauerman HL, Bates ER, Kontos MC, Li S, Garvey JL, Henry TD, Manoukian SV, Roe MT. Nationwide Analysis of Patients With ST-Segment–Elevation Myocardial Infarction Transferred for Primary Percutaneous Intervention. Circ Cardiovasc Interv 2015; 8:CIRCINTERVENTIONS.114.002450. [DOI: 10.1161/circinterventions.114.002450] [Citation(s) in RCA: 45] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background—
Current American College of Cardiology/American Heart Association guidelines recommend transfer and primary percutaneous coronary intervention (PCI) for ST-segment–elevation myocardial infarction (STEMI) patients within the time limit of first contact to device ≤120 minutes. We determined the hospital-level, patient-level, and process characteristics of timely versus delayed primary PCI for a diverse national sample of transfer patients confined to a travel distance that facilitates the process.
Methods and Results—
We studied 14 518 patients transferred from non–PCI-capable hospitals for primary PCI to 398 National Cardiovascular Data Registry Acute Coronary Treatment and Intervention Outcomes Network Registry-Get With The Guidelines hospitals between July 2008 and December 2012. Patients with estimated transfer times >60 minutes (by Google Maps driving times) were excluded from the analysis. Patients achieving first door-to-device time ≤120 minutes were compared with patients with delayed treatment; independent predictors of timely treatment were determined using generalized estimating equations logistic regression models. The median estimated transfer distance was 26.5 miles. First door-to-device ≤120 minutes was achieved in 65% of patients (n=9380); only 37% of the hospitals were high-performing hospitals (defined as risk-adjusted rate, ≥75% of transfer STEMI patients with ≤120-minute first door-to-device time). In addition to known predictors of delay (cardiogenic shock, cardiac arrest, and prolonged door-in door-out time), STEMI referral hospitals’ rural location and longer estimated transfer time were identified as predictors of delay. In this diverse national sample, regional and racial variations in care were observed. Finally, lower PCI hospital annual STEMI volume was a potent predictor of delay.
Conclusions—
More than one third of US STEMI patients transferred for primary PCI fail to achieve first door-to-device time ≤120 minutes, despite estimated transfer times <60 minutes. Delays are related to process variables, comorbidities, and lower annual PCI hospital STEMI volumes.
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Affiliation(s)
- Harold L. Dauerman
- From the University of Vermont Cardiovascular Research Institute, Burlington (H.L.D.); University of Michigan, Ann Arbor (E.R.B.); Virginia Commonwealth University, Richmond (M.C.K.); Duke Clinical Research Institute, Durham, NC (S.L., M.T.R.); Carolinas Medical Center, Charlotte, NC (J.L.G.); Cedars-Sinai Heart Institute, Los Angeles, CA (T.D.H.); and Hospital Corporation of America, Nashville, TN (S.V.M.)
| | - Eric R. Bates
- From the University of Vermont Cardiovascular Research Institute, Burlington (H.L.D.); University of Michigan, Ann Arbor (E.R.B.); Virginia Commonwealth University, Richmond (M.C.K.); Duke Clinical Research Institute, Durham, NC (S.L., M.T.R.); Carolinas Medical Center, Charlotte, NC (J.L.G.); Cedars-Sinai Heart Institute, Los Angeles, CA (T.D.H.); and Hospital Corporation of America, Nashville, TN (S.V.M.)
| | - Michael C. Kontos
- From the University of Vermont Cardiovascular Research Institute, Burlington (H.L.D.); University of Michigan, Ann Arbor (E.R.B.); Virginia Commonwealth University, Richmond (M.C.K.); Duke Clinical Research Institute, Durham, NC (S.L., M.T.R.); Carolinas Medical Center, Charlotte, NC (J.L.G.); Cedars-Sinai Heart Institute, Los Angeles, CA (T.D.H.); and Hospital Corporation of America, Nashville, TN (S.V.M.)
| | - Shuang Li
- From the University of Vermont Cardiovascular Research Institute, Burlington (H.L.D.); University of Michigan, Ann Arbor (E.R.B.); Virginia Commonwealth University, Richmond (M.C.K.); Duke Clinical Research Institute, Durham, NC (S.L., M.T.R.); Carolinas Medical Center, Charlotte, NC (J.L.G.); Cedars-Sinai Heart Institute, Los Angeles, CA (T.D.H.); and Hospital Corporation of America, Nashville, TN (S.V.M.)
| | - J. Lee Garvey
- From the University of Vermont Cardiovascular Research Institute, Burlington (H.L.D.); University of Michigan, Ann Arbor (E.R.B.); Virginia Commonwealth University, Richmond (M.C.K.); Duke Clinical Research Institute, Durham, NC (S.L., M.T.R.); Carolinas Medical Center, Charlotte, NC (J.L.G.); Cedars-Sinai Heart Institute, Los Angeles, CA (T.D.H.); and Hospital Corporation of America, Nashville, TN (S.V.M.)
| | - Timothy D. Henry
- From the University of Vermont Cardiovascular Research Institute, Burlington (H.L.D.); University of Michigan, Ann Arbor (E.R.B.); Virginia Commonwealth University, Richmond (M.C.K.); Duke Clinical Research Institute, Durham, NC (S.L., M.T.R.); Carolinas Medical Center, Charlotte, NC (J.L.G.); Cedars-Sinai Heart Institute, Los Angeles, CA (T.D.H.); and Hospital Corporation of America, Nashville, TN (S.V.M.)
| | - Steven V. Manoukian
- From the University of Vermont Cardiovascular Research Institute, Burlington (H.L.D.); University of Michigan, Ann Arbor (E.R.B.); Virginia Commonwealth University, Richmond (M.C.K.); Duke Clinical Research Institute, Durham, NC (S.L., M.T.R.); Carolinas Medical Center, Charlotte, NC (J.L.G.); Cedars-Sinai Heart Institute, Los Angeles, CA (T.D.H.); and Hospital Corporation of America, Nashville, TN (S.V.M.)
| | - Matthew T. Roe
- From the University of Vermont Cardiovascular Research Institute, Burlington (H.L.D.); University of Michigan, Ann Arbor (E.R.B.); Virginia Commonwealth University, Richmond (M.C.K.); Duke Clinical Research Institute, Durham, NC (S.L., M.T.R.); Carolinas Medical Center, Charlotte, NC (J.L.G.); Cedars-Sinai Heart Institute, Los Angeles, CA (T.D.H.); and Hospital Corporation of America, Nashville, TN (S.V.M.)
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Eckstein M, Schlesinger SA, Sanko S. Interfacility Transports Utilizing the 9-1-1 Emergency Medical Services System. PREHOSP EMERG CARE 2015; 19:490-5. [PMID: 25909809 DOI: 10.3109/10903127.2015.1005258] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
BACKGROUND With the increasing development of regional specialty centers, emergency physicians are often confronted with patients needing definitive care unavailable at their hospital. Interfacility transports (IFTs) may be a useful option to ensure timely, definitive patient care. However, since traditional IFT can be a challenging and time-consuming process, some EMS agencies that have previously limited their service to 9-1-1 emergency responses are now performing emergency IFTs. OBJECTIVE We sought to determine the frequency and nature of transfers provided by a local fire-based 9-1-1 EMS agency that recently began to provide limited IFT for time-critical emergencies. METHODS A retrospective review of paramedic reports for all IFTs between April 2007 and March 2014 in the City of Los Angeles, California. All IFTs initiated by 9-1-1 call from an emergency department (ED) and performed by Los Angeles Fire Department paramedics were included. Reason for transfer, patient demographics, and key time metrics were captured. RESULTS There were 919 IFTs during the study period, out of approximately 1,160,000 total ambulance transports (0.1%). The most frequent reason for IFT request was for transport of patients with ST segment elevation MI (STEMI) to a STEMI receiving center, followed by major trauma to a trauma center, and intracranial hemorrhage to a center with neurosurgical capability. Less common reasons included vascular emergencies, acute stroke, obstetric emergencies, and transfers to pediatric critical care facilities. Median transport time was 8 minutes (IQR 6-13 minutes) and median total time for IFT was 51 minutes (IQR 39-69 minutes). All IFTs involved a potentially life-threatening condition requiring a higher level of care than was available at the referring hospital. CONCLUSIONS Emergent ED-to-ED interfacility transport can provide access to time critical definitive care. EMS agencies that have limited the scope of their response to community 9-1-1 emergencies should have policies in place to assure timely response for emergent IFT requests.
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Postma S, Dambrink JHE, Gosselink ATM, Ottervanger JP, Kolkman E, Ten Berg JM, Suryapranata H, van 't Hof AWJ. The influence of system delay on 30-day and on long-term mortality in patients with anterior versus non-anterior ST-segment elevation myocardial infarction: a cohort study. Open Heart 2015; 2:e000201. [PMID: 25893101 PMCID: PMC4395829 DOI: 10.1136/openhrt-2014-000201] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/29/2014] [Revised: 02/09/2015] [Accepted: 03/04/2015] [Indexed: 12/21/2022] Open
Abstract
Aim To evaluate the relationship between system delay and 30-day and long-term mortality in patients with anterior versus non-anterior ST-elevation myocardial infarction (STEMI). Methods We conducted a prospective observational cohort study. Patients with STEMI who were transported to the Isala Hospital, Zwolle, and underwent primary percutaneous coronary intervention (pPCI) from 2005 until 2010 were included. These patients were divided into quartiles of system delay (time from first medical contact until reperfusion therapy): Q1–Q4. Results In total, 3041 patients were included in our study. 41% (n=1253) of the patients had an anterior myocardial infarction (MI) and 59% of the patients (n=1788) had a non-anterior MI. Only in patients with an anterior MI, prolonged system delay was associated with a higher mortality (30-day Q1: 2.6%, Q2: 3.1%, Q3: 6.8%, Q4: 7.4%, p=0.001; long-term Q1: 12.8%, Q2: 13.7%, Q3: 24.1%, Q4: 22.6%, p<0.001). After multivariable adjustment, prolonged system delay was associated with a higher 30-day and long-term mortality in patients with an anterior MI (30 day Q2: HR 1.18, 95% CI (0.46 to 3.00), Q3: HR 2.45, 95% CI (1.07 to 5.63), Q4: HR 2.25, 95% CI (0.97 to 5.25)); long-term Q2: HR 1.09, 95% CI (0.71 to 1.68), Q3: HR 1.68, 95% CI (1.13 to 2.49), Q4: HR 1.55, 95% CI (1.03 to 2.33)), but not in patients with a non-anterior MI. Conclusions Prolonged system delay significantly increased short-term as well as long-term mortality in patients with an anterior MI. This effect was not demonstrated in patients with a non-anterior MI. Therefore, it is of the greatest importance to minimise system delay in patients who present with an anterior MI.
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Affiliation(s)
| | | | | | | | | | - Jurrien M Ten Berg
- Department of Cardiology , St Antonius Hospital , Nieuwegein , The Netherlands
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Ward MJ, Kripalani S, Storrow AB, Liu D, Speroff T, Matheny M, Thomassee EJ, Vogus TJ, Munoz D, Scott C, Fredi JL, Dittus RS. Timeliness of interfacility transfer for ED patients with ST-elevation myocardial infarction. Am J Emerg Med 2015; 33:423-9. [PMID: 25618768 PMCID: PMC4385487 DOI: 10.1016/j.ajem.2014.12.067] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2014] [Accepted: 12/29/2014] [Indexed: 10/24/2022] Open
Abstract
OBJECTIVES Most US hospitals lack primary percutaneous coronary intervention (PCI) capabilities to treat patients with ST-elevation myocardial infarction (STEMI) necessitating transfer to PCI-capable centers. Transferred patients rarely meet the 120-minute benchmark for timely reperfusion, and referring emergency departments (EDs) are a major source of preventable delays. We sought to use more granular data at transferring EDs to describe the variability in length of stay at referring EDs. METHODS We retrospectively analyzed a secondary data set used for quality improvement for patients with STEMI transferred to a single PCI center between 2008 and 2012. We conducted a descriptive analysis of the total time spent at each referring ED (door-in-door-out [DIDO] interval), periods that comprised DIDO (door to electrocardiogram [EKG], EKG-to-PCI activation, and PCI activation to exit), and the relationship of each period with overall time to reperfusion (medical contact-to-balloon [MCTB] interval). RESULTS We identified 41 EDs that transferred 620 patients between 2008 and 2012. Median MCTB was 135 minutes (interquartile range [IQR] 114,172). Median overall ED DIDO was 74 minutes (IQR 56,103) and was composed of door to EKG, 5 minutes (IQR 2,11); EKG-to-PCI activation, 18 minutes (IQR 7,37); and PCI activation to exit, 44 minutes (IQR 34,56). Door-in door-out accounted for the largest proportion (60%) of overall MCTB and had the largest variability (coefficient of variability, 1.37) of these intervals. CONCLUSIONS In this cohort of transferring EDs, we found high variability and substantial delays after EKG performance for patients with STEMI. Factors influencing ED decision making and transportation coordination after PCI activation are a potential target for intervention to improve the timeliness of reperfusion in patients with STEMI.
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Affiliation(s)
- Michael J Ward
- Department of Emergency Medicine, Vanderbilt University School of Medicine, 1313 21st Ave, Nashville, TN 37232.
| | - Sunil Kripalani
- Section of Hospital Medicine, Division of General Internal Medicine and Public Health, Center for Clinical Quality and Implementation Research, Vanderbilt University School of Medicine, 1313 21st Ave, Nashville, TN 37232
| | - Alan B Storrow
- Department of Emergency Medicine, Vanderbilt University School of Medicine, 1313 21st Ave, Nashville, TN 37232
| | - Dandan Liu
- Department of Biostatistics, Vanderbilt University School of Medicine, 1313 21st Ave, Nashville, TN 37232
| | - Theodore Speroff
- Departments of Medicine and Biostatistics, Division of General Internal Medicine and Public Health, Center for Health Services Research, Vanderbilt University School of Medicine, Nashville, TN; Geriatric Research, Education, and Clinical Center, Veterans Affairs Tennessee Valley Healthcare System, Nashville, TN
| | - Michael Matheny
- Departments of Biomedical Informatics and Medicine, Division of General Internal Medicine and Public Health, Center for Health Services Research, Vanderbilt University School of Medicine, Nashville, TN; Geriatric Research, Education, and Clinical Center, Veterans Affairs Tennessee Valley Healthcare System, Nashville, TN
| | - Eric J Thomassee
- Division of Cardiology, Vanderbilt University School of Medicine, Nashville, TN
| | - Timothy J Vogus
- Owen Graduate School of Management, Vanderbilt University, Nashville, TN
| | - Daniel Munoz
- Division of Cardiology, Vanderbilt University School of Medicine, Nashville, TN
| | - Carol Scott
- Division of Cardiology, Vanderbilt University School of Medicine, Nashville, TN
| | - Joseph L Fredi
- Division of Cardiology, Vanderbilt University School of Medicine, Nashville, TN
| | - Robert S Dittus
- Department of Medicine, Institute for Medicine and Public Health, Vanderbilt University School of Medicine, Nashville, TN; Geriatric Research, Education, and Clinical Center, Veterans Affairs Tennessee Valley Healthcare System, Nashville, TN
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Purim-Shem-Tov YA, Schaer GL, Malik K, McLaughlin RR, Haw JM, Melgoza NA, Franco MM. Successful collaborative model for STEMI care between a STEMI-referral and a STEMI receiving center. Crit Pathw Cardiol 2014; 13:131-134. [PMID: 25396288 DOI: 10.1097/hpc.0000000000000025] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/04/2023]
Abstract
BACKGROUND Patients with ST-segment elevation myocardial infarction (STEMI) greatly benefit from a rapid door-to-balloon (D2B) time. For hospitals without a catheterization laboratory, it is imperative to establish partnerships with a STEMI receiving center (SRC). STEMI systems of care have been established to facilitate these relationships to improve rapid reperfusion. We describe the experience and benefits of such a relationship. METHODS A partnership between our 2 institutions was established in April 2011. Saint Anthony Hospital (SAH) of Chicago is an inner city hospital with interventional cardiologists on staff, but no catheterization laboratory. Before the partnership, STEMI patients were transferred 8 miles to a percutaneous coronary intervention (PCI) hospital on the city's north side. Rush University Medical Center (RUMC) is an academic medical center with 24/7/365 PCI capability. SAH decided that a transfer relationship with a closer SRC would benefit patient care. The following steps were taken: both hospitals signed a STEMI transfer agreement for STEMI transfers regardless of insurance status; an education process occurred at both hospitals; agreement that transferred patients would follow-up at the STEMI referring hospital (SAH); a contract with a single ambulance provider was signed; a simple STEMI protocol was adopted. RESULTS In 2010, SAH saw 20 patients with STEMI. Average time from patient arrival to leaving the emergency department (ED) [Door-in-Door-out (DIDO)] was 83 minutes, these times were not tracked carefully; approximate transfer time to SRC was 25 minutes; Door1-2-Balloon (D12B) time was not recorded. Since the new protocol, 44 patients transferred to RUMC for PCI to date. Median (inclusive minimum, maximum) time from ED arrival (D1) at referral hospital to SRC (D2) was 52 minutes (56, 192) for all PCI cases; 11 patients transferred did not have PCI; 1 patient expired upon arrival; and median time to first PCI device (D12B) was 86 minutes (53-167). DISCUSSION Streamlining STEMI patient care to reduce D2B is a major priority. We have demonstrated that establishing a transfer program between a STEMI-Referral Hospital (SRH) and SRC can markedly improve time to reperfusion. This approach has resulted in D12B that match or exceeds the D2B for nontransfer patients at most STEMI-receiving hospitals.
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Affiliation(s)
- Yanina A Purim-Shem-Tov
- From the *Rush University Medical Center, Chicago, IL; †St Anthony Hospital of Chicago, Chicago, IL; and ‡Superior Ambulance Service, Chicago, IL
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Abstract
OBJECTIVES Target door-to-device (DTD) time for ST-elevation myocardial infarction (STEMI) patients has been 90 minutes, with no distinction between urban and rural hospitals. Rural hospitals have longer DTD times for transferred patients attributed to long transportation times from referring hospitals. Longer DTD times have also been reported during after-hours. The aim of the study was to determine whether DTD times at our rural facility were impacted by arrival method, arrival time period, and season. DESIGN Retrospective chart review. SETTING Rural tertiary care center in central Wisconsin. METHODS We studied 412 patients presenting with STEMI after initiation of the Rescue One program for rapid triage and transfer from October 2006 through December 2012. They were subdivided by arrival method, arrival time (ON=Monday-Friday, 8 AM-5 PM; OFF=after-hours, weekends, holidays), and season. Median DTD times and proportions below and above 90 minutes were compared. RESULTS Median DTD time for all groups, which include both directly admitted and transferred patients, was 85 minutes with 60% of patients achieving DTD times below 90 minutes while 30-day mortality was 5.3%. Median DTD time was 67 minutes for the Emergency Department (ED) (n=164), 95 minutes for Transfers (n=204), 68 minutes for Urgent Care (n=22) and 86 minutes for Field (n=22). ED had the highest proportion of patients achieving goal DTD time (81%) compared to Transfers (42%). Patients arriving by ED during OFF hours had a median DTD time 28 minutes longer than during ON hours with 21% fewer patients achieving goal DTD time, attributed to the time required to call in the catheterization team. Seasonal variability was observed due to differences in pre-hospital ambulance transportation times in the Field group. CONCLUSIONS Our data confirm that in a rural facility such as ours, ED patients arriving during after-hours and transferred patients have longer DTD times. Methods are being implemented to shorten the time to assemble the catheterization lab team during after-hours. Better performance will be seen once the first medical contact to device (FTD) time goal of 120 minutes for transferred patients is adopted at our institution. Fibrinolytic therapy should be considered at referring institutions where the FTD time is expected to exceed 120 minutes.
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Affiliation(s)
- Victor A Abrich
- Department of Internal Medicine, Marshfield Clinic, Marshfield, Wisconsin, USA
| | - Roxann Rokey
- Department of Cardiology, Marshfield Clinic, Marshfield, Wisconsin, USA
| | - Satya S V Bhupathi
- Department of Internal Medicine, Marshfield Clinic, Marshfield, Wisconsin, USA
| | - Juan E Mesa
- Department of Cardiology, Marshfield Clinic, Marshfield, Wisconsin, USA
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Nicholson BD, Dhindsa HS, Roe MT, Chen AY, Jollis JG, Kontos MC. Relationship of the distance between non-PCI hospitals and primary PCI centers, mode of transport, and reperfusion time among ground and air interhospital transfers using NCDR's ACTION Registry-GWTG: a report from the American Heart Association Mission: Lifeline Program. Circ Cardiovasc Interv 2014; 7:797-805. [PMID: 25406204 DOI: 10.1161/circinterventions.113.001307] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND ST-segment myocardial infarction patients frequently present to non-percutaneous coronary intervention (PCI) hospitals and require interhospital transfer for primary PCI. The effect of distance and mode of transport to the PCI center and the frequency that recommended primary PCI times are met are not clear. METHODS AND RESULTS Data from the ACTION Registry(®)-GWTG™ were used to determine the distance between the Non-PCI and PCI center and first door time to balloon time based on transfer mode (ground and air) for patients having interhospital transfer for primary PCI. From July 1, 2008, to December 31, 2012, 17 052 ST-segment myocardial infarction patients were transferred to 413 PCI hospitals. The median distance from the non-PCI hospital to the primary PCI center was 31.9 miles (Q1, Q3: 19.1, 47.9; ground 25.2 miles; air 43.9 miles; P<0.001). At distances <40 miles, ground transport was the primary transport method, whereas at distances >40 miles air transport predominanted. Median first door time to balloon time time for patients transferred for primary PCI was 118 minutes (Q1, Q3: 95 152), with time for patients transported by air significantly longer (median 124 versus 113 minutes; respectively, P<0.001) than for patients transported by ground. Fifty-three percent of patients had a first door time to balloon time ≤120 minutes, with only 20% ≤90 minutes. A first door time to balloon time ≤120 minutes was more likely in ground than in air transport patients (57.0% versus 45.6%; P<0.001). CONCLUSIONS Interhospital transfer for primary PCI is associated with prolonged reperfusion times. These delays should prompt increased consideration of fibrinolytic therapy, emergency medical services hospital bypass protocols, and improved systems of care for ST-segment myocardial infarction patients requiring transfer.
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Affiliation(s)
- Benjamin D Nicholson
- From the Virginia Commonwealth University (B.D.N.), Department of Emergency Medicine (H.S.D.), and Department of Internal Medicine (M.C.K.), Richmond, VA; and Duke Clinical Research Institute, Duke University Medical Center, Durham, NC (M.T.R., A.Y.C., J.G.J.); and on behalf of the NCDR
| | - Harinder S Dhindsa
- From the Virginia Commonwealth University (B.D.N.), Department of Emergency Medicine (H.S.D.), and Department of Internal Medicine (M.C.K.), Richmond, VA; and Duke Clinical Research Institute, Duke University Medical Center, Durham, NC (M.T.R., A.Y.C., J.G.J.); and on behalf of the NCDR
| | - Matthew T Roe
- From the Virginia Commonwealth University (B.D.N.), Department of Emergency Medicine (H.S.D.), and Department of Internal Medicine (M.C.K.), Richmond, VA; and Duke Clinical Research Institute, Duke University Medical Center, Durham, NC (M.T.R., A.Y.C., J.G.J.); and on behalf of the NCDR
| | - Anita Y Chen
- From the Virginia Commonwealth University (B.D.N.), Department of Emergency Medicine (H.S.D.), and Department of Internal Medicine (M.C.K.), Richmond, VA; and Duke Clinical Research Institute, Duke University Medical Center, Durham, NC (M.T.R., A.Y.C., J.G.J.); and on behalf of the NCDR
| | - James G Jollis
- From the Virginia Commonwealth University (B.D.N.), Department of Emergency Medicine (H.S.D.), and Department of Internal Medicine (M.C.K.), Richmond, VA; and Duke Clinical Research Institute, Duke University Medical Center, Durham, NC (M.T.R., A.Y.C., J.G.J.); and on behalf of the NCDR
| | - Michael C Kontos
- From the Virginia Commonwealth University (B.D.N.), Department of Emergency Medicine (H.S.D.), and Department of Internal Medicine (M.C.K.), Richmond, VA; and Duke Clinical Research Institute, Duke University Medical Center, Durham, NC (M.T.R., A.Y.C., J.G.J.); and on behalf of the NCDR.
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92
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Minha S, Loh JP, Satler LF, Pendyala LK, Barbash IM, Magalhaes MA, Suddath WO, Pichard AD, Torguson R, Waksman R. Transfer distance effect on reperfusion: timeline of ST-elevation patients transferred for primary percutaneous coronary intervention. CARDIOVASCULAR REVASCULARIZATION MEDICINE 2014; 15:369-74. [DOI: 10.1016/j.carrev.2014.08.003] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2014] [Accepted: 08/07/2014] [Indexed: 11/25/2022]
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Windecker S, Kolh P, Alfonso F, Collet JP, Cremer J, Falk V, Filippatos G, Hamm C, Head SJ, Jüni P, Kappetein AP, Kastrati A, Knuuti J, Landmesser U, Laufer G, Neumann FJ, Richter DJ, Schauerte P, Sousa Uva M, Stefanini GG, Taggart DP, Torracca L, Valgimigli M, Wijns W, Witkowski A. 2014 ESC/EACTS Guidelines on myocardial revascularization: The Task Force on Myocardial Revascularization of the European Society of Cardiology (ESC) and the European Association for Cardio-Thoracic Surgery (EACTS)Developed with the special contribution of the European Association of Percutaneous Cardiovascular Interventions (EAPCI). Eur Heart J 2014; 35:2541-619. [PMID: 25173339 DOI: 10.1093/eurheartj/ehu278] [Citation(s) in RCA: 3291] [Impact Index Per Article: 329.1] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
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Abstract
The appropriate timing of angiography to facilitate revascularization is essential to optimize outcomes in patents with ST-segment-elevation myocardial infarction and non-ST-segment-elevation acute coronary syndromes. Timely reperfusion of the infarct-related coronary artery in ST-segment-elevation myocardial infarction both with fibrinolysis or percutaneous coronary intervention minimizes myocardial damage, reduces infarct size, and decreases morbidity and mortality. Primary percutaneous coronary intervention is the preferred reperfusion method if it can be performed in a timely manner. Strategies to reduce health system-related delays in reperfusion include regionalization of ST-segment-elevation myocardial infarction care, performing prehospital ECGs, prehospital activation of the catheterization laboratory, bypassing geographically closer nonpercutaneous coronary intervention-capable hospitals, bypassing the percutaneous coronary intervention-capable hospital emergency department, and early and consistent availability of the catheterization laboratory team. With implementation of such strategies, there has been significant improvement in process measures, including door-to-balloon time. However, despite reductions in door-to-balloon times, there has been little change during the past several years in in-hospital mortality, suggesting additional factors including patient-related delays, optimization of tissue-level perfusion, and cardioprotection must be addressed to improve patient outcomes further. Early angiography followed by revascularization when appropriate also reduces rates of death, MI, and recurrent ischemia in patients with non-ST-segment-elevation acute coronary syndromes, with the greatest benefits realized in the highest risk patients. Among patients with non-ST-segment-elevation acute coronary syndromes with multivessel disease, choice of revascularization modality should be made as in stable coronary artery disease, with a goal of complete ischemic revascularization.
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Affiliation(s)
- Akshay Bagai
- From the Terrence Donnelly Heart Centre, St. Michael's Hospital, University of Toronto, Toronto, Ontario, Canada (A.B.); Mount Sinai Medical Center and The Cardiovascular Research Foundation, New York, NY (G.D.D.); Columbia University Medical Center and The Cardiovascular Research Foundation, New York, NY (G.W.S.); and Duke Clinical Research Institute, Durham, NC (C.B.G.).
| | - George D Dangas
- From the Terrence Donnelly Heart Centre, St. Michael's Hospital, University of Toronto, Toronto, Ontario, Canada (A.B.); Mount Sinai Medical Center and The Cardiovascular Research Foundation, New York, NY (G.D.D.); Columbia University Medical Center and The Cardiovascular Research Foundation, New York, NY (G.W.S.); and Duke Clinical Research Institute, Durham, NC (C.B.G.)
| | - Gregg W Stone
- From the Terrence Donnelly Heart Centre, St. Michael's Hospital, University of Toronto, Toronto, Ontario, Canada (A.B.); Mount Sinai Medical Center and The Cardiovascular Research Foundation, New York, NY (G.D.D.); Columbia University Medical Center and The Cardiovascular Research Foundation, New York, NY (G.W.S.); and Duke Clinical Research Institute, Durham, NC (C.B.G.)
| | - Christopher B Granger
- From the Terrence Donnelly Heart Centre, St. Michael's Hospital, University of Toronto, Toronto, Ontario, Canada (A.B.); Mount Sinai Medical Center and The Cardiovascular Research Foundation, New York, NY (G.D.D.); Columbia University Medical Center and The Cardiovascular Research Foundation, New York, NY (G.W.S.); and Duke Clinical Research Institute, Durham, NC (C.B.G.)
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95
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de Andrade L, Lynch C, Carvalho E, Rodrigues CG, Vissoci JRN, Passos GF, Pietrobon R, Nihei OK, de Barros Carvalho MD. System dynamics modeling in the evaluation of delays of care in ST-segment elevation myocardial infarction patients within a tiered health system. PLoS One 2014; 9:e103577. [PMID: 25079362 PMCID: PMC4117497 DOI: 10.1371/journal.pone.0103577] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2014] [Accepted: 07/02/2014] [Indexed: 11/18/2022] Open
Abstract
Background Mortality rates amongst ST segment elevation myocardial infarction (STEMI) patients remain high, especially in developing countries. The aim of this study was to evaluate the factors related with delays in the treatment of STEMI patients to support a strategic plan toward structural and personnel modifications in a primary hospital aligning its process with international guidelines. Methods and Findings The study was conducted in a primary hospital localized in Foz do Iguaçu, Brazil. We utilized a qualitative and quantitative integrated analysis including on-site observations, interviews, medical records analysis, Qualitative Comparative Analysis (QCA) and System Dynamics Modeling (SD). Main cause of delays were categorized into three themes: a) professional, b) equipment and c) transportation logistics. QCA analysis confirmed four main stages of delay to STEMI patient’s care in relation to the ‘Door-in-Door-out’ time at the primary hospital. These stages and their average delays in minutes were: a) First Medical Contact (From Door-In to the first contact with the nurse and/or physician): 7 minutes; b) Electrocardiogram acquisition and review by a physician: 28 minutes; c) ECG transmission and Percutaneous Coronary Intervention Center team feedback time: 76 minutes; and d) Patient’s Transfer Waiting Time: 78 minutes. SD baseline model confirmed the system’s behavior with all occurring delays and the need of improvements. Moreover, after model validation and sensitivity analysis, results suggested that an overall improvement of 40% to 50% in each of these identified stages would reduce the delay. Conclusions This evaluation suggests that investment in health personnel training, diminution of bureaucracy, and management of guidelines might lead to important improvements decreasing the delay of STEMI patients’ care. In addition, this work provides evidence that SD modeling may highlight areas where health system managers can implement and evaluate the necessary changes in order to improve the process of care.
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Affiliation(s)
- Luciano de Andrade
- Department of Health Sciences, State University of Maringa, Maringa, Parana, Brazil
- Department of Nursing, State University of the West of Parana, Foz do Iguaçu, Parana, Brazil
| | - Catherine Lynch
- Division of Emergency Medicine, Department of Surgery, Duke Global Health Institute, Duke University, Durham, North Carolina, United States of America
| | - Elias Carvalho
- Nucleus of Data Processing, State University of Maringa, Maringa, Parana, Brazil
- Graduate Program in Informatics - PPGIA, Knowledge Discovery and Machine Learning Group, Pontificia Universidade Católica - PUC-PR, Curitiba, Parana, Brazil
| | - Clarissa Garcia Rodrigues
- Instituto de Cardiologia do Rio Grande do Sul - Fundação Universitária de Cardiologia, Porto Alegre, Rio Grande do Sul, Brazil
| | | | | | - Ricardo Pietrobon
- Department of Surgery, Duke University Health System, Durham, North Carolina, United States of America
| | - Oscar Kenji Nihei
- Department of Nursing, State University of the West of Parana, Foz do Iguaçu, Parana, Brazil
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Wang TY, Magid DJ, Ting HH, Li S, Alexander KP, Roe MT, Peterson ED. The quality of antiplatelet and anticoagulant medication administration among ST-segment elevation myocardial infarction patients transferred for primary percutaneous coronary intervention. Am Heart J 2014; 167:833-9. [PMID: 24890532 DOI: 10.1016/j.ahj.2014.03.002] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/22/2013] [Accepted: 03/05/2014] [Indexed: 10/25/2022]
Abstract
BACKGROUND Timely and appropriate use of antiplatelet and anticoagulant therapies has been shown to improve outcomes among ST-segment elevation myocardial infarction (STEMI) patients but has not been well described in patients transferred for primary percutaneous coronary intervention (PCI). METHODS We examined 16,801 (26%) transfer and 47,329 direct-arrival STEMI patients treated with primary PCI at 441 Acute Coronary Treatment and Intervention Outcomes Network Registry-Get With The Guidelines hospitals. Medication use was compared between transfer and direct-arrival patients to determine if these therapies were delayed or dosed in excess. RESULTS Although transfer patients were more likely to receive antiplatelet and anticoagulant therapies before catheterization, they had longer delays to initiation of heparin (35 vs. 25 minutes), clopidogrel (119 vs. 84 minutes), and glycoprotein IIb/IIIa inhibitor (107 vs. 60 minutes, P < .0001 for both). Administration of low-molecular-weight heparin and glycoprotein IIb/IIIa inhibitor at the STEMI-referring hospital was associated with longer delays to reperfusion compared with deferred administration at the STEMI-receiving hospital, whereas early use of unfractionated heparin was not. Among treated patients, those transferred were more likely to receive excess heparin dosing (adjusted odds ratio [OR] 1.28 [95% CI 1.04-1.58] for unfractionated heparin, adjusted OR 1.54 [95% CI 1.09-2.18] for low-molecular-weight heparin) and are associated with higher risks of major bleeding complications (adjusted OR 1.10, 95% CI 1.03-1.17). CONCLUSIONS ST-segment elevation myocardial infarction patients transferred for primary PCI in community practice are at risk for delayed and excessively dosed antithrombotic therapy, highlighting the need for continued quality improvement to maximize the appropriate use of these important adjunctive therapies.
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97
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Mixon TA, Colato L. Impact of mode of transportation on time to treatment in patients transferred for primary percutaneous coronary intervention. J Emerg Med 2014; 47:247-53. [PMID: 24746909 DOI: 10.1016/j.jemermed.2014.02.003] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2013] [Revised: 12/23/2013] [Accepted: 02/09/2014] [Indexed: 11/16/2022]
Abstract
BACKGROUND Patients suffering ST segment elevation myocardial infarction (STEMI) requiring transfer from a non-percutaneous coronary intervention (PCI) hospital to a PCI-capable hospital often have prolonged treatment times. OBJECTIVE For STEMI transfers, we changed from air to ground transportation, and carefully documented the impact on treatment times. METHODS This is a retrospective report between two hospitals within one STEMI system. The referring facility controls both air and ground ambulance services. After a 2-year period of air transportation with suboptimal treatment times, the referring hospital switched to ground transport. All pertinent times were carefully recorded and are reported here. RESULTS There were 43 patients included, approximately half were transported by air and half by ground. Comparing our early experience (air only) vs. our later experience (predominantly ground-transported patients), median door-in-door-out (DIDO) time at the first facility was 70 min vs. 35 min (p<0.001), median transport time was 20 min vs. 30 min (p<0.001), and median first medical contact to balloon time (FMC2b time) was 123 min vs. 90 min (p<0.001). After changing mode of transport, achievement of the national FMC2b time goal of <120 min rose from 47% to 92% (p<0.001). CONCLUSIONS We document a significantly reduced DIDO and FMC2b time after changing mode of transportation for STEMI patients transferred 30 miles for primary PCI. Utilizing ground rather than air transportation, the median FMC2b time was reduced from 123 to 90 min. We show that mode of transportation can dramatically reduce both DIDO time and FMC2b time.
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Affiliation(s)
- Timothy A Mixon
- Texas A&M College of Medicine, Temple, Texas; Division of Cardiology, Scott & White Healthcare, Temple, Texas
| | - Luis Colato
- Southwest Cardiovascular Center, Las Cruces, New Mexico
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Gonzalez AA, Dimick JB, Birkmeyer JD, Ghaferi AA. Understanding the volume-outcome effect in cardiovascular surgery: the role of failure to rescue. JAMA Surg 2014; 149:119-23. [PMID: 24336902 DOI: 10.1001/jamasurg.2013.3649] [Citation(s) in RCA: 197] [Impact Index Per Article: 19.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
IMPORTANCE To effectively guide interventions aimed at reducing mortality in low-volume hospitals, the underlying mechanisms of the volume-outcome relationship must be further explored. Reducing mortality after major postoperative complications may represent one point along the continuum of patient care that could significantly affect overall hospital mortality. OBJECTIVE To determine whether increased mortality at low-volume hospitals performing cardiovascular surgery is a function of higher postoperative complication rates or of less successful rescue from complications. DESIGN, SETTING, AND PARTICIPANTS We used patient-level data from 119434 Medicare fee-for-service beneficiaries aged 65 to 99 years undergoing coronary artery bypass grafting, aortic valve repair, or abdominal aortic aneurysm repair between January 1, 2005, and December 31, 2006. For each operation, we first divided hospitals into quintiles of procedural volume. We then assessed hospital risk-adjusted rates of mortality, major complications, and failure to rescue (ie, case fatality among patients with complications) within each volume quintile. EXPOSURE Hospital procedural volume. MAIN OUTCOMES AND MEASURES Hospital rates of risk-adjusted mortality, major complications, and failure to rescue. RESULTS For each operation, hospital volume was more strongly related to failure-to-rescue rates than to complication rates. For example, patients undergoing aortic valve replacement at very low-volume hospitals (lowest quintile) were 12% more likely to have a major complication than those at very high-volume hospitals (highest quintile) but were 57% more likely to die if a complication occurred. CONCLUSIONS AND RELEVANCE High-volume and low-volume hospitals performing cardiovascular surgery have similar complication rates but disparate failure-to-rescue rates. While preventing complications is important, hospitals should also consider interventions aimed at quickly recognizing and managing complications once they occur.
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Affiliation(s)
- Andrew A Gonzalez
- Department of Surgery, University of Illinois Hospital and Health Sciences System, Chicago2Center for Healthcare Outcomes and Policy, Department of Surgery, University of Michigan, Ann Arbor
| | - Justin B Dimick
- Center for Healthcare Outcomes and Policy, Department of Surgery, University of Michigan, Ann Arbor
| | - John D Birkmeyer
- Center for Healthcare Outcomes and Policy, Department of Surgery, University of Michigan, Ann Arbor
| | - Amir A Ghaferi
- Center for Healthcare Outcomes and Policy, Department of Surgery, University of Michigan, Ann Arbor
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99
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Brown HF. Synopsis and Review of the American College of Cardiology Foundation/American Heart Association 2013 ST-Elevation Myocardial Infarction Guideline. AACN Adv Crit Care 2014. [DOI: 10.4037/nci.0000000000000025] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022]
Abstract
The “2013 ACCF/AHA Guideline for the Management of ST-Elevation Myocardial Infarction: A Report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines” is a major revision of the 2004 guideline. This article provides a synopsis and review of the guideline focusing on changes in patient care and implementing processes to ensure quality care. The implementation of this guideline provides nursing with a unique opportunity to affect patients and families primarily by recognition of the event and education about lifestyle modification and disease management. Regionalization of emergency systems provides a novel situation for nursing to develop interdepartmental and system protocols
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Affiliation(s)
- Helen F. Brown
- Helen F. Brown is Acute Care Nurse Practitioner, Emergency Department, Anne Arundel Medical Center, Annapolis, MD 21401
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100
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Singh V, Cohen MG. Therapy in ST-elevation myocardial infarction: reperfusion strategies, pharmacology and stent selection. CURRENT TREATMENT OPTIONS IN CARDIOVASCULAR MEDICINE 2014; 16:302. [PMID: 24668011 DOI: 10.1007/s11936-014-0302-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
Abstract
OPINION STATEMENT The estimated annual incidence of new and recurrent myocardial infarction (MI) in the U.S. is 715,000 events. Primary percutaneous coronary intervention (PCI) is the reperfusion strategy of choice in most patients with acute ST-elevation myocardial infarction (STEMI). Recent advances in percutaneous techniques and devices, including manual aspiration catheters and newer generation drug eluting stents and pharmacologic therapies, such as novel antiplatelets and anticoagulants have led to significant improvements in the acute and long-term outcomes for these patients. Implementation of community-wide systems directed to shorten treatment times tied to closely monitored quality improvement processes have led to further advances in STEMI care. Recent data suggests that transradial access for primary PCI is associated with improved outcomes. This contemporary review discusses the strategies for reperfusion, pharmacological therapy and stent selection process involved in STEMI.
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Affiliation(s)
- Vikas Singh
- Cardiovascular Division, and the Elaine and Sydney Sussman Cardiac Catheterization Laboratory, University of Miami Hospital, Miller School of Medicine, 1400 N.W. 12th Avenue, Suite 1179, Miami, FL, 33136, USA
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