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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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Kragholm K, Lu D, Chiswell K, Al-Khalidi HR, Roettig ML, Roe M, Jollis J, Granger CB. Improvement in Care and Outcomes for Emergency Medical Service-Transported Patients With ST-Elevation Myocardial Infarction (STEMI) With and Without Prehospital Cardiac Arrest: A Mission: Lifeline STEMI Accelerator Study. J Am Heart Assoc 2017; 6:e005717. [PMID: 29021273 PMCID: PMC5721828 DOI: 10.1161/jaha.117.005717] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/29/2017] [Accepted: 08/23/2017] [Indexed: 11/18/2022]
Abstract
BACKGROUND Patients with ST-elevation myocardial infarction (STEMI) with out-of-hospital cardiac arrest (OHCA) may benefit from direct transport to a percutaneous cardiac intervention (PCI) hospital but have previously been less likely to bypass local non-PCI hospitals to go to a PCI center. METHODS AND RESULTS We reported time trends in emergency medical service transport and care of patients with STEMI with and without OHCA included from 171 PCI-capable hospitals in 16 US regions with participation in the Mission: Lifeline STEMI Accelerator program between July 1, 2012, and March 31, 2014. Time trends by quarter were assessed using logistic regression with generalized estimating equations to account for hospital clustering. Of 13 189 emergency medical service-transported patients, 88.7% (N=11 703; 10.5% OHCA) were taken directly to PCI hospitals. Among 1486 transfer-in patients, 21.7% had OHCA. Direct transport to a PCI center for OHCA increased from 74.7% (July 1, 2012) to 83.6% (March 31, 2014) (odds ratio per quarter, 1.07; 95% confidence interval, 1.02-1.14), versus 89.0% to 91.0% for patients without OHCA (odds ratio, 1.03; 95% confidence interval, 0.99-1.07; interaction P=0.23). The proportion with prehospital ECGs increased for patients taken directly to PCI centers (53.9%-61.9% for those with OHCA versus 73.9%-81.9% for those without OHCA; interaction P=0.12). Of 997 patients with OHCA taken directly to PCI hospitals and treated with primary PCI, first medical contact-to-device times within the guideline-recommended goal of ≤90 minutes were met for 34.5% on July 1, 2012, versus 41.8% on March 31, 2014 (51.6% and 56.1%, respectively, for 9352 counterparts without OHCA; interaction P=0.72). CONCLUSIONS Direct transport to PCI hospitals increased for patients with STEMI with and without OHCA during the 2012 to 2014 Mission: Lifeline STEMI Accelerator program. Proportions with prehospital ECGs and timely reperfusion increased for patients taken directly to PCI hospitals.
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Affiliation(s)
| | - Di Lu
- Duke Clinical Research Institute, Durham, NC
| | | | | | | | - Matthew Roe
- Duke Clinical Research Institute, Durham, NC
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53
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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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van Diepen S, Katz JN, Albert NM, Henry TD, Jacobs AK, Kapur NK, Kilic A, Menon V, Ohman EM, Sweitzer NK, Thiele H, Washam JB, Cohen MG. Contemporary Management of Cardiogenic Shock: A Scientific Statement From the American Heart Association. Circulation 2017; 136:e232-e268. [PMID: 28923988 DOI: 10.1161/cir.0000000000000525] [Citation(s) in RCA: 985] [Impact Index Per Article: 140.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Cardiogenic shock is a high-acuity, potentially complex, and hemodynamically diverse state of end-organ hypoperfusion that is frequently associated with multisystem organ failure. Despite improving survival in recent years, patient morbidity and mortality remain high, and there are few evidence-based therapeutic interventions known to clearly improve patient outcomes. This scientific statement on cardiogenic shock summarizes the epidemiology, pathophysiology, causes, and outcomes of cardiogenic shock; reviews contemporary best medical, surgical, mechanical circulatory support, and palliative care practices; advocates for the development of regionalized systems of care; and outlines future research priorities.
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Wei J, Mehta PK, Grey E, Garberich RF, Hauser R, Bairey Merz CN, Henry TD. Sex-based differences in quality of care and outcomes in a health system using a standardized STEMI protocol. Am Heart J 2017; 191:30-36. [PMID: 28888267 DOI: 10.1016/j.ahj.2017.06.005] [Citation(s) in RCA: 53] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/14/2017] [Accepted: 06/14/2017] [Indexed: 01/22/2023]
Abstract
BACKGROUND Recent data from the National Cardiovascular Data Registry indicate that women with ST-segment-elevation myocardial infarction (STEMI) continue to have higher mortality and reported delays in treatment compared with men. We aimed to determine whether the sex difference in mortality exists when treatment disparities are reduced. METHODS Using a prospective regional percutaneous coronary intervention (PCI)-based STEMI system database with a standardized STEMI protocol, we evaluated baseline characteristics, treatment, and clinical outcomes of STEMI patients stratified by sex. RESULTS From March 2003 to January 2016, 4,918 consecutive STEMI patients presented to the Minneapolis Heart Institute at Abbott Northwestern Hospital regional STEMI system including 1,416 (28.8%) women. Compared with men, women were older (68.4 vs 60.9 years) with higher rates of hypertension (66.7% vs 55.7%), diabetes (21.7% vs 17.4%), and cardiogenic shock (11.5% vs 8.0%) (all P < .001). Pre-revascularization medications and PCI were performed with same frequencies, but women were less likely to receive statin or antiplatelet therapy at discharge. After age adjustment, women had similar in-hospital mortality to men (5.1% vs 4.8%, P = .60) despite slightly longer door-to-balloon time (95 vs 92 minutes, P = .004). Five-year follow-up confirmed absence of a sex disparity in age-adjusted survival post-STEMI. CONCLUSIONS Previously reported treatment disparities between men and women are diminished in a regional PCI-based STEMI system using a standardized STEMI protocol. No sex differences in short-term or long-term age-adjusted mortality are present in this registry despite some treatment disparities. These results suggest that STEMI health care disparities and mortality in women can be improved using STEMI protocols and systems.
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Affiliation(s)
- Janet Wei
- Cedars-Sinai Heart Institute, Cedars-Sinai Medical Center, Los Angeles, CA.
| | - Puja K Mehta
- Cedars-Sinai Heart Institute, Cedars-Sinai Medical Center, Los Angeles, CA; Emory Clinical Cardiovascular Research Institute, Emory University, Atlanta, GA
| | - Elizabeth Grey
- Minneapolis Heart Institute Foundation, Abbott Northwestern Hospital, Minneapolis, MN
| | - Ross F Garberich
- Minneapolis Heart Institute Foundation, Abbott Northwestern Hospital, Minneapolis, MN
| | - Robert Hauser
- Minneapolis Heart Institute Foundation, Abbott Northwestern Hospital, Minneapolis, MN
| | - C Noel Bairey Merz
- Cedars-Sinai Heart Institute, Cedars-Sinai Medical Center, Los Angeles, CA
| | - Timothy D Henry
- Cedars-Sinai Heart Institute, Cedars-Sinai Medical Center, Los Angeles, CA
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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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Kim JH, Roh YH, Park YS, Park JM, Joung BY, Park IC, Chung SP, Kim MJ. Risk score to predict false-positive ST-segment elevation myocardial infarction in the emergency department: a retrospective analysis. Scand J Trauma Resusc Emerg Med 2017; 25:61. [PMID: 28666458 PMCID: PMC5493848 DOI: 10.1186/s13049-017-0408-7] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2017] [Accepted: 06/21/2017] [Indexed: 11/10/2022] Open
Abstract
Background The best treatment approach for ST-segment elevation myocardial infarction (STEMI) is prompt primary percutaneous coronary intervention (PCI). However, some patients show ST elevation on electrocardiography (ECG), but do not have myocardial infarction. We sought to identify the frequency of and to develop a prediction model for false-positive STEMI. Methods This study was conducted in the emergency departments (EDs) of two hospitals using the same critical pathway (CP) protocol to treat STEMI patients with primary PCI. The prediction model was developed in a derivation cohort and validated in internal and external validation cohorts. Results Of the CP-activated patients, those for whom ST elevation did not meet the ECG criteria were excluded. Among the patients with appropriate ECG patterns, the incidence of false-positive STEMI in the entire cohort was 16.3%. Independent predictors extracted from the derivation cohort for false-positive STEMI were age < 65 years (odds ratio [OR], 2.54; 95% confidence interval [CI], 1.35–4.89), no chest pain (OR, 12.04; 95% CI, 5.92–25.63), atypical chest pain (OR, 7.40; 95% CI, 3.27–17.14), no reciprocal change (OR, 4.80; 95% CI, 2.54–9.51), and concave-morphology ST elevation (OR, 14.54; 95% CI, 6.87–34.37). Based on the regression coefficients, we established a simplified risk score. In the internal and external validation cohorts, the areas under the receiver operating characteristic curves for our risk score were 0.839 (95% CI, 0.724–0.954) and 0.820 (95% CI, 0.727–0.913), respectively; the positive predictive values were 40.9% and 22.0%, respectively; and the negative predictive values were 94.9% and 96.7%, respectively. Discussion Our prediction model would help them make rapid decisions with better rationale. Conclusion We devised a model to predict false-positive STEMI. Larger-scale validation studies are needed to validate our model, and a prospective study to determine whether this model is effective in reducing improper primary PCI in actual clinical practice should be performed.
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Affiliation(s)
- Ji Hoon Kim
- Department of Emergency Medicine, Yonsei University College of Medicine, 50 Yonsei-ro, Seodaemun-gu, 03722, Seoul, Republic of Korea
| | - Yun Ho Roh
- Department of Research Affairs, Biostatistics Collaboration Unit, Yonsei University College of Medicine, 50 Yonsei-ro, Seodaemun-gu, 03722, Seoul, Republic of Korea
| | - Yoo Seok Park
- Department of Emergency Medicine, Yonsei University College of Medicine, 50 Yonsei-ro, Seodaemun-gu, 03722, Seoul, Republic of Korea
| | - Joon Min Park
- Department Emergency Medicine, Inje University Ilsan Paik Hospital, 170 Juhwa-ro, Ilsanseo-gu, 10380, Goyang-si, Gyeonggi-do, Republic of Korea
| | - Bo Young Joung
- Division of Cardiology, Department of Internal medicine, Yonsei University College of Medicine, 50 Yonsei-ro, Seodaemun-gu, 03722, Seoul, Republic of Korea
| | - In Cheol Park
- Department of Emergency Medicine, Yonsei University College of Medicine, 50 Yonsei-ro, Seodaemun-gu, 03722, Seoul, Republic of Korea
| | - Sung Phil Chung
- Department of Emergency Medicine, Yonsei University College of Medicine, 50 Yonsei-ro, Seodaemun-gu, 03722, Seoul, Republic of Korea
| | - Min Joung Kim
- Department of Emergency Medicine, Yonsei University College of Medicine, 50 Yonsei-ro, Seodaemun-gu, 03722, Seoul, Republic of Korea. .,Department of Emergency Medicine, Severance Hospital, 50 Yonsei-ro, Seodaemun-gu, Seoul, 120-752, Republic of Korea.
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Fordyce CB, Henry TD, Granger CB. Implementation of Regional ST-Segment Elevation Myocardial Infarction Systems of Care: Successes and Challenges. Interv Cardiol Clin 2017; 5:415-425. [PMID: 28581992 DOI: 10.1016/j.iccl.2016.06.001] [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: 11/26/2022]
Abstract
Current guidelines recommend that communities create and maintain a regional system of ST-segment elevation myocardial infarction (STEMI) care that includes assessment and continuous quality improvement of emergency medical services and hospital-based activities. Availability and timely access is a challenge in many areas of the United States. This article reviews clinical trial data supporting the use of primary percutaneous coronary intervention as the optimal reperfusion strategy, and fibrinolysis as an option when this is not possible. It then describes the outcomes and benefits of implementing regional systems of STEMI care, and discusses ongoing challenges for STEMI system implementation, including inadequate data collection and feedback, and hospital and physician competition.
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Affiliation(s)
| | - Timothy D Henry
- Cedars-Sinai Heart Institute, 127 South San Vicente Boulevard, Suite A3100, Los Angeles, CA 90048, USA
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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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Kragholm K, Malta Hansen C, Dupre ME, Xian Y, Strauss B, Tyson C, Monk L, Corbett C, Fordyce CB, Pearson DA, Fosbøl EL, Jollis JG, Abella BS, McNally B, Granger CB. Direct Transport to a Percutaneous Cardiac Intervention Center and Outcomes in Patients With Out-of-Hospital Cardiac Arrest. Circ Cardiovasc Qual Outcomes 2017; 10:CIRCOUTCOMES.116.003414. [DOI: 10.1161/circoutcomes.116.003414] [Citation(s) in RCA: 41] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/20/2016] [Accepted: 05/02/2017] [Indexed: 01/13/2023]
Affiliation(s)
- Kristian Kragholm
- From the Duke Clinical Research Institute, Durham, NC (K.K., C.M.H., M.E.D., Y.X., C.T., L.M., C.B.F., E.L.F., J.G.J., C.B.G.); Departments of Cardiology and Epidemiology/Biostatistics, Aalborg University Hospital, Denmark (K.K.); Department of Community and Family Medicine (M.E.D.), Nicholas School of the Environment (B.S.), Duke University, Durham, NC; Department of Neurology, Duke University Medical Center, Durham, NC (Y.X.); Center for Educational Excellence, Durham, NC (C.T.); New Hanover
| | - Carolina Malta Hansen
- From the Duke Clinical Research Institute, Durham, NC (K.K., C.M.H., M.E.D., Y.X., C.T., L.M., C.B.F., E.L.F., J.G.J., C.B.G.); Departments of Cardiology and Epidemiology/Biostatistics, Aalborg University Hospital, Denmark (K.K.); Department of Community and Family Medicine (M.E.D.), Nicholas School of the Environment (B.S.), Duke University, Durham, NC; Department of Neurology, Duke University Medical Center, Durham, NC (Y.X.); Center for Educational Excellence, Durham, NC (C.T.); New Hanover
| | - Matthew E. Dupre
- From the Duke Clinical Research Institute, Durham, NC (K.K., C.M.H., M.E.D., Y.X., C.T., L.M., C.B.F., E.L.F., J.G.J., C.B.G.); Departments of Cardiology and Epidemiology/Biostatistics, Aalborg University Hospital, Denmark (K.K.); Department of Community and Family Medicine (M.E.D.), Nicholas School of the Environment (B.S.), Duke University, Durham, NC; Department of Neurology, Duke University Medical Center, Durham, NC (Y.X.); Center for Educational Excellence, Durham, NC (C.T.); New Hanover
| | - Ying Xian
- From the Duke Clinical Research Institute, Durham, NC (K.K., C.M.H., M.E.D., Y.X., C.T., L.M., C.B.F., E.L.F., J.G.J., C.B.G.); Departments of Cardiology and Epidemiology/Biostatistics, Aalborg University Hospital, Denmark (K.K.); Department of Community and Family Medicine (M.E.D.), Nicholas School of the Environment (B.S.), Duke University, Durham, NC; Department of Neurology, Duke University Medical Center, Durham, NC (Y.X.); Center for Educational Excellence, Durham, NC (C.T.); New Hanover
| | - Benjamin Strauss
- From the Duke Clinical Research Institute, Durham, NC (K.K., C.M.H., M.E.D., Y.X., C.T., L.M., C.B.F., E.L.F., J.G.J., C.B.G.); Departments of Cardiology and Epidemiology/Biostatistics, Aalborg University Hospital, Denmark (K.K.); Department of Community and Family Medicine (M.E.D.), Nicholas School of the Environment (B.S.), Duke University, Durham, NC; Department of Neurology, Duke University Medical Center, Durham, NC (Y.X.); Center for Educational Excellence, Durham, NC (C.T.); New Hanover
| | - Clark Tyson
- From the Duke Clinical Research Institute, Durham, NC (K.K., C.M.H., M.E.D., Y.X., C.T., L.M., C.B.F., E.L.F., J.G.J., C.B.G.); Departments of Cardiology and Epidemiology/Biostatistics, Aalborg University Hospital, Denmark (K.K.); Department of Community and Family Medicine (M.E.D.), Nicholas School of the Environment (B.S.), Duke University, Durham, NC; Department of Neurology, Duke University Medical Center, Durham, NC (Y.X.); Center for Educational Excellence, Durham, NC (C.T.); New Hanover
| | - Lisa Monk
- From the Duke Clinical Research Institute, Durham, NC (K.K., C.M.H., M.E.D., Y.X., C.T., L.M., C.B.F., E.L.F., J.G.J., C.B.G.); Departments of Cardiology and Epidemiology/Biostatistics, Aalborg University Hospital, Denmark (K.K.); Department of Community and Family Medicine (M.E.D.), Nicholas School of the Environment (B.S.), Duke University, Durham, NC; Department of Neurology, Duke University Medical Center, Durham, NC (Y.X.); Center for Educational Excellence, Durham, NC (C.T.); New Hanover
| | - Claire Corbett
- From the Duke Clinical Research Institute, Durham, NC (K.K., C.M.H., M.E.D., Y.X., C.T., L.M., C.B.F., E.L.F., J.G.J., C.B.G.); Departments of Cardiology and Epidemiology/Biostatistics, Aalborg University Hospital, Denmark (K.K.); Department of Community and Family Medicine (M.E.D.), Nicholas School of the Environment (B.S.), Duke University, Durham, NC; Department of Neurology, Duke University Medical Center, Durham, NC (Y.X.); Center for Educational Excellence, Durham, NC (C.T.); New Hanover
| | - Christopher B. Fordyce
- From the Duke Clinical Research Institute, Durham, NC (K.K., C.M.H., M.E.D., Y.X., C.T., L.M., C.B.F., E.L.F., J.G.J., C.B.G.); Departments of Cardiology and Epidemiology/Biostatistics, Aalborg University Hospital, Denmark (K.K.); Department of Community and Family Medicine (M.E.D.), Nicholas School of the Environment (B.S.), Duke University, Durham, NC; Department of Neurology, Duke University Medical Center, Durham, NC (Y.X.); Center for Educational Excellence, Durham, NC (C.T.); New Hanover
| | - David A. Pearson
- From the Duke Clinical Research Institute, Durham, NC (K.K., C.M.H., M.E.D., Y.X., C.T., L.M., C.B.F., E.L.F., J.G.J., C.B.G.); Departments of Cardiology and Epidemiology/Biostatistics, Aalborg University Hospital, Denmark (K.K.); Department of Community and Family Medicine (M.E.D.), Nicholas School of the Environment (B.S.), Duke University, Durham, NC; Department of Neurology, Duke University Medical Center, Durham, NC (Y.X.); Center for Educational Excellence, Durham, NC (C.T.); New Hanover
| | - Emil L. Fosbøl
- From the Duke Clinical Research Institute, Durham, NC (K.K., C.M.H., M.E.D., Y.X., C.T., L.M., C.B.F., E.L.F., J.G.J., C.B.G.); Departments of Cardiology and Epidemiology/Biostatistics, Aalborg University Hospital, Denmark (K.K.); Department of Community and Family Medicine (M.E.D.), Nicholas School of the Environment (B.S.), Duke University, Durham, NC; Department of Neurology, Duke University Medical Center, Durham, NC (Y.X.); Center for Educational Excellence, Durham, NC (C.T.); New Hanover
| | - James G. Jollis
- From the Duke Clinical Research Institute, Durham, NC (K.K., C.M.H., M.E.D., Y.X., C.T., L.M., C.B.F., E.L.F., J.G.J., C.B.G.); Departments of Cardiology and Epidemiology/Biostatistics, Aalborg University Hospital, Denmark (K.K.); Department of Community and Family Medicine (M.E.D.), Nicholas School of the Environment (B.S.), Duke University, Durham, NC; Department of Neurology, Duke University Medical Center, Durham, NC (Y.X.); Center for Educational Excellence, Durham, NC (C.T.); New Hanover
| | - Benjamin S. Abella
- From the Duke Clinical Research Institute, Durham, NC (K.K., C.M.H., M.E.D., Y.X., C.T., L.M., C.B.F., E.L.F., J.G.J., C.B.G.); Departments of Cardiology and Epidemiology/Biostatistics, Aalborg University Hospital, Denmark (K.K.); Department of Community and Family Medicine (M.E.D.), Nicholas School of the Environment (B.S.), Duke University, Durham, NC; Department of Neurology, Duke University Medical Center, Durham, NC (Y.X.); Center for Educational Excellence, Durham, NC (C.T.); New Hanover
| | - Bryan McNally
- From the Duke Clinical Research Institute, Durham, NC (K.K., C.M.H., M.E.D., Y.X., C.T., L.M., C.B.F., E.L.F., J.G.J., C.B.G.); Departments of Cardiology and Epidemiology/Biostatistics, Aalborg University Hospital, Denmark (K.K.); Department of Community and Family Medicine (M.E.D.), Nicholas School of the Environment (B.S.), Duke University, Durham, NC; Department of Neurology, Duke University Medical Center, Durham, NC (Y.X.); Center for Educational Excellence, Durham, NC (C.T.); New Hanover
| | - Christopher B. Granger
- From the Duke Clinical Research Institute, Durham, NC (K.K., C.M.H., M.E.D., Y.X., C.T., L.M., C.B.F., E.L.F., J.G.J., C.B.G.); Departments of Cardiology and Epidemiology/Biostatistics, Aalborg University Hospital, Denmark (K.K.); Department of Community and Family Medicine (M.E.D.), Nicholas School of the Environment (B.S.), Duke University, Durham, NC; Department of Neurology, Duke University Medical Center, Durham, NC (Y.X.); Center for Educational Excellence, Durham, NC (C.T.); New Hanover
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Caldarola P, Gulizia MM, Gabrielli D, Sicuro M, De Gennaro L, Giammaria M, Grieco NB, Grosseto D, Mantovan R, Mazzanti M, Menotti A, Brunetti ND, Severi S, Russo G, Gensini GF. ANMCO/SIT Consensus Document: telemedicine for cardiovascular emergency networks. Eur Heart J Suppl 2017; 19:D229-D243. [PMID: 28751844 PMCID: PMC5520753 DOI: 10.1093/eurheartj/sux028] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Telemedicine has deeply innovated the field of emergency cardiology, particularly the treatment of acute myocardial infarction. The ability to record an ECG in the early prehospital phase, thus avoiding any delay in diagnosing myocardial infarction with direct transfer to the cath-lab for primary angioplasty, has proven to significantly reduce treatment times and mortality. This consensus document aims to analyse the available evidence and organizational models based on a support by telemedicine, focusing on technical requirements, education, and legal aspects.
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Affiliation(s)
- Pasquale Caldarola
- Cardiology Department, San Paolo Hospital, Via Caposcardicchio, 70123 Bari, Italy
| | - Michele Massimo Gulizia
- Cardiology Department, Garibal-Nesima Hospital, Ospedale Nesima-Garibaldi, Azienda di Rilievo Nazionale e Alta Specializzazione "Garibaldi", Catania, Italy
| | | | - Marco Sicuro
- Cardiology and Cardiac Intensive Care, Regionale Umberto Parini Hospital, Aosta, Italy
| | - Luisa De Gennaro
- Cardiology Department, San Paolo Hospital, Via Caposcardicchio, 70123 Bari, Italy
| | | | | | | | - Roberto Mantovan
- Cardiology Unit, Ospedale Santa Maria dei Battuti, Conegliano (Treviso), Italy
| | - Marco Mazzanti
- Cardiology Hemodynamics-CCU Department, University "Ospedali Riuniti" Hospital, Ancona, Italy
| | | | | | - Silva Severi
- Cardiology Unit, Misericordia Hospital, Grosseto, Italy
| | - Giancarmine Russo
- Italian Society for Telemedicine and eHealth (Digital SIT), Rome, Italy
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The Association between Door-to-Balloon Time of Less Than 60 Minutes and Prognosis of Patients Developing ST Segment Elevation Myocardial Infarction and Undergoing Primary Percutaneous Coronary Intervention. BIOMED RESEARCH INTERNATIONAL 2017; 2017:1910934. [PMID: 28473978 PMCID: PMC5394347 DOI: 10.1155/2017/1910934] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/21/2016] [Revised: 03/21/2017] [Accepted: 03/23/2017] [Indexed: 11/17/2022]
Abstract
Background. The study aimed to verify the effect of primary percutaneous coronary intervention (PPCI) with <60 min door-to-balloon time on ST segment elevation myocardial infarction (STEMI) patients' prognoses. Methods. Outcomes of patients receiving PPCI with door-to-balloon time of <60 min were compared with those of patients receiving PPCI with door-to-balloon time 60–90 min. Result. Totally, 241 STEMI patients (191 with Killip classes I or II) and 104 (71 with Killip classes I or II) received PPCI with door-to-balloon time <60 and 60–90 min, respectively. Killip classes I and II patients with door-to-balloon time <60 min had better thrombolysis in myocardial infarction (TIMI) flow (9.2% fewer patients with TIMI flow <3, p = 0.019) and 8.0% lower 30-day mortality rate (p < 0.001) than those with 60–90 min. After controlling the confounding factors with logistic regression, patients with door-to-balloon time <60 min had lower incidences of TIMI flow <3 (aOR = 0.4, 95% CI = 0.20–0.76), 30-day recurrent myocardial infarction (aOR = 0.3, 95% CI = 0.10–0.91), and 30-day mortality (aOR = 0.3, 95% CI = 0.09–0.77) than those with 60–90 min. Conclusion. Door-to-balloon time <60 min is associated with better blood flow in the infarct-related artery and lower 30-day recurrent myocardial infarction and 30-day mortality rates.
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Wong GC, van Diepen S, Ainsworth C, Arora RC, Diodati JG, Liszkowski M, Love M, Overgaard C, Schnell G, Tanguay JF, Wells G, Le May M. Canadian Cardiovascular Society/Canadian Cardiovascular Critical Care Society/Canadian Association of Interventional Cardiology Position Statement on the Optimal Care of the Postarrest Patient. Can J Cardiol 2017; 33:1-16. [DOI: 10.1016/j.cjca.2016.10.021] [Citation(s) in RCA: 30] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2016] [Revised: 10/18/2016] [Accepted: 10/19/2016] [Indexed: 02/07/2023] Open
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Reperfusion Options for ST Elevation Myocardial Infarction Patients with Expected Delays to Percutaneous Coronary Intervention. Interv Cardiol Clin 2016; 5:439-450. [PMID: 28581994 DOI: 10.1016/j.iccl.2016.06.004] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
Primary percutaneous coronary intervention (PCI) is the preferred reperfusion strategy for ST elevation myocardial infarction (STEMI). However, only one-third of hospitals in the US have PCI availability 24/7. For non-PCI hospitals, transfer remains the optimal strategy. For expected delays of greater than 120 minutes, a pharmacoinvasive strategy is recommended. In patients with evidence of failed reperfusion or hemodynamic instability, immediate rescue PCI should be performed. All other patients should undergo routine cardiac catheterization and PCI within 24 hours after fibrinolysis. A pharmacoinvasive strategy is best implemented within an organized regional STEMI system with prospective standardized transfer protocols.
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Jollis JG, Al-Khalidi HR, Roettig ML, Berger PB, Corbett CC, Dauerman HL, Fordyce CB, Fox K, Garvey JL, Gregory T, Henry TD, Rokos IC, Sherwood MW, Suter RE, Wilson BH, Granger CB. Regional Systems of Care Demonstration Project: American Heart Association Mission: Lifeline STEMI Systems Accelerator. Circulation 2016; 134:365-74. [PMID: 27482000 PMCID: PMC4975540 DOI: 10.1161/circulationaha.115.019474] [Citation(s) in RCA: 69] [Impact Index Per Article: 8.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/11/2015] [Accepted: 06/01/2016] [Indexed: 11/16/2022]
Abstract
BACKGROUND Up to 50% of patients fail to meet ST-segment-elevation myocardial infarction (STEMI) guideline goals recommending a first medical contact-to-device time of <90 minutes for patients directly presenting to percutaneous coronary intervention-capable hospitals and <120 minutes for transferred patients. We sought to increase the proportion of patients treated within guideline goals by organizing coordinated regional reperfusion plans. METHODS We established leadership teams, coordinated protocols, and provided regular feedback for 484 hospitals and 1253 emergency medical services (EMS) agencies in 16 regions across the United States. RESULTS Between July 2012 and December 2013, 23 809 patients presented with acute STEMI (direct to percutaneous coronary intervention hospital: 11 765 EMS transported and 6502 self-transported; 5542 transferred). EMS-transported patients differed from self-transported patients in symptom onset to first medical contact time (median, 47 versus 114 minutes), incidence of cardiac arrest (10% versus 3%), shock on admission (11% versus 3%), and in-hospital mortality (8% versus 3%; P<0.001 for all comparisons). There was a significant increase in the proportion of patients meeting guideline goals of first medical contact-to-device time, including those directly presenting via EMS (50% to 55%; P<0.001) and transferred patients (44%-48%; P=0.002). Despite regional variability, the greatest gains occurred among patients in the 5 most improved regions, increasing from 45% to 57% (direct EMS; P<0.001) and 38% to 50% (transfers; P<0.001). CONCLUSIONS This Mission: Lifeline STEMI Systems Accelerator demonstration project represents the largest national effort to organize regional STEMI care. By focusing on first medical contact-to-device time, coordinated treatment protocols, and regional data collection and reporting, we were able to increase significantly the proportion of patients treated within guideline goals.
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Affiliation(s)
- James G Jollis
- From University of North Carolina, Chapel Hill (J.G.J.); Duke Clinical Research Institute, Duke University, Durham, NC (H.R.A.-K., M.L.R., C.B.F., K.F., M.W.S., C.B.G.); Northwell Health, New Hyde Park, NY (P.B.B.); New Hanover Regional Medical Center, Wilmington, NC (C.C.C.); University of Vermont College of Medicine, Burlington (H.L.D.); Department of Emergency Medicine, Carolinas Medical Center, Charlotte, NC (J.L.G.); American Heart Association, Dallas, TX (T.G., R.E.S.); Cedars-Sinai Heart Institute, Los Angeles, CA (T.D.H.); UCLA-Olive View Medical Center, Los Angeles, CA (I.C.R.); and Sanger Heart and Vascular Institute, Carolinas HealthCare System, Charlotte, NC (B.H.W.)
| | - Hussein R Al-Khalidi
- From University of North Carolina, Chapel Hill (J.G.J.); Duke Clinical Research Institute, Duke University, Durham, NC (H.R.A.-K., M.L.R., C.B.F., K.F., M.W.S., C.B.G.); Northwell Health, New Hyde Park, NY (P.B.B.); New Hanover Regional Medical Center, Wilmington, NC (C.C.C.); University of Vermont College of Medicine, Burlington (H.L.D.); Department of Emergency Medicine, Carolinas Medical Center, Charlotte, NC (J.L.G.); American Heart Association, Dallas, TX (T.G., R.E.S.); Cedars-Sinai Heart Institute, Los Angeles, CA (T.D.H.); UCLA-Olive View Medical Center, Los Angeles, CA (I.C.R.); and Sanger Heart and Vascular Institute, Carolinas HealthCare System, Charlotte, NC (B.H.W.)
| | - Mayme L Roettig
- From University of North Carolina, Chapel Hill (J.G.J.); Duke Clinical Research Institute, Duke University, Durham, NC (H.R.A.-K., M.L.R., C.B.F., K.F., M.W.S., C.B.G.); Northwell Health, New Hyde Park, NY (P.B.B.); New Hanover Regional Medical Center, Wilmington, NC (C.C.C.); University of Vermont College of Medicine, Burlington (H.L.D.); Department of Emergency Medicine, Carolinas Medical Center, Charlotte, NC (J.L.G.); American Heart Association, Dallas, TX (T.G., R.E.S.); Cedars-Sinai Heart Institute, Los Angeles, CA (T.D.H.); UCLA-Olive View Medical Center, Los Angeles, CA (I.C.R.); and Sanger Heart and Vascular Institute, Carolinas HealthCare System, Charlotte, NC (B.H.W.)
| | - Peter B Berger
- From University of North Carolina, Chapel Hill (J.G.J.); Duke Clinical Research Institute, Duke University, Durham, NC (H.R.A.-K., M.L.R., C.B.F., K.F., M.W.S., C.B.G.); Northwell Health, New Hyde Park, NY (P.B.B.); New Hanover Regional Medical Center, Wilmington, NC (C.C.C.); University of Vermont College of Medicine, Burlington (H.L.D.); Department of Emergency Medicine, Carolinas Medical Center, Charlotte, NC (J.L.G.); American Heart Association, Dallas, TX (T.G., R.E.S.); Cedars-Sinai Heart Institute, Los Angeles, CA (T.D.H.); UCLA-Olive View Medical Center, Los Angeles, CA (I.C.R.); and Sanger Heart and Vascular Institute, Carolinas HealthCare System, Charlotte, NC (B.H.W.)
| | - Claire C Corbett
- From University of North Carolina, Chapel Hill (J.G.J.); Duke Clinical Research Institute, Duke University, Durham, NC (H.R.A.-K., M.L.R., C.B.F., K.F., M.W.S., C.B.G.); Northwell Health, New Hyde Park, NY (P.B.B.); New Hanover Regional Medical Center, Wilmington, NC (C.C.C.); University of Vermont College of Medicine, Burlington (H.L.D.); Department of Emergency Medicine, Carolinas Medical Center, Charlotte, NC (J.L.G.); American Heart Association, Dallas, TX (T.G., R.E.S.); Cedars-Sinai Heart Institute, Los Angeles, CA (T.D.H.); UCLA-Olive View Medical Center, Los Angeles, CA (I.C.R.); and Sanger Heart and Vascular Institute, Carolinas HealthCare System, Charlotte, NC (B.H.W.)
| | - Harold L Dauerman
- From University of North Carolina, Chapel Hill (J.G.J.); Duke Clinical Research Institute, Duke University, Durham, NC (H.R.A.-K., M.L.R., C.B.F., K.F., M.W.S., C.B.G.); Northwell Health, New Hyde Park, NY (P.B.B.); New Hanover Regional Medical Center, Wilmington, NC (C.C.C.); University of Vermont College of Medicine, Burlington (H.L.D.); Department of Emergency Medicine, Carolinas Medical Center, Charlotte, NC (J.L.G.); American Heart Association, Dallas, TX (T.G., R.E.S.); Cedars-Sinai Heart Institute, Los Angeles, CA (T.D.H.); UCLA-Olive View Medical Center, Los Angeles, CA (I.C.R.); and Sanger Heart and Vascular Institute, Carolinas HealthCare System, Charlotte, NC (B.H.W.)
| | - Christopher B Fordyce
- From University of North Carolina, Chapel Hill (J.G.J.); Duke Clinical Research Institute, Duke University, Durham, NC (H.R.A.-K., M.L.R., C.B.F., K.F., M.W.S., C.B.G.); Northwell Health, New Hyde Park, NY (P.B.B.); New Hanover Regional Medical Center, Wilmington, NC (C.C.C.); University of Vermont College of Medicine, Burlington (H.L.D.); Department of Emergency Medicine, Carolinas Medical Center, Charlotte, NC (J.L.G.); American Heart Association, Dallas, TX (T.G., R.E.S.); Cedars-Sinai Heart Institute, Los Angeles, CA (T.D.H.); UCLA-Olive View Medical Center, Los Angeles, CA (I.C.R.); and Sanger Heart and Vascular Institute, Carolinas HealthCare System, Charlotte, NC (B.H.W.)
| | - Kathleen Fox
- From University of North Carolina, Chapel Hill (J.G.J.); Duke Clinical Research Institute, Duke University, Durham, NC (H.R.A.-K., M.L.R., C.B.F., K.F., M.W.S., C.B.G.); Northwell Health, New Hyde Park, NY (P.B.B.); New Hanover Regional Medical Center, Wilmington, NC (C.C.C.); University of Vermont College of Medicine, Burlington (H.L.D.); Department of Emergency Medicine, Carolinas Medical Center, Charlotte, NC (J.L.G.); American Heart Association, Dallas, TX (T.G., R.E.S.); Cedars-Sinai Heart Institute, Los Angeles, CA (T.D.H.); UCLA-Olive View Medical Center, Los Angeles, CA (I.C.R.); and Sanger Heart and Vascular Institute, Carolinas HealthCare System, Charlotte, NC (B.H.W.)
| | - J Lee Garvey
- From University of North Carolina, Chapel Hill (J.G.J.); Duke Clinical Research Institute, Duke University, Durham, NC (H.R.A.-K., M.L.R., C.B.F., K.F., M.W.S., C.B.G.); Northwell Health, New Hyde Park, NY (P.B.B.); New Hanover Regional Medical Center, Wilmington, NC (C.C.C.); University of Vermont College of Medicine, Burlington (H.L.D.); Department of Emergency Medicine, Carolinas Medical Center, Charlotte, NC (J.L.G.); American Heart Association, Dallas, TX (T.G., R.E.S.); Cedars-Sinai Heart Institute, Los Angeles, CA (T.D.H.); UCLA-Olive View Medical Center, Los Angeles, CA (I.C.R.); and Sanger Heart and Vascular Institute, Carolinas HealthCare System, Charlotte, NC (B.H.W.)
| | - Tammy Gregory
- From University of North Carolina, Chapel Hill (J.G.J.); Duke Clinical Research Institute, Duke University, Durham, NC (H.R.A.-K., M.L.R., C.B.F., K.F., M.W.S., C.B.G.); Northwell Health, New Hyde Park, NY (P.B.B.); New Hanover Regional Medical Center, Wilmington, NC (C.C.C.); University of Vermont College of Medicine, Burlington (H.L.D.); Department of Emergency Medicine, Carolinas Medical Center, Charlotte, NC (J.L.G.); American Heart Association, Dallas, TX (T.G., R.E.S.); Cedars-Sinai Heart Institute, Los Angeles, CA (T.D.H.); UCLA-Olive View Medical Center, Los Angeles, CA (I.C.R.); and Sanger Heart and Vascular Institute, Carolinas HealthCare System, Charlotte, NC (B.H.W.)
| | - Timothy D Henry
- From University of North Carolina, Chapel Hill (J.G.J.); Duke Clinical Research Institute, Duke University, Durham, NC (H.R.A.-K., M.L.R., C.B.F., K.F., M.W.S., C.B.G.); Northwell Health, New Hyde Park, NY (P.B.B.); New Hanover Regional Medical Center, Wilmington, NC (C.C.C.); University of Vermont College of Medicine, Burlington (H.L.D.); Department of Emergency Medicine, Carolinas Medical Center, Charlotte, NC (J.L.G.); American Heart Association, Dallas, TX (T.G., R.E.S.); Cedars-Sinai Heart Institute, Los Angeles, CA (T.D.H.); UCLA-Olive View Medical Center, Los Angeles, CA (I.C.R.); and Sanger Heart and Vascular Institute, Carolinas HealthCare System, Charlotte, NC (B.H.W.)
| | - Ivan C Rokos
- From University of North Carolina, Chapel Hill (J.G.J.); Duke Clinical Research Institute, Duke University, Durham, NC (H.R.A.-K., M.L.R., C.B.F., K.F., M.W.S., C.B.G.); Northwell Health, New Hyde Park, NY (P.B.B.); New Hanover Regional Medical Center, Wilmington, NC (C.C.C.); University of Vermont College of Medicine, Burlington (H.L.D.); Department of Emergency Medicine, Carolinas Medical Center, Charlotte, NC (J.L.G.); American Heart Association, Dallas, TX (T.G., R.E.S.); Cedars-Sinai Heart Institute, Los Angeles, CA (T.D.H.); UCLA-Olive View Medical Center, Los Angeles, CA (I.C.R.); and Sanger Heart and Vascular Institute, Carolinas HealthCare System, Charlotte, NC (B.H.W.)
| | - Matthew W Sherwood
- From University of North Carolina, Chapel Hill (J.G.J.); Duke Clinical Research Institute, Duke University, Durham, NC (H.R.A.-K., M.L.R., C.B.F., K.F., M.W.S., C.B.G.); Northwell Health, New Hyde Park, NY (P.B.B.); New Hanover Regional Medical Center, Wilmington, NC (C.C.C.); University of Vermont College of Medicine, Burlington (H.L.D.); Department of Emergency Medicine, Carolinas Medical Center, Charlotte, NC (J.L.G.); American Heart Association, Dallas, TX (T.G., R.E.S.); Cedars-Sinai Heart Institute, Los Angeles, CA (T.D.H.); UCLA-Olive View Medical Center, Los Angeles, CA (I.C.R.); and Sanger Heart and Vascular Institute, Carolinas HealthCare System, Charlotte, NC (B.H.W.)
| | - Robert E Suter
- From University of North Carolina, Chapel Hill (J.G.J.); Duke Clinical Research Institute, Duke University, Durham, NC (H.R.A.-K., M.L.R., C.B.F., K.F., M.W.S., C.B.G.); Northwell Health, New Hyde Park, NY (P.B.B.); New Hanover Regional Medical Center, Wilmington, NC (C.C.C.); University of Vermont College of Medicine, Burlington (H.L.D.); Department of Emergency Medicine, Carolinas Medical Center, Charlotte, NC (J.L.G.); American Heart Association, Dallas, TX (T.G., R.E.S.); Cedars-Sinai Heart Institute, Los Angeles, CA (T.D.H.); UCLA-Olive View Medical Center, Los Angeles, CA (I.C.R.); and Sanger Heart and Vascular Institute, Carolinas HealthCare System, Charlotte, NC (B.H.W.)
| | - B Hadley Wilson
- From University of North Carolina, Chapel Hill (J.G.J.); Duke Clinical Research Institute, Duke University, Durham, NC (H.R.A.-K., M.L.R., C.B.F., K.F., M.W.S., C.B.G.); Northwell Health, New Hyde Park, NY (P.B.B.); New Hanover Regional Medical Center, Wilmington, NC (C.C.C.); University of Vermont College of Medicine, Burlington (H.L.D.); Department of Emergency Medicine, Carolinas Medical Center, Charlotte, NC (J.L.G.); American Heart Association, Dallas, TX (T.G., R.E.S.); Cedars-Sinai Heart Institute, Los Angeles, CA (T.D.H.); UCLA-Olive View Medical Center, Los Angeles, CA (I.C.R.); and Sanger Heart and Vascular Institute, Carolinas HealthCare System, Charlotte, NC (B.H.W.)
| | - Christopher B Granger
- From University of North Carolina, Chapel Hill (J.G.J.); Duke Clinical Research Institute, Duke University, Durham, NC (H.R.A.-K., M.L.R., C.B.F., K.F., M.W.S., C.B.G.); Northwell Health, New Hyde Park, NY (P.B.B.); New Hanover Regional Medical Center, Wilmington, NC (C.C.C.); University of Vermont College of Medicine, Burlington (H.L.D.); Department of Emergency Medicine, Carolinas Medical Center, Charlotte, NC (J.L.G.); American Heart Association, Dallas, TX (T.G., R.E.S.); Cedars-Sinai Heart Institute, Los Angeles, CA (T.D.H.); UCLA-Olive View Medical Center, Los Angeles, CA (I.C.R.); and Sanger Heart and Vascular Institute, Carolinas HealthCare System, Charlotte, NC (B.H.W.).
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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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Schoenhagen P, Roselli EE, Harris CM, Eagleton M, Menon V. Online network of subspecialty aortic disease experts: Impact of “cloud” technology on management of acute aortic emergencies. J Thorac Cardiovasc Surg 2016; 152:39-42. [DOI: 10.1016/j.jtcvs.2016.02.057] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/18/2016] [Revised: 02/22/2016] [Accepted: 02/26/2016] [Indexed: 10/22/2022]
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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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Langabeer JR, Smith DT, Cardenas-Turanzas M, Leonard BL, Segrest W, Krell C, Owan T, Eisenhauer MD, Gerard D. Impact of a Rural Regional Myocardial Infarction System of Care in Wyoming. J Am Heart Assoc 2016; 5:JAHA.116.003392. [PMID: 27207968 PMCID: PMC4889203 DOI: 10.1161/jaha.116.003392] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
Background Primary percutaneous coronary intervention (PCI) is the preferred reperfusion strategy for patients presenting with ST‐segment elevation myocardial infarction; however, to be effective, PCI must be performed in a timely manner. Rural regions are at a severe disadvantage, given the relatively sparse number of PCI hospitals and long transport times. Methods and Results We developed a standardized treatment and transfer protocol for ST‐segment elevation myocardial infarction in the rural state of Wyoming. The study design compared the time‐to‐treatment outcomes during the pre‐ and postintervention periods. Details of the program, changes in reperfusion strategies over time, and outcome improvements in treatment times were reported. From January 1, 2013, to December 31, 2014, 889 patients were treated in 11 PCI‐capable hospitals (4 in Wyoming, 7 in adjoining states). Given the large geographic distance in the state (median of 47 miles between patient and PCI center), 52% of all patients were transfers, and 36% were administered fibrinolysis at the referral facility. Following the intervention, there was a significant shift toward greater use of primary PCI as the dominant reperfusion strategy (from 47% to 60%, P=0.002), and the median total ischemic time from symptom onset to arterial reperfusion was decreased by 92 minutes (P<0.001). There was a similar significant reduction in median time from receiving center door to balloon of 11 minutes less than the baseline time (P<0.01). Conclusions Rural systems of care for ST‐segment elevation myocardial infarction require increased levels of cooperation between emergency medical services agencies and hospitals. This study confirms that total ischemic times can be reduced through a coordinated rural statewide initiative.
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Musey PI, Studnek JR, Garvey L. Characteristics of ST Elevation Myocardial Infarction Patients Who Do Not Undergo Percutaneous Coronary Intervention After Prehospital Cardiac Catheterization Laboratory Activation. Crit Pathw Cardiol 2016; 15:16-21. [PMID: 26881815 DOI: 10.1097/hpc.0000000000000069] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/05/2023]
Abstract
OBJECTIVES To assess the clinical and electrocardiographic characteristics of patients diagnosed with ST elevation myocardial infarction (STEMI) that are associated with an increased likelihood of not undergoing percutaneous coronary intervention (PCI) after prehospital Cardiac Catheterization Laboratory activation in a regional STEMI system. METHODS We performed a retrospective analysis of prehospital Cardiac Catheterization Laboratory activations in Mecklenburg County, North Carolina, between May 2008 and March 2011. Data were extracted from the prehospital patient record, the prehospital electrocardiogram, and the regional STEMI database. The independent variables of interest included objective patient characteristics as well as documented cardiac history and risk factors. Analysis was performed using descriptive statistics and logistic regression. RESULTS Two hundred thirty-one prehospital activations were included in the analysis. Five independent variables were found to be associated with an increased likelihood of not undergoing PCI: increasing age, bundle branch block, elevated heart rate, left ventricular hypertrophy, and non-white race. The variables with the most significance were any type of bundle branch block [adjusted odds ratios (AOR), 5.66; 95% confidence interval (CI), 1.91-16.76], left ventricular hypertrophy (AOR, 4.63; 95% CI, 2.03-10.53), and non-white race (AOR, 3.53; 95% CI, 1.76-7.08). Conversely, the only variable associated with a higher likelihood of undergoing PCI was the presence of arm pain (AOR, 2.94; 95% CI, 1.36-6.25). CONCLUSIONS Several of the above variables are expected electrocardiogram mimics; however, the decreased rate of PCI in non-white patients highlights an area for investigation and process improvement. This may guide the development of prehospital STEMI protocols, although avoiding false positive and inappropriate activations.
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Affiliation(s)
- Paul I Musey
- From the *Department of Emergency Medicine, Indiana University School of Medicine, Indianapolis, IN; †Mecklenburg Emergency Medical Services Agency, Charlotte, NC; and ‡Department of Emergency Medicine, Carolinas Medical Center, Charlotte, NC
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Balamurugan A, Delongchamp R, Im L, Bates J, Mehta JL. Neighborhood and Acute Myocardial Infarction Mortality as Related to the Driving Time to Percutaneous Coronary Intervention-Capable Hospital. J Am Heart Assoc 2016; 5:e002378. [PMID: 26883922 PMCID: PMC4802460 DOI: 10.1161/jaha.115.002378] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/06/2015] [Accepted: 11/18/2015] [Indexed: 11/17/2022]
Abstract
BACKGROUND Driving time to a percutaneous coronary intervention (PCI)-capable hospital is important in timely treatment of acute myocardial infarction (AMI). Our objective was to determine whether driving time from one's residence to a PCI-capable hospital contributes to AMI deaths. We conducted a cross-sectional study of age- and sex-adjusted mortality in census block groups to evaluate this question. METHODS AND RESULTS We studied all (14 027) AMI deaths that occurred during 2008-2012 in Arkansas to assess the relationship between driving time from the population center of a block group (neighborhood) to the nearest PCI-capable hospital. We estimated standardized mortality ratios in block groups that were adjusted for education (population over 25 years of age who did not graduate from high school), poverty (population living below federal poverty level), population density (population per square mile), mobility (population residing at the same address as 1 year ago), black (population that is black), rurality (rural households), geodesic distance, and driving time. The median geodesic distance and driving time were 12.8 miles (interquartile range 3.6-30.1) and 28.3 minutes (interquartile range 9.6-58.7), respectively. Risks in neighborhoods with long driving times (90th percentile) were 26% greater than risks in neighborhoods with short driving times (10th percentile), even after adjusting for education, poverty, population density, rurality, and black race (P<0.0001). CONCLUSIONS AMI mortality increases with increasing driving time to the nearest PCI-capable hospital. Improving the healthcare system by reducing time to arrive at a PCI-capable hospital could reduce AMI deaths.
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Affiliation(s)
- Appathurai Balamurugan
- Arkansas Department of Health, Little Rock, AR Department of Epidemiology, University of Arkansas for Medicine for Medical Sciences College of Public Health, Little Rock, AR Division of Cardiology, Department of Family and Preventive Medicine, University of Arkansas for Medical Sciences College of Medicine, Little Rock, AR
| | - Robert Delongchamp
- Arkansas Department of Health, Little Rock, AR Department of Epidemiology, University of Arkansas for Medicine for Medical Sciences College of Public Health, Little Rock, AR
| | - Lucille Im
- Arkansas Department of Health, Little Rock, AR
| | - Joseph Bates
- Arkansas Department of Health, Little Rock, AR Department of Epidemiology, University of Arkansas for Medicine for Medical Sciences College of Public Health, Little Rock, AR
| | - Jawahar L Mehta
- Division of Cardiology, Department of Internal Medicine, University of Arkansas for Medical Sciences College of Medicine, Little Rock, AR
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Abstract
Cardiovascular disease is one of the main fields of application for telemedicine, with benefits in almost all areas in the continuum of cardiovascular disease. The greatest impact has been shown in the early diagnosis of cardiovascular disease, in second consultation, between non-cardiologist and cardiologist and between cardiologists, and in follow-up and secondary prevention of cardiovascular disease. At present, the main area of implementation for telemedicine in cardiovascular disease is represented by pre-hospital triage, with telemedicine electrocardiogram in acute myocardial infarction. Significant results have also been achieved in the second opinion consultation of pediatric subjects with congenital cardiovascular disease, home-monitoring and the management of patients affected by chronic heart failure or with an implanted device. However, there is significant room for further improvement in delivering telemedicine assistance even in 'very-remote' populations, such as detainees, patients in developing countries or in underdeveloped areas of developed countries.
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Affiliation(s)
| | - Simonetta Scalvini
- b U.O. Cardiologia Riabilitativa , IRCCS Fondazione Salvatore Maugeri , Brescia , Italy
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73
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AlHabib KF, Sulaiman K, Al Suwaidi J, Almahmeed W, Alsheikh-Ali AA, Amin H, Al Jarallah M, Alfaleh HF, Panduranga P, Hersi A, Kashour T, Al Aseri Z, Ullah A, Altaradi HB, Nur Asfina K, Welsh RC, Yusuf S. Patient and System-Related Delays of Emergency Medical Services Use in Acute ST-Elevation Myocardial Infarction: Results from the Third Gulf Registry of Acute Coronary Events (Gulf RACE-3Ps). PLoS One 2016; 11:e0147385. [PMID: 26807577 PMCID: PMC4726591 DOI: 10.1371/journal.pone.0147385] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2015] [Accepted: 01/04/2016] [Indexed: 11/20/2022] Open
Abstract
Background Little is known about Emergency Medical Services (EMS) use and pre-hospital triage of patients with acute ST-elevation myocardial infarction (STEMI) in Arabian Gulf countries. Methods Clinical arrival and acute care within 24 h of STEMI symptom onset were compared between patients transferred by EMS (Red Crescent and Inter-Hospital) and those transferred by non-EMS means. Data were retrieved from a prospective registry of 36 hospitals in 6 Arabian Gulf countries, from January 2014 to January 2015. Results We enrolled 2,928 patients; mean age, 52.7 (SD ±11.8) years; 90% men; and 61.7% non-Arabian Gulf citizens. Only 753 patients (25.7%) used EMS; which was mostly via Inter-Hospital EMS (22%) rather than direct transfer from the scene to the hospital by the Red Crescent (3.7%). Compared to the non-EMS group, the EMS group was more likely to arrive initially at a primary or secondary health care facility; thus, they had longer median symptom-onset-to-emergency department arrival times (218 vs. 158 min; p˂.001); they were more likely to receive primary percutaneous coronary interventions (62% vs. 40.5%, p = 0.02); they had shorter door-to-needle times (38 vs. 42 min; p = .04); and shorter door-to-balloon times (47 vs. 83 min; p˂.001). High EMS use was independently predicted mostly by primary/secondary school educational levels and low or moderate socioeconomic status. Low EMS use was predicted by a history of angina and history of percutaneous coronary intervention. The groups had similar in-hospital deaths and outcomes. Conclusion Most acute STEMI patients in the Arabian Gulf region did not use EMS services. Improving Red Crescent infrastructure, establishing integrated STEMI networks, and launching educational public campaigns are top health care system priorities.
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Affiliation(s)
- Khalid F. AlHabib
- Department of Cardiac Sciences, King Fahad Cardiac Center, College of Medicine, King Saud University, Riyadh, Kingdom of Saudi Arabia
- * E-mail:
| | | | - Jassim Al Suwaidi
- Department of Cardiology, Hamad Medical Corporation (HMC), Doha, Qatar
| | - Wael Almahmeed
- Heart and Vascular Institute, Cleveland Clinic, Abu Dhabi, United Arab Emirates
| | - Alawi A. Alsheikh-Ali
- College of Medicine, Mohammed Bin Rashid University of Medicine and Health Sciences, Dubai, United Arab Emirates
- Institute of Cardiac Sciences, Sheikh Khalifa Medical City, Abu Dhabi, United Arab Emirates
- Tufts Clinical and Translational Science Institute, Tufts Medical Center, Boston, MA, United States of America
| | - Haitham Amin
- Mohammed Bin Khalifa Cardiac Center, Manama, Bahrain
| | | | - Hussam F. Alfaleh
- Department of Cardiac Sciences, King Fahad Cardiac Center, College of Medicine, King Saud University, Riyadh, Kingdom of Saudi Arabia
| | | | - Ahmad Hersi
- Department of Cardiac Sciences, King Fahad Cardiac Center, College of Medicine, King Saud University, Riyadh, Kingdom of Saudi Arabia
| | - Tarek Kashour
- Department of Cardiac Sciences, King Fahad Cardiac Center, College of Medicine, King Saud University, Riyadh, Kingdom of Saudi Arabia
| | - Zohair Al Aseri
- Emergency Department, College of Medicine, King Saud University, Riyadh, Kingdom of Saudi Arabia
| | - Anhar Ullah
- Department of Cardiac Sciences, King Fahad Cardiac Center, College of Medicine, King Saud University, Riyadh, Kingdom of Saudi Arabia
| | - Hani B. Altaradi
- Department of Cardiac Sciences, King Fahad Cardiac Center, College of Medicine, King Saud University, Riyadh, Kingdom of Saudi Arabia
| | - Kazi Nur Asfina
- Department of Cardiac Sciences, King Fahad Cardiac Center, College of Medicine, King Saud University, Riyadh, Kingdom of Saudi Arabia
| | - Robert C. Welsh
- Division of Cardiology, Mazankowski Alberta Heart Institute, University of Alberta, Edmonton, Canada
| | - Salim Yusuf
- Population Health Research Institute, Hamilton Health Sciences, McMaster University, Hamilton, Canada
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County-Level Effects of Prehospital Regionalization of Critically Ill Patients: A Simulation Study. Crit Care Med 2015; 43:1807-15. [PMID: 26102251 DOI: 10.1097/ccm.0000000000001133] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE Regionalization may improve critical care delivery, yet stakeholders cite concerns about its feasibility. We sought to determine the operational effects of prehospital regionalization of nontrauma, nonarrest critical illness. SETTING King County, Washington. DESIGN Discrete event simulation study. PATIENTS All 2006 hospital discharge data, linked to all adult, eligible patients transported by county emergency medical services agencies. INTERVENTIONS We simulated active triage of high-risk patients to designated referral centers using a validated prehospital risk score; we studied three regionalization scenarios: 1) up triage, 2) up and down triage, and 3) up and down triage after reducing ICU beds by 25%. We determined the effect on patient routing, ICU occupancy at referral and nonreferral hospitals, and emergency medical services transport times. MEASUREMENTS AND MAIN RESULTS A total of 119,117 patients were hospitalized at 11 nonreferral centers and 76,817 patients were hospitalized at three referral centers. Among 20,835 emergency medical services patients, 7,817 patients (43%) were eligible for up triage and 10,242 patients (57%) were eligible for down triage. At baseline, mean daily ICU bed occupancy was 61% referral and 47% at nonreferral hospitals. Up triage increased referral ICU occupancy to 68%, up and down triage to 64%, and up and down triage with bed reduction to 74%. Mean daily nonreferral ICU occupancy did not exceed 60%. Total emergency medical services transport time increased by less than 3% with up and down triage. CONCLUSIONS Regionalization based on prehospital triage of the critically ill can allocate high-risk patients to referral hospitals without adversely affecting ICU occupancy or prehospital travel time.
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Moura FA, Figueiredo VN, Teles BS, Barbosa MA, Pereira LR, Costa AP, Carvalho LSF, Cintra RM, Almeida OL, Quinaglia e Silva JC, Nadruz Junior W, Sposito AC. Glycosylated hemoglobin is associated with decreased endothelial function, high inflammatory response, and adverse clinical outcome in non-diabetic STEMI patients. Atherosclerosis 2015; 243:124-30. [DOI: 10.1016/j.atherosclerosis.2015.09.004] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/03/2015] [Revised: 08/23/2015] [Accepted: 09/03/2015] [Indexed: 10/23/2022]
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Brunetti ND, Tarantino N, Dellegrottaglie G, Abatecola G, De Gennaro L, Bruno AI, Bux F, Gaglione A, Di Biase M. Impact of telemedicine support by remote pre-hospital electrocardiogram on emergency medical service management of subjects with suspected acute cardiovascular disease. Int J Cardiol 2015. [DOI: 10.1016/j.ijcard.2015.06.124] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
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Rhudy JP, Bakitas MA, Hyrkäs K, Jablonski-Jaudon RA, Pryor ER, Wang HE, Alexandrov AW. Effectiveness of regionalized systems for stroke and myocardial infarction. Brain Behav 2015; 5:e00398. [PMID: 26516616 PMCID: PMC4614047 DOI: 10.1002/brb3.398] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/20/2015] [Revised: 07/18/2015] [Accepted: 08/16/2015] [Indexed: 01/08/2023] Open
Abstract
BACKGROUND Acute ischemic stroke (AIS) and ST-segment elevation myocardial infarction (STEMI) are ischemic emergencies. Guidelines recommend care delivery within formally regionalized systems of care at designated centers, with bypass of nearby centers of lesser or no designation. We review the evidence of the effectiveness of regionalized systems in AIS and STEMI. METHODS Literature was searched using terms corresponding to designation of AIS and STEMI systems and from 2010 to the present. Inclusion criteria included report of an outcome on any dependent variable mentioned in the rationale for regionalization in the guidelines and an independent variable comparing care to a non- or pre-regionalized system. Designation was defined in the AIS case as certification by the Joint Commission as either a primary (PSC) or comprehensive (CSC) stroke center. In the STEMI case, the search was conducted linking "regionalization" and "myocardial infarction" or citation as a model system by any American Heart Association statement. RESULTS For AIS, 17 publications met these criteria and were selected for review. In the STEMI case, four publications met these criteria; the search was therefore expanded by relaxing the criteria to include any historical or anecdotal comparison to a pre- or nonregionalized state. The final yield was nine papers from six systems. CONCLUSION Although regionalized care results in enhanced process and reduced unadjusted rates of disparity in access and adverse outcomes, these differences tend to become nonsignificant when adjusted for delayed presentation and hospital arrival by means other than emergency medical services. The benefits of regionalized care occur along with a temporal trend of improvement due to uptake of quality initiatives and guideline recommendations by all systems regardless of designation. Further research is justified with a randomized registry or cluster randomized design to support or refute recommendations that regionalization should be the standard of care.
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Affiliation(s)
- James P Rhudy
- School of Nursing University of Alabama at Birmingham Alabama
| | - Marie A Bakitas
- School of Nursing University of Alabama at Birmingham Alabama
| | - Kristiina Hyrkäs
- Center for Nursing Research and Quality Outcomes Maine Medical Center Birmingham Alabama
| | | | - Erica R Pryor
- School of Nursing University of Alabama at Birmingham Alabama
| | - Henry E Wang
- Department of Emergency Medicine University of Alabama at Birmingham Birmingham Alabama
| | - Anne W Alexandrov
- College of Nursing University of Tennessee Health Sciences Center Memphis Tennessee
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Association between treatment at an ST-segment elevation myocardial infarction center and neurologic recovery after out-of-hospital cardiac arrest. Am Heart J 2015; 170:516-23. [PMID: 26385035 DOI: 10.1016/j.ahj.2015.05.020] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/08/2014] [Accepted: 05/29/2015] [Indexed: 02/03/2023]
Abstract
BACKGROUND For patients resuscitated from out-of-hospital cardiac arrest (OHCA), the American Heart Association recommends regionalized care at cardiac resuscitation centers that are aligned with ST-segment elevation myocardial infarction (STEMI) centers. The effectiveness of treatment at STEMI centers remains unknown. OBJECTIVE To evaluate whether good neurologic recovery after OHCA is associated with treatment at an STEMI center and if volume of admitted OHCA patients is associated with good neurologic recovery. METHODS We included patients in the 2011 California Office of Statewide Health Planning and Development database with a "present on admission" diagnosis of cardiac arrest. Primary outcome was good neurologic recovery at hospital discharge. Hierarchical multiple logistic regression models were used to determine the association between treating hospital and good neurologic recovery after adjusting for patient factors (age, sex, race, ethnicity, insurance type, and ventricular arrest rhythm) and hospital factors (hospital size, intensive care unit bed days, trauma center designation, and teaching status). RESULTS We included 7,725 patients; two-thirds (5,202) were treated at an STEMI center and 1,869 (24%, 95% CI 23%-25%) had good neurologic recovery. After adjustment, treatment at an STEMI center with ≥40 and <40 OHCA cases/year were associated with good neurologic recovery (odds ratio 1.32 [95% CI 1.06-1.64] and 1.63 [95% CI 1.35-1.97], respectively). Higher volume of admitted OHCA patients was associated with decreased odds of good neurologic recovery (adjusted odds ratio per 10 patients 0.96, 95% CI 0.92-1.00), but this association was not statistically significant after excluding the highest-volume outlier. CONCLUSIONS Treatment at an STEMI center-regardless of its annual OHCA volume-after resuscitation from OHCA is associated with good neurologic recovery. Regionalized systems of care should prioritize STEMI centers as destinations for resuscitated OHCA patients.
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Chew DP, Horsfall M, McGavigan AD, Tideman P, Vaile JC, O'Shea C, Moyes B, De Pasquale C. Condition-specific Streaming versus an Acuity-based Model of Cardiovascular Care: A Historically-controlled Quality Improvement Study Evaluating the Association with Early Clinical Events. Heart Lung Circ 2015; 25:19-28. [PMID: 26194596 DOI: 10.1016/j.hlc.2015.05.023] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2015] [Revised: 05/25/2015] [Accepted: 05/28/2015] [Indexed: 11/18/2022]
Abstract
BACKGROUND Ensuring optimal evidence translation is challenging when health-service design has not kept pace with developments in care. Differences in patient outcomes were evident when specific cardiac conditions were discordant with the subspecialty of the cardiologists managing their care. We prospectively explored the clinical and health service implications of a "condition-based" redesign in cardiac care delivery, rather than acuity-based, within a tertiary hospital. METHODS Prospective evaluation of a disease-specific streaming model of care compared to propensity-matched historical controls, among cardiac patients admitted to a tertiary hospital cardiology unit was undertaken. The outcome measures of 30-day death, and readmission for myocardial infarction, cardiac arrhythmia, and heart failure were explored. RESULTS In total, 2018 patients admitted subsequent to the implementation of the streaming model were compared with 1830 patients admitted prior. The median age was 68.9 years, and 39.5% were female. There was no significant difference in the overall proportion of patients admitted with an acute coronary syndrome, arrthythmia or heart failure, nor their Charlson index before and after streaming. Subsequent to the implementation, there was a reduction in the use of angiography (pre: 35.4% vs. post: 31.2%, p=0.007) and echocardiography (pre: 59.4% vs. post: 55.6%, p=0.007). A reduction in length of length-of-stay was observed in the entire cohort (pre: 2.7 (range: 1.2-5.0) days vs. post: 2.3 (range 1.0-4.5) days, p=0.0003). By 30 days, the propensity-adjusted hazard ratio for major adverse cardiac events and death or any cardiovascular admission was 0.76 (95% C.I. 0.59-0.97, p=0.026). CONCLUSION Cardiac service redesign that streams cardiac patients by presenting diagnosis into teams designed to treat that condition may provide capacity and productivity gains for health services striving to improve outcome and efficiency.
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Affiliation(s)
- Derek P Chew
- School of Medicine, Flinders University of South Australia, Adelaide, SA, Australia; Department of Cardiovascular Medicine, Southern Adelaide Local Health Network, Adelaide, SA, Australia; Health Systems Research, South Australian Health and Medical Research Institute, Adelaide, SA, Australia.
| | - Matthew Horsfall
- Department of Cardiovascular Medicine, Southern Adelaide Local Health Network, Adelaide, SA, Australia; Health Systems Research, South Australian Health and Medical Research Institute, Adelaide, SA, Australia
| | - Andrew D McGavigan
- School of Medicine, Flinders University of South Australia, Adelaide, SA, Australia; Department of Cardiovascular Medicine, Southern Adelaide Local Health Network, Adelaide, SA, Australia
| | - Philip Tideman
- School of Medicine, Flinders University of South Australia, Adelaide, SA, Australia; Department of Cardiovascular Medicine, Southern Adelaide Local Health Network, Adelaide, SA, Australia
| | - Julian C Vaile
- School of Medicine, Flinders University of South Australia, Adelaide, SA, Australia; Department of Cardiovascular Medicine, Southern Adelaide Local Health Network, Adelaide, SA, Australia
| | - Catherine O'Shea
- Department of Cardiovascular Medicine, Southern Adelaide Local Health Network, Adelaide, SA, Australia
| | - Belinda Moyes
- Flinders Medical Centre, Southern Adelaide Local Health Network, Adelaide, SA, Australia
| | - Carmine De Pasquale
- School of Medicine, Flinders University of South Australia, Adelaide, SA, Australia; Department of Cardiovascular Medicine, Southern Adelaide Local Health Network, Adelaide, SA, Australia
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Pathak EB, Comins MM, Forsyth CJ, Strom JA. Routine diversion of patients with STEMI to high-volume PCI centres: modelling the financial impact on referral hospitals. Open Heart 2015. [PMID: 26196014 PMCID: PMC4488887 DOI: 10.1136/openhrt-2014-000042] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
OBJECTIVE To quantify possible revenue losses from proposed ST-elevation myocardial infarction (STEMI) patient diversion policies for small hospitals that lack high-volume percutaneous coronary intervention (PCI) capability status (ie, 'STEMI referral hospitals'). BACKGROUND Negative financial impacts on STEMI referral hospitals have been discussed as an important barrier to implementing regional STEMI bypass/transfer protocols. However, there is little empirical data available that directly quantifies this potential financial impact. METHODS Using detailed financial charges from Florida hospital discharge data, we examined the potential negative financial impact on 112 STEMI referral hospitals from losing all inpatient STEMI revenue. The main outcome was projected revenue loss (PRL), defined as total annual patient with STEMI charges as a proportion of total annual charges for all patients. We hypothesised that for most community hospitals (>90%), STEMI revenue represented only a small fraction of total revenue (<1%). We further examined the financial impact of the 'worst case' scenario of loss of all acute coronary syndrome (ACS) (ie, chest pain) patients. RESULTS PRLs were $0.33 for every $100 of patient revenue statewide for STEMI and $1.73 for ACS. At the individual hospital level, the 90th centile PRL was $0.74 for STEMI and $2.77 for ACS. PRLs for STEMI were not greater in rural areas compared with major metropolitan areas. Hospital revenue centres that would be most impacted by loss of patients with STEMI were cardiology procedures and intensive care units. CONCLUSIONS Loss of patient with STEMI revenues would result in only a small financial impact on STEMI referral hospitals in Florida under proposed STEMI diversion/rapid transfer protocols. However, spillover loss of patients with ACS would increase revenue loss for many hospitals.
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Affiliation(s)
| | - Meg M Comins
- Department of Health Policy and Management , University of South Florida , Tampa, Florida , USA
| | - Colin J Forsyth
- Department of Anthropology , University of South Florida , Tampa, Florida , USA
| | - Joel A Strom
- Department of Medicine , University of Florida College of Medicine , Jacksonville, Florida , USA
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Hsia RY, Shen YC. Percutaneous Coronary Intervention in the United States: Risk Factors for Untimely Access. Health Serv Res 2015; 51:592-609. [PMID: 26174998 DOI: 10.1111/1475-6773.12335] [Citation(s) in RCA: 39] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022] Open
Abstract
OBJECTIVE To determine how access to percutaneous coronary intervention (PCI) is distributed across demographics. DATA SOURCES Secondary data from the 2011 American Hospital Association (AHA) survey data combined with 2010 Census. STUDY DESIGN We calculated prehospital times from 32,370 ZIP codes to the nearest PCI center. We used a multivariate logit model to determine the odds of untimely access by the ZIP code's concentration of vulnerable populations. DATA COLLECTION We used ZIP code-level data on community characteristics from the 2010 Census and supplemented it with 2011 AHA survey data on service-line availability of PCI for responding hospitals. PRINCIPAL FINDINGS For approximately 306 million Americans, the median prehospital time to the nearest PCI center is 33 minutes. While 84 percent of Americans live within one hour of a PCI center, the odds of untimely access are higher in low-income (OR: 3.00; 95 percent CI: 2.39, 3.77), rural (8.10; 95 percent CI: 6.84, 9.59), and highly Hispanic communities (2.55; 95 percent CI: 1.86, 3.49). CONCLUSIONS While the majority of Americans live within 60 minutes of a PCI center, rural, low-income, and highly Hispanic communities have worse PCI access. This may translate into worse outcomes for patients with acute myocardial infarction.
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Affiliation(s)
- Renee Y Hsia
- Department of Emergency Medicine and Philip R. Lee Institute for Health Policy Studies, University of California, San Francisco, CA
| | - Yu-Chu Shen
- Naval Postgraduate School, Monterey, CA.,National Bureau of Economic Research, Cambridge, MA
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Vemulapalli S, Patel MR, Jones WS. Limb Ischemia: Cardiovascular Diagnosis and Management from Head to Toe. Curr Cardiol Rep 2015; 17:611. [DOI: 10.1007/s11886-015-0611-y] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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83
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D'Onofrio G, Safdar B, Lichtman JH, Strait KM, Dreyer RP, Geda M, Spertus JA, Krumholz HM. Sex differences in reperfusion in young patients with ST-segment-elevation myocardial infarction: results from the VIRGO study. Circulation 2015; 131:1324-32. [PMID: 25792558 DOI: 10.1161/circulationaha.114.012293] [Citation(s) in RCA: 175] [Impact Index Per Article: 19.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/14/2014] [Accepted: 01/26/2015] [Indexed: 01/27/2023]
Abstract
BACKGROUND Sex disparities in reperfusion therapy for patients with acute ST-segment-elevation myocardial infarction have been documented. However, little is known about whether these patterns exist in the comparison of young women with men. METHODS AND RESULTS We examined sex differences in rates, types of reperfusion therapy, and proportion of patients exceeding American Heart Association reperfusion time guidelines for ST-segment-elevation myocardial infarction in a prospective observational cohort study (2008-2012) of 1465 patients 18 to 55 years of age, as part of the US Variations in Recovery: Role of Gender on Outcomes of Young AMI Patients (VIRGO) study at 103 hospitals enrolling in a 2:1 ratio of women to men. Of the 1238 patients eligible for reperfusion, women were more likely to be untreated than men (9% versus 4%, P=0.002). There was no difference in reperfusion strategy for the 695 women and 458 men treated. Women were more likely to exceed in-hospital and transfer time guidelines for percutaneous coronary intervention than men (41% versus 29%; odds ratio, 1.65; 95% confidence interval, 1.27-2.16), more so when transferred (67% versus 44%; odds ratio, 2.63; 95% confidence interval, 1.17-4.07); and more likely to exceed door-to-needle times (67% versus 37%; odds ratio, 2.62; 95% confidence interval, 1.23-2.18). After adjustment for sociodemographic, clinical, and organizational factors, sex remained an important factor in exceeding reperfusion guidelines (odds ratio, 1.72; 95% confidence interval, 1.28-2.33). CONCLUSIONS Young women with ST-segment-elevation myocardial infarction are less likely to receive reperfusion therapy and more likely to have reperfusion delays than similarly aged men. Sex disparities are more pronounced among patients transferred to percutaneous coronary intervention institutions or who received fibrinolytic therapy.
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Affiliation(s)
- Gail D'Onofrio
- From Department of Emergency Medicine (G.D., B.S.) and Department of Medicine (R.P.D., H.M.K.), Yale University School of Medicine, New Haven, CT; Yale School of Public Health, New Haven, CT (J.H.L., H.M.K.); The Center for Outcomes Research and Evaluation, Yale-New Haven Hospital, New Haven, CT (K.M.S., R.P.D., M.G., H.M.K.); Saint Luke's Mid America Heart Institute and the University of Missouri, Kansas City (J.A.S.); and Center of Cardiovascular Medicine, Yale University School of Medicine, New Haven, CT (H.M.K.).
| | - Basmah Safdar
- From Department of Emergency Medicine (G.D., B.S.) and Department of Medicine (R.P.D., H.M.K.), Yale University School of Medicine, New Haven, CT; Yale School of Public Health, New Haven, CT (J.H.L., H.M.K.); The Center for Outcomes Research and Evaluation, Yale-New Haven Hospital, New Haven, CT (K.M.S., R.P.D., M.G., H.M.K.); Saint Luke's Mid America Heart Institute and the University of Missouri, Kansas City (J.A.S.); and Center of Cardiovascular Medicine, Yale University School of Medicine, New Haven, CT (H.M.K.)
| | - Judith H Lichtman
- From Department of Emergency Medicine (G.D., B.S.) and Department of Medicine (R.P.D., H.M.K.), Yale University School of Medicine, New Haven, CT; Yale School of Public Health, New Haven, CT (J.H.L., H.M.K.); The Center for Outcomes Research and Evaluation, Yale-New Haven Hospital, New Haven, CT (K.M.S., R.P.D., M.G., H.M.K.); Saint Luke's Mid America Heart Institute and the University of Missouri, Kansas City (J.A.S.); and Center of Cardiovascular Medicine, Yale University School of Medicine, New Haven, CT (H.M.K.)
| | - Kelly M Strait
- From Department of Emergency Medicine (G.D., B.S.) and Department of Medicine (R.P.D., H.M.K.), Yale University School of Medicine, New Haven, CT; Yale School of Public Health, New Haven, CT (J.H.L., H.M.K.); The Center for Outcomes Research and Evaluation, Yale-New Haven Hospital, New Haven, CT (K.M.S., R.P.D., M.G., H.M.K.); Saint Luke's Mid America Heart Institute and the University of Missouri, Kansas City (J.A.S.); and Center of Cardiovascular Medicine, Yale University School of Medicine, New Haven, CT (H.M.K.)
| | - Rachel P Dreyer
- From Department of Emergency Medicine (G.D., B.S.) and Department of Medicine (R.P.D., H.M.K.), Yale University School of Medicine, New Haven, CT; Yale School of Public Health, New Haven, CT (J.H.L., H.M.K.); The Center for Outcomes Research and Evaluation, Yale-New Haven Hospital, New Haven, CT (K.M.S., R.P.D., M.G., H.M.K.); Saint Luke's Mid America Heart Institute and the University of Missouri, Kansas City (J.A.S.); and Center of Cardiovascular Medicine, Yale University School of Medicine, New Haven, CT (H.M.K.)
| | - Mary Geda
- From Department of Emergency Medicine (G.D., B.S.) and Department of Medicine (R.P.D., H.M.K.), Yale University School of Medicine, New Haven, CT; Yale School of Public Health, New Haven, CT (J.H.L., H.M.K.); The Center for Outcomes Research and Evaluation, Yale-New Haven Hospital, New Haven, CT (K.M.S., R.P.D., M.G., H.M.K.); Saint Luke's Mid America Heart Institute and the University of Missouri, Kansas City (J.A.S.); and Center of Cardiovascular Medicine, Yale University School of Medicine, New Haven, CT (H.M.K.)
| | - John A Spertus
- From Department of Emergency Medicine (G.D., B.S.) and Department of Medicine (R.P.D., H.M.K.), Yale University School of Medicine, New Haven, CT; Yale School of Public Health, New Haven, CT (J.H.L., H.M.K.); The Center for Outcomes Research and Evaluation, Yale-New Haven Hospital, New Haven, CT (K.M.S., R.P.D., M.G., H.M.K.); Saint Luke's Mid America Heart Institute and the University of Missouri, Kansas City (J.A.S.); and Center of Cardiovascular Medicine, Yale University School of Medicine, New Haven, CT (H.M.K.)
| | - Harlan M Krumholz
- From Department of Emergency Medicine (G.D., B.S.) and Department of Medicine (R.P.D., H.M.K.), Yale University School of Medicine, New Haven, CT; Yale School of Public Health, New Haven, CT (J.H.L., H.M.K.); The Center for Outcomes Research and Evaluation, Yale-New Haven Hospital, New Haven, CT (K.M.S., R.P.D., M.G., H.M.K.); Saint Luke's Mid America Heart Institute and the University of Missouri, Kansas City (J.A.S.); and Center of Cardiovascular Medicine, Yale University School of Medicine, New Haven, CT (H.M.K.)
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84
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Lower mortality with pre-hospital electrocardiogram triage by telemedicine support in high risk acute myocardial infarction treated with primary angioplasty: Preliminary data from the Bari-BAT public Emergency Medical Service 118 registry. Int J Cardiol 2015; 185:224-8. [PMID: 25797682 DOI: 10.1016/j.ijcard.2015.03.138] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/02/2015] [Accepted: 03/07/2015] [Indexed: 11/23/2022]
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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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Nguyen B, Fennessy M, Leya F, Nowak W, Ryan M, Freeberg S, Gill J, Dieter RS, Steen L, Lewis B, Cichon M, Probst B, Jarotkiewicz M, Wilber D, Lopez JJ. Comparison of primary percutaneous coronary intervention in patients with ST-elevation myocardial infarction during and prior to availability of an in-house STEMI system: early experience and intermediate outcomes of the HARRT program for achieving routine D2B times <60 minutes. Catheter Cardiovasc Interv 2015; 86:186-96. [PMID: 25504976 DOI: 10.1002/ccd.25769] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/24/2014] [Accepted: 12/06/2014] [Indexed: 11/09/2022]
Abstract
BACKGROUND Over the last decade, significant advances in ST-elevation myocardial infarction (STEMI) workflow have resulted in most hospitals reporting door-to-balloon (D2B) times within the 90 min standard. Few programs have been enacted to systematically attempt to achieve routine D2B within 60 min. We sought to determine whether 24-hr in-house catheterization laboratory coverage via an In-House Interventional Team Program (IHIT) could achieve D2B times below 60 min for STEMI and to compare the results to the standard primary percutaneous coronary intervention (PCI) approach. METHODS An IHIT program was established consisting of an attending interventional cardiologist, and a catheterization laboratory team present in-hospital 24 hr/day. For all consecutive STEMI patients, we compared the standard primary PCI approach during the two years prior to the program (group A) to the initial 20 months of the IHIT program (group B), and repeated this analysis for only CMS-reportable patients. The D2B process was analyzed by calculating workflow intervals. The primary endpoint was D2B process times, and secondary endpoints included in-hospital and 6-month cardiovascular outcomes and resource utilization. RESULTS An IHIT program for STEMI resulted in significant reductions across all treatment intervals with an overall 57% reduction in D2B time, and an absolute reduction in mean D2B time of 71 min. There were no differences pre- and post-program implementation in regard to individual or composite components of in-hospital cardiovascular outcomes; however at 6 months, there was a reduction in cardiovascular rehospitalization after program implementation (30 vs. 5%, P < 0.01). The IHIT program resulted in a significant reduction in length-of-stay (LOS) (90 ± 102 vs. 197 ± 303 hr, P = 0.02), and critical care time (54 ± 97 vs. 149 ± 299 hr, P = 0.02). CONCLUSIONS Availability of an in-house 24-hr STEMI team significantly decreased reperfusion time and led to improved clinical outcomes and a shorter LOS for PCI-treated STEMI patients.
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Affiliation(s)
- Bryant Nguyen
- Division of Cardiology, Department of Medicine, Loyola University Medical Center, Stritch School of Medicine, Maywood, Illinois
| | - Michelle Fennessy
- Division of Cardiology, Department of Medicine, Loyola University Medical Center, Stritch School of Medicine, Maywood, Illinois
| | - Ferdinand Leya
- Division of Cardiology, Department of Medicine, Loyola University Medical Center, Stritch School of Medicine, Maywood, Illinois
| | - Wojciech Nowak
- Division of Cardiology, Department of Medicine, Loyola University Medical Center, Stritch School of Medicine, Maywood, Illinois
| | - Michael Ryan
- Division of Cardiology, Department of Medicine, Loyola University Medical Center, Stritch School of Medicine, Maywood, Illinois
| | - Sheldon Freeberg
- Division of Cardiology, Department of Medicine, Loyola University Medical Center, Stritch School of Medicine, Maywood, Illinois
| | - Jasrai Gill
- Division of Cardiology, Department of Medicine, Loyola University Medical Center, Stritch School of Medicine, Maywood, Illinois
| | - Robert S Dieter
- Division of Cardiology, Department of Medicine, Loyola University Medical Center, Stritch School of Medicine, Maywood, Illinois
| | - Lowell Steen
- Division of Cardiology, Department of Medicine, Loyola University Medical Center, Stritch School of Medicine, Maywood, Illinois
| | - Bruce Lewis
- Division of Cardiology, Department of Medicine, Loyola University Medical Center, Stritch School of Medicine, Maywood, Illinois
| | - Mark Cichon
- Division of Cardiology, Department of Medicine, Loyola University Medical Center, Stritch School of Medicine, Maywood, Illinois
| | - Beatrice Probst
- Division of Cardiology, Department of Medicine, Loyola University Medical Center, Stritch School of Medicine, Maywood, Illinois
| | - Michael Jarotkiewicz
- Division of Cardiology, Department of Medicine, Loyola University Medical Center, Stritch School of Medicine, Maywood, Illinois
| | - David Wilber
- Division of Cardiology, Department of Medicine, Loyola University Medical Center, Stritch School of Medicine, Maywood, Illinois
| | - John J Lopez
- Division of Cardiology, Department of Medicine, Loyola University Medical Center, Stritch School of Medicine, Maywood, Illinois
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Telemedicine for cardiovascular disease continuum: A position paper from the Italian Society of Cardiology Working Group on Telecardiology and Informatics. Int J Cardiol 2015; 184:452-458. [PMID: 25755064 DOI: 10.1016/j.ijcard.2015.02.023] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/16/2014] [Revised: 02/02/2015] [Accepted: 02/21/2015] [Indexed: 11/20/2022]
Abstract
Telemedicine is the provision of health care services, through the use of information and communication technology, in situations where the health care professional and the patient, or 2 health care professionals, are not in the same location. It involves the secure transmission of medical data and information, through text, sound, images, or other forms needed for the prevention, diagnosis, treatment, and follow-up of a patient. First data on implementation of telemedicine for the diagnosis and treatment of acute myocardial infarction date from more than 10 years ago. Telemedicine has a potential broad application to the cardiovascular disease continuum and in many branches of cardiology, at least including heart failure, ischemic heart disease and arrhythmias. Telemedicine might have an important role as part of a strategy for the delivery of effective health care for patients with cardiovascular disease. In this document the Working Group on Telecardiology and Informatics of the Italian Society of Cardiology intends to remark some key-points regarding potential benefit achievable with the implementation of telemedicine support in the continuum of cardiovascular disease.
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Kindermann DR, Mutter RL, Houchens RL, Barrett ML, Pines JM. Emergency department transfers and transfer relationships in United States hospitals. Acad Emerg Med 2015; 22:157-65. [PMID: 25640281 DOI: 10.1111/acem.12586] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2014] [Revised: 09/25/2014] [Accepted: 09/29/2014] [Indexed: 11/29/2022]
Abstract
OBJECTIVES The objective was to describe transfers out of hospital-based emergency departments (EDs) in the United States and to identify different characteristics of sending and receiving hospitals, travel distance during transfer, disposition on arrival to the second hospital, and median number of transfer partners among sending hospitals. METHODS Emergency department records were linked at transferring hospitals to ED and inpatient records at receiving hospitals in nine U.S. states using the 2010 Healthcare Cost and Utilization Project (HCUP) State Emergency Department Databases and State Inpatient Databases, the American Hospital Association Annual Survey, and the Trauma Information Exchange Program. Using the Clinical Classification Software (CCS) to categorize conditions, the 50 disease categories with the highest transfer rates were studied, and these were then placed into nine clinical groups. Records were included where both sending and receiving records were available; these data were tabulated to describe ED transfer patterns, hospital-to-hospital distances, final patient disposition, and number of transfer partners. RESULTS A total of 97,021 ED transfer encounters were included in the analysis from the 50 highest transfer rate disease categories. Among these, transfer rates ranged from 1% to 13%. Circulatory conditions made up about half of all transfers. Receiving hospitals were more likely to be nonprofit, teaching, trauma, and urban and have more beds with greater specialty coverage and more advanced diagnostic and therapeutic resources. The median transfer distance was 23 miles, with 25% traveling more than 40 to 50 miles. About 8% of transferred encounters were discharged from the second ED, but that varied from 0.6% to 53% across the 50 conditions. Sending hospitals had a median of seven transfer partners across all conditions and between one and four per clinical group. CONCLUSIONS Among high-transfer conditions in U.S. EDs, patients are often transferred great distances, more commonly to large teaching hospitals with greater resources. The large number of transfer partners indicates a possible lack of stable transfer relationships between U.S. hospitals.
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Affiliation(s)
- Dana R. Kindermann
- Department of Emergency Medicine; The Permanente Medical Group; Oakland CA
| | - Ryan L. Mutter
- Agency for Healthcare Research and Quality; Rockville MD
| | | | | | - Jesse M. Pines
- Departments of Emergency Medicine and Health Policy; George Washington University; Washington DC
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Kindermann DR, Mutter RL, Houchens RL, Barrett ML, Pines JM. The transfer instability index: a novel metric of emergency department transfer relationships. Acad Emerg Med 2015; 22:166-71. [PMID: 25640740 DOI: 10.1111/acem.12589] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2014] [Revised: 09/25/2014] [Accepted: 09/29/2014] [Indexed: 11/30/2022]
Abstract
OBJECTIVES In this study, the objective was to characterize emergency department (ED) transfer relationships and study the factors that predict the stability of those relationships. A metric is derived for ED transfer relationships that may be useful in assessing emergency care regionalization and as a resource for future emergency medicine research. METHODS Emergency department records at transferring hospitals were linked to ED and inpatient records at receiving hospitals in nine U.S. states using the 2010 Healthcare Cost and Utilization Project State Emergency Department Databases and State Inpatient Databases, the American Hospital Association Annual Survey, and the Trauma Information Exchange Program. Using the Clinical Classification Software to categorize conditions, high transfer rate conditions were placed into nine clinical groups. The authors created a new measure, the "transfer instability index," which estimates the effective number of "transfer partners" for each sending ED: this is designed to measure the stability of outgoing transfer relationships, where higher values of the index indicate less stable relationships. The index provides a measure of how many hospitals a transferring hospital sends its patients to (weighted by how often each transfer partner is used). Regression was used to analyze factors associated with higher values of the index. RESULTS Sending hospitals had a median of 3.5 effective transfer partners across all conditions. The calculated transfer instability indices varied from 1 to 2.4 across disease categories. In general, higher index values were associated with treating a higher proportion of publicly insured patients: 10 and 12% increases in the Medicare and Medicaid share of ED encounters, respectively, were associated with 10 and 14% increases in the effective number of transfer partners. This public insurance effect held while studying all conditions together as well as within individual disease categories, such as cardiac, neurologic, and traumatic conditions. CONCLUSIONS United States EDs that transfer patients to other hospitals often have multiple transfer partners. The stability of the transfer relationship, assessed by the transfer instability index, differs by condition. Less stable transfer relationships (i.e., hospitals with greater numbers of transfer partners) were more common in EDs with higher proportions of publicly insured patients.
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Affiliation(s)
- Dana R. Kindermann
- Department of Emergency Medicine; The Permanente Medical Group; Oakland CA
| | - Ryan L. Mutter
- Agency for Healthcare Research and Quality; Rockville MD
| | | | | | - Jesse M. Pines
- Departments of Emergency Medicine and Health Policy; George Washington University; Washington DC
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Mercuri M, Welsford M, Schwalm JD, Mehta SR, Rao-Melacini P, Sheth T, Rokoss M, Jolly SS, Velianou JL, Natarajan MK. Providing optimal regional care for ST-segment elevation myocardial infarction: a prospective cohort study of patients in the Hamilton Niagara Haldimand Brant Local Health Integration Network. CMAJ Open 2015; 3:E1-7. [PMID: 25844361 PMCID: PMC4382034 DOI: 10.9778/cmajo.20140035] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023] Open
Abstract
BACKGROUND Although considered the evidence-based best therapy for ST-segment elevation myocardial infarction (STEMI), many patients do not receive primary percutaneous coronary intervention (PCI) because of health care resource distribution and constraints. This study describes the clinical management and outcomes of all patients identified with STEMI within a region, including those who did not receive primary PCI. METHODS This study used a prospective cohort design. Patients presenting with STEMI to PCI- and non-PCI-capable hospitals in one integrated health region in Ontario were included in the study. The primary objective was to examine use of reperfusion strategies and timeliness of care. Secondary objectives included determining (through regression models) which variables were associated with mortality within 90 days, and describing patient uptake of risk-reducing therapies and activities post-STEMI. RESULTS Between Apr. 1, 2010, and Mar. 31, 2013, data were collected on 2247 consecutive patients presenting with STEMI. Patients presenting to the PCI-capable hospital were more likely to receive primary PCI (82.5% v. 65.2%, p < 0.001) and be treated within optimal treatment times. However, there was no appreciable difference in mortality at 90 days post-STEMI between patients presenting to PCI- and non-PCI-capable hospitals (7.8% v. 7.5%, p = 0.82), even after adjustment for acuity on presentation. Despite recognized risk factors, many patients were not taking evidence-based medications for risk factor modification before STEMI. INTERPRETATION A systematic approach to regional STEMI care focusing on timely access to the best available therapies, rather than the type of reperfusion provided alone, can yield favourable outcomes.
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Affiliation(s)
- Mathew Mercuri
- Department of Medicine, Division of Cardiology, Columbia University, New York ; Department of Medicine, Division of Cardiology, McMaster University, Hamilton, Ont
| | - Michelle Welsford
- Department of Medicine, Division of Emergency Medicine, McMaster University, Hamilton, Ont. ; Hamilton Health Sciences, Hamilton Ontario, Hamilton, Ont
| | - Jon-David Schwalm
- Department of Medicine, Division of Cardiology, McMaster University, Hamilton, Ont. ; Hamilton Health Sciences, Hamilton Ontario, Hamilton, Ont. ; Population Health Research Institute, Hamilton, Ont
| | - Shamir R Mehta
- Department of Medicine, Division of Cardiology, McMaster University, Hamilton, Ont. ; Hamilton Health Sciences, Hamilton Ontario, Hamilton, Ont. ; Population Health Research Institute, Hamilton, Ont
| | | | - Tej Sheth
- Department of Medicine, Division of Cardiology, McMaster University, Hamilton, Ont. ; Hamilton Health Sciences, Hamilton Ontario, Hamilton, Ont. ; Population Health Research Institute, Hamilton, Ont
| | - Michael Rokoss
- Department of Medicine, Division of Cardiology, McMaster University, Hamilton, Ont. ; Hamilton Health Sciences, Hamilton Ontario, Hamilton, Ont
| | - Sanjit S Jolly
- Department of Medicine, Division of Cardiology, McMaster University, Hamilton, Ont. ; Hamilton Health Sciences, Hamilton Ontario, Hamilton, Ont. ; Population Health Research Institute, Hamilton, Ont
| | - James L Velianou
- Department of Medicine, Division of Cardiology, McMaster University, Hamilton, Ont. ; Hamilton Health Sciences, Hamilton Ontario, Hamilton, Ont
| | - Madhu K Natarajan
- Department of Medicine, Division of Cardiology, McMaster University, Hamilton, Ont. ; Hamilton Health Sciences, Hamilton Ontario, Hamilton, Ont. ; Population Health Research Institute, Hamilton, Ont
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Lan KC, Chen SJ, Lai KC, Shih FY, Chuang YP, Mao YC, Liao WI, Yang PL. Electronic Referral System for Transferred Patients with Acute Myocardial Infarction. JOURNAL OF MEDICAL SCIENCES 2015. [DOI: 10.4103/1011-4564.173003] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
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Kaul P, Federspiel JJ, Dai X, Stearns SC, Smith SC, Yeung M, Beyhaghi H, Zhou L, Stouffer GA. Association of inpatient vs outpatient onset of ST-elevation myocardial infarction with treatment and clinical outcomes. JAMA 2014; 312:1999-2007. [PMID: 25399275 PMCID: PMC4266685 DOI: 10.1001/jama.2014.15236] [Citation(s) in RCA: 37] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/16/2023]
Abstract
IMPORTANCE Reperfusion times for ST-elevation myocardial infarction (STEMI) occurring in outpatients have improved significantly, but quality improvement efforts have largely ignored STEMI occurring in hospitalized patients (inpatient-onset STEMI). OBJECTIVE To define the incidence and variables associated with treatment and outcomes of patients who develop STEMI during hospitalization for conditions other than acute coronary syndromes (ACS). DESIGN, SETTING, AND PARTICIPANTS Retrospective observational analysis of STEMIs occurring between 2008 and 2011 as identified in the California State Inpatient Database. EXPOSURES STEMIs were classified as inpatient onset or outpatient onset based on present-on-admission codes. Patients who had a STEMI after being hospitalized for ACS were excluded from the analysis. MAIN OUTCOMES AND MEASURES Regression models were used to evaluate associations among location of onset of STEMI, resource utilization, and outcomes. Adjustments were made for patient age, sex, comorbidities, and hospital characteristics. The analysis allowed for the location of inpatient STEMI to have a multiplicative rather than an additive effect for resource utilization since these measures were highly skewed. RESULTS A total of 62,021 STEMIs were identified in 303 hospitals, of which 3068 (4.9%) occurred in patients hospitalized for non-ACS indications. Patients with inpatient-onset STEMI were older (mean, 71.5 [SD, 13.5] years vs 64.9 [SD, 14.1] years; P < .001) and more frequently female (47.4% vs 32%; P < .001) than those with outpatient-onset STEMI. Patients with inpatient-onset STEMI had higher in-hospital mortality (33.6% vs 9.2%; adjusted odds ratio (AOR), 3.05; 95% CI, 2.76-3.38; P < .001), were less likely to be discharged home (33.7% vs 69.4%; AOR, 0.38; 95% CI, 0.34-0.42; P < .001), and were less likely to undergo cardiac catheterization (33.8% vs 77.8%; AOR, 0.19; 95% CI, 0.16-0.21; P < .001) or percutaneous coronary intervention (21.6% vs 65%; AOR, 0.23; 95% CI, 0.21-0.26; P < .001). Length of stay and inpatient charges were higher for inpatient-onset STEMI (mean length of stay, 13.4 days [95% CI, 12.8-14.0 days] vs 4.7 days [95% CI, 4.6-4.8 days]; adjusted multiplicative effect, 2.51; 95% CI, 2.35-2.69; P < .001; mean inpatient charges, $245,000 [95% CI, $235,300-$254,800] vs $129,000 [95% CI, $127,900-$130,100]; adjusted multiplicative effect, 2.09; 95% CI, 1.93-2.28; P < .001). CONCLUSIONS AND RELEVANCE Patients who had a STEMI while hospitalized for a non-ACS condition, compared with those with onset of STEMI as an outpatient, were less likely to undergo invasive testing or intervention and had a higher in-hospital mortality rate.
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Affiliation(s)
- Prashant Kaul
- Division of Cardiology, University of North Carolina, Chapel Hill, NC
| | - Jerome J. Federspiel
- Department of Health Policy and Management, UNC Gillings School of Global Public Health, University of North Carolina, Chapel Hill, NC
- Sheps Center for Health Services Research, University of North Carolina, Chapel Hill, NC
| | - Xuming Dai
- Division of Cardiology, University of North Carolina, Chapel Hill, NC
| | - Sally C. Stearns
- Department of Health Policy and Management, UNC Gillings School of Global Public Health, University of North Carolina, Chapel Hill, NC
- Sheps Center for Health Services Research, University of North Carolina, Chapel Hill, NC
| | - Sidney C. Smith
- Division of Cardiology, University of North Carolina, Chapel Hill, NC
| | - Michael Yeung
- Division of Cardiology, University of North Carolina, Chapel Hill, NC
| | - Hadi Beyhaghi
- Department of Health Policy and Management, UNC Gillings School of Global Public Health, University of North Carolina, Chapel Hill, NC
| | - Lei Zhou
- Department of Health Policy and Management, UNC Gillings School of Global Public Health, University of North Carolina, Chapel Hill, NC
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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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94
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Sinnaeve PR, Zeymer U, Bueno H, Danchin N, Medina J, Sánchez-Covisa J, Licour M, Annemans L, Jukema JW, Pocock S, Storey RF, Van de Werf F. Contemporary inter-hospital transfer patterns for the management of acute coronary syndrome patients: Findings from the EPICOR study. EUROPEAN HEART JOURNAL-ACUTE CARDIOVASCULAR CARE 2014; 4:254-62. [DOI: 10.1177/2048872614551544] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/08/2014] [Accepted: 08/26/2014] [Indexed: 11/17/2022]
Affiliation(s)
| | - Uwe Zeymer
- Institut für Herzinfarktforschung Ludwigshafen, Germany
| | - Héctor Bueno
- Hospital General Universitario Gregorio Marañón, Madrid, Spain
| | - Nicolas Danchin
- Hôpital Européen Georges Pompidou and René Descartes University, Paris, France
| | - Jesús Medina
- Medical Evidence Centre AstraZeneca, Madrid, Spain
| | | | - Muriel Licour
- Medical Department, AstraZeneca France, Rueil-Malmaison, France
| | - Lieven Annemans
- I-CHER (Interuniversity Centre for Health Economics Research) UGent, VUB, Belgium
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95
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Sardi GL, Loh JP, Torguson R, Satler LF, Waksman R. Real-time, two-way interaction during ST-segment elevation myocardial infarction management improves door-to-balloon times. CARDIOVASCULAR REVASCULARIZATION MEDICINE 2014; 15:263-8. [PMID: 25178666 DOI: 10.1016/j.carrev.2014.05.005] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2014] [Accepted: 05/14/2014] [Indexed: 11/25/2022]
Abstract
OBJECTIVES The study aimed to determine if utilization of the CodeHeart application (CHap) reduces door-to-balloon (DTB) times of ST-segment elevation myocardial infarction (STEMI) patients. BACKGROUND A pre-hospital electrocardiogram improves the management of patients with STEMI. Current telecommunication systems do not permit real-time interaction with the initial care providers. Our institution developed a novel telecommunications system based on a software application that permits real-time, two-way video and voice interaction over a secured network. METHODS All STEMI system activations after implementation of the CHap were prospectively entered into a database. Consecutive CHap activations were compared to routine activations as controls, during the same time period. RESULTS A total of 470 STEMI system activations occurred; CHap was used in 83 cases (17.7%). DTB time was reduced by the use of CHap when compared to controls (CHap 103 minutes, 95% CI [87.0-118.3] vs. standard 149 minutes, 95% CI [134.0-164.8], p<0.0001), as was first call-to-balloon time (CHap 70 minutes, 95% CI [60.8-79.5] vs. standard 92 minutes, 95% CI [85.8-98.9], p=0.0002). The percentage of 'true positive' catheterization laboratory activations was nominally higher with the use of CHap, although this did not reach statistical significance [CHap 47/83 (56.6%) vs. routine 178/387 (45.9%), p=0.103]. CONCLUSION The implementation of a two-way telecommunications system allowing real-time interactions between interventional cardiologists and referring practitioners improves overall DTB time. In addition, it has the potential to decrease the frequency of false activations, thereby improving the cost efficiency of a network's STEMI system.
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Affiliation(s)
- Gabriel L Sardi
- Interventional Cardiology, MedStar Washington Hospital Center, Washington, DC
| | - Joshua P Loh
- Interventional Cardiology, MedStar Washington Hospital Center, Washington, DC
| | - Rebecca Torguson
- Interventional Cardiology, MedStar Washington Hospital Center, Washington, DC
| | - Lowell F Satler
- Interventional Cardiology, MedStar Washington Hospital Center, Washington, DC
| | - Ron Waksman
- Interventional Cardiology, MedStar Washington Hospital Center, Washington, DC.
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96
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Brunetti ND, Di Pietro G, Aquilino A, Bruno AI, Dellegrottaglie G, Di Giuseppe G, Lopriore C, De Gennaro L, Lanzone S, Caldarola P, Antonelli G, Di Biase M. Pre-hospital electrocardiogram triage with tele-cardiology support is associated with shorter time-to-balloon and higher rates of timely reperfusion even in rural areas: data from the Bari- Barletta/Andria/Trani public emergency medical service 118 registry on primary angioplasty in ST-elevation myocardial infarction. EUROPEAN HEART JOURNAL: ACUTE CARDIOVASCULAR CARE 2014; 3:204-213. [DOI: 10.1177/2048872614527009] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 08/30/2023]
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97
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Brunetti ND, Dellegrottaglie G, Di Giuseppe G, Di Biase M. Remote tele-medicine cardiologist support for care manager nursing of chronic cardiovascular disease: preliminary report. Int J Cardiol 2014; 176:552-6. [DOI: 10.1016/j.ijcard.2014.07.020] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/11/2014] [Accepted: 07/05/2014] [Indexed: 11/26/2022]
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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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99
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Danchin N, Dos Santos Teixeira N, Puymirat E. Limitaciones de los programas regionales de angioplastia coronaria primaria: ¿la estrategia farmacoinvasiva todavía es una alternativa? Rev Esp Cardiol 2014. [DOI: 10.1016/j.recesp.2014.04.006] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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100
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Weaknesses in regional primary coronary angioplasty programs: is there still a role for a pharmaco-invasive approach? ACTA ACUST UNITED AC 2014; 67:659-65. [PMID: 25037545 DOI: 10.1016/j.rec.2014.04.004] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2014] [Accepted: 04/01/2014] [Indexed: 11/27/2022]
Abstract
All guidelines recommend primary percutaneous coronary intervention as the default strategy for achieving reperfusion in ST-segment elevation myocardial infarction patients. These recommendations are based upon randomized trials which compared primary percutaneous coronary intervention with stand-alone intravenous fibrinolysis. Since the time these trials were performed, however, it has been shown in further trials that use of rescue percutaneous coronary intervention in patients without signs of reperfusion after lysis, and routine coronary angiography within 24 h of the administration of lysis for all other patients, substantially improved the results of intravenous fibrinolytic treatment. This has led to proposing the pharmaco-invasive strategy as an alternative to primary percutaneous coronary intervention. Actually, it is not uncommon that circumstances prevent performing primary percutaneous coronary intervention within the recommended time limits set by the guidelines. In such cases, using a pharmaco-invasive strategy may constitute a valid alternative. Both the STREAM randomized trial and real-world experience, in particular the long-term results from the FAST-MI registry, suggest that the pharmaco-invasive strategy, when used in an appropriate population, compares favorably with primary percutaneous coronary intervention. Therefore, implementing a pharmaco-invasive strategy protocol may be an important complement to compensate for potential weaknesses in ST-segment elevation myocardial infarction networks.
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