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García-García C, Ribas N, Recasens LL, Meroño O, Subirana I, Fernández A, Pérez A, Miranda F, Tizón-Marcos H, Martí-Almor J, Bruguera J, Elosua R. In-hospital prognosis and long-term mortality of STEMI in a reperfusion network. "Head to head" analisys: invasive reperfusion vs optimal medical therapy. BMC Cardiovasc Disord 2017; 17:139. [PMID: 28549452 PMCID: PMC5446735 DOI: 10.1186/s12872-017-0574-6] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2017] [Accepted: 05/18/2017] [Indexed: 01/15/2023] Open
Abstract
Background ST Segment Elevation Acute myocardial infarction (STEMI) preferred treatment is culprit artery reperfusion with primary percutaneous coronary intervention (PPCI). We ought to analyze the benefit of early reperfusion vs. optimal medical therapy in STEMI before and after the set-up of a regional STEMI network that prioritizes PPCI. Methods Between January 2002 and December 2013, 1268 STEMI patients were consecutively admitted in a University Hospital. Patients were classified in two groups: pre-STEMI Network (January 2002–June 2009; n = 670) and post-STEMI network (July 2009–December 2013; n = 598). Vital status was available at 2-year follow-up. Results The STEMI network increased reperfusion (89.2% vs 64.4%, p < 0.001) mainly using PCI (99.0% vs 43.9%, p < 0.001). In univariate analysis, in-hospital mortality was significantly lower in the post-STEMI network period (2.51% vs. 7.16%, p < 0.001). After multivariate adjustment, including age, sex, comorbidities, severity and reperfusion therapy, a trend to a lower in-hospital mortality was observed (post-Network OR: 0.50, 95% CI:0.16–1.59, p = 0.24); this trend disappeared when optimal medical therapy was included in the model (post-Network OR: 1.14, 95% CI:0.32–4.08, p = 0.840). No differences in 2-year mortality were observed (post-Network HR: 0.83; CI 95%: 0.55–1.25, p = 0.37). Conclusion A STEMI network with PPCI 24/7 improved reperfusion therapy, resulting in an increase on PPCI. Despite in-hospital mortality decreased with a STEMI network, 2-year mortality remained similar in both periods, pre- and post-Network. Optimal medical therapy could be as important as reperfusion therapy in a STEMI reperfusion network.
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Affiliation(s)
- C García-García
- Cardiology Department, Hospital del Mar, Parc de Salut Mar-IMIM, Barcelona, Spain. .,Cardiology Department, Hospital Universitari Germans Trias i Pujol, Carretera Canyet s/n, 08916, Badalona, Spain. .,CIBER de Enfermedades Cardiovasculares (CIBERCV), Barcelona, Spain.
| | - N Ribas
- Cardiology Department, Hospital del Mar, Parc de Salut Mar-IMIM, Barcelona, Spain.,Ph Program in Internal Medicine, Universitat Autònoma de Barcelona, Barcelona, Spain.,Heart Diseases Biomedical Research Group, IMIM (Hospital del Mar Medical Research Institute), Barcelona, Spain
| | - L L Recasens
- Cardiology Department, Hospital del Mar, Parc de Salut Mar-IMIM, Barcelona, Spain.,Heart Diseases Biomedical Research Group, IMIM (Hospital del Mar Medical Research Institute), Barcelona, Spain
| | - O Meroño
- Cardiology Department, Hospital del Mar, Parc de Salut Mar-IMIM, Barcelona, Spain.,Heart Diseases Biomedical Research Group, IMIM (Hospital del Mar Medical Research Institute), Barcelona, Spain
| | - I Subirana
- CIBER de Enfermedades Cardiovasculares (CIBERCV), Barcelona, Spain.,IMIM (Hospital del Mar Medical Research Institute), Cardiovascular Epidemiology and Genetics Group (EGEC), REGICOR Study Group, Barcelona, Spain
| | - A Fernández
- Cardiology Department, Hospital del Mar, Parc de Salut Mar-IMIM, Barcelona, Spain
| | - A Pérez
- Cardiology Department, Hospital del Mar, Parc de Salut Mar-IMIM, Barcelona, Spain
| | - F Miranda
- Cardiology Department, Hospital del Mar, Parc de Salut Mar-IMIM, Barcelona, Spain
| | - H Tizón-Marcos
- Cardiology Department, Hospital del Mar, Parc de Salut Mar-IMIM, Barcelona, Spain.,Heart Diseases Biomedical Research Group, IMIM (Hospital del Mar Medical Research Institute), Barcelona, Spain
| | - J Martí-Almor
- Cardiology Department, Hospital del Mar, Parc de Salut Mar-IMIM, Barcelona, Spain.,Heart Diseases Biomedical Research Group, IMIM (Hospital del Mar Medical Research Institute), Barcelona, Spain
| | - J Bruguera
- Cardiology Department, Hospital del Mar, Parc de Salut Mar-IMIM, Barcelona, Spain.,Heart Diseases Biomedical Research Group, IMIM (Hospital del Mar Medical Research Institute), Barcelona, Spain
| | - R Elosua
- Ph Program in Internal Medicine, Universitat Autònoma de Barcelona, Barcelona, Spain.,IMIM (Hospital del Mar Medical Research Institute), Cardiovascular Epidemiology and Genetics Group (EGEC), REGICOR Study Group, Barcelona, Spain
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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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53
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Ruptured aneurysm systems of care: A national imperative to improve clinical outcomes. J Vasc Surg 2017; 65:589-590. [DOI: 10.1016/j.jvs.2016.10.091] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2016] [Accepted: 10/14/2016] [Indexed: 12/16/2022]
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Gunnarsson SI, Mitchell J, Busch MS, Larson B, Gharacholou SM, Li Z, Raval AN. Outcomes of Physician-Staffed Versus Non-Physician-Staffed Helicopter Transport for ST-Elevation Myocardial Infarction. J Am Heart Assoc 2017; 6:JAHA.116.004936. [PMID: 28154162 PMCID: PMC5523778 DOI: 10.1161/jaha.116.004936] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background The effect of physician‐staffed helicopter emergency medical service (HEMS) on ST‐elevation myocardial infarction (STEMI) patient transfer is unknown. The purpose of this study was to evaluate the characteristics and outcomes of physician‐staffed HEMS (Physician‐HEMS) versus non‐physician‐staffed (Standard‐HEMS) in patients with STEMI. Methods and Results We studied 398 STEMI patients transferred by either Physician‐HEMS (n=327) or Standard‐HEMS (n=71) for primary or rescue percutaneous coronary intervention at 2 hospitals between 2006 and 2014. Data were collected from electronic medical records and each institution's contribution to the National Cardiovascular Data Registry. Baseline characteristics were similar between groups. Median electrocardiogram‐to‐balloon time was longer for the Standard‐HEMS group than for the Physician‐HEMS group (118 vs 107 minutes; P=0.002). The Standard‐HEMS group was more likely than the Physician‐HEMS group to receive nitroglycerin (37% vs 15%; P<0.001) and opioid analgesics (42.3% vs 21.7%; P<0.001) during transport. In‐hospital adverse outcomes, including cardiac arrest, cardiogenic shock, and serious arrhythmias, were more common in the Standard‐HEMS group (25.4% vs 11.3%; P=0.002). After adjusting for age, sex, Killip class, and transport time, patients transferred by Standard‐HEMS had increased risk of any serious in‐hospital adverse event (odds ratio=2.91; 95% CI=1.39–6.06; P=0.004). In‐hospital mortality was not statistically different between the 2 groups (9.9% in the Standard‐HEMS group vs 4.9% in the Physician‐HEMS group; P=0.104). Conclusions Patients with STEMI transported by Standard‐HEMS had longer transport times, higher rates of nitroglycerin and opioid administration, and higher rates of adjusted in‐hospital events. Efforts to better understand optimal transport strategies in STEMI patients are needed.
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Affiliation(s)
- Sverrir I Gunnarsson
- Division of Cardiovascular Medicine, Department of Medicine, University of Wisconsin, Madison, WI
| | - Joseph Mitchell
- Division of Cardiovascular Medicine, Department of Medicine, University of Wisconsin, Madison, WI
| | - Mary S Busch
- Mayo Clinic Health System-Franciscan Healthcare, La Crosse, WI
| | - Brenda Larson
- Division of Cardiovascular Medicine, Department of Medicine, University of Wisconsin, Madison, WI
| | - S Michael Gharacholou
- Mayo Clinic Health System-Franciscan Healthcare, La Crosse, WI.,Division of Cardiology, Mayo Clinic, Rochester, MN
| | - Zhanhai Li
- Department of Biostatistics and Medical Informatics, University of Wisconsin, Madison, WI
| | - Amish N Raval
- Division of Cardiovascular Medicine, Department of Medicine, University of Wisconsin, Madison, WI
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Reducing system delays in treatment of ST elevation myocardial infarction and confronting the challenges of late presentation in low and middle-income countries. Indian Heart J 2017; 69 Suppl 1:S1-S5. [PMID: 28400032 PMCID: PMC5388017 DOI: 10.1016/j.ihj.2016.12.020] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
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57
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Hira RS, Bhatt DL, Fonarow GC, Heidenreich PA, Ju C, Virani SS, Bozkurt B, Petersen LA, Hernandez AF, Schwamm LH, Eapen ZJ, Albert MA, Liang L, Matsouaka RA, Peterson ED, Jneid H. Temporal Trends in Care and Outcomes of Patients Receiving Fibrinolytic Therapy Compared to Primary Percutaneous Coronary Intervention: Insights From the Get With The Guidelines Coronary Artery Disease (GWTG-CAD) Registry. J Am Heart Assoc 2016; 5:JAHA.116.004113. [PMID: 27792640 PMCID: PMC5121508 DOI: 10.1161/jaha.116.004113] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Background Timely reperfusion after ST‐elevation myocardial infarction (STEMI) improves survival. Guidelines recommend primary percutaneous coronary intervention (PPCI) within 90 minutes of arrival at a PCI‐capable hospital. The alternative is fibrinolysis within 30 minutes for those in those for whom timely transfer to a PCI‐capable hospital is not feasible. Methods and Results We identified STEMI patients receiving reperfusion therapy at 229 hospitals participating in the Get With the Guidelines—Coronary Artery Disease (GWTG‐CAD) database (January 1, 2003 through December 31, 2008). Temporal trends in the use of fibrinolysis and PPCI, its timeliness, and in‐hospital mortality outcomes were assessed. We also assessed predictors of fibrinolysis versus PPCI and compliance with performance measures. Defect‐free care was defined as 100% compliance with all performance measures. We identified 29 190 STEMI patients, of whom 2441 (8.4%) received fibrinolysis; 38.2% of these patients achieved door‐to‐needle times ≤30 minutes. Median door‐to‐needle times increased from 36 to 60 minutes (P=0.005) over the study period. Among PPCI patients, median door‐to‐balloon times decreased from 94 to 64 minutes (P<0.0001) over the same period. In‐hospital mortality was higher with fibrinolysis than with PPCI (4.6% vs 3.3%, P=0.001) and did not change significantly over time. Patients receiving fibrinolysis were less likely to receive defect‐free care compared with their PPCI counterparts. Conclusions Use of fibrinolysis for STEMI has decreased over time with concomitant worsening of door‐to‐needle times. Over the same time period, use of PPCI increased with improvement in door‐to‐balloon times. In‐hospital mortality was higher with fibrinolysis than with PPCI. As reperfusion for STEMI continues to shift from fibrinolysis to PPCI, it will be critical to ensure that door‐to‐needle times and outcomes do not worsen.
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Affiliation(s)
- Ravi S Hira
- Division of Cardiology, University of Washington, Seattle, WA
| | - Deepak L Bhatt
- Brigham and Women's Hospital Heart & Vascular Center and Harvard Medical School, Boston, MA
| | | | - Paul A Heidenreich
- Veterans Administration Palo Alto Healthcare System, Palo Alto, CA Stanford University School of Medicine, Stanford, CA
| | - Christine Ju
- Duke Clinical Research Institute, Duke University Medical Center, Durham, NC
| | - Salim S Virani
- Michael E. DeBakey VA Medical Center, Houston, TX Division of Cardiology, Department of Medicine, Baylor College of Medicine, Houston, TX Section of Health Services Research, Department of Medicine, Baylor College of Medicine, Houston, TX Michael E. DeBakey Veterans Affairs Medical Center Health Services Research and Development Center for Innovations, Houston, TX
| | - Biykem Bozkurt
- Michael E. DeBakey VA Medical Center, Houston, TX Division of Cardiology, Department of Medicine, Baylor College of Medicine, Houston, TX
| | - Laura A Petersen
- Section of Health Services Research, Department of Medicine, Baylor College of Medicine, Houston, TX Michael E. DeBakey Veterans Affairs Medical Center Health Services Research and Development Center for Innovations, Houston, TX
| | - Adrian F Hernandez
- Duke Clinical Research Institute, Duke University Medical Center, Durham, NC
| | - Lee H Schwamm
- Department of Neurology, TeleStroke and Acute Stroke Services, Boston, MA Institute for Heart, Vascular, and Stroke Care, Massachusetts General Hospital, Boston, MA Department of Neurology, Harvard Medical School, Boston, MA
| | - Zubin J Eapen
- Duke Clinical Research Institute, Duke University Medical Center, Durham, NC
| | - Michelle A Albert
- Division of Cardiology, University of California at San Francisco, San Francisco, CA
| | - Li Liang
- Duke Clinical Research Institute, Duke University Medical Center, Durham, NC
| | - Roland A Matsouaka
- Duke Clinical Research Institute, Duke University Medical Center, Durham, NC
| | - Eric D Peterson
- Duke Clinical Research Institute, Duke University Medical Center, Durham, NC
| | - Hani Jneid
- Michael E. DeBakey VA Medical Center, Houston, TX Division of Cardiology, Department of Medicine, Baylor College of Medicine, Houston, TX
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Engelman GH, Carry PM, Kubes KM, Gleason MJ. An evaluation of pre-hospital emergency medical systems for suspected ST-elevation myocardial infarction in Colorado. Postgrad Med 2016; 128:777-782. [PMID: 27677377 DOI: 10.1080/00325481.2016.1241665] [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: 10/20/2022]
Abstract
OBJECTIVES Patients presenting with ST-elevation myocardial infarction (STEMI) benefit from rapid cardiac reperfusion therapy. Emergency medical service (EMS) agencies can improve patient outcomes by calling STEMI alerts to the receiving facility. The aim of this study was to evaluate the use of pre-hospital activation systems for suspected ST-elevation myocardial infarctions (STEMI) throughout Colorado. METHODS A cross sectional, survey design was utilized to collect all data from EMS agencies in Colorado. A univariable logistic regression model was used to identify factors predictive of an agency reporting that they utilize a STEMI activation protocol. RESULTS 84.5% [95% CI: 78.3 to 90.7%] of agencies included indicate that they utilize a STEMI activation protocol. Based on the logistic regression analysis, the number of EMT employees was significantly associated with whether or not an agency indicates that they utilize a STEMI activation protocol. For every 10% increase in the number of EMTs employed by an EMS agency, there was a 3.0 [95% CI: 1.5 to 6.0, p = 0.0012] fold increase in the odds of the agency indicating they utilize a STEMI activation protocol. CONCLUSIONS Our study provides evidence that larger agencies are more likely to utilize a STEMI activation protocol. In areas without a STEMI system of care, improvements in smaller agencies that cover more ground (with longer transport times) should be the focus for protocol implementation. Based on the current prevalence of such training, competency based training in reading ST-elevations on ECG should be considered by EMS agencies.
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Affiliation(s)
- Glenn H Engelman
- a College of Osteopathic Medicine , Rocky Vista University , Parker , CO , USA
| | - Patrick M Carry
- b Musculoskeletal Research Center , Department of Orthopedics, Children's Hospital Colorado , Aurora , CO , USA
| | - Kyle M Kubes
- a College of Osteopathic Medicine , Rocky Vista University , Parker , CO , USA
| | - Michael J Gleason
- a College of Osteopathic Medicine , Rocky Vista University , Parker , CO , USA
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Alexithymia affects the time from symptom onset to calling the emergency system in STEMI patients referred for primary PCI. Int J Cardiol 2016; 219:428-32. [DOI: 10.1016/j.ijcard.2016.06.038] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/29/2016] [Accepted: 06/12/2016] [Indexed: 11/23/2022]
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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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Bata A, Quraishi AUR, Love M, Title L, Beydoun H, Lee T, Nadeem N, Kidwai B, Kells C, Curran H. Initial experience with pre-activation of the cardiac catheterization lab and emergency room bypass for patients with ST-elevation myocardial infarction in Halifax, Nova Scotia. Int J Cardiol 2016; 222:645-647. [PMID: 27517655 DOI: 10.1016/j.ijcard.2016.07.162] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/22/2016] [Accepted: 07/27/2016] [Indexed: 01/01/2023]
Abstract
BACKGROUND To determine whether pre-activation of the cardiac catheterization lab by Emergency Health Services (EHS) with a single call system in the field was associated with reduced time to reperfusion in patients with ST-Elevation Myocardial Infarction (STEMI) undergoing primary percutaneous coronary intervention (PPCI). METHODS Consecutive STEMI patients identified by EHS and subsequently taken to the Queen Elizabeth II Health Sciences Center (QEIIHSC) for PPCI between February 1, 2011 and January 30, 2013 were examined. Patients who had pre-activation of the catheterization lab from the field (pre-act group) after the acquisition of the LifeNet® system (Physio Control, Redmond Washington) were compared to those who had usual activation (routine group) prior to the acquisition of the LifeNet® system, for outcomes including treatment timeline data and mortality. RESULTS 271 patients were included in the analysis, 149 patients in the pre-act group and 122 patients in the routine group. Door-to-device (DTD) times of less than 90min were achieved more frequently in the Pre-act group (91.9% vs. 62.2%; P<0.001). DTD time was shorter in the Pre-act group (48min IQR: 38 to 63min vs. 78min IQR: 64-101min; p=0.001) as was first medical contact-to-device (FMCTD) time (91min IQR: 78 to 106min vs. 115min IQR: 90 to 139min; P<0.001). False activation of the catheterization lab was infrequent (1.3%). CONCLUSIONS Implementation of catheterization lab pre-activation using the LifeNet® system was associated with more efficient reperfusion times as measured by reduced FMCTD and DTD times without excess false activation rates.
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Affiliation(s)
- Adil Bata
- Division of Cardiology, Queen Elizabeth II Health Sciences Center, Dalhousie University, 1796 Summer Street, Halifax Infirmary, 2nd Floor, Halifax, Nova Scotia B3H 3A7, Canada
| | - Ata Ur Rehman Quraishi
- Division of Cardiology, Queen Elizabeth II Health Sciences Center, Dalhousie University, 1796 Summer Street, Halifax Infirmary, 2nd Floor, Halifax, Nova Scotia B3H 3A7, Canada
| | - Michael Love
- Division of Cardiology, Queen Elizabeth II Health Sciences Center, Dalhousie University, 1796 Summer Street, Halifax Infirmary, 2nd Floor, Halifax, Nova Scotia B3H 3A7, Canada
| | - Lawrence Title
- Division of Cardiology, Queen Elizabeth II Health Sciences Center, Dalhousie University, 1796 Summer Street, Halifax Infirmary, 2nd Floor, Halifax, Nova Scotia B3H 3A7, Canada
| | - Hussein Beydoun
- Division of Cardiology, Queen Elizabeth II Health Sciences Center, Dalhousie University, 1796 Summer Street, Halifax Infirmary, 2nd Floor, Halifax, Nova Scotia B3H 3A7, Canada
| | - Tony Lee
- Division of Cardiology, Queen Elizabeth II Health Sciences Center, Dalhousie University, 1796 Summer Street, Halifax Infirmary, 2nd Floor, Halifax, Nova Scotia B3H 3A7, Canada
| | - Najaf Nadeem
- Division of Cardiology, Queen Elizabeth II Health Sciences Center, Dalhousie University, 1796 Summer Street, Halifax Infirmary, 2nd Floor, Halifax, Nova Scotia B3H 3A7, Canada
| | - Bakhtiar Kidwai
- Division of Cardiology, Queen Elizabeth II Health Sciences Center, Dalhousie University, 1796 Summer Street, Halifax Infirmary, 2nd Floor, Halifax, Nova Scotia B3H 3A7, Canada
| | - Catherine Kells
- Division of Cardiology, Queen Elizabeth II Health Sciences Center, Dalhousie University, 1796 Summer Street, Halifax Infirmary, 2nd Floor, Halifax, Nova Scotia B3H 3A7, Canada
| | - Helen Curran
- Division of Cardiology, Queen Elizabeth II Health Sciences Center, Dalhousie University, 1796 Summer Street, Halifax Infirmary, 2nd Floor, Halifax, Nova Scotia B3H 3A7, Canada.
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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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63
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Meloni L, Floris R, Montisci R, De Candia G, Cadeddu M, Lai G, Sori P, Ruscazio M, Pinna G, Iasiello G, Pirisi R. Care quality monitoring of a ST-segment elevation myocardial infarction programme over a 5-year period. J Cardiovasc Med (Hagerstown) 2016; 17:494-500. [DOI: 10.2459/jcm.0000000000000285] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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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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Bogaty P, Brophy JM. STEMI Treatment 2016: Is Outcome Improvement Stalling and If So, Why? Can J Cardiol 2016; 32:1193-1196. [PMID: 27094124 DOI: 10.1016/j.cjca.2016.01.022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2016] [Revised: 01/21/2016] [Accepted: 01/21/2016] [Indexed: 10/22/2022] Open
Affiliation(s)
- Peter Bogaty
- Laval University, Institut universitaire de cardiologie et de pneumologie de Québec, Québec City, Québec, Canada.
| | - James M Brophy
- McGill University (Royal Victoria Hospital), Montreal, Québec, Canada
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Neumar RW, Eigel B, Callaway CW, Estes NM, Jollis JG, Kleinman ME, Morrison LJ, Peberdy MA, Rabinstein A, Rea TD, Sendelbach S. American Heart Association Response to the 2015 Institute of Medicine Report on Strategies to Improve Cardiac Arrest Survival. Circulation 2015; 132:1049-70. [DOI: 10.1161/cir.0000000000000233] [Citation(s) in RCA: 42] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
The American Heart Association (AHA) commends the recently released Institute of Medicine (IOM) report,
Strategies to Improve Cardiac Arrest Survival: A Time to Act
(2015). The AHA recognizes the unique opportunity created by the report to meaningfully advance the objectives of improving outcomes for sudden cardiac arrest. For decades, the AHA has focused on the goal of reducing morbidity and mortality from cardiovascular disease though robust support of basic, translational, clinical, and population research. The AHA also has developed a rigorous process using the best available evidence to develop scientific, advisory, and guideline documents. These core activities of development and dissemination of scientific evidence have served as the foundation for a broad range of advocacy initiatives and programs that serve as a foundation for advancing the AHA and IOM goal of improving cardiac arrest outcomes. In response to the call to action in the IOM report, the AHA is announcing 4 new commitments to increase cardiac arrest survival: (1) The AHA will provide up to $5 million in funding over 5 years to incentivize resuscitation data interoperability; (2) the AHA will actively pursue philanthropic support for local and regional implementation opportunities to increase cardiac arrest survival by improving out-of-hospital and in-hospital systems of care; (3) the AHA will actively pursue philanthropic support to launch an AHA resuscitation research network; and (4) the AHA will cosponsor a National Cardiac Arrest Summit to facilitate the creation of a national cardiac arrest collaborative that will unify the field and identify common goals to improve survival. In addition to the AHA’s historic and ongoing commitment to improving cardiac arrest care and outcomes, these new initiatives are responsive to each of the IOM recommendations and demonstrate the AHA’s leadership in the field. However, successful implementation of the IOM recommendations will require a timely response by all stakeholders identified in the report and a coordinated approach to achieve our common goal of improved cardiac arrest outcomes.
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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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Affiliation(s)
- Zoran S Nedeljkovic
- From Evans Department of Medicine, Boston University School of Medicine, and Section of Cardiology, Boston Medical Center, Boston, MA
| | - Alice K Jacobs
- From Evans Department of Medicine, Boston University School of Medicine, and Section of Cardiology, Boston Medical Center, Boston, MA.
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69
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Prehospital triage and direct transport of patients with ST-elevation myocardial infarction to primary percutaneous coronary intervention centres: a systematic review and meta-analysis. CAN J EMERG MED 2015; 11:481-92. [DOI: 10.1017/s1481803500011684] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
ABSTRACT
Objective:
Percutaneous coronary intervention (PCI) appears to be superior to in-hospital fibrinolysis for most patients with ST-elevation myocardial infarction (STEMI). However, few hospitals have PCI capability. The optimal prehospital strategy for facilitating rapid coronary reperfusion in STEMI patients is unclear. We sought to determine whether direct transport of adult STEMI patients by emergency medical services to primary PCI centres improves 30-day all-cause mortality when compared with a strategy of transportation to the closest hospital.
Methods:
We systematically searched MEDLINE, EMBASE, Cochrane “CENTRAL” database (1980-July 2007) and several other electronic databases. Two authors independently assessed citations for relevance. Two authors independently abstracted data from included studies. We included studies that, 1) transported patients directly to a PCI-capable centre for primary PCI, 2) had a control group that was transported to the closest hospital and 3) reported outcomes of treatment time intervals, all-cause mortality, reinfarction rate, stroke rate or the frequency of cardiogenic shock. We used a random effects model to provide pooled estimates of relative risk (RR) when data allowed.
Results:
We identified 2264 citations with the search. Five studies, including 980 STEMI patients, met inclusion criteria, and were clinically heterogeneous and of variable quality. Most studies were European (3/5) and involved physician out-of-hospital care providers. There was a trend toward increased survival with direct transport to primary PCI but this was not statistically significant (RR 0.51, 95% confidence interval [CI] 0.24–1.10). One study reported nonsignificant reductions in reinfarction (RR 0.43, 95% CI 0.11–1.60) and stroke (RR 0.33, 95% CI 0.01–8.06) with direct transport for primary PCI.
Conclusion:
There is insufficient evidence to support the effectiveness of direct transport of patients with STEMI for primary PCI when compared with transportation to the closest hospital.
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Dehmer GJ, Blankenship JC, Cilingiroglu M, Dwyer JG, Feldman DN, Gardner TJ, Grines CL, Singh M. SCAI/ACC/AHA Expert Consensus Document: 2014 Update on Percutaneous Coronary Intervention Without On-Site Surgical Backup. Catheter Cardiovasc Interv 2015; 84:169-87. [PMID: 25045090 DOI: 10.1002/ccd.25371] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/27/2013] [Accepted: 12/21/2013] [Indexed: 12/11/2022]
Affiliation(s)
- Gregory J Dehmer
- Baylor Scott & White Health, Central Texas, Temple, TX. SCAI Writing Committee Member and Chair
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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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Gaieski DF, Edwards JM, Kallan MJ, Mikkelsen ME, Goyal M, Carr BG. The relationship between hospital volume and mortality in severe sepsis. Am J Respir Crit Care Med 2014; 190:665-74. [PMID: 25117723 DOI: 10.1164/rccm.201402-0289oc] [Citation(s) in RCA: 61] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023] Open
Abstract
RATIONALE Severe sepsis is increasing in incidence and has a high rate of inpatient mortality. Hospitals that treat a larger number of patients with severe sepsis may offer a survival advantage. OBJECTIVES We sought to assess the effect of severe sepsis case volume on mortality, hypothesizing that higher volume centers would have lower rates of inpatient death. METHODS We performed a retrospective cohort study over a 7-year period (2004-2010), using a nationally representative sample of hospital admissions, examining the relation between volume, urban location, organ dysfunction, and survival. MEASUREMENTS AND MAIN RESULTS To identify potential differences in outcomes, hospitals were divided into five categories (<50, 50-99, 100-249, 250-499, and 500+ annual cases) and adjusted mortality was compared by volume. A total of 914,200 patients with severe sepsis were identified over a 7-year period (2004-2010). Overall in-hospital mortality was 28.1%. In a fully adjusted model, there was an inverse relationship between severe sepsis case volume and inpatient mortality. Hospitals in the highest volume category had substantially improved survival compared with hospitals with the lowest case volume (adjusted odds ratio, 0.64; 95% confidence interval, 0.60-0.69). In cases of severe sepsis with one reported organ dysfunction, a mortality of 18.9% was found in hospitals with fewer than 50 annual cases compared with 10.4% in hospitals treating 500+ cases (adjusted odds ratio, 0.54; 95% confidence interval, 0.49-0.59). Similar differences were found in patients with up to three total organ dysfunctions. CONCLUSIONS Patients with severe sepsis treated in hospitals with higher case volumes had improved adjusted outcomes.
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Affiliation(s)
- David F Gaieski
- 1 Department of Emergency Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
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73
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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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74
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Minimizing transfer time to an ST segment elevation myocardial infarction-receiving center: a modified Delphi consensus. Crit Pathw Cardiol 2014; 13:20-4. [PMID: 24526147 DOI: 10.1097/hpc.0000000000000003] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/18/2023]
Abstract
Of patients with ST segment elevation myocardial infarction (STEMI), approximately two thirds present to a hospital not capable of percutaneous coronary intervention. Transfer to a STEMI-receiving center delays time to reperfusion in patients with STEMI, but factors that affect this delay have not been well studied. We performed a 3-round modified Delphi study to identify system practices that minimize transfer time to a STEMI-receiving center. A comprehensive literature review was used to identify candidate system practices. Emergency medical services, emergency medicine, and cardiology experts were invited to participate. Consensus was defined as 80% agreement that a variable was "very important (5)" or "important (4)" with a mean score ≥ 4.25 or 80% agreement that a variable was "not important (1)" or "somewhat important (2)" with a mean score ≤ 1.75. In round 1, participants rated the candidate items and suggested additional items. Individual feedback was provided, and participants discussed items via conference calls before rating them again in round 2. In round 3, participants ranked the consensus items from rounds 1-2 from most to least important, and the mean score for each item was calculated. Of the 98 experts invited, 29 participated in round 1, 22 in round 2, and 14 in round 3. Participants identified 18 system practices that they agree are critical in minimizing transfer time to STEMI-receiving centers, with the most important being performance of a prehospital electrocardiogram and having established transfer protocols. These factors should be considered in the development of STEMI systems of care.
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75
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Callea G, Tarricone R, Lara AM. Economic evidence of interventions for acute myocardial infarction: a review of the literature. EUROINTERVENTION 2014; 8 Suppl P:P71-6. [PMID: 22917795 DOI: 10.4244/eijv8spa12] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
AIMS The aims of this review are to identify and evaluate studies exploring the cost-effectiveness of primary angioplasty (PPCI) vs. thrombolysis (TL) for treating acute myocardial infarction (AMI). METHODS AND RESULTS A comprehensive free-text searching identified economic evaluation studies that were reviewed with respect to their effectiveness data, identification, measurement and valuation of resource data, measurement and valuation of health outcomes (clinical and QALYs) and uncertainty analysis. A total of 14 studies were included in the review: seven were economic evaluations alongside RCTs, two community-based studies or registries and five decision-analytical models. PPCI was found to be cost-effective when compared with TL in eight studies, cost-saving in three, cost-neutral in one, and not significantly different in terms of both cost and benefits in two studies. CONCLUSIONS The cost-effective evidence available is mainly derived from RCTs with stringent inclusion criteria using established catheter laboratories for providing PPCI treatment; these two components might restrict the generalisability of their "for managing patients with STEMI in hospital" settings. In order to aid policy makers on the real costs and benefits of the PPCI and TL, it is necessary to conduct more analyses with data from the real world in which there are more strategies evaluated for delivering PPCI than merely those in established catheter laboratories.
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Affiliation(s)
- Giuditta Callea
- Centre for Research on Health and Social Care Management (CERGAS), Department of Policy Analysis and Public Management, Bocconi University, Milan, Italy
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76
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Jneid H. Interplay between time of presentation, timeliness of reperfusion, and outcome after ST-segment-elevation myocardial infarction. Circ Cardiovasc Qual Outcomes 2014; 7:637-9. [PMID: 25074373 DOI: 10.1161/circoutcomes.114.001151] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Hani Jneid
- From the Division of Cardiology, the Michael E. DeBakey VA Medical Center and Baylor College of Medicine, Houston, TX.
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77
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Shamim S, McCrary J, Wayne L, Gratton M, Bogart DB. Electrocardiograhic findings resulting in inappropriate cardiac catheterization laboratory activation for ST-segment elevation myocardial infarction. Cardiovasc Diagn Ther 2014; 4:215-23. [PMID: 25009790 DOI: 10.3978/j.issn.2223-3652.2014.05.01] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2014] [Accepted: 05/04/2014] [Indexed: 11/14/2022]
Abstract
BACKGROUND Prompt reperfusion has been shown to improve outcomes in patients with acute ST-segment elevation myocardial infarction (STEMI) with a goal of culprit vessel patency in <90 minutes. This requires a coordinated approach between the emergency medical services (EMS), emergency department (ED) and interventional cardiology. The urgency of this process can contribute to inappropriate cardiac catheterization laboratory (CCL) activations. OBJECTIVES One of the major determinants of inappropriate activations has been misinterpretation of the electrocardiogram (ECG) in the patient with acute chest pain. METHODS We report the ECG findings for all CCL activations over an 18-month period after the inception of a STEMI program at our institution. RESULTS There were a total of 139 activations with 77 having a STEMI diagnosis confirmed and 62 activations where there was no STEMI. The inappropriate activations resulted from a combination of atypical symptoms and misinterpretation of the ECG (45% due to anterior ST-segment elevation) on patient presentation. The electrocardiographic abnormalities were particularly problematic in African-Americans with left ventricular hypertrophy. CONCLUSIONS In this single-center, prospective observational study, nearly half of the inappropriate STEMI activations were due to the misinterpretation of anterior ST-segment elevation and this finding was commonly seen in African-Americans with left ventricular hypertrophy.
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Affiliation(s)
- Shariq Shamim
- 1 Cardiology Fellow University of Missouri, Kansas City, USA ; 2 Quality Improvement Director, Cardiology Section Truman Medical Center, USA ; 3 Professor and Chief of the Emergency Department University of Missouri, Kansas City and Truman Medical Center, USA ; 4 Formerly Associate Professor of Medicine University of Missouri, Kansas City and Chief of Cardiology of Truman Medical Center (Retired), USA
| | - Justin McCrary
- 1 Cardiology Fellow University of Missouri, Kansas City, USA ; 2 Quality Improvement Director, Cardiology Section Truman Medical Center, USA ; 3 Professor and Chief of the Emergency Department University of Missouri, Kansas City and Truman Medical Center, USA ; 4 Formerly Associate Professor of Medicine University of Missouri, Kansas City and Chief of Cardiology of Truman Medical Center (Retired), USA
| | - Lori Wayne
- 1 Cardiology Fellow University of Missouri, Kansas City, USA ; 2 Quality Improvement Director, Cardiology Section Truman Medical Center, USA ; 3 Professor and Chief of the Emergency Department University of Missouri, Kansas City and Truman Medical Center, USA ; 4 Formerly Associate Professor of Medicine University of Missouri, Kansas City and Chief of Cardiology of Truman Medical Center (Retired), USA
| | - Matthew Gratton
- 1 Cardiology Fellow University of Missouri, Kansas City, USA ; 2 Quality Improvement Director, Cardiology Section Truman Medical Center, USA ; 3 Professor and Chief of the Emergency Department University of Missouri, Kansas City and Truman Medical Center, USA ; 4 Formerly Associate Professor of Medicine University of Missouri, Kansas City and Chief of Cardiology of Truman Medical Center (Retired), USA
| | - Douglas B Bogart
- 1 Cardiology Fellow University of Missouri, Kansas City, USA ; 2 Quality Improvement Director, Cardiology Section Truman Medical Center, USA ; 3 Professor and Chief of the Emergency Department University of Missouri, Kansas City and Truman Medical Center, USA ; 4 Formerly Associate Professor of Medicine University of Missouri, Kansas City and Chief of Cardiology of Truman Medical Center (Retired), USA
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Roe MT, Sherwood MW. Uncovering the shroud on antiplatelet therapy for patients with ST-segment elevation myocardial infarction undergoing percutaneous coronary intervention. JACC Cardiovasc Interv 2014; 7:613-4. [PMID: 24947720 DOI: 10.1016/j.jcin.2014.02.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/04/2014] [Accepted: 02/13/2014] [Indexed: 11/16/2022]
Affiliation(s)
- Matthew T Roe
- Duke Clinical Research Institute, Division of Cardiology, Duke University Medical Center, Durham, North Carolina.
| | - Matthew W Sherwood
- Duke Clinical Research Institute, Division of Cardiology, Duke University Medical Center, Durham, North Carolina
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Richmond T, Holoshitz N, Haryani A, Purim-Shem-Tov Y, Sharma G, Schaer GL. Adverse outcomes in hospitalized patients who develop ST-elevation myocardial infarction. Crit Pathw Cardiol 2014; 13:62-65. [PMID: 24827882 DOI: 10.1097/hpc.0000000000000009] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/03/2023]
Abstract
BACKGROUND There has been considerable emphasis on the care of patients with ST-elevation myocardial infarction (STEMI) with the wide implementation of protocols to quickly identify and triage them from the emergency department (ED) to a cardiac catheterization laboratory for percutaneous coronary intervention. However, a small but important number of patients with STEMI develop ST-elevation while hospitalized for another medical problem. METHODS A single-center, retrospective chart review was performed on 172 consecutive patients with STEMI who underwent emergency percutaneous coronary intervention. One hundred thirty-seven patients presenting to the ED with STEMI and 35 patients who developed STEMI while hospitalized were compared. RESULTS Hospitalized patients with STEMI had delayed reperfusion, longer hospitalization, greater rates of stent thrombosis, and greater 30-day and 1-year mortality compared with these in patients presenting with STEMI to the ED. CONCLUSIONS Optimized clinical pathways for prevention, early diagnosis, and expedited reperfusion of inpatients with STEMI are urgently needed.
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Affiliation(s)
- Tyler Richmond
- From the *Central Baptist Heart and Vascular Institute, Lexington, KY; †Division of Cardiology, Department of Internal Medicine, Rush University Medical Center, Chicago, IL; and ‡Department of Emergency Medicine, Rush University Medical Center, Chicago, IL
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80
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Wang TY, Magid DJ, Ting HH, Li S, Alexander KP, Roe MT, Peterson ED. The quality of antiplatelet and anticoagulant medication administration among ST-segment elevation myocardial infarction patients transferred for primary percutaneous coronary intervention. Am Heart J 2014; 167:833-9. [PMID: 24890532 DOI: 10.1016/j.ahj.2014.03.002] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/22/2013] [Accepted: 03/05/2014] [Indexed: 10/25/2022]
Abstract
BACKGROUND Timely and appropriate use of antiplatelet and anticoagulant therapies has been shown to improve outcomes among ST-segment elevation myocardial infarction (STEMI) patients but has not been well described in patients transferred for primary percutaneous coronary intervention (PCI). METHODS We examined 16,801 (26%) transfer and 47,329 direct-arrival STEMI patients treated with primary PCI at 441 Acute Coronary Treatment and Intervention Outcomes Network Registry-Get With The Guidelines hospitals. Medication use was compared between transfer and direct-arrival patients to determine if these therapies were delayed or dosed in excess. RESULTS Although transfer patients were more likely to receive antiplatelet and anticoagulant therapies before catheterization, they had longer delays to initiation of heparin (35 vs. 25 minutes), clopidogrel (119 vs. 84 minutes), and glycoprotein IIb/IIIa inhibitor (107 vs. 60 minutes, P < .0001 for both). Administration of low-molecular-weight heparin and glycoprotein IIb/IIIa inhibitor at the STEMI-referring hospital was associated with longer delays to reperfusion compared with deferred administration at the STEMI-receiving hospital, whereas early use of unfractionated heparin was not. Among treated patients, those transferred were more likely to receive excess heparin dosing (adjusted odds ratio [OR] 1.28 [95% CI 1.04-1.58] for unfractionated heparin, adjusted OR 1.54 [95% CI 1.09-2.18] for low-molecular-weight heparin) and are associated with higher risks of major bleeding complications (adjusted OR 1.10, 95% CI 1.03-1.17). CONCLUSIONS ST-segment elevation myocardial infarction patients transferred for primary PCI in community practice are at risk for delayed and excessively dosed antithrombotic therapy, highlighting the need for continued quality improvement to maximize the appropriate use of these important adjunctive therapies.
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81
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Miller CS, Foley JD, Floriano PN, Christodoulides N, Ebersole JL, Campbell CL, Bailey AL, Rose BG, Kinane DF, Novak MJ, McDevitt JT, Ding X, Kryscio RJ. Utility of salivary biomarkers for demonstrating acute myocardial infarction. J Dent Res 2014; 93:72S-79S. [PMID: 24879575 DOI: 10.1177/0022034514537522] [Citation(s) in RCA: 45] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023] Open
Abstract
The comparative utility of serum and saliva as diagnostic fluids for identifying biomarkers of acute myocardial infarction (AMI) was investigated. The goal was to determine if salivary biomarkers could facilitate a screening diagnosis of AMI, especially in cases of non-ST elevation MI (NSTEMI), since these cases are not readily identified by electrocardiogram (ECG). Serum and unstimulated whole saliva (UWS) collected from 92 AMI patients within 48 hours of chest pain onset and 105 asymptomatic healthy control individuals were assayed for 13 proteins relevant to cardiovascular disease, by Beadlyte technology (Luminex(®)) and enzyme immunoassays. Data were analyzed with concentration cut-points, ECG findings, logistic regression (LR) (adjusted for matching for age, gender, race, smoking, number of teeth, and oral health status), and classification and regression tree (CART) analysis. A sensitivity analysis was conducted by repetition of the CART analysis in 58 cases and 58 controls, each matched by age and gender. Serum biomarkers demonstrated AMI sensitivity and specificity superior to that of saliva, as determined by LR and CART. The predominant discriminators in serum by LR were troponin I (TnI), B-type natriuretic peptide (BNP), and creatine kinase-MB (CK-MB), and TnI and BNP by CART. In saliva, LR identified C-reactive protein (CRP) as the biomarker most predictive of AMI. A combination of smoking tobacco, UWS CRP, CK-MB, sCD40 ligand, gender, and number of teeth identified AMI in the CART decision trees. When ECG findings, salivary biomarkers, and confounders were included, AMI was predicted with 80.0% sensitivity and 100% specificity. These analyses support the potential utility of salivary biomarker measurements used with ECG for the identification of AMI. Thus, saliva-based tests may provide additional diagnostic screening information in the clinical course for patients suspected of having an AMI.
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Affiliation(s)
- C S Miller
- Department of Oral Health Practice, Center for Oral Health Research, College of Dentistry, University of Kentucky, Lexington, KY, USA
| | - J D Foley
- Division of Cardiovascular Medicine, Gill Heart Institute, University of Kentucky, Lexington, KY, USA
| | - P N Floriano
- Department of Bioengineering and Chemistry, Rice University, Houston, TX, USA
| | - N Christodoulides
- Department of Bioengineering and Chemistry, Rice University, Houston, TX, USA
| | - J L Ebersole
- Department of Oral Health Practice, Center for Oral Health Research, College of Dentistry, University of Kentucky, Lexington, KY, USA
| | - C L Campbell
- Division of Cardiovascular Medicine, Gill Heart Institute, University of Kentucky, Lexington, KY, USA
| | - A L Bailey
- Division of Cardiovascular Medicine, Gill Heart Institute, University of Kentucky, Lexington, KY, USA
| | - B G Rose
- School of Dentistry, University of Louisville, Louisville, KY, USA
| | - D F Kinane
- School of Dentistry, University of Louisville, Louisville, KY, USA
| | - M J Novak
- Department of Oral Health Practice, Center for Oral Health Research, College of Dentistry, University of Kentucky, Lexington, KY, USA
| | - J T McDevitt
- Department of Bioengineering and Chemistry, Rice University, Houston, TX, USA
| | - X Ding
- Department of Biostatistics, College of Public Health, University of Kentucky, Lexington, KY, USA
| | - R J Kryscio
- Department of Biostatistics, College of Public Health, University of Kentucky, Lexington, KY, USA Department of Statistics, College of Arts & Science, University of Kentucky, Lexington, KY, USA
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Xian Y, Smith EE, Zhao X, Peterson ED, Olson DM, Hernandez AF, Bhatt DL, Saver JL, Schwamm LH, Fonarow GC. Strategies Used by Hospitals to Improve Speed of Tissue-Type Plasminogen Activator Treatment in Acute Ischemic Stroke. Stroke 2014; 45:1387-95. [DOI: 10.1161/strokeaha.113.003898] [Citation(s) in RCA: 70] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/16/2023]
Abstract
Background and Purpose—
The benefits of intravenous tissue-type plasminogen activator in acute ischemic stroke are time dependent, and several strategies have been reported to be associated with more rapid door-to-needle (DTN) times. However, the extent to which hospitals are using these strategies and their association with DTN times have not been well studied.
Methods—
We surveyed 304 Get With The Guidelines-Stroke hospitals joining Target: Stroke regarding their baseline use of strategies to reduce DTN times in the January 2008 to December 2009 time frame before the initiation of Target: Stroke and determined the association between hospital strategies and DTN times.
Results—
Among 5460 patients receiving tissue-type plasminogen activator within 3 hours of symptom onset in surveyed hospitals, the median DTN time was 72 minutes (interquartile range, 55–94). Reported use of the different strategies varied considerably. Of 11 hospital strategies analyzed individually by multivariable analysis, 3 strategies were independently associated with shorter DTN times. These included rapid triage/stroke team notification (209/304 [69%] hospitals, 8.1-minute reduction in DTN time), single-call activation system (190/304 [63%] hospitals, 4.3 minutes), and tissue-type plasminogen activator stored in the emergency department (189/304 [62%] hospitals, 3.5 minutes). When analyzed incrementally, hospitals that used a greater number of strategies had shorter DTN times with 1.3 minutes (adjusted mean difference) saved for each strategy implemented (14 minutes if all strategies were used).
Conclusions—
Although the majority of participating hospitals reported using some strategy to reduce delays in tissue-type plasminogen activator administration for acute ischemic stroke, the strategies applied vary considerably and those most strongly associated with shorter DTN times were applied relatively less frequently.
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Affiliation(s)
- Ying Xian
- From the Duke Clinical Research Institute, Durham, NC (Y.X., X.Z., E.D.P., A.F.H.); Department of Clinical Neurosciences and Hotchkiss Brain Institute, University of Calgary, Calgary, Alberta, Canada (E.E.S.); Department of Neurology & Neurotherapeutics, Neurological Surgery, University of Texas Southwestern Medical Center, Dallas (D.M.O.); Department of Neurology, University of California, Los Angeles (J.L.S.); Department of Medicine, Brigham and Women’s Hospital and Harvard Medical School,
| | - Eric E. Smith
- From the Duke Clinical Research Institute, Durham, NC (Y.X., X.Z., E.D.P., A.F.H.); Department of Clinical Neurosciences and Hotchkiss Brain Institute, University of Calgary, Calgary, Alberta, Canada (E.E.S.); Department of Neurology & Neurotherapeutics, Neurological Surgery, University of Texas Southwestern Medical Center, Dallas (D.M.O.); Department of Neurology, University of California, Los Angeles (J.L.S.); Department of Medicine, Brigham and Women’s Hospital and Harvard Medical School,
| | - Xin Zhao
- From the Duke Clinical Research Institute, Durham, NC (Y.X., X.Z., E.D.P., A.F.H.); Department of Clinical Neurosciences and Hotchkiss Brain Institute, University of Calgary, Calgary, Alberta, Canada (E.E.S.); Department of Neurology & Neurotherapeutics, Neurological Surgery, University of Texas Southwestern Medical Center, Dallas (D.M.O.); Department of Neurology, University of California, Los Angeles (J.L.S.); Department of Medicine, Brigham and Women’s Hospital and Harvard Medical School,
| | - Eric D. Peterson
- From the Duke Clinical Research Institute, Durham, NC (Y.X., X.Z., E.D.P., A.F.H.); Department of Clinical Neurosciences and Hotchkiss Brain Institute, University of Calgary, Calgary, Alberta, Canada (E.E.S.); Department of Neurology & Neurotherapeutics, Neurological Surgery, University of Texas Southwestern Medical Center, Dallas (D.M.O.); Department of Neurology, University of California, Los Angeles (J.L.S.); Department of Medicine, Brigham and Women’s Hospital and Harvard Medical School,
| | - DaiWai M. Olson
- From the Duke Clinical Research Institute, Durham, NC (Y.X., X.Z., E.D.P., A.F.H.); Department of Clinical Neurosciences and Hotchkiss Brain Institute, University of Calgary, Calgary, Alberta, Canada (E.E.S.); Department of Neurology & Neurotherapeutics, Neurological Surgery, University of Texas Southwestern Medical Center, Dallas (D.M.O.); Department of Neurology, University of California, Los Angeles (J.L.S.); Department of Medicine, Brigham and Women’s Hospital and Harvard Medical School,
| | - Adrian F. Hernandez
- From the Duke Clinical Research Institute, Durham, NC (Y.X., X.Z., E.D.P., A.F.H.); Department of Clinical Neurosciences and Hotchkiss Brain Institute, University of Calgary, Calgary, Alberta, Canada (E.E.S.); Department of Neurology & Neurotherapeutics, Neurological Surgery, University of Texas Southwestern Medical Center, Dallas (D.M.O.); Department of Neurology, University of California, Los Angeles (J.L.S.); Department of Medicine, Brigham and Women’s Hospital and Harvard Medical School,
| | - Deepak L. Bhatt
- From the Duke Clinical Research Institute, Durham, NC (Y.X., X.Z., E.D.P., A.F.H.); Department of Clinical Neurosciences and Hotchkiss Brain Institute, University of Calgary, Calgary, Alberta, Canada (E.E.S.); Department of Neurology & Neurotherapeutics, Neurological Surgery, University of Texas Southwestern Medical Center, Dallas (D.M.O.); Department of Neurology, University of California, Los Angeles (J.L.S.); Department of Medicine, Brigham and Women’s Hospital and Harvard Medical School,
| | - Jeffrey L. Saver
- From the Duke Clinical Research Institute, Durham, NC (Y.X., X.Z., E.D.P., A.F.H.); Department of Clinical Neurosciences and Hotchkiss Brain Institute, University of Calgary, Calgary, Alberta, Canada (E.E.S.); Department of Neurology & Neurotherapeutics, Neurological Surgery, University of Texas Southwestern Medical Center, Dallas (D.M.O.); Department of Neurology, University of California, Los Angeles (J.L.S.); Department of Medicine, Brigham and Women’s Hospital and Harvard Medical School,
| | - Lee H. Schwamm
- From the Duke Clinical Research Institute, Durham, NC (Y.X., X.Z., E.D.P., A.F.H.); Department of Clinical Neurosciences and Hotchkiss Brain Institute, University of Calgary, Calgary, Alberta, Canada (E.E.S.); Department of Neurology & Neurotherapeutics, Neurological Surgery, University of Texas Southwestern Medical Center, Dallas (D.M.O.); Department of Neurology, University of California, Los Angeles (J.L.S.); Department of Medicine, Brigham and Women’s Hospital and Harvard Medical School,
| | - Gregg C. Fonarow
- From the Duke Clinical Research Institute, Durham, NC (Y.X., X.Z., E.D.P., A.F.H.); Department of Clinical Neurosciences and Hotchkiss Brain Institute, University of Calgary, Calgary, Alberta, Canada (E.E.S.); Department of Neurology & Neurotherapeutics, Neurological Surgery, University of Texas Southwestern Medical Center, Dallas (D.M.O.); Department of Neurology, University of California, Los Angeles (J.L.S.); Department of Medicine, Brigham and Women’s Hospital and Harvard Medical School,
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O'Connor RE, Nichol G, Gonzales L, Manoukian SV, Moyer PH, Rokos I, Sayre MR, Solomon RC, Wingrove GL, Brady WJ, McBride S, Lorden AL, Roettig ML, Acuna A, Jacobs AK. Emergency medical services management of ST-segment elevation myocardial infarction in the United States--a report from the American Heart Association Mission: Lifeline Program. Am J Emerg Med 2014; 32:856-63. [PMID: 24865499 DOI: 10.1016/j.ajem.2014.04.029] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2013] [Revised: 04/06/2014] [Accepted: 04/11/2014] [Indexed: 11/30/2022] Open
Abstract
OBJECTIVE ST-segment elevation myocardial infarction (STEMI) is a major cause of morbidity and mortality in the United States. Emergency medical services (EMS) agencies play a critical role in its initial identification and treatment. We conducted this study to assess EMS management of STEMI care in the United States. METHODS A structured questionnaire was administered to leaders of EMS agencies to define the elements of STEMI care related to 4 core measures: (1) electrocardiogram (ECG) capability at the scene, (2) destination protocols, (3) catheterization laboratory activation before hospital arrival, and (4) 12-lead ECG quality review. Geographic areas were grouped into large metropolitan, small metropolitan, micropolitan, and noncore (or rural) by using Urban Influence Codes, with a stratified analysis. RESULTS Data were included based on responses from 5296 EMS agencies (36% of those in the United States) serving 91% of the US population, with at least 1 valid response from each of the 50 states and the District of Columbia. Approximately 63% of agencies obtained ECGs at the scene using providers trained in ECG acquisition and interpretation. A total of 46% of EMS systems used protocols to determine hospital destination, cardiac catheterization laboratory activation, and communications with the receiving hospital. More than 75% of EMS systems used their own agency funds to purchase equipment, train personnel, and provide administrative oversight. A total of 49% of agencies have quality review programs in place. In general, EMS systems covering higher population densities had easier access to resources needed to maintain STEMI systems of care. Emergency medical services systems that have adopted all 4 core elements cover 14% of the US population. CONCLUSIONS There are large differences in EMS systems of STEMI care in the United States. Most EMS agencies have implemented at least 1 of the 4 core elements of STEMI care, with many having implemented multiple elements.
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Affiliation(s)
- Robert E O'Connor
- Department of Emergency Medicine, University of Virginia School of Medicine, Charlottesville, VA.
| | - Graham Nichol
- University of Washington-Harborview Center for Prehospital Emergency Care, University of Washington, Seattle, WA
| | | | - Steven V Manoukian
- Clinical and Physician Services Group, Hospital Corporation of America, Nashville, TN
| | | | - Ivan Rokos
- Department of Emergency Medicine, Geffen School of Medicine at UCLA, Los Angeles, CA
| | - Michael R Sayre
- Division of Emergency Medicine, Department of Medicine, University of Washington, Seattle, WA
| | | | | | - William J Brady
- Department of Emergency Medicine, University of Virginia School of Medicine, Charlottesville, VA
| | - Susan McBride
- School of Nursing, Texas Tech University Health Sciences Center, Lubbock, TX
| | - Andrea L Lorden
- Department of Health Policy and Management, Texas A&M Health Science Center, College Station, TX
| | | | | | - Alice K Jacobs
- Department of Medicine, Boston University School of Medicine, Boston, MA
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84
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Loh JP, Satler LF, Pendyala LK, Minha S, Frohna WJ, Torguson R, Chen F, Suddath WO, Pichard AD, Waksman R. Use of emergency medical services expedites in-hospital care processes in patients presenting with ST-segment elevation myocardial infarction undergoing primary percutaneous coronary intervention. CARDIOVASCULAR REVASCULARIZATION MEDICINE 2014; 15:219-25. [PMID: 24952684 DOI: 10.1016/j.carrev.2014.03.011] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2014] [Accepted: 03/20/2014] [Indexed: 11/28/2022]
Abstract
To determine whether door-to-balloon (DTB) times of patients presenting with ST-elevation myocardial infarction (STEMI) were reduced in patients transported by emergency medical services (EMS) compared to those who were self-transported. DTB time is an important measure of hospital care processes in STEMI. Use of EMS may expedite in-hospital processing and reduce DTB times. A total of 309 consecutive STEMI patients who underwent primary percutaneous coronary intervention in our institution were analyzed. Excluded were patients who received fibrinolytics, presented in cardiac arrest, were intubated, or were transferred from another hospital. EMS-transported patients (n=83) were compared to self-transported patients (n=226). The primary outcome measure was DTB time and its component time intervals. Secondary end points included symptom-to-door and symptom-to-balloon times, and correlates for DTB >90 minutes. A higher percentage of EMS-transported patients reached the time goal of DTB <90 minutes compared to self-transported patients (83.1 versus 54.3%; p<0.001). EMS-transported patients had shorter DTB times [median (IQR) minutes, 65 (50-86) versus 85 (61-126); p<0.001] due to a reduction of emergency department processing (door-to-call) time, whereas catheterization laboratory processing (call-to-balloon) times were similar in both groups. EMS-transported patients had shorter symptom-to-door [median (IQR) hours, 1.2 (0.8-3.5) versus 2.3 (1.2-7.5); p<0.001] and symptom-to-balloon [median (IQR) hours, 2.5 (1.9-4.7) versus 4.3 (2.6-9.1); p<0.001]. Independent correlates of DTB times >90 minutes were self-transport (odds ratio 5.32, 95% CI 2.65-10.70; p<0.001) and off-hours presentation (odds ratio 2.89, 95% CI 1.60-5.22; p<0.001). Use of EMS transport in STEMI patients significantly shortens time to reperfusion, primarily by expediting emergency department processes. Community education efforts should focus not only on the importance of recognizing symptoms of myocardial infarction, but also taking early action by calling the EMS.
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Affiliation(s)
- Joshua P Loh
- Interventional Cardiology, MedStar Washington Hospital Center, Washington, DC
| | - Lowell F Satler
- Interventional Cardiology, MedStar Washington Hospital Center, Washington, DC
| | | | - Sa'ar Minha
- Interventional Cardiology, MedStar Washington Hospital Center, Washington, DC
| | - William J Frohna
- Department of Emergency Medicine, MedStar Washington Hospital Center, Washington, DC
| | - Rebecca Torguson
- Interventional Cardiology, MedStar Washington Hospital Center, Washington, DC
| | - Fang Chen
- Interventional Cardiology, MedStar Washington Hospital Center, Washington, DC
| | - William O Suddath
- Interventional Cardiology, MedStar Washington Hospital Center, Washington, DC
| | - Augusto D Pichard
- Interventional Cardiology, MedStar Washington Hospital Center, Washington, DC
| | - Ron Waksman
- Interventional Cardiology, MedStar Washington Hospital Center, Washington, DC.
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Dehmer GJ, Blankenship JC, Cilingiroglu M, Dwyer JG, Feldman DN, Gardner TJ, Grines CL, Singh M. SCAI/ACC/AHA Expert Consensus Document: 2014 update on percutaneous coronary intervention without on-site surgical backup. J Am Coll Cardiol 2014; 63:2624-2641. [PMID: 24651052 DOI: 10.1016/j.jacc.2014.03.002] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
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86
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Henry JT, Christiansen E, Garberich RF, Handran CB, Larson DM, Unger BT, Henry TD. Satisfaction with emergent transfer for percutaneous coronary interventions on patients with ST-segment-elevation myocardial infarction and their families. Circ Cardiovasc Qual Outcomes 2014; 7:244-50. [PMID: 24594547 DOI: 10.1161/circoutcomes.113.000641] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Transfer for primary percutaneous coronary intervention (PCI) is superior to fibrinolysis if performed in a timely manner but frequently requires dislocation of patients and their families from their local community. Although patient satisfaction is increasingly viewed as an important quality indicator, there are no data on how emergent transfer for PCI affects patients with ST-segment-elevation myocardial infarction and their families. METHODS AND RESULTS The Minneapolis Heart Institute's Level 1 Regional ST-Segment-Elevation Myocardial Infarction program is designed to facilitate emergent transfer for PCI in patients with ST-segment-elevation myocardial infarction from 31 rural and community hospitals. To determine the effect of emergent transfer, questionnaires were given to 152 patients and their families who survived to hospital discharge with a 65.8% response rate (mean age, 63.9 years; 29% women). Ninety-five percent of patients felt the reasons and process of transfer were well explained, and 97% felt transfer for care was necessary. Despite this, 15% of patients would have preferred to stay in their local hospital. The majority of the families felt the transfer process (88%) and family member's condition (94%) were well explained. Although 99% felt it was necessary for their family member to be transferred for specialized care, 11% of families still would have preferred that their family members remain at the local community hospital. CONCLUSIONS Our results suggest that ST-segment-elevation myocardial infarction patients and families can be informed, even in time-critical situations, about the transfer process for PCI and understand the need for specialized care. Still, a significant minority would prefer to stay at their local hospital, despite acknowledging transfer for PCI provided optimal care.
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Affiliation(s)
- Jason T Henry
- Minneapolis Heart Institute Foundation at Abbott Northwestern Hospital, Minneapolis MN and University of North Dakota Medical School, Grand Forks
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87
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Hogan TM, Olade TO, Carpenter CR. A profile of acute care in an aging America: snowball sample identification and characterization of United States geriatric emergency departments in 2013. Acad Emerg Med 2014; 21:337-46. [PMID: 24628759 DOI: 10.1111/acem.12332] [Citation(s) in RCA: 46] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2013] [Revised: 09/06/2013] [Accepted: 09/07/2013] [Indexed: 11/28/2022]
Abstract
BACKGROUND The aging of America poses a challenge to emergency departments (EDs). Studies show that elderly patients have poor outcomes despite increased testing, prolonged periods of observation, and higher admission rates. In response, emergency medicine (EM) leaders have implemented strategies for improved ED elder care, enhancing expertise, equipment, policies, and protocols. One example is the development of geriatric EDs gaining in popularity nationwide. To the authors' knowledge, this is the first research to systematically identify and qualitatively characterize the existence, locations, and features of geriatric EDs across the United States. OBJECTIVES The primary objective was to determine the number, distribution, and characteristics of geriatric EDs in the United States in 2013. METHODS This was a survey with potential respondents identified via a snowball sampling of known geriatric EDs, EM professional organizations' geriatric interest groups, and a structured search of the Internet using multiple search engines. Sites were contacted by telephone, and those confirming geriatric EDs presence received the survey via e-mail. Category questions included date of opening, location, volumes, staffing, physical plant changes, screening tools, policies, and protocols. Categories were reported based on general interest to those seeking to understand components of a geriatric ED. RESULTS Thirty-six hospitals confirmed geriatric ED existence and received surveys. Thirty (83%) responded to the survey and confirmed presence or plans for geriatric EDs: 24 (80%) had existing geriatric EDs, and six (20%) were planning to open geriatric EDs by 2014. The majority of geriatric EDs are located in the Midwest (46%) and Northeast (30%) regions of the United States. Eighty percent serve from 5,000 to 20,000 elder patients annually. Seventy percent of geriatric EDs are attached to the main ED, and 66% have from one to 10 geriatric beds. Physical plant changes include modifications to beds (96%), lighting (90%), flooring (83%), visual aids (73%), and sound level (70%). Seventy-seven percent have staff overlapping with the nongeriatric portion of their ED, and 80% require geriatric staff didactics. Sixty-seven percent of geriatric EDs report discharge planning for geriatric ED patients, and 90% of geriatric EDs had direct follow-up through patient callbacks. CONCLUSIONS The snowball sample identification of U.S. geriatric EDs resulted in 30 confirmed respondents. There is significant variation in the components constituting a geriatric ED. The United States should consider external validation of self-identified geriatric EDs to standardize the quality and type of care patients can expect from an institution with an identified geriatric ED.
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Affiliation(s)
- Teresita M. Hogan
- The Section of Emergency Medicine; Department of Medicine; University of Chicago School of Medicine; Chicago IL
| | | | - Christopher R. Carpenter
- The Division of Emergency Medicine; Washington University in St. Louis School of Medicine; St. Louis MO
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88
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Tamis-Holland JE, O'Gara P. Highlights from the 2013 ACCF/AHA guidelines for the management of ST-elevation myocardial infarction and beyond. Clin Cardiol 2014; 37:252-9. [PMID: 24523153 DOI: 10.1002/clc.22258] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/26/2013] [Revised: 01/04/2014] [Indexed: 01/18/2023] Open
Abstract
ST-segment elevation myocardial infarction (STEMI) is considered a cardiology emergency requiring immediate recognition and treatment aimed at successful and early reperfusion to ensure optimal outcomes. The American College of Cardiology Foundation (ACCF) and the American Heart Association (AHA) have issued guidelines for the diagnosis and management of patients with acute myocardial infarction since 1990. These guidelines are based on clinical research exploring reperfusion modalities and adjunctive therapies. They are further supported by expert opinion where randomized trial evidence is lacking. In January 2013, the ACCF/AHA released the most recent guidelines for the management of patients with STEMI. This review focuses on the newest and most important recommendations taken from the 2013 ACCF/AHA Guidelines for the Management of STEMI and highlight important new studies that have emerged over the past year.
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89
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Bagai A, Al-Khalidi HR, Sherwood MW, Muñoz D, Roettig ML, Jollis JG, Granger CB. Regional systems of care demonstration project: Mission: Lifeline STEMI Systems Accelerator: design and methodology. Am Heart J 2014; 167:15-21.e3. [PMID: 24332137 DOI: 10.1016/j.ahj.2013.10.005] [Citation(s) in RCA: 37] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/19/2013] [Accepted: 10/14/2013] [Indexed: 10/26/2022]
Abstract
ST-segment elevation myocardial infarction (STEMI) systems of care have been associated with significant improvement in use and timeliness of reperfusion. Consequently, national guidelines recommend that each community should develop a regional STEMI care system. However, significant barriers continue to impede widespread establishment of regional STEMI care systems in the United States. We designed the Regional Systems of Care Demonstration Project: Mission: Lifeline STEMI Systems Accelerator, a national educational outcome research study in collaboration with the American Heart Association, to comprehensively accelerate the implementation of STEMI care systems in 17 major metropolitan regions encompassing >1,500 emergency medical service agencies and 450 hospitals across the United States. The goals of the program are to identify regional gaps, barriers, and inefficiencies in STEMI care and to devise strategies to implement proven recommendations to enhance the quality and consistency of care. The study interventions, facilitated by national faculty with expertise in regional STEMI system organization in partnership with American Heart Association representatives, draw upon specific resources with proven past effectiveness in augmenting regional organization. These include bringing together leading regional health care providers and institutions to establish common commitment to STEMI care improvement, developing consensus-based standardized protocols in accordance with national professional guidelines to address local needs, and collecting and regularly reviewing regional data to identify areas for improvement. Interventions focus on each component of the reperfusion process: the emergency medical service, the emergency department, the catheterization laboratory, and inter-hospital transfer. The impact of regionalization of STEMI care on clinical outcomes will be evaluated.
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90
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Salhi RA, Edwards JM, Gaieski DF, Band RA, Abella BS, Carr BG. Access to care for patients with time-sensitive conditions in Pennsylvania. Ann Emerg Med 2013; 63:572-9. [PMID: 24368055 DOI: 10.1016/j.annemergmed.2013.11.018] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2012] [Revised: 11/17/2013] [Accepted: 11/22/2013] [Indexed: 11/28/2022]
Abstract
STUDY OBJECTIVE Collective knowledge and coordination of vital interventions for time-sensitive conditions (ST-segment elevation myocardial infarction [STEMI], stroke, cardiac arrest, and septic shock) could contribute to a comprehensive statewide emergency care system, but little is known about population access to the resources required. We seek to describe existing clinical management strategies for time-sensitive conditions in Pennsylvania hospitals. METHODS All Pennsylvania emergency departments (EDs) open in 2009 were surveyed about resource availability and practice patterns for time-sensitive conditions. The frequency with which EDs provided essential clinical bundles for each condition was assessed. Penalized maximum likelihood regressions were used to evaluate associations between ED characteristics and the presence of the 4 clinical bundles of care. We used geographic information science to calculate 60-minute ambulance access to the nearest facility with these clinical bundles. RESULTS The percentage of EDs providing each of the 4 clinical bundles in 2009 ranged from 20% to 57% (stroke 20%, STEMI 32%, cardiac arrest 34%, sepsis 57%). For STEMI and stroke, presence of a board-certified/board-eligible emergency physician was significantly associated with presence of a clinical bundle. Only 8% of hospitals provided all 4 care bundles. However, 53% of the population was able to reach this minority of hospitals within 60 minutes. CONCLUSION Reliably matching patient needs to ED resources in time-dependent illness is a critical component of a coordinated emergency care system. Population access to critical interventions for the time-dependent diseases discussed here is limited. A population-based planning approach and improved coordination of care could improve access to interventions for patients with time-sensitive conditions.
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Affiliation(s)
- Rama A Salhi
- Center for Clinical Epidemiology and Biostatistics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - J Matthew Edwards
- Department of Emergency Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - David F Gaieski
- Department of Emergency Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Roger A Band
- Department of Emergency Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Benjamin S Abella
- Department of Emergency Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Brendan G Carr
- Center for Clinical Epidemiology and Biostatistics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA; Department of Emergency Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA; Center for Policy Research, Department of Emergency Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA; Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, PA.
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91
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Bertomeu V, Cequier Á, Bernal JL, Alfonso F, Anguita MP, Muñiz J, Barrabés JA, García-Dorado D, Goicolea J, Elola FJ. Mortalidad intrahospitalaria por infarto agudo de miocardio. Relevancia del tipo de hospital y la atención dispensada. Estudio RECALCAR. Rev Esp Cardiol 2013. [DOI: 10.1016/j.recesp.2013.06.008] [Citation(s) in RCA: 92] [Impact Index Per Article: 8.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
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92
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93
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Hutchison AW, Malaiapan Y, Cameron JD, Meredith IT. Pre-hospital 12 Lead ECG to Triage ST Elevation Myocardial Infarction and Long Term Improvements in Door to Balloon Times: The First 1000 Patients From the MonAMI Project. Heart Lung Circ 2013; 22:910-6. [DOI: 10.1016/j.hlc.2013.07.014] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2012] [Revised: 05/15/2013] [Accepted: 07/15/2013] [Indexed: 11/28/2022]
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94
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Rodriguez-Leor O, Fernandez-Nofrerias E, Mauri J, Carrillo X, Salvatella N, Curos A, Serra J, Oliete C, Rivas C, Bayes-Genis A. Integration of a local into a regional primary angioplasty action plan (the Catalan Codi Infart network) reduces time to reperfusion. Int J Cardiol 2013; 168:4354-7. [DOI: 10.1016/j.ijcard.2013.05.071] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/03/2013] [Accepted: 05/04/2013] [Indexed: 11/15/2022]
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95
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Bertomeu V, Cequier Á, Bernal JL, Alfonso F, Anguita MP, Muñiz J, Barrabés JA, García-Dorado D, Goicolea J, Elola FJ. In-hospital mortality due to acute myocardial infarction. relevance of type of hospital and care provided. RECALCAR study. ACTA ACUST UNITED AC 2013; 66:935-42. [PMID: 24774106 DOI: 10.1016/j.rec.2013.06.006] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2013] [Accepted: 06/07/2013] [Indexed: 11/18/2022]
Abstract
INTRODUCTION AND OBJECTIVES To investigate the relationship between in-hospital mortality due to acute myocardial infarction and type of hospital, discharge service, and treatment provided. METHODS Retrospective analysis of 100 993 hospital discharges with a principal diagnosis of myocardial infarction in hospitals of the Spanish National Health Service. In-hospital mortality was adjusted for risk following the models of the Institute for Clinical Evaluative Sciences (Canada) and the Centers for Medicare & Medicaid Services (United States). RESULTS Hospital characteristics are relevant to explain the variation in the individual probability of dying from myocardial infarction (median odds ratio: 1.3561). The risk-adjusted in-hospital mortality in cluster 3 and especially in cluster 4 hospitals (500 beds to 1000 beds and medium-high complexity) was significantly lower than in hospitals with less than 200 beds. Cluster 5 (more than 1000 beds), which includes a diverse group of hospitals, had a higher mortality rate than clusters 3 and 4. The adjusted mortality in the groups with the best and worst outcomes was 6.74% (cluster 4) and 8.49% (cluster 1), respectively. Mortality was also lower when the cardiology unit was responsible for the discharge or when angioplasty had been performed. CONCLUSIONS The typology of the hospital, treatment in a cardiology unit, and percutaneous coronary intervention are significantly associated with the survival of a patient hospitalized for myocardial infarction. We recommend that the Spanish National Health Service establish health care networks that favor percutaneous coronary intervention and the participation of cardiology units in the management of patients with acute myocardial infarction.
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Affiliation(s)
- Vicente Bertomeu
- Servicio de Cardiología, Hospital San Juan, Universidad Miguel Hernández, Alicante, Spain
| | - Ángel Cequier
- Àrea de Malalties del Cor, Hospital Universitari de Bellvitge, Universitat de Barcelona, L'Hospitalet de Llobregat, Barcelona, Spain
| | - José L Bernal
- Control de Gestión, Hospital 12 de Octubre, Madrid, Spain
| | - Fernando Alfonso
- Departamento de Cardiología Intervencionista, Instituto Cardiovascular, Hospital Universitario Clínico San Carlos, Madrid, Spain
| | | | - Javier Muñiz
- Instituto de Ciencias de la Salud, Universidad de A Coruña, A Coruña, Spain
| | - José A Barrabés
- Servicio de Cardiología, Hospital Universitario Vall d'Hebron, Universidad Autónoma de Barcelona, Barcelona, Spain
| | - David García-Dorado
- Servicio de Cardiología, Hospital Universitario Vall d'Hebron, Universidad Autónoma de Barcelona, Barcelona, Spain
| | - Javier Goicolea
- Unidad de Cardiología Intervencionista, Servicio de Cardiología, Hospital Puerta de Hierro, Majadahonda, Madrid, Spain
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Davis M, Lewell M, McLeod S, Dukelow A. A Prospective Evaluation of the Utility of the Prehospital 12-lead Electrocardiogram to Change Patient Management in the Emergency Department. PREHOSP EMERG CARE 2013; 18:9-14. [DOI: 10.3109/10903127.2013.825350] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
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97
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AlHabib KF, Alfaleh H, Hersi A, Kashour T, Alsheikh-Ali AA, Suwaidi JA, Sulaiman K, Saif SA, Almahmeed W, Asaad N, Amin H, Al-Motarreb A, Thalib L. Use of emergency medical services in the second gulf registry of acute coronary events. Angiology 2013; 65:703-9. [PMID: 24019088 DOI: 10.1177/0003319713502846] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Data are scarce regarding emergency medical service (EMS) usage by patients with acute coronary syndrome (ACS) in the Arabian Gulf region. This 9-month in-hospital prospective ACS registry was conducted in Arabian Gulf countries, with 30-day and 1-year follow-up mortality rates. Of 5184 patients with ACS, 1293 (25%) arrived at the hospital by EMS. The EMS group (vs non-EMS) was more likely to be male, have cardiac arrest on presentation, be current or exsmokers, and have moderate or severe left ventricular dysfunction and ST-segment elevation myocardial infarction (STEMI). The EMS group had higher crude mortality rates during hospitalization and after hospital discharge but not after adjustment for clinical factors and treatments. The EMSs are underused in the Arabian Gulf region. Short- and long-term mortality rates in patients with ACS are similar between those who used and did not use EMS. Quality improvement in the EMS infrastructure and establishment of integrated STEMI networks are urgently needed.
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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
| | - Hussam 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
| | - Alawi A Alsheikh-Ali
- Division of Cardiology, Institute of Cardiac Sciences, Sheikh Khalifa Medical City, Abu Dhabi, United Arab Emirates Tufts Clinical and Translational Science Institute, Tufts Medical Center, Boston, MA, USA
| | - Jassim Al Suwaidi
- Department of Cardiology, Hamad Medical Corporation (HMC), Doha, Qatar
| | | | - Shukri Al Saif
- Saud AlBabtain Cardiac Center, Dammam, Kingdom of Saudi Arabia
| | - Wael Almahmeed
- Department of Cardiology, Sheikh Khalifa Medical City, Abu Dhabi, United Arab Emirates
| | - Nidal Asaad
- Department of Cardiology, Hamad Medical Corporation (HMC), Doha, Qatar
| | - Haitham Amin
- Mohammed Bin Khalifa Cardiac Center, Manama, Bahrain
| | | | - Lukman Thalib
- Faculty of Medicine, Health Sciences Centre, Kuwait University, Kuwait
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Affiliation(s)
- Eric R Bates
- University of Michigan Health System, Ann Arbor, USA
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99
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Henry TD, Jacobs AK, Granger CB. Regional systems of care for ST-elevation myocardial infarction: do they save lives? Am Heart J 2013; 166:389-91. [PMID: 24016484 DOI: 10.1016/j.ahj.2013.06.022] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/26/2013] [Accepted: 06/29/2013] [Indexed: 02/06/2023]
Affiliation(s)
- Timothy D Henry
- Minneapolis Heart Institute Foundation at Abbott Northwestern Hospital, Minneapolis, MN; Boston Medical Center, Boston, MA; Duke Clinical Research Institute, Durham, NC.
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100
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Antman EM. Bypassing the emergency department to improve the process of care for ST-elevation myocardial infarction: necessary but not sufficient. Circulation 2013; 128:322-4. [PMID: 23788526 DOI: 10.1161/circulationaha.113.004195] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
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