Development of Systems of Care for ST-Elevation Myocardial Infarction Patients

Clinical pathway: helicopter scene STEMI protocol to facilitate long-distance transfer for primary PCI

BACKGROUND

The latest American College of Cardiology/American Heart Association guidelines recommend primary percutaneous coronary intervention (PCI) in acute ST-elevation myocardial infarction (STEMI) patients within 90 minutes from presentation to the emergency room. For interhospital transfers, the most recent PCI guidelines recommend first medical contact-to-device times ≤120 minutes. Although PCI-capable hospitals have improved door-to-balloon times, many patients present to non-PCI-capable facilities and have been excluded from national quality measures.

METHODS

In our acute myocardial infarction network, not only do we enable non-PCI hospitals to transfer STEMI patients but empower outside emergency medical services (EMS) to activate the catheterization laboratory team with a burst page and transfer STEMI patients directly from the scene. Data on patient characteristics, outcomes, and time elements were collected for "scene STEMI" patients who circumvented outlying rural non-PCI hospitals and are presented in this case series.

RESULTS

From December 2007 to November 2010, 22 STEMI patients with higher than average acuity were transported by helicopter directly to our medical center for primary PCI. Median distance from the scene to our medical center was 47 miles [25th to 75th interquartile range (IQR) = 39-71 miles]. Median EMS-to-balloon time was 120 minutes (IQR = 111-134 minutes). There were no false activations by EMS. In comparison, our median time for interhospital STEMI transfers (N = 335) was 145 minutes (IQR = 121-186 minutes) from 2007 to 2009.

CONCLUSIONS

In our single-center experience, 22 scene STEMI patients were diagnosed and appropriately triaged by EMS to our center for primary PCI. Our data show feasibility of an EMS-activated STEMI network over long distances with good reperfusion times.

Current reperfusion strategies for ST-elevation myocardial infarction in an academic medical center in a developing country: efficacy of primary percutaneous coronary intervention

OBJECTIVES

To study the reperfusion strategies currently being used in the treatment of ST-elevation myocardial infarction (STEMI) at an academic medical center in a developing country and to analyze the door-to-balloon time (DBT) in those patients undergoing primary percutaneous coronary intervention (PCI).

METHODS

The study included all patients presenting with STEMI to the emergency department at the American University of Beirut Medical Center between July 2008 and February 2010. Data were collected prospectively from the patients' medical records.

RESULTS

The study population consisted of 100 consecutive patients. Compared with an earlier study from American University of Beirut Medical Center done in 2002-2005, there was a significant increase in the utilization of primary PCI for reperfusion (81% vs. 2.5%; P < 0.001). However, the median DBT was 110 minutes, with only 30% of patients achieving a DBT ≤90 minutes. The predictors of delayed DBT (>90 minutes) were culprit lesions in the circumflex artery (P = 0.007) and delayed time from electrocardiogram to arrival in the catheterization laboratory (P < 0.001).

CONCLUSIONS

There was a significant increase in the utilization of primary PCI for reperfusion of STEMI in this academic medical center in a developing country. However, achieving a target DBT ≤90 minutes was suboptimal. Future studies are needed to analyze the logistic factors associated with delayed reperfusion to institute policies and systems that can enhance the efficacy of primary PCI as a reperfusion modality in these countries.

Reperfusion strategies and systems of care in ST-elevation myocardial infarction

Approximately 330,000 ST-elevation myocardial infarctions (STEMI) occur yearly in the United States. Emergent reperfusion is the cornerstone of STEMI therapy and the key to restoration of coronary blood flow in an infarct-related vessel. Reperfusion methods include thrombolysis, primary percutaneous coronary intervention, or both methods combined. Selection of the appropriate reperfusion strategy is essential, along with having an efficient system of care capable of delivering these therapies. Timely reperfusion is highly dependent on a well-structured care system designed to meet the needs of each individual community. This article reviews the data behind different reperfusion strategies and introduces successful systems-of-care models.

"Register and Roll": A Novel Initiative to Improve First Door-to-Balloon Time in ST Elevation Myocardial Infarction

Objective. We examined the cause of transfer delay in patients with an acute ST-segment myocardial infarction (STEMI) from non percutaneous coronary intervention (PCI) capable to PCI capable hospitals. We then implemented a novel, simple, and reliable initiative to improve the transfer process. Background. Guidelines established by the ACC/AHA call for door-to-balloon times of ≤90 minutes for patients with STEMI. When hospital transfer is necessary, this is only met in 8.6% of cases. Methods. All patients presenting with STEMI to a non-PCI capable hospital from April 2006 to February 2009 were analyzed retrospectively. After identifying causes of transfer delay the “Register and Roll” initiative was developed. An analysis of effect was conducted from March 2009 to July 2011. Results. 144 patients were included, 74 pre-initiative and 70 post- initiative. Time to EMS activation was a major delay in patient transfer. After implementation, the EMS activation time has significantly decreased and time to reperfusion approaches recommended goal (Median 114 min versus 90 min, P < 0.001), with 55% in <90 minutes. Conclusion. “Register and Roll” streamlines the triage process and improves hospital transfer times. This initiative is easily instituted and reliable in a community hospital setting where resources are limited.

Myocardial infarction: sex differences in symptoms reported to emergency dispatch

BACKGROUND

Emergency management of myocardial infarction (MI) is time-critical, because improved patient outcomes are associated with reduced time from symptom onset to definitive care. Previous studies have identified that women are less likely to present with chest pain.

OBJECTIVE

We sought to measure the effect of sex on symptoms reported to the ambulance dispatch and ambulance times for MI patients.

METHODS

The Western Australia Emergency Department Information System (EDIS) was used to identify patients with emergency department (ED) diagnoses of MI (ST-segment elevation MI and non-ST-segment elevation MI) who arrived by ambulance between January 1, 2008, and October 31, 2009. Their emergency telephone calls to the ambulance service were transcribed to identify presenting symptoms. Ambulance data were used to examine ambulance times. Sex differences were analyzed using descriptive and age-adjusted regression analysis.

RESULTS

Of 3,329 MI patients who presented to Perth EDs, 2,100 (63.1%) arrived by ambulance. After predefined exclusions, 1,681 emergency calls were analyzed. The women (n = 621; 36.9%) were older than the men (p < 0.001) and, even after age adjustment, were less likely to report chest pain (odds ratio [OR] = 0.70; 95% confidence interval [CI] 0.57, 0.88). After age adjustment, ambulance times did not differ between the male and female patients with chest pain. The women with chest pain were less likely than the men with chest pain to be allocated a "priority 1" (lights and sirens) ambulance response (men 98.3% vs. women 95.5%; OR = 0.39; 95% CI 0.18, 0.87).

CONCLUSION

Ambulance dispatch officers (and paramedics) need to be aware of potential sex differences in MI presentation in order to ensure appropriate ambulance response.

The incomplete infrastructure for interhospital patient transfer

OBJECTIVE

Interhospital transfer of critically ill patients is a common part of their care. This article sought to review the data on the current patterns of use of interhospital transfer and identify systematic barriers to optimal integration of transfer as a mechanism for improving patient outcomes and value of care.

DATA SOURCE

Narrative review of medical and organizational literature.

SUMMARY

Interhospital transfer of patients is common, but not optimized to improve patient outcomes. Although there is a wide variability in quality among hospitals of nominally the same capability, patients are not consistently transferred to the highest quality nearby hospital. Instead, transfer destinations are selected by organizational routines or non-patient-centered organizational priorities. Accomplishing a transfer is often quite difficult for sending hospitals. But once a transfer destination is successfully found, the mechanics of interhospital transfer now appear quite safe.

CONCLUSION

Important technological advances now make it possible to identify nearby hospitals best able to help critically ill patients, and to successfully transfer patients to those hospitals. However, organizational structures have not yet developed to insure that patients are optimally routed, resulting in potentially significant excess mortality.

Setting Up a Population-Based Program to Optimize ST-Segment Elevation Myocardial Infarction Care

The development of ST-segment elevation myocardial infarction (STEMI) systems of care at the city, region, or nation levels has not only improved the speed of reperfusion but also enhanced the reach of primary angioplasty to areas far from percutaneous coronary intervention (PCI) centers. Setting up a STEMI system of care is a sophisticated process that requires a solid PCI hospital and emergency medical services infrastructure, disciplined collaboration, and a focus on outcomes measurement and continuous quality improvement. This article reviews the accumulated evidence supporting the development of STEMI systems of care and offers practical insights into this process.

The utility of the prehospital electrocardiogram

OBJECTIVES

The 12-lead electrocardiogram (ECG) can capture valuable information in the prehospital setting. By the time patients are assessed by an emergency department (ED) physician, their symptoms and any ECG changes may have resolved. We sought to determine whether the prehospital electrocardiogram (pECG) could influence ED management and how often the pECG was available to and reviewed by the ED physician.

METHODS

A retrospective medical record review was conducted on a random sample of patients ≥ 18 years who had a prehospital 12-lead ECG and were transported to one of two tertiary care centres. Data were recorded onto a standardized data extraction tool. Three investigators independently compared the pECG to the first ECG obtained in the ED after patient arrival at the hospital. Any abnormalities not present on the ED ECG were adjudicated to ascertain whether they had the potential to change ED management.

RESULTS

Of 115 ambulance runs selected, 47 had no pECG attached to the ambulance call record (ACR) and another 5 were excluded (one ST elevation myocardial infarction, one cardiac arrest, three ACR missing). Of the 63 pECGs reviewed, 16 (25%) showed changes not apparent on the initial ED ECG (κ  =  0.83; 95% CI 0.74-0.93), of which 12 had differences that might influence ED management (κ  =  0.76; 95% CI 0.72-0.82). Only one hospital record contained a copy of the pECG, despite the current protocol that paramedics print two copies of the pECG on arrival in the ED (one copy for the ACR and one to be handed to the medical personnel). None of 110 ED charts documented that the pECG was reviewed by the ED physician.

CONCLUSION

The pECG has the potential to influence ED management. Improvement in paramedic and physician documentation and a formal pECG handover process appear necessary.

Expansion of a Regional ST-Segment–Elevation Myocardial Infarction System to an Entire State

Background—

Despite national guidelines calling for timely coronary artery reperfusion, treatment is often delayed, particularly for patients requiring interhospital transfer.

Methods and Results—

One hundred nineteen North Carolina hospitals developed coordinated plans to rapidly treat patients with ST-segment–elevation myocardial infarction according to presentation: walk-in, ambulance, or hospital transfer. A total of 6841 patients with ST-segment–elevation myocardial infarction (3907 directly presenting to 21 percutaneous coronary intervention hospitals, 2933 transferred from 98 non–percutaneous coronary intervention hospitals) were treated between July 2008 and December 2009 (age, 59 years; 30% women; 19% uninsured; chest pain duration, 91 minutes; shock, 9.2%). The rate of patients not receiving reperfusion fell from 5.4% to 4.0% ( P =0.04). Treatment times for hospital transfer patients substantially improved. First-hospital-door-to-device time for hospitals that adopted a “transfer for percutaneous coronary intervention” reperfusion strategy fell from 117 to 103 minutes ( P =0.0008), whereas times at hospitals with a mixed strategy of transfer or fibrinolysis fell from 195 to 138 minutes ( P =0.002). Median door-to-device times for patients presenting directly to PCI hospitals fell from 64 to 59 minutes ( P <0.001). Emergency medical services–transported patients were most likely to reach door-to-device goals, with 91% treated within 90 minutes and 52% being treated with 60 minutes. Patients treated within guideline goals had a mortality of 2.2% compared with 5.7% for those exceeding guideline recommendations ( P <0.001).

Conclusion—

Through extension of regional coordination to an entire state, rapid diagnosis and treatment of ST-segment–elevation myocardial infarction has become an established standard of care independently of healthcare setting or geographic location.

Systems of Care for ST-Segment–Elevation Myocardial Infarction: A Report From the American Heart Association’s Mission: Lifeline

Background—

National guidelines call for participation in systems to rapidly diagnose and treat ST-segment–elevation myocardial infarction (STEMI). In order to characterize currently implemented STEMI reperfusion systems and identify practices common to system organization, the American Heart Association surveyed existing systems throughout the United States.

Methods and Results—

A STEMI system was defined as an integrated group of separate entities focused on reperfusion therapy for STEMI within a geographic region that included at least 1 hospital that performs percutaneous coronary intervention and at least 1 emergency medical service agency. Systems meeting this definition were invited to participate in a survey of 42 questions based on expert panel opinion and knowledge of existing systems. Data were collected through the American Heart Association Mission: Lifeline website.

Between April 2008 and January 2010, 381 unique systems involving 899 percutaneous coronary intervention hospitals in 47 states responded to the survey, of which 255 systems (67%) involved urban regions. The predominant funding sources for STEMI systems were percutaneous coronary intervention hospitals (n = 320, 84%) and /or cardiology practices (n = 88, 23%). Predominant system characteristics identified by the survey included: STEMI patient acceptance at percutaneous coronary intervention hospital regardless of bed availability (N = 346, 97%); single phone call activation of catheterization laboratory (N = 335, 92%); emergency department physician activation of laboratory without cardiology consultation (N = 318, 87%); data registry participation (N = 311, 84%); and prehospital activation of the laboratory through emergency department notification without cardiology notification (N = 297, 78%). The most common barriers to system implementation were hospital (n = 139, 37%) and cardiology group competition (n = 81, 21%) and emergency medical services transport and finances (n = 99, 26%).

Conclusions—

This survey broadly describes the organizational characteristics of collaborative efforts by hospitals and emergency medical services to provide timely reperfusion in the United States. These findings serve as a benchmark for existing systems and should help guide healthcare teams in the process of organizing care for patients with STEMI.

Pre PCI hospital antithrombotic therapy for ST elevation myocardial infarction: striving for consensus

Strong evidence exists in favor of rapid transfer of a patient suffering an ST-elevation myocardial infarction (STEMI) to the nearest hospital with primary percutaneous coronary intervention (PCI) capability, assuming the time from first medical contact to balloon inflation can be achieved in less than 90 min. In many areas, PCI hospitals have successfully collaborated with regional non-PCI hospitals to provide primary PCI for STEMI; however, significant variations exist in how these programs are executed. For example, the pre PCI hospital administration of antithrombotic agents by emergency medical personnel can include aspirin, clopidogrel, unfractionated heparin, low molecular weight heparin, partial or full dose fibrinolytics or combinations thereof. There is little consensus on the optimal cocktail, dose and route of administration. Standardizing the pre PCI antithrombotic regimen across hospital systems may be one approach to improve timely administration of these therapies, and potentially improve STEMI outcomes.

Prevalence of acute myocardial infarction in patients with presumably new left bundle-branch block

OBJECTIVES

We assessed the prevalence of true acute myocardial infarction and the need for emergent revascularization among patients with new or presumably new left bundle branch block (nLBBB) for whom the primary percutaneous coronary intervention protocol was activated.

METHODS AND RESULTS

Among 802 patients, 69 (8.6%) had nLBBB. The chief presenting symptom was chest pain or cardiac arrest in 36 patients (52.2%) and shortness of breath in 15 (21.7%). Less than 30% of the patients had elevated cardiac troponin-I, and less than 10% had elevated creatine kinase-MB. Only 11.6% of the patients underwent emergent revascularization; the rate was higher for patients who presented with chest pain or cardiac arrest or shortness of breath than for patients who presented with other symptoms.

CONCLUSIONS

Acute myocardial infarction and the need for emergent revascularization are relatively uncommon among patients who present with nLBBB, especially when symptoms are atypical. Current guidelines for primary percutaneous coronary intervention protocol activation for nLBBB should be reconsidered.

Rates of Cardiac Catheterization Cancelation for ST-Segment Elevation Myocardial Infarction After Activation by Emergency Medical Services or Emergency Physicians

Background—

For patients with an acute ST-segment elevation myocardial infarction, cardiac catheterization laboratory (CCL) activation by emergency medical technicians or emergency physicians has been shown to substantially reduce treatment times. One drawback to this approach involves overtriage, whereby CCL staffs are activated for patients who ultimately do not require emergent coronary angiography or for patients who undergo angiography but are not found to have coronary artery occlusion.

Methods and Results—

We examined CCL activation at 14 primary angioplasty hospitals to determine the course of management, including the rate of inappropriate activation. Among 3973 activations (29% by emergency medical technicians, 71% by emergency physicians) between December 2008 and December 2009, appropriate CCL activations occurred for 3377 patients (85%), with 2598 patients (76.9% of appropriate activations) receiving primary percutaneous coronary intervention. Reasons for inappropriate activations (596 patients; 15%) included ECG reinterpretations (427 patients; 72%) or the fact that the patient was not a CCL candidate (169 patients; 28%). The rate of cancellation because of reinterpretation of emergency medical technicians' ECG (6% of all activations) was more common than for cancellation because of reinterpretation of emergency physicians' ECG (4.6%).

Conclusions—

This represents the first report of the rates of CCL cancellation for ST-segment elevation myocardial infarction system activation by emergency medical technicians and emergency physicians in a large group of hospitals organized within a statewide program. The high rate of coronary intervention and relatively low rate of inappropriate activation suggest that systematic CCL activation by emergency personnel on a broad scale is feasible and accurate, and these rates set a benchmark for ST-segment elevation myocardial infarction systems.

Prehospital 12-Lead Electrocardiogram within 60 Minutes Differentiates Proximal versus Nonproximal Left Anterior Descending Artery Myocardial Infarction

Introduction

Acute anterior myocardial infarctions caused by proximal left anterior descending (LAD) artery occlusions are associated with a higher morbidity and mortality. Early identification of high-risk patients via the 12-lead electrocardiogram (ECG) could assist physicians and emergency response teams in providing early and aggressive care for patients with anterior ST-elevation myocardial infarctions (STEMI). Approximately 25% of US hospitals have primary percutaneous coronary intervention (PCI) capability for the treatment of acute myocardial infarctions. Given the paucity of hospitals capable of PCI, early identification of more severe myocardial infarction may prompt emergency medical service routing of these patients to PCI-capable hospitals. We sought to determine if the 12 lead ECG is capable of predicting proximal LAD artery occlusions.

Methods

In a retrospective, post-hoc analysis of the Pre-Hospital Administration of Thrombolytic Therapy with Urgent Culprit Artery Revascularization pilot trial, we compared the ECG findings of proximal and nonproximal LAD occlusions for patients who had undergone an ECG within 180 minutes of symptom onset.

Results

In this study, 72 patients had anterior STEMIs, with ECGs performed within 180 minutes of symptom onset. In patients who had undergone ECGs within 60 minutes (n = 35), the mean sum of ST elevation (STE) in leads V1 through V6 plus ST depression (STD) in leads II, III, and aVF was 19.2 mm for proximal LAD occlusions and 11.7 mm for nonproximal LAD occlusions (P = 0.007). A sum STE in V1 through V6 plus STD in II, III, and aVF of at least 17.5 mm had a sensitivity of 52.3%, specificity of 92.9%, positive predictive value of 91.7%, and negative predictive value of 56.5% for proximal LAD occlusions. When the ECG was performed more than 60 minutes after symptom onset (n = 37), there was no significant difference in ST-segment deviation between the 2 groups.

Conclusion

The sum STE (V1-V6) and STD (II, III, aVF) on a 12-lead ECG can be used to predict proximal LAD occlusions if performed within the first hour of symptom onset. This should be considered a high-risk finding and may prompt prehospital direction of such patients to PCI-capable hospitals.

A percutaneous coronary intervention lab in every hospital?

BACKGROUND

In 2001, 1176 US hospitals were capable of performing primary percutaneous coronary intervention (PCI), and 79% of the population lived within 60-minute ground transport of these hospitals. We compared these estimates with data from 2006 to explore how hospital PCI capability and population access have changed over time.

METHODS AND RESULTS

We estimated the proportion of the population 18 years of age or older, living in 2006 within a 60-minute drive of a PCI-capable hospital, and we compared our estimate with a previously published report on 2001 data. Over the 5-year period, the number of PCI-capable hospitals grew from 1176 to 1695 hospitals, a relative increase of 44%; access to the procedure grew from 79.0% to 79.9% of the population, a relative increase of 1%.

CONCLUSIONS

Our data indicate a large increase in the number of hospitals capable of performing PCI from 2001 to 2006, but this increase was not associated with an appreciable change in the proportion of the population with access to the procedure. In the future, more attention is needed on changes in PCI capacity over time and on the effects of these changes on outcomes of interest such as service utilization, expenditures, patient outcomes, and population health.

Pre-hospital ECG in patients undergoing primary percutaneous interventions within an integrated system of care: reperfusion times and long-term survival benefits

AIMS

Treatment delay is a powerful predictor of survival in STEMI patients undergoing primary PCI. We investigated the effectiveness of pre-hospital triage with direct referral to PCI, alongside more conventional referral strategies.

METHODS AND RESULTS

From January 2003 to December 2007, 1,619 STEMI patients were referred for primary PCI at our cathlab through two main triage groups: i.e., 1) following pre-hospital triage (n=524), 2) via more conventional triages (n=1,095) represented by the S. Orsola-Malpighi hospital emergency department triage (hub hospital) and local hospital triage. Pre-hospital diagnosis was associated with a 76 minute reduction in pain-to-balloon time (143 [107-216] vs. 219 [149-343], p=0.001) allowing mechanical revascularisation within 90 minutes from the first medical contact in the vast majority of the patients (>80%). Clinically, pre-hospital triage showed no significant reductions in terms of adjusted long-term mortality (HR 0.81, 95% CI 0.61-1.08; p=0.16) in the overall population. However, significant adjusted survival benefits were observed in high-risk groups (i.e., cardiogenic shock, TIMI risk score >30, diabetes mellitus).

CONCLUSIONS

This study shows that pre-hospital diagnosis allows for significant reductions in primary PCI treatment delays and suggests the hypothesis that this referral strategy might provide long-term survival benefits especially in high-risk patients.

Teleconsultation in pre-hospital emergency medical services: real-time telemedical support in a prospective controlled simulation study

BACKGROUND

Teleconsultation from the scene of an emergency to an experienced physician including real-time transmission of monitoring, audio and visual information seems to be feasible. In preparation for bringing such a system into practice within the research project "Med-on-@ix", a simulation study has been conducted to investigate whether telemedical assistance (TMA) in Emergency Medical Services (EMS) has an impact on compatibility to guidelines and timing.

MATERIAL AND METHODS

In a controlled simulation study 29 EMS teams (one EMS physician, two paramedics) ran through standardized scenarios (STEMI: ST-elevation myocardial infarction; MT: major trauma) on high-fidelity patient simulators with defined complications (treatable clearly following guidelines). Team assignments were randomized and each team had to complete one scenario with and another without TMA. Analysis was based on videotaped scenarios using pre-defined scoring items and measured time intervals for each scenario.

RESULTS

Adherence to treatment algorithms improved using TMA. STEMI: cathlab informed (9/14 vs. 15/15; p=0.0169); allergies checked prior to acetylsalicylic acid (5/14 vs. 13/15; p=0.0078); analgosedation prior to cardioversion (10/14 vs. 15/15; p=0.0421); synchronized shock (6/14 vs. 14/15; p=0.0052). MT: adequate medication for intubation (3/15 vs. 10/14; p=0.0092); mean time to inform trauma centre 547 vs. 189 s (p=0.0001). No significant impairment of performance was detected in TMA groups.

CONCLUSIONS

In simulated setting TMA was able to improve treatment and safety without decline in timing. Nevertheless, further research is necessary to optimize the system for medical, organizational and technical reasons prior to the evaluation of this system in routine EMS.

Age and its relationship to acute coronary syndromes in the Saudi Project for Assessment of Coronary Events (SPACE) registry: The SPACE age study

OBJECTIVE

To characterize risk profile of acute coronary syndrome (ACS) patients in different age groups and compare management provided to in-hospital outcome.

DESIGN

Prospective multi-hospital registry.

SETTING

Seventeen secondary and tertiary care hospitals in Saudi Arabia.

PATIENTS

Five thousand and fifty-five patients with ACS. They were divided into four groups: ⩽40 years, 41-55 years, 56-70 years and ⩾70 years.

MAIN OUTCOME MEASURES

prevalence, utilization and mortality.

RESULTS

Ninety-four percent of patients <40 years compared to 68% of patients >70 years were men. Diabetes was present in 70% of patients aged 56-70 years. Smoking was present in 66% of those <40 years compared to 7% of patients >70 years. Fifty-three percent of the patients >70 years and 25% of those <40 years had history of ischemic heart disease. Sixty percent of patients <40 years presented with ST elevation myocardial infarction (STEMI) while non-ST elevation myocardial infarction was the presentation in 49% of patients >70 years. Thirty-four percent of patients >70 years compared to 10% of patients <40 years presented >12 h from symptom onset with STEMI. Fifty-four percent of patients >70 compared to 64-71% of those <70 years had coronary angiography. Twenty-four percent of patients >70 compared to 34-40% of those <70 years had percutaneous coronary intervention. Reperfusion shortfall for STEMI was 16-18% in patients >56 years compared to 11% in patients <40 years. Mortality was 7% in patients >70 years compared to 1.6-3% in patients <70 years. For all comparisons (p < 0.001).

CONCLUSIONS

Young and old ACS patients have unique risk factors and present differently. Older patients have higher in-hospital mortality as they are treated less aggressively. There is an urgent need for a national prevention program as well as a systematic improvement in the care for patients with ACS including a system of care for STEMI patients. For older patients there is a need to identify medical as well as social factors that influence the therapeutic management plans.

Hospital process intervals, not EMS time intervals, are the most important predictors of rapid reperfusion in EMS Patients with ST-segment elevation myocardial infarction

OBJECTIVE

To assess the relationship of emergency medical services (EMS) intervals and internal hospital intervals to the rapid reperfusion of patients with ST-segment elevation myocardial infarction (STEMI).

METHODS

We performed a secondary analysis of a prospectively collected database of STEMI patients transported to a large academic community hospital between January 1, 2004, and December 31, 2009. EMS and hospital data intervals included EMS scene time, transport time, hospital arrival to myocardial infarction (MI) team activation (D2Page), page to catheterization laboratory arrival (P2Lab), and catheterization laboratory arrival to reperfusion (L2B). We used two outcomes: EMS scene arrival to reperfusion (S2B) ≤90 minutes and hospital arrival to reperfusion (D2B) ≤90 minutes. Means and proportions are reported. Pearson chi-square and multivariate regression were used for analysis.

RESULTS

During the study period, we included 313 EMS-transported STEMI patients with 298 (95.2%) MI team activations. Of these STEMI patients, 295 (94.2%) were taken to the cardiac catheterization laboratory and 244 (78.0%) underwent percutaneous coronary intervention (PCI). For the patients who underwent PCI, 127 (52.5%) had prehospital EMS activation, 202 (82.8%) had D2B ≤90 minutes, and 72 (39%) had S2B ≤90 minutes. In a multivariate analysis, hospital processes EMS activation (OR 7.1, 95% CI 2.7, 18.4], Page to Lab [6.7, 95% CI 2.3, 19.2] and Lab arrival to Reperfusion [18.5, 95% CI 6.1, 55.6]) were the most important predictors of Scene to Balloon ≤ 90 minutes. EMS scene and transport intervals also had a modest association with rapid reperfusion (OR 0.85, 95% CI 0.78, 0.93 and OR 0.89, 95% CI 0.83, 0.95, respectively). In a secondary analysis, Hospital processes (Door to Page [OR 44.8, 95% CI 8.6, 234.4], Page 2 Lab [OR 5.4, 95% CI 1.9, 15.3], and Lab arrival to Reperfusion [OR 14.6 95% CI 2.5, 84.3]), but not EMS scene and transport intervals were the most important predictors D2B ≤90 minutes.

CONCLUSIONS

In our study, hospital process intervals (EMS activation, door to page, page to laboratory, and laboratory to reperfusion) are key covariates of rapid reperfusion for EMS STEMI patients and should be used when assessing STEMI care.

Improving door-to-needle times in acute ischemic stroke: the design and rationale for the American Heart Association/American Stroke Association's Target: Stroke initiative

BACKGROUND AND PURPOSE

The benefits of intravenous tissue-type plasminogen activator (tPA) in acute ischemic stroke are time-dependent, and guidelines recommend a door-to-needle time of ≤60 minutes. However, fewer than one third of acute ischemic stroke patients who receive tPA are treated within guideline-recommended door-to-needle times. This article describes the design and rationale of

TARGET

Stroke, a national initiative organized by the American Heart Association/American Stroke Association in partnership with other organizations to assist hospitals in increasing the proportion of tPA-treated patients who achieve guideline-recommended door-to-needle times.

METHODS

The initial program goal is to achieve a door-to-needle time≤60 minutes for at least 50% of acute ischemic stroke patients. Key best practice strategies previously associated with achieving faster door-to-needle times in acute ischemic stroke were identified.

RESULTS

The 10 key strategies chosen by

TARGET

Stroke include emergency medical service prenotification, activating the stroke team with a single call, rapid acquisition and interpretation of brain imaging, use of specific protocols and tools, premixing tPA, a team-based approach, and rapid data feedback. The program includes many approaches intended to promote hospital participation, implement effective strategies, share best practices, foster collaboration, and achieve stated goals. A detailed program evaluation is also included. In the first year,

TARGET

Stroke has enrolled over 1200 United States hospitals.

CONCLUSIONS

TARGET

Stroke, a multidimensional initiative to improve the timeliness of tPA administration, aims to elevate clinical performance in the care of acute ischemic stroke, facilitate the more rapid integration of evidence into clinical practice, and improve outcomes.

Care Processes Associated With Quicker Door-In–Door-Out Times for Patients With ST-Elevation–Myocardial Infarction Requiring Transfer

Background—

The ability to rapidly identify patients with ST-segment elevation–myocardial infarction (STEMI) at hospitals without percutaneous coronary intervention (PCI) and transfer them to hospitals with PCI capability is critical to STEMI regionalization efforts. Our objective was to assess the association of prehospital, emergency department (ED), and hospital processes of care implemented as part of a statewide STEMI regionalization program with door-in–door-out times at non-PCI hospitals.

Methods and Results—

Door-in–door-out times for 436 STEMI patients at 55 non-PCI hospitals were determined before (July 2005 to September 2005) and after (January 2007 to March 2007) a year-long implementation of standardized protocols as part of a statewide regionalization program (Reperfusion of Acute Myocardial Infarction in North Carolina Emergency Departments, RACE). The association of 8 system care processes (encompassing emergency medical services [EMS], ED, and hospital settings) with door-in–door-out times was determined using multivariable linear regression. Median door-in–door-out times improved significantly with the intervention (before: 97.0 minutes, interquartile range, 56.0 to 160.0 minutes; after: 58.0 minutes, interquartile range, 35.0 to 90.0 minutes; P <0.0001). Hospital, ED, and EMS care processes were each independently associated with shorter door-in–door-out times (−17.7 [95% confidence interval, −27.5 to −7.9]; −10.1 [95% confidence interval, −19.0 to −1.1], and −7.3 [95% confidence interval, −13.0 to −1.5] minutes for each additional hospital, ED, and EMS process, respectively). Combined, adoption of EMS processes was associated with the shortest median treatment times (44 versus 138 minutes for hospitals that adopted all EMS processes versus none).

Conclusions—

Prehospital, ED, and hospital processes of care were independently associated with shorter door-in–door-out times for STEMI patients requiring transfer. Adoption of several EMS processes was associated with the largest reduction in treatment times. These findings highlight the need for an integrated, system-based approach to improving STEMI care.

Use of emergency medical service transport among patients with ST-segment-elevation myocardial infarction: findings from the National Cardiovascular Data Registry Acute Coronary Treatment Intervention Outcomes Network Registry-Get With The Guidelines

BACKGROUND

Activation of emergency medical services (EMS) is critical for the early triage and treatment of patients experiencing ST-segment-elevation myocardial infarction, yet data regarding EMS use and its association with subsequent clinical care are limited.

METHODS AND RESULTS

We performed an observational analysis of 37 634 ST-segment-elevation myocardial infarction patients treated at 372 US hospitals participating in the National Cardiovascular Data Registry Acute Coronary Treatment and Intervention Outcomes Network Registry-Get With the Guidelines between January 2007 and September 2009, and examined independent patient factors associated with EMS transportation versus patient self-transportation. We found that EMS transport was used in only 60% of ST-segment-elevation myocardial infarction patients. Older patients, those living farther from the hospital, and those with hemodynamic compromise were more likely to use EMS transport. In contrast, race, income, and education level did not appear to be associated with the mode of transport. Compared with self-transported patients, EMS-transported patients had significantly shorter delays in both symptom-onset-to-arrival time (median, 89 versus 120 minutes; P<0.0001) and door-to-reperfusion time (median door-to-balloon time, 63 versus 76 minutes; P<0.0001; median door-to-needle time, 23 versus 29 minutes; P<0.0001).

CONCLUSIONS

Emergency medical services transportation to the hospital is underused among contemporary ST-segment-elevation myocardial infarction patients. Nevertheless, use of EMS transportation is associated with substantial reductions in ischemic time and treatment delays. Community education efforts are needed to improve the use of emergency transport as part of system-wide strategies to improve ST-segment-elevation myocardial infarction reperfusion care.

Which patients and where: a qualitative study of patient transfers from community hospitals

BACKGROUND

Interhospital transfer of patients is a routine part of the care at community hospitals, but the current process may lead to suboptimal patient outcomes. A microlevel analysis of the processes of patient transfer has not earlier been carried out.

RESEARCH DESIGN

We conducted semistructured qualitative interviews with care providers at 3 purposively sampled community hospitals to describe patient transfer mechanisms, focusing on perceptions of transfers and transfer candidates, choice of transfer destination, and perceived process. We interviewed physicians, nurses, and care technicians from emergency departments and intensive care units at the hospitals, and analyzed the resultant transcripts by content analysis.

RESULTS

Appropriate triage and the transfer of patients was a highly valued skill at the community hospitals. On the basis of participant accounts, the transfer process had 4 components: (1) Identifying transfer-eligible patients; (2) Identifying a destination hospital; (3) Negotiating the transfer; and (4) Accomplishing the transfer. There were common challenges at each component across hospitals. Protocolization of care was perceived to substantially facilitate transfers. Informal arrangements played a key role in the identification of the receiving hospital, but patient preferences and hospital quality were not discussed as important in decision making. The process of arranging a patient transfer placed a significant burden on the staff of community hospitals.

CONCLUSIONS

The patient transfer process is often cumbersome, varies by condition, and may not be focused on optimizing patient outcomes. Development of a more fluid transfer infrastructure may aid in implementing policies such as selective referral and regionalization.

Utility of left bundle branch block as a diagnostic criterion for acute myocardial infarction

The clinical utility of new or "presumably new" left bundle branch block (LBBB) as an electrocardiographic criterion equivalent to ST-segment elevation myocardial infarction in contemporary practice is not well established. The aim of this study was to investigate the hypothesis that new or presumably new LBBB in symptomatic patients frequently leads to an overdiagnosis of acute myocardial infarction (AMI). A retrospective analysis of data from consecutive patients in the Mayo Clinic's ST-segment elevation myocardial infarction network from July 2004 to August 2009 was conducted among 892 patients, 36 (4%) of whom had new LBBB. The frequency, clinical characteristics, serum troponin levels, coronary angiographic findings, and outcomes of patients with new LBBB suspected of having AMI were evaluated. Compared with patients without LBBB (n = 856), those with new LBBB were older (64.5 vs 72.9 years, p < 0.001), had higher Thrombolysis In Myocardial Infarction (TIMI) risk scores (22.7 vs 31.0, p < 0.005), were less likely to undergo primary percutaneous coronary intervention (86% vs 22%, p < 0.001), and had longer door-to-balloon times. Only 14 patients (39%) had final diagnoses of acute coronary syndromes, of which 12 were AMI, while 13 (36%) had cardiac diagnoses other than acute coronary syndrome and 9 (25%) had noncardiac diagnoses. Of the patients with AMI, 5 had occluded culprit arteries, of which 2 involved the left anterior descending coronary artery. A Sgarbossa score ≥ 5 had low sensitivity (14%) but 100% specificity in diagnosing AMI in the presence of new LBBB. In conclusion, new or presumably new LBBB in patients suspected of having AMI identifies a high-risk subgroup, but only a small number have AMI. Two thirds of these patients are discharged from the hospital with alternative diagnoses. The Sgarbossa criteria appear to have limited utility in clinical practice because of their low sensitivity.

A simple strategy improves prehospital electrocardiogram utilization and hospital treatment for patients with acute coronary syndrome (from the ST SMART Study)

Although the American Heart Association recommends a prehospital electrocardiogram (ECG) be recorded for all patients who access the emergency medical system with symptoms of acute coronary syndrome (ACS), widespread use of prehospital ECG has not been achieved in the United States. A 5-year prospective randomized clinical trial was conducted in a predominately rural county in northern California to test a simple strategy for acquiring and transmitting prehospital ECGs that involved minimal paramedic training and decision making. A 12-lead ECG was synthesized from 5 electrodes and continuous ST-segment monitoring was performed with ST-event ECGs automatically transmitted to the destination hospital emergency department. Patients randomized to the experimental group had their ECGs printed out in the emergency department with an audible voice alarm, whereas control patients had an ECG after hospital arrival, as was the standard of care in the county. The result was that nearly 3/4 (74%) of 4,219 patients with symptoms of ACS over the 4-year study enrollment period had a prehospital ECG. Mean time from 911 call to first ECG was 20 minutes in those with a prehospital ECG versus 79 minutes in those without a prehospital ECG (p <0.0001). Mean paramedic scene time in patients with a prehospital ECG was just 2 minutes longer than in those without a prehospital ECG (95% confidence interval 1.2 to 3.6, p <0.001). Patients with non-ST-elevation myocardial infarction or unstable angina pectoris had a faster time to first intravenous drug and there was a suggested trend for a faster door-to-balloon time and lower risk of mortality in patients with ST-elevation myocardial infarction. In conclusion, increased paramedic use of prehospital ECGs and decreased hospital treatment times for ACS are feasible with a simple approach tailored to characteristics of a local geographic region.

Does on- versus off-hours presentation impact in-hospital outcomes of ST-segment elevation myocardial infarction patients transferred to a tertiary care center?

OBJECTIVES

To determine whether in-hospital outcome differs for transferred patients with ST-segment elevation myocardial infarction (STEMI) presenting during business (ON) hours vs. after (OFF) hours.

BACKGROUND

Door-to-device (DTD) time is a prognostic factor in patients with STEMI and is longer during OFF hours. However, the in-hospital mortality is controversial.

METHODS

This registry study included 786 consecutive patients with STEMI referred for primary percutaneous coronary intervention to a tertiary care center with an on-site cardiac catheterization team 24 hrs a day/7 days (24/7) a week. ON hours were defined as weekdays 8 a.m. to 5 p.m., while OFF hours were defined as all other times, including holidays. The primary outcomes were in-hospital death, reinfarction, and length of stay (LOS).

RESULTS

ON hours (29.5%, n = 232) and OFF hours (70.5%, n = 554) groups had similar demographic and baseline characteristics. A significantly higher proportion of patients presenting ON hours had a DTD time ≤120 min compared to OFF hours patients (32.6% vs. 22.1%, P = 0.007). The rates of in-hospital death (8.2% vs. 6%), reinfarction (0% vs. 1.1%), and mean LOS (5.7 ± 6 vs. 5.7 ± 5) were not significantly different in the ON vs. OFF hours groups, all P = nonsignificant.

CONCLUSION

In a tertiary care center with an on-site cardiac catheterization team 24/7, there are no differences in in-hospital outcomes of transferred patients with STEMI during ON vs. OFF hours.

Door-to-balloon times for patients with ST-segment elevation myocardial infarction requiring interhospital transfer for primary percutaneous coronary intervention: a report from the national cardiovascular data registry

BACKGROUND

national initiatives have reduced door-to-balloon (DTB) times for direct-arrival ST-segment elevation myocardial infarction (STEMI) patients undergoing primary percutaneous coronary intervention (PCI). However, STEMI patients requiring interhospital transfer for primary PCI are often excluded from public performance assessments of this quality metric.

METHODS

we compared DTB time improvements between 2005 and 2007 for 29,248 transfer (25%) and 86,382 direct-arrival STEMI patients treated with primary PCI at 790 hospitals in the National Cardiovascular Data Catheterization PCI Registry. Among the 165 hospitals that submitted data for ≥10 patients per year, we examined the correlation between hospital-level changes in transfer and direct-arrival DTB times.

RESULTS

although DTB times decreased significantly over time for both groups, transfer STEMI patients had longer DTB times (median 149 vs 79 minutes, P < .0001), few received PCI ≤90 minutes (10% vs 63%, P < .0001), and the adjusted rate of DTB time improvement was slower (5% vs 9% relative decrease per year, P < .001) compared with direct-arrival patients. Larger annual transfer volume (not necessarily for primary PCI) was associated with greater improvement in transfer DTB times. However, there was no correlation between hospitals that improved direct-arrival DTB times and those that improved transfer DTB times (r = 0.094, P = .23).

CONCLUSIONS

although there has been modest temporal improvement in DTB times, transfer patients still rarely achieve benchmark standards. Hospitals that had greater improvements in direct-arrival DTB times were not necessarily those with greater improvements in transfer DTB times. These results highlight the need for targeted system and policy approaches to improve DTB time for transferred primary PCI patients.

Urban and rural implementation of pre-hospital diagnosis and direct referral for primary percutaneous coronary intervention in patients with acute ST-elevation myocardial infarction

AIMS

Primary percutaneous coronary intervention (PCI) is the preferred treatment for ST-elevation myocardial infarction (STEMI). The distance to primary PCI centres and the inherent time delay in delivering primary PCI, however, limit widespread use of this treatment. This study aimed to evaluate the impact of pre-hospital diagnosis on time from emergency medical services contact to balloon inflation (system delay) in an unselected cohort of patients with STEMI recruited from a large geographical area comprising both urban and rural districts.

METHODS AND RESULTS

From February 2004 until January 2007, data on pre-hospital timing and transport distance were prospectively recorded. Patients were divided into groups depending on achievement of pre-hospital diagnosis and/or direct referral to a primary PCI centre. Seven hundred and fifty-nine consecutive STEMI patients were included. In patients with a pre-hospital diagnosis and direct referral, the system delay was 92 vs. 153 min in patients without pre-hospital diagnosis (P < 0.001). Patients from rural areas were transported a median of 30 km longer than patients from urban areas; however, this prolonged the system delay by only 9 min.

CONCLUSION

Pre-hospital electrocardiographic (ECG) diagnosis and direct referral for primary PCI enables STEMI patients living far from a PCI centre to achieve a system delay comparable with patients living in close vicinity of a PCI centre.

Inter-hospital communications and transport: turning one-way funnels into two-way networks

The Inter-hospital Communications and Transport workgroup was charged with exploring the current status, barriers, and data necessary to optimize the initial destination and subsequent transfer of patients between and among acute care settings. The subtitle, "Turning Funnels Into Two-way Networks," is descriptive of the approach that the workgroup took by exploring how and when smaller facilities in suburban, rural, and frontier areas can contribute to the daily business of caring for emergency patients across the lower-acuity spectrum-in some instances with consultant support from academic medical centers. It also focused on the need to identify high-acuity patients and expedite triage and transfer of those patients to facilities with specialty resources. Draft research recommendations were developed through an iterative writing process and presented to a breakout session of Academic Emergency Medicine's 2010 consensus conference, "Beyond Regionalization: Integrated Networks of Emergency Care." Priority research areas were determined by informal consensus of the breakout group. A subsequent iterative writing process was undertaken to complete this article. A number of broad research questions are presented.

Appropriate cardiac cath lab activation: optimizing electrocardiogram interpretation and clinical decision-making for acute ST-elevation myocardial infarction

During the last few decades, acute ST-elevation on an electrocardiogram (ECG) in the proper clinical context has been a reliable surrogate marker of acute coronary occlusion requiring primary percutaneous coronary intervention (PPCI). In 2004, the American College of Cardiology/American Heart Association ST-elevation myocardial infarction (STEMI) guidelines specified ECG criteria that warrant immediate angiography in patients who are candidates for primary PPCI, but new findings have emerged that suggest a reappraisal is warranted. Furthermore, as part of integrated and efficient STEMI systems, emergency department and emergency medical services providers are now encouraged to routinely make the time-sensitive diagnosis of STEMI and promptly activate the cardiac catheterization laboratory (Cath Lab) team. Our primary objective is to provide a practical summary of updated ECG criteria for emergency coronary angiography with planned PPCI, thus allowing clinicians to maximize the rate of appropriate Cath Lab activation and minimize the rate of inappropriate Cath Lab activation. We review the evidence for ECG interpretation strategies that either increase diagnostic specificity for "classic" STEMI and left bundle-branch block or improve diagnostic sensitivity in identifying 4 STEMI-equivalents: posterior MI, acute left main occlusion, de Winter ST/T-wave complex, and certain scenarios of resuscitated cardiac arrest.

Improving patient outcomes from acute cardiovascular events through regionalized systems of care

ST-segment elevation myocardial infarction (STEMI), cardiac arrest, and ischemic stroke are a diverse group of cardiovascular illnesses linked by the necessity for timely intervention in order to maximize patient outcomes. Despite the known efficacies of therapies, such as emergent percutaneous coronary intervention (PCI), rapid administration of tissue plasminogen activator, and induction of therapeutic hypothermia after cardiac arrest, translating these discoveries into standard practice nationwide has proven difficult to achieve. Significant regional variations in practice are commonplace, and facilities with higher patient volumes of STEMI, cardiac arrest, and ischemic stroke consistently have better outcomes compared with lower-volume facilities. Such disparities in emergency care led the Institute of Medicine in 2006 to describe the existing emergency care system as "at the breaking point," and to call for "coordinated, regionalized, and accountable" systems of care. An effective and equitable regionalized emergency care system would resemble the existing US trauma system in some respects, with transparent and standard triage guidelines, cooperation between local and regional emergency medical service systems, and an integrated network of referring and receiving facilities. Emerging technologies, such as telemedicine, will likely play a significant role. Regionalized referral systems, such as designated PCI centers and designated stroke centers, are in existence, but have largely been reactive and local, and no mechanism is in place to ensure equitable distribution of such facilities across all geographic regions. As scientific advances in the treatment of these conditions continue to evolve, so too must the system of care that provides these therapies. Evidence suggests that regionalized systems of care for acute cardiovascular events may increase compliance with existing life-saving guidelines and improve patient outcomes.