A review of interventions and system changes to improve time to reperfusion for ST-segment elevation myocardial infarction

Practice and Evaluation of a Protocol for Collating Information Related to the Emergency Clinical Pathway for Patients With Acute ST-Segment Elevation Myocardial Infarction

Acute ST elevation myocardial infarction (STEMI) is a common acute and critical disease that requires rapid treatment within a limited window of time. In this study, we attempt to introduce a clinical pathway for the whole-process management of emergency STEMI based on the creation of a specific information system that matches the characteristics of emergency clinical work and evaluates their clinical value by quality control analysis. We deployed this system for 3 years and found that complications, heart failure, and medical costs during hospitalization were significantly reduced (p = 0.019) in patients with STEMI. By analyzing each link in the clinical pathway, our research indicates the clear clinical importance of developing methods to continuously improve data quality. Collectively, out research led to the optimization of an information system that will facilitate the clinical management of patients with STEMI.

Quality Improvement and Public Reporting in STEMI Care

Mortality rates for patients with ST-segment elevation myocardial infarction (STEMI) remain high despite development of novel drugs and interventions over the past several decades. There is significant variability between hospitals in use of evidence-based treatments, and substantial opportunities exist to optimize care pathways and reduce disparities in care delivery. Quality improvement interventions implemented at local, regional, and national levels have improved care processes and patient outcomes. This article reviews evidence for quality improvement interventions along the spectrum of STEMI care, describes existing systems for quality measurement, and examines local and national policy interventions, with special attention to public reporting programs.

Improving door-to-needle times for patients presenting with ST-elevation myocardial infarction at a rural district general hospital

Acute coronary syndrome is a common condition with a major global impact on healthcare resources and expenditure. International guidelines are clear in specifying that patients with acute ST-elevation myocardial infarction (STEMI) should receive urgent coronary reperfusion with either primary percutaneous coronary intervention (PCI) or thrombolysis. Although PCI is the gold standard in the treatment of STEMI, this is not always achievable in a rural hospital with no cardiac catheterization service. Consequently, local recommendations on STEMI management exist to promote timely administration of thrombolysis within 30 minutes of patient arrival. However, translating updated clinical policy into practice is a challenging and complex task that requires a multi-faceted approach with sustained engagement from local stakeholders.

Whilst working at a district general hospital in New Zealand, we noted a high incidence of patients presenting with STEMI receiving thrombolytic therapy outside the recommended 30 minutes door-to-needle time. Although final treatment was often only delayed by 5-10 minutes, we were concerned by the seemingly inconsistent management of these patients, often leading to unnecessary delays in the initiation of rapid reperfusion therapy.

We therefore championed a newly updated clinical guideline and promoted an early STEMI recognition and treatment algorithm in our hospital to raise awareness amongst staff and improve door-to-needle times. We introduced a number of simple low-cost interventions that included educational sessions for junior doctors and cardiac nursing staff, as well as posters and training on the use of a remote electronic ECG interpretation system to streamline out-of-hours management.

Overall, we found there to a be a steady improvement in door-to-needle times at our hospital, with 74% of patients receiving appropriate care within 30 minutes, compared to 43% prior to our interventions. This also translated to better patient outcomes.

This project forms part of an ongoing process to instigate quality improvements in the management of STEMI within rural institutions. Whilst we have demonstrated improved utilisation of a local STEMI guideline and streamlining of out-of-hours services, the key challenge remains to ensure that momentum of this project continues and forms a platform for sustainable clinical improvement in the long term.

Optimization of door-to-electrocardiogram time within a critical pathway for the management of acute coronary syndromes at a teaching hospital in Colombia

INTRODUCTION

Door-to-electrocardiogram (D2E) time is recognized as one of the quality parameters in the attention of acute coronary syndromes. Electrocardiogram realization within periods below 10 minutes increases the possibility to achieve quick and effective reperfusion, which has an impact on outcomes.

OBJECTIVE

To describe the results of a strategy whose goal is to improve the fulfillment of the D2E deadline below 10 minutes in adults who attend the emergency service due to chest pain with clinical suspicion of acute coronary syndromes.

METHODS

Before-and-after study that assesses D2E time upon the implementation of actions for the reorganization of the process of attention of the patients with chest pain within the context of the implementation of a critical pathway.

RESULTS

A total of 373 patients were assessed, 204 in the before stage and 169 in the after stage. The median D2E time was 16 minutes in the before stage, in 41% of the cases it was below 10 minutes; upon the implementation of the change in the process of attention of chest pain the median was 5 minutes, with 63% of the cases below 10 minutes, exhibiting a statistically significant difference.

CONCLUSIONS

The actions taken led to a lower median of D2E time and a higher percentage of patients with times below 10 minutes. However, further interventions are required to assure a higher number of patients with D2E times below 10 minutes.

Providing optimal regional care for ST-segment elevation myocardial infarction: a prospective cohort study of patients in the Hamilton Niagara Haldimand Brant Local Health Integration Network

BACKGROUND

Although considered the evidence-based best therapy for ST-segment elevation myocardial infarction (STEMI), many patients do not receive primary percutaneous coronary intervention (PCI) because of health care resource distribution and constraints. This study describes the clinical management and outcomes of all patients identified with STEMI within a region, including those who did not receive primary PCI.

METHODS

This study used a prospective cohort design. Patients presenting with STEMI to PCI- and non-PCI-capable hospitals in one integrated health region in Ontario were included in the study. The primary objective was to examine use of reperfusion strategies and timeliness of care. Secondary objectives included determining (through regression models) which variables were associated with mortality within 90 days, and describing patient uptake of risk-reducing therapies and activities post-STEMI.

RESULTS

Between Apr. 1, 2010, and Mar. 31, 2013, data were collected on 2247 consecutive patients presenting with STEMI. Patients presenting to the PCI-capable hospital were more likely to receive primary PCI (82.5% v. 65.2%, p < 0.001) and be treated within optimal treatment times. However, there was no appreciable difference in mortality at 90 days post-STEMI between patients presenting to PCI- and non-PCI-capable hospitals (7.8% v. 7.5%, p = 0.82), even after adjustment for acuity on presentation. Despite recognized risk factors, many patients were not taking evidence-based medications for risk factor modification before STEMI.

INTERPRETATION

A systematic approach to regional STEMI care focusing on timely access to the best available therapies, rather than the type of reperfusion provided alone, can yield favourable outcomes.

Minimizing transfer time to an ST segment elevation myocardial infarction-receiving center: a modified Delphi consensus

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.

Prostate cancer survivorship care in the Veterans Health Administration

The burden of prostate cancer among Veterans is substantial with over 200,000 survivors and 12,000 new diagnoses annually. Most men live with rather than die from this common and expensive disease making prostate cancer survivorship care especially important. In addition, the symptom burden after prostate cancer treatment can be substantial, last well into survivorship and lead to reduced quality of life and greater use of services. For these reasons, it is increasingly recognized that cancer survivorship care is similar to chronic disease management in requiring a combination of primary care providers and cancer specialists to deliver care over long periods of time. Because of its leadership in chronic disease care and the proportion of older men served, the Veterans Health Administration (VHA) is well positioned to become one of the national leaders in prostate cancer survivorship care. However, best practices and portfolios of quality indicators for prostate cancer survivorship care remain underdeveloped. More broadly, there is a limited consensus about who (primary care providers or prostate cancer specialists - urologists, radiation and medical oncologists) has primary responsibility for prostate cancer surveillance, and who manages the often substantial and lingering treatment-related side effects. Unclear roles and regional variation in the VHA cancer specialist workforce also complicate delivery of quality survivorship care. Ultimately, the design and implementation of tools to facilitate the delivery of optimal cancer survivorship care in VHA rests upon understanding how responsibility for survivorship care is managed and the barriers to quality survivorship care. Due to the expanding population of Veteran prostate cancer survivors, improving their quality of survivorship care through effective use of the VHA's provider workforce and latest telemedicine initiatives has potential to transform the national efficiency and effectiveness of cancer specialty care delivery.

A prospective regional registry of ST-elevation myocardial infarction in Central Romania: impact of the Stent for Life Initiative recommendations on patient outcomes

BACKGROUND

Reperfusion therapy is the treatment of choice in patients with ST-elevation myocardial infarction (STEMI) presenting within 12 hours after the onset of symptoms. However, a significant number of patients do not benefit from it because of the lack of access to well-organized emergency care. We aimed to investigate the evolution of STEMI treatment and mortality between 2004 and 2011 in an unselected population from central Romania and to demonstrate the role of a regional network in increasing the rates of reperfusion therapy with associated reduction of STEMI-related mortality in a region with very low primary percutaneous coronary intervention (pPCI) rates at baseline.

METHODS

We analyzed the data of 5,899 consecutive patients with STEMI enrolled in this prospective study since 2004, after the initiation of an STEMI network in Central Romania and with continuous support of the Stent for Life Initiative.

RESULTS

Introduction of the network was associated with an absolute change in the use of reperfusion therapy from 2004 to 2011 (26.94% vs 87.15%, P < .001) and of pPCI (10.88% vs 78.64%, P < .001) for patients presenting within 12 hours after the onset of symptoms, with a decrease of inhospital mortality from 20.73% to 6.35% (P < .001). In addition, the global inhospital mortality of all the STEMI population showed a significant decrease (23.18% vs 13.39%, P < .001).

CONCLUSIONS

Reduction of STEMI-related mortality was possible via implementation of pPCI, even in a region with low health care expenditures. The organization of an STEMI network led to a significant decrease in STEMI-related mortality, revealing the significant impact of the Stent for Life Initiative recommendations on patient outcomes.

Factors associated with presenting >12 hours after symptom onset of acute myocardial infarction among Veteran men

BACKGROUND

Approximately 2/3 of Veterans admitting to Veterans Health Administration (VHA) facilities present >12 hours after symptom onset of acute myocardial infarction (AMI) ("late presenters"). Veterans admitted to VHA facilities with AMI may delay hospital presentation for different reasons compared to their general population counter parts. Despite the large descriptive literature on factors associated with delayed presentation in the general population, the literature describing these factors among the Veteran AMI population is limited. The purpose of this analysis is to identify predictors of late presentation in the Veteran population presenting with AMI to VHA facilities. Identifying predictors will help inform and target interventions for Veterans at a high risk of late presentation.

METHODS

In our cross-sectional study, we analyzed a cohort of 335 male Veterans from nine VHA facilities with physician diagnosed AMI between April 2005 and December 2006. We compared demographics, presentation characteristics, medical history, perceptions of health, and access to health care between early and late presenting Veterans. We used standard descriptive statistics for bivariate comparisons and multivariate logistic regression to identify independent predictors of late presentation.

RESULTS

Our cohort was an average of 64 ± 10 years old and was 88% white. Sixty-eight percent of our cohort were late presenters. Bivariate comparisons found that fewer late presenters had attended at least some college or vocational school (late 53% vs. early 66%, p = 0.02). Multivariate analysis showed that presentation with ST-elevation myocardial infarction (STEMI) was associated with early presentation (OR = 0.4 95%CI [0.2, 0.9]) and ≥2 angina episodes in the prior 24 hours (versus 0-1 episode) was associated with late presentation (OR = 7.5 95%CI [3.6,15.6]).

CONCLUSIONS

A significant majority of Veterans presenting to VHA facilities with AMI were late presenters. We found few differences between early and late presenters. Having a STEMI was independently associated with early presentation and reporting ≥2 angina episodes in the 24 hours prior to hospital admission was independently associated with late presentation. These independent predictors of early and late presentation are similar to what has been reported for the general population. Despite these similarities to the general population, there may be untapped opportunities for patient education within the VHA to decrease late presentation.

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.