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Yiadom MYAB, Gong W, Bloos SM, Bunney G, Kabeer R, Pasao MA, Rodriguez F, Baugh CW, Mills AM, Gavin N, Podolsky SR, Salazar GA, Patterson B, Mumma BE, Tanski ME, Liu D. Shorter Door-to-ECG Time Is Associated with Improved Mortality in STEMI Patients. J Clin Med 2024; 13:2650. [PMID: 38731180 PMCID: PMC11084706 DOI: 10.3390/jcm13092650] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2024] [Revised: 04/09/2024] [Accepted: 04/16/2024] [Indexed: 05/13/2024] Open
Abstract
Background: Delayed intervention for ST-segment elevation myocardial infarction (STEMI) is associated with higher mortality. The association of door-to-ECG (D2E) with clinical outcomes has not been directly explored in a contemporary US-based population. Methods: This was a three-year, 10-center, retrospective cohort study of ED-diagnosed patients with STEMI comparing mortality between those who received timely (<10 min) vs. untimely (>10 min) diagnostic ECG. Among survivors, we explored left ventricular ejection fraction (LVEF) dysfunction during the STEMI encounter and recovery upon post-discharge follow-up. Results: Mortality was lower among those who received a timely ECG where one-week mortality was 5% (21/420) vs. 10.2% (26/256) among those with untimely ECGs (p = 0.016), and in-hospital mortality was 6.0% (25/420) vs. 10.9% (28/256) (p = 0.028). Data to compare change in LVEF metrics were available in only 24% of patients during the STEMI encounter and 46.5% on discharge follow-up. Conclusions: D2E within 10 min may be associated with a 50% reduction in mortality among ED STEMI patients. LVEF dysfunction is the primary resultant morbidity among STEMI survivors but was infrequently assessed despite low LVEF being an indication for survival-improving therapy. It will be difficult to assess the impact of STEMI care interventions without more consistent LVEF assessment.
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Affiliation(s)
- Maame Yaa A. B. Yiadom
- Department of Emergency Medicine, Stanford University, 900 Welch Road, Ste 350, Palo Alto, CA 94304, USA; (G.B.); (R.K.); (M.A.P.)
| | - Wu Gong
- Department of Biostatistics, Vanderbilt University Medical Center, 2525 West End Avenue, Suite 1100, Nashville, TN 37203, USA; (W.G.); (D.L.)
| | - Sean M. Bloos
- Tulane University School of Medicine, 1430 Tulane Ave., New Orleans, LA 70112, USA;
| | - Gabrielle Bunney
- Department of Emergency Medicine, Stanford University, 900 Welch Road, Ste 350, Palo Alto, CA 94304, USA; (G.B.); (R.K.); (M.A.P.)
| | - Rana Kabeer
- Department of Emergency Medicine, Stanford University, 900 Welch Road, Ste 350, Palo Alto, CA 94304, USA; (G.B.); (R.K.); (M.A.P.)
| | - Melissa A. Pasao
- Department of Emergency Medicine, Stanford University, 900 Welch Road, Ste 350, Palo Alto, CA 94304, USA; (G.B.); (R.K.); (M.A.P.)
| | - Fatima Rodriguez
- Division of Cardiovascular Medicine, Department of Medicine, Stanford University, 6453 Quarry Rd., Palo Alto, CA 94304, USA;
| | - Christopher W. Baugh
- Department of Emergency Medicine, Brigham and Women’s Hospital, Harvard University, 75 Francis Street, Boston, MA 02115, USA;
| | - Angela M. Mills
- Department of Emergency Medicine, Columbia University College of Physicians and Surgeons, 622 W 168th St., New York, NY 10032, USA;
| | - Nicholas Gavin
- Department of Emergency Medicine, Icahn School of Medicine at Mount Sinai, 1468 Madison Ave., New York, NY 10029, USA;
| | - Seth R. Podolsky
- Department of Dean Administration, Oregon Health & Sciences University, 3181 SW Sam Jackson Park Rd., Portland, OR 97239, USA;
| | - Gilberto A. Salazar
- Department of Emergency Medicine Parkland Hospital, University of Texas Southwestern Medical Center—Dallas, 5323 Harry Hines Boulevard E4.300, Dallas, TX 75390, USA;
| | - Brian Patterson
- Department of Emergency Medicine, University of Wisconsin—Madison, 800 University Bay Dr Suite 310, Madison, WI 53705, USA;
| | - Bryn E. Mumma
- Department of Emergency Medicine, University of California at Davis, 2245 45th St., Sacramento, CA 95817, USA
| | - Mary E. Tanski
- Department of Emergency Medicine, Oregon Health & Science University, 3181 SW Sam Jackson Park Rd., Portland, OR 97239, USA;
| | - Dandan Liu
- Department of Biostatistics, Vanderbilt University Medical Center, 2525 West End Avenue, Suite 1100, Nashville, TN 37203, USA; (W.G.); (D.L.)
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Kolls BJ, Ehrlich ME, Monk L, Shah S, Roettig M, Iversen E, Jollis JG, Granger CB, Graffagnino C. Regionalization of stroke systems of care in the stroke belt states: The IMPROVE stroke care quality improvement program. Am Heart J 2024; 269:72-83. [PMID: 38061683 DOI: 10.1016/j.ahj.2023.11.020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/17/2023] [Revised: 11/18/2023] [Accepted: 11/28/2023] [Indexed: 01/07/2024]
Abstract
BACKGROUND Despite guidelines and strong evidence supporting intravenous thrombolysis and endovascular thrombectomy for acute stroke, access to these interventions remains a challenge. The objective of the IMPROVE stroke care program was to accelerate acute stroke care delivery by implementing best practices and improving the regional systems of care within comprehensive stroke networks. METHODS The IMPROVE Stroke Care program was a prospective quality improvement program based on established models used in acute coronary care. Nine hub hospitals (comprehensive stroke centers), 52 regional/community referral hospitals (spokes), and over 100 emergency medical service agencies participated. Through 6 regional meetings, 49 best practices were chosen for improvement by the participating sites. Over 2 years, progress was tracked and discussed weekly and performance reviews were disseminated quarterly. RESULTS Data were collected on 21,647 stroke code activations of which 8,502 (39.3%) activations had a final diagnosis of stroke. There were 7,226 (85.0%) ischemic strokes, and thrombolytic therapy was administered 2,814 times (38.9%). There was significant overall improvement in the proportion that received lytic therapy within 45 minutes (baseline of 44.6%-60.4%). The hubs were more frequently achieving this at baseline, but both site types improved. A total of 1,455 (17.1%) thrombectomies were included in the data of which 401 (27.6%) were transferred from a spoke. There was no clinically significant change in door-to-groin times for hub-presenting thrombectomy patients, however, significant improvement occurred for transferred cases, 46 minutes (interquartile range [IQR] 36, 115.5) at baseline to 27 minutes (IQR 10, 59). CONCLUSIONS The IMPROVE program approach was successful at improving the delivery of thrombolytic intervention across the consortium at both spoke and hub sites through collaborative efforts to operationalize guideline-based care through iterative sharing of performance and best practices for implementation. Our approach allowed identification of both opportunities for improvement and operational best practices providing guidance on how best to create a regional stroke care network and operationalize the published acute stroke care guidelines.
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Affiliation(s)
- Brad J Kolls
- Department of Neurology, Duke University School of Medicine, Durham, NC; Duke Clinical Research Institute, Durham, NC.
| | - Matthew E Ehrlich
- Department of Neurology, Duke University School of Medicine, Durham, NC
| | - Lisa Monk
- Duke Clinical Research Institute, Durham, NC
| | - Shreyansh Shah
- Department of Neurology, Duke University School of Medicine, Durham, NC
| | | | - Edwin Iversen
- Department of Statistical Science, Duke University, Durham NC
| | - James G Jollis
- Duke Clinical Research Institute, Durham, NC; Division of Cardiology, Duke University School of Medicine, Durham, NC
| | - Christopher B Granger
- Duke Clinical Research Institute, Durham, NC; Division of Cardiology, Duke University School of Medicine, Durham, NC
| | - Carmelo Graffagnino
- Department of Neurology, Duke University School of Medicine, Durham, NC; Duke Clinical Research Institute, Durham, NC
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3
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Herscovici DM, Boggs KM, Cash RE, Espinola JA, Sullivan AF, Hasegawa K, Nagurney JT, Camargo CA. Development of a unified national database of primary percutaneous coronary intervention centers with co-located emergency departments, 2020. Am Heart J 2022; 254:149-155. [PMID: 36099978 DOI: 10.1016/j.ahj.2022.08.012] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/01/2022] [Revised: 08/18/2022] [Accepted: 08/21/2022] [Indexed: 06/15/2023]
Abstract
BACKGROUND Although primary percutaneous coronary intervention (pPCI) is the preferred intervention for ST-elevation myocardial infarction (STEMI), not all patients are admitted directly to an emergency department (ED) with 24/7/365 pPCI capabilities. This is partly due to a lack of a national system of known pPCI-capable EDs. Our objective was to create a unified, national database of confirmed 24/7/365 pPCI centers co-located in hospitals with EDs. METHODS We compiled all hospitals designated as Chest Pain Centers with Primary PCI by the American College of Cardiology's (ACC) National Clinical Data Registry (NCDR), all STEMI Receiving Centers designated by the American Heart Association's (AHA) Mission: Lifeline registry, and all state-designated pPCI-capable hospitals and designation criteria from state departments of health. We matched ACC, AHA, and state-designated facilities to those in the 2019 National ED Inventory (NEDI)-USA database to identify all EDs in pPCI-capable hospitals. RESULTS Overall, 467 hospitals were recognized as Chest Pain Centers with Primary PCI by ACC, 293 hospitals were recognized as being STEMI Receiving Centers by AHA, and 827 hospitals were confirmed to be pPCI-capable by state designations and operated 24/7/365. Together, there were 1,178 EDs (21% of 5,587 total) co-located in pPCI-capable hospitals operating 24/7/365. CONCLUSIONS There is substantial heterogeneity in cardiac systems of care, with large regional systems existing alongside local state-led initiatives. We created a unified national database of confirmed 24/7/365 pPCI centers co-located in hospitals with EDs. This data set will be valuable for future cardiac systems research and improving access to pPCI.
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Affiliation(s)
- Darya M Herscovici
- From the Department of Emergency Medicine, Massachusetts General Hospital, Boston, MA
| | - Krislyn M Boggs
- From the Department of Emergency Medicine, Massachusetts General Hospital, Boston, MA
| | - Rebecca E Cash
- From the Department of Emergency Medicine, Massachusetts General Hospital, Boston, MA
| | - Janice A Espinola
- From the Department of Emergency Medicine, Massachusetts General Hospital, Boston, MA
| | - Ashley F Sullivan
- From the Department of Emergency Medicine, Massachusetts General Hospital, Boston, MA
| | - Kohei Hasegawa
- From the Department of Emergency Medicine, Massachusetts General Hospital, Boston, MA
| | - John T Nagurney
- From the Department of Emergency Medicine, Massachusetts General Hospital, Boston, MA
| | - Carlos A Camargo
- From the Department of Emergency Medicine, Massachusetts General Hospital, Boston, MA.
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4
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Nguyen DD, Doll JA. Quality Improvement and Public Reporting in STEMI Care. Interv Cardiol Clin 2021; 10:391-400. [PMID: 34053625 DOI: 10.1016/j.iccl.2021.03.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
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.
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Affiliation(s)
- Dan D Nguyen
- Division of Cardiology, Department of Medicine, University of Washington, 1959 NE Pacific Street, Seattle, WA 98195, USA
| | - Jacob A Doll
- Division of Cardiology, Department of Medicine, University of Washington, 1959 NE Pacific Street, Seattle, WA 98195, USA; VA Puget Sound Health Care System, 1660 S Columbian Way, Seattle, WA 98108, USA.
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5
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Harrington JL, Granger CB. Standardizing ST-Segment Elevation Myocardial Infarction Care: Customizing Regionalization to Improve Outcomes. Circ Cardiovasc Qual Outcomes 2021; 14:e007701. [PMID: 33641340 DOI: 10.1161/circoutcomes.120.007701] [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] [Indexed: 11/16/2022]
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6
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Montoy JCC, Shen YC, Brindis RG, Krumholz HM, Hsia RY. Impact of ST-Segment-Elevation Myocardial Infarction Regionalization Programs on the Treatment and Outcomes of Patients Diagnosed With Non-ST-Segment-Elevation Myocardial Infarction. J Am Heart Assoc 2021; 10:e016932. [PMID: 33470136 PMCID: PMC7955417 DOI: 10.1161/jaha.120.016932] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Background Many communities have implemented systems of regionalized care to improve access to timely care for patients with ST-segment-elevation myocardial infarction. However, patients who are ultimately diagnosed with non-ST-segment-elevation myocardial infarctions (NSTEMIs) may also be affected, and the impact of regionalization programs on NSTEMI treatment and outcomes is unknown. We set out to determine the effects of ST-segment-elevation myocardial infarction regionalization schemes on treatment and outcomes of patients diagnosed with NSTEMIs. Methods and Results The cohort included all patients receiving care in emergency departments diagnosed with an NSTEMI at all nonfederal hospitals in California from January 1, 2005 to September 30, 2015. Data were analyzed using a difference-in-differences approach. The main outcomes were 1-year mortality and angiography within 3 days of the index admission. A total of 293 589 patients with NSTEMIs received care in regionalized and nonregionalized communities. Over the study period, rates of early angiography increased by 0.5 and mortality decreased by 0.9 percentage points per year among the overall population (95% CI, 0.4-0.6 and -1.0 to -0.8, respectively). Regionalization was not associated with early angiography (-0.5%; 95% CI, -1.1 to 0.1) or death (0.2%; 95% CI, -0.3 to 0.8). Conclusions ST-segment-elevation myocardial infarction regionalization programs were not statistically associated with changes in guideline-recommended early angiography or changes in risk of death for patients with NSTEMI. Increases in the proportion of patients with NSTEMI who underwent guideline-directed angiography and decreases in risk of mortality were accounted for by secular trends unrelated to regionalization policies.
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Affiliation(s)
| | - Yu-Chu Shen
- Graduate School of Defense Management, Naval Postgraduate School Monterey CA.,National Bureau of Economic Research Cambridge MA
| | - Ralph G Brindis
- Department of Medicine University of California, San Francisco CA.,Philip R. Lee Institute for Health Policy Studies University of California, San Francisco CA
| | - Harlan M Krumholz
- Section of Cardiovascular Medicine Department of Internal Medicine Yale School of Medicine New Haven CT.,Department of Health Policy and Management Yale School of Public Health New Haven CT.,Center for Outcomes Research and Evaluation Yale-New Haven Hospital New Haven CT
| | - Renee Y Hsia
- Department of Emergency Medicine University of California, San Francisco CA.,Philip R. Lee Institute for Health Policy Studies University of California, San Francisco CA
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7
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Kereiakes DJ, Henry TD, DeMaria AN, Bentur O, Carlson M, Seng Yue C, Martin LH, Midkiff J, Mueller M, Meek T, Garza D, Gibson CM, Coller BS. First Human Use of RUC-4: A Nonactivating Second-Generation Small-Molecule Platelet Glycoprotein IIb/IIIa (Integrin αIIbβ3) Inhibitor Designed for Subcutaneous Point-of-Care Treatment of ST-Segment-Elevation Myocardial Infarction. J Am Heart Assoc 2020; 9:e016552. [PMID: 32844723 PMCID: PMC7660780 DOI: 10.1161/jaha.120.016552] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/16/2020] [Accepted: 06/08/2020] [Indexed: 01/14/2023]
Abstract
Background Despite reductions in door-to-balloon times for primary coronary intervention, mortality from ST-segment-elevation myocardial infarction has plateaued. Early pre-primary coronary intervention treatment of ST-segment-elevation myocardial infarction with glycoprotein IIb/IIIa inhibitors improves pre-primary coronary intervention coronary flow, limits infarct size, and improves survival. We report the first human use of a novel glycoprotein IIb/IIIa inhibitor designed for subcutaneous first point-of-care ST-segment-elevation myocardial infarction treatment. Methods and Results Healthy volunteers and patients with stable coronary artery disease receiving aspirin received escalating doses of RUC-4 or placebo in a sentinel-dose, randomized, blinded fashion. Inhibition of platelet aggregation (IPA) to ADP (20 μmol/L), RUC-4 blood levels, laboratory evaluations, and clinical assessments were made through 24 hours and at 7 days. Doses were increased until reaching the biologically effective dose (the dose producing ≥80% IPA within 15 minutes, with return toward baseline within 4 hours). In healthy volunteers, 15 minutes after subcutaneous injection, mean±SD IPA was 6.9%+7.1% after placebo and 71.8%±15.0% at 0.05 mg/kg (n=6) and 84.7%±16.7% at 0.075 mg/kg (n=6) after RUC-4. IPA diminished over 90 to 120 minutes. In patients with coronary artery disease, 15 minutes after subcutaneous injection of placebo or 0.04 mg/kg (n=2), 0.05 mg/kg (n=6), and 0.075 mg/kg (n=18) of RUC-4, IPA was 14.6%±11.7%, 53.6%±17.0%, 76.9%±10.6%, and 88.9%±12.7%, respectively. RUC-4 blood levels correlated with IPA. Aspirin did not affect IPA or RUC-4 blood levels. Platelet counts were stable and no serious adverse events, bleeding, or injection site reactions were observed. Conclusions RUC-4 provides rapid, high-grade, limited-duration platelet inhibition following subcutaneous administration that appears to be safe and well tolerated. Registration URL: https://www.clinicaltrials.gov; Unique identifier: NTC03844191.
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Affiliation(s)
- Dean J. Kereiakes
- The Carl and Edyth Lindner Center for Research and Education at The Christ HospitalCincinnatiOH
| | - Tim D. Henry
- The Carl and Edyth Lindner Center for Research and Education at The Christ HospitalCincinnatiOH
| | | | - Ohad Bentur
- Allen and Frances Adler Laboratory of Blood and Vascular BiologyRockefeller UniversityNew YorkNY
| | | | | | - Linda H. Martin
- The Carl and Edyth Lindner Center for Research and Education at The Christ HospitalCincinnatiOH
| | - Jeff Midkiff
- The Carl and Edyth Lindner Center for Research and Education at The Christ HospitalCincinnatiOH
| | - Michele Mueller
- The Carl and Edyth Lindner Center for Research and Education at The Christ HospitalCincinnatiOH
| | - Terah Meek
- The Carl and Edyth Lindner Center for Research and Education at The Christ HospitalCincinnatiOH
| | - Deborah Garza
- The Carl and Edyth Lindner Center for Research and Education at The Christ HospitalCincinnatiOH
| | | | - Barry S. Coller
- Allen and Frances Adler Laboratory of Blood and Vascular BiologyRockefeller UniversityNew YorkNY
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Ehrlich ME, Kolls BJ, Roettig M, Monk L, Shah S, Xian Y, Jollis JG, Granger CB, Graffagnino C. Implementation of Best Practices-Developing and Optimizing Regional Systems of Stroke Care: Design and Methodology. Am Heart J 2020; 222:105-111. [PMID: 32028136 DOI: 10.1016/j.ahj.2020.01.004] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/29/2019] [Accepted: 01/13/2020] [Indexed: 11/18/2022]
Abstract
The AHA Guidelines recommend developing multi-tiered systems for the care of patients with acute stroke.1 An ideal stroke system of care should ensure that all patients receive the most efficient and timely care, regardless of how they first enter or access the medical care system. Coordination among the components of a stroke system is the most challenging but most essential aspect of any system of care. The Implementation of Best Practices For Acute Stroke Care-Developing and Optimizing Regional Systems of Stroke Care (IMPROVE Stroke Care) project, is designed to implement existing guidelines and systematically improve the acute stroke system of care in the Southeastern United States. Project participation includes 9 hub hospitals, approximately 80 spoke hospitals, numerous pre-hospital agencies (911, fire, and emergency medical services) and communities within the region. The goal of the IMPROVE Stroke program is to develop a regional integrated stroke care system that identifies, classifies, and treats acute ischemic stroke patients more rapidly and effectively with reperfusion therapy. The project will identify gaps and barriers to implementation of stroke systems of care, leverage existing resources within the regions, aid in designing strategies to improve care processes, bring regional representatives together to agree on and implement best practices, protocols, and plans based on guidelines, and establish methods to monitor quality of care. The impact of implementation of stroke systems of care on mortality and long-term functional outcomes will be measured.
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Affiliation(s)
- Matthew E Ehrlich
- Department of Neurology, Duke University School of Medicine, Durham, NC.
| | - Brad J Kolls
- Department of Neurology, Duke University School of Medicine, Durham, NC; Duke Clinical Research Institute, Durham, NC
| | | | - Lisa Monk
- Duke Clinical Research Institute, Durham, NC
| | - Shreyansh Shah
- Department of Neurology, Duke University School of Medicine, Durham, NC
| | - Ying Xian
- Department of Neurology, Duke University School of Medicine, Durham, NC; Duke Clinical Research Institute, Durham, NC
| | - James G Jollis
- Duke Clinical Research Institute, Durham, NC; Division of Cardiology, Duke University School of Medicine, Durham, NC
| | - Christopher B Granger
- Duke Clinical Research Institute, Durham, NC; Division of Cardiology, Duke University School of Medicine, Durham, NC
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Viana M, Laszczyńska O, Araújo C, Borges A, Barros V, Ribeiro AI, Dias P, Maciel MJ, Moreira I, Lunet N, Azevedo A. Patient and system delays in the treatment of acute coronary syndrome. Rev Port Cardiol 2020; 39:123-131. [DOI: 10.1016/j.repc.2019.07.007] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2018] [Revised: 05/10/2019] [Accepted: 07/20/2019] [Indexed: 10/24/2022] Open
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10
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Viana M, Laszczyńska O, Araújo C, Borges A, Barros V, Ribeiro AI, Dias P, Maciel MJ, Moreira I, Lunet N, Azevedo A. Patient and system delays in the treatment of acute coronary syndrome. REVISTA PORTUGUESA DE CARDIOLOGIA (ENGLISH EDITION) 2020. [DOI: 10.1016/j.repce.2019.07.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022] Open
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A Long-Forgotten Tale: The Management of Cardiogenic Shock in Acute Myocardial Infarction. JOURNAL OF CARDIOVASCULAR EMERGENCIES 2019. [DOI: 10.2478/jce-2018-0023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Abstract
Patients with acute myocardial infarction (AMI) complicated with cardiogenic shock (CS) present one of the highest mortality rates recorded in critical care. Mortality rate in this setting is reported around 45-50% even in the most experienced and well-equipped medical centers. The continuous development of ST-segment elevation acute myocardial infarction (STEMI) networks has led not only to a dramatic decrease in STEMI-related mortality, but also to an increase in the frequency of severely complicated cases who survive to be transferred to tertiary centers for life-saving treatments. The reduced effectiveness of vasoactive drugs on a severely altered hemodynamic status led to the development of new devices dedicated to advanced cardiac support. What’s more, efforts are being made to reduce time from first medical contact to initiation of mechanical support in this particular clinical context. This review aims to summarize the most recent advances in mechanical support devices, in the setting of CS-complicated AMI. At the same time, the review presents several modern concepts in the organization of complex CS centers. These specialized hubs could improve survival in this critical condition.
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13
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Gibler WB, Racadio JM, Hirsch AL, Roat TW. Continuum of Care for Acute Coronary Syndrome: Optimizing Treatment for ST-Elevation Myocardial Infarction and Non-St-Elevation Acute Coronary Syndrome. Crit Pathw Cardiol 2018; 17:114-138. [PMID: 30044253 PMCID: PMC6072372 DOI: 10.1097/hpc.0000000000000151] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Affiliation(s)
- W Brian Gibler
- President, EMCREG-International, Professor of Emergency Medicine, Department of Emergency Medicine, University of Cincinnati College of Medicine, Cincinnati, OH
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14
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Kochar A, Al-Khalidi HR, Hansen SM, Shavadia JS, Roettig ML, Fordyce CB, Doerfler S, Gersh BJ, Henry TD, Berger PB, Jollis JG, Granger CB. Delays in Primary Percutaneous Coronary Intervention in ST-Segment Elevation Myocardial Infarction Patients Presenting With Cardiogenic Shock. JACC Cardiovasc Interv 2018; 11:1824-1833. [DOI: 10.1016/j.jcin.2018.06.030] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/22/2018] [Revised: 06/14/2018] [Accepted: 06/19/2018] [Indexed: 12/27/2022]
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15
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Keys to Achieving Target First Medical Contact to Balloon Times and Bypassing Emergency Department More Important Than Distance. Cardiol Res Pract 2018; 2018:2951860. [PMID: 29951310 PMCID: PMC5987289 DOI: 10.1155/2018/2951860] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/11/2018] [Revised: 03/27/2018] [Accepted: 04/30/2018] [Indexed: 11/26/2022] Open
Abstract
Background Australian guidelines advocate primary percutaneous coronary intervention (PPCI) as the reperfusion strategy of choice for ST elevation myocardial infarction (STEMI) in patients in whom it can be performed within 90 minutes of first medical contact; otherwise, fibrinolytic therapy is preferred. In a large health district, the reperfusion strategy is often chosen in the prehospital setting. We sought to identify a distance from a PCI centre, which made it unlikely first medical contact to balloon time (FMCTB) of less than 90 minutes could be achieved in the Hunter New England health district and to identify causes of delay in patients who were triaged to a PPCI strategy. Methods and Results We studied 116 patients presenting via the ambulance service with STEMI from January 2016 to December 2016. In patients who were taken directly to the cardiac catheterisation lab, a maximum distance of 50 km from hospital resulted in 75% of patients receiving PCI within 90 minutes and approximately 95% of patients receiving PCI within 120 minutes. Patients who bypassed the emergency department (ED) were significantly more likely to have FMCTB of less than 90 minutes (p < 0.001) despite having a longer travel distance (28.5 km versus 17.4 km, p < 0.001). Patients transiting via the ED were significantly more likely to present out of hours (60 versus 24.2% p < 0.001). Conclusions Patients who do not bypass the ED have a longer FMCTB across all spectrum of distances from the PCI centre; therefore, bypassing the ED is key to achieving target FMCTB times. Using a cutoff distance of 50 km may reduce human error in estimating travel time to our PCI centre and thereby identifying patients who should receive prehospital thrombolysis.
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Aeyels D, Seys D, Sinnaeve PR, Claeys MJ, Gevaert S, Schoors D, Sermeus W, Panella M, Bruyneel L, Vanhaecht K. Managing in-hospital quality improvement: An importance-performance analysis to set priorities for ST-elevation myocardial infarction care. Eur J Cardiovasc Nurs 2018; 17:535-542. [PMID: 29448818 DOI: 10.1177/1474515118759065] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
Abstract
BACKGROUND A focus on specific priorities increases the success rate of quality improvement efforts for broad and complex-care processes. Importance-performance analysis presents a possible approach to set priorities around which to design and implement effective quality improvement initiatives. Persistent variation in hospital performance makes ST-elevation myocardial infarction care relevant to consider for importance-performance analysis. AIMS The purpose of this study was to identify quality improvement priorities in ST-elevation myocardial infarction care. METHODS Importance and performance levels of ST-elevation myocardial infarction key interventions were combined in an importance-performance analysis. Content validity indexes on 23 ST-elevation myocardial infarction key interventions of a multidisciplinary RAND Delphi Survey defined importance levels. Structured review of 300 patient records in 15 acute hospitals determined performance levels. The significance of between-hospital variation was determined by a Kruskal-Wallis test. A performance heat-map allowed for hospital-specific priority setting. RESULTS Seven key interventions were each rated as an overall improvement priority. Priority key interventions related to risk assessment, timely reperfusion by percutaneous coronary intervention and secondary prevention. Between-hospital performance varied significantly for the majority of key interventions. The type and number of priorities varied strongly across hospitals. CONCLUSIONS Guideline adherence in ST-elevation myocardial infarction care is low and improvement priorities vary between hospitals. Importance-performance analysis helps clinicians and management in demarcation of the nature, number and order of improvement priorities. By offering a tailored improvement focus, this methodology makes improvement efforts more specific and achievable.
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Affiliation(s)
- Daan Aeyels
- 1 Leuven Institute for Healthcare Policy, University of Leuven, Belgium
| | - Deborah Seys
- 1 Leuven Institute for Healthcare Policy, University of Leuven, Belgium
| | - Peter R Sinnaeve
- 2 Department of Cardiology, University Hospitals Leuven, Belgium
| | - Marc J Claeys
- 3 Department of Cardiology, Antwerp University Hospital, Belgium
| | - Sofie Gevaert
- 4 Department of Cardiology, University Hospital Ghent, Belgium
| | - Danny Schoors
- 5 Department of Cardiology, University Hospitals Brussels, Belgium
| | - Walter Sermeus
- 1 Leuven Institute for Healthcare Policy, University of Leuven, Belgium
| | - Massimiliano Panella
- 6 Department of Clinical and Experimental Medicine, Amedeo Avogadro University of Eastern Piedmont, Italy
| | - Luk Bruyneel
- 1 Leuven Institute for Healthcare Policy, University of Leuven, Belgium.,7 Department of Quality Management, University Hospitals Leuven, Belgium
| | - Kris Vanhaecht
- 1 Leuven Institute for Healthcare Policy, University of Leuven, Belgium.,7 Department of Quality Management, University Hospitals Leuven, Belgium
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17
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The Society for Vascular Surgery practice guidelines on the care of patients with an abdominal aortic aneurysm. J Vasc Surg 2018; 67:2-77.e2. [DOI: 10.1016/j.jvs.2017.10.044] [Citation(s) in RCA: 1150] [Impact Index Per Article: 191.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
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Fordyce CB, Al-Khalidi HR, Jollis JG, Roettig ML, Gu J, Bagai A, Berger PB, Corbett CC, Dauerman HL, Fox K, Garvey JL, Henry TD, Rokos IC, Sherwood MW, Wilson BH, Granger CB. Association of Rapid Care Process Implementation on Reperfusion Times Across Multiple ST-Segment-Elevation Myocardial Infarction Networks. Circ Cardiovasc Interv 2017; 10:CIRCINTERVENTIONS.116.004061. [PMID: 28082714 DOI: 10.1161/circinterventions.116.004061] [Citation(s) in RCA: 39] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/06/2016] [Accepted: 11/17/2016] [Indexed: 01/21/2023]
Abstract
BACKGROUND The Mission: Lifeline STEMI Systems Accelerator program, implemented in 16 US metropolitan regions, resulted in more patients receiving timely reperfusion. We assessed whether implementing key care processes was associated with system performance improvement. METHODS AND RESULTS Hospitals (n=167 with 23 498 ST-segment-elevation myocardial infarction patients) were surveyed before (March 2012) and after (July 2014) program intervention. Data were merged with patient-level clinical data over the same period. For reperfusion, hospitals were grouped by whether a specific process of care was implemented, preexisting, or never implemented. Uptake of 4 key care processes increased after intervention: prehospital catheterization laboratory activation (62%-91%; P<0.001), single call transfer protocol from an outside facility (45%-70%; P<0.001), and emergency department bypass for emergency medical services direct presenters (48%-59%; P=0.002) and transfers (56%-79%; P=0.001). There were significant differences in median first medical contact-to-device times among groups implementing prehospital activation (88 minutes implementers versus 89 minutes preexisting versus 98 minutes nonimplementers; P<0.001 for comparisons). Similarly, patients treated at hospitals implementing single call transfer protocols had shorter median first medical contact-to-device times (112 versus 128 versus 152 minutes; P<0.001). Emergency department bypass was also associated with shorter median first medical contact-to-device times for emergency medical services direct presenters (84 versus 88 versus 94 minutes; P<0.001) and transfers (123 versus 127 versus 167 minutes; P<0.001). CONCLUSIONS The Accelerator program increased uptake of key care processes, which were associated with improved system performance. These findings support efforts to implement regional ST-segment-elevation myocardial infarction networks focused on prehospital catheterization laboratory activation, single call transfer protocols, and emergency department bypass.
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Affiliation(s)
- Christopher B Fordyce
- From the Division of Cardiology, University of British Columbia, Vancouver, Canada (C.B.F.); Duke Clinical Research Institute, Durham, NC (C.B.F., H.R.A.-K., M.L.R., J.G., K.F., M.W.S., C.B.G.); University of North Carolina, Chapel Hill (J.G.J.); St. Michael's Hospital, University of Toronto, ON, Canada (A.B.); Northwell Health, Great Neck, 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.); Cedars-Sinai Heart Institute, Los Angeles, CA (T.D.H.); UCLA-Olive View Medical Center, Los Angeles, CA (I.C.R.); and Sanger Heart & Vascular Institute, Carolinas Medical Center, Charlotte, NC (B.H.W.).
| | - Hussein R Al-Khalidi
- From the Division of Cardiology, University of British Columbia, Vancouver, Canada (C.B.F.); Duke Clinical Research Institute, Durham, NC (C.B.F., H.R.A.-K., M.L.R., J.G., K.F., M.W.S., C.B.G.); University of North Carolina, Chapel Hill (J.G.J.); St. Michael's Hospital, University of Toronto, ON, Canada (A.B.); Northwell Health, Great Neck, 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.); Cedars-Sinai Heart Institute, Los Angeles, CA (T.D.H.); UCLA-Olive View Medical Center, Los Angeles, CA (I.C.R.); and Sanger Heart & Vascular Institute, Carolinas Medical Center, Charlotte, NC (B.H.W.)
| | - James G Jollis
- From the Division of Cardiology, University of British Columbia, Vancouver, Canada (C.B.F.); Duke Clinical Research Institute, Durham, NC (C.B.F., H.R.A.-K., M.L.R., J.G., K.F., M.W.S., C.B.G.); University of North Carolina, Chapel Hill (J.G.J.); St. Michael's Hospital, University of Toronto, ON, Canada (A.B.); Northwell Health, Great Neck, 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.); Cedars-Sinai Heart Institute, Los Angeles, CA (T.D.H.); UCLA-Olive View Medical Center, Los Angeles, CA (I.C.R.); and Sanger Heart & Vascular Institute, Carolinas Medical Center, Charlotte, NC (B.H.W.)
| | - Mayme L Roettig
- From the Division of Cardiology, University of British Columbia, Vancouver, Canada (C.B.F.); Duke Clinical Research Institute, Durham, NC (C.B.F., H.R.A.-K., M.L.R., J.G., K.F., M.W.S., C.B.G.); University of North Carolina, Chapel Hill (J.G.J.); St. Michael's Hospital, University of Toronto, ON, Canada (A.B.); Northwell Health, Great Neck, 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.); Cedars-Sinai Heart Institute, Los Angeles, CA (T.D.H.); UCLA-Olive View Medical Center, Los Angeles, CA (I.C.R.); and Sanger Heart & Vascular Institute, Carolinas Medical Center, Charlotte, NC (B.H.W.)
| | - Joan Gu
- From the Division of Cardiology, University of British Columbia, Vancouver, Canada (C.B.F.); Duke Clinical Research Institute, Durham, NC (C.B.F., H.R.A.-K., M.L.R., J.G., K.F., M.W.S., C.B.G.); University of North Carolina, Chapel Hill (J.G.J.); St. Michael's Hospital, University of Toronto, ON, Canada (A.B.); Northwell Health, Great Neck, 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.); Cedars-Sinai Heart Institute, Los Angeles, CA (T.D.H.); UCLA-Olive View Medical Center, Los Angeles, CA (I.C.R.); and Sanger Heart & Vascular Institute, Carolinas Medical Center, Charlotte, NC (B.H.W.)
| | - Akshay Bagai
- From the Division of Cardiology, University of British Columbia, Vancouver, Canada (C.B.F.); Duke Clinical Research Institute, Durham, NC (C.B.F., H.R.A.-K., M.L.R., J.G., K.F., M.W.S., C.B.G.); University of North Carolina, Chapel Hill (J.G.J.); St. Michael's Hospital, University of Toronto, ON, Canada (A.B.); Northwell Health, Great Neck, 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.); Cedars-Sinai Heart Institute, Los Angeles, CA (T.D.H.); UCLA-Olive View Medical Center, Los Angeles, CA (I.C.R.); and Sanger Heart & Vascular Institute, Carolinas Medical Center, Charlotte, NC (B.H.W.)
| | - Peter B Berger
- From the Division of Cardiology, University of British Columbia, Vancouver, Canada (C.B.F.); Duke Clinical Research Institute, Durham, NC (C.B.F., H.R.A.-K., M.L.R., J.G., K.F., M.W.S., C.B.G.); University of North Carolina, Chapel Hill (J.G.J.); St. Michael's Hospital, University of Toronto, ON, Canada (A.B.); Northwell Health, Great Neck, 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.); Cedars-Sinai Heart Institute, Los Angeles, CA (T.D.H.); UCLA-Olive View Medical Center, Los Angeles, CA (I.C.R.); and Sanger Heart & Vascular Institute, Carolinas Medical Center, Charlotte, NC (B.H.W.)
| | - Claire C Corbett
- From the Division of Cardiology, University of British Columbia, Vancouver, Canada (C.B.F.); Duke Clinical Research Institute, Durham, NC (C.B.F., H.R.A.-K., M.L.R., J.G., K.F., M.W.S., C.B.G.); University of North Carolina, Chapel Hill (J.G.J.); St. Michael's Hospital, University of Toronto, ON, Canada (A.B.); Northwell Health, Great Neck, 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.); Cedars-Sinai Heart Institute, Los Angeles, CA (T.D.H.); UCLA-Olive View Medical Center, Los Angeles, CA (I.C.R.); and Sanger Heart & Vascular Institute, Carolinas Medical Center, Charlotte, NC (B.H.W.)
| | - Harold L Dauerman
- From the Division of Cardiology, University of British Columbia, Vancouver, Canada (C.B.F.); Duke Clinical Research Institute, Durham, NC (C.B.F., H.R.A.-K., M.L.R., J.G., K.F., M.W.S., C.B.G.); University of North Carolina, Chapel Hill (J.G.J.); St. Michael's Hospital, University of Toronto, ON, Canada (A.B.); Northwell Health, Great Neck, 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.); Cedars-Sinai Heart Institute, Los Angeles, CA (T.D.H.); UCLA-Olive View Medical Center, Los Angeles, CA (I.C.R.); and Sanger Heart & Vascular Institute, Carolinas Medical Center, Charlotte, NC (B.H.W.)
| | - Kathleen Fox
- From the Division of Cardiology, University of British Columbia, Vancouver, Canada (C.B.F.); Duke Clinical Research Institute, Durham, NC (C.B.F., H.R.A.-K., M.L.R., J.G., K.F., M.W.S., C.B.G.); University of North Carolina, Chapel Hill (J.G.J.); St. Michael's Hospital, University of Toronto, ON, Canada (A.B.); Northwell Health, Great Neck, 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.); Cedars-Sinai Heart Institute, Los Angeles, CA (T.D.H.); UCLA-Olive View Medical Center, Los Angeles, CA (I.C.R.); and Sanger Heart & Vascular Institute, Carolinas Medical Center, Charlotte, NC (B.H.W.)
| | - J Lee Garvey
- From the Division of Cardiology, University of British Columbia, Vancouver, Canada (C.B.F.); Duke Clinical Research Institute, Durham, NC (C.B.F., H.R.A.-K., M.L.R., J.G., K.F., M.W.S., C.B.G.); University of North Carolina, Chapel Hill (J.G.J.); St. Michael's Hospital, University of Toronto, ON, Canada (A.B.); Northwell Health, Great Neck, 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.); Cedars-Sinai Heart Institute, Los Angeles, CA (T.D.H.); UCLA-Olive View Medical Center, Los Angeles, CA (I.C.R.); and Sanger Heart & Vascular Institute, Carolinas Medical Center, Charlotte, NC (B.H.W.)
| | - Timothy D Henry
- From the Division of Cardiology, University of British Columbia, Vancouver, Canada (C.B.F.); Duke Clinical Research Institute, Durham, NC (C.B.F., H.R.A.-K., M.L.R., J.G., K.F., M.W.S., C.B.G.); University of North Carolina, Chapel Hill (J.G.J.); St. Michael's Hospital, University of Toronto, ON, Canada (A.B.); Northwell Health, Great Neck, 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.); Cedars-Sinai Heart Institute, Los Angeles, CA (T.D.H.); UCLA-Olive View Medical Center, Los Angeles, CA (I.C.R.); and Sanger Heart & Vascular Institute, Carolinas Medical Center, Charlotte, NC (B.H.W.)
| | - Ivan C Rokos
- From the Division of Cardiology, University of British Columbia, Vancouver, Canada (C.B.F.); Duke Clinical Research Institute, Durham, NC (C.B.F., H.R.A.-K., M.L.R., J.G., K.F., M.W.S., C.B.G.); University of North Carolina, Chapel Hill (J.G.J.); St. Michael's Hospital, University of Toronto, ON, Canada (A.B.); Northwell Health, Great Neck, 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.); Cedars-Sinai Heart Institute, Los Angeles, CA (T.D.H.); UCLA-Olive View Medical Center, Los Angeles, CA (I.C.R.); and Sanger Heart & Vascular Institute, Carolinas Medical Center, Charlotte, NC (B.H.W.)
| | - Matthew W Sherwood
- From the Division of Cardiology, University of British Columbia, Vancouver, Canada (C.B.F.); Duke Clinical Research Institute, Durham, NC (C.B.F., H.R.A.-K., M.L.R., J.G., K.F., M.W.S., C.B.G.); University of North Carolina, Chapel Hill (J.G.J.); St. Michael's Hospital, University of Toronto, ON, Canada (A.B.); Northwell Health, Great Neck, 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.); Cedars-Sinai Heart Institute, Los Angeles, CA (T.D.H.); UCLA-Olive View Medical Center, Los Angeles, CA (I.C.R.); and Sanger Heart & Vascular Institute, Carolinas Medical Center, Charlotte, NC (B.H.W.)
| | - B Hadley Wilson
- From the Division of Cardiology, University of British Columbia, Vancouver, Canada (C.B.F.); Duke Clinical Research Institute, Durham, NC (C.B.F., H.R.A.-K., M.L.R., J.G., K.F., M.W.S., C.B.G.); University of North Carolina, Chapel Hill (J.G.J.); St. Michael's Hospital, University of Toronto, ON, Canada (A.B.); Northwell Health, Great Neck, 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.); Cedars-Sinai Heart Institute, Los Angeles, CA (T.D.H.); UCLA-Olive View Medical Center, Los Angeles, CA (I.C.R.); and Sanger Heart & Vascular Institute, Carolinas Medical Center, Charlotte, NC (B.H.W.)
| | - Christopher B Granger
- From the Division of Cardiology, University of British Columbia, Vancouver, Canada (C.B.F.); Duke Clinical Research Institute, Durham, NC (C.B.F., H.R.A.-K., M.L.R., J.G., K.F., M.W.S., C.B.G.); University of North Carolina, Chapel Hill (J.G.J.); St. Michael's Hospital, University of Toronto, ON, Canada (A.B.); Northwell Health, Great Neck, 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.); Cedars-Sinai Heart Institute, Los Angeles, CA (T.D.H.); UCLA-Olive View Medical Center, Los Angeles, CA (I.C.R.); and Sanger Heart & Vascular Institute, Carolinas Medical Center, Charlotte, NC (B.H.W.)
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19
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Hinohara TT, Al-Khalidi HR, Fordyce CB, Gu X, Sherwood MW, Roettig ML, Corbett CC, Monk L, Tamis-Holland JE, Berger PB, Burchenal JEB, Wilson BH, Jollis JG, Granger CB. Impact of Regional Systems of Care on Disparities in Care Among Female and Black Patients Presenting With ST-Segment-Elevation Myocardial Infarction. J Am Heart Assoc 2017; 6:JAHA.117.007122. [PMID: 29066448 PMCID: PMC5721895 DOI: 10.1161/jaha.117.007122] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND The American Heart Association Mission: Lifeline STEMI (ST-segment-elevation myocardial infarction) Systems Accelerator program, conducted in 16 regions across the United States to improve key care processes, resulted in more patients being treated within national guideline goals (time from first medical contact to device: <90 minutes for direct presenters to hospitals capable of performing percutaneous coronary intervention; <120 minutes for transfers). We examined whether the effort reduced reperfusion disparities in the proportions of female versus male and black versus white patients. METHODS AND RESULTS In total, 23 809 patients (29.3% female, 82.3% white, and 10.7% black) presented with acute STEMI between July 2012 and March 2014. Change in the proportion of patients treated within guideline goals was compared between sex and race subgroups for patients presenting directly to hospitals capable of performing percutaneous coronary intervention (n=18 267) and patients requiring transfer (n=5542). The intervention was associated with an increase in the proportion of men treated within guideline goals that presented directly (58.7-62.1%, P=0.01) or were transferred (43.3-50.7%, P<0.01). An increase was also seen among white patients who presented directly (57.7-59.9%, P=0.02) or were transferred (43.9-48.8%, P<0.01). There was no change in the proportion of female or black patients treated within guideline goals, including both those presenting directly and transferred. CONCLUSION The STEMI Systems Accelerator project was associated with an increase in the proportion of patients meeting guideline reperfusion targets for male and white patients but not for female or black patients. Efforts to organize systems of STEMI care should implement additional processes targeting barriers to timely reperfusion among female and black patients.
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Affiliation(s)
- Tomoya T Hinohara
- Duke University Medical Center, Durham, NC.,Duke Clinical Research Institute, Durham, NC
| | - Hussein R Al-Khalidi
- Duke University Medical Center, Durham, NC.,Duke Clinical Research Institute, Durham, NC
| | - Christopher B Fordyce
- Duke University Medical Center, Durham, NC.,Duke Clinical Research Institute, Durham, NC
| | | | - Matthew W Sherwood
- Duke University Medical Center, Durham, NC.,Duke Clinical Research Institute, Durham, NC
| | | | | | - Lisa Monk
- Duke Clinical Research Institute, Durham, NC
| | | | - Peter B Berger
- Cardiovascular Center for Clinical Research, Danville, PA
| | | | - B Hadley Wilson
- Sanger Heart and Vascular Institute, Carolinas HealthCare System, Charlotte, NC
| | | | - Christopher B Granger
- Duke University Medical Center, Durham, NC .,Duke Clinical Research Institute, Durham, NC
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20
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Kragholm K, Lu D, Chiswell K, Al-Khalidi HR, Roettig ML, Roe M, Jollis J, Granger CB. Improvement in Care and Outcomes for Emergency Medical Service-Transported Patients With ST-Elevation Myocardial Infarction (STEMI) With and Without Prehospital Cardiac Arrest: A Mission: Lifeline STEMI Accelerator Study. J Am Heart Assoc 2017; 6:JAHA.117.005717. [PMID: 29021273 PMCID: PMC5721828 DOI: 10.1161/jaha.117.005717] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
Background Patients with ST‐elevation myocardial infarction (STEMI) with out‐of‐hospital cardiac arrest (OHCA) may benefit from direct transport to a percutaneous cardiac intervention (PCI) hospital but have previously been less likely to bypass local non‐PCI hospitals to go to a PCI center. Methods and Results We reported time trends in emergency medical service transport and care of patients with STEMI with and without OHCA included from 171 PCI‐capable hospitals in 16 US regions with participation in the Mission: Lifeline STEMI Accelerator program between July 1, 2012, and March 31, 2014. Time trends by quarter were assessed using logistic regression with generalized estimating equations to account for hospital clustering. Of 13 189 emergency medical service–transported patients, 88.7% (N=11 703; 10.5% OHCA) were taken directly to PCI hospitals. Among 1486 transfer‐in patients, 21.7% had OHCA. Direct transport to a PCI center for OHCA increased from 74.7% (July 1, 2012) to 83.6% (March 31, 2014) (odds ratio per quarter, 1.07; 95% confidence interval, 1.02–1.14), versus 89.0% to 91.0% for patients without OHCA (odds ratio, 1.03; 95% confidence interval, 0.99–1.07; interaction P=0.23). The proportion with prehospital ECGs increased for patients taken directly to PCI centers (53.9%–61.9% for those with OHCA versus 73.9%–81.9% for those without OHCA; interaction P=0.12). Of 997 patients with OHCA taken directly to PCI hospitals and treated with primary PCI, first medical contact‐to‐device times within the guideline‐recommended goal of ≤90 minutes were met for 34.5% on July 1, 2012, versus 41.8% on March 31, 2014 (51.6% and 56.1%, respectively, for 9352 counterparts without OHCA; interaction P=0.72). Conclusions Direct transport to PCI hospitals increased for patients with STEMI with and without OHCA during the 2012 to 2014 Mission: Lifeline STEMI Accelerator program. Proportions with prehospital ECGs and timely reperfusion increased for patients taken directly to PCI hospitals.
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Affiliation(s)
| | - Di Lu
- Duke Clinical Research Institute, Durham, NC
| | | | | | | | - Matthew Roe
- Duke Clinical Research Institute, Durham, NC
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21
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Marton-Popovici M. Review. Regional Networks in Acute Cardiac Care. JOURNAL OF CARDIOVASCULAR EMERGENCIES 2017. [DOI: 10.1515/jce-2017-0021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
Abstract
In acute cardiac care, the timely initiation of life-saving measures proved to be life-saving and requires many organizational and logistic measures. One of such measures is represented by the development and implementation of a regional network dedicated for the treatment of major cardiovascular emergencies, a strategy that proved to significantly reduce mortality rates on short and long term. This review aims to describe the current status in the development of regional networks in three of the main cardiovascular emergencies: acute myocardial infarction, out-of-hospital cardiac arrest, and acute stroke. The concepts demonstrating the utility of such networks, together with their results in reducing cardiac events, are presented in this paper.
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Affiliation(s)
- Monica Marton-Popovici
- Swedish Medical Center, Department of Internal Medicine and Critical Care, Edmonds, Washington , USA
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22
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Hsia RY, Sabbagh S, Sarkar N, Sporer K, Rokos IC, Brown JF, Brindis RG, Guo J, Shen YC. Trends in Regionalization of Care for ST-Segment Elevation Myocardial Infarction. West J Emerg Med 2017; 18:1010-1017. [PMID: 29085531 PMCID: PMC5654868 DOI: 10.5811/westjem.2017.8.34592] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2017] [Revised: 07/12/2017] [Accepted: 08/08/2017] [Indexed: 11/17/2022] Open
Abstract
Introduction California has led successful regionalized efforts for several time-critical medical conditions, including ST-segment elevation myocardial infarction (STEMI), but no specific mandated protocols exist to define regionalization of care. We aimed to study the trends in regionalization of care for STEMI patients in the state of California and to examine the differences in patient demographic, hospital, and county trends. Methods Using survey responses collected from all California emergency medical services (EMS) agencies, we developed four categories – no, partial, substantial, and complete regionalization – to capture prehospital and inter-hospital components of regionalization in each EMS agency’s jurisdiction between 2005–2014. We linked the survey responses to 2006 California non-public hospital discharge data to study the patient distribution at baseline. Results STEMI regionalization-of-care networks steadily developed across California. Only 14% of counties were regionalized in 2006, accounting for 42% of California’s STEMI patient population, but over half of these counties, representing 86% of California’s STEMI patient population, reached complete regionalization in 2014. We did not find any dramatic differences in underlying patient characteristics based on regionalization status; however, differences in hospital characteristics were relatively substantial. Conclusion Potential barriers to achieving regionalization included competition, hospital ownership, population density, and financial challenges. Minimal differences in patient characteristics can establish that patient differences unlikely played any role in influencing earlier or later regionalization and can provide a framework for future analyses evaluating the impact of regionalization on patient outcomes.
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Affiliation(s)
- Renee Y Hsia
- University of California, San Francisco, Department of Emergency Medicine, San Francisco, California.,University of California, San Francisco, Philip R. Lee Institute for Health Policy Studies, San Francisco, California
| | - Sarah Sabbagh
- University of California, San Francisco, Department of Emergency Medicine, San Francisco, California
| | - Nandita Sarkar
- National Bureau of Economic Research, Cambridge, Massachusetts
| | - Karl Sporer
- University of California, San Francisco, Department of Emergency Medicine, San Francisco, California.,Alameda County Emergency Medical Services Agency, Oakland, California
| | - Ivan C Rokos
- University of California, Los Angeles-Olive View Medical Center; Geffen School of Medicine, Los Angeles, California
| | - John F Brown
- University of California, San Francisco, Department of Emergency Medicine, San Francisco, California.,San Francisco Emergency Medical Services Agency, San Francisco, California
| | - Ralph G Brindis
- University of California, San Francisco, Philip R. Lee Institute for Health Policy Studies, San Francisco, California.,University of California, San Francisco, Department of Medicine, San Francisco, California
| | - Joanna Guo
- University of California, San Francisco, Department of Emergency Medicine, San Francisco, California
| | - Yu-Chu Shen
- National Bureau of Economic Research, Cambridge, Massachusetts.,Naval Postgraduate School, Graduate School of Business and Public Policy, Monterey, California
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23
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Fordyce CB, Henry TD, Granger CB. Implementation of Regional ST-Segment Elevation Myocardial Infarction Systems of Care: Successes and Challenges. Interv Cardiol Clin 2017; 5:415-425. [PMID: 28581992 DOI: 10.1016/j.iccl.2016.06.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Current guidelines recommend that communities create and maintain a regional system of ST-segment elevation myocardial infarction (STEMI) care that includes assessment and continuous quality improvement of emergency medical services and hospital-based activities. Availability and timely access is a challenge in many areas of the United States. This article reviews clinical trial data supporting the use of primary percutaneous coronary intervention as the optimal reperfusion strategy, and fibrinolysis as an option when this is not possible. It then describes the outcomes and benefits of implementing regional systems of STEMI care, and discusses ongoing challenges for STEMI system implementation, including inadequate data collection and feedback, and hospital and physician competition.
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Affiliation(s)
| | - Timothy D Henry
- Cedars-Sinai Heart Institute, 127 South San Vicente Boulevard, Suite A3100, Los Angeles, CA 90048, USA
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24
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Maddox TM, Albert NM, Borden WB, Curtis LH, Ferguson TB, Kao DP, Marcus GM, Peterson ED, Redberg R, Rumsfeld JS, Shah ND, Tcheng JE. The Learning Healthcare System and Cardiovascular Care: A Scientific Statement From the American Heart Association. Circulation 2017; 135:e826-e857. [DOI: 10.1161/cir.0000000000000480] [Citation(s) in RCA: 67] [Impact Index Per Article: 9.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
The learning healthcare system uses health information technology and the health data infrastructure to apply scientific evidence at the point of clinical care while simultaneously collecting insights from that care to promote innovation in optimal healthcare delivery and to fuel new scientific discovery. To achieve these goals, the learning healthcare system requires systematic redesign of the current healthcare system, focusing on 4 major domains: science and informatics, patient-clinician partnerships, incentives, and development of a continuous learning culture. This scientific statement provides an overview of how these learning healthcare system domains can be realized in cardiovascular disease care. Current cardiovascular disease care innovations in informatics, data uses, patient engagement, continuous learning culture, and incentives are profiled. In addition, recommendations for next steps for the development of a learning healthcare system in cardiovascular care are presented.
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25
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White H. Modest Improvement of Reperfusion Times Across Multiple ST-Segment-Elevation Myocardial Infarction Networks With Rapid Care Process Implementation but no Effect on Mortality. Circ Cardiovasc Interv 2017; 10:e004769. [PMID: 28082715 DOI: 10.1161/circinterventions.116.004769] [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)
- Harvey White
- From the Cardiology Department, Auckland City Hospital Green Lane Cardiovascular Services, New Zealand.
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26
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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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27
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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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Merlo AE, Chauhan D, Pettit C, Hong KN, Saunders CR, Chen C, Russo MJ. Outcomes following emergent open repair for thoracic aortic dissection are improved at higher volume centers in direct admissions and transfers. J Cardiothorac Surg 2016; 11:118. [PMID: 27484472 PMCID: PMC4969670 DOI: 10.1186/s13019-016-0529-5] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2016] [Accepted: 07/28/2016] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND The purpose of this study is (1) to define the proportion of patients undergoing emergent open repair of thoracic aortic dissection admitted directly through the emergency room versus those transferred from outside hospitals and (2) to determine if a volume-outcomes relationship exists for those patients across admission types. METHODS De-identified patient-level data was obtained from the Nationwide Inpatient Sample (2004-2008). Patients undergoing emergent aortic surgery for thoracic aortic dissection (n = 1,507) were identified by ICD-9 codes and stratified by annual center volume into low volume (≤5 cases/year) (n = 963; 63.9 %), intermediate volume (6-10 cases/year) (n = 370; 24.5 %), and high volume (≥11 cases/year) (n = 174; 11.6 %) groups. The analysis was further stratified by admission type: direct admission (DA), transfer admission (TA), and other. The primary outcome was in-hospital mortality. Multivariate logistic regression analysis was performed comparing outcomes between high vs low and high vs intermediate volume centers. RESULTS Overall in-hospital mortality was 21.8 % (n = 328/1,507). Absolute percent mortality at high volume centers was significantly lower (12.6 %) than at medium (20.6 %) and low volume (23.9 %) centers. For DA patients, mortality was 10.6, 21.4, and 24.0 % for high, medium, and low volume centers respectively. For TA patients, mortality was 10.2, 12.7, and 23.5 % for high, medium, and low volume centers, respectively. Multivariate analysis suggested that patients in low volume center were more likely to die compared to high volume center (Odds Ratio 2.06, 95 % CI 1.25 - 3.38, p = 0.004). Admission source was not associated with increased mortality. CONCLUSIONS Direct admissions comprise the largest proportion of dissections regardless of volume strata, and they comprise the largest proportion in the low and intermediate volume cohorts. Admission to low volume center is an independent risk factor for increased mortality. Patients transferred to high volume centers from low volume centers have similar outcome as direct admits in terms of mortality.
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Affiliation(s)
- Aurelie E Merlo
- Cardiovascular Clinical Research Unit, Barnabas Heart Hospitals, Newark, NJ, USA.,Case Western Reserve University School of Medicine, Cleveland, OH, USA
| | - Dhaval Chauhan
- Cardiovascular Clinical Research Unit, Barnabas Heart Hospitals, Newark, NJ, USA. .,Department of Surgery, Rutgers - New Jersey Medical School, Newark, NJ, USA. .,Newark Beth Israel Medical Center, Barnabas Health Heart Centers, 201 Lyons Ave, Suite G5, Newark, NJ, 07112, USA.
| | - Chris Pettit
- Cardiovascular Clinical Research Unit, Barnabas Heart Hospitals, Newark, NJ, USA
| | - Kimberly N Hong
- Department of Health Evidence and Policy, Mount Sinai School of Medicine, New York, NY, USA
| | - Craig R Saunders
- Newark Beth Israel Medical Center, Barnabas Heart Hospitals, Newark, NJ, USA
| | - Chunguang Chen
- Newark Beth Israel Medical Center, Barnabas Heart Hospitals, Newark, NJ, USA
| | - Mark J Russo
- Cardiovascular Clinical Research Unit, Barnabas Heart Hospitals, Newark, NJ, USA.,Department of Surgery, Rutgers - New Jersey Medical School, Newark, NJ, USA.,Newark Beth Israel Medical Center, Barnabas Heart Hospitals, Newark, NJ, USA
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29
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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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Chen HY, Gore JM, Lapane KL, Yarzebski J, Person SD, Kiefe CI, Goldberg RJ. Decade-long trends in the timeliness of receipt of a primary percutaneous coronary intervention. Clin Epidemiol 2016; 8:141-9. [PMID: 27350759 PMCID: PMC4902148 DOI: 10.2147/clep.s102225] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Objectives The purpose of this study was to examine decade-long trends (2001–2011) in, and factors associated with, door-to-balloon time within 90 minutes of hospital presentation among patients hospitalized with ST-segment elevation myocardial infarction (STEMI) who received a primary percutaneous coronary intervention (PCI). Methods Residents of central Massachusetts hospitalized with STEMI who received a primary PCI at two major PCI-capable medical centers in central Massachusetts on a biennial basis between 2001 and 2011 comprised the study population (n=629). Multivariable regression analyses were used to examine factors associated with failing to receive a primary PCI within 90 minutes after emergency department (ED) arrival. Results The average age of this patient population was 61.9 years; 30.5% were women, and 91.7% were White. During the years under study, 50.9% of patients received a primary PCI within 90 minutes of ED arrival; this proportion increased from 2001/2003 (17.2%) to 2009/2011 (70.5%) (P<0.001). Having previously undergone coronary artery bypass graft surgery, arriving at the ED by car/walk-in and during off-hours were significantly associated with a higher risk of failing to receive a primary PCI within 90 minutes of ED arrival. Conclusion The likelihood of receiving a timely primary PCI in residents of central Massachusetts hospitalized with STEMI at the major teaching/community medical centers increased dramatically during the years under study. Several groups were identified for purposes of heightened surveillance and intervention efforts to reduce the likelihood of failing to receive a timely primary PCI among patients acutely diagnosed with STEMI.
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Affiliation(s)
- Han-Yang Chen
- Department of Quantitative Health Sciences, University of Massachusetts Medical School, Worcester, MA, USA
| | - Joel M Gore
- Department of Quantitative Health Sciences, University of Massachusetts Medical School, Worcester, MA, USA; Department of Medicine, University of Massachusetts Medical School, Worcester, MA, USA
| | - Kate L Lapane
- Department of Quantitative Health Sciences, University of Massachusetts Medical School, Worcester, MA, USA
| | - Jorge Yarzebski
- Department of Quantitative Health Sciences, University of Massachusetts Medical School, Worcester, MA, USA
| | - Sharina D Person
- Department of Quantitative Health Sciences, University of Massachusetts Medical School, Worcester, MA, USA
| | - Catarina I Kiefe
- Department of Quantitative Health Sciences, University of Massachusetts Medical School, Worcester, MA, USA
| | - Robert J Goldberg
- Department of Quantitative Health Sciences, University of Massachusetts Medical School, Worcester, MA, USA; Meyers Primary Care Institute, University of Massachusetts Medical School, Worcester, MA, USA
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Shams T, Zaidat O, Yavagal D, Xavier A, Jovin T, Janardhan V. Society of Vascular and Interventional Neurology (SVIN) Stroke Interventional Laboratory Consensus (SILC) Criteria: A 7M Management Approach to Developing a Stroke Interventional Laboratory in the Era of Stroke Thrombectomy for Large Vessel Occlusions. INTERVENTIONAL NEUROLOGY 2016; 5:1-28. [PMID: 27610118 PMCID: PMC4934489 DOI: 10.1159/000443617] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
Brain attack care is rapidly evolving with cutting-edge stroke interventions similar to the growth of heart attack care with cardiac interventions in the last two decades. As the field of stroke intervention is growing exponentially globally, there is clearly an unmet need to standardize stroke interventional laboratories for safe, effective, and timely stroke care. Towards this goal, the Society of Vascular and Interventional Neurology (SVIN) Writing Committee has developed the Stroke Interventional Laboratory Consensus (SILC) criteria using a 7M management approach for the development and standardization of each stroke interventional laboratory within stroke centers. The SILC criteria include: (1) manpower: personnel including roles of medical and administrative directors, attending physicians, fellows, physician extenders, and all the key stakeholders in the stroke chain of survival; (2) machines: resources needed in terms of physical facilities, and angiography equipment; (3) materials: medical device inventory, medications, and angiography supplies; (4) methods: standardized protocols for stroke workflow optimization; (5) metrics (volume): existing credentialing criteria for facilities and stroke interventionalists; (6) metrics (quality): benchmarks for quality assurance; (7) metrics (safety): radiation and procedural safety practices.
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Affiliation(s)
- Tanzila Shams
- Texas Stroke Institute, HCA North Texas Division, Dallas-Fort Worth, Tex., USA
| | - Osama Zaidat
- Mercy Neuroscience and Stroke Center, Toledo, Ohio, USA
| | - Dileep Yavagal
- Jackson Memorial Hospital, University of Miami Health System, Miami, Fla., USA
| | - Andrew Xavier
- Detroit Medical Center, Wayne State University, Detroit, Mich., USA
| | - Tudor Jovin
- UPMC Stroke Institute, University of Pittsburgh Medical Center, Pittsburg, Pa., USA
| | - Vallabh Janardhan
- Texas Stroke Institute, HCA North Texas Division, Dallas-Fort Worth, Tex., USA
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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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Marino BCA, Ribeiro ALP, Alkmim MB, Antunes AP, Boersma E, Marcolino MS. Coordinated regional care of myocardial infarction in a rural area in Brazil: Minas Telecardio Project 2. EUROPEAN HEART JOURNAL. QUALITY OF CARE & CLINICAL OUTCOMES 2016; 2:215-224. [PMID: 29474619 DOI: 10.1093/ehjqcco/qcw020] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/28/2016] [Accepted: 04/17/2016] [Indexed: 01/13/2023]
Abstract
Aims In Brazil, there are considerable disparities in access to healthcare. The aim of this study was to assess how implementation of a coordinated regional management protocol for patients with ST-elevation myocardial infarction (STEMI) affected quality of care and outcomes in a rural and deprived Brazilian region with considerable social inequalities. Methods and results The quality of care and outcomes of STEMI was evaluated in two cohorts before (n = 214) and after (n = 143) implementation of the coordinated regional management protocol. Central to this protocol was a tablet-based digital electrocardiogram (ECG) recording in the emergency ambulance that was transmitted for analysis by trained professionals. If the pre-hospital ECG was diagnostic, it triggered a management cascade involving a direct transfer to the regional intervention centre with reperfusion by primary percutaneous coronary intervention (PPCI) or pre-hospital fibrinolysis for anticipated journey times of less than or greater than 2 h, respectively. Following implementation of the protocol, the adjusted medical delay (system delay - transport time) decreased by 40% (95% confidence intervals: -66%, -13%). The proportion of patients who received reperfusion therapy increased from 70.6 to 80.8% (P = 0.045), with increases in treatment with aspirin [94.2-100% (P = 0.003)] and P2Y12 inhibitors [87.5-100% (P < 0.001)]. The odds of in-hospital death showed a non-significant decrease [odds ratio 0.73 (95% confidence intervals: 0.34-1.60)]. Conclusion The implementation of a coordinated regional management protocol for patients with STEMI led to marked improvements in the quality of care in a remote Brazilian region with limited resources.
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Affiliation(s)
- Bárbara Campos Abreu Marino
- University Hospital, Universidade Federal de Minas Gerais, Rua Maranhão 1007/601, Funcionários, Belo Horizonte, MG 30150-331, Brazil.,Medical School, Universidade Federal de Minas Gerais, Belo Horizonte, Brazil
| | - Antonio Luiz Pinho Ribeiro
- University Hospital, Universidade Federal de Minas Gerais, Rua Maranhão 1007/601, Funcionários, Belo Horizonte, MG 30150-331, Brazil.,Medical School, Universidade Federal de Minas Gerais, Belo Horizonte, Brazil
| | - Maria Beatriz Alkmim
- University Hospital, Universidade Federal de Minas Gerais, Rua Maranhão 1007/601, Funcionários, Belo Horizonte, MG 30150-331, Brazil
| | - Andre Pires Antunes
- University Hospital, Universidade Federal de Minas Gerais, Rua Maranhão 1007/601, Funcionários, Belo Horizonte, MG 30150-331, Brazil
| | - Eric Boersma
- Department of Cardiology, Erasmus MC, Rotterdam, The Netherlands
| | - Milena Soriano Marcolino
- University Hospital, Universidade Federal de Minas Gerais, Rua Maranhão 1007/601, Funcionários, Belo Horizonte, MG 30150-331, Brazil.,Medical School, Universidade Federal de Minas Gerais, Belo Horizonte, Brazil
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Rhudy JP, Bakitas MA, Hyrkäs K, Jablonski-Jaudon RA, Pryor ER, Wang HE, Alexandrov AW. Effectiveness of regionalized systems for stroke and myocardial infarction. Brain Behav 2015; 5:e00398. [PMID: 26516616 PMCID: PMC4614047 DOI: 10.1002/brb3.398] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/20/2015] [Revised: 07/18/2015] [Accepted: 08/16/2015] [Indexed: 01/08/2023] Open
Abstract
BACKGROUND Acute ischemic stroke (AIS) and ST-segment elevation myocardial infarction (STEMI) are ischemic emergencies. Guidelines recommend care delivery within formally regionalized systems of care at designated centers, with bypass of nearby centers of lesser or no designation. We review the evidence of the effectiveness of regionalized systems in AIS and STEMI. METHODS Literature was searched using terms corresponding to designation of AIS and STEMI systems and from 2010 to the present. Inclusion criteria included report of an outcome on any dependent variable mentioned in the rationale for regionalization in the guidelines and an independent variable comparing care to a non- or pre-regionalized system. Designation was defined in the AIS case as certification by the Joint Commission as either a primary (PSC) or comprehensive (CSC) stroke center. In the STEMI case, the search was conducted linking "regionalization" and "myocardial infarction" or citation as a model system by any American Heart Association statement. RESULTS For AIS, 17 publications met these criteria and were selected for review. In the STEMI case, four publications met these criteria; the search was therefore expanded by relaxing the criteria to include any historical or anecdotal comparison to a pre- or nonregionalized state. The final yield was nine papers from six systems. CONCLUSION Although regionalized care results in enhanced process and reduced unadjusted rates of disparity in access and adverse outcomes, these differences tend to become nonsignificant when adjusted for delayed presentation and hospital arrival by means other than emergency medical services. The benefits of regionalized care occur along with a temporal trend of improvement due to uptake of quality initiatives and guideline recommendations by all systems regardless of designation. Further research is justified with a randomized registry or cluster randomized design to support or refute recommendations that regionalization should be the standard of care.
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Affiliation(s)
- James P Rhudy
- School of Nursing University of Alabama at Birmingham Alabama
| | - Marie A Bakitas
- School of Nursing University of Alabama at Birmingham Alabama
| | - Kristiina Hyrkäs
- Center for Nursing Research and Quality Outcomes Maine Medical Center Birmingham Alabama
| | | | - Erica R Pryor
- School of Nursing University of Alabama at Birmingham Alabama
| | - Henry E Wang
- Department of Emergency Medicine University of Alabama at Birmingham Birmingham Alabama
| | - Anne W Alexandrov
- College of Nursing University of Tennessee Health Sciences Center Memphis Tennessee
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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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Abstract
The appropriate timing of angiography to facilitate revascularization is essential to optimize outcomes in patents with ST-segment-elevation myocardial infarction and non-ST-segment-elevation acute coronary syndromes. Timely reperfusion of the infarct-related coronary artery in ST-segment-elevation myocardial infarction both with fibrinolysis or percutaneous coronary intervention minimizes myocardial damage, reduces infarct size, and decreases morbidity and mortality. Primary percutaneous coronary intervention is the preferred reperfusion method if it can be performed in a timely manner. Strategies to reduce health system-related delays in reperfusion include regionalization of ST-segment-elevation myocardial infarction care, performing prehospital ECGs, prehospital activation of the catheterization laboratory, bypassing geographically closer nonpercutaneous coronary intervention-capable hospitals, bypassing the percutaneous coronary intervention-capable hospital emergency department, and early and consistent availability of the catheterization laboratory team. With implementation of such strategies, there has been significant improvement in process measures, including door-to-balloon time. However, despite reductions in door-to-balloon times, there has been little change during the past several years in in-hospital mortality, suggesting additional factors including patient-related delays, optimization of tissue-level perfusion, and cardioprotection must be addressed to improve patient outcomes further. Early angiography followed by revascularization when appropriate also reduces rates of death, MI, and recurrent ischemia in patients with non-ST-segment-elevation acute coronary syndromes, with the greatest benefits realized in the highest risk patients. Among patients with non-ST-segment-elevation acute coronary syndromes with multivessel disease, choice of revascularization modality should be made as in stable coronary artery disease, with a goal of complete ischemic revascularization.
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Affiliation(s)
- Akshay Bagai
- From the Terrence Donnelly Heart Centre, St. Michael's Hospital, University of Toronto, Toronto, Ontario, Canada (A.B.); Mount Sinai Medical Center and The Cardiovascular Research Foundation, New York, NY (G.D.D.); Columbia University Medical Center and The Cardiovascular Research Foundation, New York, NY (G.W.S.); and Duke Clinical Research Institute, Durham, NC (C.B.G.).
| | - George D Dangas
- From the Terrence Donnelly Heart Centre, St. Michael's Hospital, University of Toronto, Toronto, Ontario, Canada (A.B.); Mount Sinai Medical Center and The Cardiovascular Research Foundation, New York, NY (G.D.D.); Columbia University Medical Center and The Cardiovascular Research Foundation, New York, NY (G.W.S.); and Duke Clinical Research Institute, Durham, NC (C.B.G.)
| | - Gregg W Stone
- From the Terrence Donnelly Heart Centre, St. Michael's Hospital, University of Toronto, Toronto, Ontario, Canada (A.B.); Mount Sinai Medical Center and The Cardiovascular Research Foundation, New York, NY (G.D.D.); Columbia University Medical Center and The Cardiovascular Research Foundation, New York, NY (G.W.S.); and Duke Clinical Research Institute, Durham, NC (C.B.G.)
| | - Christopher B Granger
- From the Terrence Donnelly Heart Centre, St. Michael's Hospital, University of Toronto, Toronto, Ontario, Canada (A.B.); Mount Sinai Medical Center and The Cardiovascular Research Foundation, New York, NY (G.D.D.); Columbia University Medical Center and The Cardiovascular Research Foundation, New York, NY (G.W.S.); and Duke Clinical Research Institute, Durham, NC (C.B.G.)
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Huber K, Gersh BJ, Goldstein P, Granger CB, Armstrong PW. The organization, function, and outcomes of ST-elevation myocardial infarction networks worldwide: current state, unmet needs and future directions. Eur Heart J 2014; 35:1526-32. [DOI: 10.1093/eurheartj/ehu125] [Citation(s) in RCA: 53] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/10/2023] Open
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Bagai A, Jollis JG, Dauerman HL, Peng SA, Rokos IC, Bates ER, French WJ, Granger CB, Roe MT. Response to letter regarding article, "Emergency department bypass for ST-segment-elevation myocardial infarction patients identified with a prehospital electrocardiogram: a report from the American Heart Association Mission: Lifeline Program". Circulation 2014; 129:e372. [PMID: 24589703 DOI: 10.1161/circulationaha.113.008027] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Akshay Bagai
- St. Michael's Hospital, University of Toronto, Toronto, ON, Canada
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