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Scholz KH, Lengenfelder B, Jacobshagen C, Fleischmann C, Moehlis H, Olbrich HG, Jung J, Maier LS, Maier SK, Bestehorn K, Friede T, Meyer T. Long-term effects of a standardized feedback-driven quality improvement program for timely reperfusion therapy in regional STEMI care networks. EUROPEAN HEART JOURNAL. ACUTE CARDIOVASCULAR CARE 2020; 10:2048872620907323. [PMID: 32723177 DOI: 10.1177/2048872620907323] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/06/2019] [Accepted: 01/24/2020] [Indexed: 02/24/2024]
Abstract
AIMS Current European Society of Cardiology guidelines state that repetitive monitoring and feedback should be implemented for ST-elevation myocardial infarction (STEMI) treatment, but no evidence is available supporting this recommendation. We aimed to analyze the long-term effects of a formalized data assessment and systematic feedback on performance and mortality within the prospective, multicenter Feedback Intervention and Treatment Times in STEMI (FITT-STEMI) study. METHODS Regular interactive feedback sessions with local STEMI management teams were performed at six participating German percutaneous coronary intervention (PCI) centers over a 10-year period starting from October 2007. RESULTS From the first to the 10th year of study participation, all predefined key-quality indicators for performance measurement used for feedback improved significantly in all 4926 consecutive PCI-treated patients - namely, the percentages of patients with pre-hospital electrocardiogram (ECG) recordings (83.3% vs 97.1%, p < 0.0001) and ECG recordings within 10 minutes after first medical contact (41.7% vs 63.8%, p < 0.0001), pre-announcement by telephone (77.0% vs 85.4%, p = 0.0007), direct transfer to the catheterization laboratory bypassing the emergency department (29.4% vs 64.2%, p < 0.0001), and contact-to-balloon times of less than 90 minutes (37.2% vs 53.7%, p < 0.0001). Moreover, this feedback-related continuous improvement of key-quality indicators was linked to a significant reduction in in-hospital mortality from 10.8% to 6.8% (p = 0.0244). Logistic regression models confirmed an independent beneficial effect of duration of study participation on hospital mortality (odds ratio = 0.986, 95% confidence interval = 0.976-0.996, p = 0.0087). In contrast, data from a nationwide PCI registry showed a continuous increase in in-hospital mortality in all PCI-treated STEMI patients in Germany from 2008 to 2015 (n = 398,027; 6.7% to 9.2%, p < 0.0001). CONCLUSIONS Our results indicate that systematic data assessment and regular feedback is a feasible long-term strategy and may be linked to improved performance and a reduction in mortality in STEMI management.
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Affiliation(s)
| | - Björn Lengenfelder
- Department of Cardiology, University of Würzburg, Germany
- Comprehensive Heart Failure Center Würzburg, Würzburg, Germany
| | - Claudius Jacobshagen
- Department of Cardiology, Heart Center, University of Göttingen, Göttingen, Germany
| | | | - Hiller Moehlis
- Department of Cardiology, Klinikum Darmstadt, Darmstadt, Germany
| | - Hans G Olbrich
- Department of Cardiology, Asklepios Klinik Langen, Langen, Germany
| | - Jens Jung
- Department of Cardiology, Klinikum Worms, Worms, Germany
| | - Lars S Maier
- Department of Cardiology, University Hospital Regensburg, Regensburg, Germany
| | - Sebastian Kg Maier
- Comprehensive Heart Failure Center Würzburg, Würzburg, Germany
- Department of Cardiology, Klinikum Straubing, Straubing, Germany
| | - Kurt Bestehorn
- Institute for Clinical Pharmacology, Medical Faculty Carl Gustav Carus, Technical University of Dresden, Dresden, Germany
| | - Tim Friede
- Department of Medical Statistics, University Medical Center Göttingen, University of Göttingen, Göttingen, Germany
- German Center for Cardiovascular Research (DZHK), partner site Göttingen, Göttingen, Germany
| | - Thomas Meyer
- German Center for Cardiovascular Research (DZHK), partner site Göttingen, Göttingen, Germany
- Department of Psychosomatic Medicine and Psychotherapy, University Medical Center Göttingen, University of Göttingen, Göttingen, Germany
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Scholz KH, Friede T, Meyer T, Jacobshagen C, Lengenfelder B, Jung J, Fleischmann C, Moehlis H, Olbrich HG, Ott R, Elsässer A, Schröder S, Thilo C, Raut W, Franke A, Maier LS, Maier SK. Prognostic significance of emergency department bypass in stable and unstable patients with ST-segment elevation myocardial infarction. EUROPEAN HEART JOURNAL-ACUTE CARDIOVASCULAR CARE 2018; 9:34-44. [PMID: 30477317 PMCID: PMC7047304 DOI: 10.1177/2048872618813907] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Background: In ST-segment elevation myocardial infarction (STEMI) patients treated with percutaneous coronary intervention, direct transport from the scene to the catheterisation laboratory bypassing the emergency department has been shown to shorten times to reperfusion. The aim of this study was to investigate the effects of emergency department bypass on mortality in both haemodynamically stable and unstable STEMI patients. Methods: The analysis is based on a large cohort of STEMI patients prospectively included in the German multicentre Feedback Intervention and Treatment Times in ST-Elevation Myocardial Infarction (FITT-STEMI) trial. Results: Out of 13,219 STEMI patients who were brought directly from the scene by emergency medical service transportation and were treated with percutaneous coronary intervention, the majority were transported directly to the catheterisation laboratory bypassing the emergency department (n=6740, 51% with emergency department bypass). These patients had a significantly lower in-hospital mortality than their counterparts with no emergency department bypass (6.2% vs. 10.0%, P<0.0001). The reduced mortality related to emergency department bypass was observed in both stable (n=11,594, 2.8% vs. 3.8%, P=0.0024) and unstable patients presenting with cardiogenic shock (n=1625, 36.3% vs. 46.2%, P<0.0001). Regression models adjusted for the Thrombolysis In Myocardial Infarction (TIMI) risk score consistently confirmed a significant and independent predictive effect of emergency department bypass on survival in the total study population (odds ratio 0.64, 95% confidence interval 0.56–0.74, P<0.0001) and in the subgroup of shock patients (OR 0.69, 95% CI 0.54–0.88, P=0.0028). Conclusion: In STEMI patients, emergency department bypass is associated with a significant reduction in mortality, which is most pronounced in patients presenting with cardiogenic shock. Our data encourage treatment protocols for emergency department bypass to improve the survival of both haemodynamically stable patients and, in particular, unstable patients. Clinical Trial Registration: NCT00794001 ClinicalTrials.gov: NCT00794001
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Affiliation(s)
| | - Tim Friede
- Department of Medical Statistics, University Medical Center Göttingen, Germany.,DZHK (German Center for Cardiovascular Research), partner site Göttingen, Germany
| | - Thomas Meyer
- DZHK (German Center for Cardiovascular Research), partner site Göttingen, Germany.,Department of Psychosomatic Medicine and Psychotherapy, University Medical Center Göttingen, Germany
| | - Claudius Jacobshagen
- DZHK (German Center for Cardiovascular Research), partner site Göttingen, Germany.,Department of Cardiology and Pneumology, University of Göttingen, Germany
| | - Björn Lengenfelder
- Department of Cardiology, University of Würzburg, Germany.,Comprehensive Heart Failure Center Würzburg, Germany
| | - Jens Jung
- Department of Cardiology, Klinikum Worms, Germany
| | | | | | - Hans G Olbrich
- Department of Cardiology, Asklepios Klinik Langen, Germany
| | - Rainer Ott
- Department of Cardiology, Helios Klinikum Krefeld, Germany
| | | | | | | | - Werner Raut
- Department of Cardiology, Community Hospital Buchholz, Germany
| | - Andreas Franke
- Department of Cardiology, Klinikum Siloah Region Hannover, Germany
| | - Lars S Maier
- Department of Cardiology, University Hospital Regensburg, Germany
| | - Sebastian Kg Maier
- Comprehensive Heart Failure Center Würzburg, Germany.,Department of Cardiology, Klinikum Straubing, Germany
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Mercuri M, Connolly K, Natarajan MK, Welsford M, Schwalm JD. Barriers to the use of emergency medical services for ST-elevation myocardial infarction: Determining why many patients opt for self-transport. J Eval Clin Pract 2018; 24:375-379. [PMID: 29239074 DOI: 10.1111/jep.12858] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/07/2017] [Accepted: 11/08/2017] [Indexed: 11/29/2022]
Abstract
RATIONALE, AIMS, AND OBJECTIVES Access to timely ST-elevation myocardial infarction (STEMI) care is facilitated by paramedics and emergency medical services (EMS). However, a large proportion of STEMI patients do not access care through EMS. This study sought to identify patient-reported factors for their decision to use (or not use) EMS. METHODS Semi-structured interviews were conducted with a sample of STEMI patients admitted to a large tertiary care centre between November 2011 and January 2012. Participants were grouped according to mode of transportation to hospital at time of index event (EMS vs self-transport). Participant responses were classified using a published framework (modified for a STEMI population) as barriers or facilitators to EMS use, and compared between groups. RESULTS Data were collected on 61 patients (32 EMS, 29 self-transport). Mean age was 60.3 (SD 11.5), and 23% were female. EMS users were more likely to have a Killip Class >1 (25% vs 4%; P = 0.03). Self-transport patients were more likely to perceive EMS as slower (48% vs 0%) and express concerns over resources misuse (34% vs 3%; P = 0.002), when compared to EMS patients. Patients who accessed EMS were more likely to acknowledge the benefits of EMS (44% vs 7%; P = 0.001) and were more likely to have been encouraged by a family member to call EMS (34% vs 4%; P = 0.003). CONCLUSIONS STEMI patient perceptions are a key factor in determining EMS use. Health care stakeholders should target the identified barriers to improve utilization of EMS, and develop strategies to optimize care for patients who do not access EMS.
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Affiliation(s)
- Mathew Mercuri
- Department of Medicine, Division of Emergency Medicine, McMaster University, Hamilton, Canada
| | - Katherine Connolly
- Department of Medicine, Division of Cardiology, University of Toronto, Toronto, Canada
| | - Madhu K Natarajan
- Department of Medicine, Division of Cardiology, McMaster University, Hamilton, Canada; Population Health Research Institute, Hamilton, Canada
| | - Michelle Welsford
- Department of Medicine, Division of Emergency Medicine, McMaster University, Hamilton, Canada; Centre for Paramedic Education and Research, Hamilton Health Sciences, Hamilton, Canada
| | - J D Schwalm
- Department of Medicine, Division of Cardiology, McMaster University, Hamilton, Canada; Population Health Research Institute, Hamilton, Canada
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Brunetti ND, Tarantino N, Dellegrottaglie G, Abatecola G, De Gennaro L, Bruno AI, Bux F, Gaglione A, Di Biase M. Impact of telemedicine support by remote pre-hospital electrocardiogram on emergency medical service management of subjects with suspected acute cardiovascular disease. Int J Cardiol 2015. [DOI: 10.1016/j.ijcard.2015.06.124] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
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Lower mortality with pre-hospital electrocardiogram triage by telemedicine support in high risk acute myocardial infarction treated with primary angioplasty: Preliminary data from the Bari-BAT public Emergency Medical Service 118 registry. Int J Cardiol 2015; 185:224-8. [PMID: 25797682 DOI: 10.1016/j.ijcard.2015.03.138] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/02/2015] [Accepted: 03/07/2015] [Indexed: 11/23/2022]
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Fernández-Rodríguez D, Freixa X, Kasa G, Regueiro A, Cevallos J, Hernández M, Brugaletta S, Martín-Yuste V, Sabaté M, Masotti M. [Benefit of the implementation of a ST-segment elevation myocardial infarction network on women]. ARCHIVOS DE CARDIOLOGIA DE MEXICO 2015; 85:96-104. [PMID: 25736036 DOI: 10.1016/j.acmx.2014.12.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2014] [Revised: 12/12/2014] [Accepted: 12/22/2014] [Indexed: 11/18/2022] Open
Abstract
OBJECTIVE The ST-segment elevation myocardial infarction network "Codi Infart" was implemented in Catalonia (Spain) in June 2009. The objective of this study was to evaluate the impact of the implementation of the Codi Infart on women. METHOD Women referred for primary percutaneous coronary intervention, were divided into two groups according to Codi Infart: Non-Codi Infart group (January 2003 to May 2009) and Codi Infart group (June 2009 to December 2012). Place of first medical contact, time intervals in diagnosis and treatment, treatments received and rate of major cardiovascular adverse events defined as all-cause death, reinfarction or stroke in-hospital, at 30 and 180 days were compared. RESULTS From a total population of 2,426 patients, 501 (20.7%) were women. One-hundred eighty-six women (2.09 cases/month) belonged to Non-Codi Infart group and 315 women (10.16 cases/month) to Codi Infart group. The percentage of women attended increased since the introduction of CI (22.2% vs. 18.5%, P=.028). In addition, the Codi Infart group had a higher percentage of women initially attended outside our institution (84.1% vs. 16.7%, P<.001), and lower total ischemia time (220 [155-380] vs. 272 [196-456], P=.003). However, no differences in 180-day major cardiovascular adverse events were detected (14.2% vs. 15.6%, P=.692). CONCLUSIONS The implementation of the major cardiovascular adverse events allowed to increase the rate and the percentage of women with ST-segment elevation myocardial infarction treated with primary percutaneous coronary intervention and reducing total ischemic time.
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Affiliation(s)
- Diego Fernández-Rodríguez
- Servicio de Cardiología, Hospital Clínic, Barcelona, España; Servicio de Cardiología, Hospital Nuestra Señora de Candelaria, Santa Cruz de Tenerife, España
| | - Xavier Freixa
- Servicio de Cardiología, Hospital Clínic, Barcelona, España.
| | - Gizem Kasa
- Servicio de Cardiología, Hospital Clínic, Barcelona, España
| | - Ander Regueiro
- Servicio de Cardiología, Hospital Clínic, Barcelona, España; Comité Directivo, Iniciativa Stent for Life, España
| | | | | | | | | | - Manel Sabaté
- Servicio de Cardiología, Hospital Clínic, Barcelona, España; Comité Directivo, Iniciativa Stent for Life, España
| | - Mónica Masotti
- Servicio de Cardiología, Hospital Clínic, Barcelona, España
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Farshid A, Allada C, Chandrasekhar J, Marley P, McGill D, O'Connor S, Rahman M, Tan R, Shadbolt B. Shorter ischaemic time and improved survival with pre-hospital STEMI diagnosis and direct transfer for primary PCI. Heart Lung Circ 2014; 24:234-40. [PMID: 25456507 DOI: 10.1016/j.hlc.2014.09.015] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2014] [Revised: 09/15/2014] [Accepted: 09/20/2014] [Indexed: 12/26/2022]
Abstract
BACKGROUND We sought to determine if our regional program for pre-hospital STEMI diagnosis and direct transfer for primary PCI (PPCI) was associated with shorter ischaemic times and improved survival compared with ED diagnosis. METHODS STEMI diagnosis was made at the scene by pre-hospital ECG or in local EDs depending on patient presentation. Ambulance ECGs were transmitted to our ED for cath lab activation. Patient variables and outcomes at 12 months were recorded. RESULTS We treated 782 consecutive patients with PPCI during January 2008-June 2013. Cath lab activation was initiated prior to hospital arrival (pre-hospital) in 24% of cases and by ED in 76% of cases. Median total ischaemic time was 154 min for pre-hospital and 211 minutes for ED patients (p<0.0001). Mortality at 12 months was 7.9% in the ED group compared with 3.7% in the pre-hospital group (p=0.036). On multivariate Cox regression analysis including baseline and procedural variables, pre-hospital activation remained an independent predictor of mortality (HR 0.45, 95% CI 0.20-1.0, p=0.03). CONCLUSIONS Pre-hospital diagnosis of STEMI and direct transfer to the cath lab reduced total ischaemic time by 57 minutes and mortality by >50% following PPCI. Further efforts are needed to increase the proportion of STEMI patients treated using this strategy.
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Affiliation(s)
- Ahmad Farshid
- Cardiology Unit, The Canberra Hospital, Yamba Drive, Garran, Australian Capital Territory, Australia; College of Medicine, Biology and Environment, Australian National University, Canberra, ACT 2601, Australia.
| | - Chris Allada
- Cardiology Unit, The Canberra Hospital, Yamba Drive, Garran, Australian Capital Territory, Australia
| | - Jaya Chandrasekhar
- Cardiology Unit, The Canberra Hospital, Yamba Drive, Garran, Australian Capital Territory, Australia
| | - Paul Marley
- Cardiology Unit, The Canberra Hospital, Yamba Drive, Garran, Australian Capital Territory, Australia
| | - Darryl McGill
- Cardiology Unit, The Canberra Hospital, Yamba Drive, Garran, Australian Capital Territory, Australia
| | - Simon O'Connor
- Cardiology Unit, The Canberra Hospital, Yamba Drive, Garran, Australian Capital Territory, Australia
| | - Moyazur Rahman
- Cardiology Unit, The Canberra Hospital, Yamba Drive, Garran, Australian Capital Territory, Australia
| | - Ren Tan
- Cardiology Unit, The Canberra Hospital, Yamba Drive, Garran, Australian Capital Territory, Australia
| | - Bruce Shadbolt
- College of Medicine, Biology and Environment, Australian National University, Canberra, ACT 2601, Australia; Centre for Advances in Epidemiology and Information Technology, The Canberra Hospital, Yamba Drive, Garran, Australian Capital Territory, Australia
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Estévez-Loureiro R, López-Sainz &A, Pérez de Prado A, Cuellas C, Calviño Santos R, Alonso-Orcajo N, Salgado Fernández J, Vázquez-Rodríguez JM, López-Benito M, Fernández-Vázquez F. Timely reperfusion for ST-segment elevation myocardial infarction: Effect of direct transfer to primary angioplasty on time delays and clinical outcomes. World J Cardiol 2014; 6:424-433. [PMID: 24976914 PMCID: PMC4072832 DOI: 10.4330/wjc.v6.i6.424] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/19/2013] [Accepted: 04/09/2014] [Indexed: 02/07/2023] Open
Abstract
Primary percutaneous coronary intervention (PPCI) is the preferred reperfusion therapy for patients presenting with ST-segment elevation myocardial infarction (STEMI) when it can be performed expeditiously and by experienced operators. In spite of excellent clinical results this technique is associated with longer delays than thrombolysis and this fact may nullify the benefit of selecting this therapeutic option. Several strategies have been proposed to decrease the temporal delays to deliver PPCI. Among them, prehospital diagnosis and direct transfer to the cath lab, by-passing the emergency department of hospitals, has emerged as an attractive way of diminishing delays. The purpose of this review is to address the effect of direct transfer on time delays and clinical events of patients with STEMI treated by PPCI.
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