Seguridad y viabilidad del retorno precoz de pacientes transferidos para angioplastia primaria a sus centros de origen

Early inter-hospital transfer of patients with myocardial infarction without a doctor, paramedic or nurse on board: results from a French regional emergency care network

Background

In France, patients with acute coronary syndromes (ACS) are usually transferred from remote hospitals to percutaneous coronary intervention (PCI) centres in mobile intensive care units (MICUs) with on-board medical staff. They are then returned to the remote hospitals by MICU 48 h after PCI. However, MICU transportation and beds in a PCI centre are in short supply. Therefore, we investigated clinical outcomes among intermediate-risk ACS patients who were transferred in private ambulances without an on-board medic or paramedic; and returned to the remote hospital sooner after PCI.

Methods

In the French Alps, the RESURCOR network manages ‘SCA-Alp’ transfers using strict management protocols in ambulances with trained drivers and automatic external defibrillators, but without heart rhythm monitoring. We conducted an observational retrospective study that assessed outcomes (death and emergency return to the PCI centre within 48 h) in patients transferred using SCA-Alp. Our population comprised stabilized patients with ST-segment elevation myocardial infarction (STEMI) who returned to the remote hospital within 24–48 h of PCI, and uncomplicated patients with non-ST-segment elevation myocardial infarction (NSTEMI) within 24–72 h of symptom onset who come from and returned to (‘round-trip’) the remote hospital on the day of PCI (return < 12 h after PCI).

Results

Between 2010 and 2014, 101 STEMI and 490 NSTEMI patients were transferred using SCA-Alp. No adverse events occurred during transportation and no deaths were reported. Two of 591 patients (0.3% [95% confidence interval 0.1–1.4%]) experienced a stent thrombosis within 48 h of PCI that required a second urgent PCI; both were event free at 6-month follow-up.

Conclusions

Inter-hospital transfer using SCA-Alp is associated with low event rates in intermediate-risk ACS patients, allowing a more streamlined use of medical facilities and freeing-up of beds in PCI centres.

Start-up of a Cardiology Day Hospital: Activity, Quality Care and Cost-effectiveness Analysis of the First Year of Operation

INTRODUCTION AND OBJECTIVES

The cardiology day hospital (CDH) is an alternative to hospitalization for scheduled cardiological procedures. The aims of this study were to analyze the activity, quality of care and the cost-effectiveness of a CDH.

METHODS

An observational descriptive study was conducted of the health care activity during the first year of operation of DHHA. The quality of care was analyzed through the substitution rate (outpatient procedures), cancellation rates, complications, and a satisfaction survey. For cost-effectiveness, we calculated the economic savings of avoided hospital stays.

RESULTS

A total of 1646 patients were attended (mean age 69 ± 15 years, 60% men); 2550 procedures were scheduled with a cancellation rate of 4%. The most frequently cancelled procedure was electrical cardioversion. The substitution rate for scheduled invasive procedures was 66%. Only 1 patient required readmission after discharge from the CDH due to heart failure. Most surveyed patients (95%) considered the care received in the CDH to be good or very good. The saving due to outpatient-converted procedures made possible by the CDH was € 219 199.55, higher than the cost of the first year of operation.

CONCLUSIONS

In our center, the CDH allowed more than two thirds of the invasive procedures to be performed on an outpatient basis, while maintaining the quality of care. In the first year of operation, the expenses due to its implementation were offset by a significant reduction in hospital admissions.

The RECALCAR Project. Healthcare in the Cardiology Units of the Spanish National Health System, 2011 to 2014

The RECALCAR project (Spanish acronym for Resources and Quality in Cardiology Units) uses 2 data sources: a survey of cardiology units and an analysis of the Minimum Basic Data set of all hospital discharges of the Spanish National Health System. From 2011 to 2014, there was marked stability in all indicators of the availability, utilization, and productivity of cardiology units. There was significant variability between units and between the health services of the autonomous communities. There was poor implementation of process management (only 14% of the units) and scarce development of health care networks (17%). Structured cardiology units tended to have better results, in terms of both quality and efficiency. No significant differences were found between the different types of unit in the mean length of stay (5.5±1.1 days) or the ratio between successive and first consultations (2:1). The mean discharge rate was 5/1000 inhabitants/y and the mean rate of initial consultations was 16±4/1000 inhabitants/y. No duty or on-call cardiologist was available in 30% of cardiology units with 24 or more beds; of these, no critical care beds were available in 45%. Our findings support the recommendation to regionalize cardiology care and to promote the development of cardiology unit networks.

Impact on Mortality of Different Network Systems in the Treatment of ST-segment Elevation Acute Myocardial Infarction. The Spanish Experience

INTRODUCTION AND OBJECTIVES

To analyze the association between the development of network systems of care for ST-segment elevation myocardial infarction (STEMI) in the autonomous communities (AC) of Spain and the regional rate of percutaneous coronary intervention (PCI) and in-hospital mortality.

METHODS

From 2003 to 2012, data from the minimum basic data set of the Spanish taxpayer-funded health system were analyzed, including admissions from general hospitals. Diagnoses of STEMI and related procedures were codified by the International Diseases Classification. Discharge episodes (n = 302 471) were distributed in 3 groups: PCI (n = 116 621), thrombolysis (n = 46 720), or no reperfusion (n = 139 130).

RESULTS

Crude mortality throughout the evaluation period was higher for the no-PCI or thrombolysis group (17.3%) than for PCI (4.8%) and thrombolysis (8.6%) (P < .001). For the aggregate of all communities, the PCI rate increased (21.6% in 2003 vs 54.5% in 2012; P < .001) with a decrease in risk-standardized mortality rates (10.2% in 2003; 6.8% in 2012; P < .001). Significant differences were observed in the PCI rate across the AC. The development of network systems was associated with a 50% increase in the PCI rate (P < .001) and a 14% decrease in risk-standardized mortality rates (P < .001).

CONCLUSIONS

From 2003 to 2012, the PCI rate in STEMI substantially increased in Spain. The development of network systems was associated with an increase in the PCI rate and a decrease in in-hospital mortality.

Effects on length of stay and costs with same-day retransfer to the referring hospitals for patients with acute coronary syndrome after angiography and/or percutaneous coronary intervention

BACKGROUND

Fast track interventions may generate benefits for patients and hospitals by representing a potential for shorter hospital stay. The aim of this study was to investigate how same-day retransfers to the referring hospital after angiographic examination and/or percutaneous coronary intervention (PCI) at the PCI centre affected length of stay and hospital treatment costs for patients with acute coronary syndrome.

METHODS AND RESULTS

Three hundred and ninety-nine consecutive admitted patients were prospectively randomized to ordinary care with overnight stay or fast track with same-day retransfer. Length of stay at both the PCI centre and the referring hospital after the stay at the PCI centre were recorded. Costs at the PCI centre related to examinations and treatments were also collected. The ordinary care group included 206 patients and the fast track group 193 patients. Forty-six per cent underwent PCI and 10% coronary artery bypass graft (CABG) in the ordinary care group. In the fast track group 40% had PCI and 6% CABG. Length of stay was reduced at the PCI centre from a median 1.25 days for the ordinary care group to median 0.24 days for the FT group (p<0.001). Length of stay at the PCI centre was significantly reduced after selective coronary angiography and PCI but not for patients undergoing CABG. No significant difference was identified in length of stay for the referring hospitals. Total median treatment costs were reduced from NOK23,657 (US$3838) for the ordinary care group to NOK15,730 (US$2552) for the fast track group (p<0.001). The main contributor to this reduction was shorter length of stay and the corresponding reduction in ward costs at the PCI centre.

CONCLUSIONS

We conclude that fast-track intervention with same-day retransfer for patients with acute coronary syndrome to the referring hospital reduced length of stay and the hospital treatment costs for patients undergoing selective coronary angiography and PCI.

The incomplete infrastructure for interhospital patient transfer

OBJECTIVE

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

DATA SOURCE

Narrative review of medical and organizational literature.

SUMMARY

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

CONCLUSION

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

Renal insufficiency and vascular complications after primary angioplasty via femoral route. Impact of vascular closure devices use

INTRODUCTION AND OBJECTIVES

We sought to determine the incidence of vascular complications in patients with chronic kidney disease undergoing primary angioplasty via the femoral route; we also evaluated the safety and efficacy of the use of vascular closure devices in this setting.

METHODS

Registry of 527 patients undergoing primary angioplasty via the femoral route from January 2003 to December 2008. Chronic kidney disease was defined as creatinine clearance less than 60 mL/min. The primary endpoint was the presence of major vascular complications.

RESULTS

Baseline chronic kidney disease was observed in 166 (31.5%) patients. Patients with chronic kidney disease experienced higher rates of major vascular complications compared to those without worsening of renal function (8.4% vs 4.2%; P=.045), especially those requiring transfusion (6.6% vs 1.9%; P=.006). Among patients with chronic kidney disease, 129 (77.7%) received a vascular closure device and manual compression was used in 37 patients (22.3%). The risk of major vascular complications was significantly lower with vascular closure device use compared to manual compression (4.7% vs 21.6%; P=.003). Multivariable logistic regression analysis showed that the use of a vascular closure device was independently associated with a decreased risk of major vascular complications in patients with chronic kidney disease undergoing primary angioplasty (odds ratio=0.11; 95% confidence interval, 0.03-0.41; P=.001).

CONCLUSIONS

Patients with chronic kidney disease undergoing primary angioplasty via the femoral route experience higher rates of major vascular complications. The use of vascular closure devices in this group of patients is safe and is associated with lower rates of major vascular complications compared to manual compression.

[Reduction in 28 days and 6 months of acute myocardial infarction mortality from 1995 to 2005. Data from PRIAMHO I, II and MASCARA registries]

INTRODUCTION AND OBJECTIVES

To determine whether mortality from acute myocardial infarction has reduced in Spain and the possibly related therapeutic factors.

METHODS

Nine thousand, nine hundred and forty-nine patients with ST-segment elevation myocardial infarction admitted to the Coronary Care Unit were identified from PRIAMHO I, II and MASCARA registries performed in 1995, 2000 and 2005, with a 6 month follow-up.

RESULTS

From 1995 to 2005 patients were increasingly more likely to have hypertension, hyperlipidemia and anterior infarction, but age of onset and the proportion of females did not increase. Twenty-eight-day mortality rates were 12.6%, 12.3% and 6% in 1995, 2000 and 2005 respectively, and 15.3%, 14.6% and 9.4% at 6 months (both P-trend <.001). Multivariate analysis was performed and the adjusted odds ratio for 28-day mortality for an infarction occuring in 2005 (compared with 1995) was 0.62 (95% confidence interval: 0.44-0.88) whereas the adjusted hazard ratio for mortality at 6 months was 0.40 (95% confidence interval: 0.24-0.67). Other variables independently associated with lower mortality at 28 days were: reperfusion therapy, and the use of anti-thrombotic treatment, beta-blockers and angiotensin-converting enzyme inhibitors. The 28-day-6-month period had an independent protective effect on the following therapies: coronary reperfusion, and prescription of antiplatelet agents, beta-blockers and lipid lowering drugs upon discharge.

CONCLUSIONS

Twenty-eight-day and six-month mortality rates fell among patients with ST-elevation myocardial infarction in Spain from 1995 to 2005. The possibly related therapeutic factors were the following: more frequent reperfusion therapy and increased use of anti-thrombotic drugs, beta-blockers, angiotensin-converting enzyme inhibitors and lipid lowering drugs.

Safety and efficacy of femoral vascular closure devices in patients undergoing primary percutaneous coronary intervention for ST-elevation myocardial infarction

BACKGROUND

The use of vascular closure devices (VCDs) for the reduction of access site complications following percutaneous coronary intervention (PCI) remains controversial. Patients undergoing primary PCI for acute ST-segment elevation myocardial infarction (STEMI) are at high risk of femoral artery complications. A lack of information exists regarding the use of VCDs in this group of patients because they have been routinely excluded from randomized trials. This study sought to evaluate the safety and efficacy of the routine use of VCDs after primary PCI.

METHODS

A total of 558 consecutive patients undergoing primary PCI for STEMI via femoral route were studied for in-hospital outcomes through a prospective registry from January 2003 to December 2008. The primary end point was the presence of major vascular complication (MVC) defined as a composite of fatal access site bleeding, access site complication requiring interventional or surgical correction, or access site bleeding with ≥3 g/dL drop in hemoglobin or requiring blood transfusion.

RESULTS

Of the total patients, 464 (83.2%) received a VCD; and manual compression was used in 94 patients (16.8%). Major vascular complication occurred in 5.2% of patients. The risk of MVC was significantly lower with VCDs compared with manual compression (4.3% vs 9.6%, P = .036). Multivariable logistic regression analysis determined that VCD use remained an independent predictor of lower rate of MVC (odds ratio 0.38, 95% CI 0.17-0.91).

CONCLUSIONS

The use of VCDs in patients undergoing primary PCI for STEMI is safe and is associated with lower rates of MVC compared with manual compression.