Usage of ambulance transport and influencing factors in acute coronary syndrome: a cross-sectional study at a tertiary centre in China

Current status of emergency medical service use in ST-segment elevation myocardial infarction in China: Findings from China Acute Myocardial Infarction (CAMI) Registry

BACKGROUND

The mortality rate of myocardial infarction in China has increased dramatically in the past three decades. Although emergency medical service (EMS) played a pivotal role for the management of patients with ST-segment elevation myocardial infarction (STEMI), the corresponding data in China are limited.

METHODS

An observational analysis was performed in 26,305 STEMI patients, who were documented in China acute myocardial infarction (CAMI) Registry and treated in 162 hospitals from January 1st, 2013 to January 31th, 2016. We compared the differences such as demographic factors, social factors, medical history, risk factors, socioeconomic distribution and treatment strategies between EMS transport group and self-transport group.

RESULTS

Only 4336 patients (16.5%) were transported by EMS. Patients with symptom onset outside, out-of-hospital cardiac arrest and presented to province-level hospital were more likely to use EMS. Besides those factors, low systolic blood pressure, severe dyspnea or syncope, and high Killip class were also positively related to EMS activation. Notably, compared to self-transport, use of EMS was associated with a shorter prehospital delay (median, 180 vs. 245 min, P < 0.0001) but similar door-to-needle time (median, 45 min vs. 52 min, P = 0.1400) and door-to-balloon time (median, 105 min vs. 103 min, P = 0.1834).

CONCLUSIONS

EMS care for STEMI is greatly underused in China. EMS transport is associated with shorter onset-to-door time and higher rate of reperfusion, but not substantial reduction in treatment delays or mortality rate. Targeted efforts are needed to promote EMS use when chest pain occurs and to set up a unique regionalized STEMI network focusing on integration of prehospital care procedures in China.

TRIAL REGISTRATION

ClinicalTrials.gov (NCT01874691), retrospectively registered June 11, 2013.

Factors related to under-triage of patients with acute coronary syndrome in the emergency department: A retrospective study

INTRODUCTION

This study aimed to provide fundamental data to avoid under-triage in the initial severity classification of patients with suspected acute coronary syndrome (ACS) by analyzing factors associated with patients who visited the emergency department (ED).

METHODS

This retrospective study identified factors related to under-triage by comparing the characteristics of participants diagnosed with ACS and appropriately classified those who were under-triaged.

RESULTS

The probability of under-triage increased 5.402 times in patients who visited the ED immediately than in those who visited the ED through an outpatient clinic. The probability of under-triage decreased in patients who visited the ED by ambulance rather than using their personal vehicle. Furthermore, when patients experienced chest pain, the tendency for under-triage decreased. The under-triage tendency increased 8.315 times in patients with dementia.

CONCLUSIONS

Medical staff training on the classification of non-specific symptoms accompanying diseases is needed. Patients with ACS need to be aware of the symptoms that require visiting the ED and the appropriate route and method. Therefore, it is possible to avoid under-triage for possible ACS during the initial triage, and triage can be performed quickly and accurately.

Association of Symptoms and Mode of Transportation to Emergency Department in Patients With Acute Coronary Syndrome

BACKGROUND

Patients with acute coronary syndrome (ACS) with symptoms matching their expectations of a heart attack are more likely to use emergency medical services (EMS) than not.

OBJECTIVE

To determine whether presenting symptom clusters are associated with EMS use in ACS patients and if EMS use or symptom clusters are associated with prehospital delay.

METHODS

This secondary analysis used data from the PROMOTION trial, a randomized clinical trial that enrolled 3522 subjects with a history of or at risk for ACS from 5 sites in the United States, Australia, and New Zealand. Subjects were randomized to usual care or an educational intervention to reduce prehospital delay. During the 2-year follow-up, subjects admitted for ACS were asked about symptoms, time of symptom onset, and mode of transportation to the hospital. Symptoms were grouped into classic ACS, pain symptoms, and stress symptoms clusters.

RESULTS

Of 3522 subjects enrolled, 331 sought care for ACS during follow-up; 278 had transportation mode documented; 121 (44%) arrived via EMS. Classic ACS plus pain symptoms (adjusted odds ratio [AOR], 2.66; P = .011), classic ACS plus stress symptoms (AOR, 2.61; P = .007), and classic ACS plus both pain and stress symptoms (AOR, 3.90; P = .012) were associated with higher odds of EMS use versus classic ACS symptoms alone. Emergency medical services use resulted in a 68.5-minute shorter median delay (P = .002) versus non-EMS use. Symptom clusters were not predictive of delay time in the adjusted model (P = .952).

DISCUSSION

Although chest symptoms were the most prevalent symptoms for most (85%), the combination of classic ACS symptoms with other symptom clusters was associated with higher EMS use. Further research is needed to determine whether a combination of symptom clusters helps patients correctly interpret ACS symptoms to better understand how symptom clusters influence EMS use.

Barriers associated with emergency medical service activation in patients with ST-segment elevation acute coronary syndromes

Many ST-segment elevation acute coronary syndrome (STEACS) patients fail to activate the Emergency Medical System (EMS), with possible dramatic consequences. Prior studies focusing on barriers to EMS activation included patients with any acute coronary syndrome (ACS) without representation of southern European populations. We aimed to investigate the barriers to EMS call for patients diagnosed for STEACS in Italy. A prospective, single-center, survey administered to all patients treated with primary percutaneous coronary intervention for STEACS in a tertiary hospital in northern Italy from 01/06/2018 to 31/05/2020. The questionnaire was filled out by 293 patients. Of these, 191 (65.2%) activated the EMS after symptoms onset. The main reasons for failing to contact EMS were the perception that the symptoms were unrelated to an important health problem (45.5%) and that a private vehicle is faster than EMS to reach the hospital (34.7%). Patients who called a private doctor after symptoms onset did not call EMS more frequently than those who did not and 30% of the patients who did not call the EMS would still act in the same way if a new episode occurred. Previous history of cardiovascular disease was the only predictor of EMS call. Information campaigns are urgently needed to increase EMS activation in case of suspected STEACS and should be primary focused on patients without cardiovascular history, on the misperception that a private vehicle is faster than EMS activation, and on the fact that cardiac arrest occurs early and may be prevented by EMS activation.

Quantity and Quality of Healthcare Professionals, Transfer Delay and In-hospital Mortality Among ST-Segment Elevation Myocardial Infarction: A Mixed-Method Cross-Sectional Study of 89 Emergency Medical Stations in China

Background

Transfer delay provokes prolongation of prehospital time, which contributes to treatment delay that endangers patients with ST-segment elevation myocardial infarction (STEMI). A key constraint in reducing transfer delay is the shortage of emergency healthcare workers. This study was to explore the influence of the quality and quantity of healthcare professionals at emergency medical stations on transfer delay and in-hospital mortality among STEMI patients.

Methods

A cross-sectional study using mixed methods was conducted at 89 emergency stations in 9 districts in China's Shenzhen province. Based on a sample of 31 hospitals, 1,255 healthcare professionals, and 3,131 patients with STEMI, a generalized linear model was used to explore the associations between the quality and quantity of healthcare professionals and transfer delay and in-hospital mortality among STEMI patients. Qualitative data were collected and analyzed to explore the reasons for the lack of qualified healthcare professionals at emergency medical stations.

Results

The analysis of the quantity of healthcare professionals showed that an increase of one physician per 100,000 individuals was associated with decreased transfer delay for patients with STEMI by 5.087 min (95% CI −6.722, −3.452; P &lt; 0.001). An increase of one nurse per 100,000 individuals was associated with decreased transfer delay by 1.471 min (95% CI −2.943, 0.002; P=0.050). Analysis of the quality of healthcare professionals showed that an increase of one physician with an undergraduate degree per 100,000 individuals was associated with decreased transfer delay for patients with STEMI by 8.508 min (95% CI −10.457, −6.558; P &lt; 0.001). An increase of one nurse with an undergraduate degree per 100,000 individuals was associated with decreased transfer delay by 6.645 min (95% CI −8.218, −5.072; P &lt; 0.001). Qualitative analysis illustrated that the main reasons for low satisfaction of healthcare professionals at emergency medical stations included low income, limited promotion opportunities, and poor working environment.

Conclusions

The quantity and quality of emergency healthcare professionals are key factors influencing transfer delay in STEMI patients. The government should increase the quantity of healthcare professionals at emergency medical stations, strengthen the training, and improve their performance by linking with clinical pathways to enhance job enthusiasm among emergency healthcare professionals.

Time to Seek Care and Hospital Length of Stay Among Older Adults With Acute Coronary Syndrome During the COVID-19 Pandemic

The prevalence of prehospital delay is high among older adults with acute coronary syndrome (ACS). The current study aimed to examine the associated factors of prehospital delay among patients with ACS during the COVID-19 pandemic. This cross-sectional study was conducted on a convenience sample of 300 older adults with ACS admitted to the emergency department in Jordan. Data were collected from June 1 to September 1, 2020. Bivariate and multivariate analyses were used to explore the predictors of prehospital delay. Being widowed, educational level, pain intensity, the gradual onset of ACS symptoms, symptoms lasting for more than 30 minutes, patients' feeling anxious about their ACS symptoms, patients' perceiving their symptoms to be particularly dangerous, history of myocardial infarction (MI), and mode of transportation were associated with the time taken before seeking emergency care. Significant predictors of time to seek help were chief complaint of chest pain or palpitations, abrupt onset of symptoms, the associated symptom of vertigo, and a higher number of chronic illnesses; they explained about 17.9% of the variance in the time to seek care. The average time to seek care among patients with ACS during the COVID-19 pandemic was found to be longer than the average time reported by studies conducted prior the pandemic. Improved understanding of the associations between prehospital delay is crucial for optimal ACS patient outcomes under the impacts of the COVID-19 pandemic.

Health Care Quality Improvement for ST-Segment Elevation Myocardial Infarction: A Retrospective Study Based on Propensity-Score Matching Analysis

Reducing the treatment delay by organizing delivery of care on a regional basis is a priority for improving the quality of ST-segment elevated myocardial infarction (STEMI) care. This study aimed to evaluate the impact of the combined measures on quality metrics of healthcare delivery in Suzhou. The data were collected from the National Chest Pain Center (CPC) Data Reporting Database. 4775 patients were recruited, and after propensity-score matching, 1078 pairs were finally included for analysis. We examined the changes in quality metrics of care including prehospital and in-hospital processes, and clinic outcomes. Quality improvement (QI) implementation improved most process indicators. However, these improvements did not yield decreased in-hospital mortality. The door-to-balloon and the FMC-to-device time decreased from 85.0 and 98.0 min to 78 and 88 min, respectively (p < 0.001). Cases transferred directly via EMS had a greater improvement in most of process indicators. The proportion of patients transferred directly via EMS was 10.3%, much lower than that of self-transported patients at 58.3%. Tertiary hospitals showed greater performance improvement in process indicators than secondary hospitals. The percentage of cases using EMS remained low for suburban areas. The establishment of coordinated STEMI care needs to be accompanied with solving the fragmented situation of the prehospital and hospital care, and patient delay should be addressed, especially in suburban areas and on transferred-in inpatients.

The application of optimisation modelling and geospatial analysis to propose a coronary care network model for patients with ST-elevation myocardial infarction

Background

The incidence of myocardial infarction is increasing in South Africa. Prompt treatment is indicated to reduce mortality. One way of expediting treatment is to set up regional referral recommendations that can guide prehospital providers on the best reperfusion strategy for a particular patient. A coronary care network model for patients who present with ST-elevation myocardial infarction is proposed, using the North West province, of South Africa as a case study.

Methods

Geospatial analysis with network optimisation modelling was applied, to determine which strategy (prehospital thrombolysis, in-hospital thrombolysis or percutaneous coronary intervention) was most appropriate for patients presenting within each of the municipal wards of the North West province.

Results

An efficient and swift recommendation for the optimal reperfusion strategy is obtained using the current model, even in the instance of a large amount of ward data with additional constraints. For most municipal wards (204, 53%) percutaneous coronary intervention is the preferred reperfusion strategy based on proximity. For the remainder of the wards prehospital (138, 36%) or in-hospital (44, 11%) thrombolysis is recommended.

Conclusion

A scalable and efficient method of determining the optimal reperfusion strategy for a patient presenting with ST-elevation myocardial infarction in the North West province, is presented. This approach can serve as a model which can be applied to other settings and can form the basis of regional coronary care network development priorities and resource allocations.

The individual and neighborhood factors associated with the use of emergency medical services in patients with ST-elevation myocardial infarction

OBJECTIVE

The utilization of emergency medical services (EMS) varies widely among communities. In this study, we aimed to evaluate the relationship between the use of EMS by patients with ST-elevation myocardial infarction (STEMI) and the individual and neighborhood characteristics of these patients.

METHODS

We performed a secondary analysis of data from the Cardiovascular Disease Surveillance project, which included patients diagnosed with STEMI at 29 emergency centers in South Korea. Our analysis included only patients living in Seoul, and the primary outcome measured was the use of EMS. While the clinical variables of the patients were collected from the Cardiovascular Disease Surveillance registry, the 2010 National Census data was used to identify neighborhood variables such as population density, income, age, and residence type. We used a 3-level hierarchical logistic regression to estimate the effects of neighborhood-level factors on EMS use by individual patients.

RESULTS

We evaluated 1,634 patients with STEMI from 2007 to 2012. The neighborhoods were grouped into 25 counties. The regional rates of EMS use varied from 18.3% to 46.5%. The final adjusted logistic model revealed that the use of EMS was significantly associated with the average number of households (neighborhood level factor) and symptoms of syncope, cardiac arrest, and history of cardiovascular disease (individual level factors).

CONCLUSION

The individual levels factors had a greater influence on the use of EMS compared to the neighborhood-level factors.

Pre-hospital delay and emergency medical services in acute myocardial infarction

BACKGROUND/AIMS

Minimising total ischemic time (TIT) is important for improving clinical outcomes in patients with ST-segment elevation myocardial infarction who have undergone percutaneous coronary intervention (PCI). TIT has not shown a significant improvement due to persistent pre-hospital delay. This study aimed to investigate the risk factors associated with pre-hospital delay.

METHODS

Individuals enrolled in the Korea Acute Myocardial Infarction Registry-National Institutes of Health between 2011 and 2015 were included in this study. The study population was analyzed according to the symptom-to-door time (STDT; within 60 or > 60 minutes), and according to the type of hospital visit (emergency medical services [EMS], non-PCI center, or PCI center).

RESULTS

A total of 4,874 patients were included in the analysis, of whom 28.4% arrived at the hospital within 60 minutes of symptom-onset. Old age (> 65 years), female gender, and renewed ischemia were independent predictors of delayed STDT. Utilising EMS was the only factor shown to reduce STDT within 60 minutes, even when cardiogenic shock was evident. The overall frequency of EMS utilisation was low (21.7%). Female gender was associated with not utilising EMS, whereas cardiogenic shock, previous myocardial infarction, familial history of ischemic heart disease, and off-hour visits were associated with utilising EMS.

CONCLUSION

Factors associated with delayed STDT and not utilising EMS could be targets for preventive intervention to improve STDT and TIT.