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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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Jollis JG, Granger CB, Zègre-Hemsey JK, Henry TD, Goyal A, Tamis-Holland JE, Roettig ML, Ali MJ, French WJ, Poudel R, Zhao J, Stone RH, Jacobs AK. Treatment Time and In-Hospital Mortality Among Patients With ST-Segment Elevation Myocardial Infarction, 2018-2021. JAMA 2022; 328:2033-2040. [PMID: 36335474 PMCID: PMC9638953 DOI: 10.1001/jama.2022.20149] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
IMPORTANCE Recognizing the association between timely treatment and less myocardial injury for patients with ST-segment elevation myocardial infarction (STEMI), US national guidelines recommend specific treatment-time goals. OBJECTIVE To describe these process measures and outcomes for a recent cohort of patients. DESIGN, SETTING, AND PARTICIPANTS Cross-sectional study of a diagnosis-based registry between the second quarter of 2018 and the third quarter of 2021 for 114 871 patients with STEMI treated at 648 hospitals in the Get With The Guidelines-Coronary Artery Disease registry. EXPOSURES STEMI or STEMI equivalent. MAIN OUTCOMES AND MEASURES Treatment times, in-hospital mortality, and adherence to system goals (75% treated ≤90 minutes of first medical contact if the first hospital is percutaneous coronary intervention [PCI]-capable and ≤120 minutes if patients require transfer to a PCI-capable hospital). RESULTS In the study population, median age was 63 (IQR, 54-72) years, 71% were men, and 29% were women. Median time from symptom onset to PCI was 148 minutes (IQR, 111-226) for patients presenting to PCI-capable hospitals by emergency medical service, 195 minutes (IQR, 127-349) for patients walking in, and 240 minutes (IQR, 166-402) for patients transferred from another hospital. Adjusted in-hospital mortality was lower for those treated within target times vs beyond time goals for patients transported via emergency medical services (first medical contact to laboratory activation ≤20 minutes [in-hospital mortality, 3.6 vs 9.2] adjusted OR, 0.54 [95% CI, 0.48-0.60], and first medical contact to device ≤90 minutes [in-hospital mortality, 3.3 vs 12.1] adjusted OR, 0.40 [95% CI, 0.36-0.44]), walk-in patients (hospital arrival to device ≤90 minutes [in-hospital mortality, 1.8 vs 4.7] adjusted OR, 0.47 [95% CI, 0.40-0.55]), and transferred patients (door-in to door-out time <30 minutes [in-hospital mortality, 2.9 vs 6.4] adjusted OR, 0.51 [95% CI, 0.32-0.78], and first hospital arrival to device ≤120 minutes [in-hospital mortality, 4.3 vs 14.2] adjusted OR, 0.44 [95% CI, 0.26-0.71]). Regardless of mode of presentation, system goals were not met in most quarters, with the most delayed system performance among patients requiring interhospital transfer (17% treated ≤120 minutes). CONCLUSIONS AND RELEVANCE This study of patients with STEMI included in a US national registry provides information on changes in process and outcomes between 2018 and 2021.
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Affiliation(s)
- James G. Jollis
- Lindner Center for Research and Education, Cincinnati, Ohio
- Duke University, Durham, North Carolina
| | | | | | | | | | | | | | - Murtuza J. Ali
- Louisiana State University Health Sciences Center, New Orleans
| | | | - Ram Poudel
- American Heart Association, Dallas, Texas
| | - Juan Zhao
- American Heart Association, Dallas, Texas
| | | | - Alice K. Jacobs
- Boston University School of Medicine and Boston Medical Center, Boston, Massachusetts
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3
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Wang G. Cardiac catheterization laboratory activation by social media reduces reperfusion time of patients transferred for primary percutaneous coronary intervention in community hospital. ENVIRONMENTAL DISEASE 2022. [DOI: 10.4103/ed.ed_7_22] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
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Yiadom MYAB, Olubowale OO, Jenkins CA, Miller KF, West JL, Vogus TJ, Lehmann CU, Antonello VD, Bernard GR, Storrow AB, Lindsell CJ, Liu D. Understanding timely STEMI treatment performance: A 3-year retrospective cohort study using diagnosis-to-balloon-time and care subintervals. J Am Coll Emerg Physicians Open 2021; 2:e12379. [PMID: 33644777 PMCID: PMC7890036 DOI: 10.1002/emp2.12379] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2020] [Revised: 01/07/2021] [Accepted: 01/13/2021] [Indexed: 01/22/2023] Open
Abstract
OBJECTIVE From the perspective of percutaneous coronary intervention (PCI) centers, locations of ST-segment elevation myocardial infarction (STEMI) diagnosis can include a referring facility, emergency medical services (EMS) transporting to a PCI center, or the PCI center's emergency department (ED). This challenges the use of door-to-balloon-time as the primary evaluative measure of STEMI treatment pathways. Our objective was to identify opportunities to improve care by quantifying differences in the timeliness of STEMI treatment mobilization based on the location of the diagnostic ECG. METHODS This 3-year, single-center, retrospective cohort study classified patients by diagnostic ECG location: referring facility, EMS, or PCI center ED. We quantified door-to-balloon-time and diagnosis-to-balloon-time with its care subintervals. RESULTS Of 207 ED STEMI patients, 180 (87%) received PCI. Median diagnosis-to-balloon-times were shortest among the ED-diagnosed (78 minutes [interquartile range (IQR), 61-92]), followed by EMS-identified patients (89 minutes [IQR, 78-122]), and longest among those referred (140 minutes [IQR, 119-160]), reflecting time for transport to the PCI center. Conversely, referred patients had the shortest median door-to-balloon-times (38 minutes [IQR, 34-43]), followed by the EMS-identified (64 minutes [IQR, 47-77]), whereas ED-diagnosed patients had the longest (89 minutes [IQR, 70-114]), reflecting diagnosis and catheterization lab activation frequently occurring before PCI center ED arrival for referred and EMS-identified patients. CONCLUSIONS Diagnosis-to-balloon-time and its care subintervals are complementary to the traditional door-to-balloon-times as measures of the STEMI treatment process. Together, they highlight opportunities to improve timely identification among ED-diagnosed patients, use of out-of-hospital cath lab activation for EMS-identified patients, and encourage pathways for referred patients to bypass PCI center EDs.
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Affiliation(s)
- Maame Yaa A. B. Yiadom
- Department of Emergency MedicineVanderbilt University Medical CenterNashvilleTennesseeUSA
| | - Olayemi O. Olubowale
- Department of Emergency MedicineVanderbilt University Medical CenterNashvilleTennesseeUSA
| | - Cathy A. Jenkins
- Department of BiostatisticsVanderbilt University Medical CenterNashvilleTennesseeUSA
| | - Karen F. Miller
- Department of Emergency MedicineVanderbilt University Medical CenterNashvilleTennesseeUSA
| | - Jennifer L. West
- Department of Emergency MedicineVanderbilt University Medical CenterNashvilleTennesseeUSA
| | - Timothy J. Vogus
- Owen Graduate School of ManagementVanderbilt UniversityNashvilleTennesseeUSA
| | - Christoph U. Lehmann
- Department of Biomedical Informatics & PediatricsVanderbilt University Medical CenterNashvilleTennesseeUSA
| | - Victoria D. Antonello
- Department of Emergency MedicineVanderbilt University Medical CenterNashvilleTennesseeUSA
| | - Gordon R. Bernard
- Department of Medicine, Division of Critical CareVanderbilt University Medical CenterNashvilleTennesseeUSA
| | - Alan B. Storrow
- Department of Emergency MedicineVanderbilt University Medical CenterNashvilleTennesseeUSA
| | | | - Dandan Liu
- Department of BiostatisticsVanderbilt University Medical CenterNashvilleTennesseeUSA
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Liu H, Wang W, Chen H, Li Z, Feng S, Yuan Y. Can WeChat group-based intervention reduce reperfusion time in patients with ST-segment myocardial infarction? A controlled before and after study. J Telemed Telecare 2020; 26:627-637. [PMID: 31238784 DOI: 10.1177/1357633x19856473] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
BACKGROUND Pre-hospital identification of acute ST-elevation myocardial infarction and activation of the catheterization laboratory can reduce first medical contact to wire-crossing times. We conducted a study on providing 24-hour tele-electrocardiography services via the WeChat group application, aiming to reduce the time taken for diagnosis and treatment of ST-elevation myocardial infarction. METHODS A controlled before and after study was conducted on 140 ST-elevation myocardial infarction patients who were initially seen in non-percutaneous coronary intervention-capable hospital and transferred for primary percutaneous coronary intervention at our percutaneous coronary intervention centre from 1 February to 31 October 2018. The WeChat group had 70 patients with pre-hospital electrocardiography transmission via WeChat and the control group had 70 patients who did not transfer pre-hospital electrocardiography. The reperfusion time of the two groups was compared to evaluate the effect of the WeChat group intervention. RESULTS In the WeChat group versus the control group, the median symptom onset to first medical contact time was similar (129 vs 150 min, p > 0.05), but the median first medical contact to wire, door to wire and first medical contact to catheterization laboratory activity were significantly shorter (132 vs 171 minutes, p < 0.001; 60 vs 95 minutes, p < 0.001; 29 vs 74 minutes, p < 0.001, respectively). CONCLUSIONS Pre-hospital electrocardiography transfer via a WeChat group resulted in earlier reperfusion of ST-elevation myocardial infarction patients who were transferred from the non-percutaneous coronary intervention centre.
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Affiliation(s)
- Hui Liu
- Department of Cardiology, The Second Affiliated Hospital of Shantou University Medical College, China
| | - Wei Wang
- Department of Cardiology, The Second Affiliated Hospital of Shantou University Medical College, China
| | - Haojia Chen
- Department of Cardiology, The Second Affiliated Hospital of Shantou University Medical College, China
| | - Zhi Li
- Department of Cardiology, The Second Affiliated Hospital of Shantou University Medical College, China
| | - Shushuang Feng
- Department of Cardiology, The Second Affiliated Hospital of Shantou University Medical College, China
| | - Yonghong Yuan
- Department of Cardiology, The Second Affiliated Hospital of Shantou University Medical College, China
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Zeitouni M, Al-Khalidi HR, Roettig ML, Bolles MM, Doerfler SM, Fordyce CB, Hellkamp AS, Henry TD, Magdon-Ismail Z, Monk L, Nelson RD, O’Brien PK, Wilson BH, Ziada KM, Granger CB, Jollis JG. Catheterization Laboratory Activation Time in Patients Transferred With ST-Segment–Elevation Myocardial Infarction: Insights From the Mission: Lifeline STEMI Accelerator-2 Project. Circ Cardiovasc Qual Outcomes 2020; 13:e006204. [DOI: 10.1161/circoutcomes.119.006204] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background:
Catheterization laboratory (cath lab) activation time is a newly available process measure for patients with ST-segment–elevation myocardial infarction requiring inter-hospital transfers for primary percutaneous coronary intervention that reflects inter-facility communication and urgent mobilization of interventional laboratory resources. Our aim was to determine whether faster activation is associated with improved reperfusion time and outcomes in the American Heart Association Mission: Lifeline Accelerator-2 Project.
Methods and Results:
From April 2015 to March 2017, treatment times of 2063 patients with ST-segment–elevation myocardial infarction requiring inter-hospital transfer for primary percutaneous coronary intervention from 12 regions around the United States were stratified by cath lab activation time (first hospital arrival to cath lab activation within [timely] or beyond 20 minutes [delayed]). Median cath lab activation time was 26 minutes, with a delayed activation observed in 1241 (60.2%) patients. Prior cardiovascular or cerebrovascular disease, arterial hypotension at admission, and black or Latino ethnicity were independent factors of delayed cath lab activation. Timely cath lab activation patients had shorter door-in door-out times (40 versus 68 minutes) and reperfusion times (98 versus 135 minutes) with 80.1% treated within the national goal of ≤120 minutes versus 39.0% in the delayed group.
Conclusions:
Cath lab activation within 20 minutes across a geographically diverse group of hospitals was associated with performing primary percutaneous coronary intervention within the national goal of ≤120 minutes in >75% of patients. While several confounding factors were associated with delayed activation, this work suggests that this process measure has the potential to direct resources and practices to more timely treatment of patients requiring inter-hospital transfer for primary percutaneous coronary intervention.
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Affiliation(s)
- Michel Zeitouni
- Duke Clinical Research Institute, Durham, NC (M.Z., H.R.A.-K., M.L.R., S.M.D., A.S.H., L.M., C.B.G.)
| | - Hussein R. Al-Khalidi
- Duke Clinical Research Institute, Durham, NC (M.Z., H.R.A.-K., M.L.R., S.M.D., A.S.H., L.M., C.B.G.)
| | - Mayme L. Roettig
- Duke Clinical Research Institute, Durham, NC (M.Z., H.R.A.-K., M.L.R., S.M.D., A.S.H., L.M., C.B.G.)
| | | | - Shannon M. Doerfler
- Duke Clinical Research Institute, Durham, NC (M.Z., H.R.A.-K., M.L.R., S.M.D., A.S.H., L.M., C.B.G.)
| | | | - Anne S. Hellkamp
- Duke Clinical Research Institute, Durham, NC (M.Z., H.R.A.-K., M.L.R., S.M.D., A.S.H., L.M., C.B.G.)
| | - Timothy D. Henry
- The Carl and Edyth Lindner Center for Research and Education at The Christ Hospital, Cincinnati, OH (T.D.H.)
| | | | - Lisa Monk
- Duke Clinical Research Institute, Durham, NC (M.Z., H.R.A.-K., M.L.R., S.M.D., A.S.H., L.M., C.B.G.)
| | | | | | - B. Hadley Wilson
- Sanger Heart and Vascular Institute, Atrium Health, Charlotte, NC (B.H.W.)
| | - Khaled M. Ziada
- Gill Heart & Vascular Institute University of Kentucky, Lexington (K.M.Z.)
| | - Christopher B. Granger
- Duke Clinical Research Institute, Durham, NC (M.Z., H.R.A.-K., M.L.R., S.M.D., A.S.H., L.M., C.B.G.)
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7
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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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Kontos MC, Gunderson MR, Zegre-Hemsey JK, Lange DC, French WJ, Henry TD, McCarthy JJ, Corbett C, Jacobs AK, Jollis JG, Manoukian SV, Suter RE, Travis DT, Garvey JL. Prehospital Activation of Hospital Resources (PreAct) ST-Segment-Elevation Myocardial Infarction (STEMI): A Standardized Approach to Prehospital Activation and Direct to the Catheterization Laboratory for STEMI Recommendations From the American Heart Association's Mission: Lifeline Program. J Am Heart Assoc 2020; 9:e011963. [PMID: 31957530 PMCID: PMC7033830 DOI: 10.1161/jaha.119.011963] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Affiliation(s)
- Michael C Kontos
- Pauley Heart Center Virginia Commonwealth University Richmond VA
| | | | | | - David C Lange
- The Permanente Medical Group Kaiser Permanente Santa Clara Santa Clara CA
| | - William J French
- Harbor-UCLA Medical Center and Los Angeles Biomedical Institute Torrance CA.,David Geffen School of Medicine at UCLA Los Angeles CA
| | - Timothy D Henry
- The Lindner Center for Research and Education at The Christ Hospital Cincinnati OH
| | - James J McCarthy
- Department of Emergency Medicine McGovern Medical School University of Texas Health Science Center at Houston TX
| | | | - Alice K Jacobs
- Section of Cardiology Department of Medicine Boston University Medical Center Boston MA
| | | | | | - Robert E Suter
- Department of Emergency Medicine UT Southwestern and Augusta University Dallas Texas.,Department of Military and Emergency Medicine Uniformed Services University Dallas TX
| | | | - J Lee Garvey
- Department of Emergency MedicineCarolinas Medical Center Charlotte NC
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2019 Canadian Cardiovascular Society/Canadian Association of Interventional Cardiology Guidelines on the Acute Management of ST-Elevation Myocardial Infarction: Focused Update on Regionalization and Reperfusion. Can J Cardiol 2019; 35:107-132. [PMID: 30760415 DOI: 10.1016/j.cjca.2018.11.031] [Citation(s) in RCA: 89] [Impact Index Per Article: 17.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2018] [Revised: 11/29/2018] [Accepted: 11/29/2018] [Indexed: 12/15/2022] Open
Abstract
Rapid reperfusion of the infarct-related artery is the cornerstone of therapy for the management of acute ST-elevation myocardial infarction (STEMI). Canada's geography presents unique challenges for timely delivery of reperfusion therapy for STEMI patients. The Canadian Cardiovascular Society/Canadian Association of Interventional Cardiology STEMI guideline was developed to provide advice regarding the optimal acute management of STEMI patients irrespective of where they are initially identified: in the field, at a non-percutaneous coronary intervention-capable centre or at a percutaneous coronary intervention-capable centre. We had also planned to evaluate and incorporate sex and gender considerations in the development of our recommendations. Unfortunately, inadequate enrollment of women in randomized trials, lack of publication of main outcomes stratified according to sex, and lack of inclusion of gender as a study variable in the available literature limited the feasibility of such an approach. The Grading Recommendations, Assessment, Development, and Evaluation system was used to develop specific evidence-based recommendations for the early identification of STEMI patients, practical aspects of patient transport, regional reperfusion decision-making, adjunctive prehospital interventions (oxygen, opioids, antiplatelet therapy), and procedural aspects of mechanical reperfusion (access site, thrombectomy, antithrombotic therapy, extent of revascularization). Emphasis is placed on integrating these recommendations as part of an organized regional network of STEMI care and the development of appropriate reperfusion and transportation pathways for any given region. It is anticipated that these guidelines will serve as a practical template to develop systems of care capable of providing optimal treatment for a wide range of STEMI patients.
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Jeong JH, Kim DH, Kim TY, Kang C, Lee SH, Lee SB, Kim SC, Park YJ, Lim D. Effects of emergency department boarding on mortality in patients with ST-segment elevation myocardial infarction. Am J Emerg Med 2019; 38:1141-1145. [PMID: 31493979 DOI: 10.1016/j.ajem.2019.158400] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2019] [Revised: 08/05/2019] [Accepted: 08/18/2019] [Indexed: 10/26/2022] Open
Abstract
OBJECTIVE Patients with ST-segment elevation myocardial infarction (STEMI) are sometimes boarded in the emergency department (ED) after percutaneous coronary intervention (PCI). We evaluated the effects of direct and indirect admission to the CCU on mortality and the effect on length of stay (LOS) in patients with STEMI. METHOD This was a retrospective observational study of patients with STEMI between Jan 2014 and Nov 2017. The patients were divided into the direct admission (DA) group, who were admitted into the CCU immediately after PCI, and the indirect admission (IA) group, who were admitted after boarding in the ED. The primary endpoint was in-hospital mortality. Secondary endpoints were 3-month mortality, LOS in CCU and hospital, and LOS under intensive care. RESULTS During the study period, 780 patients were enrolled and analyzed. The in-hospital mortality rate and 3-month mortality rate were 5.9% (46 patients) and 8.5% (66 patients). The DA group and IA group had similar in-hospital and 3-month mortality rates (P = .50, P = .28). The median CCU LOS and hospital LOS was similar for both groups (P = .28, P = .46). However, LOS under in intensive care for the IA group was significantly longer than that of the DA group (DA, 31.9 h; IA, 38.7 h; P < .001). CONCLUSION This study suggests that direct admission after PCI and indirect admission was not associated with mortality in patients with STEMI. In addition, the stay in ED also appears to be associated with the duration of stay under critical care.
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Affiliation(s)
- Jin Hee Jeong
- Department of Emergency Medicine, Gyeongsang National University School of Medicine and Gyeongsang National University Hospital, Jinju-si, Gyeongsangnam-do, Republic of Korea; Gyeongsang Institute of Health Sciences, Gyeongsang National University School of Medicine, Jinju-si, Gyeongsangnam-do, Republic of Korea.
| | - Dong Hoon Kim
- Department of Emergency Medicine, Gyeongsang National University School of Medicine and Gyeongsang National University Hospital, Jinju-si, Gyeongsangnam-do, Republic of Korea; Gyeongsang Institute of Health Sciences, Gyeongsang National University School of Medicine, Jinju-si, Gyeongsangnam-do, Republic of Korea
| | - Tae Yun Kim
- Department of Emergency Medicine, Gyeongsang National University School of Medicine and Gyeongsang National University Hospital, Jinju-si, Gyeongsangnam-do, Republic of Korea
| | - Changwoo Kang
- Department of Emergency Medicine, Gyeongsang National University School of Medicine and Gyeongsang National University Hospital, Jinju-si, Gyeongsangnam-do, Republic of Korea
| | - Soo Hoon Lee
- Department of Emergency Medicine, Gyeongsang National University School of Medicine and Gyeongsang National University Hospital, Jinju-si, Gyeongsangnam-do, Republic of Korea
| | - Sang Bong Lee
- Department of Emergency Medicine, Gyeongsang National University School of Medicine and Gyeongsang National University Hospital, Jinju-si, Gyeongsangnam-do, Republic of Korea
| | - Seong Chun Kim
- Department of Emergency Medicine, Gyeongsang National University School of Medicine and Gyeongsang National University Changwon Hospital, Changwon, Gyeongsangnam, Republic of Korea
| | - Yong Joo Park
- Department of Emergency Medicine, Gyeongsang National University School of Medicine and Gyeongsang National University Changwon Hospital, Changwon, Gyeongsangnam, Republic of Korea
| | - Daesung Lim
- Department of Emergency Medicine, Gyeongsang National University School of Medicine and Gyeongsang National University Changwon Hospital, Changwon, Gyeongsangnam, Republic of Korea
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Fiorilli PN, Kolansky DM. Getting to the Right Place at the Right Time: Another Piece of the STEMI Puzzle. Circ Cardiovasc Interv 2019; 11:e006700. [PMID: 29716934 DOI: 10.1161/circinterventions.118.006700] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Paul N Fiorilli
- From the Cardiovascular Medicine Division, Hospital of the University of Pennsylvania, Philadelphia
| | - Daniel M Kolansky
- From the Cardiovascular Medicine Division, Hospital of the University of Pennsylvania, Philadelphia.
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12
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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: 7] [Impact Index Per Article: 1.2] [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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Shavadia JS, Roe MT, Chen AY, Lucas J, Fanaroff AC, Kochar A, Fordyce CB, Jollis JG, Tamis-Holland J, Henry TD, Bagai A, Kontos MC, Granger CB, Wang TY. Association Between Cardiac Catheterization Laboratory Pre-Activation and Reperfusion Timing Metrics and Outcomes in Patients With ST-Segment Elevation Myocardial Infarction Undergoing Primary Percutaneous Coronary Intervention. JACC Cardiovasc Interv 2018; 11:1837-1847. [DOI: 10.1016/j.jcin.2018.07.020] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/03/2018] [Revised: 07/12/2018] [Accepted: 07/17/2018] [Indexed: 12/15/2022]
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Francek L, Hlinomaz O, Groch L, Bělašková S. Analysis of time intervals related to STEMI management in 2008-2016. COR ET VASA 2018. [DOI: 10.1016/j.crvasa.2017.07.007] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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15
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Cole J, Beare R, Phan TG, Srikanth V, MacIsaac A, Tan C, Tong D, Yee S, Ho J, Layland J. Staff Recall Travel Time for ST Elevation Myocardial Infarction Impacted by Traffic Congestion and Distance: A Digitally Integrated Map Software Study. Front Cardiovasc Med 2018; 4:89. [PMID: 29359134 PMCID: PMC5766675 DOI: 10.3389/fcvm.2017.00089] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2017] [Accepted: 12/15/2017] [Indexed: 11/16/2022] Open
Abstract
Background Recent evidence suggests hospitals fail to meet guideline specified time to percutaneous coronary intervention (PCI) for a proportion of ST elevation myocardial infarction (STEMI) presentations. Implicit in achieving this time is the rapid assembly of crucial catheter laboratory staff. As a proof-of-concept, we set out to create regional maps that graphically show the impact of traffic congestion and distance to destination on staff recall travel times for STEMI, thereby producing a resource that could be used by staff to improve reperfusion time for STEMI. Methods Travel times for staff recalled to one inner and one outer metropolitan hospital at midnight, 6 p.m., and 7 a.m. were estimated using Google Maps Application Programming Interface. Computer modeling predictions were overlaid on metropolitan maps showing color coded staff recall travel times for STEMI, occurring within non-peak and peak hour traffic congestion times. Results Inner metropolitan hospital staff recall travel times were more affected by traffic congestion compared with outer metropolitan times, and the latter was more affected by distance. The estimated mean travel times to hospital during peak hour were greater than midnight travel times by 13.4 min to the inner and 6.0 min to the outer metropolitan hospital at 6 p.m. (p < 0.001). At 7 a.m., the mean difference was 9.5 min to the inner and 3.6 min to the outer metropolitan hospital (p < 0.001). Only 45% of inner metropolitan staff were predicted to arrive within 30 min at 6 p.m. compared with 100% at midnight (p < 0.001), and 56% of outer metropolitan staff at 6 p.m. (p = 0.021). Conclusion Our results show that integration of map software with traffic congestion data, distance to destination and travel time can predict optimal residence of staff when on-call for PCI.
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Affiliation(s)
- Justin Cole
- Peninsula Health Heart Service, Frankston, VIC, Australia.,Peninsula Clinical School, Monash University, Melbourne, VIC, Australia
| | - Richard Beare
- Peninsula Clinical School, Monash University, Melbourne, VIC, Australia.,Developmental Imaging, Murdoch Children's Research Institute, Parkville, VIC, Australia
| | - Thanh G Phan
- School of Clinical Sciences, Monash Health, Monash University, Melbourne, VIC, Australia
| | - Velandai Srikanth
- Peninsula Clinical School, Monash University, Melbourne, VIC, Australia
| | - Andrew MacIsaac
- Department of Cardiology, St Vincent's Hospital, Melbourne, VIC, Australia
| | | | - David Tong
- Peninsula Health Heart Service, Frankston, VIC, Australia
| | - Susan Yee
- School of Medicine, Monash University, Melbourne, VIC, Australia
| | - Jesslyn Ho
- School of Medicine, Monash University, Melbourne, VIC, Australia
| | - Jamie Layland
- Peninsula Health Heart Service, Frankston, VIC, Australia.,Peninsula Clinical School, Monash University, Melbourne, VIC, Australia.,Department of Cardiology, St Vincent's Hospital, Melbourne, VIC, Australia
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16
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Arevalo MK, Sheth KR, Menon VS, Ostrov L, Hennes H, Singla N, Koral K, Schlomer BJ, Baker LA. Straight to the Operating Room: An Emergent Surgery Track for Acute Testicular Torsion Transfers. J Pediatr 2018; 192:178-183. [PMID: 29246339 PMCID: PMC5737783 DOI: 10.1016/j.jpeds.2017.09.009] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/19/2017] [Revised: 07/19/2017] [Accepted: 09/07/2017] [Indexed: 11/26/2022]
Abstract
OBJECTIVE To assess the effect of implementing an emergency surgery track for testicular torsion transfers. We hypothesized that transferring children from other facilities diagnosed with torsion straight to the operating room (STOR) would decrease ischemia time, lower costs, and reduce testicular loss. STUDY DESIGN Demographics, arrival to incision time, hospital cost in dollars, and testicular outcome (determined by testicular ultrasound) at follow-up were retrospectively compared in all patients transferred to our tertiary care children's hospital with a diagnosis of testicular torsion from 2012 to 2016. Clinical data for STOR and non-STOR patients were compared by Wilcoxon rank-sum, 2-tailed t test, or Fisher exact test as appropriate. RESULTS Sixty-eight patients met inclusion criteria: 35 STOR and 33 non-STOR. Children taken STOR had a shorter median arrival to incision time (STOR: 54 minutes vs non-STOR: 94 minutes, P < .0001) and lower median total hospital costs (STOR: $3882 vs non-STOR: $4419, P < .0001). However, only 46.8% of STOR patients and 48.4% of non-STOR patients achieved surgery within 6 hours of symptom onset. Testicular salvage rates in STOR and non-STOR patients were not significantly different (STOR: 68.4% vs non-STOR: 36.8%, P = .1), but follow-up was poor. CONCLUSIONS STOR decreased arrival to incision time and hospital cost but did not affect testicular loss. The bulk of ischemia time in torsion transfers occurred before arrival at our tertiary care center. Further interventions addressing delays in diagnosis and transfer are needed to truly improve testicular salvage rates in these patients.
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Affiliation(s)
| | - Kunj R Sheth
- University of Texas Southwestern Medical Center, Dallas, TX
| | - Vani S Menon
- Children’s Health, Dallas, TX,University of Texas Southwestern Medical Center, Dallas, TX
| | | | - Halim Hennes
- Children’s Health, Dallas, TX,University of Texas Southwestern Medical Center, Dallas, TX
| | - Nirmish Singla
- University of Texas Southwestern Medical Center, Dallas, TX
| | - Korgun Koral
- Children’s Health, Dallas, TX,University of Texas Southwestern Medical Center, Dallas, TX
| | - Bruce J Schlomer
- Children’s Health, Dallas, TX,University of Texas Southwestern Medical Center, Dallas, TX
| | - Linda A Baker
- Children’s Health, Dallas, TX,University of Texas Southwestern Medical Center, Dallas, TX
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17
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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: 36] [Impact Index Per Article: 5.1] [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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18
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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: 12] [Impact Index Per Article: 1.7] [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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19
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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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20
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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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21
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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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Dauerman HL, Bates ER, Kontos MC, Li S, Garvey JL, Henry TD, Manoukian SV, Roe MT. Nationwide Analysis of Patients With ST-Segment–Elevation Myocardial Infarction Transferred for Primary Percutaneous Intervention. Circ Cardiovasc Interv 2015; 8:CIRCINTERVENTIONS.114.002450. [DOI: 10.1161/circinterventions.114.002450] [Citation(s) in RCA: 45] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background—
Current American College of Cardiology/American Heart Association guidelines recommend transfer and primary percutaneous coronary intervention (PCI) for ST-segment–elevation myocardial infarction (STEMI) patients within the time limit of first contact to device ≤120 minutes. We determined the hospital-level, patient-level, and process characteristics of timely versus delayed primary PCI for a diverse national sample of transfer patients confined to a travel distance that facilitates the process.
Methods and Results—
We studied 14 518 patients transferred from non–PCI-capable hospitals for primary PCI to 398 National Cardiovascular Data Registry Acute Coronary Treatment and Intervention Outcomes Network Registry-Get With The Guidelines hospitals between July 2008 and December 2012. Patients with estimated transfer times >60 minutes (by Google Maps driving times) were excluded from the analysis. Patients achieving first door-to-device time ≤120 minutes were compared with patients with delayed treatment; independent predictors of timely treatment were determined using generalized estimating equations logistic regression models. The median estimated transfer distance was 26.5 miles. First door-to-device ≤120 minutes was achieved in 65% of patients (n=9380); only 37% of the hospitals were high-performing hospitals (defined as risk-adjusted rate, ≥75% of transfer STEMI patients with ≤120-minute first door-to-device time). In addition to known predictors of delay (cardiogenic shock, cardiac arrest, and prolonged door-in door-out time), STEMI referral hospitals’ rural location and longer estimated transfer time were identified as predictors of delay. In this diverse national sample, regional and racial variations in care were observed. Finally, lower PCI hospital annual STEMI volume was a potent predictor of delay.
Conclusions—
More than one third of US STEMI patients transferred for primary PCI fail to achieve first door-to-device time ≤120 minutes, despite estimated transfer times <60 minutes. Delays are related to process variables, comorbidities, and lower annual PCI hospital STEMI volumes.
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Affiliation(s)
- Harold L. Dauerman
- From the University of Vermont Cardiovascular Research Institute, Burlington (H.L.D.); University of Michigan, Ann Arbor (E.R.B.); Virginia Commonwealth University, Richmond (M.C.K.); Duke Clinical Research Institute, Durham, NC (S.L., M.T.R.); Carolinas Medical Center, Charlotte, NC (J.L.G.); Cedars-Sinai Heart Institute, Los Angeles, CA (T.D.H.); and Hospital Corporation of America, Nashville, TN (S.V.M.)
| | - Eric R. Bates
- From the University of Vermont Cardiovascular Research Institute, Burlington (H.L.D.); University of Michigan, Ann Arbor (E.R.B.); Virginia Commonwealth University, Richmond (M.C.K.); Duke Clinical Research Institute, Durham, NC (S.L., M.T.R.); Carolinas Medical Center, Charlotte, NC (J.L.G.); Cedars-Sinai Heart Institute, Los Angeles, CA (T.D.H.); and Hospital Corporation of America, Nashville, TN (S.V.M.)
| | - Michael C. Kontos
- From the University of Vermont Cardiovascular Research Institute, Burlington (H.L.D.); University of Michigan, Ann Arbor (E.R.B.); Virginia Commonwealth University, Richmond (M.C.K.); Duke Clinical Research Institute, Durham, NC (S.L., M.T.R.); Carolinas Medical Center, Charlotte, NC (J.L.G.); Cedars-Sinai Heart Institute, Los Angeles, CA (T.D.H.); and Hospital Corporation of America, Nashville, TN (S.V.M.)
| | - Shuang Li
- From the University of Vermont Cardiovascular Research Institute, Burlington (H.L.D.); University of Michigan, Ann Arbor (E.R.B.); Virginia Commonwealth University, Richmond (M.C.K.); Duke Clinical Research Institute, Durham, NC (S.L., M.T.R.); Carolinas Medical Center, Charlotte, NC (J.L.G.); Cedars-Sinai Heart Institute, Los Angeles, CA (T.D.H.); and Hospital Corporation of America, Nashville, TN (S.V.M.)
| | - J. Lee Garvey
- From the University of Vermont Cardiovascular Research Institute, Burlington (H.L.D.); University of Michigan, Ann Arbor (E.R.B.); Virginia Commonwealth University, Richmond (M.C.K.); Duke Clinical Research Institute, Durham, NC (S.L., M.T.R.); Carolinas Medical Center, Charlotte, NC (J.L.G.); Cedars-Sinai Heart Institute, Los Angeles, CA (T.D.H.); and Hospital Corporation of America, Nashville, TN (S.V.M.)
| | - Timothy D. Henry
- From the University of Vermont Cardiovascular Research Institute, Burlington (H.L.D.); University of Michigan, Ann Arbor (E.R.B.); Virginia Commonwealth University, Richmond (M.C.K.); Duke Clinical Research Institute, Durham, NC (S.L., M.T.R.); Carolinas Medical Center, Charlotte, NC (J.L.G.); Cedars-Sinai Heart Institute, Los Angeles, CA (T.D.H.); and Hospital Corporation of America, Nashville, TN (S.V.M.)
| | - Steven V. Manoukian
- From the University of Vermont Cardiovascular Research Institute, Burlington (H.L.D.); University of Michigan, Ann Arbor (E.R.B.); Virginia Commonwealth University, Richmond (M.C.K.); Duke Clinical Research Institute, Durham, NC (S.L., M.T.R.); Carolinas Medical Center, Charlotte, NC (J.L.G.); Cedars-Sinai Heart Institute, Los Angeles, CA (T.D.H.); and Hospital Corporation of America, Nashville, TN (S.V.M.)
| | - Matthew T. Roe
- From the University of Vermont Cardiovascular Research Institute, Burlington (H.L.D.); University of Michigan, Ann Arbor (E.R.B.); Virginia Commonwealth University, Richmond (M.C.K.); Duke Clinical Research Institute, Durham, NC (S.L., M.T.R.); Carolinas Medical Center, Charlotte, NC (J.L.G.); Cedars-Sinai Heart Institute, Los Angeles, CA (T.D.H.); and Hospital Corporation of America, Nashville, TN (S.V.M.)
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23
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Stowens JC, Sonnad SS, Rosenbaum RA. Using EMS Dispatch to Trigger STEMI Alerts Decreases Door-to-Balloon Times. West J Emerg Med 2015; 16:472-80. [PMID: 25987932 PMCID: PMC4427229 DOI: 10.5811/westjem.2015.4.24248] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2014] [Revised: 04/01/2015] [Accepted: 04/02/2015] [Indexed: 11/16/2022] Open
Abstract
Introduction We sought to determine the potential reduction in door-to-balloon time (DTB) by allowing paramedics to perform prehospital ST-Elevation Myocardial Infarction (STEMI) notification using brief communications via emergency medical services (EMS) 9-1-1 dispatchers as soon as they saw a STEMI on 12-lead electrocardiogram (EKG). Our hypothesis was that earlier cardiac catheterization lab (CCL) activation would improve overall DTB and avoid delays arising from on-scene issues or the time required to deliver a full report. Methods The study setting was a single suburban community teaching hospital, which is a regional percutaneous coronary intervention (PCI) center with more than 120,000 Emergency Department (ED) visits/year and is serviced by a single tiered-response, advanced life support (ALS) paramedic-level agency. STEMI notifications from July 2009 to July 2012 occurred by either standard direct EMS-to-physician notification or by immediate 9-1-1 dispatch notification. In the 9-1-1 dispatcher-aided notification method, paramedics were asked to provide a brief one-sentence report using their lapel microphones upon immediate realization of a diagnostic EKG (usually within 1–2 minutes of patient contact). This report to the 9-1-1 dispatcher included the patient’s sex, age, and cardiologist (if known). The dispatcher then called the emergency department attending and informed them that a STEMI was being transported and that CCL activation was needed. We used retrospective chart review of a consecutive sample of patients from an existing STEMI registry to determine whether there was a statistically significant difference in DTB between the groups. Results Eight hundred fifty-six total STEMI alert patients arrived by EMS during the study. We excluded 730 notifications due to events such as cardiac arrest, arrhythmia, death, resolution of EKG changes and/or symptoms, cardiologist decision not to perform PCI, arrival as a transfer after prior stabilization at a referring facility or arriving by an EMS agency other than New Castle County EMS (NCC*EMS). Sixty-four (64) sequential patients from each group comprised the study sample. The average DTB (SD) for the standard communication method was 57.6 minutes (17.9), while that for dispatcher-aided communication was 46.1 minutes (12.8), (mean difference 57.6-46.1 minutes=11.5 minutes with a 95% CI [6.06,16.94]) p=0.0001. In the dispatcher-aided group, 92% of patients (59/64) met standards of ≤60 minute DTB time. Only 64% (41/64) met this goal in the standard communication group (p=0.0001). Conclusion Brief, early notification of STEMI by paramedics through 9-1-1 dispatchers achieves earlier CCL activation in a hospital system already using EMS-directed CCL activation. This practice significantly decreased DTB and yielded a higher percentage of patients meeting the DTB≤60 minutes quality metric.
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Affiliation(s)
- Justin C Stowens
- Christiana Care Health System, Department of Emergency Medicine, Newark, Delaware
| | - Seema S Sonnad
- Christiana Care Health System, Value Institute, Newark, Delaware
| | - Robert A Rosenbaum
- State of Delaware Office of Emergency Medical Services and Health Preparedness, Christiana Care Health System, Department of Emergency Medicine, Newark, Delaware
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Incidence of emergency department visits for ST-elevation myocardial infarction in a recent six-year period in the United States. Am J Cardiol 2015; 115:167-70. [PMID: 25465931 DOI: 10.1016/j.amjcard.2014.10.020] [Citation(s) in RCA: 43] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/22/2014] [Revised: 10/23/2014] [Accepted: 10/23/2014] [Indexed: 11/20/2022]
Abstract
The incidence and longitudinal trends of patients with ST-elevation myocardial infarction (STEMI) presenting to United States (US) emergency departments (EDs) are currently unknown. Efforts to use effective treatments for cardiovascular disease may decrease ED STEMI presentation. We conducted a descriptive epidemiological analysis of STEMI visits to EDs from 2006 to 2011 using the Nationwide ED Sample, the largest source of US ED data, to determine the incidence of patients with STEMIs presenting to the US EDs. We included adult ED visits with an International Classification of Diseases, Ninth Revision, Clinical Modification diagnosis of STEMI and calculated incidence rates for STEMI ED visits using US census population data. Incidence calculations were stratified by age group, geographic region, and year. From 2006 to 2011, there was a mean of 258,106 STEMIs presenting to EDs per year, decreasing from 300,466 in 2006 to 227,343 in 2011. Incidence of ED STEMI visits per 10,000 adults decreased from 10.1 (95% confidence interval [CI] 9.8 to 10.8) in 2006 to 7.3 (95% CI 6.8 to 7.8) in 2011. The Midwest had the highest rate of ED STEMIs at 10.0 (95% CI 9.2 to 10.8) and the West had the lowest with 6.6 (95% CI 6.1 to 7.0). The incidence of STEMI decreased for all age groups during the study period. In conclusion, we report the first national estimates of STEMI presentation to US EDs, which demonstrate decreasing incidence across all age groups and all geographic regions from 2006 to 2011. A decreasing STEMI incidence may affect the quality and timeliness of STEMI care. Continued national STEMI surveillance is needed to guide healthcare resource allocation.
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Hagiwara MA, Bremer A, Claesson A, Axelsson C, Norberg G, Herlitz J. The impact of direct admission to a catheterisation lab/CCU in patients with ST-elevation myocardial infarction on the delay to reperfusion and early risk of death: results of a systematic review including meta-analysis. Scand J Trauma Resusc Emerg Med 2014; 22:67. [PMID: 25420752 PMCID: PMC4258278 DOI: 10.1186/s13049-014-0067-x] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2013] [Accepted: 10/27/2014] [Indexed: 11/10/2022] Open
Abstract
Background For each hour of delay from fist medical contact until reperfusion in ST-elevation myocardial infarction (STEMI) there is a 10% increase in risk of death and heart failure. The aim of this review is to describe the impact of the direct admission of patients with STEMI to a Catheterisation laboratory (cath lab) as compared with transport to the emergency department (ED) with regard to delays and outcome. Methods Databases were searched for from April-June 2012 and updated January 2014: 1) Pubmed; 2) Embase; 3) Cochrane Library; 4) ProQuest Nursing and 5) Allied Health Sources. The search was restricted to studies in English, Swedish, Danish and Norwegian languages. The intervention was a protocol-based clinical pre-hospital pathway and main outcome measurements were the delay to balloon inflation and hospital mortality. Results Median delay from door to balloon was significantly shorter in the intervention group in all 5 studies reported. Difference in median delay varied between 16 minutes and 47 minutes. In all 7 included studies the time from symptom onset or first medical contact to balloon time was significantly shorter in the intervention group. The difference in median delay varied between 15 minutes and 1 hour and 35 minutes. Only two studies described hospital mortality. When combined the risk of death was reduced by 37%. Conclusion An overview of available studies of the impact of a protocol-based pre-hospital clinical pathway with direct admission to a cath lab as compared with the standard transport to the ED in ST-elevation AMI suggests the following. The delay to the start of revascularisation will be reduced. The clinical benefit is not clearly evidence based. However, the documented association between system delay and outcome defends the use of the pathway. Electronic supplementary material The online version of this article (doi:10.1186/s13049-014-0067-x) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Magnus Andersson Hagiwara
- School of Health Sciences, The Centre for Pre-hospital Research, University of Borås, SE-501 90, Borås, Sweden.
| | - Anders Bremer
- School of Health Sciences, The Centre for Pre-hospital Research, University of Borås, SE-501 90, Borås, Sweden.
| | - Andreas Claesson
- School of Health Sciences, The Centre for Pre-hospital Research, University of Borås, SE-501 90, Borås, Sweden.
| | - Christer Axelsson
- School of Health Sciences, The Centre for Pre-hospital Research, University of Borås, SE-501 90, Borås, Sweden.
| | - Gabriella Norberg
- School of Health Sciences, The Centre for Pre-hospital Research, University of Borås, SE-501 90, Borås, Sweden.
| | - Johan Herlitz
- School of Health Sciences, The Centre for Pre-hospital Research, University of Borås, SE-501 90, Borås, Sweden. .,Inst of Medicine, Department of Molecular and Clinical Medicine, Sahlgrenska University Hospital, SE-413 45, Göteborg, Sweden.
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Mehta BP, Leslie-Mazwi TM, Chandra RV, Bell DL, Sun CHJ, Hirsch JA, Rabinov JD, Rost NS, Schwamm LH, Goldstein JN, Levine WC, Gupta R, Yoo AJ. Reducing door-to-puncture times for intra-arterial stroke therapy: a pilot quality improvement project. J Am Heart Assoc 2014; 3:e000963. [PMID: 25389281 PMCID: PMC4338685 DOI: 10.1161/jaha.114.000963] [Citation(s) in RCA: 58] [Impact Index Per Article: 5.8] [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 Delays to intra-arterial therapy (IAT) lead to worse outcomes in stroke patients with proximal occlusions. Little is known regarding the magnitude of, and reasons for, these delays. In a pilot quality improvement (QI) project, we sought to examine and improve our door-puncture times. METHODS AND RESULTS For anterior-circulation stroke patients who underwent IAT, we retrospectively calculated in-hospital time delays associated with various phases from patient arrival to groin puncture. We formulated and then implemented a process change targeted to the phase with the greatest delay. We examined the impact on time to treatment by comparing the pre- and post-QI cohorts. One hundred forty-six patients (93 pre- vs. 51 post-QI) were analyzed. In the pre-QI cohort (ie, sequential process), the greatest delay occurred from imaging to the neurointerventional (NI) suite ("picture-suite": median, 62 minutes; interquartile range [IQR], 40 to 82). A QI measure was instituted so that the NI team and anesthesiologist were assembled and the suite set up in parallel with completion of imaging and decision making. The post-QI (ie, parallel process) median picture-to-suite time was 29 minutes (IQR, 21 to 41; P<0.0001). There was a 36-minute reduction in median door-to-puncture time (143 vs. 107 minutes; P<0.0001). Parallel workflow and presentation during work hours were independent predictors of shorter door-puncture times. CONCLUSIONS In-hospital delays are a major obstacle to timely IAT. A simple approach for achieving substantial time savings is to mobilize the NI and anesthesia teams during patient evaluation and treatment decision making. This parallel workflow resulted in a >30-minute (25%) reduction in median door-to-puncture times.
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Affiliation(s)
- Brijesh P Mehta
- Division of Interventional Neuroradiology, Department of Radiology, Massachusetts General Hospital, Boston, MA (B.P.M., T.M.L.M., R.V.C., D.L.B., J.A.H., J.D.R., A.J.Y.) Department of Neurology, Massachusetts General Hospital, Boston, MA (B.P.M., T.M.L.M., N.S.R., L.H.S.)
| | - Thabele M Leslie-Mazwi
- Division of Interventional Neuroradiology, Department of Radiology, Massachusetts General Hospital, Boston, MA (B.P.M., T.M.L.M., R.V.C., D.L.B., J.A.H., J.D.R., A.J.Y.) Department of Neurology, Massachusetts General Hospital, Boston, MA (B.P.M., T.M.L.M., N.S.R., L.H.S.)
| | - Ronil V Chandra
- Division of Interventional Neuroradiology, Department of Radiology, Massachusetts General Hospital, Boston, MA (B.P.M., T.M.L.M., R.V.C., D.L.B., J.A.H., J.D.R., A.J.Y.)
| | - Donnie L Bell
- Division of Interventional Neuroradiology, Department of Radiology, Massachusetts General Hospital, Boston, MA (B.P.M., T.M.L.M., R.V.C., D.L.B., J.A.H., J.D.R., A.J.Y.)
| | - Chung-Huan J Sun
- Department of Neurology, Emory University School of Medicine, Atlanta, GA (C.H.J.S.)
| | - Joshua A Hirsch
- Division of Interventional Neuroradiology, Department of Radiology, Massachusetts General Hospital, Boston, MA (B.P.M., T.M.L.M., R.V.C., D.L.B., J.A.H., J.D.R., A.J.Y.)
| | - James D Rabinov
- Division of Interventional Neuroradiology, Department of Radiology, Massachusetts General Hospital, Boston, MA (B.P.M., T.M.L.M., R.V.C., D.L.B., J.A.H., J.D.R., A.J.Y.)
| | - Natalia S Rost
- Department of Neurology, Massachusetts General Hospital, Boston, MA (B.P.M., T.M.L.M., N.S.R., L.H.S.)
| | - Lee H Schwamm
- Department of Neurology, Massachusetts General Hospital, Boston, MA (B.P.M., T.M.L.M., N.S.R., L.H.S.)
| | - Joshua N Goldstein
- Department of Emergency Medicine, Massachusetts General Hospital, Boston, MA (J.N.G.)
| | - Wilton C Levine
- Department of Anesthesia and Critical Care, Massachusetts General Hospital, Boston, MA (W.C.L.)
| | - Rishi Gupta
- Wellstar Neurosurgery, Kennestone Hospital, Marietta, GA (R.G.)
| | - Albert J Yoo
- Division of Diagnostic Neuroradiology, Massachusetts General Hospital, Boston, MA (A.J.Y.) Division of Interventional Neuroradiology, Department of Radiology, Massachusetts General Hospital, Boston, MA (B.P.M., T.M.L.M., R.V.C., D.L.B., J.A.H., J.D.R., A.J.Y.)
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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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28
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Giugliano RP, Braunwald E. The year in acute coronary syndrome. J Am Coll Cardiol 2013; 63:201-14. [PMID: 24239661 DOI: 10.1016/j.jacc.2013.10.041] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/09/2013] [Revised: 09/27/2013] [Accepted: 10/21/2013] [Indexed: 02/06/2023]
Affiliation(s)
- Robert P Giugliano
- TIMI Study Group, Division of Cardiovascular Medicine, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Eugene Braunwald
- TIMI Study Group, Division of Cardiovascular Medicine, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts.
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