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Furmanchuk A, Rydland KJ, Hsia RY, Mackersie R, Shi M, Hauser MW, Kho A, Bilimoria KY, Stey AM. Geographic Disparities in Re-triage Destinations Among Seriously Injured Californians. ANNALS OF SURGERY OPEN 2023; 4:e270. [PMID: 37456577 PMCID: PMC10348777 DOI: 10.1097/as9.0000000000000270] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/19/2023] Open
Abstract
Objective To quantify geographic disparities in sub-optimal re-triage of seriously injured patients in California. Summary of Background Data Re-triage is the emergent transfer of seriously injured patients from the emergency departments of non-trauma and low-level trauma centers to, ideally, high-level trauma centers. Some patients are re-triaged to a second non-trauma or low-level trauma center (sub-optimal) instead of a high-level trauma center (optimal). Methods This was a retrospective observational cohort study of seriously injured patients, defined by an Injury Severity Score > 15, re-triaged in California (2009-2018). Re-triages within one day of presentation to the sending center were considered. The sub-optimal re-triage rate was quantified at the state, regional trauma coordinating committees (RTCC), local emergency medical service agencies, and sending center level. A generalized linear mixed-effects regression quantified the association of sub-optimality with the RTCC of the sending center. Geospatial analyses demonstrated geographic variations in sub-optimal re-triage rates and calculated alternative re-triage destinations. Results There were 8,882 re-triages of seriously injured patients and 2,680 (30.2 %) were sub-optimal. Sub-optimally re-triaged patients had 1.5 higher odds of transfer to a third short-term acute care hospital and 1.25 increased odds of re-admission within 60 days from discharge. The sub-optimal re-triage rates increased from 29.3 % in 2009 to 38.6 % in 2018. 56.0 % of non-trauma and low-level trauma centers had at least one sub-optimal re-triage. The Southwest RTCC accounted for the largest proportion (39.8 %) of all sub-optimal re-triages in California. Conclusion High population density geographic areas experienced higher sub-optimal re-triage rates.
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Affiliation(s)
- Al’ona Furmanchuk
- Northwestern University Feinberg School of Medicine, Division of General Internal Medicine and Geriatrics, Chicago, IL
- Center for Health Information Partnerships (CHiP), Institute for Public Health and Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL, USA, Chicago, IL
| | | | - Renee Y. Hsia
- University of California San Francisco, Department of Emergency Medicine, San Francisco, CA
- Philip R. Lee Institute for Health Policy Studies, University of California San Francisco, San Francisco, CA
| | - Robert Mackersie
- University of California San Francisco, Department of Surgery, San Francisco, CA
| | - Meilynn Shi
- Northwestern University Feinberg School of Medicine, Division of General Internal Medicine and Geriatrics, Chicago, IL
| | | | - Abel Kho
- Northwestern University Feinberg School of Medicine, Division of General Internal Medicine and Geriatrics, Chicago, IL
- Center for Health Information Partnerships (CHiP), Institute for Public Health and Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL, USA, Chicago, IL
| | - Karl Y. Bilimoria
- Northwestern University Feinberg School of Medicine, Department of Surgery, Chicago, IL
| | - Anne M. Stey
- Northwestern University Feinberg School of Medicine, Department of Surgery, Chicago, IL
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French WJ, Gunderson M, Travis D, Bieniarz M, Zegre‐Hemsey J, Goyal A, Jacobs AK. Emergency Interhospital Transfer of Patients With ST‐Segment–Elevation Myocardial Infarction: Call 9‐1‐1—The American Heart Association Mission: Lifeline Program. J Am Heart Assoc 2022; 11:e026700. [DOI: 10.1161/jaha.122.026700] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
ABSTRACT: The American Heart Association Mission: Lifeline program objectives are to improve the quality of care and outcomes for patients with ST‐segment–elevation myocardial infarction. Every minute of delay in treatment adversely affects 1‐year mortality. Transfer of patients safely and timely to hospitals with primary percutaneous coronary intervention capability is needed to improve outcomes. But treatment times continue to show delays, especially during interhospital transfers. A simple 3‐step process of an interhospital “Call 9‐1‐1” protocol may expedite this process. This STAT TRANSFER process uses a systems approach that considers diverse ways in which patients access care, how EMS responds and determines destinations, how referring hospital transfers are performed, urban and rural differences, and how receiving hospitals prepare for an incoming patient with ST‐segment–elevation myocardial infarction. This initiative suggests a strategy to reduce variability in interhospital transfer times using a STAT TRANSFER and a Call 9‐1‐1 process in a system of care that involves all stakeholders.
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Affiliation(s)
- William J. French
- Geffen School of Medicine at UCLA, Cardiac Catheterization Laboratory, Harbor‐UCLA Medical Center Torrance CA
| | - Mic Gunderson
- Center for Systems Improvement, Cambridge Consulting Group; Emergency Health Services University of Maryland Baltimore County MD
| | - David Travis
- EMS Programs Hillsborough Community College Tampa FL
| | - Mark Bieniarz
- New Mexico Heart Institute Lovelace Medical Center Albuquerque NM
| | - Jessica Zegre‐Hemsey
- School of Nursing; Department of Emergency Medicine The University of North Carolina at Chapel Hill NC
| | - Abhinav Goyal
- Emory Heart and Vascular Center, Emory Healthcare; Medicine (Cardiology) Emory School of Medicine; Emory Rollins School of Public Health Atlanta GA
| | - Alice K. Jacobs
- Department of Medicine Boston University School of Medicine and Boston Medical Center Boston MA
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Young E, Khoo TW, Trochsler MI, Maddern GJ. Factors influencing interhospital transfer delays in emergency general surgery: a systematic review and narrative synthesis. ANZ J Surg 2022; 92:1314-1321. [PMID: 35437859 DOI: 10.1111/ans.17718] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2021] [Revised: 03/09/2022] [Accepted: 04/02/2022] [Indexed: 12/31/2022]
Abstract
BACKGROUND Emergency general surgery is an emerging public health issue globally, with substantial healthcare burden. Interhospital transfer of critically unwell surgical patients has been the mainstay of bridging gaps in surgical coverage in regional and rural locations, despite evidence of greater morbidity and mortality. Delays in transfer invariably occurs and compounds the situation. Our aim was to examine the factors influencing interhospital transfer delays in emergency general surgical patients. METHODS A systematic search of PubMED and EmBase, was performed by two researchers from 2020 to 23rd Feb 2021, for English articles related to interhospital transfer delays in emergency general surgical patients, with an age of >16. Articles were critically appraised and data were extracted into a pre-specified data extraction form. No data was suitable for statistical analysis and a narrative synthesis was performed instead. RESULTS Six relevant articles were identified from the search. All studies were retrospective cohort studies with moderate to high risk of bias. Lack of consultant surgeon input, after hours transfer, need for intensive care bed and poor transfer documentation may have a role in interhospital transfer delays. Patients with public health insurance, multiple comorbidities and non-emergency medical conditions experience longer transfer request time and may be at risk of precipitating interhospital transfer delays. Transfer delays are seen in transfers over longer distances. CONCLUSION There is a paucity of knowledge on what and how factors influence interhospital transfer delays in emergency general surgical patients. Well-designed prospective cohort studies are required to bridge this knowledge gap.
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Affiliation(s)
- Edward Young
- Faculty of Health and Medical Sciences, The University of Adelaide, Adelaide, South Australia, Australia
| | - Teng-Wei Khoo
- Faculty of Health and Medical Sciences, The University of Adelaide, Adelaide, South Australia, Australia
| | - Markus Ivo Trochsler
- Discipline of Surgery, The Queen Elizabeth Hospital, The University of Adelaide, Adelaide, South Australia, Australia
| | - Guy John Maddern
- Discipline of Surgery, The Queen Elizabeth Hospital, The University of Adelaide, Adelaide, South Australia, Australia
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4
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Helicopter emergency medical service for patients with acute coronary syndrome: selection validity and impact on clinical outcomes. Heart Vessels 2022; 37:1125-1135. [PMID: 35032206 DOI: 10.1007/s00380-022-02022-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/14/2021] [Accepted: 01/07/2022] [Indexed: 11/04/2022]
Abstract
Helicopter emergency medical service (HEMS) has the potential to improve prognosis for acute coronary syndrome (ACS). However, adequacy and effectiveness of HEMS have not been fully evaluated. A total of 862 ACS patients transferred by emergency medical services were divided into two groups: patients transferred by HEMS (n = 171) or by ground ambulance (GA; n = 691). Among them, angiography images for 718 patients (149 in HEMS and 569 in GA group) and optical coherence tomography (OCT) images for 374 patients (75 in HEMS and 299 in GA groups) were analyzed. Additional analysis to compare 2-year cardiac mortality between groups was conducted following propensity score matching to adjust for inter-group differences. ST-segment elevation myocardial infarction (81% vs. 66%, p < 0.001) and cardiogenic shock (Killip IV; 20% vs. 10%, p < 0.001) at admission were more prevalent in HEMS than GA group. Time from admission to balloon angioplasty was shorter in HEMS group (median 54 min vs. 69 min, p < 0.001). Antegrade coronary flow was worse in HEMS group (TIMI flow grade 0 or 1; 68% vs. 51%, p < 0.001). Plaque rupture was more frequently detected by OCT in HEMS group (68% vs. 49%, p = 0.029). Following propensity score matching, the incidence of cardiac death was significantly lower in HEMS group (6.3% vs. 14.9%, p = 0.019). In conclusion, severe ACS patients requiring early reperfusion were appropriately triaged and transferred more rapidly by HEMS. Lower mortality in HEMS group after propensity score matching suggests that HEMS may improve cardiac mortality in ACS patients.
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Artificial Intelligence: A Shifting Paradigm in Cardio-Cerebrovascular Medicine. J Clin Med 2021; 10:jcm10235710. [PMID: 34884412 PMCID: PMC8658222 DOI: 10.3390/jcm10235710] [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: 11/15/2021] [Accepted: 12/02/2021] [Indexed: 12/21/2022] Open
Abstract
The future of healthcare is an organic blend of technology, innovation, and human connection. As artificial intelligence (AI) is gradually becoming a go-to technology in healthcare to improve efficiency and outcomes, we must understand our limitations. We should realize that our goal is not only to provide faster and more efficient care, but also to deliver an integrated solution to ensure that the care is fair and not biased to a group of sub-population. In this context, the field of cardio-cerebrovascular diseases, which encompasses a wide range of conditions-from heart failure to stroke-has made some advances to provide assistive tools to care providers. This article aimed to provide an overall thematic review of recent development focusing on various AI applications in cardio-cerebrovascular diseases to identify gaps and potential areas of improvement. If well designed, technological engines have the potential to improve healthcare access and equitability while reducing overall costs, diagnostic errors, and disparity in a system that affects patients and providers and strives for efficiency.
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Ishiyama M, Kurita T, Takasaki A, Takamura T, Masuda J, Ishikura K, Seko T, Setsuda M, Kasai A, Imai H, Dohi K. Impact of Helicopter Transport on Reperfusion Times and Long-Term Outcomes in Acute Myocardial Infarction Patients in Rural Areas: A Report From the Mie Acute Coronary Syndrome Registry. Air Med J 2021; 40:337-343. [PMID: 34535242 DOI: 10.1016/j.amj.2021.05.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2021] [Revised: 04/14/2021] [Accepted: 05/03/2021] [Indexed: 11/28/2022]
Abstract
OBJECTIVE Helicopter emergency medical services (HEMS) are effective for time-sensitive conditions, such as stroke and trauma. However, prognostic data on helicopter transport for acute myocardial infarction (AMI) patients are insufficient. METHODS We registered 2,681 AMI patients in the Mie Acute Coronary Syndrome Registry and enrolled 163 patients from rural areas to HEMS base hospitals with HEMS or ground emergency medical services (GEMS). They were categorized into 4 groups according to the transportation method for interhospital transfer (direct HEMS: n = 52, direct GEMS: n = 54, interhospital HEMS: n = 32, and interhospital GEMS: n = 25). The primary end point was the emergency medical services (EMS) call-to-balloon time. The secondary end point was 2-year major adverse cardiac and cerebrovascular events. RESULTS The direct HEMS group was younger than the direct GEMS group (P = .029). The EMS call-to-balloon time was shorter in the direct HEMS and interhospital HEMS groups than in each GEMS group (P = .015 and P = .046). The incidence of 2-year major adverse cardiac and cerebrovascular events tended to be lower in both HEMS groups than in each GEMS group. CONCLUSION Direct HEMS for AMI in rural areas shortens the time from the EMS call to reperfusion when the transport distance is expected to exceed 30 km, which may result in a better patient prognosis. In addition, prehospital diagnostic modalities, such as 12-lead electrocardiography and echocardiography, may shorten the duration from the EMS call to reperfusion.
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Affiliation(s)
- Masaki Ishiyama
- Department of Cardiology and Nephrology, Mie University Graduate School of Medicine, Tsu, Mie, Japan
| | - Tairo Kurita
- Department of Cardiology and Nephrology, Mie University Graduate School of Medicine, Tsu, Mie, Japan.
| | - Akihiro Takasaki
- Department of Cardiology and Nephrology, Mie University Graduate School of Medicine, Tsu, Mie, Japan
| | - Takeshi Takamura
- Department of Cardiology, Ise Red Cross Hospital, Ise, Mie, Japan
| | - Jun Masuda
- Department of Cardiology, Mie Prefectural General Medical Center, Yokkaichi, Mie, Japan
| | - Ken Ishikura
- Emergency Critical Care Center, Mie University Graduate School of Medicine, Tsu, Mie, Japan
| | - Tetsuya Seko
- Department of Cardiology, Ise Red Cross Hospital, Ise, Mie, Japan
| | - Morimichi Setsuda
- Emergency and Critical Care Center, Ise Red Cross Hospital, Ise, Mie, Japan
| | - Atsunobu Kasai
- Department of Cardiology, Ise Red Cross Hospital, Ise, Mie, Japan
| | - Hiroshi Imai
- Emergency Critical Care Center, Mie University Graduate School of Medicine, Tsu, Mie, Japan
| | - Kaoru Dohi
- Department of Cardiology and Nephrology, Mie University Graduate School of Medicine, Tsu, Mie, Japan
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7
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Assessment of Transportation by Air for Patients with Acute ST-Elevation Myocardial Infarction from Non-PCI Centers. Healthcare (Basel) 2021; 9:healthcare9030299. [PMID: 33800429 PMCID: PMC8000528 DOI: 10.3390/healthcare9030299] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2021] [Revised: 02/20/2021] [Accepted: 03/03/2021] [Indexed: 11/16/2022] Open
Abstract
The aim of this study was to assess the delays that can potentially occur in the emergency transfer of patients with ST-elevation myocardial infarction (STEMI) to percutaneous coronary intervention (PCI) centers. We conducted a retrospective study using the medical reports pertaining to 97 patients who presented to the Emergency Department of the Emergency County Hospital of Galati during the year of 2018 with the diagnosis of STEMI and meeting eligibility criteria for PCI, thus warranting transfer to a hospital with PCI facilities. The pick-up time of patients diagnosed with acute myocardial infarction from the emergency department by the transfer crew is significantly shorter (p < 0.05) than those transferred by air, regardless of the PCI center to which the transfer was performed, Iasi or Bucharest, when compared to the time required to process the patients transferred by land to the same PCI centers. The results of the study shows that the helicopter use for transferring acute myocardial infarction patients to a PCI center must be considered, given the distance between non-PCI and PCI centers is over 200 km.
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8
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Hakim R, Revue E, Saint Etienne C, Marcollet P, Chassaing S, Decomis MP, Yafi W, Laure C, Gautier S, Godillon L, Akkoyun-Farinez J, Angoulvant D, Koning R, Motreff P, Grammatico-Guillon L, Rangé G. Does helicopter transport delay prehospital transfer for STEMI patients in rural areas? Findings from the CRAC France PCI registry. EUROPEAN HEART JOURNAL-ACUTE CARDIOVASCULAR CARE 2020; 9:958-965. [DOI: 10.1177/2048872619848976] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Aims:
The aim of this study was to analyse delays in emergency medical system transfer of ST-segment elevation myocardial infarction (STEMI) patients to percutaneous coronary intervention (PCI) centres according to transport modality in a rural French region.
Methods and results:
Data from the prospective multicentre CRAC / France PCI registry were analysed for 1911 STEMI patients: 410 transferred by helicopter and 1501 by ground transport. The primary endpoint was the percentage of transfers with first medical contact to primary percutaneous coronary intervention within the 90 minutes recommended in guidelines. The secondary endpoint was time of first medical contact to primary percutaneous coronary intervention. With helicopter transport, time of first medical contact to primary percutaneous coronary intervention in under 90 minutes was less frequently achieved than with ground transport (9.8% vs. 37.2%; odds ratio 5.49; 95% confidence interval 3.90; 7.73; P<0.0001). Differences were greatest for transfers under 50 km (13.7% vs. 44.7%; P<0.0001) and for primary transfers (22.4% vs. 49.6%; P<0.0001). The median time from first medical contact to primary percutaneous coronary intervention and from symptom onset to primary percutaneous coronary intervention (total ischaemic time) were significantly higher in the helicopter transport group than in the ground transport group (respectively, 137 vs. 103 minutes; P<0.0001 and 261 vs. 195 minutes; P<0.0001). There was no significant difference in inhospital mortality between the helicopter and ground transport groups (6.9% vs. 6.6%; P=0.88).
Conclusions:
Helicopter transport of STEMI patients was five times less effective than ground transport in maintaining the 90-minute first medical contact to primary percutaneous coronary intervention time recommended in guidelines, particularly for transfer distances less than 50 km.
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Affiliation(s)
- Radwan Hakim
- Cardiology Department, Les Hôpitaux de Chartres, France
| | - Eric Revue
- Emergency Unit Department, Les Hôpitaux de Chartres, France
| | | | | | | | | | - Wael Yafi
- Cardiology Department, Centre Hospitalo-régional de Orléans, France
| | | | | | | | | | - Denis Angoulvant
- Cardiology Department, Centre Hospitalo-Universitaire de Tours, France
| | - Rene Koning
- Cardiology Department, Clinique Saint-Hilaire, France
| | - Pascal Motreff
- Cardiology Department, Centre Hospitalo-Universitaire de Clermont-Ferrand, France
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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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Chartrain AG, Shoirah H, Jauch EC, Mocco J. A review of acute ischemic stroke triage protocol evidence: a context for discussion. J Neurointerv Surg 2018; 10:1047-1052. [PMID: 30002087 DOI: 10.1136/neurintsurg-2018-013951] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2018] [Revised: 05/08/2018] [Accepted: 05/10/2018] [Indexed: 11/03/2022]
Abstract
Endovascular thrombectomy (EVT) is now the standard of care for eligible patients with acute ischemic stroke (AIS) secondary to emergent large vessel occlusion (ELVO). However, there remains uncertainty in how hospital systems can most efficiently route patients with suspected ELVO for EVT treatment. Given the relative geographic distribution of centers with and without endovascular capabilities, the value of prehospital triage directly to centers with the ability to provide EVT remains debated. While there are no randomized trial data available to date, there is substantial evidence in the literature that may offer guidance on the subject. In this review we examine the available data in the context of improving the existing AIS triage systems and discuss how prehospital triage directly to endovascular-capable centers may confer clinical benefits for patients with suspected ELVO.
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Affiliation(s)
| | - Hazem Shoirah
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, USA
| | - Edward C Jauch
- Departments of Emergency Medicine and Neurology, Medical University of South Carolina, Charleston, South Carolina, USA
| | - J Mocco
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, USA
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11
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Sepehrvand N, Alemayehu W, Kaul P, Pelletier R, Bello AK, Welsh RC, Armstrong PW, Ezekowitz JA. Ambulance use, distance and outcomes in patients with suspected cardiovascular disease: a registry-based geographic information system study. EUROPEAN HEART JOURNAL-ACUTE CARDIOVASCULAR CARE 2018; 9:45-58. [PMID: 29652166 DOI: 10.1177/2048872618769872] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
BACKGROUND Despite guideline recommendations, the majority of patients with symptoms suggestive of acute coronary syndrome do not use emergency medical services to reach the emergency department (ED). The aim of this study was to investigate the factors associated with EMS utilisation and subsequent patient outcomes. METHODS Using administrative data, all patients who presented to an ED in the metropolitan areas of Edmonton and Calgary in the years of 2007-2013 with main ED diagnosis of acute coronary syndrome, stable angina or chest pain were included. The travel distance was estimated using the geographic information system method to approximate the distance between the ED and patient home. The clinical endpoints were the 7-day and 30-day all-cause events (death, re-hospitalisation and repeat ED visit). RESULTS Of 50,881 patients, 30.5% presented by emergency medical services. Patients with older age, female sex, ED diagnosis of acute coronary syndrome, more comorbidities and lower household income were more likely to use emergency medical services to reach the hospital. Longer travel distance was associated with higher emergency medical services use (odds ratio 1.09, 95% confidence interval 1.09-1.10), but it was not a predictor of clinical events. After adjustment for covariates and inverse propensity score weighting, emergency medical services use was associated with a higher risk of 7-day and 30-day clinical events. CONCLUSION Several demographic and clinical features were associated with higher emergency medical services use including geographical variation. Although longer travel distance was shown to be linked to higher emergency medical services use, it was not an independent predictor of patient outcome. This has implications for the design of emergency medical services systems, triage and early diagnosis and treatment options.
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Affiliation(s)
- Nariman Sepehrvand
- Canadian VIGOUR Centre, University of Alberta, Canada.,Department of Medicine, University of Alberta, Canada
| | | | - Padma Kaul
- Canadian VIGOUR Centre, University of Alberta, Canada.,Department of Medicine, University of Alberta, Canada
| | - Rick Pelletier
- Department of Renewable Resources, University of Alberta, Canada
| | - Aminu K Bello
- Department of Medicine, University of Alberta, Canada
| | - Robert C Welsh
- Canadian VIGOUR Centre, University of Alberta, Canada.,Department of Medicine, University of Alberta, Canada.,Mazankowski Alberta Heart Institute, Canada
| | | | - Justin A Ezekowitz
- Canadian VIGOUR Centre, University of Alberta, Canada.,Department of Medicine, University of Alberta, Canada.,Mazankowski Alberta Heart Institute, Canada
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12
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Funder KS, Rasmussen LS, Siersma V, Lohse N, Hesselfeldt R, Pedersen F, Hendriksen OM, Steinmetz J. Helicopter vs. ground transportation of patients bound for primary percutaneous coronary intervention. Acta Anaesthesiol Scand 2018; 62:568-578. [PMID: 29484640 PMCID: PMC5888124 DOI: 10.1111/aas.13092] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2017] [Revised: 01/23/2018] [Accepted: 01/29/2018] [Indexed: 02/06/2023]
Abstract
BACKGROUND Implementation of the first Danish helicopter emergency medical service (HEMS) was associated with reduced time from first medical contact to treatment at a specialized centre for patients with suspected ST elevation myocardial infarction (STEMI). We aimed to investigate effects of HEMS on mortality and labour market affiliation in patients admitted for primary percutaneous coronary intervention (PCI). METHODS In this prospective observational study, we included patients with suspected STEMI within the region covered by the HEMS from January 1, 2010, to April 30, 2013, transported by either HEMS or ground emergency medical services (GEMS) to the regional PCI centre. The primary outcome was 30-day mortality. RESULTS Among the 384 HEMS and 1220 GEMS patients, time from diagnostic ECG to PCI centre arrival was lower with HEMS (median 71 min vs. 78 min with GEMS; P = 0.004). Thirty-day mortality was 5.0% and 6.2%, respectively (adjusted OR = 0.82, 95% CI 0.44-1.51, P = 0.52. Involuntary early retirement rates were 0.62 (HEMS) and 0.94 (GEMS) per 100 PYR (adjusted IRR = 0.68, 0.15-3.23, P = 0.63). The proportion of patients on social transfer payments longer than half of the follow-up time was 22.1% (HEMS) vs. 21.2% (adjusted OR = 1.10, 0.64-1.90, P = 0.73). CONCLUSION In an observational study of patients with suspected STEMI in eastern Denmark, no significant beneficial effect of helicopter transport could be detected on mortality, premature labour market exit or work ability. Only a study with random allocation to one system vs. another, along with a large sample size, will allow determination of superiority of helicopter transport.
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Affiliation(s)
- K. S. Funder
- Department of Anaesthesia; Centre of Head and Orthopaedics 4231; Rigshospitalet; University of Copenhagen; Copenhagen Denmark
| | - L. S. Rasmussen
- Department of Anaesthesia; Centre of Head and Orthopaedics 4231; Rigshospitalet; University of Copenhagen; Copenhagen Denmark
| | - V. Siersma
- The Research Unit for General Practice and Section of General Practice; Department of Public Health; University of Copenhagen; Copenhagen Denmark
| | - N. Lohse
- Department of Anaesthesia; Centre of Head and Orthopaedics 4231; Rigshospitalet; University of Copenhagen; Copenhagen Denmark
| | - R. Hesselfeldt
- Department of Anaesthesia; Centre of Head and Orthopaedics 4231; Rigshospitalet; University of Copenhagen; Copenhagen Denmark
| | - F. Pedersen
- Department of Cardiology; The Heart Centre; Rigshospitalet; University of Copenhagen; Copenhagen Denmark
| | | | - J. Steinmetz
- Emergency Medical Services Copenhagen; University of Copenhagen; Ballerup Denmark
- National Helicopter Emergency Medical Services; Aarhus Denmark
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Dharma S, Andriantoro H, Purnawan I, Dakota I, Basalamah F, Hartono B, Rasmin R, Isnanijah H, Yamin M, Wijaya IP, Pratama V, Gunawan TB, Juwana YB, Suling FRW, Witjaksono AMO, Lasanudin HF, Iskandarsyah K, Priatna H, Tedjasukmana P, Wahyumandradi U, Kosasih A, Budhiarti IA, Pribadi W, Wirianta J, Lubiantoro U, Pramesti R, Widowati DR, Aminda SK, Basalamah MA, Rao SV. Characteristics, treatment and in-hospital outcomes of patients with STEMI in a metropolitan area of a developing country: an initial report of the extended Jakarta Acute Coronary Syndrome registry. BMJ Open 2016; 6:e012193. [PMID: 27580835 PMCID: PMC5013359 DOI: 10.1136/bmjopen-2016-012193] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
OBJECTIVE We studied the characteristics of patients with ST segment elevation myocardial infarction (STEMI) after expansion of a STEMI registry as part of the STEMI network programme in a metropolitan city and the surrounding area covering ∼26 million inhabitants. DESIGN Retrospective cohort study. SETTING Emergency department of 56 health centres. PARTICIPANTS 3015 patients with acute coronary syndrome, of which 1024 patients had STEMI. MAIN OUTCOME MEASURE Characteristics of reperfusion therapy. RESULTS The majority of patients with STEMI (81%; N=826) were admitted to six academic percutaneous coronary intervention (PCI) centres. PCI centres received patients predominantly (56%; N=514) from a transfer process. The proportion of patients receiving acute reperfusion therapy was higher than non-reperfused patients (54% vs 46%, p<0.001), and primary PCI was the most common method of reperfusion (86%). The mean door-to-device (DTD) time was 102±68 min. In-hospital mortality of non-reperfused patients was higher than patients receiving primary PCI or fibrinolytic therapy (9.1% vs 3.2% vs 3.8%, p<0.001). Compared with non-academic PCI centres, patients with STEMI admitted to academic PCI centres who underwent primary PCI had shorter mean DTD time (96±44 min vs 140±151 min, p<0.001), higher use of manual thrombectomy (60.2% vs13.8%, p<0.001) and drug-eluting stent implantation (87% vs 69%, p=0.001), but had similar use of radial approach and intra-aortic balloon pump (55.7% vs 67.2%, and 2.2% vs 3.4%, respectively). In patients transferred for primary PCI, TIMI risk score ≥4 on presentation was associated with a prolonged door-in to door-out (DI-DO) time (adjusted OR 2.08; 95% CI 1.09 to 3.95, p=0.02). CONCLUSIONS In the expanded JAC registry, a higher proportion of patients with STEMI received reperfusion therapy, but 46% still did not. In developing countries, focusing the prehospital care in the network should be a major focus of care to improve the DI-DO time along with improvement of DTD time at PCI centres. TRIAL REGISTRATION NUMBER NCT02319473.
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Affiliation(s)
- Surya Dharma
- Department of Cardiology and Vascular Medicine, Faculty of Medicine, University of Indonesia, National Cardiovascular Center Harapan Kita, Jakarta, Indonesia
| | - Hananto Andriantoro
- Department of Cardiology and Vascular Medicine, Faculty of Medicine, University of Indonesia, National Cardiovascular Center Harapan Kita, Jakarta, Indonesia
| | - Ismi Purnawan
- Chairman, Indonesian Heart Association, Jakarta Branch, Jakarta, Indonesia
| | - Iwan Dakota
- Department of Cardiology and Vascular Medicine, Faculty of Medicine, University of Indonesia, National Cardiovascular Center Harapan Kita, Jakarta, Indonesia
| | | | - Beny Hartono
- Binawaluya Cardiac Center, East Jakarta, Indonesia
| | - Ronaly Rasmin
- Budhi Asih General Hospital, East Jakarta, Indonesia
| | | | - Muhammad Yamin
- Division of Cardiology, Department of Internal Medicine, Faculty of Medicine, University of Indonesia, Cipto Mangunkusumo General Hospital, Central Jakarta, Indonesia
| | - Ika Prasetya Wijaya
- Division of Cardiology, Department of Internal Medicine, Faculty of Medicine, University of Indonesia, Cipto Mangunkusumo General Hospital, Central Jakarta, Indonesia
| | - Vireza Pratama
- Department of Cardiology, Gatot Soebroto Army Central Hospital, Central Jakarta, Indonesia
| | - Tjatur Bagus Gunawan
- Department of Cardiology, Dr Mintohardjo Hospital, Indonesian Naval Hospital, Central Jakarta, Indonesia
| | | | - Frits R W Suling
- Department of Cardiology, Christian University of Indonesia General Hospital, East Jakarta, Indonesia
| | - A M Onny Witjaksono
- Department of Cardiology, St Carolus General Hospital, Central Jakarta, Indonesia
| | | | | | | | | | | | | | | | - Wisnoe Pribadi
- Esnawan Antariksa Indonesian Air Force Hospital, East Jakarta, Indonesia
| | | | | | - Rini Pramesti
- Fatmawati General Hospital, South Jakarta, Indonesia
| | | | | | | | - Sunil V Rao
- Section Chief, Department of Cardiology, Duke University Medical Center, Durham VA Medical Center, Durham, North Carolina, USA
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14
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Bechtold D, Salvatierra GG, Bulley E, Cypro A, Daratha KB. Geographic Variation in Treatment and Outcomes Among Patients With AMI: Investigating Urban-Rural Differences Among Hospitalized Patients. J Rural Health 2015; 33:158-166. [PMID: 26633577 DOI: 10.1111/jrh.12165] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/05/2015] [Indexed: 12/01/2022]
Abstract
BACKGROUND The value of early invasive revascularization for patients suffering acute myocardial infarction (AMI) is well known. However, access to revascularization services varies geographically and demographically. Previous studies have not examined the influence of rural residence on revascularization rates and outcomes among patients hospitalized with AMI. METHODS Our retrospective cohort study included patients hospitalized in Washington State with a primary diagnosis of AMI from 2009 to 2012. Urban or rural residence was determined using rural-urban commuting area (RUCA) codes. Multivariable models were used to evaluate geographic variation in rates of invasive versus medical management, in-hospital mortality, rehospitalization, and subsequent revascularization procedures. RESULTS Our study included 25,156 urban dwellers and 2,770 rural residents. Adjusted models found rural patients to be at increased odds of undergoing invasive revascularization during the initial episode of AMI care (OR = 1.11; 95% CI: 1.01-1.21; P = .02) compared to urban dwelling patients. Rural patients were more likely to be transferred for care (OR = 4.28; 95% CI: 3.93-4.66; P < .001) and more likely to undergo coronary artery bypass grafting (CABG) (OR = 1.55; 95% CI: 1.35-1.78; P < .001) compared to the urban cohort. We found no significant geographic cohort differences in in-hospital mortality or subsequent revascularization rates. CONCLUSION Our findings suggest that despite limited access to cardiac care facilities, rural patients are accessing revascularization services. However, rural residents are more likely to undergo CABG during their index admission. High transfer rates suggest that rural regions rely on effective transfer networks to access invasive cardiac services.
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Affiliation(s)
- Daniel Bechtold
- School of Medicine, University of Washington, Seattle, Washington
| | | | - Emily Bulley
- School of Medicine, University of Washington, Seattle, Washington
| | - Alex Cypro
- School of Medicine, University of Washington, Seattle, Washington
| | - Kenn B Daratha
- Department of Medical Education and Biomedical Informatics, University of Washington, Spokane and Seattle, Washington.,College of Nursing, Washington State University, Spokane, Washington
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15
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Aversano T. Distance, delay, and discontent. Circ Cardiovasc Interv 2014; 7:739-40. [PMID: 25516758 DOI: 10.1161/circinterventions.114.002158] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Thomas Aversano
- From the Johns Hopkins Heart and Vascular Institute, Baltimore, MD.
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