Care Processes Associated With Quicker Door-In–Door-Out Times for Patients With ST-Elevation–Myocardial Infarction Requiring Transfer

Greater cost without greater benefit: The need to refine transfer criteria for patients with severe acute pancreatitis

BACKGROUND

Appropriate and timely care is essential in the management of severe acute pancreatitis (SAP). We hypothesized that transferred patients with SAP undergoing procedural intervention would have higher mortality compared to those managed directly at academic centers.

METHODS

This was a retrospective analysis of Maryland's statewide claims database from 2009 to 2022 of adult patients admitted with a primary diagnosis of SAP (acute pancreatitis with organ failure). Patients were divided into three groups: those admitted directly from the emergency room to academic facilities (AD), non-academic facilities (NA), or transferred to academic facilities (TR). Procedural intervention included endoscopic, percutaneous image-guided, or surgical. The primary outcome was in-hospital mortality. Secondary outcomes were admission costs, length of stay (LOS), and intensive care unit (ICU) admission.

RESULTS

There were 7,648 (48.9%) in the NA group, 6,682 (42.7%) in the AD group and 1,316 (8.4%) in the TR group. On regression analysis, odds of death were 0.57x lower in the NA group and 0.67x lower in the AD group compared to transfers (<0.001). Procedural intervention was not associated with increased mortality. Transferred patients had longer median LOS (11 vs NA = 5, AD = 6, p < 0.001), increased median cost of admission ($41k vs NA = $12k, AD = $17k, p < 0.001) and greater ICU admission (45.6% vs NA = 20.6%, AD = 23.9%, p < 0.001).

CONCLUSION

Transferred patients have greater burden of illness and cost of care without evidence of improved outcomes in the management of SAP regardless of procedural intervention. Transfer criteria for patients with SAP must be further refined to reduce unnecessary transfers.

Validity of regional network systems on reperfusion therapy in diabetes mellitus and non-diabetes mellitus patients with ST-segment elevation myocardial infarction

Background

Patients with ST-segment elevation myocardial infarction (STEMI) with diabetes mellitus (DM) had higher mortality and poorer prognosis than those without DM. Previous studies had demonstrated the effectiveness of regional network systems (RNS) for reperfusion therapy in patients with STEMI. However, the differences in nursing care with RNS in subgroups of patients with DM with STEMI were unclear. Our study aimed to evaluate the validity of RNS in reperfusion therapy in patients with STEMI with or without DM.

Methods

We retrospectively enrolled patients with STEMI who received reperfusion therapy at the chest pain center of the 920th Hospital in Kunming City, Yunnan Province from 2019 to 2021. Personal information and hospitalization information for patients with STEMI were collected through the chest pain center registration system. Univariate and multivariate logistic regression were used to analyze factors associated with outcomes in patients with STEMI who received RNS. Wilcoxon rank-sum test and chi-squared test were used to analyze the differences in reperfusion therapy times and clinical outcomes between RNS and non-RNS in patients with STEMI with or without DM.

Results

This study enrolled 1,054 patients with STEMI, including 148 patients with DM and 906 patients without DM. Logistic regression analysis indicated that DM was associated with patients with STEMI who received RNS [OR 1.590 95% CI (1.034-2.446), P = 0.035]. RNS may decrease the reperfusion therapy time in patients with STEMI and patients without DM with STEMI, including the first medical contact (FMC) to door, FMC to wire and FMC to catheterization laboratory activity (all P < 0.05). However, we found no significant difference in reperfusion therapy times with and without RNS in patients with DM (all P > 0.05).

Conclusion

Regional network systems may decrease the reperfusion therapy time in patients without DM with STEMI, but no decrease was found in patients with DM with STEMI.

Treatment Time and In-Hospital Mortality Among Patients With ST-Segment Elevation Myocardial Infarction, 2018-2021

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.

[Cardiac arrest under special circumstances]

These guidelines of the European Resuscitation Council (ERC) Cardiac Arrest under Special Circumstances are based on the 2020 International Consensus on Cardiopulmonary Resuscitation Science with Treatment Recommendations. This section provides guidelines on the modifications required for basic and advanced life support for the prevention and treatment of cardiac arrest under special circumstances; in particular, specific causes (hypoxia, trauma, anaphylaxis, sepsis, hypo-/hyperkalaemia and other electrolyte disorders, hypothermia, avalanche, hyperthermia and malignant hyperthermia, pulmonary embolism, coronary thrombosis, cardiac tamponade, tension pneumothorax, toxic agents), specific settings (operating room, cardiac surgery, cardiac catheterization laboratory, dialysis unit, dental clinics, transportation [in-flight, cruise ships], sport, drowning, mass casualty incidents), and specific patient groups (asthma and chronic obstructive pulmonary disease, neurological disease, morbid obesity, pregnancy).

European Resuscitation Council Guidelines 2021: Cardiac arrest in special circumstances

These European Resuscitation Council (ERC) Cardiac Arrest in Special Circumstances guidelines are based on the 2020 International Consensus on Cardiopulmonary Resuscitation Science with Treatment Recommendations. This section provides guidelines on the modifications required to basic and advanced life support for the prevention and treatment of cardiac arrest in special circumstances; specifically special causes (hypoxia, trauma, anaphylaxis, sepsis, hypo/hyperkalaemia and other electrolyte disorders, hypothermia, avalanche, hyperthermia and malignant hyperthermia, pulmonary embolism, coronary thrombosis, cardiac tamponade, tension pneumothorax, toxic agents), special settings (operating room, cardiac surgery, catheter laboratory, dialysis unit, dental clinics, transportation (in-flight, cruise ships), sport, drowning, mass casualty incidents), and special patient groups (asthma and COPD, neurological disease, obesity, pregnancy).

Evaluation of STEMI Regionalization on Access, Treatment, and Outcomes Among Adults Living in Nonminority and Minority Communities

IMPORTANCE

Cardiac care regionalization, specifically for patients with ST-segment elevation myocardial infarction (STEMI), has been touted as a potential mechanism to reduce systematic disparities by protocolizing the treatment of these conditions. However, it is unknown whether such regionalization arrangements have widened or narrowed disparities in access, treatment, and outcomes for minority communities.

OBJECTIVE

To determine the extent to which disparities in access, treatment, and outcomes have changed for patients with STEMI living in zip codes that are in the top tertile of the Black or Hispanic population compared with patients in nonminority zip codes in regionalized vs nonregionalized counties.

DESIGN, SETTING, AND PARTICIPANTS

This cohort study used a quasi-experimental approach exploiting the different timing of regionalization across California. Nonpublic inpatient data for all patients with STEMI from January 1, 2006, to October 31, 2015, were analyzed using a difference-in-difference-in-differences estimation approach.

EXPOSURE

Exposure to the intervention was defined as on and after the year a patient's county was exposed to regionalization.

MAIN OUTCOMES AND MEASURES

Access to percutaneous coronary intervention (PCI)-capable hospital, receipt of PCI on the same day and at any time during the hospitalization, and time-specific all-cause mortality.

RESULTS

This study included 139 494 patients with STEMI; 61.9% of patients were non-Hispanic White, 5.6% Black, 17.8% Hispanic, and 9.0% Asian; 32.8% were women. Access to PCI-capable hospitals improved by 6.3 percentage points (95% CI, 5.5 to 7.1 percentage points; P < .001) when patients in nonminority communities were exposed to regionalization. Patients in minority communities experienced a 1.8-percentage point smaller improvement in access (95% CI, -2.8 to -0.8 percentage points; P < .001), or 28.9% smaller, compared with those in nonminority communities when both were exposed to regionalization. Regionalization was associated with an improvement to same-day PCI and in-hospital PCI by 5.1 percentage points (95% CI, 4.2 to 6.1 percentage points; P < .001) and 5.0 percentage points (95% CI, 4.2 to 5.9 percentage points; P < .001), respectively, for patients in nonminority communities. Patients in minority communities experienced only 33.3% and 15.1% of that benefit. Only White patients in nonminority communities experienced mortality improvement from regionalization.

CONCLUSIONS AND RELEVANCE

Although regionalization was associated with improved access to PCI hospitals and receipt of PCI treatment, patients in minority communities derived significantly smaller improvement relative to those in nonminority communities.

Catheterization Laboratory Activation Time in Patients Transferred With ST-Segment–Elevation Myocardial Infarction: Insights From the Mission: Lifeline STEMI Accelerator-2 Project

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.

Door-in to door-out times in acute ST-segment elevation myocardial infarction in emergency departments of non-interventional hospitals: A cohort study

In France, one in eight patients with acute ST-segment elevation myocardial infarction (STEMI) is admitted direct to an emergency department (ED) in a hospital without percutaneous coronary intervention (PCI) facilities. Guidelines recommend transfer to a PCI center, with a door-in to door-out (DI-DO) time of ≤30 min. We report DI-DO times and identify the main factors affecting them.RESURCOR is a French Northern Alps registry of patients with STEMI of <12 h duration. We focused on patients admitted direct, without prehospital medical care, to EDs in 19 non-PCI centers from 2012 to 2014. We divided DI-DO time into diagnostic time (ED admission to call for transfer) and logistical time (call for transfer to ED discharge).Among 2007 patients, 240 were admitted direct to EDs in non-PCI centers; 57.9% were treated with primary angioplasty and 32.9% received thrombolysis. Median (interquartile range) DI-DO time was 92.5 (67-143) min, with a diagnostic time of 41 (23-74) min and a logistical time of 47.5 (32-69) min. Five patients (2.1%) had a DI-DO time ≤30 min. Five variables were independently associated with a shorter DI-DO time: local transfer (mobile intensive care unit [MICU] team available at referring ED) (P = .017) or transfer by air ambulance (P = .004); shorter distance from referring ED to PCI center (P < .001); shorter time from symptom onset to ED admission (P = .002); thrombolysis (P = .006); and extended myocardial infarction (P = .007).In view of longer-than-recommended DI-DO times, efforts are required to promote urgent local transfer and use of thrombolysis.

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

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.

Factors associated with door-in to door-out delays among ST-segment elevation myocardial infarction (STEMI) patients transferred for primary percutaneous coronary intervention: a population-based cohort study in Ontario, Canada

BACKGROUND

Compared to ST-segment elevation myocardial infarction (STEMI) patients who present at centres with catheterization facilities, those transferred for primary percutaneous coronary intervention (PCI) have substantially longer door-in to door-out (DIDO) times, where DIDO is defined as the time interval from arrival at a non-PCI hospital, to transfer to a PCI hospital. We aimed to identify potentially modifiable factors to improve DIDO times in Ontario, Canada and to assess the impact of DIDO times on 30-day mortality.

METHODS

A population-based, retrospective cohort study of 966 STEMI patients transferred for primary PCI in Ontario in 2012 was conducted. Baseline factors were examined across timely DIDO status. Multivariate logistic regression was used to examine independent predictors of timely DIDO as well as the association between DIDO times and 30-day mortality.

RESULTS

The median DIDO time was 55 min, with 20.1% of patients achieving the recommended DIDO benchmark of ≤30 min. Age (OR> 75 vs 18-55 0.30, 95% CI: 0.16-0.56), symptom-to-first medical contact (FMC) time (OR61-120mins vs < 60mins 0.60, 95% CI: 0.39-0.90; OR>120mins vs < 60mins 0.53, 95% CI:0.35-0.81) and emergency medical services transport with a pre-hospital electrocardiogram (ECG) (OREMS transport + ECG vs self-transport 2.63, 95% CI:1.59-4.35) were the strongest predictors of timely DIDO. Patients with timely ECG were more likely to have recommended DIDO times (33.0% vs 12.3%; P < 0.001). A significantly higher proportion of those who met the DIDO benchmark had timely FMC-to-balloon times (78.7% vs 27.4%; P < 0.001). Compared to patients with DIDO time ≤ 30 min, those with DIDO times > 90 min had significantly higher adjusted 30-day mortality rates (OR 2.82, 95% CI:1.10-7.19).

CONCLUSIONS

While benchmark DIDO times were still rarely achieved in the province, we identified several potentially modifiable factors in the STEMI system that might be targeted to improve DIDO times. Our findings that patients who received a pre-hospital ECG were still being transferred to non-PCI capable centres suggest strategies addressing this gap may improve patient outcomes.

Prehospital Antibiotic Prophylaxis for Open Fractures: Practicality and Safety

OBJECTIVE

Early antibiotic administration has been associated with a significant decrease in infection following open fractures. However, antibiotics are most effective at a time when many patients are still being transported for care. There is limited evidence that antibiotics may be safely administered for open fractures when being transported by life-flight personnel. No such data exists for ground ambulance transport of patients with open fractures. The purpose of the study was to assess the safety and feasibility of prophylactic antibiotic delivery in the prehospital setting.

METHODS

We performed a prospective observational study between January 1, 2014 and May 31, 2015 of all trauma patients transferred to a level 1 trauma center by a single affiliated ground ambulance transport service. If open fracture was suspected, the patient was indicated for antibiotic prophylaxis with 2 g IV Cefazolin. Exclusion criteria included penicillin allergy, higher priority patient care tasks, and remaining transport time insufficient for administration of antibiotics. The administration of antibiotics was recorded. Patient demographics, associated injuries, priority level (1 = life threatening injury, 2 = potentially life threatening injury, 3 = non-life threatening injury), and timing of transport and antibiotic administration were recorded as well.

RESULTS

EMTs identified 70 patients during the study period with suspected open fractures. Eight reported penicillin allergy and were not eligible for prophylaxis. The patient's clinical status and transport time allowed for administration of antibiotic prophylaxis for 32 patients (51.6%). Total prehospital time was the only variable assessed that had a significant impact on administration of prehospital antibiotics (<30 minutes = 29% vs. >30 minutes = 66%; p < 0.001). There were no allergic reactions among patients and no needle sticks or other injuries to EMT personnel related to antibiotic administration.

CONCLUSIONS

EMT personnel were able to administer prehospital antibiotic prophylaxis for a substantial portion of the identified patients without any complications for patients or providers. Given the limited training provided to EMTs prior to implementation of the antibiotic prophylaxis protocol, it is likely that further development of this initial training will lead to even higher rates of prehospital antibiotic administration for open fractures.

Another important time target in ST-elevation myocardial infarction management—door-in door-out time: Do we meet door-in door-out time targets?

Background:

In non-PCI capable hospitals, another important time to be noticed in patients who have been referred for PCI-capable centers; is the time of doo-in door-out (DIDO), defined as the duration of time from patient discharge from the transferrring hospital. In our country, there is no clear information about the duration of DIDO time and transfer time. Consequently, very little is known about how frequently these targets can be met nationally.

Objectives:

This study aimed to measure door-in door-out time for ST-elevation myocardial infarction diagnosed patients who admitted to emergency department of a hospital capable of non-percutaneous coronary intervention and to measure whether door-in door-out time meets the guidelines.

Methods:

This single-center, prospective study was conducted in emergency department (non-percutaneous coronary intervention capable) between 1 August 2015 and 1 August 2016 with patients who presented to the emergency department and were diagnosed with ST-segment elevation myocardial infarction. All the times including door-in time, door to electrocardiogram time, door to emergency medical services activation time, door to defined percutaneous coronary intervention hospital, and finally door-in door-out time were measured and recorded.

Results:

During the study period, 135 of patients met the inclusion criteria and diagnosed with ST-elevation myocardial infarction and referred to another hospital for percutaneous coronary intervention. When the median values (interquartile range of 25%–75%) of the time periods are examined, it is found door-in door-out time was 55 (43–74) min. It was found that the number of patients meeting the recommended duration of door-in door-out (30 min or less) was 12 (8.9%). Of the remaining 123 patients (91.1%), door-in door-out times were found to be over 30 min.

Conclusion:

In conclusion, our study showed that compliance with door-in door-out time is very poor and is far behind to met the criteria which is recommended by current guidelines.

Thrombectomy for Acute Ischemic Stroke: Recent Insights and Future Directions

PURPOSE OF REVIEW

Mechanical thrombectomy has become the standard of care for acute ischemic stroke with proximal large vessel occlusions (LVO). This article reviews recent research relating to thrombectomy.

RECENT FINDINGS

Thrombectomy for anterior circulation stroke with proximal LVO was first shown to be highly efficacious within 6 h of stroke onset, but "late-window" trials have further demonstrated efficacy until 24-h postonset in select patients with salvageable tissue. However, the concept of "time is brain" remains critical. Thrombectomy trials have further stimulated worldwide efforts to develop systems of care for rapid treatment of eligible patients. Thrombectomy is cost-effective and likely to have long-term efficacy for both disability and mortality outcomes. Thrombectomy is a highly efficacious acute stroke therapy. Enduring uncertainties include efficacy in patients with premorbid disability, posterior circulation, or more distal occlusions; use of bridging thrombolysis; and optimal techniques to achieve consistent revascularization and address tandem occlusions or stenoses.

Implementation of a Regional Network for ST-Segment-Elevation Myocardial Infarction (STEMI) Care and 30-Day Mortality in a Low- to Middle-Income City in Brazil: Findings From Salvador's STEMI Registry (RESISST)

Background

Few data exist on regional systems of care for the treatment of ST‐segment–elevation myocardial infarction (STEMI) in developing countries. Our objective was to describe temporal trends in 30‐day mortality and identify predictors of mortality among STEMI patients enrolled in a prospective registry in Brazil.

Methods and Results

From January 2011 to June 2013, 520 patients who received initial STEMI care at 23 nonspecialized public health units or hospitals, some of whom were transferred to a public cardiology referral center, were identified through a regional STEMI network supported by telemedicine and the local prehospital emergency medical service. We stratified patients into five 6‐month periods based on presentation date. Mean age (±SD) of patients was 62.0 (±12.2) years, and 55.6% were men. The mean Global Registry of Acute Coronary Events (GRACE) score was 145 (±34). Overall mortality at 30 days was 15.0%. Use of dual antiplatelet therapy and statins increased significantly from baseline (January 2011) to period 5 (June 2013): 61.8% to 93.6% (P<0.001) and 60.4% to 79.7% (P<0.001), respectively. Rates of primary reperfusion also increased (29.1%–53.8%; P<0.001), and more patients were transferred to the referral center (44.7%–76.3%; P=0.001). Thirty‐day mortality rates decreased from 19.8% to 5.1% (P<0.001). In multivariable analysis, factors independently associated with 30‐day mortality were higher GRACE score, history of previous stroke, lack of transfer to the referral center, and lack of use of optimized medical therapy.

Conclusions

Implementation of a regional STEMI system was associated with lower mortality and higher use of evidence‐based therapies.

Comprehensive electrocardiogram-to-device time for primary percutaneous coronary intervention in ST-segment elevation myocardial infarction: A report from the American Heart Association mission: Lifeline program

BACKGROUND

Assessing hospital-related network-level primary percutaneous coronary intervention (PCI) performance for ST-segment elevation myocardial infarction (STEMI) is challenging due to differential time-to-treatment metrics based on location of diagnostic electrocardiogram (ECG) for STEMI.

METHODS

STEMI patients undergoing primary PCI at 588 PCI-capable hospitals in AHA Mission: Lifeline (2008-2013) were categorized by initial STEMI identification location: PCI-capable hospitals (Group 1); pre-hospital setting (Group 2); and non-PCI-capable hospitals (Group 3). Patient-specific time-to-treatment categories were converted to minutes ahead of or behind their group-specific mean; average time-to-treatment difference for all patients at a given hospital was termed comprehensive ECG-to-device time. Hospitals were then stratified into tertiles based on their comprehensive ECG-to-device times with negative values below the mean representing shorter (faster) time intervals.

RESULTS

Of 117,857 patients, the proportion in Groups 1, 2, and 3 were 42%, 33%, and 25%, respectively. Lower rates of heart failure and cardiac arrest at presentation are noted within patients presenting to high-performing hospitals. Median comprehensive ECG-to-device time was shortest at -9 minutes (25th, 75th percentiles: -13, -6) for the high-performing hospital tertile, 1 minute (-1, 3) for middle-performing, and 11 minutes (7, 16) for low-performing. Unadjusted rates of in-hospital mortality were 2.3%, 2.6%, and 2.7%, respectively, but the adjusted risk of in-hospital mortality was similar across tertiles.

CONCLUSIONS

Comprehensive ECG-to-device time provides an integrated hospital-related network-level assessment of reperfusion timing metrics for primary PCI, regardless of the location for STEMI identification; further validation will delineate how this metric can be used to facilitate STEMI care improvements.

Regional "Call 911" Emergency Department Protocol to Reduce Interfacility Transfer Delay for Patients With ST-Segment-Elevation Myocardial Infarction

BACKGROUND

We evaluated the first-medical-contact-to-balloon (FMC2B) time after implementation of a "Call 911" protocol for ST-segment-elevation myocardial infarction (STEMI) interfacility transfers in a regional system.

METHODS AND RESULTS

This is a retrospective cohort study of consecutive patients with STEMI requiring interfacility transfer from a STEMI referring hospital, to one of 35 percutaneous coronary intervention-capable STEMI receiving centers (SRCs). The Call 911 protocol allows the referring physician to activate 911 to transport a patient with STEMI to the nearest SRC for primary percutaneous coronary intervention. Patients with interfacility transfers were identified over a 4-year period (2011-2014) from a registry to which SRCs report treatment and outcomes for all patients with STEMI transported via 911. The primary outcomes were median FMC2B time and the proportion of patients achieving the 120-minute goal. FMC2B for primary 911 transports were calculated to serve as a system reference. There were 2471 patients with STEMI transferred to SRCs by 911 transport during the study period, of whom 1942 (79%) had emergent coronary angiography and 1410 (73%) received percutaneous coronary intervention. The median age was 61 years (interquartile range [IQR] 52-71) and 73% were men. The median FMC2B time was 111 minutes (IQR 88-153) with 56% of patients meeting the 120-minute goal. The median STEMI referring hospital door-in-door-out time was 53 minutes (IQR 37-89), emergency medical services transport time was 9 minutes (IQR 7-12), and SRC door-to-balloon time was 44 minutes (IQR 32-60). For primary 911 patients (N=4827), the median FMC2B time was 81 minutes (IQR 67-97).

CONCLUSIONS

Using a Call 911 protocol in this regional cardiac care system, patients with STEMI requiring interfacility transfers had a median FMC2B time of 111 minutes, with 56% meeting the 120-minute goal.

Association of Rapid Care Process Implementation on Reperfusion Times Across Multiple ST-Segment-Elevation Myocardial Infarction Networks

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.

Improving Transfer Times for Acute Ischemic Stroke Patients to a Comprehensive Stroke Center

BACKGROUND AND OBJECTIVE

The transfer of acute ischemic stroke (AIS) patients to a comprehensive stroke center (CSC) must be rapid. Delays pose an obstacle to time-sensitive stroke treatments and, therefore, increase the likelihood of exclusion from endovascular stroke therapy. This study aims to evaluate the impact of the Stroke Rescue Program, with its goal of minimizing interfacility transfer delays and increasing the number of transport times completed within 60 minutes.

METHODS

The Stroke Rescue Program was initiated to facilitate the rapid transfer of AIS patients from regional primary stroke centers (PSCs) to the network's CSC. The transfer process was divided into 3 time elements: transport 1 time (initial phone call from the PSC until emergency medical service [EMS] arrival at the PSC), emergency department (ED) time (EMS PSC arrival to PSC departure), and transport 2 time (PSC departure to CSC arrival). The total transport time target was set at less than 60 minutes. Protocols and procedures were implemented with a focus on decreasing the ED time.

RESULTS

Comparing baseline (preimplementation) quarter (n = 21) to postproject quarter (1 year later, n = 31), the percent transported within 60 minutes increased from 62% to 81%. A statistically significant improvement was seen for both median ED time (23 minutes versus 14 minutes; U = 171, P < .01) and median total transport time (56 minutes versus 44 minutes; U = 199, P < .05).

CONCLUSION

Interfacility transfer protocols minimizing the time paramedics spend in a PSC ED can significantly reduce total transfer time to a comprehensive stroke center.

Outcomes following emergent open repair for thoracic aortic dissection are improved at higher volume centers in direct admissions and transfers

BACKGROUND

The purpose of this study is (1) to define the proportion of patients undergoing emergent open repair of thoracic aortic dissection admitted directly through the emergency room versus those transferred from outside hospitals and (2) to determine if a volume-outcomes relationship exists for those patients across admission types.

METHODS

De-identified patient-level data was obtained from the Nationwide Inpatient Sample (2004-2008). Patients undergoing emergent aortic surgery for thoracic aortic dissection (n = 1,507) were identified by ICD-9 codes and stratified by annual center volume into low volume (≤5 cases/year) (n = 963; 63.9 %), intermediate volume (6-10 cases/year) (n = 370; 24.5 %), and high volume (≥11 cases/year) (n = 174; 11.6 %) groups. The analysis was further stratified by admission type: direct admission (DA), transfer admission (TA), and other. The primary outcome was in-hospital mortality. Multivariate logistic regression analysis was performed comparing outcomes between high vs low and high vs intermediate volume centers.

RESULTS

Overall in-hospital mortality was 21.8 % (n = 328/1,507). Absolute percent mortality at high volume centers was significantly lower (12.6 %) than at medium (20.6 %) and low volume (23.9 %) centers. For DA patients, mortality was 10.6, 21.4, and 24.0 % for high, medium, and low volume centers respectively. For TA patients, mortality was 10.2, 12.7, and 23.5 % for high, medium, and low volume centers, respectively. Multivariate analysis suggested that patients in low volume center were more likely to die compared to high volume center (Odds Ratio 2.06, 95 % CI 1.25 - 3.38, p = 0.004). Admission source was not associated with increased mortality.

CONCLUSIONS

Direct admissions comprise the largest proportion of dissections regardless of volume strata, and they comprise the largest proportion in the low and intermediate volume cohorts. Admission to low volume center is an independent risk factor for increased mortality. Patients transferred to high volume centers from low volume centers have similar outcome as direct admits in terms of mortality.

Direct Transfer From the Referring Hospitals to the Catheterization Laboratory to Minimize Reperfusion Delays for Primary Percutaneous Coronary Intervention: Insights From the National Cardiovascular Data Registry

BACKGROUND

For patients with ST-segment-elevation myocardial infarction (STEMI) requiring interhospital transfer for primary percutaneous coronary intervention, direct transfer from the STEMI referral hospital to the catheterization laboratory (cath lab) at the STEMI receiving hospital may expedite reperfusion, but can be logistically challenging.

METHODS AND RESULTS

We studied 33,901 STEMI patients transferred for primary percutaneous coronary intervention in the Acute Coronary Treatment and Intervention Outcomes Network Registry-Get With The Guidelines from July 2008 to December 2012. The majority of patients were transferred directly to the cath lab (26,510 [78.2%]), and 7391 patients (21.8%) were transferred first to the hospital emergency department/ward. We observed significant interhospital variation in transfer patterns; only 21% of STEMI receiving hospitals routinely transferred >90% of STEMI patients to the cath lab directly. Compared with patients transferred first to the emergency department/ward, STEMI patients transferred to the cath lab had significantly lower first door-to-balloon times (median 191 versus 116 minutes, P<0.0001). After multivariable logistic regression, patients transferred directly to the cath lab also had lower adjusted mortality risk (odds ratio 0.58, 95% confidence interval 0.51-0.66, P<0.0001). Cardiogenic shock, heart failure signs/symptoms, and nonsystem reasons for reperfusion delay were present in 11%, 15%, and 28% of patients transferred first to the emergency department/ward, respectively. The association of direct cath lab transfer with lower mortality persisted after excluding patients with these reasons for delay to primary percutaneous coronary intervention (adjusted odds ratio 0.62, 95% confidence interval 0.46-0.84, P=0.002).

CONCLUSIONS

Direct transfer of STEMI patients to the cath lab for primary percutaneous coronary intervention was associated with significantly faster reperfusion and lower mortality risk compared with transfer first to the emergency department/ward.

Nationwide Analysis of Patients With ST-Segment–Elevation Myocardial Infarction Transferred for Primary Percutaneous Intervention

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.

Type III open tibia fractures: immediate antibiotic prophylaxis minimizes infection

OBJECTIVE

To examine the association between antibiotic timing and deep infection of type III open tibia fractures.

DESIGN

Retrospective prognostic study.

SETTING

Level 1 Trauma Center.

PATIENTS

The study population included 137 patients after exclusions for missing data (13), nonreconstructible limbs (9), and/or absence of 90-day outcome data (3).

INTERVENTION

An observational study of antibiotic timing.

MAIN OUTCOME MEASUREMENT

Deep infection within 90 days.

RESULTS

Age, smoking, diabetes, injury severity score, type IIIA versus 3B/C injury, and time to surgical debridement were not associated with infection on univariate analysis. Greater than 5 days to wound coverage (P < 0.001) and greater than 66 minutes to antibiotics (P < 0.01) were univariate predictors of infection. Multivariate analysis found wound coverage beyond 5 days [odds ratio, 7.39; 95% confidence interval (CI), 2.33-23.45; P < 0.001] and antibiotics beyond 66 minutes (odds ratio, 3.78; 95% CI, 1.16-12.31; P = 0.03) independently predicted infection. Immediate antibiotics and early coverage limited the infection rate (1 of 36, 2.8%) relative to delay in either factor (6 of 59, 10.2%) or delay in both factors (17 of 42, 40.5%).

CONCLUSIONS

Time from injury to antibiotics and to wound coverage independently predict infection of type III open tibia fractures. Both should be achieved as early as possible, with coverage being dependent on the condition of the wound. Given the relatively short therapeutic window for antibiotic prophylaxis (within an hour of injury), prehospital antibiotics may substantially improve outcomes for severe open fractures.

LEVEL OF EVIDENCE

Prognostic Level II. See Instructions for Authors for a complete description of levels of evidence.

Relationship of the distance between non-PCI hospitals and primary PCI centers, mode of transport, and reperfusion time among ground and air interhospital transfers using NCDR's ACTION Registry-GWTG: a report from the American Heart Association Mission: Lifeline Program

BACKGROUND

ST-segment myocardial infarction patients frequently present to non-percutaneous coronary intervention (PCI) hospitals and require interhospital transfer for primary PCI. The effect of distance and mode of transport to the PCI center and the frequency that recommended primary PCI times are met are not clear.

METHODS AND RESULTS

Data from the ACTION Registry(®)-GWTG™ were used to determine the distance between the Non-PCI and PCI center and first door time to balloon time based on transfer mode (ground and air) for patients having interhospital transfer for primary PCI. From July 1, 2008, to December 31, 2012, 17 052 ST-segment myocardial infarction patients were transferred to 413 PCI hospitals. The median distance from the non-PCI hospital to the primary PCI center was 31.9 miles (Q1, Q3: 19.1, 47.9; ground 25.2 miles; air 43.9 miles; P<0.001). At distances <40 miles, ground transport was the primary transport method, whereas at distances >40 miles air transport predominanted. Median first door time to balloon time time for patients transferred for primary PCI was 118 minutes (Q1, Q3: 95 152), with time for patients transported by air significantly longer (median 124 versus 113 minutes; respectively, P<0.001) than for patients transported by ground. Fifty-three percent of patients had a first door time to balloon time ≤120 minutes, with only 20% ≤90 minutes. A first door time to balloon time ≤120 minutes was more likely in ground than in air transport patients (57.0% versus 45.6%; P<0.001).

CONCLUSIONS

Interhospital transfer for primary PCI is associated with prolonged reperfusion times. These delays should prompt increased consideration of fibrinolytic therapy, emergency medical services hospital bypass protocols, and improved systems of care for ST-segment myocardial infarction patients requiring transfer.

Minimizing transfer time to an ST segment elevation myocardial infarction-receiving center: a modified Delphi consensus

Of patients with ST segment elevation myocardial infarction (STEMI), approximately two thirds present to a hospital not capable of percutaneous coronary intervention. Transfer to a STEMI-receiving center delays time to reperfusion in patients with STEMI, but factors that affect this delay have not been well studied. We performed a 3-round modified Delphi study to identify system practices that minimize transfer time to a STEMI-receiving center. A comprehensive literature review was used to identify candidate system practices. Emergency medical services, emergency medicine, and cardiology experts were invited to participate. Consensus was defined as 80% agreement that a variable was "very important (5)" or "important (4)" with a mean score ≥ 4.25 or 80% agreement that a variable was "not important (1)" or "somewhat important (2)" with a mean score ≤ 1.75. In round 1, participants rated the candidate items and suggested additional items. Individual feedback was provided, and participants discussed items via conference calls before rating them again in round 2. In round 3, participants ranked the consensus items from rounds 1-2 from most to least important, and the mean score for each item was calculated. Of the 98 experts invited, 29 participated in round 1, 22 in round 2, and 14 in round 3. Participants identified 18 system practices that they agree are critical in minimizing transfer time to STEMI-receiving centers, with the most important being performance of a prehospital electrocardiogram and having established transfer protocols. These factors should be considered in the development of STEMI systems of care.

The quality of antiplatelet and anticoagulant medication administration among ST-segment elevation myocardial infarction patients transferred for primary percutaneous coronary intervention

BACKGROUND

Timely and appropriate use of antiplatelet and anticoagulant therapies has been shown to improve outcomes among ST-segment elevation myocardial infarction (STEMI) patients but has not been well described in patients transferred for primary percutaneous coronary intervention (PCI).

METHODS

We examined 16,801 (26%) transfer and 47,329 direct-arrival STEMI patients treated with primary PCI at 441 Acute Coronary Treatment and Intervention Outcomes Network Registry-Get With The Guidelines hospitals. Medication use was compared between transfer and direct-arrival patients to determine if these therapies were delayed or dosed in excess.

RESULTS

Although transfer patients were more likely to receive antiplatelet and anticoagulant therapies before catheterization, they had longer delays to initiation of heparin (35 vs. 25 minutes), clopidogrel (119 vs. 84 minutes), and glycoprotein IIb/IIIa inhibitor (107 vs. 60 minutes, P < .0001 for both). Administration of low-molecular-weight heparin and glycoprotein IIb/IIIa inhibitor at the STEMI-referring hospital was associated with longer delays to reperfusion compared with deferred administration at the STEMI-receiving hospital, whereas early use of unfractionated heparin was not. Among treated patients, those transferred were more likely to receive excess heparin dosing (adjusted odds ratio [OR] 1.28 [95% CI 1.04-1.58] for unfractionated heparin, adjusted OR 1.54 [95% CI 1.09-2.18] for low-molecular-weight heparin) and are associated with higher risks of major bleeding complications (adjusted OR 1.10, 95% CI 1.03-1.17).

CONCLUSIONS

ST-segment elevation myocardial infarction patients transferred for primary PCI in community practice are at risk for delayed and excessively dosed antithrombotic therapy, highlighting the need for continued quality improvement to maximize the appropriate use of these important adjunctive therapies.

Impact of mode of transportation on time to treatment in patients transferred for primary percutaneous coronary intervention

BACKGROUND

Patients suffering ST segment elevation myocardial infarction (STEMI) requiring transfer from a non-percutaneous coronary intervention (PCI) hospital to a PCI-capable hospital often have prolonged treatment times.

OBJECTIVE

For STEMI transfers, we changed from air to ground transportation, and carefully documented the impact on treatment times.

METHODS

This is a retrospective report between two hospitals within one STEMI system. The referring facility controls both air and ground ambulance services. After a 2-year period of air transportation with suboptimal treatment times, the referring hospital switched to ground transport. All pertinent times were carefully recorded and are reported here.

RESULTS

There were 43 patients included, approximately half were transported by air and half by ground. Comparing our early experience (air only) vs. our later experience (predominantly ground-transported patients), median door-in-door-out (DIDO) time at the first facility was 70 min vs. 35 min (p<0.001), median transport time was 20 min vs. 30 min (p<0.001), and median first medical contact to balloon time (FMC2b time) was 123 min vs. 90 min (p<0.001). After changing mode of transport, achievement of the national FMC2b time goal of <120 min rose from 47% to 92% (p<0.001).

CONCLUSIONS

We document a significantly reduced DIDO and FMC2b time after changing mode of transportation for STEMI patients transferred 30 miles for primary PCI. Utilizing ground rather than air transportation, the median FMC2b time was reduced from 123 to 90 min. We show that mode of transportation can dramatically reduce both DIDO time and FMC2b time.

Withholding and termination of resuscitation of adult cardiopulmonary arrest secondary to trauma: resource document to the joint NAEMSP-ACSCOT position statements

In the setting of traumatic cardiopulmonary arrest, protocols that direct emergency medical service (EMS) providers to withhold or terminate resuscitation, when clinically indicated, have the potential to decrease unnecessary use of warning lights and sirens and save valuable public health resources. Protocols to withhold resuscitation should be based on the determination that there are no obvious signs of life, the injuries are obviously incompatible with life, there is evidence of prolonged arrest, and there is a lack of organized electrocardiographic activity. Termination of resuscitation is indicated when there are no signs of life and no return of spontaneous circulation despite appropriate field EMS treatment that includes minimally interrupted cardiopulmonary resuscitation. Further research is needed to determine the appropriate duration of cardiopulmonary resuscitation before termination of resuscitation and the proper role of direct medical oversight in termination of resuscitation protocols. This article is the resource document to the position statements, jointly endorsed by the National Association of EMS Physicians and the American College of Surgeons' Committee on Trauma, on withholding and termination of resuscitation in traumatic cardiopulmonary arrest.

Emergency medical services as a strategy for improving ST-elevation myocardial infarction system treatment times

BACKGROUND

Reducing delays in time to treatment is a key goal of ST-elevation myocardial infarction (STEMI) emergency care. Emergency medical services (EMS) are a critical component of the STEMI chain of survival.

STUDY OBJECTIVE

We sought to assess the impact of the careful integration of EMS as a strategy for improving systemic treatment times for STEMI.

METHODS

We conducted a study of all 747 nontransfer STEMI patients who underwent primary percutaneous coronary intervention (PCI) in Dallas County, Texas from October 1, 2010 through December 31, 2011. EMS leaders from 24 agencies and 15 major PCI receiving hospitals collected and shared common, de-identified patient data. We used 15 months of data to develop a generalized linear regression to assess the impact of EMS on two treatment metrics-hospital door to balloon (D2B) time, and symptom onset to arterial reperfusion (SOAR) time, a new metric we developed to assess total treatment times.

RESULTS

We found statistically significant reductions in median D2B (11.1-min reduction) and SOAR (63.5-min reduction) treatment times when EMS transported patients to the receiving facility, compared to self-transport. In addition, when trained EMS paramedics field-activated the cardiac catheterization laboratory using predefined specified protocols, D2B times were reduced by 38% (43 min) after controlling for confounding variables, and field activation was associated with a 21.9% reduction (73 min) in the mean SOAR time (both with p < 0.001).

CONCLUSION

Active EMS engagement in STEMI treatment was associated with significantly lower D2B and total coronary reperfusion times.

Clinical pathway: helicopter scene STEMI protocol to facilitate long-distance transfer for primary PCI

BACKGROUND

The latest American College of Cardiology/American Heart Association guidelines recommend primary percutaneous coronary intervention (PCI) in acute ST-elevation myocardial infarction (STEMI) patients within 90 minutes from presentation to the emergency room. For interhospital transfers, the most recent PCI guidelines recommend first medical contact-to-device times ≤120 minutes. Although PCI-capable hospitals have improved door-to-balloon times, many patients present to non-PCI-capable facilities and have been excluded from national quality measures.

METHODS

In our acute myocardial infarction network, not only do we enable non-PCI hospitals to transfer STEMI patients but empower outside emergency medical services (EMS) to activate the catheterization laboratory team with a burst page and transfer STEMI patients directly from the scene. Data on patient characteristics, outcomes, and time elements were collected for "scene STEMI" patients who circumvented outlying rural non-PCI hospitals and are presented in this case series.

RESULTS

From December 2007 to November 2010, 22 STEMI patients with higher than average acuity were transported by helicopter directly to our medical center for primary PCI. Median distance from the scene to our medical center was 47 miles [25th to 75th interquartile range (IQR) = 39-71 miles]. Median EMS-to-balloon time was 120 minutes (IQR = 111-134 minutes). There were no false activations by EMS. In comparison, our median time for interhospital STEMI transfers (N = 335) was 145 minutes (IQR = 121-186 minutes) from 2007 to 2009.

CONCLUSIONS

In our single-center experience, 22 scene STEMI patients were diagnosed and appropriately triaged by EMS to our center for primary PCI. Our data show feasibility of an EMS-activated STEMI network over long distances with good reperfusion times.

The incomplete infrastructure for interhospital patient transfer

OBJECTIVE

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

DATA SOURCE

Narrative review of medical and organizational literature.

SUMMARY

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

CONCLUSION

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

Setting Up a Population-Based Program to Optimize ST-Segment Elevation Myocardial Infarction Care

The development of ST-segment elevation myocardial infarction (STEMI) systems of care at the city, region, or nation levels has not only improved the speed of reperfusion but also enhanced the reach of primary angioplasty to areas far from percutaneous coronary intervention (PCI) centers. Setting up a STEMI system of care is a sophisticated process that requires a solid PCI hospital and emergency medical services infrastructure, disciplined collaboration, and a focus on outcomes measurement and continuous quality improvement. This article reviews the accumulated evidence supporting the development of STEMI systems of care and offers practical insights into this process.

Comparative Effectiveness of Population Interventions to Improve Access to Reperfusion for ST-Segment–Elevation Myocardial Infarction in Australia

Background—

Improving timely access to reperfusion is a major goal of ST-segment–elevation myocardial infarction care. We sought to compare the population impact of interventions proposed to improve timely access to reperfusion therapy in Australia.

Methods and Results—

Australian hospitals, population, and road network data were integrated using Geographical Information Systems. Hospitals were classified into those that provided primary percutaneous coronary intervention (PPCI) or fibrinolysis. Population impact of interventions proposed to improve timely access to reperfusion (PPCI, fibrinolysis, or both) were modeled and compared. Timely access to reperfusion was defined as the proportion of the population capable of reaching a fibrinolysis facility ≤60 minutes or a PPCI facility ≤120 minutes from emergency medical services activation. The majority (93.2%) of the Australian population has timely access to reperfusion, mainly (53%) through fibrinolysis. Only 40.2% of the population had timely access to PPCI, and access to PPCI services is particularly limited in regional and nonexistent in remote areas. Optimizing the emergency medical services’ response or increasing PPCI services resulted in marginal improvement in timely access (1.8% and 3.7%, respectively). Direct transport to PPCI facilities and interhospital transfer for PPCI improves timely access to PPCI for 19.4% and 23.5% of the population, respectively. Prehospital fibrinolysis markedly improved access to timely reperfusion in regional and remote Australia.

Conclusions—

Significant gaps in timely provision of reperfusion remain in Australia. Systematic implementation of changes in service delivery has potential to improve timely access to PPCI for a majority of the population and improve access to fibrinolysis to those living in regional and remote areas.

National performance on door-in to door-out time among patients transferred for primary percutaneous coronary intervention

BACKGROUND

Delays in treatment time are commonplace for patients with ST-segment elevation acute myocardial infarction who must be transferred to another hospital for percutaneous coronary intervention. Experts have recommended that door-in to door-out (DIDO) time (ie, time from arrival at the first hospital to transfer from that hospital to the percutaneous coronary intervention hospital) should not exceed 30 minutes. We sought to describe national performance in DIDO time using a new measure developed by the Centers for Medicare & Medicaid Services.

METHODS

We report national median DIDO time and examine associations with patient characteristics (age, sex, race, contraindication to fibrinolytic therapy, and arrival time) and hospital characteristics (number of beds, geographic region, location [rural or urban], and number of cases reported) using a mixed effects multivariable model.

RESULTS

Among 13,776 included patients from 1034 hospitals, only 1343 (9.7%) had a DIDO time within 30 minutes, and DIDO exceeded 90 minutes for 4267 patients (31.0%). Mean estimated times (95% CI) to transfer based on multivariable analysis were 8.9 (5.6-12.2) minutes longer for women, 9.1 (2.7-16.0) minutes longer for African Americans, 6.9 (1.6-11.9) minutes longer for patients with contraindication to fibrinolytic therapy, shorter for all age categories (except >75 years) relative to the category of 18 to 35 years, 15.3 (7.3-23.5) minutes longer for rural hospitals, and 14.4 (6.6-21.3) minutes longer for hospitals with 9 or fewer transfers vs 15 or more in 2009 (all P < .001).

CONCLUSION

Among patients presenting to emergency departments and requiring transfer to another facility for percutaneous coronary intervention, the DIDO time rarely met the recommended 30 minutes.

Circulation: Cardiovascular Quality and Outcomes Editors' Picks

The following are highlights from the new series, Circulation: Cardiovascular Quality and Outcomes Topic Review. This series will summarize the most important manuscripts, as selected by the editors, that have published in the Circulation portfolio. The objective of this new series is to provide our readership with a timely, comprehensive selection of important papers that are relevant to the quality and outcomes and general cardiology audience. The studies included in this article represent the most significant research in the area of ST-segment elevation myocardial infarction care and address improvements in the timeliness of care, strategies for initial treatment—particularly with respect to reperfusion therapies—and trends.