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Winkler K, McKinney J, Reale C, Anders S, Rubenstein M, Cavagnini L, Crowe R, Ward MJ. A Qualitative Analysis of Barriers to Evidence-Based Care in the Prehospital Management of Patients with Suspected Acute Coronary Syndrome. PREHOSP EMERG CARE 2024:1-9. [PMID: 38981118 DOI: 10.1080/10903127.2024.2372817] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2024] [Accepted: 06/20/2024] [Indexed: 07/11/2024]
Abstract
OBJECTIVES Prehospital electrocardiogram (ECG) and administration of aspirin are evidence-based strategies for patients with acute coronary syndrome (ACS). However, emergency medical services (EMS) compliance in patients with suspected ACS varies widely. We sought to understand the barriers to prehospital ECG acquisition and aspirin administration for patients with suspected ACS. METHODS In this qualitative study, we interviewed EMS clinicians at three geographically diverse United States (U.S.)-based EMS agencies. We interviewed practicing clinicians and quality and operations leaders at these agencies. Based on the Reach, Effectiveness, Adoption, Implementation, and Maintenance (RE-AIM) framework, interviews were recorded, transcribed, and analyzed using a grounded qualitative approach with open coding. The Systems Engineering Initiative for Patient Safety (SEIPS) framework and a constant comparison technique were used to identify and refine themes. RESULTS Twenty-five paramedics and 20 additional agency personnel participated. Median age was 41 (IQR: 34-51) years and 13 (29%) were female. Themes were organized using SEIPS and longitudinally through four phases of an EMS call. During the pre-arrival phase, staffing challenges, training quality, and dispatch may anchor EMS clinicians on a diagnosis. During the diagnosis and treatment phase, safety and communication barriers may take priority over care delivery. Additionally, EMS clinicians must allocate assets (e.g. whether to send an advanced life support unit) and financial resources; veteran EMS clinicians identified their experience whereas newer clinicians cited their recent education when making these decisions. Also, diagnostic uncertainty due to increasing patient complexity and atypical presentations contributed to diagnostic errors. During the response and transport phase, the scope of practice limits the use and interpretation of the ECG, with clinicians reporting that liberal use of ECG led to more rapid decision-making. Finally, in the after phase, personnel reported the "psychologically taxing" nature of the job contributing to biases, bad habits, and burnout. Performance feedback was desired for personal development, though currently perceived as infrequent and punitive. CONCLUSIONS Multiple, interrelated themes underscored the complexities of delivering evidence-based care to prehospital patients with ACS. Education in ECG interpretation, resource allocation, bias, and enhancing feedback may serve as strategies to address the identified barriers.
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Affiliation(s)
- Kailey Winkler
- Department of Emergency Medicine, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Jared McKinney
- Department of Emergency Medicine, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Carrie Reale
- Center for Research and Innovation in Systems Safety, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Shilo Anders
- Center for Research and Innovation in Systems Safety, Vanderbilt University Medical Center, Nashville, Tennessee
- Department of Biomedical Informatics, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Melissa Rubenstein
- Department of Emergency Medicine, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Lauren Cavagnini
- Department of Emergency Medicine, Vanderbilt University Medical Center, Nashville, Tennessee
| | | | - Michael J Ward
- Department of Emergency Medicine, Vanderbilt University Medical Center, Nashville, Tennessee
- Department of Biomedical Informatics, Vanderbilt University Medical Center, Nashville, Tennessee
- Geriatric Research, Education, and Clinical Center (GRECC), Tennessee Valley Healthcare System, Nashville, Tennessee
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2
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Yang J, Zhao Y, Wang J, Ma L, Xu H, Leng W, Wang Y, Wang Y, Wang Z, Gao X, Yang Y. Current status of emergency medical service use in ST-segment elevation myocardial infarction in China: Findings from China Acute Myocardial Infarction (CAMI) Registry. Int J Cardiol 2024; 406:132040. [PMID: 38614365 DOI: 10.1016/j.ijcard.2024.132040] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/05/2024] [Revised: 04/01/2024] [Accepted: 04/10/2024] [Indexed: 04/15/2024]
Abstract
BACKGROUND The mortality rate of myocardial infarction in China has increased dramatically in the past three decades. Although emergency medical service (EMS) played a pivotal role for the management of patients with ST-segment elevation myocardial infarction (STEMI), the corresponding data in China are limited. METHODS An observational analysis was performed in 26,305 STEMI patients, who were documented in China acute myocardial infarction (CAMI) Registry and treated in 162 hospitals from January 1st, 2013 to January 31th, 2016. We compared the differences such as demographic factors, social factors, medical history, risk factors, socioeconomic distribution and treatment strategies between EMS transport group and self-transport group. RESULTS Only 4336 patients (16.5%) were transported by EMS. Patients with symptom onset outside, out-of-hospital cardiac arrest and presented to province-level hospital were more likely to use EMS. Besides those factors, low systolic blood pressure, severe dyspnea or syncope, and high Killip class were also positively related to EMS activation. Notably, compared to self-transport, use of EMS was associated with a shorter prehospital delay (median, 180 vs. 245 min, P < 0.0001) but similar door-to-needle time (median, 45 min vs. 52 min, P = 0.1400) and door-to-balloon time (median, 105 min vs. 103 min, P = 0.1834). CONCLUSIONS EMS care for STEMI is greatly underused in China. EMS transport is associated with shorter onset-to-door time and higher rate of reperfusion, but not substantial reduction in treatment delays or mortality rate. Targeted efforts are needed to promote EMS use when chest pain occurs and to set up a unique regionalized STEMI network focusing on integration of prehospital care procedures in China. TRIAL REGISTRATION ClinicalTrials.gov (NCT01874691), retrospectively registered June 11, 2013.
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Affiliation(s)
- Jingang Yang
- Coronary Heart Disease Center, Department of Cardiology, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Science and Peking Union Medical College, Beijing, China
| | - Yanyan Zhao
- Medical Research and Biometrics Center, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Science and Peking Union Medical College, Beijing, China
| | - Jianyi Wang
- Coronary Heart Disease Center, Department of Cardiology, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Science and Peking Union Medical College, Beijing, China
| | - Liyuan Ma
- Coronary Heart Disease Center, Department of Cardiology, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Science and Peking Union Medical College, Beijing, China
| | - Haiyan Xu
- Coronary Heart Disease Center, Department of Cardiology, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Science and Peking Union Medical College, Beijing, China
| | - Wenxiu Leng
- Coronary Heart Disease Center, Department of Cardiology, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Science and Peking Union Medical College, Beijing, China
| | - Yang Wang
- Medical Research and Biometrics Center, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Science and Peking Union Medical College, Beijing, China
| | - Yan Wang
- Department of Cardiology, Xiamen Cardiovascular Hospital Xiamen University, Xia Men, Fujian Province, China
| | - Zhifang Wang
- Department of Cardiology, Xinxiang Central Hospital, Xinxiang, He Nan Province, China
| | - Xiaojin Gao
- Coronary Heart Disease Center, Department of Cardiology, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Science and Peking Union Medical College, Beijing, China.
| | - Yuejin Yang
- Coronary Heart Disease Center, Department of Cardiology, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Science and Peking Union Medical College, Beijing, China.
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Muharram FR, Multazam CECZ, Harmadha WS, Andrianto A, Salsabilla SA, Dakota I, Andriantoro H, Firman D, Montain MM, Prakoso R, Anggraeni D. Distribution of catheterisation laboratories in Indonesia 2017-2022: a nationwide survey. THE LANCET REGIONAL HEALTH. SOUTHEAST ASIA 2024; 26:100418. [PMID: 38764713 PMCID: PMC11101891 DOI: 10.1016/j.lansea.2024.100418] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/11/2023] [Revised: 02/06/2024] [Accepted: 04/24/2024] [Indexed: 05/21/2024]
Abstract
Background Geographical terrains of Indonesia pose a major hindrance to transportation. The difficulty of transportation affects the provision of acute time-dependent therapy such as percutaneous coronary intervention (PCI). Also, Indonesia's aging population would have a significant impact on the prevalence of acute coronary syndrome in the next decade. Therefore, the analysis and enhancement of cardiovascular care are crucial. The catheterisation laboratory performs PCI procedures. In the current study, we mapped the number and distribution of catheterisation laboratories in Indonesia. Methods A direct survey was used to collect data related to catheterisation laboratory locations in July 2022. The population data was sourced from the Ministry of Home Affairs. The recent growth of catheterisation laboratories was examined and evaluated based on geographical areas. The main instruments for comparing regions and changes throughout time are the ratio of catheterisation laboratories per 100,000 population and the Gini index (a measure of economic and healthcare inequality. Gini index ranges from 0 to 1, with greater values indicating more significant levels of inequality). Regression analysis was carried out to see how the number of catheterisation laboratories was affected by health demand (prevalence) and economic capacity (Gross Domestic Regional Product [GDRP] per Capita). Findings The number of catheterisation laboratories in Indonesia significantly increased from 181 to 310 during 2017-2022, with 44 of the 119 new labs built in an area that did not have one. Java has the most catheterisation laboratories (208, 67%). The catheterisation laboratory ratio in the provinces of Indonesia ranges from 0.0 in West Papua and Maluku to 4.46 in Jakarta; the median is 1.09 (IQR 0.71-1.18). The distribution remains a problem, as shown by the high catheterisation laboratory Gini index (0.48). Regression shows that distribution of catheterisation laboratories was significantly affected by GDRP and the prevalence of heart disease. Interpretation The number of catheterisation laboratories in Indonesia has increased significantly recently, however, maldistribution remains a concern. To improve Indonesia's cardiovascular emergency services, future development of catheterisation laboratories must be better planned considering the facility's accessibility and density. Funding Airlangga Research Fund - Universitas Airlangga.
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Affiliation(s)
- Farizal Rizky Muharram
- Department of Global Health and Social Medicine, Harvard Medical School, Boston, MA, USA
| | | | | | - Andrianto Andrianto
- Faculty of Medicine, Airlangga University, Soetomo General Hospital, Surabaya, Indonesia
| | | | - Iwan Dakota
- Department of Cardiology and Vascular Medicine, Faculty of Medicine, University of Indonesia, National Cardiovascular Centre Harapan Kita, West Jakarta, Indonesia
| | - Hananto Andriantoro
- Department of Cardiology and Vascular Medicine, Faculty of Medicine, University of Indonesia, National Cardiovascular Centre Harapan Kita, West Jakarta, Indonesia
| | - Doni Firman
- Department of Cardiology and Vascular Medicine, Faculty of Medicine, University of Indonesia, National Cardiovascular Centre Harapan Kita, West Jakarta, Indonesia
| | - Maya Marinda Montain
- Department of Cardiology and Vascular Medicine, Faculty of Medicine, University of Indonesia, National Cardiovascular Centre Harapan Kita, West Jakarta, Indonesia
| | - Radityo Prakoso
- Department of Cardiology and Vascular Medicine, Faculty of Medicine, University of Indonesia, National Cardiovascular Centre Harapan Kita, West Jakarta, Indonesia
| | - Dilla Anggraeni
- Department of Cardiology and Vascular Medicine, Faculty of Medicine, University of Indonesia, National Cardiovascular Centre Harapan Kita, West Jakarta, Indonesia
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Stevenson MJ, Kenigsberg BB, Singam NSV, Papolos AI. Shock Teams: A Contemporary Review. Curr Cardiol Rep 2023; 25:1657-1663. [PMID: 37861851 DOI: 10.1007/s11886-023-01983-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 10/11/2023] [Indexed: 10/21/2023]
Abstract
PURPOSE OF REVIEW Cardiogenic shock (CS) is a time-sensitive and often fatal condition. To address this issue, many centers have developed multidisciplinary shock teams with a common goal of expediting the recognition and treatment of CS. In this review, we examine the mission, structure, implementation, and outcomes reported by these early shock teams. RECENT FINDINGS To date, there have been four observational shock team analyses, each providing unique insight into the utility of the shock team. The limited available data supports that shock teams are associated with improved CS mortality. However, there is considerable operational heterogeneity among shock teams, and randomized data assessing their value and best practices in both local and regional care models are needed.
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Affiliation(s)
- Margaret J Stevenson
- Department of Critical Care and Division of Cardiology, MedStar Washington Hospital Center, 110 Irving St NW, Suite 1A-27, Washington, DC, 20010, USA
| | - Benjamin B Kenigsberg
- Department of Critical Care and Division of Cardiology, MedStar Washington Hospital Center, 110 Irving St NW, Suite 1A-27, Washington, DC, 20010, USA
| | - Narayana Sarma V Singam
- Department of Critical Care and Division of Cardiology, MedStar Washington Hospital Center, 110 Irving St NW, Suite 1A-27, Washington, DC, 20010, USA
| | - Alexander I Papolos
- Department of Critical Care and Division of Cardiology, MedStar Washington Hospital Center, 110 Irving St NW, Suite 1A-27, Washington, DC, 20010, USA.
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Tern PJW, Vaswani A, Yeo KK. Identifying and Solving Gaps in Pre- and In-Hospital Acute Myocardial Infarction Care in Asia-Pacific Countries. Korean Circ J 2023; 53:594-605. [PMID: 37653695 PMCID: PMC10475691 DOI: 10.4070/kcj.2023.0169] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2023] [Accepted: 06/25/2023] [Indexed: 09/02/2023] Open
Abstract
Acute myocardial infarction (AMI) is a major cause of morbidity and mortality in the Asia-Pacific region, and mortality rates differ between countries in the region. Systems of care have been shown to play a major role in determining AMI outcomes, and this review aims to highlight pre-hospital and in-hospital system deficiencies and suggest possible improvements to enhance quality of care, focusing on Korea, Japan, Singapore and Malaysia as representative countries. Time to first medical contact can be shortened by improving patient awareness of AMI symptoms and the need to activate emergency medical services (EMS), as well as by developing robust, well-coordinated and centralized EMS systems. Additionally, performing and transmitting pre-hospital electrocardiograms, algorithmically identifying patients with high risk AMI and developing hospital networks that appropriately divert such patients to percutaneous coronary intervention-capable hospitals have been shown to be beneficial. Within the hospital environment, developing and following clinical practice guidelines ensures that treatment plans can be standardised, whilst integrated care pathways can aid in coordinating care within the healthcare institution and can guide care even after discharge. Prescription of guideline directed medical therapy for secondary prevention and patient compliance to medications can be further optimised. Finally, the authors advocate for the establishment of more regional, national and international AMI registries for the formal collection of data to facilitate audit and clinical improvement.
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Affiliation(s)
- Paul Jie Wen Tern
- Department of Cardiology, National Heart Centre Singapore, Singapore
| | - Amar Vaswani
- Department of Cardiology, National Heart Centre Singapore, Singapore
| | - Khung Keong Yeo
- Department of Cardiology, National Heart Centre Singapore, Singapore.
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Osho A, Fernandes MF, Poudel R, de Lemos J, Hong H, Zhao J, Li S, Thomas K, Kikuchi DS, Zegre-Hemsey J, Ibrahim N, Shah NS, Hollowell L, Tamis-Holland J, Granger CB, Cohen M, Henry T, Jacobs AK, Jollis JG, Yancy CW, Goyal A. Race-Based Differences in ST-Segment-Elevation Myocardial Infarction Process Metrics and Mortality From 2015 Through 2021: An Analysis of 178 062 Patients From the American Heart Association Get With The Guidelines-Coronary Artery Disease Registry. Circulation 2023; 148:229-240. [PMID: 37459415 DOI: 10.1161/circulationaha.123.065512] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/07/2023] [Accepted: 06/13/2023] [Indexed: 07/20/2023]
Abstract
BACKGROUND Systems of care have been developed across the United States to standardize care processes and improve outcomes in patients with ST-segment-elevation myocardial infarction (STEMI). The effect of contemporary STEMI systems of care on racial and ethnic disparities in achievement of time-to-treatment goals and mortality in STEMI is uncertain. METHODS We analyzed 178 062 patients with STEMI (52 293 women and 125 769 men) enrolled in the American Heart Association Get With The Guidelines-Coronary Artery Disease registry between January 1, 2015, and December 31, 2021. Patients were stratified into and outcomes compared among 3 racial and ethnic groups: non-Hispanic White, Hispanic White, and Black. The primary outcomes were the proportions of patients achieving the following STEMI process metrics: prehospital ECG obtained by emergency medical services; hospital arrival to ECG obtained within 10 minutes for patients not transported by emergency medical services; arrival-to-percutaneous coronary intervention time within 90 minutes; and first medical contact-to-device time within 90 minutes. A secondary outcome was in-hospital mortality. Analyses were performed separately in women and men, and all outcomes were adjusted for age, comorbidities, acuity of presentation, insurance status, and socioeconomic status measured by social vulnerability index based on patients' county of residence. RESULTS Compared with non-Hispanic White patients with STEMI, Hispanic White patients and Black patients had lower odds of receiving a prehospital ECG and achieving targets for door-to-ECG, door-to-device, and first medical contact-to-device times. These racial disparities in treatment goals were observed in both women and men, and persisted in most cases after multivariable adjustment. Compared with non-Hispanic White women, Hispanic White women had higher adjusted in-hospital mortality (odds ratio, 1.39 [95% CI, 1.12-1.72]), whereas Black women did not (odds ratio, 0.88 [95% CI, 0.74-1.03]). Compared with non-Hispanic White men, adjusted in-hospital mortality was similar in Hispanic White men (odds ratio, 0.99 [95% CI, 0.82-1.18]) and Black men (odds ratio, 0.96 [95% CI, 0.85-1.09]). CONCLUSIONS Race- or ethnicity-based disparities persist in STEMI process metrics in both women and men, and mortality differences are observed in Hispanic White compared with non-Hispanic White women. Further research is essential to evolve systems of care to mitigate racial differences in STEMI outcomes.
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Affiliation(s)
- Asishana Osho
- Department of Surgery, Division of Cardiac Surgery, Massachusetts General Hospital, Boston (A.O.)
| | | | - Ram Poudel
- American Heart Association, Dallas, TX (R.P., H.H., J.Z., S.L., K.T., L.H.)
| | - James de Lemos
- University of Texas Southwestern Medical Center, Dallas (J.d.L.)
| | - Haoyun Hong
- American Heart Association, Dallas, TX (R.P., H.H., J.Z., S.L., K.T., L.H.)
| | - Juan Zhao
- American Heart Association, Dallas, TX (R.P., H.H., J.Z., S.L., K.T., L.H.)
| | - Shen Li
- American Heart Association, Dallas, TX (R.P., H.H., J.Z., S.L., K.T., L.H.)
| | - Kathie Thomas
- American Heart Association, Dallas, TX (R.P., H.H., J.Z., S.L., K.T., L.H.)
| | - Daniel S Kikuchi
- Osler Medical Residency, Johns Hopkins Hospital, Baltimore, MD (D.S.K.)
| | | | - Nasrien Ibrahim
- Harvard T.H. Chan School of Public Health, Boston, MA (N.I.)
| | - Nilay S Shah
- Department of Medicine, Division of Cardiology, Northwestern University Medical School, Chicago, IL (N.S.S., C.W.Y.)
| | - Lori Hollowell
- American Heart Association, Dallas, TX (R.P., H.H., J.Z., S.L., K.T., L.H.)
| | | | | | | | - Timothy Henry
- The Christ Hospital Heart and Vascular Institute, Cincinnati, OH (T.H., J.G.J.)
| | | | - James G Jollis
- The Christ Hospital Heart and Vascular Institute, Cincinnati, OH (T.H., J.G.J.)
| | - Clyde W Yancy
- Department of Medicine, Division of Cardiology, Northwestern University Medical School, Chicago, IL (N.S.S., C.W.Y.)
| | - Abhinav Goyal
- Department of Medicine, Division of Cardiology, Emory University School of Medicine, Atlanta, GA (A.G.)
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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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Fujita H. Cloud-Based Prehospital Electrocardiography May Save More ST-Segment-Elevation Myocardial Infarction Patients in Regional Medical Systems. Circ J 2022; 86:1488-1489. [PMID: 36070931 DOI: 10.1253/circj.cj-22-0528] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Affiliation(s)
- Hideo Fujita
- Division of Cardiovascular Medicine, Saitama Medical Center, Jichi Medical University
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9
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Yong CM, Tamis‐Holland JE. “Goldilocks” Approach to Deferred Stenting in ST‐Segment–Elevation Myocardial Infarction. J Am Heart Assoc 2022; 11:e025947. [PMID: 35574950 PMCID: PMC9238551 DOI: 10.1161/jaha.122.025947] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Affiliation(s)
- Celina M. Yong
- Division of Cardiovascular Medicine Stanford University School of Medicine Stanford CA
- Veterans Affairs Palo Alto Healthcare System Palo Alto CA
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10
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The shock team: a multidisciplinary approach to early patient phenotyping and appropriate care escalation in cardiogenic shock. Curr Opin Cardiol 2022; 37:241-249. [PMID: 35612936 DOI: 10.1097/hco.0000000000000967] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
PURPOSE OF REVIEW Cardiogenic shock (CS) is a highly morbid condition with mortality remaining greater than 30% despite improved pathophysiologic understanding and access to mechanical circulatory support (MCS). In response, shock teams modeled on successful multidisciplinary care structures for other diseases are being implemented nationwide. RECENT FINDINGS Primary data supporting a benefit of shock team implementation on patient outcomes are relatively limited and entirely observational. Four single-center before-and-after studies and one multicenter registry study have demonstrated improved outcomes in patients with CS, potentially driven by increased pulmonary artery catheter (PAC) utilization and earlier (and more appropriate) initiation of MCS. Shock teams are also supported by a growing body of literature recognizing the independent benefit of the interventions they seek to implement, including patient phenotyping with PAC use and an algorithmic approach to CS care. Though debated, MCS is also highly likely to improve CS outcomes when applied appropriately, which further supports a multidisciplinary shock team approach to patient and device selection. SUMMARY Shock teams likely improve patient outcomes by facilitating early patient phenotyping and appropriate intervention. Institutions should strongly consider adopting a multidisciplinary shock team approach to CS care, though additional data supporting these interventions are needed.
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11
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Handran CB, Kunz M, Larson DM, Garberich RF, Baran K, Henry JT, Sharkey SW, Henry TD. The impact of regional STEMI systems on protocol use and quality improvement initiatives in community hospitals without cardiac catheterization laboratories. AMERICAN HEART JOURNAL PLUS : CARDIOLOGY RESEARCH AND PRACTICE 2022; 13:100077. [PMID: 38560053 PMCID: PMC10978212 DOI: 10.1016/j.ahjo.2021.100077] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 08/03/2021] [Revised: 11/16/2021] [Accepted: 11/19/2021] [Indexed: 04/04/2024]
Abstract
Study objective Since the 1990s, national guidelines have recommended hospitals develop STEMI treatment protocols and monitor quality. A 2003 survey of Minnesota hospitals without cardiac catheterization laboratories (CCL) found <2/3 had STEMI protocols, <50% had a quality assessment (QA) process, and protocols in existence were incomplete. We evaluated temporal changes in STEMI processes in relationship to changes in mortality. Design setting and participants Follow-up surveys were mailed to emergency departments at 108 Minnesota hospitals without CCL. Results Among 87% of responding hospitals, 89% had formal protocols or guidelines for STEMI management compared to 63% in 2003 (p < 0.001). In 2010, 67% of hospitals had triage/transfer criteria and 15% of hospitals used protocols for transfer decisions, compared to only 8% (p < 0.001) and 1% (p = 0.098), respectively, in 2003. The percentage of hospitals transferring patients with STEMI from the emergency department increased from 23% in 2003 to 56% in 2010 (p < 0.001). During this time, age-adjusted acute MI mortality rate in Minnesota decreased 33% and was more pronounced in areas with regional STEMI systems. Conclusions Since 2003, utilization of STEMI guidelines, protocols, and standing orders in Minnesota hospitals without CCL has markedly improved with <10% of hospitals lacking specific STEMI management protocols. The majority of hospitals routinely transfer patients with STEMI for primary PCI and have comprehensive QA processes. This improvement was stimulated by regional STEMI systems, further supporting the current class I recommendation for STEMI systems of care in current guidelines. The decline in Minnesota STEMI mortality paralleled the growth of regional STEMI systems.
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Affiliation(s)
| | - Miranda Kunz
- Minneapolis Heart Institute Foundation at Abbott Northwestern Hospital, Minneapolis, MN, United States of America
| | - David M. Larson
- Ridgeview Medical Center, Waconia, MN, United States of America
| | - Ross F. Garberich
- Minneapolis Heart Institute Foundation at Abbott Northwestern Hospital, Minneapolis, MN, United States of America
| | - Kelsey Baran
- Berkshire Medical Center, Pittsfield, MA, United States of America
| | - Jason T. Henry
- Sarah Cannon Research Institute at HealthONE, Denver, CO, United States of America
| | - Scott W. Sharkey
- Minneapolis Heart Institute Foundation at Abbott Northwestern Hospital, Minneapolis, MN, United States of America
| | - Timothy D. Henry
- The Carl and Edyth Lindner Center for Research and Education, The Christ Hospital, Cincinnati, OH, United States of America
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12
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Jacobs AK, Ali MJ, Best PJ, Bieniarz MC, Bufalino VJ, French WJ, Henry TD, Hollowell L, Jauch EC, Kurz MC, Levy M, Patel P, Spier T, Stone RH, Tataris KL, Thomas RJ, Zègre-Hemsey JK. Systems of Care for ST-Segment-Elevation Myocardial Infarction: A Policy Statement From the American Heart Association. Circulation 2021; 144:e310-e327. [PMID: 34641735 DOI: 10.1161/cir.0000000000001025] [Citation(s) in RCA: 33] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
The introduction of Mission: Lifeline significantly increased timely access to percutaneous coronary intervention for patients with ST-segment-elevation myocardial infarction (STEMI). In the years since, morbidity and mortality rates have declined, and research has led to significant developments that have broadened our concept of the STEMI system of care. However, significant barriers and opportunities remain. From community education to 9-1-1 activation and emergency medical services triage and from emergency department and interfacility transfer protocols to postacute care, each critical juncture presents unique challenges for the optimal care of patients with STEMI. This policy statement sets forth recommendations for how the ideal STEMI system of care should be designed and implemented to ensure that patients with STEMI receive the best evidence-based care at each stage in their illness.
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13
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Chang KY, Chiu N, Aggarwal R. In-Hospital Mortality for Inpatient Percutaneous Coronary Interventions in the United States. Am J Cardiol 2021; 159:30-35. [PMID: 34503823 DOI: 10.1016/j.amjcard.2021.08.018] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/09/2021] [Revised: 08/02/2021] [Accepted: 08/03/2021] [Indexed: 11/18/2022]
Abstract
Cardiovascular mortality is substantially higher in rural communities compared with urban communities. Understanding if disparities in inpatient percutaneous coronary intervention (PCI) persist in the United States will help inform initiatives to improve cardiovascular health. Of the more than 7 million hospitalizations in the National Inpatient Sample (2016), we identified 80,793 unweighted hospitalizations for PCI using ICD-10 procedure codes. Using survey weights, these hospitalizations projected 371,040 US admissions for inpatient PCI. For the primary analysis, we determined the association between hospital urban-rural designation and in-hospital mortality after inpatient PCI. In the secondary analysis, we evaluated the association between teaching status and this outcome. Multivariable logistic regression models, adjusted for multiple risk factors and patient characteristics, were used. Of the 371,430 hospitalizations for inpatient PCI, there were 108.9 (±2.2) admissions per 100,000 US population from urban hospitals and 152.9 (±6.3) from rural hospitals. Of the urban hospitals, there were 77.7 (±1.9) admissions per 100,000 US population at teaching hospitals (71.7%) and 30.7 (±1.0) at urban nonteaching hospitals (28.3%). In-hospital mortality did not differ between urban and rural hospitals (1.8% urban vs 1.9% rural, adjusted odds ratio for rural compared with urban: 1.15 [95% confidence interval 0.98, 1.34], p = 0.08). In urban hospitals, however, in-hospital mortality was higher in nonteaching hospitals than in teaching hospitals (2.0% nonteaching vs 1.7% teaching, adjusted odds ratio for teaching compared with nonteaching: 1.17 [95% confidence interval 1.01, 1.36], p = 0.04). In conclusion, in-hospital mortality rates after inpatient PCI were similar between urban and rural hospitals in the United States. However, among urban hospitals, nonteaching hospitals had higher rates of in-hospital mortality after PCI. In conclusion, solutions to address disparities for inpatient PCI outcomes between teaching and nonteaching hospitals are needed.
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Affiliation(s)
- Katie Y Chang
- University of Cincinnati College of Medicine, Cincinnati, Ohio
| | - Nicholas Chiu
- Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
| | - Rahul Aggarwal
- Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts.
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14
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Govea A, Lipinksi J, Patel MP. Prehospital Evaluation, ED Management, Transfers, and Management of Inpatient STEMI. Interv Cardiol Clin 2021; 10:293-306. [PMID: 34053616 DOI: 10.1016/j.iccl.2021.03.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
ST elevation myocardial infarction diagnoses have reduced in number over the past 10 years; however, associated morbidity and mortality remain high. Societal guidelines focus on early diagnosis and timely access to reperfusion, preferably percutaneous coronary intervention (PCI), with fibrinolytics reserved for those who cannot receive timely PCI. Proposed algorithms recommend emergency department bypass in stable patients with a clear diagnosis to reduced door-to-balloon time. Emergency providers should limit their evaluation, focusing on life-threatening comorbidities, unstable vitals, or contraindications to a catheterization laboratory. In-hospital patients prove diagnostically challenging because they may be unable to express symptoms, and reperfusion strategies can complicate other diagnoses.
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Affiliation(s)
- Alayn Govea
- Division of Cardiovascular Medicine, UC San Diego, San Diego, CA, USA; UC San Diego Sulpizio Cardiovascular Center, 9452 Medical Center Drive #7411, La Jolla, CA 92037, USA
| | - Jerry Lipinksi
- UC San Diego Sulpizio Cardiovascular Center, 9452 Medical Center Drive #7411, La Jolla, CA 92037, USA; Department of Internal Medicine, UC San Diego, San Diego, CA, USA
| | - Mitul P Patel
- UC San Diego Sulpizio Cardiovascular Center, 9452 Medical Center Drive #7411, La Jolla, CA 92037, USA; Division of Cardiovascular Medicine, UC San Diego Cardiovascular Institute, San Diego, CA, USA.
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15
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Damluji AA, van Diepen S, Katz JN, Menon V, Tamis-Holland JE, Bakitas M, Cohen MG, Balsam LB, Chikwe J. Mechanical Complications of Acute Myocardial Infarction: A Scientific Statement From the American Heart Association. Circulation 2021; 144:e16-e35. [PMID: 34126755 DOI: 10.1161/cir.0000000000000985] [Citation(s) in RCA: 125] [Impact Index Per Article: 41.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
Abstract
Over the past few decades, advances in pharmacological, catheter-based, and surgical reperfusion have improved outcomes for patients with acute myocardial infarctions. However, patients with large infarcts or those who do not receive timely revascularization remain at risk for mechanical complications of acute myocardial infarction. The most commonly encountered mechanical complications are acute mitral regurgitation secondary to papillary muscle rupture, ventricular septal defect, pseudoaneurysm, and free wall rupture; each complication is associated with a significant risk of morbidity, mortality, and hospital resource utilization. The care for patients with mechanical complications is complex and requires a multidisciplinary collaboration for prompt recognition, diagnosis, hemodynamic stabilization, and decision support to assist patients and families in the selection of definitive therapies or palliation. However, because of the relatively small number of high-quality studies that exist to guide clinical practice, there is significant variability in care that mainly depends on local expertise and available resources.
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16
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Shah T, Haimi I, Yang Y, Gaston S, Taoutel R, Mehta S, Lee HJ, Zambahari R, Baumbach A, Henry TD, Grines CL, Lansky A, Tirziu D. Meta-Analysis of Gender Disparities in In-hospital Care and Outcomes in Patients with ST-Segment Elevation Myocardial Infarction. Am J Cardiol 2021; 147:23-32. [PMID: 33640366 DOI: 10.1016/j.amjcard.2021.02.015] [Citation(s) in RCA: 34] [Impact Index Per Article: 11.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/14/2020] [Revised: 02/06/2021] [Accepted: 02/19/2021] [Indexed: 12/26/2022]
Abstract
Gender disparities in ST-segment elevation myocardial infarction (STEMI) outcomes continue to be reported worldwide; however, the magnitude of this gap remains unknown. To evaluate gender-based discrepancies in clinical outcomes and identify the primary driving factors a global meta-analysis was performed. Studies were selected if they included all comers with STEMI, reported gender specific patient characteristics, treatments, and outcomes, according to the registered PROSPERO protocol: CRD42020161469. A total of 56 studies (705,098 patients, 31% females) were included. Females were older, had more comorbidities and received less antiplatelet therapy and primary percutaneous coronary intervention (PCI). Females experienced significantly longer delays to first medical contact (mean difference 42.5 min) and door-to-balloon time (mean difference 4.9 min). In-hospital, females had increased rates of mortality (odds ratio [OR] 1.91, 95% confidence interval [CI] 1.84 to 1.99, p <0.00001), repeat myocardial infarction (MI) (OR 1.25, 95% CI 1.00 to 1.56, p=0.05), stroke (OR 1.67, 95% CI 1.27 to 2.20, p <0.001), and major bleeding (OR 1.82, 95% CI 1.56 to 2.12, p <0.00001) compared with males. Older age at presentation was the primary driver of excess mortality in females, although other factors including lower rates of primary PCI and aspirin usage, and longer door-to-balloon times contributed. In contrast, excess rates of repeat MI and stroke in females appeared to be driven, at least in part, by lower use of primary PCI and P2Y12 inhibitors, respectively. In conclusion, despite improvements in STEMI care, women continue to have in-hospital rates of mortality, repeat MI, stroke, and major bleeding up to 2-fold higher than men. Gender disparities in in-hospital outcomes can largely be explained by age differences at presentation but comorbidities, delays to care and suboptimal treatment experienced by women may contribute to the gender gap.
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17
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Shen Y, Hsia RY. Differential benefits of cardiac care regionalization based on driving time to percutaneous coronary intervention. Acad Emerg Med 2021; 28:519-529. [PMID: 33319420 DOI: 10.1111/acem.14195] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2020] [Revised: 11/25/2020] [Accepted: 12/09/2020] [Indexed: 11/28/2022]
Abstract
BACKGROUND Patients with ST-elevation myocardial infarction (STEMI) require timely reperfusion, and percutaneous coronary intervention (PCI) decreases morbidity and mortality. Regionalization of STEMI care has increased timeliness and use of PCI, but it is unknown whether benefits to regionalization depend on a community's distance from its nearest PCI center. We sought to determine whether STEMI regionalization benefits, measured by access to PCI centers, timeliness of treatment (same-day or in-hospital PCI), and mortality, differ by baseline distance to nearest PCI center. METHODS Using a difference-in-difference-in-differences model, we examined access to PCI-capable hospitals, receipt of PCI either on the day of admission or during the care episode, and health outcomes for patients hospitalized from January 1, 2006, to September 30, 2015. RESULTS Of 139,408 patients (2006 to 2015), 51% could reach the nearest PCI center in <30 minutes, and 49% required ≥30 minutes driving time. For communities with baseline access ≥30 minutes, regionalization increased the probability of admission to a PCI-capable hospital by 9.4% and also increased the likelihood of receiving same-day PCI (by 11.2%) and PCI during the hospitalization (by 7.4%). Patients living within 30 minutes did not accrue significant benefits (measured by admission to a PCI-capable hospital or receipt of PCI) from regionalization initiatives. Regionalization more than halved access disparities and completely eliminated treatment disparities between communities ≥30 minutes and communities <30 minutes from the nearest PCI hospital. CONCLUSIONS Measured by likelihood of admission to a PCI-capable facility and receipt of PCI, benefits of STEMI regionalization in California accrued only to patients whose nearest PCI center was ≥30 minutes away. We found no mortality benefits of regionalization based on distance from PCI center. Our results suggest that policymakers focus STEMI regionalization efforts in communities that are not already well serviced by PCI-capable hospitals.
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Affiliation(s)
- Yu‐Chu Shen
- Graduate School of Defense Management Naval Postgraduate School Monterey California USA
- National Bureau of Economic Research Cambridge Massachusetts USA
| | - Renee Y. Hsia
- Department of Emergency Medicine University of California at San Francisco San Francisco California USA
- Philip R. Lee Institute for Health Policy StudiesUniversity of California at San Francisco San Francisco California USA
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18
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Krishnamoorthy P, Vengrenyuk A, Wasielewski B, Barman N, Bander J, Sweeny J, Baber U, Dangas G, Gidwani U, Syros G, Singh M, Vengrenyuk Y, Ezenkwele U, Tamis-Holland J, Chu K, Warshaw A, Kukar A, Bai M, Darrow B, Garcia H, Oliver B, Sharma SK, Kini AS. Mobile application to optimize care for ST-segment elevation myocardial infarction patients in a large healthcare system, STEMIcathAID: rationale and design. EUROPEAN HEART JOURNAL. DIGITAL HEALTH 2021; 2:189-201. [PMID: 36712391 PMCID: PMC9707921 DOI: 10.1093/ehjdh/ztab010] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/03/2020] [Revised: 01/05/2021] [Accepted: 01/27/2021] [Indexed: 02/01/2023]
Abstract
Aims Technological advancements have transformed healthcare. System delays in transferring patients with ST-segment elevation myocardial infarction (STEMI) to a primary percutaneous coronary intervention (PCI) centre are associated with worse clinical outcomes. Our aim was to design and develop a secure mobile application, STEMIcathAID, streamlining communication, and coordination between the STEMI care teams to reduce ischaemia time and improve patient outcomes. Methods and results The app was designed for transfer of patients with STEMI to a cardiac catheterization laboratory (CCL) from an emergency department (ED) of either a PCI capable or a non-PCI capable hospital. When a suspected STEMI arrives to a non-PCI hospital ED, the ED physician uploads the electrocardiogram and relevant patient information. An instant notification is simultaneously sent to the on-call CCL attending and transfer centre. The attending reviews the information, makes a video call and decides to either accept or reject the transfer. If accepted, on-call CCL team members receive an immediate push notification and begin communicating with the ED team via a HIPAA compliant chat. The app provides live GPS tracking of the ambulance and frequent clinical status updates of the patient. In addition, it allows for screening of STEMI patients in cardiogenic shock. Prior to discharge, important data elements have to be entered to close the case. Conclusion We developed a novel mobile app to optimize care for STEMI patients and facilitate electronic extraction of relevant performance metrics to improve allocation of resources and reduction of costs.
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Affiliation(s)
- Parasuram Krishnamoorthy
- The Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, Mount Sinai Hospital, One Gustave L. Levy Place, Box 1030, New York, NY 10029, USA
| | - Andriy Vengrenyuk
- The Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, Mount Sinai Hospital, One Gustave L. Levy Place, Box 1030, New York, NY 10029, USA
| | - Brian Wasielewski
- The Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, Mount Sinai Hospital, One Gustave L. Levy Place, Box 1030, New York, NY 10029, USA
| | - Nitin Barman
- The Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, Mount Sinai Hospital, One Gustave L. Levy Place, Box 1030, New York, NY 10029, USA
| | - Jeffrey Bander
- The Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, Mount Sinai Hospital, One Gustave L. Levy Place, Box 1030, New York, NY 10029, USA
| | - Joseph Sweeny
- The Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, Mount Sinai Hospital, One Gustave L. Levy Place, Box 1030, New York, NY 10029, USA
| | - Usman Baber
- The Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, Mount Sinai Hospital, One Gustave L. Levy Place, Box 1030, New York, NY 10029, USA
| | - George Dangas
- The Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, Mount Sinai Hospital, One Gustave L. Levy Place, Box 1030, New York, NY 10029, USA
| | - Umesh Gidwani
- The Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, Mount Sinai Hospital, One Gustave L. Levy Place, Box 1030, New York, NY 10029, USA
| | - Georgios Syros
- Department of Cardiology, Mount Sinai Queens, Mount Sinai Hospital, New York, NY, USA
| | | | - Yuliya Vengrenyuk
- The Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, Mount Sinai Hospital, One Gustave L. Levy Place, Box 1030, New York, NY 10029, USA
| | - Ugo Ezenkwele
- Emergency Department, Mount Sinai Queens, Mount Sinai Hospital, New York, NY, USA
| | - Jacqueline Tamis-Holland
- Department of Cardiology, Mount Sinai Morningside and Mount Sinai West, Mount Sinai Hospital, New York, NY, USA
| | - Kenny Chu
- Information Technology Department, Mount Sinai Hospital, New York, NY, USA
| | - Abraham Warshaw
- Department of, Population Health Science and Policy, Mount Sinai Hospital, New York, NY, USA
| | - Atul Kukar
- The Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, Mount Sinai Hospital, One Gustave L. Levy Place, Box 1030, New York, NY 10029, USA
| | - Matthew Bai
- Emergency Department, Mount Sinai Queens, Mount Sinai Hospital, New York, NY, USA
| | - Bruce Darrow
- The Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, Mount Sinai Hospital, One Gustave L. Levy Place, Box 1030, New York, NY 10029, USA,Information Technology Department, Mount Sinai Hospital, New York, NY, USA
| | - Haydee Garcia
- The Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, Mount Sinai Hospital, One Gustave L. Levy Place, Box 1030, New York, NY 10029, USA
| | - Beth Oliver
- The Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, Mount Sinai Hospital, One Gustave L. Levy Place, Box 1030, New York, NY 10029, USA
| | - Samin K Sharma
- The Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, Mount Sinai Hospital, One Gustave L. Levy Place, Box 1030, New York, NY 10029, USA
| | - Annapoorna S Kini
- The Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, Mount Sinai Hospital, One Gustave L. Levy Place, Box 1030, New York, NY 10029, USA,Corresponding author. Tel: +1 212 241 4181, Fax: +1 212 534 2845,
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19
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Brindis RG, Bates ER, Henry TD. Value of Registries in ST-Segment-Elevation Myocardial Infarction Care in Both the Pre-Coronavirus Disease 2019 and the Coronavirus Disease 2019 Eras. J Am Heart Assoc 2020; 10:e019958. [PMID: 33345555 PMCID: PMC7955494 DOI: 10.1161/jaha.120.019958] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Affiliation(s)
- Ralph G Brindis
- Department of Medicine and the Philip R. Lee Institute for Health Policy Studies University of California, San Francisco CA
| | - Eric R Bates
- Division of Cardiovascular Medicine Department of Internal Medicine University of Michigan Ann Arbor MI
| | - Timothy D Henry
- The Carl and Edyth Lindner Center for Research and Education The Christ Hospital Cincinnati OH
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20
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Samsky MD, Krucoff MW, Morrow DA, Abraham WT, Aguel F, Althouse AD, Chen E, Cigarroa JE, DeVore AD, Farb A, Gilchrist IC, Henry TD, Hochman JS, Kapur NK, Morrow V, Ohman EM, O'Neill WW, Piña IL, Proudfoot AG, Sapirstein JS, Seltzer JH, Senatore F, Shinnar M, Simonton CA, Tehrani BN, Thiele H, Truesdell AG, Waksman R, Rao SV. Cardiac safety research consortium "shock II" think tank report: Advancing practical approaches to generating evidence for the treatment of cardiogenic shock. Am Heart J 2020; 230:93-97. [PMID: 33011148 DOI: 10.1016/j.ahj.2020.09.015] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/23/2020] [Accepted: 09/23/2020] [Indexed: 12/29/2022]
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21
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Sather J, Littauer R, Finn E, Matouk C, Sheth K, Parwani V, Pham L, Ulrich A, Rothenberg C, Venkatesh AK. A Multimodal Intervention to Improve the Quality and Safety of Interhospital Care Transitions for Nontraumatic Intracerebral and Subarachnoid Hemorrhage. Jt Comm J Qual Patient Saf 2020; 47:99-106. [PMID: 33358659 DOI: 10.1016/j.jcjq.2020.10.003] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2020] [Revised: 10/15/2020] [Accepted: 10/16/2020] [Indexed: 11/26/2022]
Abstract
BACKGROUND Regionalization of care has increased interhospital transfers (IHTs) of nontraumatic intracerebral hemorrhage (ICH) and subarachnoid hemorrhage (SAH) to specialized centers yet exposes patients to the latent risks inherent to IHT. The researchers examined how a multimodal quality improvement intervention affected quality and safety measures for patients with ICH or SAH exposed to IHT. METHODS Pre and post analyses of timeliness, effectiveness, and communication outcome measures were performed for patients transferred to an urban, academic center with nontraumatic ICH/SAH following implementation of a multimodal intervention. Intervention components included clinical practice guideline dissemination, IHT process redesign, electronic patient arrival notification, electronic imaging exchange, and electronic health record improvements. Three months of preintervention outcomes were compared to six months of postintervention outcomes to assess impact and sustainability of the intervention; t-tests and chi-square tests were used to compare continuous and proportional outcomes, respectively. RESULTS The IHT study population included 106 patients (37 preintervention, 69 postintervention). Significant improvements were observed in timeliness outcomes, including emergency department (ED) time to admission order (preintervention median: 66 minutes vs. postintervention: 33 minutes, p = 0.008), ED boarding time (preintervention median: 223 minutes vs. postintervention: 93 minutes, p = 0.001), and ED length of stay (preintervention median: 300 minutes vs. postintervention: 150 minutes, p ≤ 0.0001). Verbal communication between ED and neurocritical care clinicians prior to IHT improved from 40.0% preintervention to 90.9% postintervention. CONCLUSION Application of scripted quality improvement interventions as part of the IHT process is feasible and effective at improving the timeliness of care and communication of critical information in patients with nontraumatic ICH/SAH.
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22
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Affiliation(s)
- D Andrew Wilkinson
- Department of Neurosurgery, Penn State Health Milton S. Hershey Medical Center, Hershey, Pennsylvania (D.A.W.)
| | - Ashutosh P Jadhav
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona (A.P.J., A.F.D.)
| | - Andrew F Ducruet
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona (A.P.J., A.F.D.)
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23
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Katz JN, Sinha SS, Alviar CL, Dudzinski DM, Gage A, Brusca SB, Flanagan MC, Welch T, Geller BJ, Miller PE, Leonardi S, Bohula EA, Price S, Chaudhry SP, Metkus TS, O'Brien CG, Sionis A, Barnett CF, Jentzer JC, Solomon MA, Morrow DA, van Diepen S. COVID-19 and Disruptive Modifications to Cardiac Critical Care Delivery: JACC Review Topic of the Week. J Am Coll Cardiol 2020; 76:72-84. [PMID: 32305402 PMCID: PMC7161519 DOI: 10.1016/j.jacc.2020.04.029] [Citation(s) in RCA: 45] [Impact Index Per Article: 11.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/04/2020] [Revised: 04/13/2020] [Accepted: 04/13/2020] [Indexed: 12/12/2022]
Abstract
The COVID-19 pandemic has presented a major unanticipated stress on the workforce, organizational structure, systems of care, and critical resource supplies. To ensure provider safety, to maximize efficiency, and to optimize patient outcomes, health systems need to be agile. Critical care cardiologists may be uniquely positioned to treat the numerous respiratory and cardiovascular complications of the SARS-CoV-2 and support clinicians without critical care training who may be suddenly asked to care for critically ill patients. This review draws upon the experiences of colleagues from heavily impacted regions of the United States and Europe, as well as lessons learned from military mass casualty medicine. This review offers pragmatic suggestions on how to implement scalable models for critical care delivery, cultivate educational tools for team training, and embrace technologies (e.g., telemedicine) to enable effective collaboration despite social distancing imperatives.
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Affiliation(s)
- Jason N Katz
- Division of Cardiology, Duke University, Durham, North Carolina.
| | - Shashank S Sinha
- Inova Heart and Vascular Institute, Inova Fairfax Medical Center, Falls Church, Virginia. https://twitter.com/ShashankSinhaMD
| | - Carlos L Alviar
- Leon H. Charney Division of Cardiology, New York University Langone Medical Center NYU Langone Medical Center, New York, New York
| | - David M Dudzinski
- Division of Cardiology, Massachusetts General Hospital, Boston, Massachusetts
| | - Ann Gage
- Division of Cardiology, Cleveland Clinic, Cleveland, Ohio
| | - Samuel B Brusca
- Critical Care Medicine, National Institutes of Health Clinical Center, Bethesda, Maryland
| | - M Casey Flanagan
- Inova Heart and Vascular Institute, Inova Fairfax Medical Center, Falls Church, Virginia
| | - Timothy Welch
- Inova Heart and Vascular Institute, Inova Fairfax Medical Center, Falls Church, Virginia; Virginia Heart, Falls Church, Virginia
| | - Bram J Geller
- Division of Cardiology, Maine Medical Center, Portland, Maine
| | - P Elliott Miller
- Section of Cardiovascular Medicine, Yale University School of Medicine, New Haven, Connecticut
| | - Sergio Leonardi
- Coronary Care Unit and Laboratory of Clinical and Experimental Cardiology-Fondazione IRCCS Policlinico San Matteo, and Department of Molecular Medicine, University of Pavia, Pavia, Italy
| | - Erin A Bohula
- TIMI Study Group, Cardiovascular Division, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Susanna Price
- Royal Brompton and Harefield NHS Foundation Trust, Royal Brompton Hospital, London, United Kingdom
| | | | - Thomas S Metkus
- Division of Cardiology, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Connor G O'Brien
- Division of Cardiovascular Medicine, Stanford University School of Medicine, Palo Alto, California
| | - Alessandro Sionis
- Intensive Cardiac Care Unit, Cardiology Department, Hospital de la Santa Creu i Sant Pau, Biomedical Research Institute IIB-SantPaul, Universidad Autonoma de Barcelona, Barcelona, Spain
| | | | - Jacob C Jentzer
- Department of Cardiovascular Medicine and Division of Pulmonary and Critical Care Medicine, Mayo Clinic, Rochester, Minnesota
| | - Michael A Solomon
- Critical Care Medicine, National Institutes of Health Clinical Center, Bethesda, Maryland; Cardiovascular Branch, National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, Maryland
| | - David A Morrow
- TIMI Study Group, Cardiovascular Division, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Sean van Diepen
- Department of Critical Care and Division of Cardiology, Department of Medicine, University of Alberta Hospital, Alberta, Canada. https://twitter.com/seanvandiepen
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24
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Yin X, He Y, Zhang J, Song F, Liu J, Sun G, Liang Y, Ye J, Hu Y, Song M, Chen C, Xu Q, Tan N, Chen J, Liu Y, Liu H, Tian M. Patient-level and system-level barriers associated with treatment delays for ST elevation myocardial infarction in China. Heart 2020; 106:1477-1482. [PMID: 32580976 DOI: 10.1136/heartjnl-2020-316621] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/24/2020] [Revised: 05/10/2020] [Accepted: 05/17/2020] [Indexed: 11/03/2022] Open
Abstract
OBJECTIVE This study aims to understand the current ST elevated myocardial infarction (STEMI) treatment process in Guangdong Province and explore patient-level and system-level barriers associated with delay in STEMI treatment, so as to provide recommendations for improvement. METHODS This is a qualitative study. Data were collected using semistructured, face-to-face individual interviews from April 2018 to January 2019. Participants included patients with STEMI, cardiologists and nurses from hospitals, emergency department doctors, primary healthcare providers, local health governors, and coordinators at the emergency medical system (EMS). An inductive thematic analysis was adopted to generate overarching themes and subthemes for potential causes of STEMI treatment delay. The WHO framework for people-centred integrated health services was used to frame recommendations for improving the health system. RESULTS Thirty-two participants were interviewed. Patient-level barriers included poor knowledge in recognising STEMI symptoms and not calling EMS when symptoms occurred. Limited capacity of health professionals in hospitals below the tertiary level and lack of coordination between hospitals of different levels were identified as the main system-level barriers. Five recommendations were provided: (1) enhance public health education; (2) strengthen primary healthcare workforce; (3) increase EMS capacity; (4) establish an integrated care model; and (5) harness government's responsibilities. CONCLUSIONS Barriers associated with delay in STEMI treatment were identified at both patient and system levels. The results of this study provide a useful evidence base for future intervention development to improve the quality of STEMI treatment and patient outcomes in China and other countries in a similar situation.
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Affiliation(s)
- Xuejun Yin
- The George Institute for Global Health, University of New South Wales, Sydney, New South Wales, Australia
| | - Yibo He
- Department of Cardiology, Guangdong Provincial Key Laboratory of Coronary Heart Disease, Guangdong Cardiovascular Institute, Guangdong Provincial People's Hospital, Guangdong Academy of Medical Sciences, Guangzhou, China
| | - Jing Zhang
- School of Public Health, University of New South Wales, Sydney, New South Wales, Australia
| | - Feier Song
- Department of Emergency and Critical Care Medicine, Guangdong Provincial People's Hospital, Guangdong Academy of Medical Sciences, Guangzhou, China
| | - Jin Liu
- Department of Cardiology, Guangdong Provincial Key Laboratory of Coronary Heart Disease, Guangdong Cardiovascular Institute, Guangdong Provincial People's Hospital, Guangdong Academy of Medical Sciences, Guangzhou, China
| | - Guoli Sun
- Department of Cardiology, Guangdong Provincial Key Laboratory of Coronary Heart Disease, Guangdong Cardiovascular Institute, Guangdong Provincial People's Hospital, Guangdong Academy of Medical Sciences, Guangzhou, China
| | - Yan Liang
- Department of Cardiology, Maoming People's Hospital, Maoming, China
| | - Jianfeng Ye
- Department of Cardiology, Dongguan TCM Hospital, Dongguan, China
| | - Yunzhao Hu
- Department of Cardiology, The First People's Hospital of Shunde, Shunde, China
| | - Mingcai Song
- Department of Cardiology, Guangzhou Panyu Central Hospital, Guangzhou, Guangdong, China
| | - Cong Chen
- Department of Cardiology, Maoming People's Hospital, Maoming, China
| | - Qingbo Xu
- Department of Cardiology, Maoming People's Hospital, Maoming, China
| | - Ning Tan
- Department of Cardiology, Guangdong Provincial Key Laboratory of Coronary Heart Disease, Guangdong Cardiovascular Institute, Guangdong Provincial People's Hospital, Guangdong Academy of Medical Sciences, Guangzhou, China
| | - Jiyan Chen
- Department of Cardiology, Guangdong Provincial Key Laboratory of Coronary Heart Disease, Guangdong Cardiovascular Institute, Guangdong Provincial People's Hospital, Guangdong Academy of Medical Sciences, Guangzhou, China
| | - Yong Liu
- Department of Cardiology, Guangdong Provincial Key Laboratory of Coronary Heart Disease, Guangdong Cardiovascular Institute, Guangdong Provincial People's Hospital, Guangdong Academy of Medical Sciences, Guangzhou, China
| | - Hueiming Liu
- The George Institute for Global Health, University of New South Wales, Sydney, New South Wales, Australia
| | - Maoyi Tian
- The George Institute for Global Health, University of New South Wales, Sydney, New South Wales, Australia
- The George Institute for Global Health, Beijing, China
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25
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Jacobs AK, Ali M, Best PJ, Bieniarz M, Cohen MG, French WJ, Fonarow GC, Granger CB, Goyal A, Henry TD, Hollowell L, Jneid H, Jollis JG, Katz JN, Mason P, Menon V, Redlener M, Tamis-Holland JE, Zegre-Hemsey J. Temporary Emergency Guidance to STEMI Systems of Care During the COVID-19 Pandemic: AHA's Mission: Lifeline. Circulation 2020; 142:199-202. [PMID: 32363905 PMCID: PMC7365666 DOI: 10.1161/circulationaha.120.048180] [Citation(s) in RCA: 25] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Alice K. Jacobs
- Boston University School of Medicine and Boston Medical Center, MA (A.K.J)
| | - Murtuza Ali
- Louisiana State University School of Medicine, New Orleans (M.A.)
| | | | | | | | - William J. French
- Harbor-University of California, Los Angeles, Medical Center (W.J.F.)
| | - Gregg C. Fonarow
- University of California, Los Angeles, Division of Cardiology (G.C.F.)
| | | | - Abhinav Goyal
- Emory University Hospital Midtown, Atlanta, GA (A.G.)
| | | | | | - Hani Jneid
- Baylor College of Medicine, The Michael E. DeBakey VA Medical Center, Houston, TX (H.J.)
| | - James G. Jollis
- Duke University School of Medicine, Durham, NC (C.B.G., J.G.J., J.N.K.)
| | - Jason N. Katz
- Duke University School of Medicine, Durham, NC (C.B.G., J.G.J., J.N.K.)
| | - Peter Mason
- Medical College of Wisconsin, Milwaukee (P.M.)
| | - Venu Menon
- Cleveland Clinic, Lerner College of Medicine, Case Western Reserve University, OH (V.M.)
| | - Michael Redlener
- The Icahn School of Medicine at Mount Sinai, New York, NY (M.R.)
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26
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Caixeta A, Franken M, Katz M, Lemos PA, Gomes I, Yokota PK, V Alliegro P, Pesaro EE, Neto MC, Valentine CM, Brindis RG, Makdisse M. Benchmarking as a quality of care improvement tool for patients with ST-elevation myocardial infarction: an NCDR ACTION Registry experience in Latin America. Int J Qual Health Care 2020; 32:A1-A8. [PMID: 31832665 DOI: 10.1093/intqhc/mzz115] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2019] [Revised: 08/21/2019] [Accepted: 11/13/2019] [Indexed: 11/13/2022] Open
Abstract
OBJECTIVE We aim to examine the effect of benchmarking on quality-of-care metrics in patients presenting with ST-elevation myocardial infarction (STEMI) through the implementation of the American College of Cardiology (ACC) National Cardiovascular Data Registry (NCDR) ACTION Registry. DESIGN From January 2005 to December 2017, 712 patients underwent primary percutaneous coronary intervention PCI-499 before NCDR ACTION Registry implementation (prior to 2013) and 213 after implementation. SETTING STEMI. PARTICIPANTS 712 patients. INTERVENTION(S) Primary PCI. MAIN OUTCOME MEASURE(S) We examined hospital performance for the quality indicators in processes and outcomes of the management of patients presenting with STEMI. Outcome measures include door-to-balloon time (DBT), antiplatelet therapy and anti-ischemic drugs prescribed at discharge from pre-NCDR ACTION Registry to post-implementation. RESULTS There was improvement in DBT, decreasing from 94 min in 2012 (before NCDR adoption) to reach a median of 47 min in 2017 (Ptrend < 0.001). The percentage of cases with the optimal DBT of < 90 min increased from 55.8% before to 90.1% after the implementation of the NCDR ACTION Registry (Ptrend < 0.001). The rate of aspirin (90.3-100%, P < 0.001), P2Y12 inhibitor (70.1-78.4%, P = 0.02), beta-blocker (76.8-100%, P < 0.001) and angiotensin-converting enzyme inhibitors or angiotensin receptor blockers (60.1-99.5%, P < 0.001) prescribed at discharge increased from pre-NCDR ACTION Registry to post-implementation. Adjusted mortality before and after NCDR ACTION Registry implementation showed significant change (from 9.04 to 5.92%; P = 0.027). CONCLUSIONS The introduction of the ACC NCDR ACTION Registry led to incremental gains in the quality in STEMI management through the benchmarking of process of care and clinical outcomes, achieving reduced DBT, improving guideline-directed medication adherence and increasing patient safety, treatment efficacy and survival.
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Affiliation(s)
| | | | - Marcelo Katz
- Hospital Israelita Albert Einstein, São Paulo, Brazil
| | - Pedro A Lemos
- Hospital Israelita Albert Einstein, São Paulo, Brazil
| | - Ivanise Gomes
- Hospital Israelita Albert Einstein, São Paulo, Brazil
| | | | | | | | | | | | - Ralph G Brindis
- Philip R. Lee Institute for Health Policy Studies, University of California, San Francisco, CA
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27
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Kontos MC, Gunderson MR, Zegre-Hemsey JK, Lange DC, French WJ, Henry TD, McCarthy JJ, Corbett C, Jacobs AK, Jollis JG, Manoukian SV, Suter RE, Travis DT, Garvey JL. Prehospital Activation of Hospital Resources (PreAct) ST-Segment-Elevation Myocardial Infarction (STEMI): A Standardized Approach to Prehospital Activation and Direct to the Catheterization Laboratory for STEMI Recommendations From the American Heart Association's Mission: Lifeline Program. J Am Heart Assoc 2020; 9:e011963. [PMID: 31957530 PMCID: PMC7033830 DOI: 10.1161/jaha.119.011963] [Citation(s) in RCA: 23] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Affiliation(s)
- Michael C Kontos
- Pauley Heart Center Virginia Commonwealth University Richmond VA
| | | | | | - David C Lange
- The Permanente Medical Group Kaiser Permanente Santa Clara Santa Clara CA
| | - William J French
- Harbor-UCLA Medical Center and Los Angeles Biomedical Institute Torrance CA.,David Geffen School of Medicine at UCLA Los Angeles CA
| | - Timothy D Henry
- The Lindner Center for Research and Education at The Christ Hospital Cincinnati OH
| | - James J McCarthy
- Department of Emergency Medicine McGovern Medical School University of Texas Health Science Center at Houston TX
| | | | - Alice K Jacobs
- Section of Cardiology Department of Medicine Boston University Medical Center Boston MA
| | | | | | - Robert E Suter
- Department of Emergency Medicine UT Southwestern and Augusta University Dallas Texas.,Department of Military and Emergency Medicine Uniformed Services University Dallas TX
| | | | - J Lee Garvey
- Department of Emergency MedicineCarolinas Medical Center Charlotte NC
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28
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Granger CB, Bates ER, Jollis JG, Antman EM, Nichol G, O'Connor RE, Gregory T, Roettig ML, Peng SA, Ellrodt G, Henry TD, French WJ, Jacobs AK. Improving Care of STEMI in the United States 2008 to 2012. J Am Heart Assoc 2020; 8:e008096. [PMID: 30596310 PMCID: PMC6405711 DOI: 10.1161/jaha.118.008096] [Citation(s) in RCA: 70] [Impact Index Per Article: 17.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
Background We aimed to determine the change in treatment strategies and times to treatment over the first 5 years of the Mission: Lifeline program. Methods and Results We assessed pre‐ and in‐hospital care and outcomes from 2008 to 2012 for patients with ST‐segment–elevation myocardial infarction at US hospitals, using data from the National Cardiovascular Data Registry Acute Coronary Treatment and Intervention Outcomes Network Registry—Get With The Guidelines Registry. In‐hospital adjusted mortality was calculated including and excluding cardiac arrest as a reason for primary percutaneous coronary intervention delay. A total of 147 466 patients from 485 hospitals were analyzed. There was a decrease in the proportion of eligible patients not treated with reperfusion (6.2% versus 3.3%) and treated with fibrinolytic therapy (13.4% versus 7.0%). Median time from symptom onset to first medical contact was unchanged (≈50 minutes). Use of prehospital ECGs increased (45% versus 71%). All major reperfusion times improved: median first medical contact‐to‐device for emergency medical systems transport to percutaneous coronary intervention–capable hospitals (93 to 84 minutes), first door‐to‐device for transfers for primary percutaneous coronary intervention (130 to 112 minutes), and door‐in–door‐out at non–percutaneous coronary intervention–capable hospitals (76 to 62 minutes) (all P<0.001 over 5 years). Rates of cardiogenic shock and cardiac arrest, and overall in‐hospital mortality increased (5.7% to 6.3%). Adjusted mortality excluding patients with known cardiac arrest decreased by 14% at 3 years and 25% at 5 years (P<0.001). Conclusions Quality of care for patients with ST‐segment–elevation myocardial infarction improved over time in Mission: Lifeline, including increased use of reperfusion therapy and faster times‐to‐treatment. In‐hospital mortality improved for patients without cardiac arrest but did not appear to improve overall as the number of these high‐risk patients increased.
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Affiliation(s)
| | - Eric R Bates
- 2 Department of Internal Medicine University of Michigan Ann Arbor MI
| | - James G Jollis
- 1 Division of Cardiology Duke Clinical Research Institute Durham NC
| | | | - Graham Nichol
- 4 University of Washington-Harborview Center for Prehospital Emergency Care University of Washington Seattle WA
| | - Robert E O'Connor
- 5 Department of Emergency Medicine University of Virginia School of Medicine Charlottesville VA
| | | | - Mayme L Roettig
- 1 Division of Cardiology Duke Clinical Research Institute Durham NC
| | | | - Gray Ellrodt
- 8 Department of Medicine Berkshire Medical Center Pittsfield MA
| | | | - William J French
- 10 Department of Medicine Harbor-University of California at Los Angeles Medical Center Torrance CA
| | - Alice K Jacobs
- 11 Department of Medicine Boston University School of Medicine Boston MA
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29
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Bates ER. Achieving Aspirational Goals in Providing Primary Percutaneous Coronary Intervention Care. JACC Cardiovasc Interv 2019; 12:2269-2271. [PMID: 31678082 DOI: 10.1016/j.jcin.2019.08.010] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/31/2019] [Accepted: 08/06/2019] [Indexed: 10/25/2022]
Affiliation(s)
- Eric R Bates
- Division of Cardiovascular Medicine, Department of Internal Medicine, University of Michigan, Ann Arbor, Michigan.
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30
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Carr BG, Kilaru AS, Karp DN, Delgado MK, Wiebe DJ. Quality Through Coopetition: An Empiric Approach to Measure Population Outcomes for Emergency Care-Sensitive Conditions. Ann Emerg Med 2019; 72:237-245. [PMID: 29685369 DOI: 10.1016/j.annemergmed.2018.03.004] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2017] [Revised: 01/29/2018] [Accepted: 02/28/2018] [Indexed: 10/28/2022]
Abstract
STUDY OBJECTIVE We develop a novel approach for measuring regional outcomes for emergency care-sensitive conditions. METHODS We used statewide inpatient hospital discharge data from the Pennsylvania Healthcare Cost Containment Council. This cross-sectional, retrospective, population-based analysis used International Classification of Diseases, Ninth Revision, Clinical Modification diagnosis codes to identify admissions for emergency care-sensitive conditions (ischemic stroke, ST-segment elevation myocardial infarction, out-of-hospital cardiac arrest, severe sepsis, and trauma). We analyzed the origin and destination patterns of patients, grouped hospitals with a hierarchical cluster analysis, and defined boundary shapefiles for emergency care service regions. RESULTS Optimal clustering configurations determined 10 emergency care service regions for Pennsylvania. CONCLUSION We used cluster analysis to empirically identify regional use patterns for emergency conditions requiring a communitywide system response. This method of attribution allows regional performance to be benchmarked and could be used to develop population-based outcome measures after life-threatening illness and injury.
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Affiliation(s)
- Brendan G Carr
- Department of Emergency Medicine, Sidney Kimmel Medical College, Thomas Jefferson University, Philadelphia, PA.
| | - Austin S Kilaru
- Department of Emergency Medicine, Highland Hospital, Oakland, CA
| | - David N Karp
- Department of Emergency Medicine, Sidney Kimmel Medical College, Thomas Jefferson University, Philadelphia, PA; Department of Biostatistics, Epidemiology, and Informatics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - M Kit Delgado
- Department of Emergency Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Douglas J Wiebe
- Department of Biostatistics, Epidemiology, and Informatics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
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31
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Fiorilli PN, Kolansky DM. Getting to the Right Place at the Right Time: Another Piece of the STEMI Puzzle. Circ Cardiovasc Interv 2019; 11:e006700. [PMID: 29716934 DOI: 10.1161/circinterventions.118.006700] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Paul N Fiorilli
- From the Cardiovascular Medicine Division, Hospital of the University of Pennsylvania, Philadelphia
| | - Daniel M Kolansky
- From the Cardiovascular Medicine Division, Hospital of the University of Pennsylvania, Philadelphia.
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32
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Gaskin DJ, Zare H, Delarmente BA. The Supply of Hospital Care to Minority and Low-Income Communities and the Hospital Readmission Reduction Program. Med Care Res Rev 2019; 78:77-84. [PMID: 31291812 DOI: 10.1177/1077558719861242] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
To determine if the Centers for Medicare and Medicaid Services Hospital Readmission Reduction Program reduced hospital discharges for penalized conditions in minority and low-income communities, we used hospital discharge data for 2006 and 2013 from Arizona, California, Colorado, Florida, New Jersey, New York, North Carolina, and Wisconsin and readmission data from the Medicare Hospital Compare website. Negative binomial regression was used for 6,564 zip codes for each year to estimate the association between the expected penalty for an excess readmission in the hospital service area and the number of hospital discharges for penalized conditions (acute myocardial infarction, congestive heart failure, and pneumonia) for zip codes. The results showed that the expected penalty for excess readmissions had a negative association with the number of discharges for acute myocardial infarction, congestive heart failure, and pneumonia. The negative association increased with the percentage of minority residents but not with the poverty rate.
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Affiliation(s)
| | - Hossein Zare
- Johns Hopkins University, Baltimore, MD, USA.,University of Maryland, Baltimore, MD, USA
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33
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Karsan RB, Powell AG, Nanjaiah P, Mehta D, Valtzoglou V. The top 100 manuscripts in emergency cardiac surgery. Potential role in cardiothoracic training. A bibliometric analysis. Ann Med Surg (Lond) 2019; 43:5-12. [PMID: 31193454 PMCID: PMC6531840 DOI: 10.1016/j.amsu.2019.05.002] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2019] [Revised: 04/29/2019] [Accepted: 05/09/2019] [Indexed: 12/15/2022] Open
Abstract
Background Emergency Cardiac Surgery (ECS) is a component of cardiothoracic training. Citations are considered to represent a papers influence. Bibliometric analyses allow us to identify the most influential work, and future research. We aim to highlight the key research themes within ECS and determine their potential impact on cardiothoracic training. Methods Thomas Reuters Web of Science was searched using terms [Emergency AND Card* AND Surg*]. Results were ranked by citation and reviewed by a panel of cardiac surgeons to identify the top 100 cited papers relevant to ECS. Papers were analysed by topic, journal and impact. Regression analysis was used to determine a link between impact factor and scientific impact. Results 3823 papers were identified. Median citations for the top 100 was 88. The paper with the highest impact was by Nashef et al. focusing on the use of EuroSCORE (2043 citations). The Annals of Thoracic Surgery published most papers (n = 18:1778 citations). The European Journal of Cardiothoracic Surgery coveted the most citations (n = 2649). The USA published most papers (n = 55).The most ubiquitous topics were; risk stratification, circulatory support and aortic surgery. A positive relationship between journal impact fact and the scientific impact of manuscripts in ECS (P = 0.043) was deduced. Conclusion This study is the first of its kind and identified the papers which are likely to the contribute most to training and understanding of ECS. A papers influence is partially determined by journal impact factor. Bibliometric analysis is a potent tool to identify surgical training needs.
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Affiliation(s)
- Rickesh B Karsan
- Department of Cardiothoracic Surgery, University Hospital of Wales, Heath Park, Cardiff, CF14 4XW, UK
| | - Arfon Gmt Powell
- Division of Cancer and Genetics, Cardiff University, Heath Park, Cardiff, CF14 4XW, UK.,Department of Surgery, University Hospital of Wales, Heath Park, Cardiff, CF14 4XW, UK
| | - Prakash Nanjaiah
- Department of Cardiothoracic Surgery, University Hospital of Wales, Heath Park, Cardiff, CF14 4XW, UK
| | - Dheeraj Mehta
- Department of Cardiothoracic Surgery, University Hospital of Wales, Heath Park, Cardiff, CF14 4XW, UK
| | - Vasileious Valtzoglou
- Department of Cardiothoracic Surgery, University Hospital of Wales, Heath Park, Cardiff, CF14 4XW, UK
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34
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Froats M, Reed A, Dionne R, Maloney J, Duncan S, Burns R, Sinclair J, Austin M. The Safety of Bypass to Percutaneous Coronary Intervention Facility by Basic Life Support Providers in Patients with ST-Elevation Myocardial Infarction in Prehospital Setting. J Emerg Med 2018; 55:792-798. [DOI: 10.1016/j.jemermed.2018.09.006] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2017] [Revised: 04/24/2018] [Accepted: 09/01/2018] [Indexed: 10/28/2022]
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35
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Rebeiz A, Sasso R, Bachir R, Mneimneh Z, Jabbour R, El Sayed M. Emergency Medical Services Utilization and Outcomes of Patients with ST-Elevation Myocardial Infarction in Lebanon. J Emerg Med 2018; 55:827-835. [PMID: 30301584 DOI: 10.1016/j.jemermed.2018.09.016] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2018] [Revised: 07/30/2018] [Accepted: 09/01/2018] [Indexed: 11/26/2022]
Abstract
BACKGROUND Arrival of patients with ST-elevation myocardial infarction (STEMI) by Emergency Medical Services (EMS) results in shorter reperfusion times and lower mortality in developed countries. OBJECTIVES This study examines EMS use by STEMI patients in Lebanon and associated clinical outcomes. METHODS A retrospective observational study with chart review was carried out for STEMI patients arriving to the Emergency Department of a tertiary care center in Lebanon between January 1, 2013 and August 31, 2016. A descriptive analysis was done and followed by a bivariate analysis comparing two groups of patients (EMS vs. Non-EMS). RESULTS A total of 280 patients were included in the study. They were mostly male (71.8%). Mean age was 65.1 years (95% confidence interval [CI] 63.4-66.9). Only 12.5% (95% CI 8.6-16.4) presented by EMS. Chest pain (81.1%) was the most common presenting symptom. Anterior myocardial infarction was the most common electrocardiogram (ECG) diagnosis (51.4%). Most patients were admitted (98.2%), and 72.0% of these patients were treated with primary percutaneous coronary intervention. Cardiogenic shock was the most frequent in-hospital complication (6.2%). The mortality rate was 7.1%. Mean door-to-ECG and door-to-balloon times were 10.8 (95% CI 7.1-14.4) min and 106.2 (95% CI 95.9-116.6) min, respectively. Patients' characteristics, presenting symptoms, outcomes, and performance metrics were similar between the two groups. CONCLUSION EMS is underutilized by STEMI patients in Lebanon and is not associated with improvement in clinical outcomes. Medical oversight and quality initiatives focusing on outcomes of patients with timely sensitive emergencies are needed to advance the prehospital care system in Lebanon.
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Affiliation(s)
- Abdallah Rebeiz
- Department of Internal Medicine, American University of Beirut Medical Center, Beirut, Lebanon
| | - Roula Sasso
- Department of Emergency Medicine, American University of Beirut Medical Center, Beirut, Lebanon
| | - Rana Bachir
- Department of Emergency Medicine, American University of Beirut Medical Center, Beirut, Lebanon
| | - Zeina Mneimneh
- Quality, Accreditation & Risk Management Department, American University of Beirut Medical Center, Beirut, Lebanon
| | - Rima Jabbour
- Department of Emergency Medicine, American University of Beirut Medical Center, Beirut, Lebanon
| | - Mazen El Sayed
- Department of Emergency Medicine, American University of Beirut Medical Center, Beirut, Lebanon; EMS and Prehospital Care Program, Department of Emergency Medicine, American University of Beirut Medical Center, Beirut, Lebanon
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36
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Developing a Rural, Community-Based Registry for Cardiovascular Quality Improvement. Qual Manag Health Care 2018; 27:209-214. [PMID: 30260928 DOI: 10.1097/qmh.0000000000000189] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Cardiovascular disease is one of the leading causes of death, yet most evidence is collected from small clinical trials or individual hospital providers. Achieving scalable data to enable quality improvements (QIs) remains a challenge. We investigate whether a registry that is shared by multiple providers and integrates data longitudinally could help drive QIs across a large rural geographic region. METHODS We describe a case study involving the development of an informatics infrastructure across the entire state of Wyoming. This rural, regional, community-based cardiovascular system of care involved all interventional hospitals in the state as well as all surrounding states. Data exchange was initiated between 36 hospitals, and 56 ambulance agencies, to a centralized registry for clinical analytics and QI for patients with acute myocardial infarction. RESULTS After 3 years, the registry maintained all documented acute myocardial infarctions across Wyoming. Median total ischemic time (time from patient's symptom onset to definitive treatment) had a 36.7% improvement during the program. Changes in quality for the rural community included reduction in overall treatment times, as well as enhanced training, standardized protocols, and community awareness. We also share key lessons learned. CONCLUSIONS Collaborative data registries for emergency cardiovascular care can help providers and communities measure and improve the quality of the care across regions.
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37
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Victor SM, Mullasari AS. Systems of care for STEMI in developing countries – the way forward. ASIAINTERVENTION 2018; 4:74-76. [PMID: 36484000 PMCID: PMC9706771 DOI: 10.4244/aijv4i1a15] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/17/2023]
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38
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Prehospital delay in patients with ST-segment elevation myocardial infarction: time for change. Coron Artery Dis 2018; 29:368-370. [PMID: 29979256 DOI: 10.1097/mca.0000000000000629] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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39
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Javat D, Heal C, Banks J, Buchholz S, Zhang Z. Regional to tertiary inter-hospital transfer versus in-house percutaneous coronary intervention in acute coronary syndrome. PLoS One 2018; 13:e0198272. [PMID: 29927947 PMCID: PMC6013182 DOI: 10.1371/journal.pone.0198272] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2017] [Accepted: 05/16/2018] [Indexed: 11/19/2022] Open
Abstract
RATIONALE To address the inaccessibility of interventional cardiac services in North Queensland a new cardiac catheterisation laboratory (CCL) was established in Mackay Base Hospital (MBH) in February 2014. OBJECTIVE To determine whether the provision of in-house angiography and/or percutaneous coronary intervention (PCI) 1) minimises treatment delays 2) further reduces the risk of mortality, recurrent myocardial infarction (MI) and recurrent ischaemia 3) improves patient satisfaction and 4) minimises cost expenditure compared with inter-hospital transfer for patients with acute coronary syndrome (ACS). METHODS We compared ACS patients who were transferred to tertiary centres from July 2012 to June 2013 with those who received in-house angiography and/or PCI from February 2015 to January 2016. The primary outcome was the composite of all-cause mortality, recurrent myocardial infarction (MI) or recurrent ischaemia at six months. Pre-specified secondary outcomes were the composite of all-cause mortality, recurrent MI or recurrent ischaemia at one month, a summated patient satisfaction score and the proportional cost savings generated between 2015 and 2016. RESULTS We included consecutive samples of 203 patients from July 2012 to June 2013 and 229 patients from February 2015 to January 2016. There was a reduction in the median time to treatment of 3.2 days and a reduction in the median length of stay of four days amongst all ACS patients receiving in-house angiography and/or PCI. The primary outcome occurred in 14 (6.9%) patients in the 2012 to 2013 group, as compared with 18 (7.9%) patients in the 2015 to 2016 group (OR = 0.71, 95% CI 0.24-2.1, P = 0.54). The secondary outcome at one month occurred in four (2.0%) patients in the 2012 to 2013 group, as compared with three (1.3%) patients in the 2015 to 2016 group (OR = 1.2, 95% CI 0.11-13.1, P = 0.87). There was a statistically significant improvement in the summated patient satisfaction score amongst patients who received in-house angiography and/or PCI (U = 1918, P <0.05 two tailed). A calculation of estimated cost savings showed a reduction in proportional cost of $14 481 (51%) per ACS patient receiving in house angiography and/or PCI between 2015 and 2016. CONCLUSION This study suggests that the provision of regional in-house angiography and/or PCI for the treatment of ACS minimises delays to invasive treatment by 3.2 days, minimises the median length of stay by four days, significantly improves patient satisfaction and reduces proportional treatment costs by $14 481 (51%) per patient. Currently, however, it appears that that in-house treatment does not further reduce the risk of mortality, recurrent MI and recurrent ischaemia at one and six months.
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Affiliation(s)
- Delara Javat
- Department of Cardiology, Mackay Base Hospital, Mackay, QLD, Australia
- Mackay Clinical School, School of Medicine and Dentistry, James Cook University, Mackay Campus, Mackay, QLD, Australia
- * E-mail:
| | - Clare Heal
- Mackay Clinical School, School of Medicine and Dentistry, James Cook University, Mackay Campus, Mackay, QLD, Australia
- Mackay Institute for Research and Innovation (MIRI), Mackay, QLD, Australia
| | - Jennifer Banks
- Mackay Clinical School, School of Medicine and Dentistry, James Cook University, Mackay Campus, Mackay, QLD, Australia
- Mackay Institute for Research and Innovation (MIRI), Mackay, QLD, Australia
| | - Stefan Buchholz
- Department of Cardiology, Mackay Base Hospital, Mackay, QLD, Australia
- Mackay Clinical School, School of Medicine and Dentistry, James Cook University, Mackay Campus, Mackay, QLD, Australia
- HeartCare Western Australia, Suite 21, St John of God Hospital, Southwest Health Campus, Bunbury, WA, Australia
| | - Zhihua Zhang
- Department of Cardiology, Mackay Base Hospital, Mackay, QLD, Australia
- Mackay Clinical School, School of Medicine and Dentistry, James Cook University, Mackay Campus, Mackay, QLD, Australia
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40
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Factors influencing patient delay before primary percutaneous coronary intervention in ST-segment elevation myocardial infarction: The Stent for life initiative in Portugal. Rev Port Cardiol 2018; 37:409-421. [DOI: 10.1016/j.repc.2017.07.014] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2017] [Revised: 05/11/2017] [Accepted: 07/05/2017] [Indexed: 11/21/2022] Open
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Pereira H, Calé R, Pinto FJ, Pereira E, Caldeira D, Mello S, Vitorino S, Almeida MDS, Mimoso J. Factors influencing patient delay before primary percutaneous coronary intervention in ST-segment elevation myocardial infarction: The Stent for life initiative in Portugal. REVISTA PORTUGUESA DE CARDIOLOGIA (ENGLISH EDITION) 2018. [DOI: 10.1016/j.repce.2017.07.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/14/2022] Open
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Chang BL, Mercer MP, Bosson N, Sporer KA. Variations in Cardiac Arrest Regionalization in California. West J Emerg Med 2018; 19:259-265. [PMID: 29560052 PMCID: PMC5851497 DOI: 10.5811/westjem.2017.10.34869] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2017] [Revised: 10/14/2017] [Accepted: 10/11/2017] [Indexed: 11/11/2022] Open
Abstract
Introduction The development of cardiac arrest centers and regionalization of systems of care may improve survival of patients with out-of-hospital cardiac arrest (OHCA). This survey of the local EMS agencies (LEMSA) in California was intended to determine current practices regarding the treatment and routing of OHCA patients and the extent to which EMS systems have regionalized OHCA care across California. Methods We surveyed all of the 33 LEMSA in California regarding the treatment and routing of OHCA patients according to the current recommendations for OHCA management. Results Two counties, representing 29% of the California population, have formally regionalized cardiac arrest care. Twenty of the remaining LEMSA have specific regionalization protocols to direct all OHCA patients with return of spontaneous circulation to designated percutaneous coronary intervention (PCI)-capable hospitals, representing another 36% of the population. There is large variation in LEMSA ability to influence inhospital care. Only 14 agencies (36%), representing 44% of the population, have access to hospital outcome data, including survival to hospital discharge and cerebral performance category scores. Conclusion Regionalized care of OHCA is established in two of 33 California LEMSA, providing access to approximately one-third of California residents. Many other LEMSA direct OHCA patients to PCI-capable hospitals for primary PCI and targeted temperature management, but there is limited regional coordination and system quality improvement. Only one-third of LEMSA have access to hospital data for patient outcomes.
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Affiliation(s)
- Brian L Chang
- University of California San Francisco School of Medicine, Department of Emergency Medicine, San Francisco, California
| | - Mary P Mercer
- University of California San Francisco School of Medicine, Department of Emergency Medicine, San Francisco, California
| | - Nichole Bosson
- Los Angeles County Emergency Medical Service Agency, Los Angeles, California.,Harbor-UCLA Medical Center and the Los Angeles Biomedical Research Institute, Carson, California
| | - Karl A Sporer
- University of California San Francisco School of Medicine, Department of Emergency Medicine, San Francisco, California.,Alameda County Emergency Medical Service Agency, Alameda, California
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Jollis JG, Al-Khalidi HR, Roettig ML, Berger PB, Corbett CC, Doerfler SM, Fordyce CB, Henry TD, Hollowell L, Magdon-Ismail Z, Kochar A, McCarthy JJ, Monk L, O’Brien P, Rea TD, Shavadia J, Tamis-Holland J, Wilson BH, Ziada KM, Granger CB. Impact of Regionalization of ST-Segment–Elevation Myocardial Infarction Care on Treatment Times and Outcomes for Emergency Medical Services–Transported Patients Presenting to Hospitals With Percutaneous Coronary Intervention. Circulation 2018; 137:376-387. [DOI: 10.1161/circulationaha.117.032446] [Citation(s) in RCA: 81] [Impact Index Per Article: 13.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/17/2017] [Accepted: 11/08/2017] [Indexed: 11/16/2022]
Abstract
Background:
Regional variations in reperfusion times and mortality in patients with ST-segment–elevation myocardial infarction are influenced by differences in coordinating care between emergency medical services (EMS) and hospitals. Building on the Accelerator-1 Project, we hypothesized that time to reperfusion could be further reduced with enhanced regional efforts.
Methods:
Between April 2015 and March 2017, we worked with 12 metropolitan regions across the United States with 132 percutaneous coronary intervention–capable hospitals and 946 EMS agencies. Data were collected in the ACTION (Acute Coronary Treatment and Intervention Outcomes Network)-Get With The Guidelines Registry for quarterly Mission: Lifeline reports. The primary end point was the change in the proportion of EMS-transported patients with first medical contact to device time ≤90 minutes from baseline to final quarter. We also compared treatment times and mortality with patients treated in hospitals not participating in the project during the corresponding time period.
Results:
During the study period, 10 730 patients were transported to percutaneous coronary intervention–capable hospitals, including 974 in the baseline quarter and 972 in the final quarter who met inclusion criteria. Median age was 61 years; 27% were women, 6% had cardiac arrest, and 6% had shock on admission; 10% were black, 12% were Latino, and 10% were uninsured. By the end of the intervention, all process measures reflecting coordination between EMS and hospitals had improved, including the proportion of patients with a first medical contact to device time of ≤90 minutes (67%–74%;
P
<0.002), a first medical contact to device time to catheterization laboratory activation of ≤20 minutes (38%–56%;
P
<0.0001), and emergency department dwell time of ≤20 minutes (33%–43%;
P
<0.0001). Of the 12 regions, 9 regions reduced first medical contact to device time, and 8 met or exceeded the national goal of 75% of patients treated in ≤90 minutes. Improvements in treatment times corresponded with a significant reduction in mortality (in-hospital death, 4.4%–2.3%;
P
=0.001) that was not apparent in hospitals not participating in the project during the same time period.
Conclusions:
Organization of care among EMS and hospitals in 12 regions was associated with significant reductions in time to reperfusion in patients with ST-segment–elevation myocardial infarction as well as in in-hospital mortality. These findings support a more intensive regional approach to emergency care for patients with ST-segment–elevation myocardial infarction.
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Affiliation(s)
- James G. Jollis
- Duke Clinical Research Institute, Duke University, Durham, NC (J.G.J., H.R.A.-K., M.L.R., S.D., A.K., L.M., J.S., C.B.G.)
- University of North Carolina, Chapel Hill (J.G.J.)
| | - Hussein R. Al-Khalidi
- Duke Clinical Research Institute, Duke University, Durham, NC (J.G.J., H.R.A.-K., M.L.R., S.D., A.K., L.M., J.S., C.B.G.)
| | - Mayme L. Roettig
- Duke Clinical Research Institute, Duke University, Durham, NC (J.G.J., H.R.A.-K., M.L.R., S.D., A.K., L.M., J.S., C.B.G.)
| | | | | | - Shannon M. Doerfler
- Duke Clinical Research Institute, Duke University, Durham, NC (J.G.J., H.R.A.-K., M.L.R., S.D., A.K., L.M., J.S., C.B.G.)
| | | | | | | | | | - Ajar Kochar
- Duke Clinical Research Institute, Duke University, Durham, NC (J.G.J., H.R.A.-K., M.L.R., S.D., A.K., L.M., J.S., C.B.G.)
| | - James J. McCarthy
- McGovern School of Medicine, University of Texas Health Science Center at Houston (J.J.M.)
| | - Lisa Monk
- Duke Clinical Research Institute, Duke University, Durham, NC (J.G.J., H.R.A.-K., M.L.R., S.D., A.K., L.M., J.S., C.B.G.)
| | | | | | - Jay Shavadia
- Duke Clinical Research Institute, Duke University, Durham, NC (J.G.J., H.R.A.-K., M.L.R., S.D., A.K., L.M., J.S., C.B.G.)
| | | | - B. Hadley Wilson
- Sanger Heart and Vascular Institute, Carolinas HealthCare System, Charlotte, NC (B.H.W.)
| | | | - Christopher B. Granger
- Duke Clinical Research Institute, Duke University, Durham, NC (J.G.J., H.R.A.-K., M.L.R., S.D., A.K., L.M., J.S., C.B.G.)
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The Society for Vascular Surgery practice guidelines on the care of patients with an abdominal aortic aneurysm. J Vasc Surg 2018; 67:2-77.e2. [DOI: 10.1016/j.jvs.2017.10.044] [Citation(s) in RCA: 1150] [Impact Index Per Article: 191.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
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45
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Lotfi AS, Klein LW. The Metamorphosis of ST-Segment Elevation Myocardial Infarction Programs. JACC Cardiovasc Interv 2017; 10:2574-2576. [DOI: 10.1016/j.jcin.2017.06.056] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/10/2017] [Revised: 06/16/2017] [Accepted: 06/20/2017] [Indexed: 10/18/2022]
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A Novel Survey Tool to Quantify the Degree and Duration of STEMI Regionalization Across California. Crit Pathw Cardiol 2017; 15:103-5. [PMID: 27465005 DOI: 10.1097/hpc.0000000000000085] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
INTRODUCTION California has been a global leader in regionalization efforts for time-critical medical conditions. A total of 33 local emergency medical service agencies (LEMSAs) exist, providing an organized EMS framework across the state for almost 40 years. We sought to develop a survey tool to quantify the degree and duration of ST-elevation myocardial infarction (STEMI) regionalization over the last decade in California. METHODS The project started with the development of an 8-question survey tool via a multi-disciplinary expert consensus process. Next, the survey tool was distributed at the annual meeting of administrators and medical directors of California LEMSAs to get responses valid through December, 2014. The first scoring approach was the Total Regionalization Score (TRS) and used answers from all 8 questions. The second approach was called the Core Score, and it focused on only 4 survey questions by assuming that the designation of STEMI Receiving Centers must have occurred at the beginning of any LEMSA's regionalization effort. Scores were ranked and grouped into tertiles. RESULTS All 33 LEMSAs in California participated in this survey. The TRS ranged from 15 to 162. The Core Score range was much narrower, from 2 to 30. In comparing TRS and Core Score rankings, the top-tertiles were quite similar. More rank variation occurred between mid- and low-tertiles. CONCLUSION This study evaluated the degree and duration of STEMI network regionalization from 2004 to 2014 in California, and ranked 33 LEMSAs into tertiles based upon their TRS and their Core Score. Successful application of the 8-item survey and ranking strategies across California suggests that this approach can be used to assess regionalization in other states or countries around the world.
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van Diepen S, Katz JN, Albert NM, Henry TD, Jacobs AK, Kapur NK, Kilic A, Menon V, Ohman EM, Sweitzer NK, Thiele H, Washam JB, Cohen MG. Contemporary Management of Cardiogenic Shock: A Scientific Statement From the American Heart Association. Circulation 2017; 136:e232-e268. [PMID: 28923988 DOI: 10.1161/cir.0000000000000525] [Citation(s) in RCA: 981] [Impact Index Per Article: 140.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Cardiogenic shock is a high-acuity, potentially complex, and hemodynamically diverse state of end-organ hypoperfusion that is frequently associated with multisystem organ failure. Despite improving survival in recent years, patient morbidity and mortality remain high, and there are few evidence-based therapeutic interventions known to clearly improve patient outcomes. This scientific statement on cardiogenic shock summarizes the epidemiology, pathophysiology, causes, and outcomes of cardiogenic shock; reviews contemporary best medical, surgical, mechanical circulatory support, and palliative care practices; advocates for the development of regionalized systems of care; and outlines future research priorities.
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Hsia RY, Sabbagh S, Sarkar N, Sporer K, Rokos IC, Brown JF, Brindis RG, Guo J, Shen YC. Trends in Regionalization of Care for ST-Segment Elevation Myocardial Infarction. West J Emerg Med 2017; 18:1010-1017. [PMID: 29085531 PMCID: PMC5654868 DOI: 10.5811/westjem.2017.8.34592] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2017] [Revised: 07/12/2017] [Accepted: 08/08/2017] [Indexed: 11/17/2022] Open
Abstract
Introduction California has led successful regionalized efforts for several time-critical medical conditions, including ST-segment elevation myocardial infarction (STEMI), but no specific mandated protocols exist to define regionalization of care. We aimed to study the trends in regionalization of care for STEMI patients in the state of California and to examine the differences in patient demographic, hospital, and county trends. Methods Using survey responses collected from all California emergency medical services (EMS) agencies, we developed four categories – no, partial, substantial, and complete regionalization – to capture prehospital and inter-hospital components of regionalization in each EMS agency’s jurisdiction between 2005–2014. We linked the survey responses to 2006 California non-public hospital discharge data to study the patient distribution at baseline. Results STEMI regionalization-of-care networks steadily developed across California. Only 14% of counties were regionalized in 2006, accounting for 42% of California’s STEMI patient population, but over half of these counties, representing 86% of California’s STEMI patient population, reached complete regionalization in 2014. We did not find any dramatic differences in underlying patient characteristics based on regionalization status; however, differences in hospital characteristics were relatively substantial. Conclusion Potential barriers to achieving regionalization included competition, hospital ownership, population density, and financial challenges. Minimal differences in patient characteristics can establish that patient differences unlikely played any role in influencing earlier or later regionalization and can provide a framework for future analyses evaluating the impact of regionalization on patient outcomes.
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Affiliation(s)
- Renee Y Hsia
- University of California, San Francisco, Department of Emergency Medicine, San Francisco, California.,University of California, San Francisco, Philip R. Lee Institute for Health Policy Studies, San Francisco, California
| | - Sarah Sabbagh
- University of California, San Francisco, Department of Emergency Medicine, San Francisco, California
| | - Nandita Sarkar
- National Bureau of Economic Research, Cambridge, Massachusetts
| | - Karl Sporer
- University of California, San Francisco, Department of Emergency Medicine, San Francisco, California.,Alameda County Emergency Medical Services Agency, Oakland, California
| | - Ivan C Rokos
- University of California, Los Angeles-Olive View Medical Center; Geffen School of Medicine, Los Angeles, California
| | - John F Brown
- University of California, San Francisco, Department of Emergency Medicine, San Francisco, California.,San Francisco Emergency Medical Services Agency, San Francisco, California
| | - Ralph G Brindis
- University of California, San Francisco, Philip R. Lee Institute for Health Policy Studies, San Francisco, California.,University of California, San Francisco, Department of Medicine, San Francisco, California
| | - Joanna Guo
- University of California, San Francisco, Department of Emergency Medicine, San Francisco, California
| | - Yu-Chu Shen
- National Bureau of Economic Research, Cambridge, Massachusetts.,Naval Postgraduate School, Graduate School of Business and Public Policy, Monterey, California
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Confronting system barriers for ST- elevation MI in low and middle income countries with a focus on India. Indian Heart J 2017; 70:185-190. [PMID: 29455776 PMCID: PMC5903067 DOI: 10.1016/j.ihj.2017.06.020] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2017] [Revised: 06/19/2017] [Accepted: 06/29/2017] [Indexed: 01/05/2023] Open
Abstract
Our previous research found seven specific factors that cause system delays in ST-elevation Myocardial infarction management in developing countries. These delays, in conjunction with a lack of organized STEMI systems of care, result in inefficient processes to treat AMI in developing countries. In our present opinion paper, we have specifically explored the three most pertinent causes that afflict the seven specific factors responsible for system delays. In doing so, we incorporated a unique strategy of global STEMI expertise. With this methodology, the recommendations were provided by expert Indian cardiologist and final guidelines were drafted after comprehensive discussions by the entire group of submitting authors. We expect these recommendations to be utilitarian in improving STEMI care in developing countries.
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50
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Fordyce CB, Henry TD, Granger CB. Implementation of Regional ST-Segment Elevation Myocardial Infarction Systems of Care: Successes and Challenges. Interv Cardiol Clin 2017; 5:415-425. [PMID: 28581992 DOI: 10.1016/j.iccl.2016.06.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Current guidelines recommend that communities create and maintain a regional system of ST-segment elevation myocardial infarction (STEMI) care that includes assessment and continuous quality improvement of emergency medical services and hospital-based activities. Availability and timely access is a challenge in many areas of the United States. This article reviews clinical trial data supporting the use of primary percutaneous coronary intervention as the optimal reperfusion strategy, and fibrinolysis as an option when this is not possible. It then describes the outcomes and benefits of implementing regional systems of STEMI care, and discusses ongoing challenges for STEMI system implementation, including inadequate data collection and feedback, and hospital and physician competition.
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Affiliation(s)
| | - Timothy D Henry
- Cedars-Sinai Heart Institute, 127 South San Vicente Boulevard, Suite A3100, Los Angeles, CA 90048, USA
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