Expedited transfer for primary percutaneous coronary intervention: a program evaluation

Temporal Trends in Reperfusion Delivery and Clinical Outcomes Following Implementation of a Regional STEMI Protocol – a 12 Year Perspective

Background

The Vancouver Coastal Health (VCH) ST-elevation myocardial infarction (STEMI) program aimed to increase access to primary percutaneous coronary intervention (PPCI) and reduce first-medical-contact-to-device times (FMC-DTs). We evaluated the long-term program impact on PPCI access and FMC-DT, and overall and reperfusion-specific in-hospital mortality.

Methods

We analyzed all VCH STEMI patients between June 2007 and November 2019. The primary outcome was the proportion of patients receiving PPCI over 4 program implementation phases over 12 years. We also evaluated overall changes in median FMC-DT and the proportion of patients achieving guideline-mandated FMC-DT, in addition to overall and reperfusion-specific in-hospital mortality.

Results

A total of 3138 of 4305 VCH STEMI patients were treated with PPCI. PPCI rates increased from 40.2% to 78.7% from 2007 to 2019 (P < 0.001). From phase 1 to 4, median FMC-DT improved from 118 to 93 minutes (percutaneous coronary intervention [PCI]-capable hospitals, P < 0.001) and from 174 to 118 minutes (non-PCI-capable hospitals, P < 0.001), with a concomitant increase in those achieving guideline-mandated FMC-DT (35.5% to 66.1%, P < 0.001). Overall in-hospital mortality was 9.0% (P = 0.20 across phases), with mortality differing significantly by reperfusion strategy (4.0% fibrinolysis, 5.7% PPCI, 30.6% no reperfusion therapy, P < 0.001). Mortality significantly decreased from phase 1 to phase 4 at non-PCI-capable centres (9.6% to 3.9%, P = 0.022) but not at PCI-capable centres (8.7% vs 9.9%, P = 0.27).

Conclusions

A regional STEMI program increased the proportion of patients who received PPCI and improved reperfusion times over 12 years. Although no statistically significant decrease occurred in overall regional mortality incidence, mortality incidence was decreased for patients presenting to non-PCI-capable centres.

Primary Percutaneous Coronary Intervention and Application of the Pharmacoinvasive Approach Within ST-Elevation Myocardial Infarction Care Networks

The management of acute ST-elevation myocardial infarction (STEMI) has transitioned from observation and reactive treatment of hemodynamic and arrhythmic complications to accelerated reperfusion and application of evidence-based treatment to minimize morbidity and mortality. International research established the importance of timely reperfusion therapy and the application of fibrinolysis, primary percutaneous coronary intervention (PCI), and subsequent development of the pharmacoinvasive approach. Clinician thought leaders developed and investigated comprehensive systems of care to optimize the outcomes of patients with STEMI, with a key focus in Canada being the integration of prehospital paramedics in diagnosis, triage, and treatment. This article will review highlights of these interventions and identify future challenges and opportunities in STEMI patient care.

Potential accuracy of prehospital NIHSS-based triage for selection of candidates for acute endovascular stroke therapy

OBJECTIVE

Whether patients with acute stroke and large vessel occlusion (LVO) benefit from prehospital identification and diversion by emergency medical services (EMS) to an endovascular stroke therapy (EST)-capable center is controversial. We sought to estimate the accuracy of field-based identification of potential EST candidates in a hypothetical best-of-all-worlds situation.

METHODS

In Kaiser Permanente Northern California, all acute stroke patients arriving at its 21 stroke centers between 7:00 am and midnight from January 2016 to December 2019 were evaluated by teleneurologists on arrival. Initial National Institutes of Health Stroke Scale (NIHSS) score, presence of LVO, and referral for EST were obtained from standardized teleneurology notes. Factors associated with LVO were evaluated using generalized estimating equations accounting for clustering by facility.

RESULTS

Among 13,377 patients brought in by EMS with potential stroke, 7168 (53.6%) were not candidates for acute stroke interventions. Of the remaining 6089 cases, 2,573 (42.3%) had an NIHSS score >10, the cutoff with a higher association for LVO. Only 703 patients (27.3% with NIHSS score >10) were ultimately diagnosed with LVO and referred for EST. Across all NIHSS scores, only 884 (6.6%) suspected acute stroke patients had LVO and EST referral.

CONCLUSIONS

Even if field-based tools were as accurate as NIHSS scoring and predictions by stroke neurologists, only about 1 in 4 acute stroke patients diverted to EST-capable centers would benefit by receiving EST. Depending on geography and stroke center performance on door-to-needle time, many systems may be better served by focusing on expediting evaluation, treatment with intravenous thrombolysis, and transfer to EST-capable centers.

2019 Canadian Cardiovascular Society/Canadian Association of Interventional Cardiology Guidelines on the Acute Management of ST-Elevation Myocardial Infarction: Focused Update on Regionalization and Reperfusion

Rapid reperfusion of the infarct-related artery is the cornerstone of therapy for the management of acute ST-elevation myocardial infarction (STEMI). Canada's geography presents unique challenges for timely delivery of reperfusion therapy for STEMI patients. The Canadian Cardiovascular Society/Canadian Association of Interventional Cardiology STEMI guideline was developed to provide advice regarding the optimal acute management of STEMI patients irrespective of where they are initially identified: in the field, at a non-percutaneous coronary intervention-capable centre or at a percutaneous coronary intervention-capable centre. We had also planned to evaluate and incorporate sex and gender considerations in the development of our recommendations. Unfortunately, inadequate enrollment of women in randomized trials, lack of publication of main outcomes stratified according to sex, and lack of inclusion of gender as a study variable in the available literature limited the feasibility of such an approach. The Grading Recommendations, Assessment, Development, and Evaluation system was used to develop specific evidence-based recommendations for the early identification of STEMI patients, practical aspects of patient transport, regional reperfusion decision-making, adjunctive prehospital interventions (oxygen, opioids, antiplatelet therapy), and procedural aspects of mechanical reperfusion (access site, thrombectomy, antithrombotic therapy, extent of revascularization). Emphasis is placed on integrating these recommendations as part of an organized regional network of STEMI care and the development of appropriate reperfusion and transportation pathways for any given region. It is anticipated that these guidelines will serve as a practical template to develop systems of care capable of providing optimal treatment for a wide range of STEMI patients.

Revisiting Health Regionalization in Canada

Twenty years ago, many of Canada’s provinces began to introduce regional health authorities to address problems with their health care systems. With this action, the provinces sought to achieve advances in community decision-making, the integration of health services, and the provision of care in the home and community. The authorities were also to help restrict health care costs. An assessment of the authorities indicates, however, that over the past two decades they have been unable to meet their objectives. Community representatives continue to play little role in determining the appropriate health services for their regions. Gains have been made towards integrating health services, but the plan for a near seamless set of health services has not been realized. Funding for health services remains focused on hospital and physician care, and health care expenditures have until very recently been little affected by regional authorities. This disappointing performance has caused some provinces to abandon their regional authorities, but this article argues that the provision of greater autonomy and a better public appreciation of their role and potential may lead to more successful regional authorities. Accordingly, the objective of this article is to reveal the shortcomings of regional health authorities in Canada while at the same time arguing that changes can be made to increase the chances of more workable authorities.

Area Median Income and Metropolitan Versus Nonmetropolitan Location of Care for Acute Coronary Syndromes: A Complex Interaction of Social Determinants

Background

Metropolitan versus nonmetropolitan status and area median income may independently affect care for and outcomes of acute coronary syndromes. We sought to determine whether location of care modifies the association among area income, receipt of cardiac catheterization, and mortality following an acute coronary syndrome in a universal health care system.

Methods and Results

We studied a cohort of 14 012 acute coronary syndrome patients admitted to cardiology services between April 18, 2004, and December 31, 2011, in southern Alberta, Canada. We used multivariable logistic regression to determine the odds of cardiac catheterization within 1 day and 7 days of admission and the odds of 30‐day and 1‐year mortality according to area median household income quintile for patients presenting at metropolitan and nonmetropolitan hospitals. In models adjusting for area income, patients who presented at nonmetropolitan facilities had lower adjusted odds of receiving cardiac catheterization within 1 day of admission (odds ratio 0.22, 95% CI 0.11–0.46, P<0.001). Among nonmetropolitan patients, when examined by socioeconomic status, each incremental decrease in income quintile was associated with 10% lower adjusted odds of receiving cardiac catheterization within 7 days (P<0.001) and 24% higher adjusted odds of 30‐day mortality (P=0.008) but no significant difference for 1‐year mortality (P=0.12). There were no differences in adjusted mortality among metropolitan patients.

Conclusion

Within a universal health care system, the association among area income and receipt of cardiac catheterization and 30‐day mortality differed depending on the location of initial medical care for acute coronary syndromes. Care protocols are required to improve access to care and outcomes in patients from low‐income nonmetropolitan communities.

Impact of a rapid access protocol on decreasing door-to-balloon time in acute ST elevation myocardial infarction

Objective:

Ischemic cardiovascular disease is the leading cause of death in Canada. In ST elevation myocardial infarction (STEMI), time to reperfusion is a key determinant in reducing morbidity and mortality with percutaneous coronary intervention (PCI) being the preferred reperfusion strategy. Where PCI is available, delays to definitive care include times to electrocardiogram (ECG) diagnosis and cardiovascular laboratory access. In 2004, the Cardiac Care Network of Ontario recommended implementation of an emergency department (ED) protocol to reduce reperfusion time by transporting patients with STEMI directly to the nearest catheterization laboratory. The model was implemented in Frontenac County in April 2005. The objective of this study was to assess the effectiveness of a protocol for rapid access to PCI in reducing door-to-balloon times in STEMI.

Methods:

Two 1-year periods before and after implementation of a rapid access to PCI protocol (ending March 2005 and June 2006, respectively) were studied. Administrative databases were used to identify all subjects with STEMI who were transported by regional emergency medical services (EMS) and received emergent PCI. The primary outcome measure was time from ED arrival to first balloon inflation (door-to-balloon time). Times are presented as medians and interquartile ranges (IQRs). Statistical comparisons were made using the Mann–Whitney U test and presented graphically with Kaplan–Meier curves.

Results:

Patients transported under the rapid access protocol (n = 39) were compared with historical controls (n = 42). Median door-to-balloon time was reduced from 87 minutes (IQR 67–108) preprotocol to 62 minutes (IQR 40–80) postprotocol (p &lt; 0.001).

Conclusion:

In our region, implementation of an EMS protocol for rapid access to PCI significantly reduced time to reperfusion for patients with STEMI.

Prehospital triage and direct transport of patients with ST-elevation myocardial infarction to primary percutaneous coronary intervention centres: a systematic review and meta-analysis

Objective:

Percutaneous coronary intervention (PCI) appears to be superior to in-hospital fibrinolysis for most patients with ST-elevation myocardial infarction (STEMI). However, few hospitals have PCI capability. The optimal prehospital strategy for facilitating rapid coronary reperfusion in STEMI patients is unclear. We sought to determine whether direct transport of adult STEMI patients by emergency medical services to primary PCI centres improves 30-day all-cause mortality when compared with a strategy of transportation to the closest hospital.

Methods:

We systematically searched MEDLINE, EMBASE, Cochrane “CENTRAL” database (1980-July 2007) and several other electronic databases. Two authors independently assessed citations for relevance. Two authors independently abstracted data from included studies. We included studies that, 1) transported patients directly to a PCI-capable centre for primary PCI, 2) had a control group that was transported to the closest hospital and 3) reported outcomes of treatment time intervals, all-cause mortality, reinfarction rate, stroke rate or the frequency of cardiogenic shock. We used a random effects model to provide pooled estimates of relative risk (RR) when data allowed.

Results:

We identified 2264 citations with the search. Five studies, including 980 STEMI patients, met inclusion criteria, and were clinically heterogeneous and of variable quality. Most studies were European (3/5) and involved physician out-of-hospital care providers. There was a trend toward increased survival with direct transport to primary PCI but this was not statistically significant (RR 0.51, 95% confidence interval [CI] 0.24–1.10). One study reported nonsignificant reductions in reinfarction (RR 0.43, 95% CI 0.11–1.60) and stroke (RR 0.33, 95% CI 0.01–8.06) with direct transport for primary PCI.

Conclusion:

There is insufficient evidence to support the effectiveness of direct transport of patients with STEMI for primary PCI when compared with transportation to the closest hospital.

Providing optimal regional care for ST-segment elevation myocardial infarction: a prospective cohort study of patients in the Hamilton Niagara Haldimand Brant Local Health Integration Network

BACKGROUND

Although considered the evidence-based best therapy for ST-segment elevation myocardial infarction (STEMI), many patients do not receive primary percutaneous coronary intervention (PCI) because of health care resource distribution and constraints. This study describes the clinical management and outcomes of all patients identified with STEMI within a region, including those who did not receive primary PCI.

METHODS

This study used a prospective cohort design. Patients presenting with STEMI to PCI- and non-PCI-capable hospitals in one integrated health region in Ontario were included in the study. The primary objective was to examine use of reperfusion strategies and timeliness of care. Secondary objectives included determining (through regression models) which variables were associated with mortality within 90 days, and describing patient uptake of risk-reducing therapies and activities post-STEMI.

RESULTS

Between Apr. 1, 2010, and Mar. 31, 2013, data were collected on 2247 consecutive patients presenting with STEMI. Patients presenting to the PCI-capable hospital were more likely to receive primary PCI (82.5% v. 65.2%, p < 0.001) and be treated within optimal treatment times. However, there was no appreciable difference in mortality at 90 days post-STEMI between patients presenting to PCI- and non-PCI-capable hospitals (7.8% v. 7.5%, p = 0.82), even after adjustment for acuity on presentation. Despite recognized risk factors, many patients were not taking evidence-based medications for risk factor modification before STEMI.

INTERPRETATION

A systematic approach to regional STEMI care focusing on timely access to the best available therapies, rather than the type of reperfusion provided alone, can yield favourable outcomes.

The impact of direct admission to a catheterisation lab/CCU in patients with ST-elevation myocardial infarction on the delay to reperfusion and early risk of death: results of a systematic review including meta-analysis

Background

For each hour of delay from fist medical contact until reperfusion in ST-elevation myocardial infarction (STEMI) there is a 10% increase in risk of death and heart failure. The aim of this review is to describe the impact of the direct admission of patients with STEMI to a Catheterisation laboratory (cath lab) as compared with transport to the emergency department (ED) with regard to delays and outcome.

Methods

Databases were searched for from April-June 2012 and updated January 2014: 1) Pubmed; 2) Embase; 3) Cochrane Library; 4) ProQuest Nursing and 5) Allied Health Sources. The search was restricted to studies in English, Swedish, Danish and Norwegian languages.

The intervention was a protocol-based clinical pre-hospital pathway and main outcome measurements were the delay to balloon inflation and hospital mortality.

Results

Median delay from door to balloon was significantly shorter in the intervention group in all 5 studies reported. Difference in median delay varied between 16 minutes and 47 minutes.

In all 7 included studies the time from symptom onset or first medical contact to balloon time was significantly shorter in the intervention group. The difference in median delay varied between 15 minutes and 1 hour and 35 minutes. Only two studies described hospital mortality. When combined the risk of death was reduced by 37%.

Conclusion

An overview of available studies of the impact of a protocol-based pre-hospital clinical pathway with direct admission to a cath lab as compared with the standard transport to the ED in ST-elevation AMI suggests the following. The delay to the start of revascularisation will be reduced. The clinical benefit is not clearly evidence based. However, the documented association between system delay and outcome defends the use of the pathway.

Electronic supplementary material

The online version of this article (doi:10.1186/s13049-014-0067-x) contains supplementary material, which is available to authorized users.

The effect of a regional care model on cardiac catheterization rates in patients with Acute Coronary Syndromes

BACKGROUND

Patients with ACS often present to community hospitals without on-site cardiac catheterization and revascularization therapies. Transfer to specialized cardiac procedural centers is necessary to provide access to these procedures. We evaluated process of care within a regional care model by comparing cardiac catheterization and revascularization rates and outcomes in ACS patients presenting to community and interventional hospitals.

METHODS

We evaluated a total of 6154 patients with ACS admitted to Southern Alberta hospitals (where a distinct regional care model for ACS exists) between January 1, 2005 and December 31, 2009. We compared cardiac catheterization and revascularization rates during index hospitalization among patients admitted to community and interventional hospitals. Thirty day and 1-year survival were also evaluated.

RESULTS

Catheterization was performed more often in patients presenting to community hospitals compared to the interventional facility (respectively 69.5% and 51.4%, p < 0.0001). Catheterization within 72 hours of admission occurred in 48% of patients presenting to the interventional center and in 68.3% of community patients (P < 0.0001). In patients undergoing catheterization, revascularization (PCI and/or CABG) was also performed more frequently in the community group (74.5% vs 56.1%, P < 0.0001). Risk adjusted mortality rates were the same for patients undergoing cardiac catheterization regardless of hospital of initial presentation.

CONCLUSION

ACS patients presenting to community centers associated with a regional care model had effective access to cardiac catheterization and revascularization. These findings support the importance of regional initiatives and processes of care that facilitate access to cardiac catheterization for all ACS patients.

Timely reperfusion for ST-segment elevation myocardial infarction: Effect of direct transfer to primary angioplasty on time delays and clinical outcomes

Primary percutaneous coronary intervention (PPCI) is the preferred reperfusion therapy for patients presenting with ST-segment elevation myocardial infarction (STEMI) when it can be performed expeditiously and by experienced operators. In spite of excellent clinical results this technique is associated with longer delays than thrombolysis and this fact may nullify the benefit of selecting this therapeutic option. Several strategies have been proposed to decrease the temporal delays to deliver PPCI. Among them, prehospital diagnosis and direct transfer to the cath lab, by-passing the emergency department of hospitals, has emerged as an attractive way of diminishing delays. The purpose of this review is to address the effect of direct transfer on time delays and clinical events of patients with STEMI treated by PPCI.

Endothelin-B Receptors and Left Ventricular Dysfunction after Regional versus Global Ischaemia-Reperfusion in Rat Hearts

Background. Endothelin-1 (ET-1) is implicated in left ventricular dysfunction after ischaemia-reperfusion. ETA and ETB receptors mediate diverse actions, but it is unknown whether these actions depend on ischaemia type and duration. We investigated the role of ETB receptors after four ischaemia-reperfusion protocols in isolated rat hearts. Methods. Left ventricular haemodynamic variables were measured in the Langendorff-perfused model after 40- and 20-minute regional or global ischaemia, followed by 30-minute reperfusion. Wild-type (n = 39) and ETB-deficient (n = 41) rats were compared. Infarct size was measured using fluorescent microspheres after regional ischaemia-reperfusion. Results. Left ventricular dysfunction was more prominent in ETB-deficient rats, particularly after regional ischaemia. Infarct size was smaller (P = 0.006) in wild-type (31.5 ± 4.4%) than ETB-deficient (45.0 ± 7.3%) rats after 40 minutes of regional ischaemia-reperfusion. Although the recovery of left ventricular function was poorer after 40-minute ischaemia-reperfusion, end-diastolic pressure in ETB-deficient rats was higher after 20 than after 40 minutes of regional ischaemia-reperfusion. Conclusion. ETB receptors exert cytoprotective effects in the rat heart, mainly after regional ischaemia-reperfusion. Longer periods of ischaemia suppress the recovery of left ventricular function after reperfusion, but the role of ETB receptors may be more important during the early phases.

To transmit or not to transmit: how good are emergency medical personnel in detecting STEMI in patients with chest pain?

BACKGROUND

There is growing use of prehospital electrocardiograms (ECGs) in establishing early diagnosis of ST segment myocardial infarction (STEMI) to facilitate early reperfusion. This study aimed to determine the predictive value of prehospital ECGs interpreted by nonphysician emergency medical services (EMS) in chest pain presentations.

METHODS

In our city of 658,700 people, EMS/paramedics received 21 hours of instruction on STEMI management, ECG acquisition, and interpretation. Suspected STEMI ECGs were wirelessly transmitted to and discussed with a physician for possible therapy. ECGs deemed negative for STEMI by EMS were not transmitted; patients were transported to the closest hospital without prehospital physician involvement.

RESULTS

From July 21, 2008 to July 21, 2010, there were 5426 chest pain calls to EMS, 380 were suspected STEMI cases. The remaining ECGs were deemed negative for STEMI by EMS. To audit the nontransmitted ECGs we analyzed 323 consecutive patients over 2 selected months (January and June 2010) for comparison. Of nontransmitted cases there was 1 missed and 2 STEMIs that developed subsequently. Based on 380 transmitted and 323 nontransmitted cases, the sensitivity and specificity of EMS detecting STEMI were 99.6% and 67.6%, respectively. The positive and negative predictive values for STEMI were 59.5% and 99.7%, respectively.

CONCLUSIONS

Our findings demonstrate nonphysician EMS interpretation of STEMI on prehospital ECG has excellent sensitivity and high negative predictive value. This finding supports the use of prehospital ECGs interpreted by EMS to help identify and facilitate treatment of STEMI. These results may have broad implications on staffing models for first responder/EMS units.

Emergency medical services response time and mortality in an urban setting

BACKGROUND

A common tenet in emergency medical services (EMS) is that faster response equates to better patient outcome, translated by some EMS operations into a goal of a response time of 8 minutes or less for advanced life support (ALS) units responding to life-threatening events.

OBJECTIVE

To explore whether an 8-minute EMS response time was associated with mortality.

METHODS

This was a one-year retrospective cohort study of adults with a life-threatening event as assessed at the time of the 9-1-1 call (Medical Priority Dispatch System Echo- or Delta-level event). The study setting was an urban all-ALS EMS system serving a population of approximately 1 million. Response time was defined as 9-1-1 call receipt to ALS unit arrival on scene, and outcome was defined as all-cause mortality at hospital discharge. Potential covariates included patient acuity, age, gender, and combined scene and transport interval time. Stratified analysis and logistic regression were used to assess the response time-mortality association.

RESULTS

There were 7,760 unit responses that met the inclusion criteria; 1,865 (24%) were ≥8 minutes. The average patient age was 56.7 years (standard deviation = 21.5). For patients with a response time ≥8 minutes, 7.1% died, compared with 6.4% for patients with a response time ≤7 minutes 59 seconds (risk difference 0.7%; 95% confidence interval [CI]: -0.5%, 2.0%). The adjusted odds ratio of mortality for ≥8 minutes was 1.19 (95% CI: 0.97, 1.47). An exploratory analysis suggested there may be a small beneficial effect of response ≤7 minutes 59 seconds for those who survived to become an inpatient (adjusted odds ratio = 1.30; 95% CI: 1.00, 1.69).

CONCLUSIONS

These results call into question the clinical effectiveness of a dichotomous 8-minute ALS response time on decreasing mortality for the majority of adult patients identified as having a life-threatening event at the time of the 9-1-1 call. However, this study does not suggest that rapid EMS response is undesirable or unimportant for certain patients. This analysis highlights the need for further research on who may benefit from rapid EMS response, whether these individuals can be identified at the time of the 9-1-1 call, and what the optimum response time is.

Temporal associations of early patient transfers and mortality with the implementation of a regional myocardial infarction care model

BACKGROUND

In order to reduce the delays encountered through patient transfer, regional care models have been developed that directly transport subsets of acute myocardial infarction (AMI) patients to hospitals with percutaneous coronary intervention (PCI) facilities. Calgary is a Canadian city that implemented this type of model in 2004.

METHODS

The study population included 9768 AMI patients admitted to Calgary hospitals between 1997 and 2007. Administrative data were used to define patients who were directly admitted to the PCI hospital and those transferred there after initial admission to a hospital without specialized cardiac care. The differences in clinical characteristics and mortality trends of patients grouped by hospital delivery site and transfer practice are described.

RESULTS

The proportion of patients directly admitted to a PCI hospital has increased with the implementation of a regional care model. Among patients admitted to non-PCI facilities, the patients who are transferred are younger, more likely to be male, have a shorter length of stay, and have lower proportions of several comorbid conditions. The risk-adjusted in-hospital mortality odds ratio for patients who received care at the PCI hospital postmodel relative to those treated at non-PCI hospitals premodel was 0.38 (95% confidence interval, 0.31-0.47). The corresponding adjusted odds ratio was 0.60 (0.47-0.76).

CONCLUSIONS

Our results suggest changing care over time and trends toward improved outcomes. Patients' clinical characteristics appear to play a major role in the decision to transfer. Avoidance of the risk treatment paradox through refinement of regional transfer protocols ought to be a priority.

Six Sigma process utilization in reducing door-to-balloon time at a single academic tertiary care center

BACKGROUND

Rapid reperfusion in patients with ST-elevation myocardial infarction (STEMI) is associated with lower mortality. Reduction in door-to-balloon (D2B) time for percutaneous coronary intervention requires multidisciplinary cooperation, process analysis, and quality improvement methodology.

METHODS

Six Sigma methodology was used to reduce D2B times in STEMI patients presenting to a tertiary care center. Specific steps in STEMI care were determined, time goals were established, and processes were changed to reduce each step's duration. Outcomes were tracked, and timely feedback was given to providers.

RESULTS

After process analysis and implementation of improvements, mean D2B times decreased from 128 to 90 minutes. Improvement has been sustained; as of June 2010, the mean D2B was 56 minutes, with 100% of patients meeting the 90-minute window for the year.

CONCLUSION

Six Sigma methodology and immediate provider feedback result in significant reductions in D2B times. The lessons learned may be extrapolated to other primary percutaneous coronary intervention centers.

Impact of a statewide ST-segment-elevation myocardial infarction regionalization program on treatment times for women, minorities, and the elderly

BACKGROUND

Prior studies have demonstrated differences in time to reperfusion for ST-segment-elevation myocardial infarction (STEMI) in women, minorities, and the elderly, relative to their counterparts. Regionalization has been shown to improve overall STEMI treatment times, but its impact on care differences among these important patient subgroups is unknown. The objective of this analysis was to assess the impact of a statewide system of STEMI care (The Reperfusion of Acute Myocardial Infarction in North Carolina Emergency Departments) on treatment times according to patient sex, race, and age.

METHODS AND RESULTS

STEMI treatment times were determined before (July 2005 to September 2005) and after (January 2007 to March 2007) a year-long implementation of coordinated regional treatment protocols. Times in the pre- and postintervention periods were compared by mixed-effects models. A total of 2063 STEMI patients were analyzed: 1140 at percutaneous coronary intervention hospitals and 923 at non-percutaneous coronary intervention hospitals. The Reperfusion of Acute Myocardial Infarction in North Carolina Emergency Departments was associated with significant improvements in treatment times in women and the elderly, including door-to-ECG, door-to-device, door-in-door-out, and door-to-needle times (all P<0.05). Temporal improvements in treatment times at percutaneous coronary intervention hospitals were not significantly different in blacks than in whites. There was a reduction in baseline treatment disparities in door-to-ECG times in women versus men (4.4-minute reduction in difference; 95% CI, -8.1 to -0.4; P=0.03). After Reperfusion of Acute Myocardial Infarction in North Carolina Emergency Departments, an age-treatment time gap persisted in the elderly, relative to younger patients.

CONCLUSIONS

A statewide STEMI regionalization program was associated with comparable improvement in treatment times for female, black, and elderly patients compared with middle-aged, white male patients. Nevertheless, there remain opportunities to further narrow treatment differences, particularly among the elderly.

Underuse of prehospital strategies to reduce time to reperfusion for ST-elevation myocardial infarction patients in 5 Canadian provinces

OBJECTIVE

Timely reperfusion therapy for ST-elevation myocardial infarction (STEMI) is an important determinant of outcome, yet targets for time to treatment are frequently unmet in North America. Prehospital strategies can reduce time to reperfusion. We sought to determine the extent to which emergency medical services (EMS) use these strategies in Canada.

METHODS

We carried out a cross-sectional survey in 2007 of ground EMS operators in British Columbia, Alberta, Ontario, Quebec and Nova Scotia. We focused on the use of 4 prehospital strategies: 1) 12-lead electrocardiogram (ECG), 2) routine expedited emergency department (ED) transfer of STEMI patients (from a referring ED to a percutaneous coronary intervention [PCI] centre), 3) prehospital bypass (ambulance bypass of local EDs to transport patients directly to PCI centres) and 4) prehospital fibrinolysis.

RESULTS

Ninety-seven ambulance operators were surveyed, representing 15 681 paramedics serving 97% of the combined provincial populations. Of the operators surveyed, 68% (95% confidence interval [CI] 59%-77%) had ambulances equipped with 12-lead ECGs, ranging from 40% in Quebec to 100% in Alberta and Nova Scotia. Overall, 47% (95% CI 46%-48%) of paramedics were trained in ECG acquisition and 40% (95% CI 39%-41%) were trained in ECG interpretation. Only 18% (95% CI 10%-25%) of operators had prehospital bypass protocols; 45% (95% CI 35%-55%) had protocols for expedited ED transfer. Prehospital fibrinolysis was available only in Alberta. All EMS operators in British Columbia, Alberta and Nova Scotia used at least 1 of the 4 prehospital strategies, and one-third of operators in Ontario and Quebec used 0 of 4. In major urban centres, at least 1 of the 3 prehospital strategies 12-lead ECG acquisition, bypass or expedited transfer was used, but there was considerable variation within and across provinces.

CONCLUSION

The implementation of widely recommended prehospital STEMI strategies varies substantially across the 5 provinces studied, and relatively simple existing technologies, such as prehospital ECGs, are underused in many regions. Substantial improvements in prehospital services and better integration with hospital-based care will be necessary in many regions of Canada if optimal times to reperfusion, and associated outcomes, are to be achieved.

Improving bedside to departure care in air transport of ST segment elevation myocardial infarction patients: a 2-year retrospective study of performance

INTRODUCTION

Rapid treatment after the initial diagnosis of an ST segment elevation myocardial infarction (STEMI) is critical to ensure positive outcomes. The objective of the study was to evaluate time-sensitive indicators adversely affecting performance during helicopter transport of STEMI patients from remote areas to a percutaenous coronary intervention (PCI) facility. A particular focus was to examine confounding factors that affected the time from arrival at bedside/event to the time of departure to a PCI facility.

METHODS

A 24-month retrospective chart audit of STEMI cases was undertaken. Data from initial liftoff to return of the patient from a referring facility were tracked for time-sequencing and patterns of events that lead to delayed transport. The standard deviation was used to assess abnormal variances.

RESULTS

No deaths were recorded from any of the 32 cases identified for inclusion in the study, and survival analysis was unobtainable. There was a significant correlation (r = 0.613, P = .0001) between time spent on the ground stabilizing the patient and total mission time. The need for the transport team to initiate vasopressor therapy was the most cited reason for delay in liftoff to the receiving facility.

CONCLUSION

Time from arrival at remote bedside and subsequent transfer to a PCI facility had the most variability. Enhancing communication times between referring agency and air medical personnel and stabilizing the patient before transport may be the most significant components in reducing transfer times and ensuring optimal outcomes.

Clinical pathways: effects on professional practice, patient outcomes, length of stay and hospital costs

BACKGROUND

Clinical pathways are structured multidisciplinary care plans used by health services to detail essential steps in the care of patients with a specific clinical problem. They aim to link evidence to practice and optimise clinical outcomes whilst maximising clinical efficiency.

OBJECTIVES

To assess the effect of clinical pathways on professional practice, patient outcomes, length of stay and hospital costs.

SEARCH STRATEGY

We searched the Database of Abstracts of Reviews of Effectiveness (DARE), the Effective Practice and Organisation of Care (EPOC) Register, the Cochrane Central Register of Controlled Trials (CENTRAL) and bibliographic databases including MEDLINE, EMBASE, CINAHL, NHS EED and Global Health. We also searched the reference lists of relevant articles and contacted relevant professional organisations.

SELECTION CRITERIA

Randomised controlled trials, controlled clinical trials, controlled before and after studies and interrupted time series studies comparing stand alone clinical pathways with usual care as well as clinical pathways as part of a multifaceted intervention with usual care.

DATA COLLECTION AND ANALYSIS

Two review authors independently screened all titles to assess eligibility and methodological quality. Studies were grouped into those comparing clinical pathways with usual care and those comparing clinical pathways as part of a multifaceted intervention with usual care.

MAIN RESULTS

Twenty-seven studies involving 11,398 participants met the eligibility and study quality criteria for inclusion. Twenty studies compared stand alone clinical pathways with usual care. These studies indicated a reduction in in-hospital complications (odds ratio (OR) 0.58; 95% confidence interval (CI) 0.36 to 0.94) and improved documentation (OR 13.65: 95%CI 5.38 to 34.64). There was no evidence of differences in readmission to hospital or in-hospital mortality. Length of stay was the most commonly employed outcome measure with most studies reporting significant reductions. A decrease in hospital costs/ charges was also observed, ranging from WMD +261 US$ favouring usual care to WMD -4919 US$ favouring clinical pathways (in US$ dollar standardized to the year 2000). Considerable heterogeneity prevented meta-analysis of length of stay and hospital cost results. An assessment of whether lower hospital costs contributed to cost shifting to another health sector was not undertaken.Seven studies compared clinical pathways as part of a multifaceted intervention with usual care. No evidence of differences were found between intervention and control groups.

AUTHORS' CONCLUSIONS

Clinical pathways are associated with reduced in-hospital complications and improved documentation without negatively impacting on length of stay and hospital costs.

Access to primary percutaneous coronary intervention for ST-segment elevation myocardial infarction in Canada: a geographic analysis

BACKGROUND

Primary percutaneous coronary intervention (PCI) is preferred over fibrinolysis for the treatment of ST-segment elevation myocardial infarction (STEMI). In the United States, nearly 80% of people aged 18 years and older have access to a PCI facility within 60 minutes. We conducted this study to evaluate the areas in Canada and the proportion of the population aged 40 years and older with access to a PCI facility within 60, 90 and 120 minutes.

METHODS

We used geographic information systems to estimate travel times by ground transport to PCI facilities across Canada. Time to dispatch, time to patient and time at the scene were considered in the overall access times. Using 2006 Canadian census data, we extracted the number of adults aged 40 years and older who lived in areas with access to a PCI facility within 60, 90 and 120 minutes. We also examined the effect on these estimates of the hypothetical addition of new PCI facilities in underserved areas.

RESULTS

Only a small proportion of the country's geographic area was within 60 minutes of a PCI facility. Despite this, 63.9% of Canadians aged 40 and older had such access. This proportion varied widely across provinces, from a low of 15.8% in New Brunswick to a high of 72.6% in Ontario. The hypothetical addition of a single facility to each of 4 selected provinces could increase the proportion by 3.2% to 4.3%, depending on the province. About 470 000 adults would gain access in such a scenario of new facilities.

INTERPRETATION

We found that nearly two-thirds of Canada's population aged 40 years and older had timely access to PCI facilities. The proportion varied widely across the country. Such information can inform the development of regionalized STEMI care models.

A survey of primary percutaneous coronary intervention for patients with ST segment elevation myocardial infarction in Canadian hospitals

BACKGROUND

Historically, access to primary percutaneous coronary intervention (PCI) for the treatment of patients with ST segment elevation myocardial infarction (STEMI) has been limited in Canada. Recent studies have identified innovative strategies to improve timely access and reduce reperfusion time. Accordingly, the contemporary use of primary PCI treatment in Canada was ascertained.

METHODS

A cross-sectional survey of all 38 Canadian hospitals that were capable of performing PCI procedures was conducted from June 2007 to November 2007. The survey focused on the practice of primary PCI for patients with STEMI and whether the hospitals had implemented internal strategies to reduce 'door-to-balloon' times. Analyses were performed at the level of geographical regions.

RESULTS

Overall, 71% of PCI hospitals (27 of 38) provided around-the-clock primary PCI for patients with STEMI, but the proportion of PCI hospitals offering this service varied widely, from 33% to 100% across regions. All Canadian PCI hospitals provided around-the-clock rescue PCI treatment to STEMI patients who had failed fibrinolytic therapy. In terms of strategies that are associated with reduced reperfusion time, it was observed that only 42% of PCI hospitals (16 of 38) provided feedback on door-to-balloon time to the emergency department and to the cardiac catheterization laboratories within one week of the primary PCI procedure. Overall, 24% of the hospitals had not adopted any of the four identified strategies to improve door-to-balloon time.

CONCLUSION

Although the majority of Canadian hospitals with PCI capability provide around-the-clock primary PCI for patients with STEMI, significant variations in this practice exist across the country. Canadian PCI hospitals have not consistently adopted strategies that are associated with improved door-to-balloon time.

Determining geographic areas and populations with timely access to cardiac catheterization facilities for acute myocardial infarction care in Alberta, Canada

Background

This study uses geographic information systems (GIS) as a tool to evaluate and visualize the general accessibility of areas within the province of Alberta (Canada) to cardiac catheterization facilities. Current American and European guidelines suggest performing catheterization within 90 minutes of the first medical contact. For this reason, this study evaluates the populated places that are within a 90 minute transfer time to a city with a catheterization facility. The three modes of transport considered in this study are ground ambulance, rotary wing air ambulance and fixed wing air ambulance.

Methods

Reference data from the Alberta Chart of Call were interpolated into continuous travel time surfaces. These continuous surfaces allowed for the delineation of isochrones: lines that connect areas of equal time. Using Dissemination Area (DA) centroids to represent the adult population, the population numbers were extracted from the isochrones using Statistics Canada census data.

Results

By extracting the adult population from within isochrones for each emergency transport mode analyzed, it was found that roughly 70% of the adult population of Alberta had access within 90 minutes to catheterization facilities by ground, roughly 66% of the adult population had access by rotary wing air ambulance and that no population had access within 90 minutes using the fixed wing air ambulance. An overall understanding of the nature of air vs. ground emergency travel was also uncovered; zones were revealed where the use of one mode would be faster than the others for reaching a facility.

Conclusion

Catheter intervention for acute myocardial infarction is a time sensitive procedure. This study revealed that although a relatively small area of the province had access within the 90 minute time constraint, this area represented a large proportion of the population. Within Alberta, fixed wing air ambulance is not an effective means of transporting patients to a catheterization facility within the 90 minute time frame, though it becomes advantageous as a means of transportation for larger distances when there is less urgency.

Reperfusion times for ST elevation myocardial infarction: a prospective audit

BACKGROUND

New published guidelines recommend treatment of ST elevation myocardial infarction (STEMI) within 30 minutes of first medical contact to thrombolysis and 90 minutes to primary percutaneous coronary intervention (PCI).

OBJECTIVES

To determine how a tertiary care center compares to these new guidelines and to evaluate the success of measures directed to shorten delays.

METHODS

This was a prospectively designed audit loop using retrospective chart review. Specific time intervals were evaluated: 1) T2 (ER presentation to diagnostic EKG; 2) T ER (ER presentation to reperfusion); and 3) T AHA (first medical contact to reperfusion). Results of the initial 12-month data were conveyed to Emergency Room staff and a dedicated EKG machine was placed in the ER for the subsequent 12 months, and the results were then re-analyzed.

RESULTS

In 2003-4, 58 patients with STEMI were identified, with 41 (70.7%) receiving reperfusion. Of those receiving thrombolysis, median T AHA was 54 [37-72] minutes, with 12.0%<30 minutes, while those receiving PCI, median T AHA was 58 [43-78] minutes, with 25.0%<90 minutes. In 2004-5, 52 patients had STEMI, with 40 (76.9%) receiving reperfusion. The percentage of patients meeting the guidelines was 14.3% for the thrombolysis group and 11.1% for the PCI group. Introduction of a dedicated EKG machine led to a strong trend towards improvement in median T2 (22 vs 10 minutes; P=0.07), but other treatment times remained unchanged.

CONCLUSIONS

Treatment times are longer than recommended guidelines. More comprehensive strategies and improved coordination of medical services are required to shorten pre-contact and post-contact response times.