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Nelson BD, McLaughlin CJ, Rivera OE, Kaul K, Ferdock AJ, Matuzsan ZM, Yazdanyar AR, Gopal JV, Patel AY, Chaska RM, Feldman BA, Jacoby JL. Implementation of a Novel Prehospital Clinical Decision Tool and ECG Transmission for STEMI Significantly Reduces Door-to-Balloon Time and Sex-Based Disparities. PREHOSP EMERG CARE 2024:1-7. [PMID: 38771723 DOI: 10.1080/10903127.2024.2357595] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2024] [Accepted: 04/30/2024] [Indexed: 05/23/2024]
Abstract
BACKGROUND An important method employed to reduce door to balloon time (DTBT) for ST segment elevation Myocardial Infarctions (STEMIs) is a prehospital MI alert. The purpose of this retrospective study was to examine the effects of an educational intervention using a novel decision support method of STEMI notification and prehospital electrocardiogram (ECG) transmission on DTBT. METHODS An ongoing database (April 4, 2000 - present) is maintained to track STEMI alerts. In 2007, an MI alert program began; emergency medicine physicians could activate a "prehospital MI alert". In October 2015, modems were purchased for Emergency Medical Services personnel to transmit ECGs. There was concurrent implementation of a decision support tool for identifying STEMI. Sex was assigned as indicated in the medical record. Data were analyzed in two groups: Pre-2016 (PRE) and 2016-2022 (POST). RESULTS In total, 3,153 patients (1,301 PRE; 1,852 POST) were assessed; the average age was 65.2 years, 32.6% female, 87.7% white with significant differences in age and race between the two cohorts. Of the total 3,153 MI alerts, 239 were false activations, leaving 2,914 for analysis. 2,115 (72.6%) had cardiac catheterization while 16 (6.7%) of the 239 had a cardiac catheterization. There was an overall decrease in DTBT of 27.5% PRE to POST of prehospital ECG transmission (p < 0.001); PRE median time was 74.5 min vs. 55 min POST. There was no significant difference between rates of cardiac catheterization PRE and POST for all patients. After accounting for age, race, and mode of arrival, DTBT was 12.2% longer in women, as compared to men (p < 0.001) PRE vs. POST. DTBT among women was significantly shorter when comparing PRE to POST periods (median 77 min vs. 60 min; p = 0.0001). There was no significant sex difference in the proportion of those with cardiac catheterization between the two cohorts (62.5% vs. 63.5%; p = 0.73). CONCLUSION Introduction of a decision support tool with prehospital ECG transmission with prehospital ECG transmission decreased overall DTBT by 20 min (27.5%). Women in the study had a 17-minute decrease in DTBT (22%), but their DTBT remained 12.2% longer than men for reasons that remain unclear.
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Affiliation(s)
- Bryan D Nelson
- Lehigh Valley Health Network, Morsani College of Medicine, Heart and Vascular Institute/University of South Florida, Allentown, Pennsylvania
| | - Conor J McLaughlin
- Lehigh Valley Health Network, Department of Emergency and Hospital Medicine, Morsani College of Medicine, University of South Florida, Allentown, Pennsylvania
| | - Orlando E Rivera
- Lehigh Valley Health Network, Morsani College of Medicine, Heart and Vascular Institute/University of South Florida, Allentown, Pennsylvania
- Emergency Medical Services, Hospital of Second Chances Health System, Norristown, Pennsylvania
| | - Kashyap Kaul
- Lehigh Valley Health Network, Department of Emergency and Hospital Medicine, Morsani College of Medicine, University of South Florida, Allentown, Pennsylvania
| | - Andrew J Ferdock
- Lehigh Valley Health Network, Department of Emergency and Hospital Medicine, Morsani College of Medicine, University of South Florida, Allentown, Pennsylvania
| | - Zachary M Matuzsan
- Lehigh Valley Health Network, Department of Emergency and Hospital Medicine, Morsani College of Medicine, University of South Florida, Allentown, Pennsylvania
- Center for Health Care Education, Morsani College of Medicine, Lehigh Valley Health Network Campus, University of South Florida, Center Valley, Pennsylvania
| | - Ali R Yazdanyar
- Lehigh Valley Health Network, Department of Emergency and Hospital Medicine, Morsani College of Medicine, University of South Florida, Allentown, Pennsylvania
- Department of Medicine, Division of Hospital Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Jay V Gopal
- Center for Health Care Education, Morsani College of Medicine, Lehigh Valley Health Network Campus, University of South Florida, Center Valley, Pennsylvania
- Department of Internal Medicine, Medical University of South Carolina, Charleston, South Carolina
| | - Ayushi Y Patel
- Center for Health Care Education, Morsani College of Medicine, Lehigh Valley Health Network Campus, University of South Florida, Center Valley, Pennsylvania
- Lehigh Valley Health Network, Department of Obstetrics and Gynecology, University of South Florida, Morsani College of Medicine, Allentown, Pennsylvania
| | - Rachael M Chaska
- Center for Health Care Education, Morsani College of Medicine, Lehigh Valley Health Network Campus, University of South Florida, Center Valley, Pennsylvania
- Department of Emergency Medicine, Henry Ford Hospital, Detroit, Michigan
| | - Bruce A Feldman
- Lehigh Valley Health Network, Morsani College of Medicine, Heart and Vascular Institute/University of South Florida, Allentown, Pennsylvania
| | - Jeanne L Jacoby
- Lehigh Valley Health Network, Department of Emergency and Hospital Medicine, Morsani College of Medicine, University of South Florida, Allentown, Pennsylvania
- Center for Health Care Education, Morsani College of Medicine, Lehigh Valley Health Network Campus, University of South Florida, Center Valley, Pennsylvania
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Byrne RA, Rossello X, Coughlan JJ, Barbato E, Berry C, Chieffo A, Claeys MJ, Dan GA, Dweck MR, Galbraith M, Gilard M, Hinterbuchner L, Jankowska EA, Jüni P, Kimura T, Kunadian V, Leosdottir M, Lorusso R, Pedretti RFE, Rigopoulos AG, Rubini Gimenez M, Thiele H, Vranckx P, Wassmann S, Wenger NK, Ibanez B. 2023 ESC Guidelines for the management of acute coronary syndromes. EUROPEAN HEART JOURNAL. ACUTE CARDIOVASCULAR CARE 2024; 13:55-161. [PMID: 37740496 DOI: 10.1093/ehjacc/zuad107] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 09/24/2023]
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3
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Byrne RA, Rossello X, Coughlan JJ, Barbato E, Berry C, Chieffo A, Claeys MJ, Dan GA, Dweck MR, Galbraith M, Gilard M, Hinterbuchner L, Jankowska EA, Jüni P, Kimura T, Kunadian V, Leosdottir M, Lorusso R, Pedretti RFE, Rigopoulos AG, Rubini Gimenez M, Thiele H, Vranckx P, Wassmann S, Wenger NK, Ibanez B. 2023 ESC Guidelines for the management of acute coronary syndromes. Eur Heart J 2023; 44:3720-3826. [PMID: 37622654 DOI: 10.1093/eurheartj/ehad191] [Citation(s) in RCA: 549] [Impact Index Per Article: 549.0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 08/26/2023] Open
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de Vries NM, Zepeda-Echavarria A, van de Leur RR, Loen V, Vos MA, Boonstra MJ, Wildbergh TX, Jaspers JE, van der Zee R, Slump CH, Doevendans PA, van Es R. Detection of Ischemic ST-Segment Changes Using a Novel Handheld ECG Device in a Porcine Model. JACC. ADVANCES 2023; 2:100410. [PMID: 38939006 PMCID: PMC11198505 DOI: 10.1016/j.jacadv.2023.100410] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/20/2022] [Revised: 03/20/2023] [Accepted: 05/08/2023] [Indexed: 06/29/2024]
Abstract
Background Portable, smartphone-sized electrocardiography (ECG) has the potential to reduce time to treatment for patients suffering acute cardiac ischemia, thereby lowering the morbidity and mortality. In the UMC Utrecht, a portable, smartphone-sized, multi-lead precordial ECG recording device (miniECG 1.0, UMC Utrecht) was developed. Objectives The purpose of this study was to investigate the ability of the miniECG to capture ischemic ECG changes in a porcine coronary occlusion model. Methods In 8 animals, antero-septal myocardial infarction was induced by 75-minute occlusion of the left anterior descending artery, after the first or second diagonal. MiniECG and 12-lead ECG recordings were acquired simultaneously before, during and after coronary artery occlusion and ST-segment deviation was evaluated. Results During the complete occlusion and reperfusion period, miniECG showed large ST-segment deviation in comparison to 12-lead ECG. MiniECG ST-segment deviation was observed within 1 minute for most animals. The miniECG was positive for ischemia (ie, ST-segment deviation ≥1 mm) for 99.7% (Q1-Q3: 99.6%-99.9%) of the occlusion time, while the 12-lead was only positive for 79.8% (Q1-Q3: 81.1%-98.7%) of the time (P = 0.018). ST-segment deviation reached maxima of 10.5 mm [95% CI: 6.5-14.5 mm] vs 5.0 mm [95% CI: 2.0-8.0 mm] for the miniECG vs 12-lead ECG, respectively. Conclusions MiniECG ST-segment deviation was observed early and was of large magnitude during 75 minutes of porcine transmural antero-septal infarction. The miniECG was positive for ischemia for the complete occlusion period. These findings demonstrate the potential of the miniECG in the detection of cardiac ischemia. Although clinical research is required, data suggests that the miniECG is a promising tool for the detection of cardiac ischemia.
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Affiliation(s)
- Nynke M. de Vries
- Department of Cardiology, University Medical Center Utrecht, Utrecht University, Utrecht, the Netherlands
- TechMed Centre, University of Twente, Enschede, the Netherlands
| | - Alejandra Zepeda-Echavarria
- Department of Medical Technology and Clinical Physics, University Medical Center Utrecht, Utrecht University, Utrecht, the Netherlands
| | - Rutger R. van de Leur
- Department of Cardiology, University Medical Center Utrecht, Utrecht University, Utrecht, the Netherlands
| | - Vera Loen
- Department of Medical Physiology, University Medical Center Utrecht, Utrecht University, Utrecht, the Netherlands
| | - Marc A. Vos
- Department of Medical Physiology, University Medical Center Utrecht, Utrecht University, Utrecht, the Netherlands
| | - Machteld J. Boonstra
- Department of Cardiology, University Medical Center Utrecht, Utrecht University, Utrecht, the Netherlands
| | | | - Joris E.N. Jaspers
- Department of Medical Technology and Clinical Physics, University Medical Center Utrecht, Utrecht University, Utrecht, the Netherlands
| | - Rien van der Zee
- Stichting Cardiovasculaire Biologie, Delft, the Netherlands
- HeartEye B.V., Delft, the Netherlands
| | | | - Pieter A. Doevendans
- Department of Cardiology, University Medical Center Utrecht, Utrecht University, Utrecht, the Netherlands
- HeartEye B.V., Delft, the Netherlands
- Netherlands Heart Institute, Utrecht, the Netherlands
| | - René van Es
- Department of Cardiology, University Medical Center Utrecht, Utrecht University, Utrecht, the Netherlands
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Kuc A, Isenberg DL, Kraus CK, Ackerman D, Sigal A, Herres J, Brandler ES, Cooney DR, Nomura JT, Mullen MT, Zhao H, Gentile NT. Factors associated with door-in-door-out times in large vessel occlusion stroke patients undergoing endovascular therapy. Am J Emerg Med 2023; 69:87-91. [PMID: 37084482 DOI: 10.1016/j.ajem.2023.04.009] [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: 12/05/2022] [Revised: 03/30/2023] [Accepted: 04/04/2023] [Indexed: 04/23/2023] Open
Abstract
INTRODUCTION In the management of large vessel occlusion stroke (LVOS), patients are frequently evaluated first at a non-endovascular stroke center and later transferred to an endovascular stroke center (ESC) for endovascular treatment (EVT). The door-in-door-out time (DIDO) is frequently used as a benchmark for transferring hospitals though there is no universally accepted nor evidenced-based DIDO time. The goal of this study was to identify factors affecting DIDO times in LVOS patients who ultimately underwent EVT. METHODS The Optimizing Prehospital Use of Stroke Systems of Care-Reacting to Changing Paradigms (OPUS-REACH) registry is comprised of all LVOS patients who underwent EVT at one of nine endovascular centers in the Northeast United States between 2015 and 2020. We queried the registry for all patients who were transferred from a non-ESC to one of the nine ESCs for EVT. Univariate analysis was performed using t-tests to obtain a p value. A priori, we defined a p value of <0.05 as significant. Multiple logistic regression was conducted to determine the association of variables to estimate an odds ratio. RESULTS 511 patients were included in the final analysis. The mean DIDO times for all patients was 137.8 min. Vascular imaging and treatment at a non-certified stroke center were associated with longer DIDO times by 23 and 14 min, respectively. On multivariate analyses, the acquisition of vascular imaging was associated with 16 additional minutes spent at the non-ESC while presentation to a non-stroke certified hospital was associated with 20 additional minutes spent at the transferring hospital. The administration of intravenous thrombolysis (IVT) was associated with 15 min less spent at the non-ESC. DISCUSSION Vascular imaging and non-stroke certified stroke centers were associated with longer DIDO times. Non-ESCs should integrate vascular imaging into their workflow as feasible to reduce DIDO times. Further work examining other details regarding the transfer process such as transfer via ground or air, could help further identify opportunities to improve DIDO times.
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Affiliation(s)
- Alexander Kuc
- Department of Emergency Medicine, Cooper University Hospital, United States of America
| | - Derek L Isenberg
- Department of Emergency Medicine, Lewis Katz School of Medicine at Temple University, United States of America.
| | - Chadd K Kraus
- Department of Emergency Medicine, Geisinger, United States of America
| | - Daniel Ackerman
- Department of Neurology, St. Lukes Health System, United States of America
| | - Adam Sigal
- Department of Emergency Medicine, Tower Health, United States of America
| | - Joseph Herres
- Department of Emergency Medicine, Einstein Health System, United States of America
| | - Ethan S Brandler
- Department of Emergency Medicine, State University of New York-Stony Brook, United States of America
| | - Derek R Cooney
- Department of Emergency Medicine, State University of New York-Upstate, United States of America
| | - Jason T Nomura
- Department of Emergency Medicine, Christiana Care, United States of America
| | - Michael T Mullen
- Department of Neurolology, Lewis Katz School of Medicine at Temple University, United States of America
| | - Huaqing Zhao
- Center for Biostatistics and Epidemiology, Department of Biomedical Education and Data Science, Lewis Katz School of Medicine at Temple University, United States of America
| | - Nina T Gentile
- Department of Emergency Medicine, Lewis Katz School of Medicine at Temple University, United States of America
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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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Baldi E, Camporotondo R, Gnecchi M, Totaro R, Guida S, Costantino I, Repetto A, Savastano S, Sacchi MC, Bollato C, Giglietta F, Oltrona Visconti L, Leonardi S. Barriers associated with emergency medical service activation in patients with ST-segment elevation acute coronary syndromes. Intern Emerg Med 2022; 17:1165-1174. [PMID: 34826051 PMCID: PMC8616749 DOI: 10.1007/s11739-021-02894-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/04/2021] [Accepted: 11/13/2021] [Indexed: 11/12/2022]
Abstract
Many ST-segment elevation acute coronary syndrome (STEACS) patients fail to activate the Emergency Medical System (EMS), with possible dramatic consequences. Prior studies focusing on barriers to EMS activation included patients with any acute coronary syndrome (ACS) without representation of southern European populations. We aimed to investigate the barriers to EMS call for patients diagnosed for STEACS in Italy. A prospective, single-center, survey administered to all patients treated with primary percutaneous coronary intervention for STEACS in a tertiary hospital in northern Italy from 01/06/2018 to 31/05/2020. The questionnaire was filled out by 293 patients. Of these, 191 (65.2%) activated the EMS after symptoms onset. The main reasons for failing to contact EMS were the perception that the symptoms were unrelated to an important health problem (45.5%) and that a private vehicle is faster than EMS to reach the hospital (34.7%). Patients who called a private doctor after symptoms onset did not call EMS more frequently than those who did not and 30% of the patients who did not call the EMS would still act in the same way if a new episode occurred. Previous history of cardiovascular disease was the only predictor of EMS call. Information campaigns are urgently needed to increase EMS activation in case of suspected STEACS and should be primary focused on patients without cardiovascular history, on the misperception that a private vehicle is faster than EMS activation, and on the fact that cardiac arrest occurs early and may be prevented by EMS activation.
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Affiliation(s)
- Enrico Baldi
- Department of Molecular Medicine, Section of Cardiology, c/o Fondazione IRCCS Policlinico San Matteo, University of Pavia, Viale Golgi 19, 27100, Pavia, Italy.
- Cardiac Intensive Care Unit, Arrhythmia and Electrophysiology and Experimental Cardiology, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy.
| | - Rita Camporotondo
- Cardiac Intensive Care Unit, Arrhythmia and Electrophysiology and Experimental Cardiology, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy
| | - Massimiliano Gnecchi
- Department of Molecular Medicine, Section of Cardiology, c/o Fondazione IRCCS Policlinico San Matteo, University of Pavia, Viale Golgi 19, 27100, Pavia, Italy
- Cardiac Intensive Care Unit, Arrhythmia and Electrophysiology and Experimental Cardiology, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy
| | - Rossana Totaro
- Cardiac Intensive Care Unit, Arrhythmia and Electrophysiology and Experimental Cardiology, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy
| | - Stefania Guida
- Cardiac Intensive Care Unit, Arrhythmia and Electrophysiology and Experimental Cardiology, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy
| | - Ilaria Costantino
- Cardiac Intensive Care Unit, Arrhythmia and Electrophysiology and Experimental Cardiology, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy
| | - Alessandra Repetto
- Division of Cardiology, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy
| | - Simone Savastano
- Division of Cardiology, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy
| | - Maria Clara Sacchi
- Cardiac Intensive Care Unit, Arrhythmia and Electrophysiology and Experimental Cardiology, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy
| | - Carola Bollato
- Anestesia E Rianimazione II Cardiopolmonare, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy
| | - Federica Giglietta
- Department of Molecular Medicine, Section of Cardiology, c/o Fondazione IRCCS Policlinico San Matteo, University of Pavia, Viale Golgi 19, 27100, Pavia, Italy
| | | | - Sergio Leonardi
- Department of Molecular Medicine, Section of Cardiology, c/o Fondazione IRCCS Policlinico San Matteo, University of Pavia, Viale Golgi 19, 27100, Pavia, Italy
- Cardiac Intensive Care Unit, Arrhythmia and Electrophysiology and Experimental Cardiology, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy
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Sturm RC, Jones TL, Youngquist ST, Shah RU. Regional Systems of Care in ST Elevation Myocardial Infarction. Interv Cardiol Clin 2021; 10:281-291. [PMID: 34053615 DOI: 10.1016/j.iccl.2021.03.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/12/2023]
Abstract
ST-segment elevation myocardial infarction is a medical emergency with significant health care delivery challenges to ensure rapid triage and treatment. Several developments over the past decades have led to improved care delivery, decreased time to reperfusion, and decreased mortality. Still, significant challenges remain to further optimize the delivery of care for this patient population.
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Affiliation(s)
- Robert C Sturm
- Division of Cardiovascular Medicine, University of Utah, 30 N. 1900 E, Room 4A100, Salt Lake City, UT, 84132, USA.
| | - Tara L Jones
- Division of Cardiovascular Medicine, University of Utah, 30 N. 1900 E, Room 4A100, Salt Lake City, UT, 84132, USA
| | - Scott T Youngquist
- Division of Emergency Medicine, University of Utah, 30 N 1900 E 1C026, Salt Lake City, UT 84132, USA
| | - Rashmee U Shah
- Division of Cardiovascular Medicine, University of Utah, 30 N. 1900 E, Room 4A100, Salt Lake City, UT, 84132, USA
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Lazarus G, Kirchner HL, Siswanto BB. Prehospital tele-electrocardiographic triage improves the management of acute coronary syndrome in rural populations: A systematic review and meta-analysis. J Telemed Telecare 2020; 28:632-641. [PMID: 32996348 DOI: 10.1177/1357633x20960627] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
INTRODUCTION Acute coronary syndrome (ACS) patients residing in rural areas are predisposed to higher risk of poor outcomes due to substantial delays in disease management, emphasising the importance of emerging telecardiology technologies in delivering emergency services in such settings. This meta-analysis aimed to investigate the impacts of prehospital telecardiology strategies on the clinical outcomes of rural ACS patients. METHODS A literature search was performed of articles published up to April 2020 through six databases. Included studies were assessed for bias risk using the ROBINS-I tool, and a random-effects model was utilised to estimate effect sizes. Certainty of evidence was assessed using the Grading of Recommendations Assessment, Development, and Evaluation (GRADE). RESULTS Twelve studies with a total of 3989 patients were included in this review. Prehospital telecardiology in the form of tele-electrocardiography (tele-ECG) enabled prompt diagnosis and triage, resulting in a decreased door-to-balloon (DTB) time (mean difference = -25.53 minutes, 95% confidence interval (CI) -36.08 to -14.97 minutes; I2 = 98%), as well as lower in-hospital mortality (odds ratio (OR) = 0.57, 95% CI 0.36-0.92) and long-term mortality (OR = 0.52, 95% CI 0.39-0.69) rates, both with negligible heterogeneity (I2 = 0%). GRADE assessment yielded very low to moderate certainty of evidence.Conclusion Prehospital tele-ECG appeared to be an effective and worthwhile approach in the management of rural ACS patients, as shown by moderate quality evidence on lower long-term mortality. Given the uncertainties of the evidence quality on DTB time and in-hospital mortality, future studies with a higher quality of evidence are required to confirm our findings.
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Affiliation(s)
| | - H L Kirchner
- Department of Population Health Sciences, Geisinger Clinic, USA
| | - Bambang B Siswanto
- Department of Cardiology and Vascular Medicine, Faculty of Medicine, Universitas Indonesia, National Cardiovascular Center Harapan Kita, Indonesia
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Zeitouni M, Al-Khalidi HR, Roettig ML, Bolles MM, Doerfler SM, Fordyce CB, Hellkamp AS, Henry TD, Magdon-Ismail Z, Monk L, Nelson RD, O’Brien PK, Wilson BH, Ziada KM, Granger CB, Jollis JG. Catheterization Laboratory Activation Time in Patients Transferred With ST-Segment–Elevation Myocardial Infarction: Insights From the Mission: Lifeline STEMI Accelerator-2 Project. Circ Cardiovasc Qual Outcomes 2020; 13:e006204. [DOI: 10.1161/circoutcomes.119.006204] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background:
Catheterization laboratory (cath lab) activation time is a newly available process measure for patients with ST-segment–elevation myocardial infarction requiring inter-hospital transfers for primary percutaneous coronary intervention that reflects inter-facility communication and urgent mobilization of interventional laboratory resources. Our aim was to determine whether faster activation is associated with improved reperfusion time and outcomes in the American Heart Association Mission: Lifeline Accelerator-2 Project.
Methods and Results:
From April 2015 to March 2017, treatment times of 2063 patients with ST-segment–elevation myocardial infarction requiring inter-hospital transfer for primary percutaneous coronary intervention from 12 regions around the United States were stratified by cath lab activation time (first hospital arrival to cath lab activation within [timely] or beyond 20 minutes [delayed]). Median cath lab activation time was 26 minutes, with a delayed activation observed in 1241 (60.2%) patients. Prior cardiovascular or cerebrovascular disease, arterial hypotension at admission, and black or Latino ethnicity were independent factors of delayed cath lab activation. Timely cath lab activation patients had shorter door-in door-out times (40 versus 68 minutes) and reperfusion times (98 versus 135 minutes) with 80.1% treated within the national goal of ≤120 minutes versus 39.0% in the delayed group.
Conclusions:
Cath lab activation within 20 minutes across a geographically diverse group of hospitals was associated with performing primary percutaneous coronary intervention within the national goal of ≤120 minutes in >75% of patients. While several confounding factors were associated with delayed activation, this work suggests that this process measure has the potential to direct resources and practices to more timely treatment of patients requiring inter-hospital transfer for primary percutaneous coronary intervention.
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Affiliation(s)
- Michel Zeitouni
- Duke Clinical Research Institute, Durham, NC (M.Z., H.R.A.-K., M.L.R., S.M.D., A.S.H., L.M., C.B.G.)
| | - Hussein R. Al-Khalidi
- Duke Clinical Research Institute, Durham, NC (M.Z., H.R.A.-K., M.L.R., S.M.D., A.S.H., L.M., C.B.G.)
| | - Mayme L. Roettig
- Duke Clinical Research Institute, Durham, NC (M.Z., H.R.A.-K., M.L.R., S.M.D., A.S.H., L.M., C.B.G.)
| | | | - Shannon M. Doerfler
- Duke Clinical Research Institute, Durham, NC (M.Z., H.R.A.-K., M.L.R., S.M.D., A.S.H., L.M., C.B.G.)
| | | | - Anne S. Hellkamp
- Duke Clinical Research Institute, Durham, NC (M.Z., H.R.A.-K., M.L.R., S.M.D., A.S.H., L.M., C.B.G.)
| | - Timothy D. Henry
- The Carl and Edyth Lindner Center for Research and Education at The Christ Hospital, Cincinnati, OH (T.D.H.)
| | | | - Lisa Monk
- Duke Clinical Research Institute, Durham, NC (M.Z., H.R.A.-K., M.L.R., S.M.D., A.S.H., L.M., C.B.G.)
| | | | | | - B. Hadley Wilson
- Sanger Heart and Vascular Institute, Atrium Health, Charlotte, NC (B.H.W.)
| | - Khaled M. Ziada
- Gill Heart & Vascular Institute University of Kentucky, Lexington (K.M.Z.)
| | - Christopher B. Granger
- Duke Clinical Research Institute, Durham, NC (M.Z., H.R.A.-K., M.L.R., S.M.D., A.S.H., L.M., C.B.G.)
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11
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Clot S, Rocher T, Morvan C, Cardine M, Lotfi M, Turk J, Usseglio P, Descotes-Genon V, Vanzetto G, Savary D, Debaty G, Belle L. Door-in to door-out times in acute ST-segment elevation myocardial infarction in emergency departments of non-interventional hospitals: A cohort study. Medicine (Baltimore) 2020; 99:e20434. [PMID: 32501989 PMCID: PMC7306318 DOI: 10.1097/md.0000000000020434] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
In France, one in eight patients with acute ST-segment elevation myocardial infarction (STEMI) is admitted direct to an emergency department (ED) in a hospital without percutaneous coronary intervention (PCI) facilities. Guidelines recommend transfer to a PCI center, with a door-in to door-out (DI-DO) time of ≤30 min. We report DI-DO times and identify the main factors affecting them.RESURCOR is a French Northern Alps registry of patients with STEMI of <12 h duration. We focused on patients admitted direct, without prehospital medical care, to EDs in 19 non-PCI centers from 2012 to 2014. We divided DI-DO time into diagnostic time (ED admission to call for transfer) and logistical time (call for transfer to ED discharge).Among 2007 patients, 240 were admitted direct to EDs in non-PCI centers; 57.9% were treated with primary angioplasty and 32.9% received thrombolysis. Median (interquartile range) DI-DO time was 92.5 (67-143) min, with a diagnostic time of 41 (23-74) min and a logistical time of 47.5 (32-69) min. Five patients (2.1%) had a DI-DO time ≤30 min. Five variables were independently associated with a shorter DI-DO time: local transfer (mobile intensive care unit [MICU] team available at referring ED) (P = .017) or transfer by air ambulance (P = .004); shorter distance from referring ED to PCI center (P < .001); shorter time from symptom onset to ED admission (P = .002); thrombolysis (P = .006); and extended myocardial infarction (P = .007).In view of longer-than-recommended DI-DO times, efforts are required to promote urgent local transfer and use of thrombolysis.
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Affiliation(s)
- Sandrine Clot
- Emergency Department and Emergency Medical Service, Metropole Savoie Hospital, Chambery
| | - Thomas Rocher
- Emergency Department and Emergency Medical Service, Annecy Hospital, Annecy
| | - Claire Morvan
- Biostatistician, RENAU (Reseau Nord Alpin des Urgences), Annecy
| | - Mathieu Cardine
- Emergency Department and Emergency Medical Service, Grenoble University Hospital, Grenoble
| | | | - Julien Turk
- Emergency Department and Emergency Medical Service, Metropole Savoie Hospital, Chambery
| | - Pascal Usseglio
- Emergency Department and Emergency Medical Service, Metropole Savoie Hospital, Chambery
| | | | - Gerald Vanzetto
- Department of Cardiology, Grenoble University Hospital, Grenoble, France
| | - Dominique Savary
- Emergency Department and Emergency Medical Service, Annecy Hospital, Annecy
| | - Guillaume Debaty
- Emergency Department and Emergency Medical Service, Grenoble University Hospital, Grenoble
| | - Loic Belle
- Department of Cardiology, Annecy Hospital, Annecy
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12
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Improving Electrocardiography Diagnostic Accuracy in Emergency Medical Services Personnel. CJC Open 2019; 1:28-34. [PMID: 32159079 PMCID: PMC7063641 DOI: 10.1016/j.cjco.2018.11.006] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2018] [Accepted: 11/29/2018] [Indexed: 01/06/2023] Open
Abstract
Background Accuracy of electrocardiogram (ECG) interpretation is important for identification of ST-elevation myocardial infarction (STEMI) by Emergency Medical Services (EMS) personnel who recognize STEMI in the field and activate the coronary catheterization laboratory. According to previous research, there is improvement in diagnosis of STEMIs for healthcare providers who read an average of > 20 ECGs per week. This study evaluated the effectiveness of online ECG modules on improving diagnostic accuracy. Methods EMS personnel received 25 ECGs per week to interpret via an online program. Diagnostic accuracy was assessed for improvement via completion of an ECG evaluation package before and after the intervention. Job satisfaction data were collected to determine the impact of the educational initiative. Results A total of 64 participants completed the study. Overall, there was an improvement in ECG diagnostic accuracy from 50.8% to 61.2% (95% confidence interval [CI], 7.7-13.2; P < 0.0001). Specifically, there was significant improvement in the diagnosis of STEMI (8.5%; 95% CI, 4.9-12.3; P < 0.003) and supraventricular tachycardia (39.0%; 95% CI, 17.2-60.8; P < 0.008), with a trend toward improvement in all other diagnoses. These effects were sustained to 3 months (9.6%; 95% CI, 6.4-12.7; P < 0.0001). Improvement was seen regardless of employment experience and training. There was no significant impact on job satisfaction. Conclusions ECG exposure remains an important factor in improving the accuracy of ECG diagnosis in EMS personnel. Online education modules provide an easily accessible way of improving ECG interpretation with the opportunity for positive downstream effects on patient outcomes and resource use.
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13
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A Long-Forgotten Tale: The Management of Cardiogenic Shock in Acute Myocardial Infarction. JOURNAL OF CARDIOVASCULAR EMERGENCIES 2019. [DOI: 10.2478/jce-2018-0023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Abstract
Patients with acute myocardial infarction (AMI) complicated with cardiogenic shock (CS) present one of the highest mortality rates recorded in critical care. Mortality rate in this setting is reported around 45-50% even in the most experienced and well-equipped medical centers. The continuous development of ST-segment elevation acute myocardial infarction (STEMI) networks has led not only to a dramatic decrease in STEMI-related mortality, but also to an increase in the frequency of severely complicated cases who survive to be transferred to tertiary centers for life-saving treatments. The reduced effectiveness of vasoactive drugs on a severely altered hemodynamic status led to the development of new devices dedicated to advanced cardiac support. What’s more, efforts are being made to reduce time from first medical contact to initiation of mechanical support in this particular clinical context. This review aims to summarize the most recent advances in mechanical support devices, in the setting of CS-complicated AMI. At the same time, the review presents several modern concepts in the organization of complex CS centers. These specialized hubs could improve survival in this critical condition.
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14
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Sakai T, Nishiyama O, Onodera M, Matsuda S, Wakisawa S, Nakamura M, Morino Y, Itoh T. Predictive ability and efficacy for shortening door-to-balloon time of a new prehospital electrocardiogram-transmission flow chart in patients with ST-elevation myocardial infarction – Results of the CASSIOPEIA study. J Cardiol 2018; 72:335-342. [DOI: 10.1016/j.jjcc.2018.03.011] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/19/2017] [Revised: 03/02/2018] [Accepted: 03/12/2018] [Indexed: 12/19/2022]
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15
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Redlener M, Olivieri P, Loo GT, Munjal K, Hilton MT, Potkin KT, Levy M, Rabrich J, Gunderson MR, Braithwaite SA. National Assessment of Quality Programs in Emergency Medical Services. PREHOSP EMERG CARE 2018; 22:370-378. [PMID: 29297735 DOI: 10.1080/10903127.2017.1380094] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
OBJECTIVE This study aims to understand the adoption of clinical quality measurement throughout the United States on an EMS agency level, the features of agencies that do participate in quality measurement, and the level of physician involvement. It also aims to barriers to implementing quality improvement initiatives in EMS. METHODS A 46-question survey was developed to gather agency level data on current quality improvement practices and measurement. The survey was distributed nationally via State EMS Offices to EMS agencies nation-wide using Surveymonkey©. A convenience sample of respondents was enrolled between August and November, 2015. Univariate, bivariate and multiple logistic regression analyses were conducted to describe demographics and relationships between outcomes of interest and their covariates using SAS 9.3©. RESULTS A total of 1,733 surveys were initiated and 1,060 surveys had complete or near-complete responses. This includes agencies from 45 states representing over 6.23 million 9-1-1 responses annually. Totals of 70.5% (747) agencies reported dedicated QI personnel, 62.5% (663) follow clinical metrics and 33.3% (353) participate in outside quality or research program. Medical director hours varied, notably, 61.5% (649) of EMS agencies had <5 hours of medical director time per month. Presence of medical director time was correlated with tracking of QI measures. Air medical [OR 9.64 (1.13, 82.16)] and hospital-based EMS agencies [OR 2.49 (1.36, 4.59)] were more likely to track quality measures compared to fire-based agencies. Agencies in rural only environments were less likely to follow clinical quality metrics. (OR 0.47 CI 0.31 -0.72 p < 0.0004). For those that track QI measures, the most common are; Response Time (Emergency) (68.3%), On-Scene Time (66.4%), prehospital stroke screen (64.6%), aspirin administration (64.5%), and 12 lead ECG in chest pain patients (63.0%). CONCLUSIONS EMS agencies in the United States have significant practice variability with regard to quality improvement resources, medical direction and specific clinical quality measures. More research is needed to understand the impact of this variation on patient care outcomes.
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16
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Ibanez B, James S, Agewall S, Antunes MJ, Bucciarelli-Ducci C, Bueno H, Caforio ALP, Crea F, Goudevenos JA, Halvorsen S, Hindricks G, Kastrati A, Lenzen MJ, Prescott E, Roffi M, Valgimigli M, Varenhorst C, Vranckx P, Widimský P. [2017 ESC Guidelines for the management of acute myocardial infarction in patients presenting with ST-segment elevation.]. Eur Heart J 2018; 39:119-177. [PMID: 29457615 DOI: 10.1093/eurheartj/ehx393] [Citation(s) in RCA: 6056] [Impact Index Per Article: 1009.3] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Affiliation(s)
- Borja Ibanez
- Department of Cardiology, IIS-Fundación Jiménez Díaz University Hospital, Madrid, Spain.
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17
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Kuhn EN, Warmus BA, Davis MC, Oster RA, Guthrie BL. Identification and Cost of Potentially Avoidable Transfers to a Tertiary Care Neurosurgery Service: A Pilot Study. Neurosurgery 2017; 79:541-8. [PMID: 27489167 DOI: 10.1227/neu.0000000000001378] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023] Open
Abstract
BACKGROUND Thousands of neurosurgical emergencies are transferred yearly to tertiary care facilities to assume a higher level of care. Several studies have examined how neurosurgical transfers influence patient outcomes, but characteristics of potentially avoidable transfers have yet to be investigated. OBJECTIVE To identify whether potentially avoidable transfers represent a significant portion of transfers to a tertiary neurosurgical facility. METHODS In this cohort study, we evaluated 916 neurosurgical patients transferred to a tertiary care facility over a 2-year period. Transfers were classified as potentially avoidable when no neurosurgical diagnostic test, intervention, or intensive monitoring was deemed necessary (n = 180). The remaining transfers were classified as justifiable (n = 736). The main outcomes and measures were age, sex, diagnosis, insurance status, intervention, distance of transfer, length of hospital and intensive care unit stay, mortality, discharge disposition, and cost. RESULTS Nearly 20% of transfers were identified as being potentially avoidable. Although some of these patients had suffered devastating, irrecoverable neurological insults, many had innocuous conditions that did not require transfer to a higher level of care. Justifiable transfers tend to involve patients with nontraumatic intracranial hemorrhage and cranial neoplasm. Both groups were admitted to the intensive care unit at the same rate (approximately 70% of patients). Finally, the direct transportation cost of potentially avoidable transfers was $1.46 million over 2 years. CONCLUSION This study identified the frequency and expense of potentially avoidable transfers. There is a need for closer examination of the clinical and financial implications of potentially avoidable transfers. ABBREVIATIONS CI, confidence intervalIQR, interquartile rangeJT, justifiable transferOR, odds ratioPAT, potentially avoidable transferUAB, University of Alabama at Birmingham.
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Affiliation(s)
- Elizabeth N Kuhn
- ‡Department of Neurological Surgery, §Medical Scientist Training Program, and ¶Department of Medicine, Division of Preventive Medicine, University of Alabama at Birmingham, Birmingham, Alabama
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18
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Marton-Popovici M. Review. Regional Networks in Acute Cardiac Care. JOURNAL OF CARDIOVASCULAR EMERGENCIES 2017. [DOI: 10.1515/jce-2017-0021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
Abstract
In acute cardiac care, the timely initiation of life-saving measures proved to be life-saving and requires many organizational and logistic measures. One of such measures is represented by the development and implementation of a regional network dedicated for the treatment of major cardiovascular emergencies, a strategy that proved to significantly reduce mortality rates on short and long term. This review aims to describe the current status in the development of regional networks in three of the main cardiovascular emergencies: acute myocardial infarction, out-of-hospital cardiac arrest, and acute stroke. The concepts demonstrating the utility of such networks, together with their results in reducing cardiac events, are presented in this paper.
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Affiliation(s)
- Monica Marton-Popovici
- Swedish Medical Center, Department of Internal Medicine and Critical Care, Edmonds, Washington , USA
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19
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Pathan SA, Soulek J, Qureshi I, Werman H, Reimer A, Brunko MW, Alinier G, Irfan FB, Thomas SH. Helicopter EMS and rapid transport for ST-elevation myocardial infarction: The HEARTS study. JOURNAL OF EMERGENCY MEDICINE, TRAUMA AND ACUTE CARE 2017. [DOI: 10.5339/jemtac.2017.8] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
Background: Helicopter emergency medical services (HEMS) and ground EMS (GEMS) are both integral parts of out-of-hospital transport systems for patients with ST-elevation myocardial infarction (STEMI) undergoing emergency transport for primary percutaneous coronary intervention (PPCI). There are firm data linking time savings for PPCI transports with improved outcome. A previous pilot analysis generated preliminary estimates for potential HEMS-associated time savings for PPCI transports. Methods: This non-interventional multicenter study conducted over the period 2012–2014 at six centers in the USA and in the State of Qatar assessed a consecutive series of HEMS transports for PPCI; at one center consecutive GEMS transports of at least 15 miles were also assessed if they came from sites that also used HEMS (dual-mode referring hospitals). The study assessed time from ground or air EMS dispatch to transport a patient to a cardiac center, through to the time of patient arrival at the receiving cardiac unit, to determine proportions of patients arriving within accepted 90- and 120-minute time windows for PPCI. Actual times were compared to “route-mapping” GEMS times generated using geographical information software. HEMS' potential time savings were calculated using program-specific aircraft characteristics, and the potential time savings for HEMS was translated into estimated mortality benefit. Results: The study included 257 HEMS and 27 GEMS cases. HEMS cases had a high rate of overall transport time (from dispatch to receiving cardiac unit arrival) that fell within the predefined windows of 90 minutes (67.7% of HEMS cases) and 120 minutes (91.1% of HEMS cases). As compared to the calculated GEMS times, HEMS was estimated to accrue a median time saving of 32 minutes (interquartile range, 17–46). The number needed to transport for HEMS to get one additional case to PPCI within 90 minutes was 3. In the varied contexts of this multicenter study, the number of lives saved by HEMS, solely through time savings, was calculated as 1.34 per 100 HEMS PPCI transports. Conclusions: In this multicenter study, HEMS PPCI transport was found to be appropriate as defined by meeting predefined time windows. The overall estimate for lives saved through time savings alone was consistent with previous pilot data and was also generally consistent with favorable cost-effectiveness. Further research is necessary to confirm these findings, but judicious HEMS deployment for PPCI transports is justified by these data.
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Affiliation(s)
- Sameer A. Pathan
- 1Department of Emergency Medicine, Hamad General Hospital and Weill Cornell Medical College, Doha, Qatar
| | - Jason Soulek
- 2Department of Emergency Medicine, University of Oklahoma College of Medicine, Tulsa, Oklahoma, USA
| | - Isma Qureshi
- 1Department of Emergency Medicine, Hamad General Hospital and Weill Cornell Medical College, Doha, Qatar
| | - Howard Werman
- 3Department of Emergency Medicine and MedFlight of Ohio, Ohio State University, Columbus, Ohio, USA
| | - Andrew Reimer
- 4Cleveland Clinic Critical Care Transport and Francis Payne Bolton School of Nursing, Case Western Reserve University, Cleveland, Ohio, USA
| | | | - Guillaume Alinier
- 6Hamad Medical Corporation Ambulance Service, Doha, Qatar
- 7School of Health and Social Work, University of Hertfordshire, Hatfield, Hertfordshire, UK
- 8Department of Public Health and Wellbeing, Northumbria University, Newcastle upon Tyne, NE7 7XA, UK
| | - Furqan B. Irfan
- 1Department of Emergency Medicine, Hamad General Hospital and Weill Cornell Medical College, Doha, Qatar
| | - Stephen H. Thomas
- 1Department of Emergency Medicine, Hamad General Hospital and Weill Cornell Medical College, Doha, Qatar
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20
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Chen H, Liu J, Xiang D, Qin W, Zhou M, Tian Y, Wang M, Yang J, Gao Q. Coordinated Digital-Assisted Program Improved Door-to-Balloon Time for Acute Chest Pain Patients. Int Heart J 2016; 57:310-6. [DOI: 10.1536/ihj.15-415] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Affiliation(s)
- Hao Chen
- Department of Medical, Guangzhou General Hospital of Guangzhou Military Command
- HuaBo Bio Pharmaceutical Institute of GuangZhou
| | - Jian Liu
- Department of Hospital Office, Guangzhou General Hospital of Guangzhou Military Command
| | - Dingcheng Xiang
- Department of Cardiovascular, Guangzhou General Hospital of Guangzhou Military Command
| | - Weiyi Qin
- Department of Emergency, Guangzhou General Hospital of Guangzhou Military Command
| | - Minwei Zhou
- Department of Medical, Guangzhou General Hospital of Guangzhou Military Command
| | - Yan Tian
- Department of Information Center, Guangzhou General Hospital of Guangzhou Military Command
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