Accelerator-2: Streamlined Regional STEMI Care Speeds Up Treatment, Lowers Mortality
In 12 US cities, researchers made changes in how to triage STEMI patients that led to reductions in treatment delays and better outcomes.
ANAHEIM, CA—In 12 US cities, the implementation of regionalized treatment protocols to diagnose and treat acute myocardial infarction led to significant declines in treatment times, according to the results of a new study.
In addition to an improvement in the time from first medical contact to device implantation across several US regions, researchers also observed significant reductions in the risks of mortality and heart failure.
“Every day in the United States, people die from the fragmented delivery of cardiac care,” said lead investigator James Jollis, MD (Duke Clinical Research Institute, Durham, NC). “In patients with a myocardial infarction from an abruptly closed artery, the national standard involves paramedic diagnosis with an EKG and calling in the catheterization team prior to hospital arrival so that patients are treated quickly before complications and severe heart muscle damage ensue.”
With that background, Jollis presented the results of the STEMI Accelerator-2 study at the American Heart Association (AHA) 2017 Scientific Sessions. The study included 6,695 STEMI patients who were transported directly to PCI-capable hospitals by emergency medical services (EMS) providers trained to identified STEMI via ECG and authorized to activate the catheterization laboratory.
STEMI Accelerator-2 is an initiative of the AHA’s Mission: Lifeline that is coordinated by the Duke Clinical Research Institute. As part of the project, the researchers implemented a fulltime regional coordinator and expert mentors to work with hospital leaders and physicians to establish local protocols for acute MI treatment.
“The processes reflected the concept of moving care forward so that paramedics could do the job of emergency physicians in activating the cath labs,” said Jollis.
Gregg Fonarow, MD (University of California, Los Angeles), who spoke with the media during a press conference announcing the results, emphasized that reducing treatment time requires a coordinated effort among hospitals, physicians, EMS, and others.
“What we’ve seen here is incredibly impressive, because overall the intervention has led to faster [treatment] times,” said Fonarow. “Importantly, we’re seeing that this translated with regards to in-hospital mortality, a decline over time, that was not seen in regions not targeted by the Accelerator program.”
Nine of 12 Regions Reduced Treatment Times
The STEMI Accelerator-2 project spanned 12 cities and involved 139 primary PCI hospitals and 971 EMS agencies. At baseline, the lab was activated within 20 minutes of first medical contact in 38% of patients and between 20 and less than 30 minutes in another 24% of patients. At study completion, the cath lab was activated within 20 minutes of medical contact in 56% of patients (and within 20 to 30 minutes in another 22% of patients). Additionally, wait times also declined, with more patients spending less than 20 minutes in the emergency department.
Nationally, nine of the 12 regions showed an improvement in achieving the 90 minutes or less goal for first medical contact to device implantation.
At baseline, in-hospital mortality was 4.4% among all STEMI patients treated at the identified hospitals. At the completion of the study, in-hospital mortality declined to 2.3% (P < 0.008). Similarly, the rate of congestive heart failure declined from 7.4% at baseline to 5.0% at study completion (P = 0.03).
In an analysis comparing mortality in patients participating in the Accelerator-2 study versus STEMI patients in other Mission: Lifeline hospitals, researchers observed a statistically significant trend for declining mortality for Accelerator-2 patients and no difference in mortality over time in the other group.
“We know we should go fast because of the clinical trials,” study co-author Mayme Roettig, RN, MSN (Duke Clinical Research Institute), told TCTMD. “We know time matters.”
Roettig said the key to the Accelerator-2 project is the “neutral” regional coordinator, because the health systems are hugely competitive for profitable cardiovascular patients. This allowed the hospitals to buy into the project. As part of Accelerator-2, they raised approximately $4 million in research and education grants to support the labor of the regional coordinators and mentors who worked with hospitals and physicians.
Kirk Garratt, MD (Christiana Care Health System, Newark, DE), president of the Society for Cardiovascular Angiography and Interventions, was also impressed with the results. Speaking with TCTMD, he noted that the first phase of the Mission: Lifeline project demonstrated that it was possible to implement processes of care, but the overall results were somewhat underwhelming. After that experience, the group made changes, isolating hospitals that were able to participate fully in the program and creating a role for the regional coordinator.
“If you go about things the right way, the kind of results you’d expect from a management plan that contains variability and puts standardized processes in place does result in processes improvement,” said Garratt. “And there is reason to believe that these improvements yield better patient outcomes.”
Regarding mortality, Garratt said the magnitude of benefit is bigger than what might be predicted, particularly given the sample size. However, he noted, the clinical outcomes were analyzed purely to get a sense “they were moving in the right direction” with the various changes made at the regional level.
He pointed out that delays in STEMI treatment could be affected by traffic in large cities such as New York. In more rural areas it is difficult to assemble the cath lab team given longer travel times to hospital. “The reasons for delay differ,” said Garratt. “The beauty of the Mission: Lifeline program is that it tried to take into account all possible barriers to quick and effective care and make recommendations at each step to overcome those barriers.”
Barriers and Opportunities
To TCTMD, Fonarow said the RACE and RACE-2 studies showed that a regional approach, with clinicians working together with EMS for coordinated care, could reduce treatment times. Accelerator-2, he added, shows that the project can be “scaled up” across the country to disparate healthcare systems.
“What’s the message?” he asked. “Every community in the country should have this type of approach. Finding a way for the resources will be critical.”
Jollis said that “barriers and opportunities” to instituting the processes of care to streamline treatment tend to be local and regional. “Healthcare is amazingly different every place you live,” said Jollis. As for the changes that had largest impact on getting patients treated faster, he said the project was designed to “move care forward.”
“If you’re a paramedic, and you have a common regional plan that was agreed to, it doesn’t matter what time of day or where you’re heading, you do the same thing,” said Jollis. “That allows frontline providers to act rather than standing still and waiting to see what the doctor wants them do.”
To TCTMD, Jollis said the “call-off” rate, where emergency department physicians overrule the EMS after determining the patient is not having a STEMI, ranges from 10% to 15%. For them, if the EMS has a call-off rate of less than 20%, they believe the paramedic is doing a good job.
“We know it’s never going to be 100%,” added Fonarow. “Ideally, somewhere around 15%, where the paramedic is right 85% of the time, is right on. We don’t want to make it too restrictive, where they don’t activate the lab, and then find out after the fact the patient had an MI.”
Jollis JG, on behalf of the STEMI Accelerator 2 investigators. Impact of regionalization of ST-elevation myocardial infarction care on treatment times and outcomes for emergency medical services transported patients presenting to hospitals with percutaneous coronary intervention. Presented at: American Heart Association 2017 Scientific Sessions. November 14, 2017. Anaheim, CA
- Authors report no conflicts of interest.