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Patients with suspected ST-segment elevation myocardial infarction (STEMI) who present first to a hospital that does not offer primary percutaneous intervention (PCI) stand a better chance of receiving timely reperfusion if the delay in transfer to a PCI-capable center is minimized. This can be encouraged by a coordinated system of STEMI care in the emergency medical services (EMS) and receiving hospital settings, according to findings published online June 28, 2011, ahead of print in Circulation: Cardiovascular Quality and Outcomes.

Investigators led by Seth W. Glickman, MD, of Duke University School of Medicine (Durham, NC), looked at the door-in to door-out times of 436 STEMI patients who presented at 55 non-PCI hospitals in North Carolina for 3 months before (July 2005-September 2005) and 3 months after (January 2007-March 2007) implementation of standardized protocols for optimizing reperfusion times instituted by the Reperfusion of Acute Myocardial Infarction in North Carolina Emergency Departments (RACE) program. These data were correlated with information on which of 8 recommended care processes were actually adopted at the individual centers in order to quantify their contribution to reducing transfer times.

Median door-in/door-out times improved significantly from 97 minutes (IQR 56-160 minutes) in the period before the RACE intervention to 58 minutes (IQR 35-90 minutes) afterward (P < 0.0001).

Eight recommended quality-improvement processes were grouped into 3 phases of care: EMS or prehospital, emergency department (ED), and transfer hospital. The percentage of hospitals that adopted measures in each category rose after the RACE program was implemented (table 1).

Table 1. Hospitals Using Recommended Care Processes

 
In general, hospitals that adopted more EMS processes tended also to implement the recommended ED and hospital processes.

Each care process significantly shortened door-in/door-out times. Moreover, adoption of additional processes within each category reduced door-in/door-out times (P < 0.001 for all comparisons). For example, transfer times for hospitals that adopted all of the recommended processes in a category were considerably lower than times for hospitals that adopted none:

• EMS: 44 minutes vs. 138 minutes
• ED: 54 minutes vs. 110 minutes
• Hospital: 48 minutes vs. 110 minutes

In these comparisons, EMS improvements contributed most to reducing delays.

Multivariable analysis showed that use of recommended care processes in each of the 3 categories was independently associated with shorter treatment delays. Specifically, adoption of 1 additional process in each category reduced door-in/door-out time (table 2).

Table 2. Change per Quality Process Adopted

There was an interaction between time and ED care processes (P = 0.007), suggesting that the RACE program helped optimize ED-related STEMI care, but no such relationship was found with EMS or hospital care processes.

These findings “highlight the need for an integrated, system-based approach to improving STEMI care, including a special focus on EMS,” the authors conclude.

In a telephone interview, Bruce R. Brodie, MD, of the LeBauer Cardiovascular Research Foundation (Greensboro, NC), agreed. “This is one of the first studies to document how important systems of care are to good outcomes [in terms of timely primary PCI],” he told TCTMD. “You can have good physicians but poor systems of care and you’re going to have poor outcomes.”

To Dr. Brodie, one of the most important, albeit expected, findings was the value of EMS vehicles having ECG equipment and the personnel trained to use it. “Being able to get an ECG and transmit it to the hospital gives you a huge head start on the whole process,” he said. Moreover, if the EMS technician can identify a STEMI, the patient may then be routed directly to the PCI hospital—the preferred strategy—provided it is not too distant and the patient doesn’t need immediate care.

Even in the ED, the most common reason for delay is failure to get an ECG upfront, Dr. Brodie said, adding that this omission is especially likely to occur when patients come to the hospital on their own and do not have typical symptoms, so a cardiac cause may not be suspected immediately.  For that reason, having the test performed within 10 minutes of a patient’s arrival is a key goal, he advised.

Yet another common holdup occurs when a patient is ready for transfer to the PCI hospital but transportation has to be dispatched from somewhere else, Dr. Brodie said. That is the rationale for the recommendation to use a local ambulance.

Transfer within 45 minutes is a reasonable goal, Dr. Brodie commented, assuming that the times required for transportation to a PCI center and then the interval from cath lab to reperfusion are about 30 minutes each. Though American guidelines recommend a time of no more than 90 minutes from first medical contact to reperfusion, “I think the European guideline of 2 hours is still regarded as a good time [window for  performing primary PCI],” he said.

In the paper, Dr. Glickman and colleagues observe that “there are unique challenges to providing timely STEMI care at non-PCI hospitals and rural EMS settings,” because these hospitals not only have limited financial and personnel resources but also see fewer STEMI cases and are less likely than larger centers to have standardized protocols for acute MI care. “This lack of experience and formal quality management may contribute to uncertainty about how to arrange for urgent coronary interventions at tertiary centers,” the authors point out.

Nonetheless, there has been considerable progress in the past few years in achieving timely primary PCI, Dr. Brodie noted, much of it due to the American Heart Association’s efforts in setting guidelines and helping hospitals meet them.

 

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Source:
Glickman SW, Lytle BL, Ou F-S, et al. Care processes associated with quicker door-in-door-out for patients with ST-elevation-myocardial infarction requiring transfer: Results from a statewide regionalization program. Circ Cardiovasc Qual Outcomes. 2011;Epub ahead of print.

 

 

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