RACE: Regional STEMI Care System Improves Time to Reperfusion, Survival

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A uniform and comprehensive approach to organizing ST-segment elevation myocardial infarction (STEMI) care across North Carolina on a voluntary basis has produced marked improvements in timely coronary reperfusion, according to study results published online June 4, 2012, ahead of print in Circulation. Patients presenting directly to hospitals with percutaneous coronary intervention (PCI) capability received the fastest treatment, while those requiring hospital transfer showed the greatest improvements in treatment time.

James G. Jollis, MD, of the Duke Clinical Research Institute (Durham, NC), and colleagues analyzed data from 6,841 STEMI patients treated from July 2008 to December 2009 at 21 PCI hospitals and 98 non-PCI hospitals in North Carolina. All the centers had implemented standardized protocols for optimizing reperfusion times instituted by the Regional Approach to Cardiovascular Emergencies (RACE) project. Performance data were assessed at 3-month intervals over the course of the study period.

Less Time to Reperfusion

More than half of the patients presented directly to PCI hospitals (57%), and the rest were transferred (43%). Fifty-five percent were transported to the first facility via emergency medical services (EMS), and 43% of patients were walk-ins although between the first and last 3-month periods, there was an increase in the percentage of patients presenting to PCI hospitals who arrived by EMS (70% to 75%; P = 0.04).

During the final quarter of data collection, prehospital ECGs were identified for 88% of patients presenting to PCI centers via EMS and for 32% of patients presenting to non-PCI centers (P < 0.0001).

Among 5,888 eligible patients, the proportion not receiving reperfusion fell from 5.4% to 4.0% (P = 0.04) largely attributable to a 4% absolute decline in eligible untreated patients at non-PCI hospitals (P < 0.01). Primary PCI use for reperfusion increased from 52% to 66% in non-PCI hospitals, while fibrinolysis decreased from 41% to 31% of eligible patients.

Over the study period, median door-to-device times for patients presenting directly to PCI hospitals fell from 64 to 59 minutes (P < 0.001), with improvements in both self-presenting patients (79 to 73 minutes; P = 0.01) and EMS-transported patients (58 to 55 minutes; P = 0.06). The proportion of patients presenting directly who underwent PCI within 90 minutes increased from 83% to 89%.

For patients transported directly to PCI hospitals by EMS, prehospital ECG rates increased from 67% to 88%. This improvement was accompanied by a decline in median time from first medical contact to device, which fell from 103 to 91 minutes (P < 0.0001), with 50% of patients being treated within 90 minutes by the last 3-month period. The percentage of patients receiving device activation within 90 minutes of first medical contact increased from 36% to 50% (P = 0.0002).

Treatment times for patients transferred between hospitals for primary PCI significantly improved. The median time from first hospital door-to-device activation for 1,175 patients transferred from the 52 hospitals that adopted a “transfer for PCI” strategy fell from 117 minutes to 103 minutes (P = 0.0008), with 39% patients being treated within the 90-minute goal by the end of the RACE project.

Patients treated within guideline-recommended times had a mortality of 2.2% compared to 5.7% for patients whose treatment time exceeded the cutoffs (P = 0.001) Overall, in-hospital mortality was 5.7% (95% CI 5.2%-6.3%) during the study period, amounting to 5.9% during the first half of the RACE project and 5.5% during the second half. Other clinical outcomes, bleeding, stroke, hemorrhagic stroke, congestive heart failure, and shock did not significantly vary over the study period.

Sharing Makes the Difference

The RACE system is the largest of its kind in the country, according to the authors, and it “demonstrates that systematic barriers in timely reperfusion can be overcome with a broadly organized voluntary effort to fill leadership gaps in health care.”

Utilizing a “universal approach,” the authors were able to “establish and embed a standard of care independent of health care setting or geographic location of the patient. By the end of our intervention, our protocols were adopted by state regulation for all EMS agencies, and all PCI hospitals voluntarily agreed to continue sharing data and support regional care.”

The authors note that there is still work to be done to ensure that the maximum number of patients can achieve optimal results. Specifically, they cite patients transported by EMS and those transported between hospitals for primary PCI. Suggested improvements include:

• Adopting cath lab activation by paramedics as a universal standard of care
• Adding “scene time and transport time” to the 90-minute door-to-device goal
• Cross training laboratory, emergency department, and intensive care unit personnel to cover emergent STEMI patients

In a telephone interview with TCTMD, Harlan M. Krumholz, MD, SM, of the Yale School of Medicine (New Haven, CT), said the RACE project has shown great success since its initiation, and he credits the majority of the benefits to passionate leadership.

“They pulled together a group of people with great enthusiasm who were seeking to motivate others and who spent a lot of time travelling the state to pull this consortium together,” he said. “No matter how well you have your plan in place, it requires individuals with enthusiasm and energy to pull together.”

Likewise, Alice K. Jacobs, MD, of Boston University School of Medicine (Boston, MA), told TCTMD in an e-mail communication that “bringing stakeholders together to implement local strategies is critical to the success of systems of care.”

A ‘Conceptual’ Barrier

“The most important care decisions for heart attack patients are made long before they get to the hospital,” Dr. Jollis said in a press release. “These coordinated care systems should be in every single hospital and every single EMS system in the country.”

However, Dr. Krumholz stressed that this is easier said than done.

“One of the problems with [a system like this is] that in the past people haven’t seen themselves as part of the same team,” he explained. “The group that sends the patient sort of feels like their job is over, and the group receiving feels like their job doesn’t start until the patient arrives. At the end, it’s because of inefficiencies in the process the overall [door-to-device] time is slow.”

According to Dr. Krumholz, the main barrier to creating and following through with a system like RACE is “mostly conceptual.” The system in North Carolina instead gives everyone a “shared sense of purpose.”

“We’ve been trained to think very tribally about our own institutions, but not necessarily be very collaborative across institutions,” he said. “A patient, particularly one that has to be moved from one hospital to another, is not thinking in that segmented fashion [but] hoping that everyone is working together to help them.”

Other states must take the proper steps to learn from the RACE program, Dr. Krumholz continued. “We have to find ways to replicate this effort, to find the people who want to be a part of it,” he concluded. “This shows the power of working together and it should be something that every state should seek to achieve.”

 

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Source:
Jollis JG, Al-Khalidi HR, Monk L, et al. Expansion of a regional ST-segment elevation myocardial infarction system to an entire state. Circulation. 2012;Epub ahead of print.

 

 

Related Stories:

• Health Care System Delays Associated with Mortality in STEMI Patients
• Complex Factors Behind Choice of Reperfusion Strategy in STEMI
• RACE: Regional systems for reperfusion improve STEMI quality of care

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