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CHICAGO – Regional coordination of emergency care provided modest but significant improvements in timely reperfusion of patients with ST-elevation myocardial infarction.
In the massive Mission Lifeline: STEMI Accelerator project, in-hospital mortality was 3.6% for patients who spent 30 minutes or less between the hospital door and cardiac catheter lab door, compared with 7% for those with times spent in the emergency department of 30-45 minutes and 10.8% for patients with ED times of more than 45 minutes (P < .001), after adjustment for clinical risk factors such as cardiac arrest and cardiogenic shock among patients presenting directly to a percutaneous coronary intervention–capable hospital via emergency medical services.
“While this relationship may have residual confounding, we believe that it shows ED time is an important indicator of the coordination of care,” Dr. Matthew Sherwood said at the American Heart Association scientific sessions.
Patrice Wendling/Frontline Medical News
Dr. Matthew Sherwood
The American College of Cardiology Foundation/AHA guidelines recommend the use of regional systems of care for STEMI patients and set a system goal for first medical contact to device time of 90 minutes or less for patients presenting directly to a percutaneous intervention–capable hospital and 120 minutes or less for those transferred from a non-PCI hospital to a PCI facility.
Only half of patients are treated within guideline goals, largely because of delays related to fragmentation of the health care system and lack of coordination between EMS agencies and acute care hospitals, said Dr. Sherwood, an interventional cardiology fellow with Duke University in Durham, N.C. For example, only 17% of EMS agencies can preactivate cardiac catheter labs in all receiving hospitals.
The STEMI Accelerator study sought to improve STEMI care between 484 hospitals and 1,253 EMS agencies in 16 cities, including New York, St. Louis, Pittsburgh, and Houston, representing roughly 10% of the U.S. population.
Leaders of emergency medical services, ED physicians, and interventional cardiologists were brought together in each region to identify areas for improvement and establish a regional coordinator who would implement a feedback system. They also developed a uniform protocol for preactivation for STEMI by EMS providers and coordinated a plan for rapid transfer of all STEMI patients to appropriate facilities.
At least 70% of PCI centers were also required to enroll in the National Cardiovascular Data Registry–Action GWTG registry for data collection, Dr. Sherwood said.
The Mission Lifeline: STEMI Systems Accelerator operations manual was also distributed at the national level to assist regions in developing their own, more individualized protocols. In New York City, that involved 16 PCI hospitals in downtown Manhattan developing a plan for STEMI patients to bypass the ED and go directly to the catheter lab – a move that has paid off in improved time to device delivery, he said.
The analysis included 23,809 patients with STEMI treated from the third quarter of 2012 to the first quarter of 2014. Of these, 11,765 presented directly to a PCI center via EMS, 6,502 presented to a PCI center via their own transportation, and 5,542 transferred from a non–PCI capable facility for further care. Their median age was 60 years, 29% were female, and 16% had no insurance.
For all three patient groups, there was a modest, but significant improvement from baseline to Q1 2014 in the percentage of patients meeting first medical contact to device time goals, including: direct-presenting patients (62% vs. 65%; P = .025), direct-presenting patients transported by EMS (54% vs. 59%; P = .0046), and patients requiring hospital transfer (50% vs. 53%; P = .007), Dr. Sherwood reported.
While the overall study showed modest improvements, there was a significant amount of variation in regional time and performance improvements. For example, among patients presenting directly to a PCI hospital, some regions showed up to 20% increases in the proportion of patients treated within guideline goals, he said.
Unadjusted in-hospital mortality also declined over the study period for participating regions, compared with national rates, suggesting that regional STEMI programs can provide important improvements to public health, Dr. Sherwood concluded.
Speaking as a practitioner in one of the contributing hospitals, panelist Dr. Roxana Mehran of Mount Sinai Hospital in New York, said that the STEMI program was invaluable in expanding their focus beyond door to balloon time.
“This particular program was extremely helpful for us in not just the timing of getting the patient, but also on the post discharge, which is also a part of this program,” she said. “I must tell you it had a huge impact, and we saw our numbers change dramatically just over the few quarters we saw patients.”