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Li Y, Cao G. FACTORS INFLUENCING LATE PROGNOSIS IN PATIENTS WITH ACUTE ST-SEGMENT ELEVATION MYOCARDIAL INFARCTION TREATED WITH DIRECT PERCUTANEOUS CORONARY INTERVENTION. Shock 2024; 62:505-511. [PMID: 39158524 DOI: 10.1097/shk.0000000000002432] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/20/2024]
Abstract
ABSTRACT Objective: To investigate factors influencing the late prognosis of patients with acute ST-segment elevation myocardial infarction treated by direct percutaneous coronary intervention. Methods: We retrospectively analyzed 349 ST-segment elevation myocardial infarction patients treated with direct percutaneous coronary intervention. Patients were categorized based on catheter laboratory activation time (CLAT) (≤15 or >15 min), time of arrival (working hours or out-of-hours), and mode of arrival (emergency medical services transportation or self-presentation). The primary endpoint was the 2-year major adverse cardiovascular events (MACEs), defined as all-cause death, nonfatal myocardial infarction, and target vessel revascularization. Results: Patients with CLAT ≤15 min showed significant differences in oxygen saturation, FMC-to-device time, symptom-to-device time, symptom-to-FMC time, presentation mode, presentation duration, and MACEs (all P < 0.005). Self-presentation (odds ratio = 0.593, 95% confidence interval = 0.413-0.759) and out-of-hours presentation (odds ratio = 0.612, 95% confidence interval = 0.433-0.813) were risk factors for CLAT >15 min. The working-hours group showed significant differences in FMC-to-device time, activation-to-arrival time at the catheter laboratory, and the number of cases with activation time ≤15 min (all P < 0.005). The emergency medical services and self-presentation groups differed significantly in age, blood pressure, FMC-to-device time, and electrocardiography-to-CLAT (all P < 0.005). Conclusion: Reducing CLAT to 15 min significantly lowers the 2-year MACE rate. Self-presentation and out-of-hours presentation are risk factors for delayed catheter laboratory activation.
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Affiliation(s)
- Yonghong Li
- Department of Emergency, Beijing Pinggu District Hospital, Beijing, China
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Keene T, Newman E, Pammer K. Can degrading information about patient symptoms in vignettes alter clinical reasoning in paramedics and paramedic students? An experimental application of fuzzy trace theory. Australas Emerg Care 2023; 26:279-283. [PMID: 36792390 DOI: 10.1016/j.auec.2023.02.002] [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] [Received: 08/19/2022] [Revised: 01/05/2023] [Accepted: 02/07/2023] [Indexed: 02/16/2023]
Abstract
BACKGROUND Research has shown paramedics form rapid intuitive impressions on first, meeting a patient and these impressions subsequently affected their clinical reasoning. We report an experiment where theory-based interventions are developed with the goal of reducing reliance on intuitive reasoning by paramedics and paramedic students in simulated patients. METHOD Australian paramedics (n = 213; 49% female) and paramedicine students (n = 83; 55% female) attending paramedic conferences completed a 2 × 2 fully between participants experiment. They saw a written clinical vignette designed to be representative of Acute Coronary Syndrome (ACS) in which key clinical information was precise or degraded (stimulus), they then either chose the single most likely diagnosis from a list, or ranked competing diagnoses (response). Outcome variables were diagnostic rate and response time. RESULTS There were no differences in the proportion of participants choosing ACS across the four stimulus-response conditions (0.75 [0.65, 0.84] vs 0.79 [0.68, 0.87] vs, 0.78 [0.65, 0.87] vs 0.72 [0.59, 0.82], p = 0.42) CONCLUSION: This is the first study attempting to experimentally examine clinical reasoning in paramedics using a theory-based intervention. Neither of the interventions tested succeeded in altering measures of clinical reasoning. Similar to previous research on physicians, paramedic reasoning appears robust to manipulation.
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Affiliation(s)
- Toby Keene
- The Australian National University, Australia.
| | - Eryn Newman
- The Australian National University, Australia
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Keene T, Pammer K, Lord B, Shipp C. Fluency and confidence predict paramedic diagnostic intuition: An experimental study of applied dual-process theory. Int Emerg Nurs 2022; 61:101126. [DOI: 10.1016/j.ienj.2021.101126] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2021] [Revised: 11/25/2021] [Accepted: 12/10/2021] [Indexed: 11/05/2022]
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Nawrocki PS, Levy M, Tang N, Trautman S, Margolis A. Interfacility Transport of the Pregnant Patient: A 5-year Retrospective Review of a Single Critical Care Transport Program. PREHOSP EMERG CARE 2018; 23:377-384. [PMID: 30188241 DOI: 10.1080/10903127.2018.1519005] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
Abstract
INTRODUCTION Interfacility transport of the pregnant patient poses a challenge for prehospital providers as it is an infrequent but potentially high acuity encounter. Knowledge of clinically significant events (CSEs) that occur during these transports is important both to optimize patient safety and also to help enhance crew training and preparedness. This study evaluated a critical care transport program's 5-year longitudinal experience transporting pregnant patients by ground and air, and described CSEs that occurred during the out-of-hospital phase of care. METHODS This study was a retrospective review of pregnant patients transported by a single critical care transport system into and within a large academic healthcare system. Patients who were pregnant, and were transported from a referring facility to one of the 2 receiving centers within Johns Hopkins Health System between January 1, 2012 and December 31, 2016 were included in this study. The primary outcome of interest was the occurrence of a predefined clinically significant event (CSE) during transport, while a secondary outcome of interest was the indication for transfer. RESULTS During the study period 1,223 pregnant patients were transported by our critical care transport service. There were 1,101 patients who met inclusion criteria; 693 (62.9%) of whom were transported by ground and 408 (37.1%) who were transported by rotor wing aircraft. The top 3 indications for transfer comprised 71.4% of all patients and included; preterm labor, hypertensive disorder of pregnancy, and other maternal life threatening disorder. The most common events that occurred across all transports were: exacerbation of hypertensive disease requiring intervention (4.5%), hypotension (1.3%), and altered mental status (0.2%). CONCLUSIONS Incidence of CSEs during the interfacility transport of pregnant patients within our critical care transport system is low (6.0%). Knowledge of the clinically significant events that occur during EMS transport is a vital component of ensuring system quality and optimizing patient safety. This data can be used to augment and focus provider education and training to mitigate and optimize response to future events.
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Kodama N, Nakamura T, Yanishi K, Nakanishi N, Zen K, Yamano T, Shiraishi H, Shirayama T, Shiraishi J, Sawada T, Kohno Y, Kitamura M, Furukawa K, Matoba S. Impact of Door-to-Balloon Time in Patients With ST-Elevation Myocardial Infarction Who Arrived by Self-Transport - Acute Myocardial Infarction-Kyoto Multi-Center Risk Study Group. Circ J 2017; 81:1693-1698. [PMID: 28637970 DOI: 10.1253/circj.cj-17-0083] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/24/2024]
Abstract
BACKGROUND Patients with ST-elevation myocardial infarction (STEMI) who arrive at a hospital via self-transport reportedly have a delayed door-to-balloon time (DBT). However, the clinical impacts of delayed DBT on in-hospital mortality among such patients are not well known. METHODS AND RESULTS In total, 1,172 STEMI patients who underwent primary percutaneous coronary intervention between January 2009 and December 2013 from the Acute Myocardial Infarction (AMI) Kyoto Registry were analyzed. Compared with the emergency medical service (EMS) group (n=804), the self-transport group (n=368) was younger and had a significantly longer DBT (115 min vs. 90 min, P<0.01), with fewer patients having a Killip classification of 2 or higher. The in-hospital mortality rate was lower in the self-transport group than in the EMS group (3.3% vs. 7.1%, P<0.01). A DBT >90 min was an independent predictor of in-hospital mortality in EMS patients (odds ratio (OR)=2.43, P=0.01) but not in self-transport patients (OR=0.89, P=0.87). CONCLUSIONS The present study demonstrated that there was no relationship between in-hospital prognosis and DBT ≤90 min in STEMI patients using self-transport. The prognosis of these patients cannot be improved by focusing only on DBT. Treatment strategies based on means of transport should also be considered.
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Affiliation(s)
- Naotoshi Kodama
- Department of Cardiovascular Medicine, Graduate School of Medical Science, Kyoto Prefectural University of Medicine
| | - Takeshi Nakamura
- Department of Cardiovascular Medicine, Graduate School of Medical Science, Kyoto Prefectural University of Medicine
| | - Kenji Yanishi
- Department of Cardiovascular Medicine, Graduate School of Medical Science, Kyoto Prefectural University of Medicine
| | - Naohiko Nakanishi
- Department of Cardiovascular Medicine, Graduate School of Medical Science, Kyoto Prefectural University of Medicine
| | - Kan Zen
- Department of Cardiovascular Medicine, Graduate School of Medical Science, Kyoto Prefectural University of Medicine
| | - Tetsuhiro Yamano
- Department of Cardiovascular Medicine, Graduate School of Medical Science, Kyoto Prefectural University of Medicine
| | - Hirokazu Shiraishi
- Department of Cardiovascular Medicine, Graduate School of Medical Science, Kyoto Prefectural University of Medicine
| | - Takeshi Shirayama
- Department of Cardiovascular Medicine, Graduate School of Medical Science, Kyoto Prefectural University of Medicine
| | - Jun Shiraishi
- Department of Cardiology, Kyoto First Red Cross Hospital
| | | | - Yoshio Kohno
- Department of Cardiology, Kyoto First Red Cross Hospital
| | | | | | - Satoaki Matoba
- Department of Cardiovascular Medicine, Graduate School of Medical Science, Kyoto Prefectural University of Medicine
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Akimbaeva Z, Ismailov Z, Akanov AA, Radišauskas R, Padaiga Ž. Assessment of coronary care management and hospital mortality from ST-segment elevation myocardial infarction in the Kazakhstan population: Data from 2012 to 2015. MEDICINA-LITHUANIA 2017; 53:58-65. [PMID: 28256299 DOI: 10.1016/j.medici.2017.01.006] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/12/2016] [Revised: 12/02/2016] [Accepted: 01/30/2017] [Indexed: 11/26/2022]
Abstract
OBJECTIVE The aim of this study was to assess and evaluate factors related to coronary care management and hospital mortality in patients with ST-segment elevation myocardial infarction (STEMI) hospitalized in the Kazakhstan County and city hospitals in which percutaneous coronary intervention (PCI) was performed during the period of 2012-2015. MATERIALS AND METHODS A total of 22,176 adult patients (18> years) with acute STEMI were hospitalized from January 2012 to December 2015. All the investigated STEMI patients underwent PCI. RESULTS The mean age of STEMI patients was 61.52±11.48 years, 72.2% of the patients were male and 75.2% living in the rural regions. The mean time from hospitalization to PCI was 2104.41±5060.68min (median 95.0 and IQR 1034.5). The mean and median of time from hospitalization to PCI tended to decrease from 2747.7±5793.9min and 155.0min in 2012 to 1874.7±4759.2min and 73.5min in 2015. Among all STEMI events the percentage of patients from hospitalization to PCI within 0-59min was up to 39.0% during all study period. From 2012 to 2015, the percentage of STEMI patients with short time (0-59min) of hospitalization to PCI tended to increase in average by 11.4% per year (P=0.09). Among all STEMI patients hospital mortality from 2012 to 2015 did not change significantly and ranged from 9.0% in 2012 to 8.6% in 2015. By multiple logistic regression analysis, study years (2012), gender (female), age (60> years), time from hospitalization to PCI (60>min) and number of bed-days were statistically significant factors associated with patients' hospital mortality from STEMI with PCI. CONCLUSIONS The present study demonstrated that hospitalization delay in the treatment of STEMI patients in Kazakhstan population was without significant changes, meanwhile the number of patients perfused within 1h from hospitalization to PCI tended to increase during 2012-2015. The higher hospital mortality was associated with study year, female gender, older age, longer-time from hospitalization to PCI and shorter hospitalization.
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Affiliation(s)
| | | | | | - Ričardas Radišauskas
- Institute of Cardiology, Medical Academy, Lithuanian University of Health Sciences, Kaunas, Lithuania.
| | - Žilvinas Padaiga
- Department of Preventive Medicine, Faculty of Public Health, Medical Academy, Lithuanian University of Health Sciences, Kaunas, Lithuania
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Achieving timely percutaneous reperfusion for rural ST-elevation myocardial infarction patients by direct transport to an urban PCI-hospital. JOURNAL OF GERIATRIC CARDIOLOGY : JGC 2016; 13:840-845. [PMID: 27928226 PMCID: PMC5131199 DOI: 10.11909/j.issn.1671-5411.2016.10.012] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Abstract
Backgrounds ST-elevation myocardial infarction (STEMI) guidelines recommend reperfusion by primary percutaneous coronary intervention (PCI) ≤ 90 min from time of first medical contact (FMC). This strategy is challenging in rural areas lacking a nearby PCI-capable hospital. Recommended reperfusion times can be achieved for STEMI patients presenting in rural areas without a nearby PCI-capable hospital by ground transportation to a central PCI-capable hospital by use of protocol-driven emergency medical service (EMS) STEMI field triage protocol. Methods Sixty STEMI patients directly transported by EMS from three rural counties (Nassau, Camden and Charlton Counties) within a 50-mile radius of University of Florida Health-Jacksonville (UFHJ) from 01/01/2009 to 12/31/2013 were identified from its PCI registry. The STEMI field triage protocol incorporated three elements: (1) a cooperative agreement between each of the rural emergency medical service (EMS) agency and UFHJ; (2) performance of a pre-hospital ECG to facilitate STEMI identification and laboratory activation; and (3) direct transfer by ground transportation to the UFHJ cardiac catheterization laboratory. FMC-to-device (FMC2D), door-to-device (D2D), and transit times, the day of week, time of day, and EMS shift times were recorded, and odds ratio (OR) of achieving FMC2D times was calculated. Results FMC2D times were shorter for in-state STEMIs (81 ± 17 vs. 87 ± 19 min), but D2D times were similar (37 ± 18 vs. 39 ± 21 min). FMC2D ≤ 90 min were achieved in 82.7% in-state STEMIs compared to 52.2% for out-of-state STEMIs (OR = 4.4, 95% CI: 1.24–15.57; P = 0.018). FMC2D times were homogenous after adjusting for weekday vs. weekend, EMS shift times. Nine patients did not meet FMC2D ≤ 90 min. Six were within 10 min of target; all patient achieved FMC2D ≤ 120 min. Conclusions Guideline-compliant FMC2D ≤ 90 min is achievable for rural STEMI patients within a 50 mile radius of a PCI-capable hospital by use of protocol-driven EMS ground transportation. As all patients achieved a FMC2D time ≤ 120 min, bypass of non-PCI capable hospitals may be reasonable in this situation.
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Choi SW, Shin SD, Ro YS, Song KJ, Lee YJ, Lee EJ. Effect of Emergency Medical Service Use and Inter-hospital Transfer on Time to Percutaneous Coronary Intervention in Patients with ST Elevation Myocardial Infarction: A Multicenter Observational Study. PREHOSP EMERG CARE 2016; 20:66-75. [DOI: 10.3109/10903127.2015.1056892] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
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Prehospital triage and direct transport of patients with ST-elevation myocardial infarction to primary percutaneous coronary intervention centres: a systematic review and meta-analysis. CAN J EMERG MED 2015; 11:481-92. [DOI: 10.1017/s1481803500011684] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
ABSTRACT
Objective:
Percutaneous coronary intervention (PCI) appears to be superior to in-hospital fibrinolysis for most patients with ST-elevation myocardial infarction (STEMI). However, few hospitals have PCI capability. The optimal prehospital strategy for facilitating rapid coronary reperfusion in STEMI patients is unclear. We sought to determine whether direct transport of adult STEMI patients by emergency medical services to primary PCI centres improves 30-day all-cause mortality when compared with a strategy of transportation to the closest hospital.
Methods:
We systematically searched MEDLINE, EMBASE, Cochrane “CENTRAL” database (1980-July 2007) and several other electronic databases. Two authors independently assessed citations for relevance. Two authors independently abstracted data from included studies. We included studies that, 1) transported patients directly to a PCI-capable centre for primary PCI, 2) had a control group that was transported to the closest hospital and 3) reported outcomes of treatment time intervals, all-cause mortality, reinfarction rate, stroke rate or the frequency of cardiogenic shock. We used a random effects model to provide pooled estimates of relative risk (RR) when data allowed.
Results:
We identified 2264 citations with the search. Five studies, including 980 STEMI patients, met inclusion criteria, and were clinically heterogeneous and of variable quality. Most studies were European (3/5) and involved physician out-of-hospital care providers. There was a trend toward increased survival with direct transport to primary PCI but this was not statistically significant (RR 0.51, 95% confidence interval [CI] 0.24–1.10). One study reported nonsignificant reductions in reinfarction (RR 0.43, 95% CI 0.11–1.60) and stroke (RR 0.33, 95% CI 0.01–8.06) with direct transport for primary PCI.
Conclusion:
There is insufficient evidence to support the effectiveness of direct transport of patients with STEMI for primary PCI when compared with transportation to the closest hospital.
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Piggott Z, Weldon E, Strome T, Chochinov A. Application of Lean principles to improve early cardiac care in the emergency department. CAN J EMERG MED 2015; 13:325-32. [DOI: 10.2310/8000.2011.110284] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
ABSTRACTObjective:To achieve our goal of excellent emergency cardiac care, our institution embarked on a Lean process improvement initiative. We sought to examine and quantify the outcome of this project on the care of suspected acute coronary syndrome (ACS) patients in our emergency department (ED).Methods:Front-line ED staff participated in several rapid improvement events, using Lean principles and techniques such as waste elimination, supply chain streamlining, and standard work to increase the value of the early care provided to patients with suspected ACS. A chart review was also conducted. To evaluate our success, proportions of care milestones (first electrocardiogram [ECG], ECG interpretation, physician assessment, and acetylsalicylic acid [ASA] administration) meeting target times were chosen as outcome metrics in this before-and-after study.Results:The proportion of cases with 12-lead ECGs completed within 10 minutes of patient triage increased by 37.4% (p< 0.0001). The proportion of cases with physician assessment initiated within 60 minutes increased by 12.1% (p= 0.0251). Times to ECG, physician assessment, and ASA administration also continued to improve significantly over time (pvalues < 0.0001). Post-Lean, the median time from ECG performance to physician interpretation was 3 minutes. All of these improvements were achieved using existing staff and resources.Conclusions:The application of Lean principles can significantly improve attainment of early diagnostic and therapeutic milestones of emergency cardiac care in the ED.
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Nippak PMD, Pritchard J, Horodyski R, Ikeda-Douglas CJ, Isaac WW. Evaluation of a regional ST-elevation myocardial infarction primary percutaneous coronary intervention program at the Rouge Valley Health System. BMC Health Serv Res 2014; 14:449. [PMID: 25269747 PMCID: PMC4263118 DOI: 10.1186/1472-6963-14-449] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2013] [Accepted: 09/24/2014] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND ST-elevation myocardial infarction (STEMI) remains the second leading cause of death in Canada. Primary percutaneous coronary intervention (PCI) has been recognized as an effective method for treating STEMI. Improved access to primary PCI can be achieved through the implementation of regional PCI centres, which was the impetus for implementing the PCI program in an east Toronto hospital in 2009. As such, the purpose of this study was to measure the efficacy of this program regional expansion. METHODS A retrospective review of 101 patients diagnosed with STEMI from May to Sept 2010 was conducted. The average door-to-balloon time for these STEMI patients was calculated and the door-to-balloon times using different methods of arrival were analyzed. Method of arrival was by one of three ways: paramedic initiated referral; patient walk-ins to PCI centre emergency department; or transfer after walk-in to community hospital emergency department. RESULTS The study found that mean door-to balloon time for PCI was 112.5 minutes. When the door-to-balloon times were compared across the three arrival methods, patients who presented by paramedic-initiated referral had significantly shorter door-to-balloon times, (89.5 minutes) relative to those transferred (120.9 minutes) and those who walked into a PCI centre (126.7 minutes) (p = 0.047). CONCLUSIONS The findings suggest that the partnership between the hospital and its EMS partners should be continued, and paramedic initiated referral should be expanded across Canada and EMS systems where feasible, as this level of coverage does not currently exist nationwide. Investments in regional centres of excellence and the creation of EMS partnerships are needed to enhance access to primary PCI.
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Affiliation(s)
- Pria M D Nippak
- Health Services Management Department, Ryerson University, 350 Victoria St, Toronto, ON M2K 5B3, Canada.
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Kritikou I, Chalkias A, Koutsovasilis A, Xanthos T. Characteristics and survival to discharge of patients with STEMI between a PPCI-capable hospital and a non-PPCI hospital: a prospective observational study. ACUTE CARDIAC CARE 2014; 16:118-22. [PMID: 25133785 DOI: 10.3109/17482941.2014.944539] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
INTRODUCTION Primary percutaneous coronary intervention (PPCI) is a key therapeutic method in the treatment of ST-elevation myocardial infarction (STEMI). We studied the characteristics and survival to discharge in STEMI patients who presented in a PPCI-capable hospital and a non-PPCI hospital. PATIENTS AND METHODS This prospective observational study included 240 consecutive patients. One basic questionnaire was distributed along with an explanatory letter to the participants, who were followed until discharge from the hospital or death. RESULTS Of the 240 patients, 234 (97.5%) survived to hospital discharge. Only 6 (5%) patients who were initially presented to a non-PPCI hospital died after inter-facility transfer. Also, 36 (92.3%) of the 39 patients with an intervening time of over 90 min were admitted initially in a non-PPCI hospital. Although there was a statistically significant correlation between the type of the hospital and the delay from the onset of symptoms to PPCI (P=0.001), such correlation was not found between the delay PPCI and the outcome of the patients (P>0.05). CONCLUSION Patients with STEMI may be transferred to a non-PPCI hospital due to the lack of prehospital triage. However, prompt inter-facility transfer results in good outcome.
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Affiliation(s)
- Irene Kritikou
- National and Kapodistrian University of Athens, Medical School, MSc 'Cardiopulmonary Resuscitation' , Athens , Greece
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Estévez-Loureiro R, López-Sainz &A, Pérez de Prado A, Cuellas C, Calviño Santos R, Alonso-Orcajo N, Salgado Fernández J, Vázquez-Rodríguez JM, López-Benito M, Fernández-Vázquez F. Timely reperfusion for ST-segment elevation myocardial infarction: Effect of direct transfer to primary angioplasty on time delays and clinical outcomes. World J Cardiol 2014; 6:424-433. [PMID: 24976914 PMCID: PMC4072832 DOI: 10.4330/wjc.v6.i6.424] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/19/2013] [Accepted: 04/09/2014] [Indexed: 02/07/2023] Open
Abstract
Primary percutaneous coronary intervention (PPCI) is the preferred reperfusion therapy for patients presenting with ST-segment elevation myocardial infarction (STEMI) when it can be performed expeditiously and by experienced operators. In spite of excellent clinical results this technique is associated with longer delays than thrombolysis and this fact may nullify the benefit of selecting this therapeutic option. Several strategies have been proposed to decrease the temporal delays to deliver PPCI. Among them, prehospital diagnosis and direct transfer to the cath lab, by-passing the emergency department of hospitals, has emerged as an attractive way of diminishing delays. The purpose of this review is to address the effect of direct transfer on time delays and clinical events of patients with STEMI treated by PPCI.
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Shavelle DM, Chen AY, Matthews RV, Roe MT, de Lemos JA, Jollis J, Thomas JL, French WJ. Predictors of reperfusion delay in patients with ST elevation myocardial infarction self-transported to the hospital (from the American Heart Association's Mission: Lifeline Program). Am J Cardiol 2014; 113:798-802. [PMID: 24393257 DOI: 10.1016/j.amjcard.2013.11.036] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/19/2013] [Revised: 11/18/2013] [Accepted: 11/18/2013] [Indexed: 11/19/2022]
Abstract
Primary percutaneous coronary intervention for ST elevation myocardial infarction (STEMI) is beneficial if performed in a timely manner. Self-transport patients with STEMI have prolonged treatment times compared with Emergency Medical Services-transported patients. This study evaluated self-transport patients with STEMI undergoing primary percutaneous coronary intervention to identify factors associated with prolonged door-to-balloon (D2B) times. From January 2007 to March 2011, data for 13,379 self-transport patients with STEMI treated at 432 hospitals in the Acute Coronary Treatment Intervention Outcomes Network Registry-Get With The Guidelines Registry were evaluated. Patients with a D2B time >90 minutes were compared with those with D2B time ≤90 minutes. Factors associated with prolonged D2B (>90 minutes) were explored using logistic generalized estimating equations. The median (twenty-fifth, seventy-fifth percentiles) D2B time for the entire cohort was 72 minutes (58, 86), and 19% had a D2B time of >90 minutes. Over the study period, there was a significant increase in the percentage of patients achieving D2B time ≤90 minutes. There were significant baseline differences between patients with D2B time ≤ versus >90 minutes. The main factors associated with prolonged treatment time were off-hour presentation (weekends and 7 p.m. to 7 a.m. weekdays), not obtaining an electrocardiogram within 10 minutes of hospital arrival, previous coronary artery bypass surgery, black race, older age, and female gender. In conclusion, although prolonged delay from arrival to electrocardiographic acquisition is a modifiable factor contributing to prolonged D2B times among self-transport patients with STEMI, additional factors (age, race, and gender) indicate that historic disparities for cardiovascular care still persist in terms of contemporary metrics for STEMI reperfusion.
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Affiliation(s)
- David M Shavelle
- Division of Cardiovascular Medicine, University of Southern California, Los Angeles, California.
| | - Anita Y Chen
- Duke Clinical Research Institute, Duke University Medical Center, Durham, North Carolina
| | - Ray V Matthews
- Division of Cardiovascular Medicine, University of Southern California, Los Angeles, California
| | - Matthew T Roe
- Duke Clinical Research Institute, Duke University Medical Center, Durham, North Carolina
| | - James A de Lemos
- Division of Cardiology, University of Texas Southwestern Medical Center, Dallas, Texas
| | - James Jollis
- Duke Clinical Research Institute, Duke University Medical Center, Durham, North Carolina
| | - Joseph L Thomas
- Division of Cardiology, Harbor UCLA Medical Center, Torrance, California
| | - William J French
- Division of Cardiology, Harbor UCLA Medical Center, Torrance, California
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Blomstedt K, Nilsson H, Johansson A. The public's perception of prehospital emergency care in the County of Skane, southern Sweden. Int Emerg Nurs 2013; 21:136-42. [PMID: 23615522 DOI: 10.1016/j.ienj.2012.05.004] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2012] [Revised: 05/24/2012] [Accepted: 05/31/2012] [Indexed: 11/26/2022]
Abstract
INTRODUCTION The prehospital emergency care has had a rapid progress in Sweden in terms of technology, treatments and personnel education demands. In the County of Skane there is at least one specialized nurse in every ambulance. Possible misuses of the resources by the public have been acknowledged. AIM To investigate the public's use, knowledge and expectations of the prehospital emergency care in Skane, southern Sweden. METHOD A cross sectional descriptive survey, using a stratified sampling. Inclusion criteria were: 18 year or older and currently living in Skane. RESULTS Of 735 people who were asked 54.4% (n=400) chose to participate in the study. 44.0% of the respondents had been transported with ambulance. 34.5% of the respondents believed that the lowest educated personnel responsible for the patient was the paramedic. The results show that the respondents trust the personnel's knowledge and work skills. Older informants expected faster treatment by a physician when arriving by ambulance to the hospital, regardless of medical condition. CONCLUSION The public had confidence in the ambulance personnel's knowledge, ability to make assessment and give treatment despite not being updated on the current competence of the personnel. A positive experience of contact with the ambulance service was distinct.
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Park YH, Kang GH, Song BG, Chun WJ, Lee JH, Hwang SY, Oh JH, Park K, Kim YD. Factors related to prehospital time delay in acute ST-segment elevation myocardial infarction. J Korean Med Sci 2012; 27:864-9. [PMID: 22876051 PMCID: PMC3410232 DOI: 10.3346/jkms.2012.27.8.864] [Citation(s) in RCA: 35] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/18/2012] [Accepted: 05/17/2012] [Indexed: 12/20/2022] Open
Abstract
Despite recent successful efforts to shorten the door-to-balloon time in patients with acute ST-segment elevation myocardial infarction (STEMI), prehospital delay remains unaffected. Nonetheless, the factors associated with prehospital delay have not been clearly identified in Korea. We retrospectively evaluated 423 patients with STEMI. The mean symptom onset-to-door time was 255 ± 285 (median: 150) min. The patients were analyzed in two groups according to symptom onset-to-door time (short delay group: ≤ 180 min vs long delay group: > 180 min). Inhospital mortality was significantly higher in long delay group (6.9% vs 2.8%; P = 0.048). Among sociodemographic and clinical variables, diabetes, low educational level, triage via other hospital, use of private transport and night time onset were more prevalent in long delay group (21% vs 30%; P = 0.038, 47% vs 59%; P = 0.013, 72% vs 82%; P = 0.027, 25% vs 41%; P < 0.001 and 33% vs 48%; P = 0.002, respectively). In multivariate analysis, low educational level (1.66 [1.08-2.56]; P = 0.021), symptom onset during night time (1.97 [1.27-3.04]; P = 0.002), triage via other hospital (1.83 [1.58-5.10]; P = 0.001) and private transport were significantly associated with prehospital delay (3.02 [1.81-5.06]; P < 0.001). In conclusion, prehospital delay is more frequent in patients with low educational level, symptom onset during night time, triage via other hospitals, and private transport, and is associated with higher inhospital mortality.
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Affiliation(s)
- Yong Hwan Park
- Division of Cardiology, Department of Internal Medicine, Samsung Changwon Hospital, Sungkyunkwan University School of Medicine, Changwon, Korea
| | - Gu Hyun Kang
- Division of Cardiology, Department of Internal Medicine, Samsung Changwon Hospital, Sungkyunkwan University School of Medicine, Changwon, Korea
| | - Bong Gun Song
- Division of Cardiology, Department of Internal Medicine, Samsung Changwon Hospital, Sungkyunkwan University School of Medicine, Changwon, Korea
| | - Woo Jung Chun
- Division of Cardiology, Department of Internal Medicine, Samsung Changwon Hospital, Sungkyunkwan University School of Medicine, Changwon, Korea
| | - Jun Ho Lee
- Department of Emergency Medicine, Samsung Changwon Hospital, Sungkyunkwan University School of Medicine, Changwon, Korea
| | - Seong Youn Hwang
- Department of Emergency Medicine, Samsung Changwon Hospital, Sungkyunkwan University School of Medicine, Changwon, Korea
| | - Ju Hyeon Oh
- Division of Cardiology, Department of Internal Medicine, Samsung Changwon Hospital, Sungkyunkwan University School of Medicine, Changwon, Korea
| | - Kyungil Park
- Division of Cardiology, Department of Internal Medicine, Dong-A University College of Medicine, Busan, Korea
| | - Young Dae Kim
- Division of Cardiology, Department of Internal Medicine, Dong-A University College of Medicine, Busan, Korea
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Patel M, Dunford JV, Aguilar S, Castillo E, Patel E, Fisher R, Ochs G, Mahmud E. Pre-hospital electrocardiography by emergency medical personnel: effects on scene and transport times for chest pain and ST-segment elevation myocardial infarction patients. J Am Coll Cardiol 2012; 60:806-11. [PMID: 22840530 DOI: 10.1016/j.jacc.2012.03.071] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/14/2011] [Revised: 03/12/2012] [Accepted: 03/13/2012] [Indexed: 11/20/2022]
Abstract
OBJECTIVES This study sought to measure the impact of pre-hospital (PH) electrocardiography (ECG) on scene-to-hospital time for patients with chest pain of cardiac origin and those with ST-segment elevation myocardial infarction (STEMI). BACKGROUND Pre-hospital ECG decreases door-to balloon (D2B) time for STEMI patients. However, obtaining a PH ECG might prolong scene time. We investigated the impact of obtaining a PH ECG on both scene and transport times for patients with chest pain suspected of cardiac origin. METHODS City of San Diego Emergency Medical System runsheets of patients with chest pain from January 2003 to April 2008 were analyzed. The scene times and transport times were compared before (from January 2003 to December 2005) and after (from January 2006 to April 2008) implementation of the PH ECG. Among patients with a PH ECG, median scene times and transport times were compared in patients with and without STEMI. RESULTS There were 21,742 patients evaluated for chest pain during the study period. Implementation of PH ECG resulted in minimal increases in median scene time (19 min, 10 s vs. 19 min, 28 s, p = 0.002) and transport time (13 min, 16 s vs. 13 min, 28 s, p = 0.007). However, compared with chest pain patients, in STEMI patients (n = 303), shorter median scene time (17 min, 51 s vs. 19 min, 31 s, p < 0.001), transport time (12 min, 34 s vs. 13 min, 31 s, p = 0.006), and scene-to-hospital time was observed (30 min, 45 s vs. 33 min, 29 s, p < 0.001). CONCLUSIONS Obtaining a PH ECG for patients with chest pain minimally prolongs scene and transport times. Further, for STEMI patients, both scene times and transport times are actually reduced leading to a potential reduction in total ischemic time.
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Affiliation(s)
- Mitul Patel
- Division of Cardiovascular Medicine, University of California, San Diego, CA, USA
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A systematic review of factors predicting door to balloon time in ST-segment elevation myocardial infarction treated with percutaneous intervention. Int J Cardiol 2012; 157:8-23. [DOI: 10.1016/j.ijcard.2011.06.042] [Citation(s) in RCA: 53] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/15/2011] [Revised: 03/17/2011] [Accepted: 06/06/2011] [Indexed: 11/22/2022]
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Mixon TA, Suhr E, Caldwell G, Greenberg RD, Colato F, Blackwell J, Jo CH, Dehmer GJ. Retrospective Description and Analysis of Consecutive Catheterization Laboratory ST-Segment Elevation Myocardial Infarction Activations With Proposal, Rationale, and Use of a New Classification Scheme. Circ Cardiovasc Qual Outcomes 2012; 5:62-9. [DOI: 10.1161/circoutcomes.111.961672] [Citation(s) in RCA: 38] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Affiliation(s)
- Timothy A. Mixon
- From the Division of Cardiology (T.A.M., F.C., J.B., G.J.D.), the Department of Emergency Medicine (E.S., R.D.G.), the Cardiac Catheterization Laboratory (G.C.), and the Department of Research and Statistics (C.-H.J.), Scott & White Healthcare, Temple, TX
| | - Eunice Suhr
- From the Division of Cardiology (T.A.M., F.C., J.B., G.J.D.), the Department of Emergency Medicine (E.S., R.D.G.), the Cardiac Catheterization Laboratory (G.C.), and the Department of Research and Statistics (C.-H.J.), Scott & White Healthcare, Temple, TX
| | - Gerald Caldwell
- From the Division of Cardiology (T.A.M., F.C., J.B., G.J.D.), the Department of Emergency Medicine (E.S., R.D.G.), the Cardiac Catheterization Laboratory (G.C.), and the Department of Research and Statistics (C.-H.J.), Scott & White Healthcare, Temple, TX
| | - Robert D. Greenberg
- From the Division of Cardiology (T.A.M., F.C., J.B., G.J.D.), the Department of Emergency Medicine (E.S., R.D.G.), the Cardiac Catheterization Laboratory (G.C.), and the Department of Research and Statistics (C.-H.J.), Scott & White Healthcare, Temple, TX
| | - Fernando Colato
- From the Division of Cardiology (T.A.M., F.C., J.B., G.J.D.), the Department of Emergency Medicine (E.S., R.D.G.), the Cardiac Catheterization Laboratory (G.C.), and the Department of Research and Statistics (C.-H.J.), Scott & White Healthcare, Temple, TX
| | - Jeffry Blackwell
- From the Division of Cardiology (T.A.M., F.C., J.B., G.J.D.), the Department of Emergency Medicine (E.S., R.D.G.), the Cardiac Catheterization Laboratory (G.C.), and the Department of Research and Statistics (C.-H.J.), Scott & White Healthcare, Temple, TX
| | - Chan-Hee Jo
- From the Division of Cardiology (T.A.M., F.C., J.B., G.J.D.), the Department of Emergency Medicine (E.S., R.D.G.), the Cardiac Catheterization Laboratory (G.C.), and the Department of Research and Statistics (C.-H.J.), Scott & White Healthcare, Temple, TX
| | - Gregory J. Dehmer
- From the Division of Cardiology (T.A.M., F.C., J.B., G.J.D.), the Department of Emergency Medicine (E.S., R.D.G.), the Cardiac Catheterization Laboratory (G.C.), and the Department of Research and Statistics (C.-H.J.), Scott & White Healthcare, Temple, TX
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Patel AB, Quan H, Faris P, Knudtson ML, Traboulsi M, Li B, Ghali WA. Temporal associations of early patient transfers and mortality with the implementation of a regional myocardial infarction care model. Can J Cardiol 2011; 27:731-8. [PMID: 22014858 DOI: 10.1016/j.cjca.2011.08.114] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2011] [Revised: 07/29/2011] [Accepted: 08/01/2011] [Indexed: 11/17/2022] Open
Abstract
BACKGROUND In order to reduce the delays encountered through patient transfer, regional care models have been developed that directly transport subsets of acute myocardial infarction (AMI) patients to hospitals with percutaneous coronary intervention (PCI) facilities. Calgary is a Canadian city that implemented this type of model in 2004. METHODS The study population included 9768 AMI patients admitted to Calgary hospitals between 1997 and 2007. Administrative data were used to define patients who were directly admitted to the PCI hospital and those transferred there after initial admission to a hospital without specialized cardiac care. The differences in clinical characteristics and mortality trends of patients grouped by hospital delivery site and transfer practice are described. RESULTS The proportion of patients directly admitted to a PCI hospital has increased with the implementation of a regional care model. Among patients admitted to non-PCI facilities, the patients who are transferred are younger, more likely to be male, have a shorter length of stay, and have lower proportions of several comorbid conditions. The risk-adjusted in-hospital mortality odds ratio for patients who received care at the PCI hospital postmodel relative to those treated at non-PCI hospitals premodel was 0.38 (95% confidence interval, 0.31-0.47). The corresponding adjusted odds ratio was 0.60 (0.47-0.76). CONCLUSIONS Our results suggest changing care over time and trends toward improved outcomes. Patients' clinical characteristics appear to play a major role in the decision to transfer. Avoidance of the risk treatment paradox through refinement of regional transfer protocols ought to be a priority.
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Affiliation(s)
- Alka B Patel
- Department of Community Health Sciences, University of Calgary, Calgary, Alberta, Canada
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Verbeek PR, Ryan D, Turner L, Craig AM. Serial prehospital 12-lead electrocardiograms increase identification of ST-segment elevation myocardial infarction. PREHOSP EMERG CARE 2011; 16:109-14. [PMID: 21954895 DOI: 10.3109/10903127.2011.614045] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
BACKGROUND Many prehospital protocols require acquisition of a single 12-lead electrocardiogram (ECG) when assessing a patient for ST-segment elevation myocardial infarction (STEMI). However, it is known that ECG evidence of STEMI can evolve over time. OBJECTIVES To determine how often the first and, if necessary, second or third prehospital ECGs identified STEMI, and the time intervals associated with acquiring these ECGs and arrival at the emergency department (ED). METHODS We retrospectively analyzed 325 consecutive prehospital STEMIs identified between June 2008 and May 2009 in a large third-service emergency medical services (EMS) system. If the first ECG did not identify STEMI, protocol required a second ECG just before transport and, if necessary, a third ECG before entering the receiving ED. Paramedics who identified STEMI at any time bypassed participating local EDs, taking patients directly to the percutaneous coronary intervention (PCI) center. Paramedics used computerized ECG interpretation with STEMI diagnosis defined as an "acute MI" report by GE/Marquette 12-SL software in ZOLL E-series defibrillator/cardiac monitors (ZOLL Medical, Chelmsford, MA). We recorded the time of each ECG, and the ordinal number of the diagnostic ECG. We then determined the number of cases and frequency of STEMI diagnosis on the first, second, or third ECG. We also measured the interval between ECGs and the interval from the initial positive ECG to arrival at the ED. Results. STEMI was identified on the first prehospital ECG in 275 cases, on the second ECG in 30 cases, and on the third ECG in 20 cases (cumulative percentages of 84.6%, 93.8%, and 100%, respectively). For STEMIs identified on the second or third ECG, 90% were identified within 25 minutes after the first ECG. The median times from identification of STEMI to arrival at the ED were 17.5 minutes, 11.0 minutes, and 0.7 minutes for STEMIs identified on the first, second, and third ECGs, respectively. CONCLUSIONS A single prehospital ECG would have identified only 84.6% of STEMI patients. This suggests caution using a single prehospital ECG to rule out STEMI. Three serial ECGs acquired over 25 minutes is feasible and may be valuable in maximizing prehospital diagnostic yield, particularly where emergent access to PCI exists.
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Affiliation(s)
- P Richard Verbeek
- Division of Prehospital Care, Sunnybrook Health Science Centre, University of Toronto, Toronto, Ontario, Canada.
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Brunetti ND, De Gennaro L, Dellegrottaglie G, Amoruso D, Antonelli G, Di Biase M. A regional prehospital electrocardiogram network with a single telecardiology "hub" for public emergency medical service: technical requirements, logistics, manpower, and preliminary results. Telemed J E Health 2011; 17:727-33. [PMID: 21916616 DOI: 10.1089/tmj.2011.0053] [Citation(s) in RCA: 33] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND In patients with a major cardiac event, the first priority is to minimize time-to-treatment. For many patients, the first and fastest contact with the health system is through emergency medical services (EMS). However, delay to treatment is still significant in developed countries, and international guidelines therefore recommend that EMS use prehospital electrocardiogram (ECG). Many communities are implementing prehospital ECG programs, with different technical solutions. METHODS We report on a region-wide prehospital ECG telecardiology program that involved 233,657 patients from all over Apulia (4 million inhabitants), Italy, who called the public regional free EMS telephone number "118." Prehospital ECG was transmitted by mobile phone to a single regional telecardiology "hub" where a cardiologist available 24/7 promptly reported the ECG, having a briefing with on-scene EMS personnel and EMS district central; patients were then directed to fibrinolysis or primary percutaneous coronary intervention (PCI) as appropriate. RESULTS Patients were >70 years in 51% of cases, and 55% of prehospital ECGs were unremarkable; the remaining 45% showed signs suggesting acute coronary syndrome (ACS) in 18%, arrhythmias in 20%, and minor findings in 62%. In cases of suspected ACS (chest pain), ECG findings were normal in 77% of patients; 74% of subjects with suspected ACS were screened within 30' from the onset of symptoms. CONCLUSIONS A regional single telecardiology hub providing prehospital ECG for a sole regional public EMS provides an example of a prehospital ECG network optimizing quality of ECG report and uniformity of EMS assistance in a large region-wide network.
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Geographic variations in percutaneous coronary interventions and coronary artery bypass graft surgery among Tennessee elders. South Med J 2011; 104:389-96. [PMID: 21886026 DOI: 10.1097/smj.0b013e3182186fdc] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
OBJECTIVES Coronary heart disease often presents with ST segment elevation acute myocardial infarction (STEMI). The American College of Cardiology/American Heart Association guidelines stress prompt reperfusion for STEMI. Examining geographic variations in treatment with PPCI (percutaneous primary coronary intervention) and CABG (coronary artery bypass graft) among metropolitan, micropolitan and non-micropolitan rural residents provides a descriptive basis for generating hypotheses concerning place and receipt of guidelines-based treatment. METHODS Using ICD-9 codes for STEMI and excluding beneficiaries with pre-existing MI in claims data, yielded a subset of 18,775 Tennessee Medicare beneficiaries experiencing STEMI from 1996 to 2002. The outcome variable is type of treatment, i.e., in accord (PPCI or CABG present) or not in accord (PPCI or CABG absent) with guidelines. Independent variables include type county residence, hospital volume, race, gender, and age. Analyses include cross-tabulation and logistic regression, estimating separate models by age and type of MI. RESULTS Micropolitan residents with STEMI have the lowest rates for PPCI (18.8%) versus 28.1% percent for metropolitan and 24.2% for non-micropolitan rural residents. CABG follows similar patterns at lower overall rates. Treatment at a heart center with high volume PPCI mediated the relationship between the likelihood of PPCI and place. CONCLUSION The correspondence between metropolitan and rural utilization suggests that access to a full range of treatment options and likelihood of "best practice" care is not dependent on metropolitan residence. This presents the possibility that with some policy changes, e.g., centralization of emergency heart care, the same may ultimately be true for micropolitan residents.
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Hospital-based strategies contributing to percutaneous coronary intervention time reduction in the patient with ST-segment elevation myocardiaI infarction: a review of the "system-of-care" approach. Am J Emerg Med 2011; 30:491-8. [PMID: 21514087 DOI: 10.1016/j.ajem.2011.02.011] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2010] [Revised: 02/09/2011] [Accepted: 02/12/2011] [Indexed: 01/09/2023] Open
Abstract
A myriad of hospital-wide initiatives have been implemented with the goal of decreasing door-to-balloon time. Much of the evidence behind the common strategies used is unknown; multiple strategies have been suggested in the reduction to the use of this important time-sensitive intervention. Among 8 primary strategies, 2 have substantial evidence to support their implementation in the attempt to reduce door-to-balloon time in ST-segment elevation myocardial infarction (STEMI), including emergency physician activation of the cardiac catheterization laboratory and prehospital activation of the STEMI alert process. Two strategies have moderate evidence to support their use, including real-time data feedback to team members and team-based approach to STEMI management. The remaining 4 strategies have no quantitative evidence to support their use, including single call to a central paging system, expecting the cardiac catheterization laboratory personnel to arrive within 20 minutes of activation, attending cardiologist on site (within the hospital), and senior management commitment to the project. Although all the STEMI systems of care reviewed are associated with a decreased in time to treatment, only a few have sufficient quantitative evidence to support their implementation. To be effective, the movement to decrease time to treatment of STEMI at any hospital must be composed of an institutional response that includes multiple disciplines. Success also requires active participation from nurses, members of the catheterization team, and hospital leadership.
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Selker HP, Beshansky JR, Ruthazer R, Sheehan PR, Sayah AJ, Atkins JM, Aufderheide TP, Pirrallo RG, D'Agostino RB, Massaro JM, Griffith JL. Emergency medical service predictive instrument-aided diagnosis and treatment of acute coronary syndromes and ST-segment elevation myocardial infarction in the IMMEDIATE trial. PREHOSP EMERG CARE 2011; 15:139-48. [PMID: 21366431 PMCID: PMC4104416 DOI: 10.3109/10903127.2010.545478] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
BACKGROUND A challenge for emergency medical service (EMS) is accurate identification of acute coronary syndromes (ACS) and ST-segment elevation myocardial infarction (STEMI) for immediate treatment and transport. The electrocardiograph-based acute cardiac ischemia time-insensitive predictive instrument (ACI-TIPI) and the thrombolytic predictive instrument (TPI) have been shown to improve diagnosis and treatment in emergency departments (EDs), but their use by paramedics in the community has been less studied. OBJECTIVE To identify candidates for participation in the Immediate Myocardial Metabolic Enhancement During Initial Assessment and Treatment in Emergency Care (IMMEDIATE) Trial, we implemented EMS use of the ACI-TIPI and the TPI in out-of-hospital electrocardiographs and evaluated its impact on paramedic on-site identification of ACS and STEMI as a community-based approach to improving emergency cardiac care. METHODS Ambulances in the study municipalities were outfitted with electrocardiographs with ACI-TIPI and TPI software. Using a before-after quasi-experimental design, in Phase 1, for seven months, paramedics were provided with the ACI-TIPI/TPI continuous 0-100% predictions automatically printed on electrocardiogram (ECG) text headers to supplement their identification of ACS; in Phase 2, for 11 months, paramedics were told to identify ACS based on an ACI-TIPI cutoff probability of ACS ≥ 75% and/or TPI detection of STEMI. In Phase 3, this cutoff approach was used in seven additional municipalities. Confirmed diagnoses of ACS, acute myocardial infarction (AMI), and STEMI were made by blinded physician review for 100% of patients. RESULTS In Phase 1, paramedics identified 107 patients as having ACS; in Phase 2, 104. In Phase 1, 45.8% (49) of patients so identified had ACS confirmed, which increased to 76.0% (79) in Phase 2 (p < 0.001). Of those with ACS, 59.2% (29) had AMI in Phase 1 versus 84.8% (67) with AMI in Phase 2 (p < 0.01), and STEMI was confirmed in 40.8% (20) versus 68.4% (54), respectively (p < 0.01). In Phase 3, of 226 patients identified by paramedics as having ACS, 74.3% (168) had ACS confirmed, of whom 81.0% (136) had AMI and 65.5% (110) had STEMI. Among patients with ACS, the proportion who received percutaneous coronary intervention (PCI) was 30.6% (15) in Phase 1, increasing to 57.0% (45) in Phase 2 (p < 0.004) and 50.6% (85) in Phase 3, and the proportions of patients with STEMI receiving PCI rose from 75.0% (15) to 83.3% (45) (p < 0.4) and 82.7% (91). CONCLUSIONS In a wide range of EMS systems, use of electrocardiographs with ACI-TIPI and TPI decision support using a 75% ACI-TIPI cutoff improves paramedic diagnostic performance for ACS, AMI, and STEMI and increases the proportions of patients who receive PCI.
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Affiliation(s)
- Harry P Selker
- Center for Cardiovascular Health Services Research, Institute for Clinical Research and Health Policy Studies, Tufts Medical Center and Tufts University School of Medicine, Boston, Massachusetts 02111, USA.
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Bossaert L, O'Connor RE, Arntz HR, Brooks SC, Diercks D, Feitosa-Filho G, Nolan JP, Hoek TLV, Walters DL, Wong A, Welsford M, Woolfrey K. Part 9: Acute coronary syndromes: 2010 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science with Treatment Recommendations. Resuscitation 2011; 81 Suppl 1:e175-212. [PMID: 20959169 DOI: 10.1016/j.resuscitation.2010.09.001] [Citation(s) in RCA: 39] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
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Kelly EW, Kelly JD, Hiestand B, Wells-Kiser K, Starling S, Hoekstra JW. Six Sigma process utilization in reducing door-to-balloon time at a single academic tertiary care center. Prog Cardiovasc Dis 2011; 53:219-26. [PMID: 21130919 DOI: 10.1016/j.pcad.2010.08.002] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Rapid reperfusion in patients with ST-elevation myocardial infarction (STEMI) is associated with lower mortality. Reduction in door-to-balloon (D2B) time for percutaneous coronary intervention requires multidisciplinary cooperation, process analysis, and quality improvement methodology. METHODS Six Sigma methodology was used to reduce D2B times in STEMI patients presenting to a tertiary care center. Specific steps in STEMI care were determined, time goals were established, and processes were changed to reduce each step's duration. Outcomes were tracked, and timely feedback was given to providers. RESULTS After process analysis and implementation of improvements, mean D2B times decreased from 128 to 90 minutes. Improvement has been sustained; as of June 2010, the mean D2B was 56 minutes, with 100% of patients meeting the 90-minute window for the year. CONCLUSION Six Sigma methodology and immediate provider feedback result in significant reductions in D2B times. The lessons learned may be extrapolated to other primary percutaneous coronary intervention centers.
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Affiliation(s)
- Elizabeth W Kelly
- Department of Emergency Medicine, Wake Forest University Health Sciences, Winston-Salem, NC 27157, USA.
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O'Connor RE, Bossaert L, Arntz HR, Brooks SC, Diercks D, Feitosa-Filho G, Nolan JP, Vanden Hoek TL, Walters DL, Wong A, Welsford M, Woolfrey K. Part 9: Acute coronary syndromes: 2010 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations. Circulation 2010; 122:S422-65. [PMID: 20956257 DOI: 10.1161/circulationaha.110.985549] [Citation(s) in RCA: 76] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/17/2023]
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Arntz HR, Bossaert L, Danchin N, Nicolau N. Initiales Management des akuten Koronarsyndroms. Notf Rett Med 2010. [DOI: 10.1007/s10049-010-1371-2] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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Studnek JR, Garvey L, Blackwell T, Vandeventer S, Ward SR. Association Between Prehospital Time Intervals and ST-Elevation Myocardial Infarction System Performance. Circulation 2010; 122:1464-9. [PMID: 20876439 DOI: 10.1161/circulationaha.109.931154] [Citation(s) in RCA: 55] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background—
Among individuals experiencing an ST segment–elevation myocardial infarction, current guidelines recommend that the interval from first medical contact to percutaneous coronary intervention be ≤90 minutes. The objective of this study was to determine whether prehospital time intervals were associated with ST-elevation myocardial infarction system performance, defined as first medical contact to percutaneous coronary intervention.
Methods and Results—
Study patients presented with an acute ST-elevation myocardial infarction diagnosed by prehospital ECG between May 2007 and March 2009. Prehospital time intervals were as follows: 9-1-1 call receipt to ambulance on scene ≤10 minutes, ambulance on scene to 12-lead ECG acquisition ≤8 minutes, on-scene time ≤15 minutes, prehospital ECG acquisition to ST-elevation myocardial infarction team notification ≤10 minutes, and scene departure to patient on cardiac catheterization laboratory table ≤30 minutes. Time intervals were derived and analyzed with descriptive statistics and logistic regression. There were 181 prehospital patients who received percutaneous coronary intervention, with 165 (91.1) having complete data. Logistic regression indicated that table time, response time, and on-scene time were the benchmark time intervals with the greatest influence on the probability of achieving percutaneous coronary intervention in ≤90 minutes. Individuals with a time from scene departure to arrival on cardiac catheterization laboratory table of ≤30 minutes were 11.1 times (3.4 to 36.0) more likely to achieve percutaneous coronary intervention in ≤90 minutes than those with extended table times.
Conclusions—
In this patient population, prehospital timing benchmarks were associated with system performance. Although meeting all 5 benchmarks may be an ideal goal, this model may be more useful for identifying areas for system improvement that will have the greatest clinical impact.
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Affiliation(s)
- Jonathan R. Studnek
- From the Carolinas Medical Center, Center for Prehospital Medicine (J.R.S.) and Department of Emergency Medicine (L.G., T.B.), and Mecklenburg EMS Agency (J.R.S., S.V., S.R.W.), Charlotte, NC
| | - Lee Garvey
- From the Carolinas Medical Center, Center for Prehospital Medicine (J.R.S.) and Department of Emergency Medicine (L.G., T.B.), and Mecklenburg EMS Agency (J.R.S., S.V., S.R.W.), Charlotte, NC
| | - Tom Blackwell
- From the Carolinas Medical Center, Center for Prehospital Medicine (J.R.S.) and Department of Emergency Medicine (L.G., T.B.), and Mecklenburg EMS Agency (J.R.S., S.V., S.R.W.), Charlotte, NC
| | - Steven Vandeventer
- From the Carolinas Medical Center, Center for Prehospital Medicine (J.R.S.) and Department of Emergency Medicine (L.G., T.B.), and Mecklenburg EMS Agency (J.R.S., S.V., S.R.W.), Charlotte, NC
| | - Steven R. Ward
- From the Carolinas Medical Center, Center for Prehospital Medicine (J.R.S.) and Department of Emergency Medicine (L.G., T.B.), and Mecklenburg EMS Agency (J.R.S., S.V., S.R.W.), Charlotte, NC
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Arntz HR, Bossaert LL, Danchin N, Nikolaou NI. European Resuscitation Council Guidelines for Resuscitation 2010 Section 5. Initial management of acute coronary syndromes. Resuscitation 2010; 81:1353-63. [DOI: 10.1016/j.resuscitation.2010.08.016] [Citation(s) in RCA: 52] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
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Accelerated management of patients with ST-segment elevation myocardial infarction in the ED. Am J Emerg Med 2010; 29:650-5. [PMID: 20825868 DOI: 10.1016/j.ajem.2010.01.037] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2010] [Revised: 01/25/2010] [Accepted: 01/25/2010] [Indexed: 10/19/2022] Open
Abstract
PURPOSES The objective of this study was to evaluate improvement opportunities in the emergency department for timely ST-segment elevation myocardial infarction management and evaluated the new process flow. BASIC PROCEDURES In a prospective study, we compared time from door to cath laboratory before and after implementation of a new ST-segment elevation myocardial infarction (STEMI) protocol. The new protocol included a blend of strategies to reduce door to cath laboratory time. MAIN FINDINGS We included 55 patients. After implementing a new STEMI protocol, we included 54 patients. Time to cath laboratory was 21 (interquartile range, 9-40) minutes before and 10 (interquartile range 5-25) minutes after initiation of the new protocol (P = .02). A door to cath laboratory time less than 15 minutes was reached in 36% of our patients in phase 1 and in 61% in phase 2 (odds ratio; 0.36, 95% confidence interval, 0.16-0.81; P = .01). PRINCIPAL CONCLUSION Simple changes in organizational strategies resulted in a significantly faster care for patients with acute uncomplicated STEMI.
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Herlitz J, Wireklintsundström B, Bång A, Berglund A, Svensson L, Blomstrand C. Early identification and delay to treatment in myocardial infarction and stroke: differences and similarities. Scand J Trauma Resusc Emerg Med 2010; 18:48. [PMID: 20815939 PMCID: PMC2944143 DOI: 10.1186/1757-7241-18-48] [Citation(s) in RCA: 45] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2010] [Accepted: 09/06/2010] [Indexed: 12/20/2022] Open
Abstract
Background The two major complications of atherosclerosis are acute myocardial infarction (AMI) and acute ischemic stroke. Both are life-threatening conditions characterised by the abrupt cessation of blood flow to respective organs, resulting in an infarction. Depending on the extent of the infarction, loss of organ function varies considerably. In both conditions, it is possible to limit the extent of infarction with early intervention. In both conditions, minutes count. This article aims to describe differences and similarities with regard to the way patients, bystanders and health care providers act in the acute phase of the two diseases with the emphasis on the pre-hospital phase. Method A literature search was performed on the PubMed, Embase (Ovid SP) and Cochrane Library databases. Results In both conditions, symptoms vary considerably. Patients appear to suspect AMI more frequently than stroke and, in the former, there is a gender gap (men suspect AMI more frequently than women). With regard to detection of AMI and stroke at dispatch centre and in Emergency Medical Service (EMS) there is room for improvement in both conditions. The use of EMS appears to be higher in stroke but the overall delay to hospital admission is shorter in AMI. In both conditions, the fast track concept has been shown to influence the delay to treatment considerably. In terms of diagnostic evaluation by the EMS, more supported instruments are available in AMI than in stroke. Knowledge of the importance of early treatment has been reported to influence delays in both AMI and stroke. Conclusion Both in AMI and stroke minutes count and therefore the fast track concept has been introduced. Time to treatment still appears to be longer in stroke than in AMI. In the future improvement in the early detection as well as further shortening to start of treatment will be in focus in both conditions. A collaboration between cardiologists and neurologists and also between pre-hospital and in-hospital care might be fruitful.
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Affiliation(s)
- Johan Herlitz
- Institute of Medicine, Department of Molecular and Clinical Medicine, Sahlgrenska University Hospital, SE-413 45 Göteborg, Sweden.
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Glickman SW, Granger CB, Ou FS, O'Brien S, Lytle BL, Cairns CB, Mears G, Hoekstra JW, Garvey JL, Peterson ED, Jollis JG. Impact of a statewide ST-segment-elevation myocardial infarction regionalization program on treatment times for women, minorities, and the elderly. Circ Cardiovasc Qual Outcomes 2010; 3:514-21. [PMID: 20807883 DOI: 10.1161/circoutcomes.109.917112] [Citation(s) in RCA: 64] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
BACKGROUND Prior studies have demonstrated differences in time to reperfusion for ST-segment-elevation myocardial infarction (STEMI) in women, minorities, and the elderly, relative to their counterparts. Regionalization has been shown to improve overall STEMI treatment times, but its impact on care differences among these important patient subgroups is unknown. The objective of this analysis was to assess the impact of a statewide system of STEMI care (The Reperfusion of Acute Myocardial Infarction in North Carolina Emergency Departments) on treatment times according to patient sex, race, and age. METHODS AND RESULTS STEMI treatment times were determined before (July 2005 to September 2005) and after (January 2007 to March 2007) a year-long implementation of coordinated regional treatment protocols. Times in the pre- and postintervention periods were compared by mixed-effects models. A total of 2063 STEMI patients were analyzed: 1140 at percutaneous coronary intervention hospitals and 923 at non-percutaneous coronary intervention hospitals. The Reperfusion of Acute Myocardial Infarction in North Carolina Emergency Departments was associated with significant improvements in treatment times in women and the elderly, including door-to-ECG, door-to-device, door-in-door-out, and door-to-needle times (all P<0.05). Temporal improvements in treatment times at percutaneous coronary intervention hospitals were not significantly different in blacks than in whites. There was a reduction in baseline treatment disparities in door-to-ECG times in women versus men (4.4-minute reduction in difference; 95% CI, -8.1 to -0.4; P=0.03). After Reperfusion of Acute Myocardial Infarction in North Carolina Emergency Departments, an age-treatment time gap persisted in the elderly, relative to younger patients. CONCLUSIONS A statewide STEMI regionalization program was associated with comparable improvement in treatment times for female, black, and elderly patients compared with middle-aged, white male patients. Nevertheless, there remain opportunities to further narrow treatment differences, particularly among the elderly.
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Underuse of prehospital strategies to reduce time to reperfusion for ST-elevation myocardial infarction patients in 5 Canadian provinces. CAN J EMERG MED 2010; 11:473-80. [PMID: 19788792 DOI: 10.1017/s1481803500011672] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
OBJECTIVE Timely reperfusion therapy for ST-elevation myocardial infarction (STEMI) is an important determinant of outcome, yet targets for time to treatment are frequently unmet in North America. Prehospital strategies can reduce time to reperfusion. We sought to determine the extent to which emergency medical services (EMS) use these strategies in Canada. METHODS We carried out a cross-sectional survey in 2007 of ground EMS operators in British Columbia, Alberta, Ontario, Quebec and Nova Scotia. We focused on the use of 4 prehospital strategies: 1) 12-lead electrocardiogram (ECG), 2) routine expedited emergency department (ED) transfer of STEMI patients (from a referring ED to a percutaneous coronary intervention [PCI] centre), 3) prehospital bypass (ambulance bypass of local EDs to transport patients directly to PCI centres) and 4) prehospital fibrinolysis. RESULTS Ninety-seven ambulance operators were surveyed, representing 15 681 paramedics serving 97% of the combined provincial populations. Of the operators surveyed, 68% (95% confidence interval [CI] 59%-77%) had ambulances equipped with 12-lead ECGs, ranging from 40% in Quebec to 100% in Alberta and Nova Scotia. Overall, 47% (95% CI 46%-48%) of paramedics were trained in ECG acquisition and 40% (95% CI 39%-41%) were trained in ECG interpretation. Only 18% (95% CI 10%-25%) of operators had prehospital bypass protocols; 45% (95% CI 35%-55%) had protocols for expedited ED transfer. Prehospital fibrinolysis was available only in Alberta. All EMS operators in British Columbia, Alberta and Nova Scotia used at least 1 of the 4 prehospital strategies, and one-third of operators in Ontario and Quebec used 0 of 4. In major urban centres, at least 1 of the 3 prehospital strategies 12-lead ECG acquisition, bypass or expedited transfer was used, but there was considerable variation within and across provinces. CONCLUSION The implementation of widely recommended prehospital STEMI strategies varies substantially across the 5 provinces studied, and relatively simple existing technologies, such as prehospital ECGs, are underused in many regions. Substantial improvements in prehospital services and better integration with hospital-based care will be necessary in many regions of Canada if optimal times to reperfusion, and associated outcomes, are to be achieved.
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Nikolić Heitzler V, Babic Z, Milicic D, Bergovec M, Raguz M, Mirat J, Strozzi M, Plazonic Z, Giunio L, Steiner R, Starcevic B, Vukovic I. Results of the Croatian Primary Percutaneous Coronary Intervention Network for patients with ST-segment elevation acute myocardial infarction. Am J Cardiol 2010; 105:1261-7. [PMID: 20403476 DOI: 10.1016/j.amjcard.2009.12.041] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/05/2009] [Revised: 12/16/2009] [Accepted: 12/16/2009] [Indexed: 11/18/2022]
Abstract
The Republic of Croatia, with a gross domestic product per capita of US$11,554 in 2008, is an economically less-developed Western country. The goal of the present investigation was to prove that a well-organized primary percutaneous coronary intervention network in an economically less-developed country equalizes the prospects of all patients with acute ST-segment elevation myocardial infarction at a level comparable to that of more economically developed countries. We prospectively investigated 1,190 patients with acute ST-segment elevation myocardial infarction treated with primary PCI in 8 centers across Croatia (677 nontransferred and 513 transferred). The postprocedural Thrombolysis In Myocardial Infarction flow, in-hospital mortality, and incidence of major adverse cardiovascular events (ie, mortality, pectoral angina, restenosis, reinfarction, coronary artery bypass graft, and cerebrovascular accident rate) during 6 months of follow-up were compared between the nontransferred and transferred subgroups and in the subgroups of older patients, women, and those with cardiogenic shock. In all investigated patients, the average door-to-balloon time was 108 minutes, and the total ischemic time was 265 minutes. Postprocedural Thrombolysis In Myocardial Infarction 3 flow was established in 87.1% of the patients, and the in-hospital mortality rate was 4.4%. No statistically significant difference was found in the results of treatment between the transferred and nontransferred patients overall or in the subgroups of patients >75 years, women, and those with cardiogenic shock. In conclusion, the Croatian Primary Percutaneous Coronary Intervention Network has ensured treatment results of acute ST-segment elevation myocardial infarction comparable to those of randomized studies and registries of more economically developed countries.
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Affiliation(s)
- Vjeran Nikolić Heitzler
- Coronary Care Unit, Cardiovascular Department, Sestre Milosrdnice University Hospital, Zagreb, Croatia
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Daudelin DH, Sayah AJ, Kwong M, Restuccia MC, Porcaro WA, Ruthazer R, Goetz JD, Lane WM, Beshansky JR, Selker HP. Improving use of prehospital 12-lead ECG for early identification and treatment of acute coronary syndrome and ST-elevation myocardial infarction. Circ Cardiovasc Qual Outcomes 2010; 3:316-23. [PMID: 20484201 PMCID: PMC3103142 DOI: 10.1161/circoutcomes.109.895045] [Citation(s) in RCA: 28] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Performance of prehospital ECGs expedites identification of ST-elevation myocardial infarction and reduces door-to-balloon times for patients receiving reperfusion therapy. To fully realize this benefit, emergency medical service performance must be measured and used in feedback reporting and quality improvement. METHODS AND RESULTS This quasi-experimental design trial tested an approach to improving emergency medical service prehospital ECGs using feedback reporting and quality improvement interventions in 2 cities' emergency medical service agencies and receiving hospitals. All patients age > or =30 years, calling 9-1-1 with possible acute coronary syndrome, were included. In total, 6994 patients were included: 1589 patients in the baseline period without feedback and 5405 in the intervention period when there were feedback reports and quality improvement interventions. Mean age was 66+/-17 years, and women represented 51%. Feedback and quality improvement increased prehospital ECG performance for patients with acute coronary syndrome from 76% to 93% (P=<0.0001) and for patients with ST-elevation myocardial infarction from 77% to 99% (P=<0.0001). Aspirin administration increased from 75% to 82% (P=0.001), but the median total emergency medical service run time remained the same at 22 minutes. The proportion of patients with door-to-balloon times of < or =90 minutes increased from 27% to 67% (P=0.006). CONCLUSIONS Feedback reports and quality improvement improved prehospital ECG performance for patients with acute coronary syndrome and ST-elevation myocardial infarction and increased aspirin administration without prehospital transport delays. Improvements in door-to-balloon times were also seen.
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Field triage reduces treatment delay and improves long-term clinical outcome in patients with acute ST-segment elevation myocardial infarction treated with primary percutaneous coronary intervention. J Am Coll Cardiol 2010; 54:2296-302. [PMID: 19958965 DOI: 10.1016/j.jacc.2009.06.056] [Citation(s) in RCA: 59] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/08/2009] [Revised: 06/12/2009] [Accepted: 06/30/2009] [Indexed: 11/17/2022]
Abstract
OBJECTIVES We evaluated the independent impact of field triage on treatment delay and long-term clinical outcome in a large contemporary, consecutive population of ST-segment elevation myocardial infarction (STEMI) patients undergoing primary percutaneous coronary intervention (pPCI). BACKGROUND Reduction of treatment delay is crucial for patients with STEMI. METHODS From January 2005 to July 2008, 1,437 STEMI patients were treated with pPCI at a single high-volume invasive center. We present the 1-year outcome in this observational registry study. RESULTS A total of 616 patients were admitted by field triage and 821 by emergency departments. Baseline and angiographic variables were similar in the 2 populations. Patients admitted by field triage had a significantly shorter median door-to-balloon time compared with patients admitted by emergency department triage (83 min, interquartile range 67 to 100 min vs. 103 min, interquartile range 80 to 135 min; p<0.001). Door-to-balloon times of less than the recommended 90 min were achieved in 61% of field triage patients, but only in 36% of nonfield-triage patients (p<0.001). After adjustment for relevant baseline variables, patients admitted by field triage had a reduced risk of reaching the combined end point of all-cause mortality or nonfatal myocardial infarction (hazard ratio: 0.67; 95% confidence interval: 0.46 to 0.97; p=0.035). CONCLUSIONS This study shows that field triage of STEMI patients to pPCI significantly reduces treatment delay and improves outcome. These results emphasize the value of field triage as an important tool in the quest to improve clinical outcomes in STEMI patients undergoing pPCI.
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Optimizing door-to-balloon times for STEMI interventions – Results from the SINCERE database. J Saudi Heart Assoc 2009; 21:229-43. [DOI: 10.1016/j.jsha.2009.10.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
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Blankenship JC, Skelding KA, Scott TD, Buckley J, Zimmerman DK, Temple A, Sartorius J, Jimenez E, Berger PB. ST-elevation myocardial infarction patients can be enrolled in randomized trials before emergent coronary intervention without sacrificing door-to-balloon time. Am Heart J 2009; 158:400-7. [PMID: 19699863 DOI: 10.1016/j.ahj.2009.06.022] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/14/2009] [Accepted: 06/21/2009] [Indexed: 10/20/2022]
Abstract
BACKGROUND Multicenter trials are necessary to compare the effectiveness of new drugs and devices for patients with ST-elevation myocardial infarction (STEMI) percutaneous coronary intervention (PCI). However, enrollment of STEMI patients in clinical trials could be detrimental to patients if it significantly delayed reperfusion therapy. We sought to determine whether STEMI patients treated with PCI could be enrolled in clinical trials without prolonging door-to-balloon times. METHODS At a single PCI center between October 17, 2004, and December 31, 2007, patients were enrolled in 1 of 4 trials requiring central enrollment and informed consent if (1) a study was actively enrolling, (2) the patient met inclusion/exclusion criteria, (3) and a study nurse was available. Median door-to-balloon times were compared for patients enrolled in clinical trials compared to those not enrolled. RESULTS Of 581 STEMI patients treated with PCI, 123 were enrolled in clinical trials and 458 were not. For patients transferred for PCI, community hospital door-to-balloon times were similar for research and nonresearch patients (104 vs 108 minutes, P = .4). For patients presenting directly to the PCI center, median door-to-balloon times were similar for research (55 minutes) and nonresearch patients (44 minutes, P = .5) after adjustment for age, culprit artery, and operator. CONCLUSIONS Patients with STEMI may be enrolled in clinical trials with no significant delay in achieving reperfusion. For patients presenting directly to the PCI center, median door-to-balloon times well under 90 minutes can be achieved even with enrollment into clinical trials.
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Sivagangabalan G, Ong AT, Narayan A, Sadick N, Hansen PS, Nelson GC, Flynn M, Ross DL, Boyages SC, Kovoor P. Effect of prehospital triage on revascularization times, left ventricular function, and survival in patients with ST-elevation myocardial infarction. Am J Cardiol 2009; 103:907-12. [PMID: 19327414 DOI: 10.1016/j.amjcard.2008.12.007] [Citation(s) in RCA: 52] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/25/2008] [Revised: 12/07/2008] [Accepted: 12/07/2008] [Indexed: 10/21/2022]
Abstract
Shorter reperfusion times lead to better outcomes in patients with ST-elevation myocardial infarction (STEMI). We assessed the efficacy of prehospital triage with bypass of community hospitals and early activation of the cardiac catheterization team on revascularization times, left ventricular (LV) ejection fraction, and survival. Patients with STEMI (624) were divided into 3 groups determined by site of triage: ambulance field triage (163), interventional center emergency department (202), and 3 community hospital emergency departments (259). Compared with community hospital and interventional center triages, ambulance field triage resulted in a significant median decrease in door-to-balloon times of 68 and 27 minutes, respectively (p <0.001). LV ejection fraction was highest in the field triage group (52 +/- 13%) compared with the interventional center (49 +/- 12%) and community hospital (48 +/- 12%, p = 0.017) groups. Thirty-day mortality was lowest in the ambulance field group (3%) compared with the interventional facility (11%) and community hospital (4%, p = 0.007) groups. There was a significant difference in long-term survival with up to 30-month follow-up among the 3 triage groups (p = 0.041). With time-dependent Cox regression modeling the difference in survival was significant only during the first week after STEMI (p = 0.020). Every extra minute of symptom onset to reperfusion time was associated with a relative risk of long-term mortality of 1.003 (95% confidence interval 1.000 to 1.006, p = 0.027). In conclusion, field triage of patient with STEMI decreased revascularization times, which preserved LV function, and improved early survival.
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The Door-to-Balloon Alliance for Quality: Who Joins National Collaborative Efforts and Why? Jt Comm J Qual Patient Saf 2009; 35:93-9. [DOI: 10.1016/s1553-7250(09)35012-6] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
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Ting HH, Krumholz HM, Bradley EH, Cone DC, Curtis JP, Drew BJ, Field JM, French WJ, Gibler WB, Goff DC, Jacobs AK, Nallamothu BK, O'Connor RE, Schuur JD. Implementation and Integration of Prehospital ECGs Into Systems of Care for Acute Coronary Syndrome. Circulation 2008; 118:1066-79. [DOI: 10.1161/circulationaha.108.190402] [Citation(s) in RCA: 179] [Impact Index Per Article: 10.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
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Dorsch MF, Greenwood JP, Priestley C, Somers K, Hague C, Blaxill JM, Wheatcroft SB, Mackintosh AF, McLenachan JM, Blackman DJ. Direct ambulance admission to the cardiac catheterization laboratory significantly reduces door-to-balloon times in primary percutaneous coronary intervention. Am Heart J 2008; 155:1054-8. [PMID: 18513519 DOI: 10.1016/j.ahj.2008.01.014] [Citation(s) in RCA: 66] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/26/2007] [Accepted: 01/19/2008] [Indexed: 12/31/2022]
Abstract
BACKGROUND Primary percutaneous coronary intervention (PCI) is the preferred treatment for ST-segment elevation myocardial infarction (STEMI) provided it can be delivered within 90 minutes of hospital admission. In clinical practice this target is difficult to achieve. We aimed to determine the effect of direct ambulance admission to the cardiac catheterization laboratory on door-to-balloon and call-to-balloon times in primary PCI. METHODS We performed a prospective evaluation of a new system of paramedic electrocardiogram diagnosis of STEMI and subsequent direct ambulance admission to the cardiac catheterization laboratory for primary PCI. Door-to-balloon and call-to-balloon times were recorded for all patients. Direct admissions were compared with admissions via the emergency room of the interventional center and of 2 referring hospitals. All times are quoted as medians. RESULTS Five hundred and seventy-seven patients (70% male, age 63 +/- 13 years) underwent primary PCI between April 2005 and May 2007. After February 2006, 172 (44%) of 387 patients were admitted directly from the ambulance to the catheterization laboratory. Directly admitted patients had significantly reduced door-to-balloon (58 vs 105 minutes, P < .001) and call-to-balloon times (105 vs 143 minutes, P < .001). The 90-minute target for door-to-balloon time was achieved in 94% of direct admissions compared to 29% of patients referred from the emergency room. CONCLUSIONS Direct admission of patients with suspected STEMI from the ambulance service to the catheterization laboratory significantly reduces time to treatment in primary PCI and allows the 90-minute door-to-balloon time target to be reliably achieved.
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