Emergency Department Bypass for ST-Segment–Elevation Myocardial Infarction Patients Identified With a Prehospital Electrocardiogram

Abstract

Background-For patients identified before hospital arrival with ST-segment-elevation myocardial infarction, bypassing the emergency department (ED) with direct transport to the catheterization laboratory may shorten reperfusion times. Methods and Results-We studied 12 581 ST-segment-elevation myocardial infarction patients identified with a prehospital ECG treated at 371 primary percutaneous coronary intervention-capable US hospitals participating in the Acute Coronary Treatment and Intervention Outcomes Network Registry-Get With The Guidelines, including those participating in the American Heart Association Mission: Lifeline program from 2008 to 2011. Reperfusion times with primary percutaneous coronary intervention and in-hospital mortality rates were compared between patients undergoing ED evaluation and those bypassing the ED. ED bypass occurred in 1316 patients (10.5%). These patients had a lower frequency of heart failure and shock on presentation and nonsystem reasons for delay in percutaneous coronary intervention. ED bypass occurred more frequently during working hours compared with off-hours (18.3% versus 4.3%); ED bypass rate varied significantly across hospitals (median, 3.3%; range, 0%-71% The unadjusted in-hospital mortality rate was lower among ED bypass patients (2.7% versus 4.1%; P=0.01), but the adjusted mortality risk was similar (adjusted odds ratio, 0.69; 95% confidence interval, 0.45-1.03; P=0.07). Conclusions-Among ST-segment-elevation myocardial infarction patients identified with a prehospital ECG, the rate of ED bypass varied significantly across US hospitals, but ED bypass occurred infrequently and was mostly isolated to working hours. Because ED bypass was associated with shorter reperfusion times and numerically lower mortality rates, further exploration of and advocacy for the implementation of this process appear warranted. Bagai et al ED Bypass in STEMI 353 Editorial see p 322 Clinical Perspective on p 359We evaluated the contemporary use of ED bypass at hospitals participating in the National Cardiovascular Data Registry (NCDR) Acute Coronary Treatment and Intervention Outcomes Network Registry-Get With The Guidelines (ACTION Registry-GWTG), including those participating in the AHA Mission: Lifeline program to delineate the uptake of this strategy in the United States, as well as its impact on reperfusion times for STEMI patients undergoing primary PCI. We also evaluated patient and hospital factors associated with ED bypass and investigated the association of ED bypass with in-hospital mortality rates. MethodsAll patients admitted with STEMI from the ACTION Registry-GWTG from July 1, 2008, to March 31, 2011, were included in the initial study population because this time frame encompassed revisions to the data collection form designed to capture expanded data elements of prehospital treatments and evaluation. The ACTION Registry-GWTG serves as a hospital data collection and evaluation mechanism for the AHA's Mission: Lifeline program and has been described previously.7 A diagno...

Improvement in Care and Outcomes for Emergency Medical Service–Transported Patients With ST‐Elevation Myocardial Infarction (STEMI) With and Without Prehospital Cardiac Arrest: A Mission: Lifeline STEMI Accelerator Study

“…These improvements were not seen for transfer‐in patients. Although PCI‐capable hospitals in recent years have increased in numbers by almost 50%, and 90% of Americans currently live within 60 minutes of a PCI‐capable facility,17, 18, 19, 20 45% of the patients treated with primary PCI were still not treated within the guideline‐recommended goals, in line with previous reports 5, 11, 12. Even though improvement may have continued to occur beyond the study measurement period, it is still highly likely that further efforts will be needed to maintain and improve quality of the regional efforts seen in this study.…”

“…Despite decades of evidence, including randomized trial data calling for primary PCI within FMC2D times of ≤90 minutes for direct EMS‐transported cases and ≤120 minutes for patients requiring interhospital transfer, up to 30% to 50% of all patients with STEMI are not treated within these guideline‐recommended goals for timely reperfusion 5, 10, 11, 12, 13, 14. Previous studies have shown that patients with STEMI with OHCA constitute an important subgroup, with significantly higher rates of system delay and mortality relative to patients with STEMI without OHCA 1.…”

Sex Differences in Reperfusion in Young Patients With ST-Segment–Elevation Myocardial Infarction

“…EMS field activation of the catheterization laboratory is associated with shorter door-to-balloon times than emergency department activation for either walk-in patients or patients arriving by EMS without field activation. 40,41 Our data show that there is room for improvement for both sexes, because 44% of men also exceeded the recommended guidelines when transferred. EMS field activation and regionalization of care are particularly promising in light of the new American Heart Association/American College of Cardiology guidelines that emphasize reducing ischemia time by measuring the delays in Field Medical Contact in an attempt to reduce field delays, 36 and improve long-term outcomes.…”

Cardiovascular Admissions, Readmissions, and Transitions of Care

“…This poor adherence to these guidelines is likely a result of numerous factors, including multiple, separate EMS providers across the U.S. healthcare system with different individual protocols; ambulances without physician staffing; significant variation in geographic areas and terrain throughout the country; lack of a consistent information technology infrastructure to support the routine digital transmission of ECGs for physician review to minimize false catheterization laboratory activations; and dispersal of primary PCI services across a large number of hospitals. [10]…”