Expedited transfer for primary percutaneous coronary intervention: a program evaluation

Villiers, J. S. De; Anderson, Todd J.; McMeekin, James; Leung, Raymond; Traboulsi, Mouhieddin

doi:10.1503/cmaj.060902

Cited by 37 publications

(28 citation statements)

References 36 publications

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“…These patients from high income areas may be more successful in advocating for urgent referrals to a tertiary care center for more aggressive care or may be preferentially referred for these procedures, even more so than high‐income area patients from the metropolitan center. Last, equity in metropolitan centers may reflect active quality improvement protocols put in place to improve door‐to‐balloon times and cardiac care in metropolitan centers but not in nonmetropolitan centers 39. This may also explain why area income gradients were not seen with emergent angiography use within 1 day of presentation; this choice is more likely to be protocol driven for patients with high‐risk features of myocardial infarction, allowing less potential for referral bias.…”

Section: Discussionmentioning

confidence: 99%

Area Median Income and Metropolitan Versus Nonmetropolitan Location of Care for Acute Coronary Syndromes: A Complex Interaction of Social Determinants

Fabreau

Leung

Southern

et al. 2016

JAHA

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BackgroundMetropolitan versus nonmetropolitan status and area median income may independently affect care for and outcomes of acute coronary syndromes. We sought to determine whether location of care modifies the association among area income, receipt of cardiac catheterization, and mortality following an acute coronary syndrome in a universal health care system.Methods and ResultsWe studied a cohort of 14 012 acute coronary syndrome patients admitted to cardiology services between April 18, 2004, and December 31, 2011, in southern Alberta, Canada. We used multivariable logistic regression to determine the odds of cardiac catheterization within 1 day and 7 days of admission and the odds of 30‐day and 1‐year mortality according to area median household income quintile for patients presenting at metropolitan and nonmetropolitan hospitals. In models adjusting for area income, patients who presented at nonmetropolitan facilities had lower adjusted odds of receiving cardiac catheterization within 1 day of admission (odds ratio 0.22, 95% CI 0.11–0.46, P<0.001). Among nonmetropolitan patients, when examined by socioeconomic status, each incremental decrease in income quintile was associated with 10% lower adjusted odds of receiving cardiac catheterization within 7 days (P<0.001) and 24% higher adjusted odds of 30‐day mortality (P=0.008) but no significant difference for 1‐year mortality (P=0.12). There were no differences in adjusted mortality among metropolitan patients.ConclusionWithin a universal health care system, the association among area income and receipt of cardiac catheterization and 30‐day mortality differed depending on the location of initial medical care for acute coronary syndromes. Care protocols are required to improve access to care and outcomes in patients from low‐income nonmetropolitan communities.

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Section: Discussionmentioning

confidence: 99%

Area Median Income and Metropolitan Versus Nonmetropolitan Location of Care for Acute Coronary Syndromes: A Complex Interaction of Social Determinants

Fabreau

Leung

Southern

et al. 2016

JAHA

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“…7 Other recommended strategies to meet reperfusion target times are expedited transfer of STEMI patients from hospitals without PCI capabilities to hospitals with PCI capabilities, and bypassing a non-PCI hospital for a PCI hospital when EMS personnel suspect STEMI. 1,7,[19][20][21][22][23][24] Finally, a number of clinical trials, including several from Canada, have demonstrated the feasibility and safety of prehospital administration of fibrinolytics to patients with STEMI, 11,[25][26][27][28][29][30][31][32] and this is recommended as an alternative strategy for EMS systems capable of fibrinolytic therapy to minimize total ischemic time. 8,19 The degree to which EMS operators have adopted recommended strategies to detect and facilitate treatment of STEMI patients is unclear, despite growing evidence that the strategies are effective in reducing reperfusion delays.…”

Section: Introductionmentioning

confidence: 99%

Underuse of prehospital strategies to reduce time to reperfusion for ST-elevation myocardial infarction patients in 5 Canadian provinces

Schull

Vaillancourt²,

Donovan³

et al. 2009

CJEM

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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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“…Canada has been at the forefront of this movement with established regional approaches in major urban centres, albeit based on various reperfusion strategies (12)(13)(14).…”

Section: The Canadian Perspective On the Systems Approach To Stemi Mamentioning

confidence: 99%

“…A prehospital paramedic-based diagnosis with the triage of patients directly to a centre capable of expedited primary PCI has been successfully employed within the Canadian health care environment. Evidence supports bypassing the ED by direct transfer of patients diagnosed before hospitalization to the catheterization laboratory, which has been demonstrated to reduce time to treatment by 30 min to 50 min (12,13,(23)(24)(25)(26). Assessment and stabilization in the ED or coronary care unit may be appropriate in specific situations including when the prehospital diagnosis is in doubt, the catheterization laboratory staff is not readily available (off-hours or committed to another procedure) and when a patient requires urgent resuscitation due to electrical or hemodynamic instability.…”

Section: The Canadian Perspective On the Systems Approach To Stemi Mamentioning

confidence: 99%

Canadian Cardiovascular Society Working Group: Providing a perspective on the 2007 focused update of the American College of Cardiology and American Heart Association 2004 guidelines for the management of ST elevation myocardial infarction

Welsh

Travers

Huynh

et al. 2009

Canadian Journal of Cardiology

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Expedited transfer for primary percutaneous coronary intervention: a program evaluation

Cited by 37 publications

References 36 publications

Area Median Income and Metropolitan Versus Nonmetropolitan Location of Care for Acute Coronary Syndromes: A Complex Interaction of Social Determinants

Area Median Income and Metropolitan Versus Nonmetropolitan Location of Care for Acute Coronary Syndromes: A Complex Interaction of Social Determinants

Underuse of prehospital strategies to reduce time to reperfusion for ST-elevation myocardial infarction patients in 5 Canadian provinces

Canadian Cardiovascular Society Working Group: Providing a perspective on the 2007 focused update of the American College of Cardiology and American Heart Association 2004 guidelines for the management of ST elevation myocardial infarction

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