Integrated Regional Networks for ST-Segment–Elevation Myocardial Infarction Care in Developing Countries

Abstract

This article describes the development and operation of the Integrated Regional STEMI Network in Salvador, Bahia, Brazil, and defines its basic components. Moreover, we present a preliminary STEMI registry, including patients' demographics, clinical, interval times, and primary reperfusion © 2012 American Heart Association, Inc. Background-Regionalized integrated networks for ST-segment-elevation myocardial infarction (STEMI) care have been proposed as a step forward in overcoming real-world obstacles, but data are lacking on its performance in developing countries. We describe an integrated regional STEMI network in Salvador, Bahia, Brazil.Methods and Results-The network was created in 2009. It was coordinated by the prehospital emergency medical service and encompassed the public emergency system (prehospital mobile units, community-based emergency units, general hospitals, and cardiology reference centers). The 12-lead ECGs are interpreted via telemedicine. This network operates as follows: The Telemedicine Center sends each ECG suggestive of STEMI to a Regional STEMI Alert Team, which, together with emergency medical services, offers support for thrombolysis or immediate transfer for primary percutaneous coronary intervention. In 14 months, there were 433 suspected victims, of which in 287 (76.5%) the STEMI could be confirmed (age, 62.1±12.5 years; 63.4% men). Most of them were self-transported. The median pain-to-admission time was 180 minutes (interquartile range, 90-473 minutes), and the median admission-to-ECG time was 159.5 minutes (interquartile range, 83.5-340 minutes). The median interval time between the ECG and the telemedicine report was 31 minutes (interquartile range, 21-44 minutes). For those who sought medical attention and had an ECG performed within 12 hours after symptoms onset (n=119), the reperfusion rate was 75.6% (34.4% by thrombolysis and 65.6% by primary percutaneous coronary intervention).Conclusions-Regional STEMI networks may be feasible in developing countries. Preliminary results showed this network to be effective, achieving primary reperfusion rates comparable with those reported internationally despite the obstacles faced.(Circ Cardiovasc Qual Outcomes. 2013;6:9-17.)

What evidence is there on the effectiveness of different models of delivering urgent care? A rapid review

“…(b) Studies reporting data on activity within clinical networks for specific conditions such as stroke, 230,231 trauma, 232,233 primary or community care 234,235 and ST elevation myocardial infarction. 236 Most of these studies claimed that clinical networks had improved care by, for example, increasing numbers of patients admitted to specialist facilities, 230,232 receiving thrombolysis for stroke 231 and improving mortality from trauma, 233 but all of them reported current activity and had not made any assessment of differences in care compared with before the network became operational or, therefore, whether the network had improved care. …”

Implementation of a Regional Network for ST‐Segment–Elevation Myocardial Infarction (STEMI) Care and 30‐Day Mortality in a Low‐ to Middle‐Income City in Brazil: Findings From Salvador's STEMI Registry (RESISST)

“…The complete description of the network has been previously published 5. In summary, once a patient with suspected STEMI arrives at the healthcare unit or at a participating hospital, and the first ECG is performed, the tracing is forwarded to the STEMI network physicians via the Telemedicine Center, which is responsible for identifying ECG findings of STEMI.…”

“…Large gaps in STEMI care remain in Brazil. Compared with other countries, there is a striking time delay from onset of symptoms to presentation at the emergency department and delay to the first ECG 5. In addition, the populations of low‐ and middle‐income countries such as Brazil are more exposed to cardiovascular risk factors and have less access to health care, including emergency medical services.…”

“…The Registry of STEMI care of Salvador (RESISST) is a Brazilian registry that includes patients with STEMI who were first seen in small healthcare units or tertiary hospitals in the country's public Unified Health System. Populations of STEMI patients such as this have been poorly represented in existing registries 5. The primary objective of RESISST was to identify predictors of 30‐day mortality among patients with STEMI from a low‐ to middle‐income population.…”

Tempos de acesso a serviços de saúde face ao infarto do miocárdio

“…The efficacy of these networks has been verified in international studies (23,24) , as illustrated by a specific recommendation of the American Heart Association. (25) Nevertheless, successful care delivery to infarction victims does not exclusively depend on the creation of care networks, but on raising the victims' awareness on the need to visit an emergency service early, on integrated efforts by the community, health professionals and managers, as well as on public policies focused on the organization and structuring of the care network, including equipment, material and qualified staff.…”