Regional Systems of Care for Patients With ST-Elevation Myocardial Infarction

Abstract

ST-segment-elevation myocardial infarction (STEMI) presents a true medical emergency, where the relationship between treatment (reperfusion) and mortality is measured in minutes. Fortunately, when administered early in properly selected patients, both fibrinolytic therapy and primary percutaneous coronary intervention (PCI) have been associated with significant reductions in mortality. 1,2 Unfortunately, it has become increasingly clear that only a minority of STEMI patients receive fibrinolytic therapy within 30 minutes from door-to-needle or receive primary PCI within 90 minutes from door-to-balloon as recommended by the guidelines from the American College of Cardiology/American Heart Association (AHA). 3 Articles pp 721 and 729Moreover, as enthusiasm for primary PCI as the preferred reperfusion modality has escalated, the importance of time to treatment has gained increased recognition. Door-to-balloon time is now included as 1 of the core quality measures collected and reported by the Centers for Medicare and Medicaid and The Joint Commission. Furthermore, although the performance of primary PCI has increased from 18% to 53% worldwide during the past 7 years (with an expected decrease in use of fibrinolytic therapy from 50% to 28%), nearly 30% of patients still do not receive either form of therapy even in the absence of contraindications. 4 It is these realities of the current status of reperfusion therapy that have fostered the concept of systems and centers of care for STEMI patients and interest in the exploration of the feasibility of establishment of regional STEMI networks. It is not surprising that healthcare systems and hospitals across the country are examining their standards of care and organizing quality improvement initiatives to decrease time to treatment and increase adherence to evidence-based therapies for patients with STEMI. 5,6 In this issue of Circulation, 2 pioneering model regional approaches that use integrated systems of care to increase the number of STEMI patients with timely access to a PCI facility are reported.Based on the premise that primary PCI is superior to fibrinolysis even when transfer from a non-PCI-capable facility to a primary PCI center is necessary, Henry and colleagues 7 developed a PCI-based treatment system with an integrated transfer program for STEMI patients at 30 hospitals within 210 miles from the Minneapolis Heart Institute at Abbott Northwestern Hospital. Participating hospitals were divided into zone 1 (Ͻ60 miles) and zone 2 (60 to Յ210 miles) from the Minneapolis Heart Institute. A standardized treatment protocol was developed on the basis of American College of Cardiology/AHA guidelines that was identical for the PCI center, zone 1, and zone 2 hospitals except that zone 2 patients received half-dose tenecteplase (in the absence of a contraindication to fibrinolytic therapy) in anticipation of a lengthy transfer time. At each hospital, training of all personnel (emergency medical services, emergency department, primary care physicians) was performed, t...

The Impact of a Statewide Pre-Hospital STEMI Strategy to Bypass Hospitals Without Percutaneous Coronary Intervention Capability on Treatment Times

“…Regional and statewide systems for rapid STEMI care are being developed [3][4][5][6] to improve the overall use of and timing of PCI and improve patient outcomes. [7][8][9][10] The American Heart Association's Mission Lifeline initiative is part of this national effort to regionalize STEMI care and shorten reperfusion times.…”

Use of Emergency Medical Service Transport Among Patients With ST-Segment–Elevation Myocardial Infarction

“…3 The American Heart Association's Mission: Lifeline initiative aims to increase the number of patients with timely access to reperfusion by addressing the continuum of care for STEMI, beginning with patient recognition of symptoms (http://www.heart.org). Emergency medical services (EMS) activation is critical not only for rapid transport to the hospital, but also to provide the opportunity for early assessment and treatment, as well as activities such as evaluation of hemodynamic stability, prehospital medical stabilization, prehospital ECG in certain areas, and expedited communication with the accepting hospital.…”

“…1,2 Care processes to expedite emergency treatment of acute MI patients after presentation to the hospital have been well defined. 1,3 In recent years, the adoption of these care processes has led to significant reductions in the time from hospital door arrival to reperfusion. 1,2,4,5 …”

2009 Focused Updates: ACC/AHA Guidelines for the Management of Patients With ST‐Elevation Myocardial Infarction (Updating the 2004 Guideline and 2007 Focused Update) and ACC/AHA/SCAI Guidelines on Percutaneous Coronary Intervention (Updating the 2005 Guideline and 2007 Focused Update)

“…82 The development of regional systems of STEMI care is a matter of utmost importance. 83,84 This includes encouraging the participation of key stakeholders in collaborative efforts to evaluate care using standardized performance and quality improvement measures, such as those endorsed by the ACC and the AHA for ACS. 85 Standardized quality-of-care data registries designed to track and measure outcomes, complications, and adherence to evidence-based processes of care for ACS are also critical: programs such as the National Cardiovascular Data Registry ACTION Registry, the AHA's ''Get With The Guidelines'' quality improvement program, and those performance-measurement systems required by the Joint Commission and the Centers for Medicare and Medic-aid Services.…”