Systems of Care for ST-Segment–Elevation Myocardial Infarction: A Report From the American Heart Association’s Mission: Lifeline

Abstract

Background— National guidelines call for participation in systems to rapidly diagnose and treat ST-segment–elevation myocardial infarction (STEMI). In order to characterize currently implemented STEMI reperfusion systems and identify practices common to system organization, the American Heart Association surveyed existing systems throughout the United States. Methods and Results— A STEMI system was defined as an integrated group of separate entities focused on reperfusion therapy for STEMI within a geographic region that included at least 1 hospital that performs percutaneous coronary intervention and at least 1 emergency medical service agency. Systems meeting this definition were invited to participate in a survey of 42 questions based on expert panel opinion and knowledge of existing systems. Data were collected through the American Heart Association Mission: Lifeline website. Between April 2008 and January 2010, 381 unique systems involving 899 percutaneous coronary intervention hospitals in 47 states responded to the survey, of which 255 systems (67%) involved urban regions. The predominant funding sources for STEMI systems were percutaneous coronary intervention hospitals (n = 320, 84%) and /or cardiology practices (n = 88, 23%). Predominant system characteristics identified by the survey included: STEMI patient acceptance at percutaneous coronary intervention hospital regardless of bed availability (N = 346, 97%); single phone call activation of catheterization laboratory (N = 335, 92%); emergency department physician activation of laboratory without cardiology consultation (N = 318, 87%); data registry participation (N = 311, 84%); and prehospital activation of the laboratory through emergency department notification without cardiology notification (N = 297, 78%). The most common barriers to system implementation were hospital (n = 139, 37%) and cardiology group competition (n = 81, 21%) and emergency medical services transport and finances (n = 99, 26%). Conclusions— This survey broadly describes the organizational characteristics of collaborative efforts by hospitals and emergency medical services to provide timely reperfusion in the United States. These findings serve as a benchmark for existing systems and should help guide healthcare teams in the process of organizing care for patients with STEMI.

From Concept to Reality

“…16 These findings are encouraging and likely underestimate the true extent of growth and development of regional STEMI systems. The survey indicated that the funding was provided by the primary PCI hospital (84%) or cardiology practice (23%) in the majority of cases.…”

Needed Dialog

“…There are several barriers that have been identified that similarly may be negatively affecting patient outcomes in these community-based systems. 45 These data suggest that too many stroke centers and physicians providing advanced acute stroke therapy may actually negatively affect patient outcomes after stroke. If this is the case, how then do we rectify the need for expedient care, if only finite number of centers are available?…”

Declining Use Rates of Revascularization for Medicare Patients

“…With programs such as the American Heart Association's Mission: Lifeline and the American College of Cardiology's Acute Coronary Treatment and Intervention Outcomes Network (ACTION) that have promoted target-vessel revascularization of patients with STEMI, a greater increase in emergency PCIs would be expected during this 5-year period. 5,6 Mission: Lifeline and ACTION may have accounted for some increase in new facilities performing PCI during this period.…”