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

Abstract

Background— The ultimate treatment goal for ST-segment elevation myocardial infarction (STEMI) is rapid reperfusion via primary percutaneous intervention (PCI). North Carolina has adopted a statewide STEMI referral strategy that advises paramedics to bypass local hospitals and transport STEMI patients directly to a PCI-capable hospital, even if a non-PCI-capable hospital is closer. Methods and Results— We assessed the adherence of emergency medical services to this STEMI protocol, as well as subsequent associations with patient treatment times and outcomes by linking data from the Acute Coronary Treatment and Intervention Outcomes Network Registry ® —Get With the Guidelines ™ and a statewide emergency medical services data system from June 2008 to September 2010 for all patients with STEMI. Patients were divided into those (1) transported directly to a PCI hospital, thereby bypassing a closer non-PCI hospital and (2) first taken to a closer non-PCI center and later transferred to a PCI hospital. Among 6010 patients with STEMI, 1288 were eligible and included in our study cohort. Of these, 826 (64%) were transported directly to a PCI facility, whereas 462 (36%) were first taken to a non-PCI hospital and later transferred. In a multivariable model, increase in differential driving time and cardiac arrest were associated with a lesser likelihood of being taken directly to a PCI center, whereas a history of PCI was associated with a higher likelihood of being taken directly to a PCI center. Patients sent directly to a PCI center were more likely to have times between first medical contact and PCI within guideline recommendations. Conclusions— We found that patients who were sent directly to a PCI center had significantly shorter time to reperfusion.

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.…”

The impact of transferring patients with ST-segment elevation myocardial infarction to percutaneous coronary intervention-capable hospitals on clinical outcomes

“…Rapid reperfusion by primary percutaneous coronary intervention (PCI) is the preferred strategy for treating patients with ST-segment elevation myocardial infarction (STEMI) [1]. Guidelines recommend that reperfusion therapy with primary PCI should be administered as soon as possible to all eligible patients with STEMI.…”

“…However, several studies have shown that pre-hospital electrocardiographic diagnosis and direct referral to PCI-capable hospitals decrease the time delay in treating patients with STEMI [1,8,9]. Quality improvement strategies have reduced door-to-balloon times for direct-arrival patients with STEMI undergoing primary PCI.…”

Impact of Doctor Car with Mobile Cloud ECG in Reducing Door-to- Balloon Time of Japanese ST-Elevation Myocardial Infarction Patients

“…The patients who had no ST change were transferred to other hospitals without PCI capability. 25) They may have needed a gastroscopy exam later on. This Doctor Car with a mobile cloud ECG system contributed to the effective and economical use of regional medical resources.…”