A quality improvement program at the University of North Carolina significantly improved the recognition and treatment of ST-segment elevation MI (STEMI) in patients who were hospitalized at a tertiary healthcare facility in a noncardiac service.
During the program, nurses, medical teams and allied healthcare professionals received training on the recognition of inpatient STEMI and the importance of the timely reperfusion. Electrocardiogram (ECG) technicians and nurses were also required to notify the cardiologist immediately and the ECG indicated the patient was having an acute MI.
In addition, the healthcare facility established an inpatient STEMI protocol and a cardiac response team and reviewed each inpatient STEMI on a monthly basis.
Lead researcher George A. Stouffer, MD, of the University of North Carolina, and colleagues published their results online in JAMA Cardiology on Sept. 21.
“These results show that it is possible to expedite care of these patients,” Stouffer said in a news release. “Our study was not large enough to determine whether these changes will result in improved survival across the country but the results are encouraging.”
Previous studies found that inpatient STEMIs were associated with a 2- to 10-fold higher mortality rate compared with outpatient STEMIs, according to the researchers. They noted that substantial delays in recognizing and treating inpatient STEMIs could be factors in the higher mortality rates.
In this study, the intervention group included 45 patients who participated in the quality improvement program from Jan. 1, 2012, to April 15, 2016. The control group included 48 patients on non-cardiac services who developed an inpatient STEMI from Jan. 1, 2007, to July 31, 2011, and did not participate in the quality improvement program.
The researchers noted that patients had in the intervention group had more rapid recognition of symptoms and ECG acquisition and significantly shorter ECG to first device activation (FDA) times. The intervention group had a 72 percent lower symptom to FDA times compared with the control group. The researchers added that there was significant improvement in 2012, but the improvement slowed in 2013 and 2014 before a renewed commitment to the program led to significant improvements in 2015 and 2016.
“One of the hallmarks of the [quality improvement program] was empowerment of nurses and other health care professionals to recognize inpatient STEMI and activate the response team,” the researchers wrote. “Although bypassing the primary medical team is unusual in the inpatient setting, this [quality improvement program] established a protocol for rapid identification and triage of inpatient STEMIs that closely resembles the paradigm for outpatient STEMIs.”
The study had a few limitations, according to the researchers, including the use of a historical cohort for the control group. They also noted that the hospital had 24-hour, on-site cardiology support, which may limit the generalizability to other facilities.
“This is one of the first studies to identify ways to improve care of patients who have a heart attack while in the hospital,” Stouffer said. “Based on our encouraging results, Dr. Dai and Dr. Smith at UNC are coordinating a study of 17 leading hospitals around the United States that are implementing these changes. We anxiously await the results, as this would be the first study to show that the very high mortality associated with in-hospital STEMI could be reduced.”