Circ: Statewide STEMI systems are a 'no-brainer' due to positive outcomes
“The bottom line is that time is muscle. The sooner you intervene, the less heart injury, fewer complications and lower the mortality,” Jollis, of the Duke Clinical Research Institute a Duke University in Durham, N.C., said.
Jollis and colleagues aimed to improve these types of inter-hospital delays by implementing a coordinated regional care system across North Carolina. The goal was to help determine whether expanding a STEMI network to all hospitals and EMS agencies could help close the gap within STEMI care.
Their study, published online June 4 in Circulation, showed that the system did just that.
Between July 2008 and December 2009, 6,841 patients presented with acute STEMI at 21 hospitals throughout the state of North Carolina. Of those, 3,907 patients presented directly to the hospital and 2,933 were transferred to PCI-capable facilities. The authors reported that the median age of the patients was 59 years, 30 percent were women and 15 percent were either African-American or Latino.
From onset to ECG, the median duration of chest pain was reported to be 91 minutes. Fifty-five percent of patients were transferred via EMS, while 43 percent presented as a walk-in. The rate of patients who did not receive reperfusion fell from 5.4 percent to 4 percent over the duration of the study.
The authors noted that this drop could be attributed to the 4 percent decline in eligible but untreated patients at non-PCI hospitals. PCI use increased from 52 to 66 percent during the study period in non-PCI hospitals.
Door-to-device times also dropped during the study period. In fact, patients who presented to PCI hospitals saw door-to-device times drop from 64 to 59 minutes. These numbers for self-presenting patients and EMS transported patients went from 79 to 73 minutes and 58 to 55 minutes, respectively. In addition, the authors saw improvement in treatment times for transfer patients.
“The clinical impact will be the change to emergency cardiac care so that the rapid diagnosis of the treatment of MI will be a standard for every EMS agency and every hospital,” Jollis said. Additionally, he said that the collaborative fashion used in this model will eliminate many problems with such transfers such as worrying about who’s on call, where the patient is being transferred or what time of day it is.
“In this model, everyone knows their job and can execute it quickly and efficiently,” Jollis said.
During the evaluation, Jollis et al found that the proportion of patients who underwent PCI within the 90-minute window increased from 83 percent to 89 percent. Additionally, the rate of pre-hospital ECG use increased from 67 to 88 percent for patients who were transported to PCI-capable hospitals via EMS. Mortality was also lower in patients who were treated within the guideline goals compared with those who exceeded the current recommendations, 2.2 percent vs. 5.7 percent, respectively.
For hospitals that adopted a "transfer to PCI" strategy, time from door to device activation fell 117 minutes to 103 minutes; 39 percent of patients were treated within the 90-minute window.
“Currently, there is nothing in the U.S. healthcare system to mediate between competing hospitals and competing physician groups or between EMS agencies in hospitals. These are separate entities,” Jollis said. Therefore, he advised that hospitals and EMS agencies within a state work together to overcome competition as a means to improve care.
However, getting the various stakeholders on board will be the major challenge. Jollis said that this will work best if states identify leaders from more than one hospital to help get everyone on board and collaborating. “You need to come up with a systematic plan.
"By extending our organization to an entire state, rapid diagnosis and treatment of STEMI has become an embedded standard of care independent of healthcare setting or geographic location," Jollis et al summed in the study.
Jollis said that more research is in the works to evaluate these types of care systems at 20 city/metro areas around the country. Duke is collaborating with the American Heart Association in an attempt to organize these types of care regions across the states. The initiative— Mission Lifeline: STEMI Systems Accelerator—aims to lower mortality and quicken time to diagnosis.
“We see four times more deaths from MI than motor vehicle accidents,” Jollis summed. “It is a no-brainer that we need these systems in place." Eventually, these programs are expected to expand to include stroke, cardiac arrest and others in an all-encompassing cardiovascular emergency care system.