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In the largest effort to organize ST-segment–elevation myocardial infarction (STEMI) care in the United States, researchers found that participating facilities saw small but clear improvements in first medical contact–to–device time.
The STEMI Systems Accelerator project intervention included 484 hospitals and 1253 emergency medical services (EMS) agencies across 16 regions. The project was designed to implement coordinated care in selected major metropolitan regions, including New York, Atlanta, and Houston.
James G. Jollis, MD, of the University of North Carolina in Chapel Hill, and colleagues hoped that organizing leadership, data collection, common protocols, and conducting ongoing data review with timely feedback would result in more patients receiving primary percutaneous coronary intervention (PCI) within treatment guidelines. Their findings were recently published in Circulation.
Established guidelines call for PCI within 90 minutes of paramedic arrival for patients who are taken directly to a PCI-capable hospital by EMS, and within 120 minutes of first medical contact for patients requiring interhospital transfer. Approximately 30% to 50% of patients do not receive treatment that meets those guidelines.
The project was organized and executed between March 2012 and July 2014. In analyzing results at participating medical facilities, researchers found “significant but modest” increases in the percentage of patients meeting guideline goals.
A total of 18 267 patients presented directly to a PCI-capable hospital and 5542 were transferred from hospitals without PCI capability. Among those who presented to PCI-capable facilities, 64% were transported by EMS and 36% arrived via self-transport.
The proportion of patients who presented directly to a PCI-capable center treated within guideline goals increased from 59% to 61% (P=.005). The subset of EMS-transported patients increased from 50% to 55% (P<.001), and the subset of transferred patients increased from 44% to 48% (P=.002).
Overall in-hospitality mortality was 6.1%, with the highest rate for EMS-transported patients (8.2%) and a lower rate for self-transported patients who presented directly to a PCI-capable hospital (2.7%). Patients who were transferred to a PCI-capable hospital experienced an intermediate level of mortality (5.5%).
Dr Jollis and colleagues also observed substantial regional differences, with the greatest improvements seen in EMS-transported patients. For the 5 most improved regions among EMS-transported patients, the proportion of those treated within 90 minutes increased from 45% to 57%, with an increase from 56% to 76% (P<.001 for both) in the most improved region.
For transferred patients, the proportion treated within 120 minutes increased from 38% to 50% (P<.001), with the most improved region increasing from 33% to 56% (trend test, P=.16).
“An important observation from our study is that symptom duration for patients presenting to EMS was markedly shorter,” researchers added. “This finding identifies an opportunity to achieve remarkably shorter total ischemic time (symptom onset to reperfusion) and allows modest improvements in time to result in major improvement in salvage (and survival) because these patients are on the steep part of the curve describing the association of time and morality.”
Reference
Jolis JG, Al-Khalidi HR, Roettig ML, et al; on behalf of For the Mission: Lifeline STEMI Systems Accelerator Project. Regional systems of care demonstration project. American Heart Association Mission: Lifeline STEMI Systems Accelerator. Circulation. 2016;134:365–374. doi: 10.1161/CIRCULATIONAHA.115.019474.
