This clinical feature is sponsored by Philips.
Timely diagnosis and restoration of coronary artery flow remains the cornerstone of treatment for patients with ST-elevation myocardial infarction (STEMI). During the past six years, enormous efforts by hospitals and medical professionals have focused on a specific phase of coronary reperfusion, namely the “door-to-balloon” process. As a result of this work, more than 90% of patients presenting to hospitals with percutaneous coronary intervention (PCI) facilities are now treated within 90 minutes of hospital arrival.(1)
However, despite the improvements in door-to-balloon time, the current emergency cardiac care system often performs well below its potential. In 2012, more than half of the STEMI patients who called 9-1-1, and those transferred from outside emergency departments (EDs), haven’t met the new guideline goals for reperfusion: EMS arrival to device deployment within 90 minutes for EMS-transported patients, and first hospital door-to-device within 120 minutes for transferred patients.(2,3) Paramedics should play a pivotal role in coronary reperfusion. Pre-notification and laboratory activation can reduce door-to-balloon times below 30 minutes.
These time goals can only be achieved with the expansion of STEMI protocols beyond the 1,400 hospitals with PCI facilities to the 3,600 hospitals lacking such capability and to the more than 15,000 EMS agencies in the U.S. Emergency cardiac care systems must evolve beyond the PCI hospital door with implementation on a regional basis.
Following the examples of such models as Los Angeles County and North Carolina, every hospital and EMS agency within a region should have a pre-specified and coordinated plan in which healthcare professionals know their role in the identification, diagnosis and expediting treatment of patients experiencing acute myocardial infarction.(4-7)
In order to meet the full potential of emergency cardiac care, the Regional Systems of Care Demonstration Project: Mission: Lifeline STEMI System Accelerator Program, funded in part by two-year grants from Philips Healthcare, The MEDICINES Company and Abiomed, has selected 20 regions across the U.S. for sustained efforts to regionalize coronary reperfusion plans. These 20 sites were selected based on leadership, organization and facilities, and their likelihood of developing coordinated diagnosis and treatment plans in every hospital and EMS agency in their region.
The STEMI Accelerator Program is designed to build on the experience of successfully implemented regional systems. According to a national survey of 381 STEMI systems conducted by the American Heart Association (AHA), the single most commonly cited barriers to system implementation were hospital and physician competition.(8) The program’s interventions are led by national faculty and local AHA staff who will serve as neutral intermediaries between EMS agencies, hospitals and physicians within a region.
A number of tenets are central to this accelerator intervention. It’s designed to build or advance systems that are ultimately self-sustaining and use existing regional and national resources whenever possible, such as the ACTION Registry®-GWTGTM data and regional system reports. The program focuses on supporting leaders within each region to design, implement and sustain the system.
The ultimate goal is to establish rapid diagnosis and treatment of STEMI as a uniformed standard of care across every EMS agency and hospital within a region. When it comes to building emergency cardiac systems, a number of key features are shared across regions, including implementing national guidelines, similar ECG equipment and protocols, and having hospital systems to support rapid PCI. Many issues are unique to specific regions, largely based on the interplay of geography, government and market forces. Thus, the project will be guided by EMS providers in each region regarding challenges and barriers.
The project’s intervention will follow an approach that was developed a number of regional STEMI systems. The initial focus will be on the establishment of leadership, common data and funding. Funding is primarily required to support data collection and analysis, and to provide a neutral “feet on the ground” regional system coordinator/implementer. Next, all PCI hospitals in the region will be organized to provide rapid intervention on a systematic basis that includes single call catheterization laboratory activation by paramedics and emergency physicians on a 24/7 basis, accepting all patients regardless of bed availability, participation in the regional data registry, and adoption of regional reperfusion protocols. In developing these protocols, the focus has been directed toward three patient scenarios that have the most potential to save time and lives: patients presenting by EMS, patients transferred from hospitals lacking PCI facilities, and patients with early signs of cardiogenic shock.
With pre-specified and uniform protocols, paramedics, nurses and emergency physicians who first come into contact with patients can rapidly implement treatment plans without delay for consultation or need to identify the accepting facility.
Once PCI hospitals have adopted the above processes to rapidly provide coronary reperfusion, coordinators and leaders will work with EMS agencies and non-PCI hospitals to adopt a STEMI diagnosis and treatment plan consistent with regional protocols and local resources. A final step involves ongoing measurement and feedback through Mission: Lifeline™ regional system reports, targeting opportunities for continued improvement.
The Accelerator Program has a two-year time horizon from conception to implementation. In order to measure the effects of the intervention, data will be examined from all participating regions relative to changes in treatment times and outcomes. Involving EMS on a regional basis will result in improved treatment times and lower in-hospital mortality.
1. Krumholz HM, Herrin J, Miller LE, et al. Improvements in door-to-balloon time in the United States, 2005 to 2010. Circulation. 2011;124(9):1,038–1,045.
2. American College of Cardiology National Cardiovascular Data Registry (ACCNCDR). The ACTION Registry-GWTG National slide set Quarter 3 2010-Quarter 2 2012. ACCNCDR. December, 2011.
3. Levine GN, Bates ER, Blankenship JC, et al. 2011 ACCF/AHA/SCAI guideline for percutaneous coronary intervention: A report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines and the Society for Cardiovascular Angiography and Interventions. Catheter Cardiovasc Interv. 2012;79(3):453–495.
4. Rokos IC, Larson DM, Henry TD, et al. Rational for establishing regional ST-elevation myocardial infarction receiving center (SRS) networks. Am Heart J. 2006;152(4):661–667.
5. Rokos IC, French WJ, Koenig WJ, et al. Integration of pre-hospital electrocardiograms and ST-elevation myocardial infarction receiving centers (SRC) networks: Impact on door-to-balloon time across 10 independent regions. JACC Cardiovasc Interv. 2009;2(4):339–346.
6. Jollis JG, Roettig ML, Aluko AO, et al. Implementation of a Statewide System for Coronary Reperfusion for ST-Segment Elevation Myocardial Infarction. JAMA. 2007;298(20):2,371–2,380.
7. Jollis JG, Al-Khalidi HR, Monk L, et al.; on behalf of the Regional Approach to Cardiovascular Emergencies (RACE) Investigators. Expansion of a Regional ST-Segment-Elevation Myocardial Infarction System to an Entire State. Circulation. 2012;126(2):189-195. Epub 2012 Jun 4.
8. Jollis JG, Granger CB, Henry TD, et al. Systems of care for ST-segment-elevation myocardial infarction: A report from the American Heart Association’s Mission: Lifeline. Circ Cardiovasc Qual Outcomes. 2012;5(4):423–428.