Bypassing the Emergency Department to Improve the Process of Care... Myocardial Infarction: Necessary but Not Sufficient

Bypassing the Emergency Department to Improve the Process of Care... Myocardial Infarction: Necessary but Not Sufficient

Bypassing the Emergency Department to Improve the Process of Care for ST-Elevation
Myocardial Infarction: Necessary but Not Sufficient
Elliott M. Antman
Circulation. published online June 20, 2013;
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DOI: 10.1161/CIRCULATIONAHA.113.004195
Bypassing the Emergency Department to Improve the Process of Care for
ST-Elevation Myocardial Infarction: Necessary but Not Sufficient
Running title: Antman; Shortening the time to reperfusion for STEMI
Elliott M. Antman, MD
Card
rd
dio
iova
vasc
va
scul
sc
ular
ul
a D
ivis
iv
i ion, Brigham and Women’s
’ss H
ospital, Harvard Me
Medi
d cal School, Boston, MA
di
Cardiovascular
Division,
Hospital,
Medical
Ad
ddr
dres
ess for
for Correspondence:
C rr
Co
rres
esp
ponden
nd ncee:
Address
Elli
iot
ottt M. A
ntma
nt
man,
n,, M
D
Elliott
Antman,
MD
C rd
Ca
dio
ova
v sc
scul
ullar D
ivis
iv
isio
i n
io
Cardiovascular
Division
Brigham and Women’s Hospital
75 Francis Street
Boston, MA 02115
Tel: 617-732-7149
Fax: 617-975-0990
E-mail: eantman@rics.bwh.harvard.edu
Journal Subject Codes: Atherosclerosis:[87] Coronary circulation, Ethics and policy:[100]
Health policy and outcome research, Thrombosis:[172] Arterial thrombosis, Diagnostic
testing:[29] Coronary imaging: angiography/ultrasound/Doppler/CC
Key words: systems of care, ST-segment elevation myocardial infarction, Editorial, myocardial
infarction, acute coronary syndrome, systems of care
1
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DOI: 10.1161/CIRCULATIONAHA.113.004195
The last several decades have been marked by dramatic advances in the management of patients
with an acute decompensation of ischemic heart disease. A now common phrase in our clinical
lexicon is acute coronary syndrome (ACS), which is further subdivided into presentations with
and without ST-segment elevation on the ECG – thus dividing ACS presentations into STsegment elevation MI (STEMI) and unstable angina/non-ST-segment MI (UA/NSTEMI). 1
Given the time urgency of restoring antegrade flow in the culprit coronary artery in STEMI, it is
understandable that a major focus of clinical research has been defining the optimal reperfusion
regimen – first with fibrinolysis and later catheter-based interventions.
In 2006, an AHA Consensus Statement was published outlining the fact that, at the time,
only a minority of patients with STEMI in the United States received primary per
errcu
utane
n ou
ne
ouss
percutaneous
coronary intervention (PCI) and, in those who did, fewer than 40% were treated within 90
minu
mi
nute
nu
tess af
te
afte
terr ho
te
osp
spit
ital arrival. 2 The AHA conven
convened
eneed an acute MII A
en
Advisory
dvvis
isoory
or Working Group that
minutes
after
hospital
agreed
ag
greeed
e the nex
next
xt sstep
teep iin
n th
the
he pr
proc
process
oces
esss afte
aafter
f er tthe
he in
ini
initial
itiall cconsensus
onssensuus st
stat
statement
attem
men
entt was
was to develop
dev
vellop
o ann
implementation
increase
number
patients
with
STEMI
mpl
plem
emen
em
enta
taati
tion
on pplan
laan to
to eestablish
stab
st
bli
l sh a ssystem
yste
ys
t m of
te
of ccare
a e to
ar
o in
ncre
reaase
re
ase th
thee nu
numb
mberr ooff pa
mb
pati
t en
ti
nts w
ithh ST
TEMI
EM
who receivedd timely
tim
mel
elyy access
a ce
ac
c sss to
to primary
prim
pr
imar
im
a y PCI.
ar
PCI.. Within
W th
Wi
hin
i a year,
yea
ear,
r, a conference
con
onfeere
r nc
ncee was
was held
held with
wit
ih
representation from all the key stakeholders, the success of early model STEMI systems was
reviewed, and the AHA launched Mission:Lifeline, an initiative to improve the quality of care
and outcomes for patients with STEMI and to improve the healthcare system readiness and
response to STEMI. 3
Several remarkable achievements of Mission:Lifeline over the last six years are worth
noting. A robust website exists that is the central clearing house to learn more about
Mission:Lifeline, get the latest news on hot topics, access tools and resources, and register/locate
a system of care for STEMI. 4 As of June 2013, a total of 680 STEMI systems were registered
2
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DOI: 10.1161/CIRCULATIONAHA.113.004195
across the U.S. – covering 67% of our nation’s population.
In an earlier report published in 2012 when 381 unique systems involving 899 PCI
hospitals from 47 states responded to a survey via the Mission:Lifeline website, the
organizational characteristics of the collaborative efforts to provide timely reperfusion for
STEMI in the U.S. were summarized. 5 Of note, at the time, 55% of systems reported the
availability of 12 lead ECGs in their EMS vehicles. The 12 lead ECG was transmitted to a
hospital in 68% of systems. Interpretation of the tracing was performed by paramedics in 63%
and by computer in 34% of systems. When the prehospital ECG revealed a STEMI, the
catheterization laboratory was activated via ED notification in 78% of systems; 19% involved a
dire
dire
recttly
ly..
cardiologist for activation and 15% permitted an EMT to activate the laboratoryy directly.
In a complementary quality improvement effort, the American College of Cardiology
nittia
iate
tedd th
te
thee D
2B
B Alliance
Al
in 2006 to improve do
oor
or--to-device tim
mes
e inn PC
PCI-capable hospitals
initiated
D2B
door-to-device
times
caariing
n for patie
ient
nts wi
ith
t S
TEMI
TE
M . 6 The
MI
The N
National
atiion
onal C
Cardiovascular
ardiov
ovas
ov
ascu
cula
cu
larr Da
Data
ta R
Registry
egis
isttry
try (N
(NCDR)
NCD
CDR
R) C
Cath
athh P
at
PCI
CI
caring
patients
with
STEMI.
Registry
Regi
Re
gist
gi
stry
st
ry was
was uused
seed as tthe
hee ddata
atta co
collection
oll
llec
ecti
ec
tioon
on ttool
ooll fo
oo
forr th
the
he D2B
D2 B A
Alliance.
lli
liian
a ce.
c e. T
The
he ggoal
oaal was
was fo
for
participating
g ho
hosp
hospitals
spit
sp
ital
it
a s to
al
o tre
treat
reat
re
at 75
75%
% of
o ttheir
heir
he
ir nnontransfer
ontr
on
trran
ansf
sfer
sf
er S
STEMI
TEMI
TE
MI ppatients
attie
ient
ntss wi
nt
with
within
thin
th
in
n 990
0 minutes
minu
mi
n tes or less
lesss
of hospital arrival. Hospitals participating in the D2B quality improvement project did show
progressive increases in the proportion of patients treated within 90 minutes with attainment of
the 75% goal by 2009. 7 To examine national trends in D2B, in particular asking whether
improvements were noted in hospitals outside of registry settings, data submitted to the Centers
for Medicare and Medicaid Services from 2005 through 2010 were analyzed. The median
hospital D2B declined from 97 minutes in 2005 to 64 minutes in 2010. 8
Since “time is muscle,” it is a reasonable question to ask whether there are any
components of the system delay that can be minimized to help shorten the time to reperfusion.
3
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DOI: 10.1161/CIRCULATIONAHA.113.004195
In this issue, Bagai and colleagues provide a report from Mission:Lifeline on 12,581 STEMI
patients. 9 The data were collected from hospitals in the National Cardiovascular Data Registry
Acute Coronary Treatment and Intervention Outcomes Network Registry-Get With The
Guidelines (ACTION REGISTRY-GWTG) program. The analysis focused on STEMI patients
with a pre-hospital ECG who were transported by EMS directly to a PCI-capable hospital. The
purpose of the study was to evaluate the frequency of bypassing the Emergency Department
(ED) and admitting the patient directly to the catheterization laboratory. During the period
between 2008 and 2011, ED-bypass occurred in 10.5% of patients. The use of ED-bypass
increased slightly from 8.5% in 2008 to 11.5% in 2011. Of note, about 50% of the STEMI
patients were transported by EMS but the use off pre-hospital ECG recordings inc
nccreeas
a ed ffrom
rom
ro
m
increased
47% to 55%. STEMI patients who were handled via the ED-bypass pathway were less likely to
haave hhad
ad a pprior
riorr M
I to present in cardiogenic sh
I,
hoc
o k, or have a non
o -sys
on
ysste
tem
m reason for delay in
have
MI,
shock,
non-system
P
CII (e
((e.g.
.g. cardiac
card
dia
iacc arrest,
arre
resst, difficulty
diff
di
ffic
ff
icul
ic
ulty
ty with
with
h consent,
conssent, need
need for
forr intubation).
intu
ntubat
atio
ion)
n). Bypassing
Bypas
ypasssi
sing
ng tthe
he ED
ED was
was
PCI
as
sso
soci
ciat
ci
a ed w
at
ith a 20
ith
20 minute
min
nut
ute saving
s vi
sa
ving
ng in
in the
t e time
th
time fr
ffrom
om fi
irstt m
irst
ed
dic
icaal
al ccontact
onta
on
taactt ((FMC)
FMC)
FM
C) tto
o de
dev
vicce
ce
associated
with
first
medical
device
activation (68
68
8 minutes
min
nut
utes
ess versus
verrsu
suss 888 minutes
min
inuttes
e w
henn th
he
he ED
E w
as nnot
ott bbypassed).
yp
pas
asse
sed)
se
d).. S
d)
ig
gni
nifi
fica
fi
cant
ca
n ly more
when
the
was
Significantly
STEMI patients who bypassed the ED had a FMC-device time d90 minutes (80.7%) compared
with those who underwent evaluation in the ED (53.7%). The median duration of time spent in
the ED was 30 minutes. Of note, presentation during working hours was highly correlated with
ED bypass (Odds Ratio 7.58 [6.47-8.89] p<0.0001). It is quite logical that ED bypass occurred
more frequently during regular working hours, since that is when it is more likely that staff
members are present in the catheterization laboratory to care for an acutely ill patient with
STEMI.
Despite the shortening of FMC-device time associated with ED bypass, there was no
4
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DOI: 10.1161/CIRCULATIONAHA.113.004195
difference in the adjusted in-hospital mortality compared with ED evaluation. How can we
reconcile the fact that ED bypass was associated with a lower system delay but did not translate
into improved in-hospital outcomes? Terkelsen et al. report from Western Denmark (55% of that
nation’s population) that between 2002 and 2008, a total of 6209 STEMI patients were admitted
for primary PCI at one of three high-volume PCI centers, in 95% of cases being transported by a
single EMS system. 10 They found that for every 1 hour increase in system delay, the hazard
ratio (HR) for long-term mortality (median follow-up of 3.4 years) in Cox regression analysis
was 1.10 (1.04-1.16), p=0.002. It is possible that the lack of a signal of mortality benefit from
ED bypass in the report from Bagai was too small an impact of system delay (30 minutes) and
oo short a follow-up period (in hospital outcomes).
too
Other epidemiologic considerations may also confound the ability to detect a signal of the
be
ene
nefi
fitt of E
fi
D bypass.
byypa
passs. Those who were selected
d ffor
or ED bypass in
n thee rreport
epor
ep
o t from Bagai tended
benefit
ED
a e less com
av
ompl
pliccatted
dS
TEMI
TE
MI ppresentations,
reeseent
ntatio
onss, w
ere li
ikely
ike
ely to
o hhave
ave a lo
ave
low
wer mo
wer
m
rtal
rt
alit
al
itty risk,
riskk, and
ri
an
nd
too hhave
complicated
STEMI
were
likely
lower
mortality
we
ere
r therefore
the
h re
refo
forre
fo
re less
lesss likely
likkely
li
ly
y to
to show
s ow a benefit
sh
benef
efit
it of
of ED
ED bypass
bypa
by
pass
pa
ss after
after
er adjusting
adj
d us
usti
tinng ffor
orr rrisk
iskk fa
is
fac
ct rs that
ctor
thatt
were
factors
drive mortalit
ityy or
o eexcluding
x lu
xc
ludi
d ng ppatients
attie
ient
ntss wi
nt
with
th hheart
eart
ea
rt ffailure/shock
ailu
ai
lure
lu
re/s
/ssho
hock
ck oorr no
nnon-system
n sy
nsyst
stem
st
em rreasons
easo
ea
sons
so
n ffor
ns
or delay. 9
mortality
A dissociation between changes in components of system delay and in-hospital mortality
has also been reported for D2B. Wang et al. examined data from 101 hospitals in the GWTG
program between 2005 and 2007. Although D2B times decreased from 101 to 87 minutes, inhospital mortality was not significantly changed (5.1% versus 4.7%; p=0.09). 11 There was no
correlation between changes in D2B time and composite quality measures. They speculate that a
singular focus on one measure such as D2B may have “crowded out” attention to other aspects of
hospital care that bear on mortality. Another consideration comes from an NCDR report by
Rathore et al. who analyzed the relationship between D2B time and in-hospital mortality in
5
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DOI: 10.1161/CIRCULATIONAHA.113.004195
43,801 patients with STEMI treated with primary PCI. 12 The D2B-mortality relationship is
relatively flat between 45 and 105 minutes of D2B time and then rises more sharply as D2B
increases progressively above 105 minutes. Thus, shortening of D2B time by 13 minutes from
101 to 87 minutes will have less of an impact than shortening D2B time from a higher baseline.
What are we to do with all this information and what are the next big steps for improving
systems of care for STEMI?
1.
Focusing on a single component of system delay such as D2B or redefining the “door” by
bypassing the ED is useful as a performance measure for PCI-capable centers but is not a
sufficient measure for improving an overall system’s performance in caring for STEMI
patients.10 Comprehensive care improvement programs that address all steps between
bet
etwe
ween
we
en admission
adm
dmis
issi
is
sion
and discharge after STEMI are needed to ensure that evidence-based therapies are delivered.
2..
Cont
Co
Continued
ntin
nt
inueed fo
in
focus on expansion and refinem
refinement
emeent off systemss ooff ca
em
care
are ffor
or STEMI patients is a
hi h priority and
high
and iss emphasized
empha
mpha
hassize
size
zedd inn the
the most
most recent
recen
nt ACC/AHA
ACC/
ACC/
C/A
AHA STEMI
STE
TEMI
MI guidelines.
guuide
deeli
line
nes.
s.133 It would
would
ould be
be
highly
high
hi
ghly
gh
ly ddesirable
esir
es
irab
ir
able
ab
le tto
o se
seee gr
grea
greater
eate
teer ccoordination
oord
oo
rdin
rd
inat
a io
at
ionn am
among
mon
ongg tthe
hee ma
man
many
ny ddisparate
ny
ispa
is
para
pa
rate
ra
te E
EMS
MS ssystems
yste
ys
teems
m aaround
roun
ro
u d th
un
the
he
U.S. that care
re ffor
o S
or
STEMI
TEMI
TE
M ppatients.
atie
at
i nt
nts.
s Mission:Lifeline
s.
M ss
Mi
ssio
io
on:
n:Li
Life
Li
feli
fe
line
li
n iiss a logical
ne
logi
lo
gica
gi
caal quality
q al
qu
alit
ityy improvement
it
im
mpr
p ovvem
emen
entt platform onn
en
to which a much more organized pre-hospital network could be engrafted. This would be
facilitated if STEMI and out of hospital cardiac events were mandated reportable events to public
health authorities.
3.
Ultimately we need to see a reduction in total ischemic time, which involves recognition
of STEMI symptoms by patients. 14 Every health care provider needs to make each office visit
with a patient who has or is at risk for ischemic heart disease a teachable moment to review and
rehearse the appropriate actions to be taken when the symptoms of STEMI appear. The
American Heart Association is actively assisting clinicians and patients in this regard through its
6
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DOI: 10.1161/CIRCULATIONAHA.113.004195
educational website “Warning Signs of a Heart Attack”
(http://www.heart.org/HEARTORG/Conditions/HeartAttack/WarningSignsofaHeartAttack/Warn
ing-Signs-of-a-Heart-Attack_UCM_002039_Article.jsp). Even the best organized system will
not work effectively if patients delay in recognizing their symptoms and 50% of STEMI patients
are not transported by EMS.
Conflict of Interest Disclosures: Dr. Antman was a member of the Advisory Working Group
that ultimately led to the development of Mission:Lifeline. He was Chair of the Writing
Committee for the ACC/AHA STEMI Guideline published in 2004. He is President-Elect of the
American Heart Association for 2013-2014.
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