Coronary artery disease
An Approach to Shorten Time to Infarct Artery Patency in Patients With ST-Segment Elevation Myocardial Infarction

https://doi.org/10.1016/j.amjcard.2006.12.058Get rights and content

We developed a regional strategy to decrease the time to percutaneous coronary intervention (PCI) for patients with acute ST-segment elevation myocardial infarction (STEMI). Protocols were created for paramedics and referring hospitals to identify and directly triage all patients with STEMI to a single PCI center. Time to PCI reperfusion and in-hospital mortality were assessed in 233 consecutive patients with STEMI. Ninety-minute initial hospital door-to-patent infarct artery was achieved in 58.3% of paramedic-diagnosed and directly triaged patients compared with 37.5% of “walk-ins” to the PCI hospital and with only 5.2% of those transferred from another hospital emergency department (ED; p <0.001). Overall in-hospital mortality was 2.1%, 0% in paramedic identified patients, and 0% in those walk-ins to the PCI hospital ED compared with 4.3% for those transferred from a referring hospital ED (p = 0.007). Paramedic diagnosis of STEMI and direct triage to a prealerted interventional hospital for primary PCI was associated with a high percentage of patients achieving <90-minute infarct artery patency. Substantial delays remained for those who presented initially to a non-PCI hospital ED despite the expedited protocol. In conclusion, this observational study suggests that wider use of paramedic electrocardiographic STEMI diagnosis and direct triage to a prealerted PCI hospital catheterization team may help improve outcomes of patients with STEMI.

Section snippets

Setting

The PCI hospital is a 356-bed regional referral center. The catchment area includes 3 rural counties in Oregon and northern California having 4 community hospitals located 2, 12, 32, and 52 miles away from a regional medical center. The study was initiated between June 2003 and December 2004 as part of a regional quality-improvement project to decrease PCI treatment delays for patients with STEMI.

Protocol

The protocol was implemented through the collaboration of 16 cardiologists from 2 practice groups,

Data verification and selection of cases

Cases were identified by retrospective review by a data analyst (KAB). A random sample of 30 cases was selected for inter-rater reliability confirmation by the cardiology primary investigator (BWG). All data were verified for accuracy between the data analyst (KAB) and a statistical data analyst (AMR). Discrepancies were resolved by consensus.

Patient baseline characteristics

From June 2003 to December 2004, 233 consecutive patients met protocol criteria for the diagnosis of STEMI. Their mean age was 66.1 ± 11.9 years; ∼75%

Discussion

A coordinated, prehospital, regional emergency response for patients with STEMI markedly improved time to PCI. The protocol required <6 hours of “heart equivalent discomfort,” a diagnostic electrocardiogram showing STEMI, and direct triage by paramedics to the prealerted PCI hospital, often bypassing other smaller hospitals. There were significant time savings to achieving an open artery for patients initially seen by paramedics compared with regional hospital ED walk-in patients who were

Acknowledgment

We thank Karen A. Bales, RN, BSN, Dr. Douglas Burwell, Dr. Nicholas Dienel, Dr. John Forsyth, Dr. Gary Foster, Dr. Michael Fugit, Dr. Mark Huth, Dr. Ken Lightheart, Dr. David Martin, Dr. Minor Mathews, Dr. Brian Morrison, Dr. Bruce Patterson, Dr. Eric Pena, Dr. Brad Personious, Dr. Richard Schaefer, Mercy Flights, American Medical Response, Ashland Fire & Rescue, Rogue River Fire District, Northern Siskiyou Ambulance, Medford Fire Department, Jackson County Fire District #3, Rogue Valley

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