From the Journals

STEMI: Hospital destination policies improve time to first medical contact


Key clinical point: Significantly faster time to guideline-recommended treatment was seen in states that adopted STEMI hospital destination policies that allow EMS to bypass facilities that are not PCI capable.

Major finding: Primary PCI was delivered within the guideline-recommended time from first contact for 58% of patients living in states with hospital destination policies, compared with 48% of patients in states with no such policies.

Study details: A report from the American Heart Association’s Mission: Lifeline program that was based on analysis of 2013-2014 registry data for six states with bypass policies and six matched control states without bypass policies.

Disclosures: The AHA Mission: Lifeline program funded the project. One study coauthor reported serving as the medical director at ZOLL Medical. The others had no conflicts reported.

Source: Green J et al. Circ Cardiovasc Interv. 2018 May;11(5):e005706.

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Progress is modest, but forward

The important and comprehensive analysis by Jacqueline Green, MD, MPH, and her colleagues showed that care and outcomes of STEMI patients can be improved without increasing the number of PCI-capable facilities.

“The results indicate that simply living in a state which has a statewide prehospital plan for EMS [emergency medical services] transport is associated with improved treatment times for heart attack patients,” Daniel M. Kolansky, MD, and Paul N. Fiorilli, MD, wrote in an editorial.

Dr. Green and her colleagues did show that adopting statewide EMS policies which steer STEMI patients directly to PCI-capable hospitals was associated with significantly faster delivery of guideline-directed therapy.

However, the 4-minute improvement in mean door-to-balloon times for states with EMS destination policies versus those with no such policies is “modest,” according to the editorial authors.

“While it is difficult to be certain of the clinical significance of these findings, as the authors point out, it would seem that any action that shortens reperfusion time is an important step in the right direction,” they wrote.

Beyond prehospital EMS transport programs, there are many other aspects of care that could be improved to optimize timely delivery of care to STEMI patients.

Those aspects include routine use of prehospital ECG transmission, development of community outreach programs to help patients recognize symptoms, and more development of regionalized systems of care to reduce time from EMS activation to appropriate treatment.

“Although much work has already been accomplished to expedite the care of these patients, we need to continue to put together all the pieces of this puzzle to provide the best possible heart attack care for our patients,” Dr. Kolansky and Dr. Fiorilli concluded.

Dr. Kolansky and Dr. Fiorilli are with the cardiovascular medicine division at Hospital of the University of Pennsylvania in Philadelphia. These comments are derived from their editorial in Circulation: Cardiovascular Interventions . They had no disclosures.



Patients with ST-elevation myocardial infarction (STEMI) may get more timely treatment when state policies allow emergency medical services to steer patients to percutaneous coronary intervention (PCI)–capable hospitals, results of a registry study suggested.

Time to receipt of guideline-recommended therapy was significantly faster for states that had adopted STEMI hospital destination policies that permit bypassing closer facilities that are not PCI capable, according to results of the study, which was published in Circulation: Cardiovascular Interventions.

A blurry motion of an ambulance speeding by a hospital. JazzIRT/iStock/Getty Images
For patients living in states with such hospital destination policies, PCI was delivered within the guideline-recommended time in 58% of cases, compared with 48% for patients in states without such policies, the data show.

In addition, the mean door-to-balloon time was 48 minutes for patients in states with emergency medical services (EMS) destination policies, versus 52 minutes for patients in states with no destination policies.

These findings provide a compelling case for state-level policies to allow EMS to take patients directly to PCI-capable centers, according to lead study author Jacqueline Green, MD, MPH, a cardiologist at Piedmont Heart Institute in Fayetteville, Ga.

“A policy that improves access to timely care for even an additional 10% of patients could have a significant impact on a population level,” Dr. Green said in a statement.

The analysis by Dr. Green and her colleagues was based on 2013-2014 registry data for six states with bypass policies (Delaware, Iowa, Maryland, North Carolina, Pennsylvania, and Massachusetts) and six control states without bypass policies that were matched based on region, hospital density, and registry participation.

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