Delays in reperfusion were substantially reduced for patients with ST-segment elevation myocardial infarction after a statewide program was introduced in North Carolina.
The results of the program were announced on Nov. 4 at the annual scientific sessions of the American Heart Association in Orlando and simultaneously published online (JAMA 2007 Nov. 4 [Epubdoi:10.1001/jama.298.20.joc70124]).
Described as “one of the largest and most extensive regional systems … for the reperfusion of STEMI developed in the United States,” the program was modeled on systems for general trauma care. The program streamlined protocols and coordinated emergency medical services, hospital emergency departments, catheterization labs, and interhospital transfer, according to Dr. Christopher B. Granger of the division of cardiology at Duke University, Durham, N.C., and his associates.
After this program was instituted, the proportion of PCI patients who achieved door-to-device times of 90 minutes or less increased from 57% to 72%, and the median interval decreased from 85 minutes to 74 minutes, the researchers noted.
For patients who presented to hospitals that didn't perform PCI and therefore had to be transferred, the median door-to-device time dropped from 165 minutes to 128 minutes. Median door-in to door-out times decreased from 120 minutes to 71 minutes, “one of the greatest reductions observed in the study,” Dr. Granger and his associates said.
For patients undergoing fibrinolysis, the proportion who achieved door-to-needle times of less than 30 minutes rose from 35% to 52%, and the median interval decreased from 35 minutes to 29 minutes.
The program shaved times by eliminating waits for a cardiology consultation and by having an on-call interventional cardiologist identified at all times.
The emergency physician or paramedic could activate the nearest catheterization laboratory at any hour on any day of the week with a single phone call. Emergency department physicians or medical technicians were allowed to start treatment without waits for a cardiology consultation.
The on-call interventional cardiologist eliminated delays that result when “trying to determine which cardiologist from several competing groups would intervene.” Time to treatment was trimmed in remote areas by encouraging the use of local ambulances rather than helicopters or mobile critical care units. Other strategies included leaving patients “on the stretcher” when appropriate for more rapid evaluation and transfer.
Since STEMI “was a relatively infrequent event for most emergency personnel” to encounter, the program established a specific reperfusion plan that would cover most patients and would sidestep clinician delays that resulted from “indecision” and the need to develop individualized treatment plans.
ICU nurses staffed catheterization labs on an emergency basis, when night and weekend coverage by the usual staff couldn't be arranged. Certain procedures conducted by paramedics and medical technicians were modified to save time. For example, use of intravenous drips such as heparin or nitroglycerin were minimized because substantial delays were associated with establishing and changing infusion lines.
Additionally, the program addressed the limitations of regions with severe restrictions on available equipment and personnel. In resource-poor regions, intermediate-level emergency medical technicians were allowed to perform electrocardiograms. Paramedics were sometimes allowed to interpret ECGs, sometimes with the aid of computer algorithms or via electronic transmission to a physician.
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