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; Circulation is published by the American Heart Association, 7272 Greenville Avenue, Dallas, TX 75231 Copyright © 2013 American Heart Association, Inc. All rights reserved. Print ISSN: 0009-7322. Online ISSN: 1524-4539 The online version of this article, along with updated information and services, is located on the World Wide Web at: http://circ.ahajournals.org/content/early/2013/06/20/CIRCULATIONAHA.113.004195 Permissions: Requests for permissions to reproduce figures, tables, or portions of articles originally published in Circulation can be obtained via RightsLink, a service of the Copyright Clearance Center, not the Editorial Office. Once the online version of the published article for which permission is being requested is located, click Request Permissions in the middle column of the Web page under Services. Further information about this process is available in the Permissions and Rights Question and Answer document. Reprints: Information about reprints can be found online at: http://www.lww.com/reprints Subscriptions: Information about subscribing to Circulation is online at: http://circ.ahajournals.org//subscriptions/ Downloaded from http://circ.ahajournals.org/ at Duke University--Durham on June 21, 2013 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 Downloaded from http://circ.ahajournals.org/ at Duke University--Durham on June 21, 2013 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 Downloaded from http://circ.ahajournals.org/ at Duke University--Durham on June 21, 2013 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 Downloaded from http://circ.ahajournals.org/ at Duke University--Durham on June 21, 2013 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 Downloaded from http://circ.ahajournals.org/ at Duke University--Durham on June 21, 2013 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 Downloaded from http://circ.ahajournals.org/ at Duke University--Durham on June 21, 2013 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 Downloaded from http://circ.ahajournals.org/ at Duke University--Durham on June 21, 2013 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. References: 1. 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