A systems-based approach to STEMI care reduces sex disparities and improves STEMI care and outcomes in women.

Background: Systems to improve ST-segment–elevation myocardial infarction (STEMI) care have traditionally focused on improving door-to-balloon time. However, prompt guideline-directed medical therapy and transradial primary percutaneous coronary intervention (PCI) are also associated with reduced STEMI mortality. The incremental prognostic value of each facet of STEMI care on clinical outcomes within a STEMI system of care is unknown. Methods and Results: We implemented systems-based strategies at our hospital to improve 3 STEMI care metrics: (1) prompt guideline-directed medical therapy before sheath insertion for PCI, (2) use of transradial primary PCI, and (3) door-to-balloon time. We assessed the incremental association of metrics achieved with in-hospital adverse events and 30-day mortality. Of 1272 consecutive patients with STEMI treated with PCI at our hospital (January 1, 2011, to December 31, 2016), the percentage with achievement of zero, 1, 2, or 3 STEMI care metrics was 7.1%, 24.1%, 43.8%, and 25.1%; and 30-day mortality was 15.6%, 8.6%, 3.6%, and 3.2%, respectively (log-rank P <0.001). After adjusting for known clinical predictors of STEMI in-hospital mortality, achievement of at least 2 STEMI care metrics was associated with significantly reduced in-hospital mortality (odds ratio, 0.39; 95% CI, 0.16–0.96; P =0.041). Each metric provided incremental prognostic value when modeled in stepwise order of their occurrence in clinical practice (final model C statistic, 0.677; P <0.001). Conclusions: Prompt guideline-directed medical therapy before sheath insertion for PCI, transradial primary PCI, and door-to-balloon time add incremental prognostic value in STEMI care. Expanding STEMI systems of care from a singular focus on door-to-balloon time to a comprehensive focus on multifaceted STEMI care offers an opportunity to further improve STEMI outcomes.

Background and Purpose-Studies have demonstrated the importance of early stroke treatment. If a neuroprotective agent (NA) clinical trial is successful, the greatest benefit might be attained with early prehospital administration. This study determined the potential reduction in time to treatment of stroke patients when NAs were administered in the prehospital setting. Methods-Twenty-three urban emergency medical services (EMS) agencies participated in this study. Prehospital personnel completed a stroke assessment checklist on any potential stroke victim. The checklist collected clinical inclusion/exclusion criteria for NA administration and event/decision times. Patients meeting the hypothetical clinical inclusion criteria were enrolled into this study. Time data included scene arrival/departure, emergency department (ED) arrival, and estimated time of theoretical NA administration. The reduction in time to stroke treatment was calculated as the difference between the time of ED arrival and the reported time of NA administration. The t test and simple linear regression were used to probe for differences in treatment time reduction between selected subgroups. EMS personnel's ability to obtain informed consent for theoretical NA administration was calculated. Results-Two hundred twenty-two patients were enrolled in this study; of these, 75 were deemed eligible for hypothetical NA administration and had complete time data.

The American Heart Association estimates an annual incidence of stroke in the United States at 700,000, leading to over 150,000 deaths. Of all strokes, approximately 88% are ischemic and 12% are hemorrhagic. Almost half of all stroke deaths occur in the out-of-hospital environment.1 Within a given region, the emergency medical services (EMS) system has an important role in the management of the acute stroke patient. Decisions made by EMS personnel can affect treatment and contribute to the immediate, short-term, and long-term outcomes of the patient. Because the patient may require emergent treatment regardless if the stroke is ischemic or hemorrhagic, EMS personnel should manage all potential stroke patients in a time-dependent nature. Proper treatment and disposition of the stroke patient begins in the out-of-hospital environment, continues in the emergency department, and then extends to the inpatient admission. This article reviews the literature on the out-of-hospital treatment of stroke patients and the role of EMS in the development of stroke systems of care.

Background: Since 2006 the Center for Medicare and Medicaid Services has allowed hospitals to exclude public reporting of door to balloon (D2B) time data for STEMI patients with cardiopulmonary arrest (CPA) within 90 minutes after hospital arrival, a high risk group with 30% in-hospital mortality. In July 2014, we implemented a high reliability STEMI process with rapid reperfusion goals for all STEMI patients treated with primary PCI at our center with no patient exclusions (figure). We studied D2B times for patients with and without in-hospital CPA before and after implementation of our high reliability STEMI process to clarify whether exclusion from public reporting on the basis of CPA is justified. Methods: We compared consecutive cases of STEMI treated with primary PCI at our center before (January 2013 to July 15 th , 2014) and after (July 16 th , 2014 to October 2016) implementation of a high reliability STEMI process, and we assessed D2B times in patients with and without in-hospital CPA prior to primary PCI. The primary endpoint was the % of patients treated within guideline D2B times ( < 90 minutes for ED presenting patients or < 120 minutes for inter-hospital transfer patients). Results: Over the study period 795 cases of STEMI were treated with primary PCI at our center. The control group constituted 37.4% (297/795) of patients who were treated prior to July 15 th , 2014, and the high reliability group constituted 62.6% (498/795) of patients treated after July 15 th , 2014. Patients presenting to our primary ED were 27.3% (217/795), inter-hospital transfer patients were 69.1% (549/795), and in-hospital STEMI patients were 3.6% (29/795). CPA within 90 minutes of hospital arrival occurred in 6.3% (50/795) of patients overall, and CPA was more prevalent in the control group vs the high reliability group (8.8% [26/297] vs 4.8% [24/498], P=0.027). In the control group patients with CPA were less likely to achieve goal D2B times compared to patients without CPA (30.8% [8/26] vs 60.5% [164/271], P=0.003), whereas in the high reliability group there was no difference in the rate of achievement of goal D2B times in patients with vs without CPA (75.0% [18/24] vs 81.6% [387/474], P=0.418). Conclusion: High reliability STEMI processes can improve delivery of care for the most vulnerable and highest risk patients.

Background: Systems-based strategies to improve STEMI care have traditionally focused on improving door to balloon time (D2BT) performance. However, prompt guideline-directed medical therapy (GDMT) and use of radial access for PCI are also associated with reduced mortality in patients with STEMI. The incremental value of each facet of STEMI care on mortality is unknown. Methods: On 7/15/14 we implemented a comprehensive four-step STEMI protocol at our institution: (1) ED physician cath lab activation (2) Safe STEMI Handoff Checklist with GDMT decision support (3) immediate transfer to an immediately available cath lab and (4) radial access for PCI. The protocol was intended to minimize care variability in GDMT (aspirin, P2Y12 inhibitor, and anticoagulant) prior to PCI, use of radial access for PCI, and D2BT. We studied consecutive patients with STEMI treated with PCI at our center (1/1/11-12/31/16) to assess the incremental prognostic value of these STEMI care processes using logistic regression models. Results: Of 1272 participants mean age was 61+/-12 years and 68% were men. STEMI presenting location was 25% primary ED, 69% inter-hospital transfer, and 6% in-hospital. The rates of GDMT prior to PCI (74% vs 83%, P<0.001) and radial access for PCI (19% vs. 67%, P<0.001) improved and median D2BT (106 [81-140] vs. 90 [68-109], P<0.001) decreased after implementation of the comprehensive four-step STEMI protocol. In a multivariable model, GDMT prior to PCI (OR 0.42, 95% CI 0.25-0.71, P=0.001), radial access for PCI (OR 0.44, 95% CI 0.23-0.82, P=0.002), and decreasing D2BT (10min decrease: OR 0.96, 95% CI 0.94-0.99, P=0.007) were each independently associated with reduced odds of in-hospital mortality. Step-wise modeling of the risk of in-hospital mortality demonstrated that GDMT prior to PCI, radial access for PCI, and D2BT performance provided incremental prognostic value when added in stepwise order of the occurrence of these care processes in clinical practice (Figure). Conclusions: Prompt GDMT administration, radial access for PCI, and D2BT performance add incremental prognostic value. Expanding STEMI systems of care from a singular focus on D2BT to a comprehensive focus on multi-faceted STEMI care offers an opportunity to further improve STEMI outcomes.

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