Development of Systems of Care for ST-Elevation Myocardial Infarction Patients

Moyer, Peter; Ornato, Joseph P.; Brady, William J.; Davis, Leslie L.; Ghaemmaghami, Chris A.; Gibler, W. Brian; Mears, Greg; Mosesso, Vincent N.; Zane, Richard D.

doi:10.1161/circulationaha.107.184047

Cited by 59 publications

(28 citation statements)

References 37 publications

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“…However, this term remained in the model because previous research has indicated the importance of bundling ECG acquisition and hospital notification together. 6 It is important to recognize that not all of these individual components may be feasible for implementation in any 1 EMS system. Focusing on individual components with an overall design for implementation may prove beneficial for EMS systems attempting to improve STEMI care.…”

Section: Discussionmentioning

confidence: 99%

“…These times were grouped together as an expression of the integration of prehospital and in-hospital services, one of the key elements of successful chest pain evaluation centers. 6 With prearrival notification of STEMI patients, the PCI centers in this study prepared the CCL and admitted patients directly to the CCL when possible. In some cases, the CCL was not prepared for patient admission by the time of EMS arrival at the hospital.…”

Section: Limitationsmentioning

confidence: 99%

“…1,2 Local, state, and national programs have aimed to reduce time to PCI by integrating the prehospital and in-hospital care of STEMI patients. [3][4][5][6] The early acquisition of prehospital 12-lead ECGs and subsequent hospital notification in patients with symptoms of an acute coronary syndrome is a Class I recommendation and has been shown to reduce time to PCI. [7][8][9][10][11][12][13] However, there is little additional guidance on how emergency medical services (EMS) should optimize their time before hospital arrival.…”

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confidence: 99%

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Association Between Prehospital Time Intervals and ST-Elevation Myocardial Infarction System Performance

et al. 2010

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Background-Among individuals experiencing an ST segment-elevation myocardial infarction, current guidelines recommend that the interval from first medical contact to percutaneous coronary intervention be Յ90 minutes. The objective of this study was to determine whether prehospital time intervals were associated with ST-elevation myocardial infarction system performance, defined as first medical contact to percutaneous coronary intervention. Methods and Results-Study patients presented with an acute ST-elevation myocardial infarction diagnosed by prehospital ECG between May 2007 and March 2009. Prehospital time intervals were as follows: 9-1-1 call receipt to ambulance on scene Յ10 minutes, ambulance on scene to 12-lead ECG acquisition Յ8 minutes, on-scene time Յ15 minutes, prehospital ECG acquisition to ST-elevation myocardial infarction team notification Յ10 minutes, and scene departure to patient on cardiac catheterization laboratory table Յ30 minutes. Time intervals were derived and analyzed with descriptive statistics and logistic regression. There were 181 prehospital patients who received percutaneous coronary intervention, with 165 (91.1%) having complete data. Logistic regression indicated that table time, response time, and on-scene time were the benchmark time intervals with the greatest influence on the probability of achieving percutaneous coronary intervention in Յ90 minutes. Individuals with a time from scene departure to arrival on cardiac catheterization laboratory table of Յ30 minutes were 11.1 times (3.4 to 36.0) more likely to achieve percutaneous coronary intervention in Յ90 minutes than those with extended table times. Conclusions-In this patient population, prehospital timing benchmarks were associated with system performance.Although meeting all 5 benchmarks may be an ideal goal, this model may be more useful for identifying areas for system improvement that will have the greatest clinical impact. (Circulation.

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Section: Discussionmentioning

confidence: 99%

Section: Limitationsmentioning

confidence: 99%

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confidence: 99%

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Association Between Prehospital Time Intervals and ST-Elevation Myocardial Infarction System Performance

et al. 2010

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“…9 EMT-basic personnel provide basic life support, including first aid, cardiopulmonary resuscitation, oxygen, and early defibrillation. EMT-intermediate and EMTparamedic personnel provide advanced life support, including intubation and intravenous medications.…”

Section: What Training and Maintenance Of Competency Do Ems Providersmentioning

confidence: 99%

Implementation and Integration of Prehospital ECGs Into Systems of Care for Acute Coronary Syndrome

Ting¹,

Krumholz²,

Bradley³

et al. 2008

Circulation

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221

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Clinical case: A 58-year-old woman called 9-1-1 with acute onset of chest pain that had persisted for 30 minutes. She had a history of hypertension, hyperlipidemia, and type 2 diabetes mellitus but no previous history of myocardial infarction or heart failure. Her medications included aspirin, atorvastatin, lisinopril, and metoprolol. Paramedics were dispatched, and a prehospital ECG demonstrated 3-to 4-mm ST-segment elevation in leads I, aVL, and V 2 through V 6 (Figure 1). Her examination revealed a regular pulse of 90 bpm, a blood pressure of 100/60 mm Hg, clear lungs, and normal heart sounds with no murmurs. Paramedics interpreted the prehospital ECG and activated the catheterization laboratory en route to the hospital. On hospital arrival, the patient was transported directly to the catheterization laboratory. Coronary angiography demonstrated an occluded proximal left anterior descending artery, which was successfully treated with balloon angioplasty and a stent. The pertinent time intervals were as follows: paramedic dispatch to balloon time, 56 minutes; paramedic arrival at the scene to balloon time, 46 minutes; hospital door to balloon time, 23 minutes. Her biomarkers revealed a peak troponin T of 2.42 ng/mL and a peak creatine kinase muscle-brain isoenzyme of 26.8 ng/mL. An echocardiogram demonstrated normal left ventricular ejection fraction of 55%, with mild anterior hypokinesis, and the patient was discharged on hospital day 3. Current Guidelines for Prehospital ECGs Among Patients With ST-Segment-Elevation Myocardial InfarctionAmerican Heart Association national guidelines, 1-3 as well as other consensus and scientific statements, 4 -11 recommend that emergency medical services (EMS) acquire and use prehospital ECGs to evaluate patients with suspected acute coronary syndrome. Despite these recommendations, prehospital ECGs are used in fewer than 10% of patients with ST-segment-elevation myocardial infarction (STEMI), 12,13 and this rate has not substantially changed since the mid1990s. Furthermore, even when a prehospital ECG is acquired, the information is often not effectively translated into action and coordinated with hospital systems of care to decrease delays in reperfusion therapy. 13 The purpose of this article is to summarize evidence concerning the benefits of using prehospital ECGs, review barriers and challenges to routine use, and recommend approaches to enhance their effectiveness for improving quality of care for patients with acute coronary syndromes.The American Heart Association makes every effort to avoid any actual or potential conflicts of interest that may arise as a result of an outside relationship or a personal, professional, or business interest of a member of the writing panel. Specifically, all members of the writing group are required to complete and submit a Disclosure Questionnaire showing all such relationships that might be perceived as real or potential conflicts of interest.

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“…To improve the prognosis of AMI, it is essential to quickly identify the underlying disease and transport the patient to an appropriate medical institution promptly. While performing the initial treatment, the quick judgment must be made by the emergency rescue team 1,2) . However, sometimes it is difficult to implement the above measures in regions which are in remote locations from a medical institution.…”

Section: Introductionmentioning

confidence: 99%

Survival of a Refractory Ventricular Fibrillation by Cooperative Treatments

Tase

Ohno

Hasegawa

et al. 2010

FJMS

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: In the case of acute myocardial infarction (AMI), prompt and appropriate initial treatment is essential for increasing the rate of survival and early reperfusion is a main determinant factor for long -term prognosis. The survival of a patient with refractory ventricular fibrillation was made possible by cooperative emergency medical care including air medical transport, despite long distance to the hospital. The patient was a 60 -year -old man. Under a diagnosis of AMI, a helicopter emergency medical service (HEMS) with medical staff on board was requested. Although ventricular fibrillation (VF) occurred at the scene, quick and appropriate advanced cardiovascular life support (ACLS) was provided by the attending doctor, leading to the return of heartbeat. Since the patient still exhibited serious bradycardia and cardiac failure, he was airlifted while undergoing transcutaneous pacing. Upon arrival at the hospital, the patient underwent emergency percutaneous coronary intervention (PCI). During the PCI, VF recurred and chest compressions and a total of 17 defibrillations were performed. The PCI was continued with percutaneous cardiopulmonary support (PCPS). The patient survived without sequelae. Smoother cooperation between prehospital medical procedures and post -hospital emergency care is considered to be essential for the survival of patients such as this case.

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Development of Systems of Care for ST-Elevation Myocardial Infarction Patients

Cited by 59 publications

References 37 publications

Association Between Prehospital Time Intervals and ST-Elevation Myocardial Infarction System Performance

Association Between Prehospital Time Intervals and ST-Elevation Myocardial Infarction System Performance

Implementation and Integration of Prehospital ECGs Into Systems of Care for Acute Coronary Syndrome

Survival of a Refractory Ventricular Fibrillation by Cooperative Treatments

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