Quality of healthcare and admission rates for acute cardiac events during COVID-19 pandemic: a retrospective cohort study on ST-segment-elevation myocardial infarction in China.

OBJECTIVE: To evaluate changes in admission rates for and quality of healthcare of ST-segment-elevation myocardial infarction (STEMI) during the period of the COVID-19 outbreak and postoutbreak. METHODS: We conducted a retrospective study among patients with STEMI in the outbreak time and the postoutbreak time. DESIGN: To examine the changes in the admission rates and in quality of healthcare, by comparison between periods of the postoutbreak and the outbreak, and between the postoutbreak and the corresponding periods. SETTING: Data for this analysis were included from patients discharge diagnosed with STEMI from all the hospitals of Suzhou in each month of the year until the end of July 2020. PARTICIPANTS: 1965 STEMI admissions. PRIMARY AND SECONDARY OUTCOME MEASURES: The primary outcome was the number of moecondary outcomnthly STEMI admissions, and the secondary outcomes were the quality metrics of STEMI healthcare. RESULTS: There were a 53% and 38% fall in daily admissions at the phase of outbreak and postoutbreak, compared with the 2019 corresponding. There remained a gap in actual number of postoutbreak admissions at 306 and the predicted number at 497, an estimated 26 deaths due to STEMI would have been caused by not seeking healthcare. Postoutbreak period of 2020 compared with corresponding period of 2019, the percentage of cases transferred by ambulance decreased from 9.3% to 4.2% (p=0.013), the door-to-balloon median time increased from 17.5 to 34.0 min (p=0.001) and the rate of percutaneous coronary intervention (PCI) therapy declined from 71.3% to 60.1% (p=0.002). CONCLUSIONS: The impact of public health restrictions may lead to unexpected out-of-hospital deaths and compromised quality of healthcare for acute cardiac events. Delay or absence in patients should be continuously considered avoiding the secondary disaster of the pandemic. System delay should be modifiable for reversing the worst clinical outcomes from the COVID-19 outbreak, by coordination measures with focus on the balance between timely PCI procedure and minimising contamination of cardiac catheterisation rooms.

A stepped wedge cluster randomized control trial to evaluate the implementation and effectiveness of optimized initiatives in improving quality of care for ST segment elevation myocardial infarction in response to the COVID-19 outbreak.

BACKGROUND: The National Chest Pain Center Accreditation Program (CHANGE) is the first hospital-based, multifaceted, nationwide quality improvement (QI) initiative, to monitor and improve the quality of the ST segment elevation myocardial infarction (STEMI) care in China. The QI initiatives, as implementation strategies, include a bundle of evidence-based interventions adapted for implementation in China. During the pandemic of coronavirus disease 2019 (COVID-19), fear of infection with severe acute respiratory syndrome coronavirus 2, national lockdowns, and altered health care priorities have highlighted the program's importance in improving STEMI care quality. This study aims to minimize the adverse impact of the COVID-19 pandemic on the quality of STEMI care, by developing interventions that optimize the QI initiatives, implementing and evaluating the optimized QI initiatives, and developing scale-up activities of the optimized QI initiatives in response to COVID-19 and other public health emergencies. METHODS: A stepped wedge cluster randomized control trial will be conducted in three selected cities of China: Wuhan, Suzhou, and Shenzhen. Two districts have been randomly selected in each city, yielding a total of 24 registered hospitals. This study will conduct a rollout in these hospitals every 3 months. The 24 hospitals will be randomly assigned to four clusters, and each cluster will commence the intervention (optimized QI initiatives) at one of the four steps. We will conduct hospital-based assessments, questionnaire surveys among health care providers, community-based household surveys, and key informant interviews during the trial. All outcome measures will be organized using the RE-AIM (reach, effectiveness, adoption, implementation, maintenance) framework, including implementation outcomes, service outcomes (e.g., treatment time), and patient outcomes (e.g., in-hospital mortality and 1-year complication). The Consolidated Framework for Implementation Research framework will be used to identify factors that influence implementation of the optimized QI interventions. DISCUSSION: The study findings could be translated into a systematic solution to implementing QI initiatives in response to COVID-19 and future potential major public health emergencies. Such actionable knowledge is critical for implementors of scale-up activities in low- and middle-income settings. TRIAL REGISTRATION: ChiCTR 2100043319 . Registered on 10 February 2021.