Comparing ST-segment elevation myocardial infarction care between patients residing in central and remote locations: a retrospective case series.

INTRODUCTION: People who experience an ST-elevation myocardial infarction (STEMI) due to an occluded coronary artery require prompt treatment. Treatments to open a blocked artery are called reperfusion therapies (RTs) and can include intravenous pharmacological thrombolysis (TL) or primary percutaneous coronary intervention (pPCI) in a cardiac catheterisation laboratory (cath lab). Optimal RT (ORT) with pPCI or TL reduces morbidity and mortality. In remote areas, a number of geographical and organisational barriers may influence access to ORT. These are not well understood and the exact proportion of patients who receive ORT and the relationship to time of day and remoteness from the cardiac cath lab is unknown. The aim of this retrospective study was to compare the characteristics of ORT delivery in central and remote locations in the north of Scotland and to identify potential barriers to optimal care with a view to service redesign. METHOD: The study was set in the north of Scotland. All patients who attended hospital with a STEMI between March 2014 and April 2015 were identified from national coding data. A data collection form was developed by the research team in several iterative stages. Clinical details were collected retrospectively from patients' discharge letters. Data included treatment location, date of admission, distance of patient from the cath lab, route of access to health care, left ventricular function and RT received. Distance of patients from the cath lab was described as remote if they were more than 90 minutes of driving time from the cardiac cath lab and central if they were 90 minutes or less of driving time from the regional centre. For patients who made contact in a pre-hospital setting, ORT was defined as pre-hospital TL (PHT) or pPCI. For patients who self-presented to the hospital first, ORT was defined as in-hospital TL or pPCI. Data were described as mean (standard deviation) as appropriate. Chi-squared and student's t-test were used as appropriate. Each case was reviewed to determine if ORT was received; if ORT was not received, the reasons for this were recorded to identify potentially modifiable barriers. RESULTS: Of 627 acute myocardial infarction patients initially identified, 131 had a STEMI, and the others were non-STEMI. From this STEMI cohort, 82 (62%) patients were classed as central and 49 (38%) were remote. In terms of initial therapy, 26 (20%) received pPCI, 19 (15%) received PHTs, 52 (40%) received in-hospital TL, while 33 (25%) received no initial RT. ORT was received by 53 (65%) central and 20 (41%) remote patients; χ²=7.05, degrees of freedom =130, p<0.01).Several recurring barriers were identified. CONCLUSION: This study has demonstrated a significant health inequality between the treatment of STEMI in remote compared to central locations. Potential barriers identified include staffing availability and training, public awareness and inter-hospital communication. This suggests that there remain significant opportunities to improve STEMI care for people living in the north of Scotland.

Identification of barriers to the implementation of evidence-based practice for pre-hospital thrombolysis.

INTRODUCTION: Thrombolysis for patients with an ST elevation myocardial infarction (STEMI) is most effective if given promptly. In remote areas, pre-hospital thrombolysis has been shown to be effective and reduce mortality. However, pre-hospital thrombolysis may offer advantages even in urban areas in terms of reduced 'call to needle' times. General practitioners' attitudes are crucial in the delivery of this service. Differences in perceptions between rural or remote and urban GPs have not been examined previously. The aim of this study was to investigate the attitudes and beliefs of GPs with a view to pre-empting potential barriers to service redesign. METHODS: A questionnaire was sent by email and conventional post to all local GPs (n = 261) located in the study area (Highland Region in the North of Scotland). Data were entered into an Excel spreadsheet for statistical analysis. For the purposes of further analysis the data were divided into three groups: 'urban', 'rural' and 'undefined'. Data were analysed by either unpaired Student's t-test or chi(2) statistic as appropriate, with significance taken at the 5% level. Qualitative responses were grouped following thematic analysis. RESULTS: There was a 49% (n = 127) response. More questionnaires were returned by conventional post than email (106 vs 21, p < 0.0001). There did not appear to be a relationship between confidence in giving pre-hospital thrombolysis and number of years worked as a GP. Rural GPs who had previously administered pre-hospital thrombolysis reported higher confidence compared with GPs who had never given pre-hospital thrombolysis (7.5 +/- 1.7 vs 6.3 +/- 2.0, p = 0.01). Responses to two open questions: 'What do you think are the main factors preventing delivery of pre-hospital thrombolysis?' and 'What more could be done to increase your own willingness to administer pre-hospital thrombolysis?' were classified into four areas: training, experience, organisational and equipment issues. CONCLUSIONS: Several potential barriers to improving the uptake of pre-hospital thrombolysis were highlighted and included training, experience, equipment and organisational factors. Rural GPs were more likely to be confident to give thrombolysis. To implement pre-hospital thrombolysis in areas closer to hospitals may require greater support and training of urban GPs, who reported lower confidence in ECG analysis. Many GPs, while under-confident, reported a desire for further training to improve skills. Other GPs clearly stated that they did not consider emergency treatment of myocardial infarction in terms of thrombolysis as part of their role and that the treatment of acute STEMI in the community should be performed by the ambulance service. This view was held by urban rather than rural GPs. In remote areas it is clear that lack of ambulance crews and poor communication between the ambulance service and GPs leads to instances of 'scoop and run' to hospital, even when the distances are considerable and local GPs have the ability and desire to administer pre-hospital thrombolysis. Clear local clinical care pathways are recommended.