Cardiac Rehabilitation in a Rural Setting: OPTIMIZATION OF REFERRAL AND PARTICIPATION RATES.

PURPOSE: The cardiac rehabilitation (CR) program at Dartmouth-Hitchcock Medical Center (DHMC) devotes a nurse to the inpatient units in an attempt to optimize the referral process. This report defines the rates of referral and participation at DHMC and explores potential factors that affect participation. METHODS: Seven hundred ten consecutive patients who underwent percutaneous coronary intervention, coronary artery bypass grafting, or valve surgery from January 1, 2015 to June 30, 2015 were reviewed to determine whether the patient was referred for CR. Participation rates and the effect of time delay and patient-specific factors on participation were examined. RESULTS: Six hundred ninety-eight (98%) of the 710 post-procedural patients were evaluated by the inpatient rehabilitation nurse. One hundred sixty-seven patients were ineligible for outpatient therapy on the basis of established criteria; the remaining 543 patients were referred to DHMC or regional rehabilitation programs. Of those referred to the on-site program at DHMC, 84% participated. Of those referred to regional programs, 60% participated. There was an inverse correlation (r = -0.82; P = .003) between wait times and participation rates for the various programs. CONCLUSIONS: Despite its rural location with a large geographic catchment area, DHMC achieves high rates of CR referral and participation. The approach used at DHMC, which includes a CR nurse working with the inpatient cardiac services, a strong level of integration with the physician community, and well-developed relationships with regional rehabilitation programs, may be helpful for those programs wishing to improve referral and participation rates. Shorter wait times between hospital discharge and initiation of rehabilitation may improve participation rates.

Bivalirudin versus heparin, without glycoprotein inhibition, in percutaneous coronary intervention: A comparison of ischemic and hemorrhagic outcomes over 10years.

OBJECTIVE: The choice of antithrombotic agent used during percutaneous coronary intervention (PCI) is controversial. While earlier studies suggested a reduction in bleeding events with bivalirudin, these studies were confounded by the concomitant use of glycoprotein IIbIIIa inhibitors (GPI) in the heparin group. More recent studies have challenged the superiority of bivalirudin, pointing to an increased risk of stent thrombosis. Real-world data remains limited. METHODS: We queried our institutional catheterization laboratory database for all PCI cases performed between January 2003 and December 2012 using only heparin or only bivalirudin (no use of GPI). We collected data on relevant patient and procedural characteristics and compared both efficacy and safety outcomes. We adjusted for baseline differences using coarsened exacting matching. RESULTS: 8061 cases met our inclusion criteria. Of these, 34.9% were performed with heparin alone and 65.1% with bivalirudin. After adjusting for baseline differences, we found that those patients receiving heparin had a slightly lower risk of post-procedural abrupt vessel closure (0.1% vs 0.5%). All other outcomes favored bivalirudin including procedural success (97.2% vs 95.5%), transfusion within 72h (2.2% vs 4.8%), retroperitoneal bleeding (0.1% vs 0.8%), and all-cause mortality (0.9% vs 1.9%). Subgroup analysis suggested that outcomes were different only in non-elective cases and non STEMI cases. CONCLUSION: Heparin appears to offer the advantage of slightly reduced risk of abrupt vessel closure post-procedure but at the cost of increased hemorrhagic complications and all-cause mortality. This difference in outcomes may be limited to non-elective and non STEMI cases with femoral access.

Reducing contrast-induced acute kidney injury using a regional multicenter quality improvement intervention.

BACKGROUND: Contrast-induced acute kidney injury (CI-AKI) is associated with increased morbidity and mortality after percutaneous coronary interventions and is a patient safety objective of the National Quality Forum. However, no formal quality improvement program to prevent CI-AKI has been conducted. Therefore, we sought to determine whether a 6-year regional multicenter quality improvement intervention could reduce CI-AKI after percutaneous coronary interventions. METHODS AND RESULTS: We conducted a prospective multicenter quality improvement study to prevent CI-AKI (serum creatinine increase ≥0.3 mg/dL within 48 hours or ≥50% during hospitalization) among 21 067 nonemergent patients undergoing percutaneous coronary interventions at 10 hospitals between 2007 and 2012. Six intervention hospitals participated in the quality improvement intervention. Two hospitals with significantly lower baseline rates of CI-AKI, which served as benchmark sites and were used to develop the intervention, and 2 hospitals not receiving the intervention were used as controls. Using time series analysis and multilevel poisson regression clustering to the hospital level, we calculated adjusted risk ratios for CI-AKI comparing the intervention period to baseline. Adjusted rates of CI-AKI were significantly reduced in hospitals receiving the intervention by 21% (risk ratio, 0.79; 95% confidence interval: 0.67-0.93; P=0.005) for all patients and by 28% in patients with baseline estimated glomerular filtration rate <60 mL/min per 1.73 m(2) (risk ratio, 0.72; 95% confidence interval: 0.56-0.91; P=0.007). Benchmark hospitals had no significant changes in CI-AKI. Key qualitative system factors associated with improvement included multidisciplinary teams, limiting contrast volume, standardized fluid orders, intravenous fluid bolus, and patient education about oral hydration. CONCLUSIONS: Simple cost-effective quality improvement interventions can prevent ≤1 in 5 CI-AKI events in patients with undergoing nonemergent percutaneous coronary interventions.

Therapeutic hypothermia-induced electrocardiographic changes and relations to in-hospital mortality.

BACKGROUND: Therapeutic hypothermia improves survival for selected patients who remain comatose after cardiac arrest. Hypothermia triggers changes in electrocardiographic (ECG) parameters; however, the association of these changes to in-hospital mortality remains unclear. HYPOTHESIS: QT interval changes induced by therapeutic hypothermia are not associated with in-hospital mortality. METHODS: We retrospectively compared precooling ECG parameters to ECG parameters during hypothermia on all consecutive patients with available information who received hypothermia at our academic medical center between December 2006 and July 2012 (N = 101; 24% women). Paired 2-sample t test was used to compare precooling vs cooling ECG parameters. In-hospital mortality related to ECG parameter changes was compared using the Pearson χ(2) test. RESULTS: Therapeutic hypothermia resulted in increases in PR and QTc intervals and decreases in heart rate and QRS intervals (P for all <0.02). During hospitalization, 45 of the 101 patients died. Survivors vs nonsurvivors did not differ in heart rate change (P = 0.74), PR change (P = 0.57), QRS change (P = 0.09), or QTc change (P = 0.67). Comparing patients who had reduced QTc intervals with hypothermia to those who had prolonged QTc with hypothermia, 14 out of 30 died in the former group, whereas 31 out of 71 died in the latter group (46.7% vs 43.7%, odds ratio [OR]: 1.13, 95% CI: 0.48-2.66). Patients presenting with right bundle branch block (RBBB) had a higher risk of in-hospital death compared to those without RBBB (72.2% vs 38.6%, OR: 4.14, 95% CI: 1.35-12.73). CONCLUSIONS: Therapeutic hypothermia prolonged QTc interval with no association to in-hospital mortality. Presence of RBBB on initial presentation was related to increased mortality.

Predicting readmission or death after acute ST-elevation myocardial infarction.

BACKGROUND: Risk factors for emergent readmissions or death after acute myocardial infarction (AMI) are important in identifying patients at risk for major adverse events. However, there has been limited investigation conducted of prospective clinical registries to determine relevant risk factors. HYPOTHESIS: We hypothesize 30-day readmission or death could be predicted using patient, procedural, and process factors. METHODS: Patients presenting with ST-elevation myocardial infarction (STEMI) from 2006 to 2011 were prospectively enrolled in a STEMI registry (1271 patients). Thirty-day readmission was ascertained by administrative claims data. Death was determined by linking to the Social Security Death Master File. Univariate and stepwise multivariate logistic regression was conducted with Hosmer-Lemeshow goodness-of-fit statistics for model calibration and receiver operating characteristic (ROC) curve for model discrimination. RESULTS: The combined end point of 30-day readmission or postdischarge death included 135 patients (10.6%), including 109 emergent readmissions and 26 deaths. Factors associated with an increase risk of 30-day readmission or postdischarge death included age ≥ 80 years, diabetes, chest pain or cardiac arrest at presentation, and 3-vessel disease found at initial angiography. Factors associated with a decreased risk of 30-day readmission or postdischarge death included transfer to the catheterization lab from another emergency department, clopidogrel given during the procedure hypercholesterolemia, and receiving aspirin, ß-blockers, and angiotensin-converting enzyme or angiotensin receptor blocker inhibitors at discharge. Index admission outcomes indicative of readmission or death postdischarge only included a new diagnosis of congestive heart failure. The model discriminated well with an ROC of 0.71 (95% confidence interval: 0.66-0.76). CONCLUSIONS: Prehospitalization factors are overlooked and are important factors to incorporate in routine risk prediction models for readmission or death within 30 days following an AMI.

Sex disparities in pre-hospital and hospital treatment of ST-segment elevation myocardial infarction.

OBJECTIVE: To determine whether sex disparities exist in pre-hospital and hospital time to treatment in patients with ST-segment elevation myocardial infarction (STEMI). BACKGROUND: Evidence suggests that women experience poorer quality of care for STEMI. METHODS: A retrospective cohort study was conducted on 177 consecutive patients with STEMI who received primary percutaneous coronary intervention at a rural, tertiary medical center between January 2006 and October 2009. A subgroup analysis was conducted to evaluate time to treatment during a period of no-focused process improvement compared with a time period of focused, non­sex-specific process improvement; the post period included implementation of the STEMI process upgrade (STEP-UP) quality-improvement (QI) program. RESULTS: Median first-emergency-medical-services-contact-to-balloon (E2B) angioplasty time was significantly longer for women compared with men. A Cox proportional hazards model revealed that men had a significantly shorter E2B time than women. After adjustment for differences between sex groups at presentation, the effect of sex on E2B was no longer statistically significant. A similar effect was observed in door-to-balloon (D2B) angioplasty time. The subgroup analysis revealed that from baseline, both men and women experienced improvement in E2B time after implementation of the STEP-UP QI program. Men and women also experienced improvement in D2B time after implementation of the STEP-UP QI program. CONCLUSIONS: Women with STEMI experienced significantly longer E2B and D2B times compared with men with STEMI, although these differences did not persist after adjustment for differences between sex groups at presentation. In addition to standard STEMI-care QI practices, sex-specific processes and interventions at the systems level may be needed to improve time to treatment for women with STEMI.

Primary percutaneous coronary intervention for patients presenting with ST-segment elevation myocardial infarction: process improvement in a rural ST-segment elevation myocardial infarction receiving center.

BACKGROUND: Rural ST-segment elevation myocardial infarction (STEMI) care networks may be particularly disadvantaged in achieving a door-to-balloon time (D2B) of less than or equal to 90 minutes recommended in current guidelines. ST-ELEVATION MYOCARDIAL INFARCTION PROCESS UPGRADE PROJECT: A multidisciplinary STEMI process upgrade group at a rural percutaneous coronary intervention center implemented evidence-based strategies to reduce time to electrocardiogram (ECG) and D2B, including catheterization laboratory activation triggered by either a prehospital ECG demonstrating STEMI or an emergency department physician diagnosing STEMI, single-call catheterization laboratory activation, catheterization laboratory response time less than or equal to 30 minutes, and prompt data feedback. EVALUATING SUCCESS: An ongoing regional STEMI registry was used to collect process time intervals, including time to ECG and D2B, in a consecutive series of STEMI patients presenting before (group 1) and after (group 2) strategy implementation. Significant reductions in time to first ECG in the emergency department and D2B were seen in group 2 compared with group 1. CONCLUSIONS: Important improvement in the process of acute STEMI patient care was accomplished in the rural percutaneous coronary intervention center setting by implementing evidence-based strategies.

Primary percutaneous coronary intervention for patients presenting with ST-elevation myocardial infarction: process improvements in rural prehospital care delivered by emergency medical services.

BACKGROUND: Safe and effective patient care for ST-elevation myocardial infarction (STEMI) relies on prompt emergency medical service (EMS) and established care coordination with receiving hospitals to conduct primary percutaneous coronary intervention (PCI). Likewise, a new emphasis has been placed on first medical contact-to-balloon (E2B) times as opposed to door-to-balloon times, identifying prehospital care as an important contributing factor for high-quality STEMI care. Therefore, we evaluated EMS processes of care before and after a period of continuous quality improvement to improve E2B times in our rural tertiary care medical center. METHODS: A retrospective, consecutive cohort study was conducted on 177 patients who received primary PCI at Dartmouth-Hitchcock Medical Center, a rural hospital, from January 1, 2006 to October 31, 2009. This cohort was stratified from January 1, 2008 to May 1, 2008 (n = 88) and May 1, 2008 to October 31, 2009 (n = 89), to acknowledge periods of no improvement (pre) and continuous quality improvement (post) in STEMI care. Primary outcome measures included frequency of non-PCI-capable hospital bypass, E2B, and frequency of prehospital electrocardiogram (ECG) and cardiac catheterization laboratory (CCL) activation. Descriptive statistics and log-rank tests were used to determine whether measures differed significantly by time period. A time-to-event analysis was conducted using a Cox proportional hazards model to assess the impact of outcomes measures on E2B pre/post-May 1, 2008. RESULTS: Patients who presented before May 1, 2008 had longer E2B times compared with patients in the post-May 1, 2008 cohort (145.1 minutes vs 115.2 minutes, t test P = .01). A log-rank test confirmed this (pre: 130 minutes vs post: 106 minutes, χ(2) = 5.3, log-rank P = .02). Similarly, patients who presented before May 1, 2008 had lower percentages of prehospital ECGs (49% vs 80%, P = .001) and CCL activations (4% vs 32%, P < .001). When prehospital ECGs (140 minutes vs 106 minutes, χ(2) = 5.9, log-rank P = .01) or CCL activations (125 minutes vs 98 minutes, χ(2) = 4.2, log-rank P = .04) were conducted, E2B times were significantly reduced. Patients who received both prehospital ECGs and prehospital CCL activations had significantly reduced E2B times compared with those who did not (125 minutes vs 91 minutes, χ(2) = 4.8, P = .02). CONCLUSIONS: The time saving benefits of prehospital ECGs may not be fully realized unless prehospital CCL activations also occur. EMS providers achieved further reductions in median E2B of approximately 24 minutes when prehospital ECGs were combined with prehospital CCL activation. Every effort should be made by PCI-capable medical centers to assess prehospital STEMI care and to integrate EMS providers into regional STEMI care quality improvement initiatives and education.