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1.
JAMA Netw Open ; 6(6): e2317831, 2023 06 01.
Artigo em Inglês | MEDLINE | ID: mdl-37294567

RESUMO

Importance: Insurance status has been associated with whether patients with ST-segment elevation myocardial infarction (STEMI) presenting to emergency departments are transferred to other facilities, but whether the facility's percutaneous coronary intervention capabilities mediate this association is unknown. Objective: To examine whether uninsured patients with STEMI were more likely than patients with insurance to experience interfacility transfer. Design, Setting, and Participants: This observational cohort study compared patients with STEMI with and without insurance who presented to California emergency departments between January 1, 2010, and December 31, 2019, using the Patient Discharge Database and Emergency Department Discharge Database from the California Department of Health Care Access and Information. Statistical analyses were completed in April 2023. Exposures: Primary exposures were lack of insurance and facility percutaneous coronary intervention capabilities. Main Outcomes and Measures: The primary outcome was transfer status from the presenting emergency department of a percutaneous coronary intervention-capable hospital, defined as a facility performing 36 percutaneous coronary interventions per year. Multivariable logistic regression models with multiple robustness checks were performed to determine the association of insurance status with the odds of transfer. Results: This study included 135 358 patients with STEMI, of whom 32 841 patients (24.2%) were transferred (mean [SD] age, 64 [14] years; 10 100 women [30.8%]; 2542 Asian individuals [7.7%]; 2053 Black individuals [6.3%]; 8285 Hispanic individuals [25.2%]; 18 650 White individuals [56.8%]). After adjusting for time trends, patient factors, and transferring hospital characteristics (including percutaneous coronary intervention capabilities), patients who were uninsured had lower odds of experiencing interfacility transfer than those with insurance (adjusted odds ratio, 0.93; 95% CI, 0.88-0.98; P = .01). Conclusions and Relevance: After accounting for a facility's percutaneous coronary intervention capabilities, lack of insurance was associated with lower odds of emergency department transfer for patients with STEMI. These findings warrant further investigation to understand the characteristics of facilities and outcomes for uninsured patients with STEMI.


Assuntos
Infarto do Miocárdio com Supradesnível do Segmento ST , Humanos , Feminino , Pessoa de Meia-Idade , Infarto do Miocárdio com Supradesnível do Segmento ST/epidemiologia , Infarto do Miocárdio com Supradesnível do Segmento ST/terapia , Pessoas sem Cobertura de Seguro de Saúde , Serviço Hospitalar de Emergência , Cobertura do Seguro , California/epidemiologia
3.
J Am Coll Cardiol ; 76(11): 1375-1384, 2020 09 15.
Artigo em Inglês | MEDLINE | ID: mdl-32330544

RESUMO

The worldwide pandemic caused by the novel acute respiratory syndrome coronavirus 2 has resulted in a new and lethal disease termed coronavirus disease-2019 (COVID-19). Although there is an association between cardiovascular disease and COVID-19, the majority of patients who need cardiovascular care for the management of ischemic heart disease may not be infected with this novel coronavirus. The objective of this document is to provide recommendations for a systematic approach for the care of patients with an acute myocardial infarction (AMI) during the COVID-19 pandemic. There is a recognition of two major challenges in providing recommendations for AMI care in the COVID-19 era. Cardiovascular manifestations of COVID-19 are complex with patients presenting with AMI, myocarditis simulating an ST-elevation myocardial infarction (STEMI) presentation, stress cardiomyopathy, non-ischemic cardiomyopathy, coronary spasm, or nonspecific myocardial injury, and the prevalence of COVID-19 disease in the U.S. population remains unknown with risk of asymptomatic spread. This document addresses the care of these patients focusing on 1) the varied clinical presentations; 2) appropriate personal protection equipment (PPE) for health care workers; 3) role of the Emergency Department, Emergency Medical System and the Cardiac Catheterization Laboratory; and 4) Regional STEMI systems of care. During the COVID-19 pandemic, primary PCI remains the standard of care for STEMI patients at PCI capable hospitals when it can be provided in a timely fashion, with an expert team outfitted with PPE in a dedicated CCL room. A fibrinolysis-based strategy may be entertained at non-PCI capable referral hospitals or in specific situations where primary PCI cannot be executed or is not deemed the best option.


Assuntos
Serviço Hospitalar de Cardiologia/organização & administração , Infecções por Coronavirus , Serviço Hospitalar de Emergência/organização & administração , Controle de Infecções , Infarto do Miocárdio , Pandemias , Intervenção Coronária Percutânea , Pneumonia Viral , Terapia Trombolítica , Betacoronavirus , COVID-19 , Infecções por Coronavirus/diagnóstico , Infecções por Coronavirus/epidemiologia , Infecções por Coronavirus/fisiopatologia , Infecções por Coronavirus/prevenção & controle , Diagnóstico Diferencial , Humanos , Controle de Infecções/métodos , Controle de Infecções/organização & administração , Infarto do Miocárdio/epidemiologia , Infarto do Miocárdio/terapia , Inovação Organizacional , Pandemias/prevenção & controle , Intervenção Coronária Percutânea/métodos , Intervenção Coronária Percutânea/tendências , Pneumonia Viral/diagnóstico , Pneumonia Viral/epidemiologia , Pneumonia Viral/fisiopatologia , Pneumonia Viral/prevenção & controle , Medição de Risco , SARS-CoV-2 , Terapia Trombolítica/métodos , Terapia Trombolítica/tendências , Estados Unidos
4.
Catheter Cardiovasc Interv ; 96(2): 336-345, 2020 08.
Artigo em Inglês | MEDLINE | ID: mdl-32311816

RESUMO

The worldwide pandemic caused by the novel acute respiratory syndrome coronavirus 2 has resulted in a new and lethal disease termed coronavirus disease 2019 (COVID-19). Although there is an association between cardiovascular disease and COVID-19, the majority of patients who need cardiovascular care for the management of ischemic heart disease may not be infected with this novel coronavirus. The objective of this document is to provide recommendations for a systematic approach for the care of patients with an acute myocardial infarction (AMI) during the COVID-19 pandemic. There is a recognition of two major challenges in providing recommendations for AMI care in the COVID-19 era. Cardiovascular manifestations of COVID-19 are complex with patients presenting with AMI, myocarditis simulating an ST-elevation myocardial infarction (STEMI) presentation, stress cardiomyopathy, non-ischemic cardiomyopathy, coronary spasm, or nonspecific myocardial injury, and the prevalence of COVID-19 disease in the US population remains unknown with risk of asymptomatic spread. This document addresses the care of these patients focusing on (a) varied clinical presentations; (b) appropriate personal protection equipment (PPE) for health care workers; (c) the roles of the emergency department, emergency medical system, and the cardiac catheterization laboratory (CCL); and (4) regional STEMI systems of care. During the COVID-19 pandemic, primary percutaneous coronary intervention (PCI) remains the standard of care for STEMI patients at PCI-capable hospitals when it can be provided in a timely manner, with an expert team outfitted with PPE in a dedicated CCL room. A fibrinolysis-based strategy may be entertained at non-PCI-capable referral hospitals or in specific situations where primary PCI cannot be executed or is not deemed the best option.


Assuntos
Betacoronavirus , Cardiologia , Consenso , Angiografia Coronária , Infecções por Coronavirus/complicações , Infarto do Miocárdio/terapia , Intervenção Coronária Percutânea/métodos , Pneumonia Viral/complicações , COVID-19 , Infecções por Coronavirus/epidemiologia , Gerenciamento Clínico , Eletrocardiografia , Humanos , Incidência , Infarto do Miocárdio/complicações , Infarto do Miocárdio/diagnóstico , Pandemias , Pneumonia Viral/epidemiologia , SARS-CoV-2 , Sociedades Médicas , Taxa de Sobrevida/tendências , Estados Unidos/epidemiologia
5.
Circ Cardiovasc Qual Outcomes ; 11(8): e004464, 2018 08.
Artigo em Inglês | MEDLINE | ID: mdl-30354373

RESUMO

BACKGROUND: Prehospital ECG-based cardiac catheterization laboratory (CCL) activation for ST-segment-elevation myocardial infarction reduces door-to-balloon times, but CCL cancellations (CCLX) remain a challenging problem. We examined the reasons for CCLX, clinical characteristics, and outcomes of patients presenting as ST-segment-elevation myocardial infarction activations who receive emergent coronary angiography (EA) compared with CCLX. METHODS AND RESULTS: We reviewed all consecutive CCL activations between January 1, 2012, and December 31, 2014 (n=1332). Data were analyzed comparing 2 groups stratified as EA (n=466) versus CCLX (n=866; 65%). Reasons for CCLX included bundle branch block (21%), poor-quality prehospital ECG (18%), non-ST-segment-elevation myocardial infarction ST changes (18%), repolarization abnormality (13%), and arrhythmia (8%). A multivariate logistic regression model using age, peak troponin, and initial ECG findings had a high discriminatory value for determining EA versus CCLX (C statistic, 0.985). CCLX subjects were older and more likely to be women, have prior coronary artery bypass grafting, or a paced rhythm ( P<0.0001 for all). All-cause mortality did not differ between groups at 1 year or during the study period (mean follow-up, 2.186±1.167 years; 15.8% EA versus 16.2% CCLX; P=0.9377). Cardiac death was higher in the EA group (11.8% versus 3.0%; P<0.0001). After adjusting for clinical variables associated with survival, CCLX was associated with an increased risk for all-cause mortality during the study period (hazard ratio, 1.82; 95% CI, 1.28-2.59; P=0.0009). CONCLUSIONS: In this study, prehospital ECG without overreading or transmission lead to frequent CCLX. CCLX subjects differ with regard to age, sex, risk factors, and comorbidities. However, CCLX patients represent a high-risk population, with frequently positive cardiac enzymes and similar short- and long-term mortality compared with EA. Further studies are needed to determine how quality improvement initiatives can lower the rates of CCLX and influence clinical outcomes.


Assuntos
Cateterismo Cardíaco , Angiografia Coronária , Eletrocardiografia , Serviços Médicos de Emergência/métodos , Intervenção Coronária Percutânea , Infarto do Miocárdio com Supradesnível do Segmento ST/diagnóstico , Infarto do Miocárdio com Supradesnível do Segmento ST/terapia , Procedimentos Desnecessários , Idoso , Idoso de 80 Anos ou mais , Cateterismo Cardíaco/tendências , Tomada de Decisão Clínica , Angiografia Coronária/tendências , Eletrocardiografia/tendências , Serviços Médicos de Emergência/tendências , Feminino , Nível de Saúde , Humanos , Masculino , Pessoa de Meia-Idade , Seleção de Pacientes , Intervenção Coronária Percutânea/tendências , Valor Preditivo dos Testes , Sistema de Registros , Reprodutibilidade dos Testes , Estudos Retrospectivos , Fatores de Risco , Infarto do Miocárdio com Supradesnível do Segmento ST/mortalidade , Infarto do Miocárdio com Supradesnível do Segmento ST/fisiopatologia , Fatores de Tempo , Tempo para o Tratamento , Procedimentos Desnecessários/tendências
7.
Indian Heart J ; 70(1): 185-190, 2018.
Artigo em Inglês | MEDLINE | ID: mdl-29455776

RESUMO

Our previous research found seven specific factors that cause system delays in ST-elevation Myocardial infarction management in developing countries. These delays, in conjunction with a lack of organized STEMI systems of care, result in inefficient processes to treat AMI in developing countries. In our present opinion paper, we have specifically explored the three most pertinent causes that afflict the seven specific factors responsible for system delays. In doing so, we incorporated a unique strategy of global STEMI expertise. With this methodology, the recommendations were provided by expert Indian cardiologist and final guidelines were drafted after comprehensive discussions by the entire group of submitting authors. We expect these recommendations to be utilitarian in improving STEMI care in developing countries.


Assuntos
Países em Desenvolvimento , Reperfusão Miocárdica/métodos , Medição de Risco , Infarto do Miocárdio com Supradesnível do Segmento ST , Terapia Trombolítica/métodos , Eletrocardiografia , Humanos , Índia/epidemiologia , Pobreza , Fatores de Risco , Infarto do Miocárdio com Supradesnível do Segmento ST/economia , Infarto do Miocárdio com Supradesnível do Segmento ST/epidemiologia , Infarto do Miocárdio com Supradesnível do Segmento ST/terapia
8.
West J Emerg Med ; 18(6): 1010-1017, 2017 10.
Artigo em Inglês | MEDLINE | ID: mdl-29085531

RESUMO

INTRODUCTION: California has led successful regionalized efforts for several time-critical medical conditions, including ST-segment elevation myocardial infarction (STEMI), but no specific mandated protocols exist to define regionalization of care. We aimed to study the trends in regionalization of care for STEMI patients in the state of California and to examine the differences in patient demographic, hospital, and county trends. METHODS: Using survey responses collected from all California emergency medical services (EMS) agencies, we developed four categories - no, partial, substantial, and complete regionalization - to capture prehospital and inter-hospital components of regionalization in each EMS agency's jurisdiction between 2005-2014. We linked the survey responses to 2006 California non-public hospital discharge data to study the patient distribution at baseline. RESULTS: STEMI regionalization-of-care networks steadily developed across California. Only 14% of counties were regionalized in 2006, accounting for 42% of California's STEMI patient population, but over half of these counties, representing 86% of California's STEMI patient population, reached complete regionalization in 2014. We did not find any dramatic differences in underlying patient characteristics based on regionalization status; however, differences in hospital characteristics were relatively substantial. CONCLUSION: Potential barriers to achieving regionalization included competition, hospital ownership, population density, and financial challenges. Minimal differences in patient characteristics can establish that patient differences unlikely played any role in influencing earlier or later regionalization and can provide a framework for future analyses evaluating the impact of regionalization on patient outcomes.


Assuntos
Programas Médicos Regionais/tendências , Infarto do Miocárdio com Supradesnível do Segmento ST/epidemiologia , Idoso , Idoso de 80 Anos ou mais , California/epidemiologia , Eletrocardiografia , Feminino , Acessibilidade aos Serviços de Saúde/estatística & dados numéricos , Humanos , Masculino , Pessoa de Meia-Idade , Programas Médicos Regionais/estatística & dados numéricos , Infarto do Miocárdio com Supradesnível do Segmento ST/terapia , Inquéritos e Questionários
11.
Circ Cardiovasc Interv ; 10(1)2017 01.
Artigo em Inglês | MEDLINE | ID: mdl-28082714

RESUMO

BACKGROUND: The Mission: Lifeline STEMI Systems Accelerator program, implemented in 16 US metropolitan regions, resulted in more patients receiving timely reperfusion. We assessed whether implementing key care processes was associated with system performance improvement. METHODS AND RESULTS: Hospitals (n=167 with 23 498 ST-segment-elevation myocardial infarction patients) were surveyed before (March 2012) and after (July 2014) program intervention. Data were merged with patient-level clinical data over the same period. For reperfusion, hospitals were grouped by whether a specific process of care was implemented, preexisting, or never implemented. Uptake of 4 key care processes increased after intervention: prehospital catheterization laboratory activation (62%-91%; P<0.001), single call transfer protocol from an outside facility (45%-70%; P<0.001), and emergency department bypass for emergency medical services direct presenters (48%-59%; P=0.002) and transfers (56%-79%; P=0.001). There were significant differences in median first medical contact-to-device times among groups implementing prehospital activation (88 minutes implementers versus 89 minutes preexisting versus 98 minutes nonimplementers; P<0.001 for comparisons). Similarly, patients treated at hospitals implementing single call transfer protocols had shorter median first medical contact-to-device times (112 versus 128 versus 152 minutes; P<0.001). Emergency department bypass was also associated with shorter median first medical contact-to-device times for emergency medical services direct presenters (84 versus 88 versus 94 minutes; P<0.001) and transfers (123 versus 127 versus 167 minutes; P<0.001). CONCLUSIONS: The Accelerator program increased uptake of key care processes, which were associated with improved system performance. These findings support efforts to implement regional ST-segment-elevation myocardial infarction networks focused on prehospital catheterization laboratory activation, single call transfer protocols, and emergency department bypass.


Assuntos
Prestação Integrada de Cuidados de Saúde/organização & administração , Reperfusão Miocárdica/métodos , Avaliação de Processos em Cuidados de Saúde/organização & administração , Infarto do Miocárdio com Supradesnível do Segmento ST/terapia , Tempo para o Tratamento/organização & administração , Cateterismo Cardíaco , Serviço Hospitalar de Cardiologia/organização & administração , Procedimentos Clínicos/organização & administração , Prestação Integrada de Cuidados de Saúde/normas , Serviços Médicos de Emergência/organização & administração , Serviço Hospitalar de Emergência/organização & administração , Mortalidade Hospitalar , Humanos , Reperfusão Miocárdica/efeitos adversos , Reperfusão Miocárdica/mortalidade , Reperfusão Miocárdica/normas , Transferência de Pacientes/organização & administração , Avaliação de Processos em Cuidados de Saúde/normas , Avaliação de Programas e Projetos de Saúde , Melhoria de Qualidade , Indicadores de Qualidade em Assistência à Saúde , Sistema de Registros , Infarto do Miocárdio com Supradesnível do Segmento ST/diagnóstico , Infarto do Miocárdio com Supradesnível do Segmento ST/mortalidade , Fatores de Tempo , Tempo para o Tratamento/normas , Resultado do Tratamento , Estados Unidos
12.
Rev Cardiovasc Med ; 17(1-2): 1-6, 2016.
Artigo em Inglês | MEDLINE | ID: mdl-27667375

RESUMO

Over the past 20 years, care for patients with ST-elevation myocardial infarction (STEMI) has rapidly evolved, not just in terms of how patients are treated, but where patients are treated. The advent of regional STEMI systems of care has decreased the number of "eligible but untreated" patients while improving access to primary percutaneous coronary intervention for patients. These regional STEMI systems of care have consistently demonstrated that rapid transport of STEMI patients is safe and effective, and have shown marked improvements in a variety of clinical outcomes. However, no two STEMI systems are alike, and each must be tailored to the unique geographic, political, and socioeconomic challenges of the region. This article takes an in-depth look at two of the earliest STEMI systems within the United States: the Minneapolis Heart Institute and the Los Angeles County STEMI receiving network.


Assuntos
Serviço Hospitalar de Cardiologia/organização & administração , Intervenção Coronária Percutânea , Infarto do Miocárdio com Supradesnível do Segmento ST/terapia , Acessibilidade aos Serviços de Saúde , Pesquisa sobre Serviços de Saúde , Humanos , Los Angeles , Minnesota , Estudos de Casos Organizacionais , Objetivos Organizacionais , Garantia da Qualidade dos Cuidados de Saúde , Regionalização da Saúde , Fatores de Tempo
13.
Circulation ; 134(5): 365-74, 2016 Aug 02.
Artigo em Inglês | MEDLINE | ID: mdl-27482000

RESUMO

BACKGROUND: Up to 50% of patients fail to meet ST-segment-elevation myocardial infarction (STEMI) guideline goals recommending a first medical contact-to-device time of <90 minutes for patients directly presenting to percutaneous coronary intervention-capable hospitals and <120 minutes for transferred patients. We sought to increase the proportion of patients treated within guideline goals by organizing coordinated regional reperfusion plans. METHODS: We established leadership teams, coordinated protocols, and provided regular feedback for 484 hospitals and 1253 emergency medical services (EMS) agencies in 16 regions across the United States. RESULTS: Between July 2012 and December 2013, 23 809 patients presented with acute STEMI (direct to percutaneous coronary intervention hospital: 11 765 EMS transported and 6502 self-transported; 5542 transferred). EMS-transported patients differed from self-transported patients in symptom onset to first medical contact time (median, 47 versus 114 minutes), incidence of cardiac arrest (10% versus 3%), shock on admission (11% versus 3%), and in-hospital mortality (8% versus 3%; P<0.001 for all comparisons). There was a significant increase in the proportion of patients meeting guideline goals of first medical contact-to-device time, including those directly presenting via EMS (50% to 55%; P<0.001) and transferred patients (44%-48%; P=0.002). Despite regional variability, the greatest gains occurred among patients in the 5 most improved regions, increasing from 45% to 57% (direct EMS; P<0.001) and 38% to 50% (transfers; P<0.001). CONCLUSIONS: This Mission: Lifeline STEMI Systems Accelerator demonstration project represents the largest national effort to organize regional STEMI care. By focusing on first medical contact-to-device time, coordinated treatment protocols, and regional data collection and reporting, we were able to increase significantly the proportion of patients treated within guideline goals.


Assuntos
American Heart Association/organização & administração , Infarto do Miocárdio com Supradesnível do Segmento ST/terapia , Tempo para o Tratamento , Morte Súbita Cardíaca , Eletrocardiografia , Serviços Médicos de Emergência , Serviço Hospitalar de Emergência , Fidelidade a Diretrizes , Parada Cardíaca , Mortalidade Hospitalar , Humanos , Transferência de Pacientes , Intervenção Coronária Percutânea , Guias de Prática Clínica como Assunto , Infarto do Miocárdio com Supradesnível do Segmento ST/mortalidade , Choque Cardiogênico/mortalidade , Tempo para o Tratamento/estatística & dados numéricos , Transporte de Pacientes , Estados Unidos
14.
Crit Pathw Cardiol ; 15(3): 103-5, 2016 09.
Artigo em Inglês | MEDLINE | ID: mdl-27465005

RESUMO

INTRODUCTION: California has been a global leader in regionalization efforts for time-critical medical conditions. A total of 33 local emergency medical service agencies (LEMSAs) exist, providing an organized EMS framework across the state for almost 40 years. We sought to develop a survey tool to quantify the degree and duration of ST-elevation myocardial infarction (STEMI) regionalization over the last decade in California. METHODS: The project started with the development of an 8-question survey tool via a multi-disciplinary expert consensus process. Next, the survey tool was distributed at the annual meeting of administrators and medical directors of California LEMSAs to get responses valid through December, 2014. The first scoring approach was the Total Regionalization Score (TRS) and used answers from all 8 questions. The second approach was called the Core Score, and it focused on only 4 survey questions by assuming that the designation of STEMI Receiving Centers must have occurred at the beginning of any LEMSA's regionalization effort. Scores were ranked and grouped into tertiles. RESULTS: All 33 LEMSAs in California participated in this survey. The TRS ranged from 15 to 162. The Core Score range was much narrower, from 2 to 30. In comparing TRS and Core Score rankings, the top-tertiles were quite similar. More rank variation occurred between mid- and low-tertiles. CONCLUSION: This study evaluated the degree and duration of STEMI network regionalization from 2004 to 2014 in California, and ranked 33 LEMSAs into tertiles based upon their TRS and their Core Score. Successful application of the 8-item survey and ranking strategies across California suggests that this approach can be used to assess regionalization in other states or countries around the world.


Assuntos
Serviço Hospitalar de Emergência/organização & administração , Programas Médicos Regionais/organização & administração , Infarto do Miocárdio com Supradesnível do Segmento ST/epidemiologia , Inquéritos e Questionários , California/epidemiologia , Eletrocardiografia , Humanos , Morbidade/tendências
15.
Interv Cardiol Clin ; 5(4): 451-469, 2016 10.
Artigo em Inglês | MEDLINE | ID: mdl-28581995

RESUMO

First-medical-contact-to-device (FMC2D) times have improved over the past decade, as have clinical outcomes for patients presenting with ST-elevation myocardial infarction (STEMI). However, with improvements in FMC2D times, false activation of the cardiac catheterization laboratory (CCL) has become a challenging problem. The authors define false activation as any patient who does not warrant emergent coronary angiography for STEMI. In addition to clinical outcome measures for these patients, STEMI systems should collect data regarding the total number of CCL activations, the total number of emergency coronary angiograms, and the number revascularization procedures performed.


Assuntos
Acessibilidade aos Serviços de Saúde , Mau Uso de Serviços de Saúde/estatística & dados numéricos , Intervenção Coronária Percutânea , Infarto do Miocárdio com Supradesnível do Segmento ST/terapia , Angiografia Coronária , Eletrocardiografia , Serviços Médicos de Emergência , Mau Uso de Serviços de Saúde/prevenção & controle , Humanos , Avaliação de Processos e Resultados em Cuidados de Saúde , Tempo para o Tratamento
16.
JAMA Intern Med ; 175(2): 207-15, 2015 Feb.
Artigo em Inglês | MEDLINE | ID: mdl-25485876

RESUMO

IMPORTANCE: Guidelines for patients with ST-segment elevation myocardial infarction (STEMI) recommend timely reperfusion with primary percutaneous coronary intervention (pPCI) or fibrinolysis. Among patients with STEMI who require interhospital transfer, it is unclear how reperfusion strategy selection and outcomes vary with interhospital drive times. OBJECTIVE: To assess the association of estimated interhospital drive times with reperfusion strategy selection among transferred patients with STEMI in the United States. DESIGN, SETTING, AND PARTICIPANTS: We identified 22,481 patients eligible for pPCI or fibrinolysis who were transferred from 1771 STEMI referring centers to 366 STEMI receiving centers in the Acute Coronary Treatment and Intervention Outcomes Network Registry-Get With the Guidelines database between July 1, 2008, and March 31, 2012. MAIN OUTCOMES AND MEASURES: In-hospital mortality and major bleeding. RESULTS: The median estimated interhospital drive time was 57 minutes (interquartile range [IQR], 36-88 minutes). When the estimated drive time exceeded 30 minutes, only 42.6% of transfer patients treated with pPCI achieved the first door-to-balloon time within 120 minutes. Only 52.7% of eligible patients with a drive time exceeding 60 minutes received fibrinolysis. Among 15,437 patients with estimated drive times of 30 to 120 minutes who were eligible for fibrinolysis or pPCI, 5296 (34.3%) received pretransfer fibrinolysis, with a median door-to-needle time of 34 minutes (IQR, 23-53 minutes). After fibrinolysis, the median time to transfer to the STEMI receiving center was 49 minutes (IQR, 34-69 minutes), and 97.1% underwent follow-up angiography. Patients treated with fibrinolysis vs pPCI had no significant mortality difference (3.7% vs 3.9%; adjusted odds ratio, 1.13; 95% CI, 0.94-1.36) but had higher bleeding risk (10.7% vs 9.5%; adjusted odds ratio, 1.17; 95% CI, 1.02-1.33). CONCLUSIONS AND RELEVANCE: In the United States, neither fibrinolysis nor pPCI is being optimally used to achieve guideline-recommended reperfusion targets. For patients who are unlikely to receive timely pPCI, pretransfer fibrinolysis, followed by early transfer for angiography, may be a reperfusion option when potential benefits of timely reperfusion outweigh bleeding risk.


Assuntos
Fibrinolíticos/uso terapêutico , Infarto do Miocárdio/tratamento farmacológico , Reperfusão Miocárdica/estatística & dados numéricos , Transferência de Pacientes/estatística & dados numéricos , Intervenção Coronária Percutânea/estatística & dados numéricos , Sistema de Registros , Idoso , Comportamento de Escolha , Feminino , Mortalidade Hospitalar , Humanos , Masculino , Pessoa de Meia-Idade , Guias de Prática Clínica como Assunto , Fatores de Tempo , Estados Unidos
17.
Am J Emerg Med ; 32(8): 856-63, 2014 Aug.
Artigo em Inglês | MEDLINE | ID: mdl-24865499

RESUMO

OBJECTIVE: ST-segment elevation myocardial infarction (STEMI) is a major cause of morbidity and mortality in the United States. Emergency medical services (EMS) agencies play a critical role in its initial identification and treatment. We conducted this study to assess EMS management of STEMI care in the United States. METHODS: A structured questionnaire was administered to leaders of EMS agencies to define the elements of STEMI care related to 4 core measures: (1) electrocardiogram (ECG) capability at the scene, (2) destination protocols, (3) catheterization laboratory activation before hospital arrival, and (4) 12-lead ECG quality review. Geographic areas were grouped into large metropolitan, small metropolitan, micropolitan, and noncore (or rural) by using Urban Influence Codes, with a stratified analysis. RESULTS: Data were included based on responses from 5296 EMS agencies (36% of those in the United States) serving 91% of the US population, with at least 1 valid response from each of the 50 states and the District of Columbia. Approximately 63% of agencies obtained ECGs at the scene using providers trained in ECG acquisition and interpretation. A total of 46% of EMS systems used protocols to determine hospital destination, cardiac catheterization laboratory activation, and communications with the receiving hospital. More than 75% of EMS systems used their own agency funds to purchase equipment, train personnel, and provide administrative oversight. A total of 49% of agencies have quality review programs in place. In general, EMS systems covering higher population densities had easier access to resources needed to maintain STEMI systems of care. Emergency medical services systems that have adopted all 4 core elements cover 14% of the US population. CONCLUSIONS: There are large differences in EMS systems of STEMI care in the United States. Most EMS agencies have implemented at least 1 of the 4 core elements of STEMI care, with many having implemented multiple elements.


Assuntos
Serviços Médicos de Emergência/estatística & dados numéricos , Infarto do Miocárdio/diagnóstico , Cateterismo Cardíaco/estatística & dados numéricos , Eletrocardiografia/estatística & dados numéricos , Serviços Médicos de Emergência/organização & administração , Pesquisas sobre Atenção à Saúde , Humanos , Infarto do Miocárdio/terapia , Garantia da Qualidade dos Cuidados de Saúde/estatística & dados numéricos , Serviços de Saúde Rural/estatística & dados numéricos , Sociedades Médicas , Inquéritos e Questionários , Estados Unidos/epidemiologia , Serviços Urbanos de Saúde/estatística & dados numéricos
20.
Circulation ; 128(4): 352-9, 2013 Jul 23.
Artigo em Inglês | MEDLINE | ID: mdl-23788525

RESUMO

BACKGROUND: For patients identified before hospital arrival with ST-segment-elevation myocardial infarction, bypassing the emergency department (ED) with direct transport to the catheterization laboratory may shorten reperfusion times. METHODS AND RESULTS: We studied 12 581 ST-segment-elevation myocardial infarction patients identified with a prehospital ECG treated at 371 primary percutaneous coronary intervention-capable US hospitals participating in the Acute Coronary Treatment and Intervention Outcomes Network Registry-Get With The Guidelines, including those participating in the American Heart Association Mission: Lifeline program from 2008 to 2011. Reperfusion times with primary percutaneous coronary intervention and in-hospital mortality rates were compared between patients undergoing ED evaluation and those bypassing the ED. ED bypass occurred in 1316 patients (10.5%). These patients had a lower frequency of heart failure and shock on presentation and nonsystem reasons for delay in percutaneous coronary intervention. ED bypass occurred more frequently during working hours compared with off-hours (18.3% versus 4.3%); ED bypass rate varied significantly across hospitals (median, 3.3%; range, 0%-71%). First medical contact to device activation time was shorter (median, 68 minutes [interquartile range, 54-85 minutes] versus 88 minutes [interquartile range, 73-106 minutes]; P<0.0001) and achieved within 90 minutes more frequently (80.7% versus 53.7%; P<0.0001) with ED bypass. The unadjusted in-hospital mortality rate was lower among ED bypass patients (2.7% versus 4.1%; P=0.01), but the adjusted mortality risk was similar (adjusted odds ratio, 0.69; 95% confidence interval, 0.45-1.03; P=0.07). CONCLUSIONS: Among ST-segment-elevation myocardial infarction patients identified with a prehospital ECG, the rate of ED bypass varied significantly across US hospitals, but ED bypass occurred infrequently and was mostly isolated to working hours. Because ED bypass was associated with shorter reperfusion times and numerically lower mortality rates, further exploration of and advocacy for the implementation of this process appear warranted.


Assuntos
Serviços Médicos de Emergência/estatística & dados numéricos , Serviço Hospitalar de Emergência/estatística & dados numéricos , Infarto do Miocárdio/terapia , Reperfusão Miocárdica/estatística & dados numéricos , Tempo para o Tratamento/estatística & dados numéricos , Transporte de Pacientes/estatística & dados numéricos , Idoso , American Heart Association , Cateterismo Cardíaco/estatística & dados numéricos , Eletrocardiografia , Serviços Médicos de Emergência/organização & administração , Serviço Hospitalar de Emergência/organização & administração , Feminino , Mortalidade Hospitalar , Humanos , Masculino , Pessoa de Meia-Idade , Infarto do Miocárdio/diagnóstico , Infarto do Miocárdio/mortalidade , Avaliação de Programas e Projetos de Saúde , Sistema de Registros/estatística & dados numéricos , Tempo para o Tratamento/organização & administração , Transporte de Pacientes/organização & administração , Estados Unidos
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