Improving use of prehospital 12-lead ECG for early identification and treatment of acute coronary syndrome and ST-elevation myocardial infarction

Types and effects of feedback for emergency ambulance staff: a systematic mixed studies review and meta-analysis

BACKGROUND

Extensive research has been conducted into the effects of feedback interventions within many areas of healthcare, but prehospital emergency care has been relatively neglected. Exploratory work suggests that enhancing feedback and follow-up to emergency medical service (EMS) staff might provide staff with closure and improve clinical performance. Our aim was to summarise the literature on the types of feedback received by EMS professionals and its effects on the quality and safety of patient care, staff well-being and professional development.

METHODS

A systematic review and meta-analysis, including primary research studies of any method published in peer-reviewed journals. Studies were included if they contained information on systematic feedback to emergency ambulance staff regarding their performance. Databases searched from inception were MEDLINE, Embase, AMED, PsycINFO, HMIC, CINAHL and Web of Science, with searches last updated on 2 August 2022. Study quality was appraised using the Mixed Methods Appraisal Tool. Data analysis followed a convergent integrated design involving simultaneous narrative synthesis and random effects multilevel meta-analyses.

RESULTS

The search strategy yielded 3183 articles, with 48 studies meeting inclusion criteria after title/abstract screening and full-text review. Interventions were categorised as audit and feedback (n=31), peer-to-peer feedback (n=3), postevent debriefing (n=2), incident-prompted feedback (n=1), patient outcome feedback (n=1) or a combination thereof (n=4). Feedback was found to have a moderate positive effect on quality of care and professional development with a pooled effect of d=0.50 (95% CI 0.34, 0.67). Feedback to EMS professionals had large effects in improving documentation (d=0.73 (0.00, 1.45)) and protocol adherence (d=0.68 (0.12, 1.24)), as well as small effects in enhancing cardiac arrest performance (d=0.46 (0.06, 0.86)), clinical decision-making (d=0.47 (0.23, 0.72)), ambulance times (d=0.43 (0.12, 0.74)) and survival rates (d=0.22 (0.11, 0.33)). The between-study heterogeneity variance was estimated at σ2=0.32 (95% CI 0.22, 0.50), with an I2 value of 99% (95% CI 98%, 99%), indicating substantial statistical heterogeneity.

CONCLUSION

This review demonstrated that the evidence base currently does not support a clear single point estimate of the pooled effect of feedback to EMS staff as a single intervention type due to study heterogeneity. Further research is needed to provide guidance and frameworks supporting better design and evaluation of feedback interventions within EMS.

PROSPERO REGISTRATION NUMBER

CRD42020162600.

Ambulance nurses' experiences of using prehospital guidelines for patients with acute chest pain - A qualitative study

BACKGROUND

Ambulance nurses have an important role in early recognition and treatment often being the first medical contact for patients with acute chest pain. However, there is sparse knowledge on the experiences of ambulance nurses with regard to use of Prehospital Guidelines for patients with Acute Chest Pain.

AIM

To explore ambulance nurses' experiences of using prehospital guidelines for patients with acute coronary syndrome.

METHOD

A qualitative descriptive study design. Semi-structured interviews with 22 ambulance nurses recruited through purposive sampling strategy. The material was transcribed and analysed using content analysis.

RESULTS

Two main categories emerged from the results. The first category Sense of professional obligation included experiences of having an important role in caring for patients with acute chest pain. Understanding this role and the collaboration in the chain of care prompted ambulance nurses to adhere to the guidelines. However, not receiving enough feedback on the provided care made them uncertain whether to use guidelines. The second category Clinical difficulties using guidelines consisted of experiences of being surrounded by practical challenges while using guidelines. Ambulance nurses meet these challenges by relying on their clinical experience, which sometimes led to them deviating from the guidelines.

CONCLUSIONS

The ambulance nurses experienced a mixture of feeling secure and insecure when using the guidelines. Foremost, when encountering patients with unspecific chest pain, they felt a lack of feedback and an insufficient collaboration within the chain of care, which made them deviate from guidelines. To increase adherence in guidelines, post-registration education to update the knowledge and skills about guidelines for acute chest pain is needed followed by formal inter-disciplinary feedback on the care provided.

Prognostic Implications of Door-to-Balloon Time and Onset-to-Door Time on Mortality in Patients With ST -Segment-Elevation Myocardial Infarction Treated With Primary Percutaneous Coronary Intervention

Background In patients with ST-segment-elevation myocardial infarction, timely reperfusion therapy with door-to-balloon (D2B) time <90 minutes is recommended by the current guidelines. However, whether further shortening of symptom onset-to-door (O2D) time or D2B time would enhance survival of patients with ST-segment-elevation myocardial infarction remains unclear. Therefore, the current study aimed to evaluate the prognostic impact of O2D or D2B time in patients with ST-segment-elevation myocardial infarction who underwent primary percutaneous coronary intervention. Methods and Results We analyzed 5243 patients with ST-segment-elevation myocardial infarction were treated at 20 tertiary hospitals capable of primary percutaneous coronary intervention in Korea. The association between O2D or D2B time with all-cause mortality at 1 year was evaluated. The median O2D time was 2.0 hours, and the median D2B time was 59 minutes. A total of 92.2% of the total population showed D2B time ≤90 minutes. In univariable analysis, 1-hour delay of D2B time was associated with a 55% increased 1-year mortality, whereas 1-hour delay of O2D time was associated with a 4% increased 1-year mortality. In multivariable analysis, D2B time showed an independent association with mortality (adjusted hazard ratio, 1.90; 95% CI , 1.51-2.39; P<0.001). Reducing D2B time within 45 minutes showed further decreased risk of mortality compared with D2B time >90 minutes (adjusted hazard ratio, 0.30; 95% CI , 0.19-0.42; P<0.001). Every reduction of D2B time by 30 minutes showed continuous reduction of 1-year mortality (90 to 60 minutes: absolute risk reduction, 2.4%; number needed to treat, 41.9; 60 to 30 minutes: absolute risk reduction, 2.0%; number needed to treat, 49.2). Conclusions Shortening D2B time was significantly associated with survival benefit, and the survival benefit of shortening D2B time was consistently observed, even <60 to 90 minutes.

Exploring paramedic perceptions of feedback using a phenomenological approach

Objectives:

Despite widespread advocacy of a feedback culture in healthcare, paramedics receive little feedback on their clinical performance. Provision of ‘outcome feedback’, or information concerning health-related patient outcomes following incidents that paramedics have attended, is proposed, to provide paramedics with a means of assessing and developing their diagnostic and decision-making skills. To inform the design of feedback mechanisms, this study aimed to explore the perceptions of paramedics concerning current feedback provision and to discover their attitudes towards formal provision of patient outcome feedback.

Methods:

Convenience sampling from a single ambulance station in the United Kingdom (UK) resulted in eight paramedics participating in semi-structured interviews. Interpretative phenomenological analysis was employed to generate descriptive and interpretative themes related to both current and potential feedback provision.

Results:

The perception that only exceptional incidents initiate feedback, and that often the required depth of information supplied is lacking, resulted in some participants describing an isolation of their daily practice. Barriers and limitations of the informal processes currently employed to access feedback were also highlighted. Formal provision of outcome feedback was anticipated by participants to benefit the integration and progression of the paramedic profession as a whole, in addition to facilitating the continued development and well-being of the individual clinician. Participants anticipated feedback to be delivered electronically to minimise resource demands, with delivery initiated by the individual clinician. However, a level of support or supervision may also be required to minimise the potential for harmful consequences.

Conclusions:

Establishing a just feedback culture within paramedic practice may reduce a perceived isolation of clinical practice, enabling both individual development and progression of the profession. Carefully designed formal outcome feedback mechanisms should be initiated and subsequently evaluated to establish resultant benefits and costs.

TRANSLATOR Database-A Vision for a Multi-Institutional Research Network

The formation of the CTSI One Health Alliance (COHA) network has generated the infrastructure necessary to support "Big Data" collaborative comparative and translational research in veterinary medicine. We describe the first step in the design, implementation, and dissemination of a collaborative information technology infrastructure that will serve the public and clinicians (COHA public/member based web site at https://ctsaonehealthalliance.org/) and its research focused COHA Research Workbench application. The core research infrastructure, TRANSLATOR (TRanslational ANimal Shared ColLAboraTive Observational Research), represents the foundation of a federated research-capable network to enable pooling large datasets from both electronic health records and publications. The public facing COHA website is a mechanism for both the dissemination of knowledge to the public and to foster collaborations amongst veterinary clinician scientists and the greater medical research community.

Review article: Impact of 12-lead electrocardiography system of care on emergency medical service delays in ST-elevation myocardial infarction: A systematic review and meta-analysis

To assess the impact of prehospital 12-lead electrocardiography (PH ECG) on emergency medical service (EMS) delay in patients with ST-elevation myocardial infarction (STEMI), we systematically searched five online electronic databases, including MEDLINE, Embase, Emcare, Cochrane Library and CINAHL, between 1990 and August 2017. Controlled trials and observational studies comparing EMS time delays with and without PH ECG in STEMI patients were eligible. Two reviewers independently screened studies for eligibility, extracted data and appraised study quality. The primary outcome was the time elapsed between scene arrival and hospital arrival. The secondary outcomes were response time, scene time, transport time and emergency call-to-hospital arrival time. Random effects models were used to pool weighted mean differences in EMS delay. Seven moderate-quality studies (two controlled trials and five observational) involving 81 005 participants were included in the data synthesis. The primary treatment strategy was in-hospital thrombolysis and percutaneous coronary intervention in four and three studies, respectively. PH ECG was associated with a 7.0 min increase in scene arrival-to-hospital arrival time (three studies; n = 80 628; 95% CI 6.7-7.2; I² = 0.0%) and a 2.9 min increase in scene time (four studies; n = 377; 95% CI 1.2-4.6; I² = 0.0%). PH ECG had no effect on transport or call-to-hospital intervals, although both measures showed evidence of heterogeneity. In patients with STEMI, PH ECG is associated with a modest increase in EMS delays. Measurement and improvement of EMS system delays may help to expedite treatment for STEMI.

e-Transmission of ECGs for expert consultation results in improved triage and treatment of patients with acute ischaemic chest pain by ambulance paramedics

AIMS

In pre-hospital settings handled by paramedics, identification of patients with myocardial infarction (MI) remains challenging when automated electrocardiogram (ECG) interpretation is inconclusive. We aimed to identify those patients and to get them on the right track to primary percutaneous coronary intervention (PCI).

METHODS AND RESULTS

In the Rotterdam-Rijnmond region, automated ECG devices on all ambulances were supplemented with a modem, enabling transmission of ECGs for online expert interpretation. The diagnostic protocol for acute chest pain was modified and monitored for 1 year. Patients with an ECG that met the criteria for ST-elevation myocardial infarction (STEMI) were immediately transported to a PCI hospital. ECGs that did not meet the STEMI criteria, but showed total ST deviation ≥800 µv were transmitted for online interpretation by the ECG expert. Online supervision was offered as a service if ECGs showed conduction disorders, or had an otherwise 'suspicious' pattern according to the ambulance paramedics. We enrolled 1,076 patients with acute ischaemic chest pain who did not meet the automated STEMI criteria. Their mean age was 63 years; 64% were men. After online consultation, 735 (68%) patients were directly transported to a PCI hospital for further treatment. PCI within 90 min was performed in 115 patients.

CONCLUSION

During a 1-year evaluation of the modified pre-hospital triage protocol for patients with acute ischaemic chest pain, over 100 acute MI patients with an initially inconclusive ECG received primary PCI within 90 min. Because of these results, we decided to continue the operation of the modified protocol.

Comprehensive electrocardiogram-to-device time for primary percutaneous coronary intervention in ST-segment elevation myocardial infarction: A report from the American Heart Association mission: Lifeline program

BACKGROUND

Assessing hospital-related network-level primary percutaneous coronary intervention (PCI) performance for ST-segment elevation myocardial infarction (STEMI) is challenging due to differential time-to-treatment metrics based on location of diagnostic electrocardiogram (ECG) for STEMI.

METHODS

STEMI patients undergoing primary PCI at 588 PCI-capable hospitals in AHA Mission: Lifeline (2008-2013) were categorized by initial STEMI identification location: PCI-capable hospitals (Group 1); pre-hospital setting (Group 2); and non-PCI-capable hospitals (Group 3). Patient-specific time-to-treatment categories were converted to minutes ahead of or behind their group-specific mean; average time-to-treatment difference for all patients at a given hospital was termed comprehensive ECG-to-device time. Hospitals were then stratified into tertiles based on their comprehensive ECG-to-device times with negative values below the mean representing shorter (faster) time intervals.

RESULTS

Of 117,857 patients, the proportion in Groups 1, 2, and 3 were 42%, 33%, and 25%, respectively. Lower rates of heart failure and cardiac arrest at presentation are noted within patients presenting to high-performing hospitals. Median comprehensive ECG-to-device time was shortest at -9 minutes (25th, 75th percentiles: -13, -6) for the high-performing hospital tertile, 1 minute (-1, 3) for middle-performing, and 11 minutes (7, 16) for low-performing. Unadjusted rates of in-hospital mortality were 2.3%, 2.6%, and 2.7%, respectively, but the adjusted risk of in-hospital mortality was similar across tertiles.

CONCLUSIONS

Comprehensive ECG-to-device time provides an integrated hospital-related network-level assessment of reperfusion timing metrics for primary PCI, regardless of the location for STEMI identification; further validation will delineate how this metric can be used to facilitate STEMI care improvements.

Delayed Care and Mortality Among Women and Men With Myocardial Infarction

BACKGROUND

Women with ST-segment-elevation myocardial infarction (STEMI) have higher mortality rates than men. We investigated whether sex-related differences in timely access to care among STEMI patients may be a factor associated with excess risk of early mortality in women.

METHODS AND RESULTS

We identified 6022 STEMI patients who had information on time of symptom onset to time of hospital presentation at 41 hospitals participating in the ISACS-TC (International Survey of Acute Coronary Syndromes in Transitional Countries) registry (NCT01218776) from October 2010 through April 2016. Patients were stratified into time-delay cohorts. We estimated the 30-day risk of all-cause mortality in each cohort. Despite similar delays in seeking care, the overall time from symptom onset to hospital presentation was longer for women than men (median: 270 minutes [range: 130-776] versus 240 minutes [range: 120-600]). After adjustment for baseline variables, female sex was independently associated with greater risk of 30-day mortality (odds ratio: 1.58; 95% confidence interval, 1.27-1.97). Sex differences in mortality following STEMI were no longer observed for patients having delays from symptom onset to hospital presentation of ≤1 hour (odds ratio: 0.77; 95% confidence interval, 0.29-2.02).

CONCLUSIONS

Sex difference in mortality following STEMI persists and appears to be driven by prehospital delays in hospital presentation. Women appear to be more vulnerable to prolonged untreated ischemia.

CLINICAL TRIAL REGISTRATION

URL: https://www.clinicaltrials.gov/. Unique identifier: NCT01218776.

Adherence to Cardiac Practice Guidelines in the Management of Non-ST-Elevation Acute Coronary Syndromes: A Systematic Literature Review

BACKGROUND

In the management of non-ST-elevation acute coronary syndrome (NSTACS) a gap between guideline-recommended care and actual practice has been reported. A systematic overview of the actual extent of this gap, its potential impact on patient-outcomes, and influential factors is lacking.

OBJECTIVE

To examine the extent of guideline adherence, to study associations with the occurrence of adverse cardiac events, and to identify factors associated with guideline adherence.

METHOD

Systematic literature review, for which PUBMED, EMBASE, CINAHL, and the Cochrane library were searched until March 2016. Further, a manual search was performed using reference lists of included studies. Two reviewers independently performed quality-assessment and data extraction of the eligible studies.

RESULTS

Adherence rates varied widely within and between 45 eligible studies, ranging from less than 5.0 % to more than 95.0 % for recommendations on acute and discharge pharmacological treatment, 34.3 % - 93.0 % for risk stratification, and 16.0 % - 95.8 % for performing coronary angiography. Seven studies indicated that higher adherence rates were associated with lower mortality. Several patient-related (e.g. age, gender, co-morbidities) and organization-related (e.g. teaching hospital) factors influencing adherence were identified.

CONCLUSION

This review showed wide variation in guideline adherence, with a substantial proportion of NST-ACS patients possibly not receiving guideline-recommended care. Consequently, lower adherence might be associated with a higher risk for poor prognosis. Future research should further investigate the complex nature of guideline adherence in NST-ACS, its impact on clinical care, and factors influencing adherence. This knowledge is essential to optimize clinical management of NSTACS patients and could guide future quality improvement initiatives.

Effects of prehospital 12-lead ECG on processes of care and mortality in acute coronary syndrome: a linked cohort study from the Myocardial Ischaemia National Audit Project

OBJECTIVE

To describe patterns of prehospital ECG (PHECG) use and determine its association with processes and outcomes of care in patients with ST-elevation myocardial infarction (STEMI) and non-STEMI.

METHODS

Population-based linked cohort study of a national myocardial infarction registry.

RESULTS

288 990 patients were admitted to hospitals via emergency medical services (EMS) between 1 January 2005 and 31 December 2009. PHECG use increased overall (51% vs 64%, adjusted OR (aOR) 2.17, 95% CI 2.12 to 2.22), and in STEMI (64% vs 79%, aOR 2.34, 95% CI 2.25 to 2.44). Patients who received PHECG were younger (71 years vs 74 years, P<0.0001); and less likely to be female (33.1% vs 40.3%, OR 0.87, 95% CI 0.86 to 0.89), or to have comorbidities than those who did not. For STEMI, reperfusion was more frequent in those having PHECG (83.5% vs 74.4%, p<0.0001). PHECG was associated with more primary percutaneous coronary intervention patients achieving call-to-balloon time <90 min (27.9% vs 21.4%, aOR 1.38, 95% CI 1.24 to 1.54) and more patients who received fibrinolytic therapy achieving door-to-needle time <30 min (90.6% vs 83.7%, aOR 2.13, 95% CI 1.91 to 2.38). Patients with PHECG exhibited significantly lower 30-day mortality rates than those who did not (7.4% vs 8.2%, aOR 0.94, 95% CI 0.91 to 0.96).

CONCLUSIONS

Findings from this national MI registry demonstrate a survival advantage in STEMI and non-STEMI patients when PHECG was used.

Reduction in STEMI transfer times utilizing a municipal "911" ambulance service

INTRODUCTION

The time interval from diagnosis to reperfusion therapy for patients experiencing ST-segment elevation myocardial infarction (STEMI) has a significant impact on morbidity and mortality.

HYPOTHESIS

It is hypothesized that the time required for interfacility patient transfers from a community hospital to a regional percutaneous coronary intervention (PCI) center using an Advanced Life Support (ALS) transfer ambulance service is no different than utilizing the "911" ALS ambulance.

METHODS

Quality assurance data collected by a tertiary care center cardiac catheterization program were reviewed retrospectively. Data were collected on all patients with STEMI requiring interfacility transfer from a local community hospital to the tertiary care center's PCI suite, approximately 16 miles away by ground, 12 miles by air. In 2009, transfers of patients with STEMI were redirected to the municipal ALS ambulance service, instead of the hospital's contracted ALS transfer service. Data were collected from January 2007 through May 2013. Temporal data were compared between transports initiated through the contracted ALS ambulance service and the municipal ALS service. Data points included time of initial transport request and time of ambulance arrival to the sending facility and the receiving PCI suite.

RESULTS

During the 4-year study period, 63 patients diagnosed with STEMI and transferred to the receiving hospital's PCI suite were included in this study. Mean times from the transport request to arrival of the ambulance at the sending hospital's emergency department were six minutes (95% CI, 4-7 minutes) via municipal ALS and 13 minutes (95% CI, 9-16 minutes) for the ALS transfer service. The mean times from the ground transport request to arrival at the receiving hospital's PCI suite when utilizing the municipal ALS ambulance and hospital contracted ALS ambulance services were 48 minutes (95% CI, 33-64 minutes) and 56 minutes (95% CI 52-59 minutes), respectively. This eight-minute period represented a 14% (P = .001) reduction in the mean transfer time to the PCI suite for patients transported via the municipal ALS ambulance.

CONCLUSION

In the appropriate setting, the use of the municipal "911" ALS ambulance service for the interfacility transport of patients with STEMI appears advantageous in reducing door-to-catheterization times.

Emergency medical services as a strategy for improving ST-elevation myocardial infarction system treatment times

BACKGROUND

Reducing delays in time to treatment is a key goal of ST-elevation myocardial infarction (STEMI) emergency care. Emergency medical services (EMS) are a critical component of the STEMI chain of survival.

STUDY OBJECTIVE

We sought to assess the impact of the careful integration of EMS as a strategy for improving systemic treatment times for STEMI.

METHODS

We conducted a study of all 747 nontransfer STEMI patients who underwent primary percutaneous coronary intervention (PCI) in Dallas County, Texas from October 1, 2010 through December 31, 2011. EMS leaders from 24 agencies and 15 major PCI receiving hospitals collected and shared common, de-identified patient data. We used 15 months of data to develop a generalized linear regression to assess the impact of EMS on two treatment metrics-hospital door to balloon (D2B) time, and symptom onset to arterial reperfusion (SOAR) time, a new metric we developed to assess total treatment times.

RESULTS

We found statistically significant reductions in median D2B (11.1-min reduction) and SOAR (63.5-min reduction) treatment times when EMS transported patients to the receiving facility, compared to self-transport. In addition, when trained EMS paramedics field-activated the cardiac catheterization laboratory using predefined specified protocols, D2B times were reduced by 38% (43 min) after controlling for confounding variables, and field activation was associated with a 21.9% reduction (73 min) in the mean SOAR time (both with p < 0.001).

CONCLUSION

Active EMS engagement in STEMI treatment was associated with significantly lower D2B and total coronary reperfusion times.

Efficacy and limitations of a STEMI network: 3 years of experience within the myocardial infarction network of the region of Augsburg - HERA

AIMS

The HERA Registry investigates logistics, adherence to standards, time intervals, and mortality in a regional network for primary percutaneous coronary intervention (PPCI) in ST-elevation myocardial infarction (STEMI) in a mixed urban and rural area.

METHODS AND RESULTS

We included 826 consecutive patients (pts) within the HERA network with its dedicated PPCI strategy (female n = 243, mean age 64 years, range 25-98 years) with acute STEMI (May 2007 until January 2010). 680 pts (82 %) received PPCI and 45 (5.4 %) acute bypass surgery. Of 512 pts seen by an emergency physician (EP) as first medical contact (FMC) 87 % received on-scene 12-lead ECG. ECG transmission rate to the PPCI center was 29 %. Median FMC-to-balloon time (CBT) was 135 min and door-to-balloon time (DBT) 70 min. With EP FMC DBT was 38 min with direct transfer to cath lab (n = 70), 69 min via ICU (n = 240), and 132 min via ER (n = 91, p < 0.01). Out of 826 pts, 143(17.3 %) presented in cardiogenic shock. In-hospital mortality was 8.8 % (n = 73), 35.7 % for shock pts versus 3.2 % for non-shock pts (p < 0.01). For pts receiving PPCI, in-hospital mortality was 6.2 %, for shock pts (n = 107) 28.0 %, and for non-shock pts (n = 573) 2.1 % (p < 0.01).

CONCLUSION

Prehospital management, CBT and DBT compare favourably to data from studies and registries, but do not yet fulfill strict guideline requirements. Real world mortality in non-shock pts is very low. Direct transfer to cath lab reduces DBTs by 49 %. For this crucial improvement, transmission of a 12-lead ECG to the PPCI center is mandatory.

Adherence to guidelines and protocols in the prehospital and emergency care setting: a systematic review

A gap between guidelines or protocols and clinical practice often exists, which may result in patients not receiving appropriate care. Therefore, the objectives of this systematic review were (1) to give an overview of professionals' adherence to (inter)national guidelines and protocols in the emergency medical dispatch, prehospital and emergency department (ED) settings, and (2) to explore which factors influencing adherence were described in studies reporting on adherence. PubMed (including MEDLINE), CINAHL, EMBASE and the Cochrane database for systematic reviews were systematically searched. Reference lists of included studies were also searched for eligible studies. Identified articles were screened on title, abstract and year of publication (≥1990) and were included when reporting on adherence in the eligible settings. Following the initial selection, articles were screened full text and included if they concerned adherence to a (inter)national guideline or protocol, and if the time interval between data collection and publication date was <10 years. Finally, articles were assessed on reporting quality. Each step was undertaken by two independent researchers. Thirty-five articles met the criteria, none of these addressed the emergency medical dispatch setting or protocols. Median adherence ranged from 7.8-95% in the prehospital setting, and from 0-98% in the ED setting. In the prehospital setting, recommendations on monitoring came with higher median adherence percentages than treatment recommendations. For both settings, cardiology treatment recommendations came with relatively low median adherence percentages. Eight studies identified patient and organisational factors influencing adherence. The results showed that professionals' adherence to (inter)national prehospital and emergency department guidelines shows a wide variation, while adherence in the emergency medical dispatch setting is not reported. As insight in influencing factors for adherence in the emergency care settings is minimal, future research should identify such factors to allow the development of strategies to improve adherence and thus improve quality of care.

The Editors. Circulation: Cardiovascular Quality and Outcomes Editors' Picks

The following are highlights from the new series, Circulation: Cardiovascular Quality and Outcomes Topic Review. This series will summarize the most important manuscripts, as selected by the editors, that have published in the Circulation portfolio. The objective of this new series is to provide our readership with a timely, comprehensive selection of important papers that are relevant to the quality and outcomes and general cardiology audience. The studies included in this article represent the most significant research in the area of ST-segment elevation myocardial infarction care and address improvements in the timeliness of care, strategies for initial treatment—particularly with respect to reperfusion therapies—and trends.

Improvements in door-to-balloon time in the United States, 2005 to 2010

BACKGROUND

Registry studies have suggested improvements in door-to-balloon times, but a national assessment of the trends in door-to-balloon times is lacking. Moreover, we do not know whether improvements in door-to-balloon times were shared equally among patient and hospital groups.

METHODS AND RESULTS

This analysis includes all patients reported by hospitals to the Centers for Medicare & Medicaid Services for inclusion in the time to percutaneous coronary intervention (acute myocardial infarction-8) inpatient measure from January 1, 2005, through September 30, 2010. For each calendar year, we summarized the characteristics of patients reported for the measure, including the number and percentage in each group, the median time to primary percutaneous coronary intervention, and the percentage with time to primary percutaneous coronary intervention within 75 minutes and within 90 minutes. Door-to-balloon time declined from a median of 96 minutes in the year ending December 31, 2005, to a median of 64 minutes in the 3 quarters ending September 30, 2010. There were corresponding increases in the percentage of patients who had times <90 minutes (44.2% to 91.4%) and <75 minutes (27.3% to 70.4%). The declines in median times were greatest among groups that had the highest median times during the first period: patients >75 years of age (median decline, 38 minutes), women (35 minutes), and blacks (42 minutes).

CONCLUSION

National progress has been achieved in the timeliness of treatment of patients with ST-segment-elevation myocardial infarction who undergo primary percutaneous coronary intervention.