Regional Systems of Care for Patients With ST-Elevation Myocardial Infarction

Inequities in ambulance allocation associated with transfer delay and mortality in acute coronary syndrome patients: evidence from 89 emergency medical stations in China

BACKGROUND

Allocation of healthcare resources has a great influence on treatment and outcome of patients. This study aimed to access the inequality of ambulance allocation across regions, and estimate the associations between ambulance density and pre-hospital transfer time and mortality of acute coronary syndromes (ACS) patients.

METHODS

This cross-sectional study was based on an integrated database of electronic medical system for 3588 ACS patients from 31 hospitals, ambulance information of 89 emergency medical stations, and public geographical information of 8 districts in Shenzhen, China. The primary outcomes were the associations between ambulance allocation and transfer delay and in-hospital mortality of ACS patients. The Theil index and Gini coefficient were used to assess the fairness and inequality degree of ambulance allocation. Logistic regression was used to model the associations.

RESULTS

There was a significant inequality in ambulance allocation in Shenzhen (Theil index: 0.59), and the inequality of inter-districts (Theil index: 0.38) was greater than that of intra-districts (Theil index: 0.21). The gap degree of transfer delay, ambulance allocation, and mortality across districts resulted in a Gini coefficient of 0.35, 0.53, 0.65, respectively. Ambulance density was negatively associated with pre-hospital transfer time (OR = 0.79, 95%CI: 0.64,0.97, P = 0.026), with in-hospital mortality (OR = 0.31, 95%CI:0.14,0.70, P = 0.005). The ORs of Theil index in transfer time and in-hospital mortality were 1.09 (95%CI:1.01,1.10, P < 0.001) and 1.80 (95%CI:1.15,3.15, P = 0.009), respectively.

CONCLUSIONS

Regional inequities existed in ambulance allocation and has a significant impact on pre-hospital transfer delay and in-hospital mortality of ACS patients. It was suggested to increase the ambulance accessibility and conduct health education for public.

Development of a unified national database of primary percutaneous coronary intervention centers with co-located emergency departments, 2020

BACKGROUND

Although primary percutaneous coronary intervention (pPCI) is the preferred intervention for ST-elevation myocardial infarction (STEMI), not all patients are admitted directly to an emergency department (ED) with 24/7/365 pPCI capabilities. This is partly due to a lack of a national system of known pPCI-capable EDs. Our objective was to create a unified, national database of confirmed 24/7/365 pPCI centers co-located in hospitals with EDs.

METHODS

We compiled all hospitals designated as Chest Pain Centers with Primary PCI by the American College of Cardiology's (ACC) National Clinical Data Registry (NCDR), all STEMI Receiving Centers designated by the American Heart Association's (AHA) Mission: Lifeline registry, and all state-designated pPCI-capable hospitals and designation criteria from state departments of health. We matched ACC, AHA, and state-designated facilities to those in the 2019 National ED Inventory (NEDI)-USA database to identify all EDs in pPCI-capable hospitals.

RESULTS

Overall, 467 hospitals were recognized as Chest Pain Centers with Primary PCI by ACC, 293 hospitals were recognized as being STEMI Receiving Centers by AHA, and 827 hospitals were confirmed to be pPCI-capable by state designations and operated 24/7/365. Together, there were 1,178 EDs (21% of 5,587 total) co-located in pPCI-capable hospitals operating 24/7/365.

CONCLUSIONS

There is substantial heterogeneity in cardiac systems of care, with large regional systems existing alongside local state-led initiatives. We created a unified national database of confirmed 24/7/365 pPCI centers co-located in hospitals with EDs. This data set will be valuable for future cardiac systems research and improving access to pPCI.

Reperfusion Therapy Optimization in Acute Myocardial Infarction with ST-Segment Elevation using WhatsApp®-Based Telemedicine

BACKGROUND

About 40% of patients with ST-segment elevation myocardial infarction (STEMI) in Brazil do not receive reperfusion therapy.

OBJECTIVE

The use of a telemedicine network based on WhatsApp® could increase the percentage of patients receiving reperfusion therapy.

METHODS

A cross-sectional study analyzed outcomes before and after the organization of a telemedicine network to send the electrocardiogram via WhatsApp® of patients suspected of STEMI from 25 municipalities that are members of the Regional Health Department of Ribeirão Preto (DRS-XIII) to a tertiary hospital, which could authorize immediate patient transfer using the same system. The analyzed outcomes included the percentage of patients who received reperfusion therapy and the in-hospital mortality rate. A p value < 0.05 was considered statistically significant.

RESULTS

The study compared 82 patients before (February 1, 2016 to January 31, 2018) with 196 patients after this network implementation (February 1, 2018 to January 31, 2020). After implementing this network, there was a significant increase in the proportion of patients who received reperfusion therapy (60% vs. 92%), relative risk (RR): 1.594 [95% confidence interval (CI) 1.331 - 1.909], p < 0.0001 and decrease in the in-hospital mortality rate (13.4% vs. 5.6%), RR: 0.418 [95%CI 0.189 - 0.927], p = 0.028.

CONCLUSION

The use of WhatsApp®-based telemedicine has led to an increase in the percentage of patients with STEMI who received reperfusion therapy and a decrease in the in-hospital mortality rate.

Rural-Urban Disparities in Outcomes of Myocardial Infarction, Heart Failure, and Stroke in the United States

BACKGROUND

U.S. policy efforts have focused on reducing rural-urban health inequities. However, it is unclear whether gaps in care and outcomes remain among older adults with acute cardiovascular conditions.

OBJECTIVES

This study aims to evaluate rural-urban differences in procedural care and mortality for acute myocardial infarction (AMI), heart failure (HF), and ischemic stroke.

METHODS

This is a retrospective cross-sectional study of Medicare fee-for-service beneficiaries aged ≥65 years with acute cardiovascular conditions from 2016 to 2018. Cox proportional hazards models with random hospital intercepts were fit to examine the association of presenting to a rural (vs urban) hospital and 30- and 90-day patient-level mortality.

RESULTS

There were 2,182,903 Medicare patients hospitalized with AMI, HF, or ischemic stroke from 2016 to 2018. Patients with AMI were less likely to undergo cardiac catherization (49.7% vs 63.6%, P < 0.001), percutaneous coronary intervention (42.1% vs 45.7%, P < 0.001) or coronary artery bypass graft (9.0% vs 10.2%, P < 0.001) within 30 days at rural versus urban hospitals. Thrombolysis rates (3.1% vs 10.1%, P < 0.001) and endovascular therapy (1.8% vs 3.6%, P < 0.001) for ischemic stroke were lower at rural hospitals. After adjustment for demographics and clinical comorbidities, the 30-day mortality HR was significantly higher among patients presenting to rural hospitals for AMI (HR: 1.10, 95% CI: 1.08 to 1.12), HF (HR: 1.15; 95% CI: 1.13 to 1.16), and ischemic stroke (HR: 1.20; 95% CI: 1.18 to 1.22), with similar patterns at 90 days. These differences were most pronounced for the subset of critical access hospitals that serve remote, rural areas.

CONCLUSIONS

Clinical, public health, and policy efforts are needed to improve rural-urban gaps in care and outcomes for acute cardiovascular conditions.

Systems of Care in Cardiogenic Shock

Cardiogenic shock presents a significant challenge to the medical community, and there is much debate as to the best classification system and treatment mechanisms. As interventions and technologies improve, systems of care for patients with cardiogenic shock must evolve as well. This review describes the current treatment models for cardiogenic shock, including the "hub-and-spoke" model, and defines specific characteristics of the ideal system of care for this patient population.

Contemporary Management of Out-of-hospital Cardiac Arrest in the Cardiac Catheterisation Laboratory: Current Status and Future Directions

Out-of-hospital cardiac arrest (OHCA) is an important cause of mortality and morbidity in developed countries and remains an important public health burden. A primary cardiac aetiology is common in OHCA patients, and so patients are increasingly brought to specialist cardiac centres for consideration of coronary angiography, percutaneous coronary intervention and mechanical circulatory support. This article focuses on the management of OHCA in the cardiac catheterisation laboratory. In particular, it addresses conveyance of the OHCA patient direct to a specialist centre, the role of targeted temperature management, pharmacological considerations, provision of early coronary angiography and mechanical circulatory support.

Inter-hospital transfer and patient outcomes: a retrospective cohort study

BACKGROUND

Inter-hospital transfer (IHT, the transfer of patients between hospitals) occurs regularly and exposes patients to risks of discontinuity of care, though outcomes of transferred patients remains largely understudied.

OBJECTIVE

To evaluate the association between IHT and healthcare utilisation and clinical outcomes.

DESIGN

Retrospective cohort.

SETTING

CMS 2013 100 % Master Beneficiary Summary and Inpatient claims files merged with 2013 American Hospital Association data.

PARTICIPANTS

Beneficiaries≥age 65 enrolled in Medicare A and B, with an acute care hospitalisation claim in 2013 and 1 of 15 top disease categories.

MAIN OUTCOME MEASURES

Cost of hospitalisation, length of stay (LOS) (of entire hospitalisation), discharge home, 3 -day and 30- day mortality, in transferred vs non-transferred patients.

RESULTS

The final cohort consisted of 53 420 transferred patients and 53 420 propensity-score matched non-transferred patients. Across all 15 disease categories, IHT was associated with significantly higher costs, longer LOS and lower odds of discharge home. Additionally, IHT was associated with lower propensity-matched odds of 3-day and/or 30- day mortality for some disease categories (acute myocardial infarction, stroke, sepsis, respiratory disease) and higher propensity-matched odds of mortality for other disease categories (oesophageal/gastrointestinal disease, renal failure, congestive heart failure, pneumonia, renal failure, chronic obstructivepulmonary disease, hip fracture/dislocation, urinary tract infection and metabolic disease).

CONCLUSIONS

In this nationally representative study of Medicare beneficiaries, IHT was associated with higher costs, longer LOS and lower odds of discharge home, but was differentially associated with odds of early death and 30 -day mortality depending on patients' disease category. These findings demonstrate heterogeneity among transferred patients depending on the diagnosis, presenting a nuanced assessment of this complex care transition.

Rationale and design of: A Randomized tRial of Expedited transfer to a cardiac arrest center for non-ST elevation out-of-hospital cardiac arrest: The ARREST randomized controlled trial

BACKGROUND

Out-of-hospital cardiac arrest (OHCA) is a global public health issue. There is wide variation in both regional and inter-hospital survival rates from OHCA and overall survival remains poor at 7%. Regionalization of care into cardiac arrest centers (CAC) improves outcomes following cardiac arrest from ST elevation myocardial infarction (STEMI) through concentration of services and greater provider experience. The International Liaison Committee on Resuscitation (ILCOR) recommends delivery of all post-arrest patients to a CAC, but that randomized controlled trials are necessary in patients without ST elevation (STE).

METHODS/DESIGN

Following completion of a pilot randomized trial to assess safety and feasibility of conducting a large-scale randomized controlled trial in patients following OHCA of presumed cardiac cause without STE, we present the rationale and design of A Randomized tRial of Expedited transfer to a cardiac arrest center for non-ST elevation OHCA (ARREST). In total 860 patients will be enrolled and randomized (1:1) to expedited transfer to CAC (24/7 access to interventional cardiology facilities, cooling and goal-directed therapies) or to the current standard of care, which comprises delivery to the nearest emergency department. Primary outcome is 30-day all-cause mortality and secondary outcomes are 30-day and 3-month neurological status and 3, 6 and 12-month mortality. Patients will be followed up for one year after enrolment.

CONCLUSION

Post-arrest care is time-critical, requires a multi-disciplinary approach and may be more optimally delivered in centers with greater provider experience. This trial would help to demonstrate if regionalization of post-arrest care to CACs reduces mortality in patients without STE, which could dramatically reshape emergency care provision.

Current Trends for ST-segment Elevation Myocardial Infarction during the Past 5 Years in Rural Areas of China's Liaoning Province: A Multicenter Study

Background:

Since 2010, two versions of National Guidelines aimed at promoting the management of ST-segment elevation myocardial infarction (STEMI) have been formulated by the Chinese Society of Cardiology. However, little is known about the changes in clinical characteristics, management, and in-hospital outcomes in rural areas.

Methods:

In the present multicenter, cross-sectional study, participants were enrolled from rural hospitals located in Liaoning province in Northeast China, during two different periods (from June 2009 to June 2010 and from January 2015 to December 2015). Data collection was conducted using a standardized questionnaire. In total, 607 and 637 STEMI patients were recruited in the 2010 and 2015 cohorts, respectively.

Results:

STEMI patients in rural hospitals were older in the second group (63 years vs. 65 years, P = 0.039). We found increases in the prevalence of hypertension, prior percutaneous coronary intervention (PCI), and prior stroke. Over the past 5 years, the cost during hospitalization almost doubled. The proportion of STEMI patients who underwent emergency reperfusion had significantly increased from 42.34% to 54.47% (P < 0.0001). Concurrently, the proportion of primary PCI increased from 3.62% to 10.52% (P < 0.0001). The past 5 years have also seen marked increases in the use of guideline-recommended drugs and clinical examinations. However, in-hospital mortality and major adverse cardiac events did not significantly change over time (13.01% vs. 10.20%, P = 0.121; 13.34% vs. 13.66%, P = 0.872).

Conclusions:

Despite the great progress that has been made in guideline-recommended therapies, in-hospital outcomes among rural STEMI patients have not significantly improved. Therefore, there is still substantial room for improvement in the quality of care.

ST segment elevation myocardial infarction in patients hospitalized for non-cardiac conditions

BACKGROUND

Timely use of primary percutaneous coronary intervention (PCI) is the standard of care for patients with ST segment elevation myocardial infarction (STEMI). Most patients with STEMI present via emergency medical services or self-transport to the emergency department (ED) and relatively little is known about the minority of patients that develop STEMI while hospitalized for non-cardiac conditions. The objective of this study was to analyze treatment times and clinical outcome for in-hospital STEMI patients.

METHODS

Two-hundred fifty-five patients with STEMI treated at Keck Medical Center of USC and Los Angeles County USC Medical Center from January, 2009 to December, 2013 were retrospectively analyzed. Demographics, treatment time intervals and clinical outcome were collected. Patients arriving via the ED (ED STEMI Group, n=228; 89%) were compared to patients that developed in-hospital STEMI (In-hospital STEMI Group, n=27; 11%).

RESULTS

Patients with in-hospital STEMI were similar in age, gender and associated medical conditions to ED STEMI patients. In-hospital STEMI patients were less likely to present with chest pain compared to ED STEMI patients, 5% vs. 79%, respectively, p<0.0001. Time from first abnormal electrocardiogram to device was 195±202min for in-hospital STEMI Group compared to door to device time of 88±64min for ED STEMI Group, p<0.001. Length of hospital stay was significantly longer for in-hospital STEMI Group compared to ED STEMI Group, 13±10 vs. 6.8±7.8days, respectively, p<0.001. In-hospital mortality was significantly higher for the in-hospital STEMI Group compared to the ED STEMI Group, 37% vs. 7%, respectively, p<0.001.

CONCLUSIONS

In-hospital STEMI patients have significant treatment delays and worse clinical outcome compared to STEMI patients that present via the emergency department. Additional efforts are required to promptly identify in-hospital patients that develop STEMI.

New Developments in the Treatment of Acute Myocardial Infarction Associated with Out-of-Hospital Cardiac Arrest. A Review

Out-of-hospital cardiac arrest (OHCA) occurring as the first manifestation of an acute myocardial infarction is associated with very high mortality rates. As in comatose patients the etiology of cardiac arrest may be unclear, especially in cases without ST-segment elevation on the surface electrocardiogram, the decision to perform or not to perform urgent coronary angiography can have a significant impact on the prognosis of these patients. This review summarises the current knowledge and recommendations for treating patients with acute myocardial infarction presenting with OHCA. New therapeutic measures for the post-resuscitation phase are presented, such as hypothermia or extracardiac life support, together with strategies aiming to restore the coronary flow in the resuscitation phase using intra-arrest percutaneous revascularization performed during resuscitation. The role of regional networks in providing rapid access to the hospital facilities and to a catheterization laboratory for these critical cardiovascular emergencies is described.

Non-eligibility for reperfusion therapy in patients presenting with ST-segment elevation myocardial infarction: Contemporary insights from the National Cardiovascular Data Registry (NCDR)

BACKGROUND

Reperfusion therapy is lifesaving in patients presenting with ST-segment elevation myocardial infarction (STEMI). Contemporary data describing the characteristics and outcomes of patients presenting with STEMI not receiving reperfusion therapy are lacking.

METHODS

Using the ACTION Registry-GWTG database, we examined 219,726 STEMI patients (January 2007-December 2013) at 721 percutaneous coronary intervention (PCI)-capable hospitals in United States. Clinical characteristics and in-hospital outcomes were stratified by those who underwent reperfusion (n = 188,200; 86%), those who did not undergo reperfusion with a reason for ineligibility (n = 27,179; 12%), and those without reperfusion but had no reason for ineligibility (n = 4,347; 2%).

RESULTS

Compared with STEMI patients receiving reperfusion therapy, the nonreperfusion groups were older, were more often female, and had higher rates of hypertension, diabetes, prior myocardial infarction, prior stroke, atrial fibrillation, and left bundle-branch block and heart failure on presentation. The major reason for reperfusion noneligibility was coronary anatomy not suitable for PCI (33%). Presence of 3-vessel coronary disease was more common in the nonreperfusion groups (with or without a documented reason) compared with reperfusion group (38% and 36% vs 26%, P < .001, respectively). In-hospital mortality was higher in patients not receiving reperfusion therapy with or without a documented reason compared with the reperfusion group (adjusted odds ratio [95% CI] 1.88 [1.78-1.99] and 1.37 [1.21-1.57], respectively).

CONCLUSION

Most patients with STEMI not receiving reperfusion therapy had a documented reason. Coronary anatomy not suitable for PCI was the major contributor to ineligibility. In-hospital mortality was higher in patients not receiving reperfusion therapy.

Impact of Time of Presentation on Process Performance and Outcomes in ST-Segment–Elevation Myocardial Infarction

Background—

Prior studies demonstrated that patients with ST-segment–elevation myocardial infarction presenting during off-hours (weeknights, weekends, and holidays) have slower reperfusion times. Recent nationwide initiatives have emphasized 24/7 quality care in ST-segment–elevation myocardial infarction. It remains unclear whether patients presenting off-hours versus on-hours receive similar quality care in contemporary practice.

Methods and Results—

Using Acute Coronary Treatment and Intervention Outcomes Network-Get With The Guidelines (ACTION-GWTG) database, we examined ST-segment–elevation myocardial infarction performance measures in patients presenting off-hours (n=27 270) versus on-hours (n=15 972; January 2007 to September 2010) at 447 US centers. Key quality measures assessed were aspirin use within first 24 hours, door-to-balloon time, door-to-ECG time, and door-to-needle time. In-hospital risk-adjusted all-cause mortality was calculated. Baseline demographic and clinical characteristics were similar. Aspirin use within 24 hours approached 99% in both groups. Among patients undergoing primary percutaneous coronary intervention (n=41 979; 97.1%), median door-to-balloon times were 56 versus 72 minutes ( P <0.0001) for on-hours versus off-hours. The proportion of patients achieving door-to-balloon time ≤90 minutes was 87.8% versus 79.2% ( P <0.0001), respectively. There were no differences attaining door-to-ECG time ≤10 minutes (73.4% versus 74.3%, P =0.09) and door-to-needle time ≤30 minutes (62.3% versus 58.7%; P =0.44) between on-hours versus off-hours. Although in-hospital all-cause mortality was similar (4.2%) in both groups, the risk-adjusted all-cause mortality was higher for patients presenting off-hours (odds ratio, 1.13; 95% confidence interval, 1.02–1.26).

Conclusions—

In contemporary community practice, achievement of quality performance measures in patients presenting with ST-segment–elevation myocardial infarction was high, regardless of time of presentation. Door-to-balloon time was, however, slightly delayed (by an average of 16 minutes), and risk-adjusted in-hospital mortality was 13% higher in patients presenting off-hours.

Neurological outcomes after extracorporeal cardiopulmonary resuscitation in patients with out-of-hospital cardiac arrest: a retrospective observational study in a rural tertiary care center

BACKGROUND

In a rural region with few medical resources, we have promoted the strategy that if an out-of-hospital cardiac arrest (OHCA) patient is likely reversible, he or she should be transported directly from the scene of cardiac arrest to the only tertiary care center where extracorporeal cardiopulmonary resuscitation (ECPR) is readily available. We investigated 1-month survival and neurological outcomes after ECPR in OHCA patients at this center.

METHODS

We implemented a retrospective review of OHCA patients of heterogeneous origin in whom ECPR was performed. Demographic characteristics, cardiopulmonary resuscitation, ECPR details, and neurological outcomes were evaluated. Cerebral performance categories were used to assign each patient to favorable or unfavorable outcome groups.

RESULTS

Fifty OHCA patients underwent ECPR. Presumed causes of OHCA were cardiac etiology in 32 patients, accidental hypothermia in 7 patients, and other causes in 11 patients. Overall, 13 patients (26%) survived and 10 patients (20%) had favorable outcomes. Of the 32 patients with OHCA of cardiac origin, 5 patients (16%) had favorable outcomes. Of the seven patients with OHCA of hypothermic origin, five patients (71%) had favorable outcomes. No clinically reliable predictors to identify ECPR candidates were found. However, all nine OHCA patients over 70 years of age had unfavorable outcomes (P = 0.224). In addition, all seven patients who satisfied the basic life support termination-of-resuscitation rule had unfavorable outcomes (P = 0.319).

CONCLUSIONS

ECPR can be a useful means to rescue OHCA patients who are unresponsive to conventional cardiopulmonary resuscitation in a rural tertiary care center, in a manner similar to that observed in the urban regions.

SOPs and the right hospitals to improve outcome after cardiac arrest

Approximately 400,000 Europeans are yearly resuscitated from out-of-hospital cardiac arrest (OHCA).(1,2) Despite evolving evidence based guidelines for cardiopulmonary resuscitation (CPR), survival rates after OHCA has not improved much in several places around the world. However, a potential for improved survival is absolutely present, based on the huge spread in worldwide survival; some cities with survival over 20-30% and some cities with just a few percent.(1,2) These survival differences can partly be explained by different definitions of OHCA,(2) but mainly due to the overall quality of the local Chain of Survival (COS)(3); early arrest recognition and call for help, early CPR, early defibrillation and early post resuscitation care. By identifying and thereafter improving weak links in the local COS, survival can indeed increase. This review will focus on the quality of the last link in the COS, the hospital treatment after return of spontaneuous circulation (ROSC), and how good quality post resuscitation care can improve not only survival, but survival with neurologically intact outcome.

Effect of intensive care after cardiac arrest on patient outcome: a database analysis

Introduction

The study aimed to determine the impact of treatment frequency, hospital size, and capability on mortality of patients admitted after cardiac arrest for postresuscitation care to different intensive care units.

Methods

Prospectively recorded data from 242,588 adults consecutively admitted to 87 Austrian intensive care units over a period of 13 years (1998 to 2010) were analyzed retrospectively. Multivariate analysis was used to assess the effect of the frequency of postresuscitation care on mortality, correcting for baseline parameters, severity of illness, hospital size, and capability to perform coronary angiography and intervention.

Results

In total, 5,857 patients had had cardiac arrest and were admitted to an intensive care unit. Observed hospital mortality was 56% in the cardiac-arrest cohort (3,302 nonsurvivors). Patients treated in intensive care units with a high frequency of postresuscitation care generally had high severity of illness (median Simplified Acute Physiology Score (SAPS II), 65). Intensive care units with a higher frequency of care showed improved risk-adjusted mortality. The SAPS II adjusted, observed-to-expected mortality ratios (O/E-Ratios) in the three strata (<18; 18 to 26; >26 resuscitations per ICU per year) were 0.869 (95% confidence interval, 0.844 to 894), 0.876 (0.850 to 0.902), and 0.808 (0.784 to 0.833).

Conclusions

In this database analysis, a high frequency of post-cardiac arrest care at an intensive care unit seemed to be associated with improved outcome of cardiac-arrest patients. We were able to identify patients who seemed to profit more from high frequency of care, namely, those with an intermediate severity of illness. Considering these findings, cardiac-arrest care centers might be a reasonable step to improve outcome in this specific population of cardiac-arrest patients.

Prevalence and factors associated with false positive suspicion of acute aortic syndrome: experience in a patient population transferred to a specialized aortic treatment center

STUDY OBJECTIVE

Acute aortic syndrome (AAS) is a medical emergency that requires prompt diagnosis and treatment at specialized centers. We sought to determine the frequency and etiology of false positive activation of a regional AAS network in a patient population emergently transferred for suspected AAS.

METHODS

We evaluated 150 consecutive patients transferred from community emergency departments directly to our Cardiac Intensive Care Unit (CICU) with a diagnosis of suspected AAS between March, 2010 and August, 2011. A final diagnosis of confirmed acute Type A, acute Type B dissection, and false positive suspicion of dissection was made in 63 (42%), 70 (46.7%) and 17 (11.3%) patients respectively.

RESULTS

Of the 17 false positive transfers, ten (58.8%) were suspected Type A dissection and seven (41.2%) were suspected Type B dissection. The initial hospital diagnosis in 15 (88.2%) patients was made by a computed tomography (CT) scan and 10 (66.6%) of these patients required repeat imaging with an ECG-synchronized CT to definitively rule out AAS. Five (29.4%) patients had prior history of open or endovascular aortic repair. Overall in-hospital mortality was 9.3%.

CONCLUSIONS

The diagnosis of AAS is confirmed in most patients emergently transferred for suspected AAS. False positive activation in this setting is driven primarily by uncertainty secondary to motion-artifact of the ascending aorta and the presence of complex anatomy following prior aortic intervention. Network-wide standardization of imaging strategies, and improved sharing of imaging may further improve triage of this complex patient population.

Regional variability in survival outcomes of out-of-hospital cardiac arrest: the All-Japan Utstein Registry

OBJECTIVE

There is a paucity of studies on the degree of regional variability in out-of-hospital cardiac arrest (OHCA) outcomes, particularly in neurological outcome. This study aimed to determine whether there is a significant regional variation in survival outcomes of OHCA across Japan.

METHODS

We analyzed a prospective, nation-wide, population-based database (All-Japan Utstein Registry) involving all Japanese individuals who had non-traumatic OHCA resuscitated by emergency responders from January 2005 through December 2010. The primary study endpoint was favourable neurological survival at 1 month, defined as Cerebral Performance Category 1 or 2. We compared unadjusted and multivariable-adjusted rates of the outcome among seven geographic regions.

RESULTS

In the total catchment population of 128 million, there were 539,641 non-traumatic OHCA patients. Unadjusted neurologically favourable survival varied across regions from 1.9% to 3.1% (rate difference, 1.2%; 95%CI, 1.0-1.3%); the Northeast region had a significantly lower rate compared to the Midwest region (unadjusted rate ratio, 0.62; 95%CI, 0.60-0.64). This disparity became larger after adjusting for patient- and prehospital-level confounders (adjusted rate ratio, 0.52; 95%CI, 0.51-0.54). Among 35,153 OHCA patients with return of spontaneous circulation, unadjusted neurologically favourable survival varied from 26.4% to 34.7% (rate difference, 8.3%; 95%CI, 6.6-10.1%); the East region had a significantly lower rate compared to the Midwest region (adjusted rate ratio, 0.72; 95%CI, 0.68-0.76).

CONCLUSION

In this prospective, nation-wide, population-based study in Japan, we found a two-fold regional difference in neurologically favourable survival after OHCA, suggesting regional disparities in prehospital care and in-hospital post-resuscitation care.

Prehospital system delay in ST-segment elevation myocardial infarction care: a novel linkage of emergency medicine services and in hospital registry data

BACKGROUND

Emergency medical services (EMS) are critical in the treatment of ST-segment elevation myocardial infarction (STEMI). Prehospital system delays are an important target for improving timely STEMI care, yet few limited data are available.

METHODS

Using a deterministic approach, we merged EMS data from the North Carolina Pre-hospital Medical Information System (PreMIS) with data from the Reperfusion of Acute Myocardial Infarction in Carolina Emergency Departments-Emergency Response (RACE-ER) Project. Our sample included all patients with STEMI from June 2008 to October 2010 who arrived by EMS and who had primary percutaneous coronary intervention (PCI). Prehospital system delays were compared using both RACE-ER and PreMIS to examine agreement between the 2 data sources.

RESULTS

Overall, 8,680 patients with STEMI in RACE-ER arrived at a PCI hospital by EMS; 21 RACE-ER hospitals and 178 corresponding EMS agencies across the state were represented. Of these, 6,010 (69%) patients were successfully linked with PreMIS. Linked and notlinked patients were similar. Overall, 2,696 patients were treated with PCI only and were taken directly to a PCI-capable hospital by EMS; 1,750 were transferred from a non-PCI facility. For those being transported directly to a PCI center, 53% reached the 90-minute target guideline goal. For those transferred from a non-PCI facility, 24% reached the 120-minute target goal for primary PCI.

CONCLUSIONS

We successfully linked prehospital EMS data with in hospital clinical data. With this linked STEMI cohort, less than half of patients reach goals set by guidelines. Such a data source could be used for future research and quality improvement interventions.

The incomplete infrastructure for interhospital patient transfer

OBJECTIVE

Interhospital transfer of critically ill patients is a common part of their care. This article sought to review the data on the current patterns of use of interhospital transfer and identify systematic barriers to optimal integration of transfer as a mechanism for improving patient outcomes and value of care.

DATA SOURCE

Narrative review of medical and organizational literature.

SUMMARY

Interhospital transfer of patients is common, but not optimized to improve patient outcomes. Although there is a wide variability in quality among hospitals of nominally the same capability, patients are not consistently transferred to the highest quality nearby hospital. Instead, transfer destinations are selected by organizational routines or non-patient-centered organizational priorities. Accomplishing a transfer is often quite difficult for sending hospitals. But once a transfer destination is successfully found, the mechanics of interhospital transfer now appear quite safe.

CONCLUSION

Important technological advances now make it possible to identify nearby hospitals best able to help critically ill patients, and to successfully transfer patients to those hospitals. However, organizational structures have not yet developed to insure that patients are optimally routed, resulting in potentially significant excess mortality.

Assessment of temporal trends in mortality with implementation of a statewide ST-segment elevation myocardial infarction (STEMI) regionalization program

STUDY OBJECTIVE

Although regionalized care for ST-segment elevation myocardial infarction (STEMI) has improved the use of timely reperfusion therapy, its effect on patient outcomes has been difficult to assess. Our objective is to explore temporal trends in STEMI mortality with the implementation of a statewide STEMI regionalization program (Reperfusion of Acute Myocardial Infarction in North Carolina Emergency Departments [RACE]).

METHODS

We compared trends in inpatient mortality among STEMI patients treated at North Carolina (NC) hospitals participating in the RACE program, relative to those not participating, using state inpatient claims data. Using Medicare claims data, we compared trends in 30-day mortality among Medicare beneficiaries in NC with those nationally. Logistic models with random effects were used to evaluate the association of the program with mortality.

RESULTS

From 2005 to 2007, inpatient mortality for 6,565 STEMI patients treated at NC hospitals participating in RACE decreased from 11.6% to 10.1% (risk difference -1.5%; 95% confidence interval [CI] -3.0% to 0.04%), whereas inpatient mortality among 5,850 STEMI patients treated at NC nonparticipating hospitals decreased from 10.2% to 8.6% (risk difference -1.6%; 95% CI -3.1% to 0.10%); (adjusted odds ratio 1.28; 95% CI 0.88 to 1.85 for temporal differences between groups). During the same period, 30-day STEMI mortality among Medicare beneficiaries decreased from 22.7% to 21.4% in NC (risk difference -1.28%; 95% CI -3.60% to 1.03%) and from 22.3% to 21.6% nationally (risk difference -0.71%, 95% CI -1.13% to -0.29%; adjusted odds ratio 0.99, 95% CI 0.85 to 1.15 for temporal differences between regions).

CONCLUSION

The initiation of a statewide STEMI collaborative care model was associated with a reduction in mortality rates according to claims data, yet these changes were similar to those seen nationally. Further study is needed to evaluate regionalized systems of STEMI care and to determine the role of claims data to evaluate population-based STEMI outcomes.

Use of emergency medical service transport among patients with ST-segment-elevation myocardial infarction: findings from the National Cardiovascular Data Registry Acute Coronary Treatment Intervention Outcomes Network Registry-Get With The Guidelines

BACKGROUND

Activation of emergency medical services (EMS) is critical for the early triage and treatment of patients experiencing ST-segment-elevation myocardial infarction, yet data regarding EMS use and its association with subsequent clinical care are limited.

METHODS AND RESULTS

We performed an observational analysis of 37 634 ST-segment-elevation myocardial infarction patients treated at 372 US hospitals participating in the National Cardiovascular Data Registry Acute Coronary Treatment and Intervention Outcomes Network Registry-Get With the Guidelines between January 2007 and September 2009, and examined independent patient factors associated with EMS transportation versus patient self-transportation. We found that EMS transport was used in only 60% of ST-segment-elevation myocardial infarction patients. Older patients, those living farther from the hospital, and those with hemodynamic compromise were more likely to use EMS transport. In contrast, race, income, and education level did not appear to be associated with the mode of transport. Compared with self-transported patients, EMS-transported patients had significantly shorter delays in both symptom-onset-to-arrival time (median, 89 versus 120 minutes; P<0.0001) and door-to-reperfusion time (median door-to-balloon time, 63 versus 76 minutes; P<0.0001; median door-to-needle time, 23 versus 29 minutes; P<0.0001).

CONCLUSIONS

Emergency medical services transportation to the hospital is underused among contemporary ST-segment-elevation myocardial infarction patients. Nevertheless, use of EMS transportation is associated with substantial reductions in ischemic time and treatment delays. Community education efforts are needed to improve the use of emergency transport as part of system-wide strategies to improve ST-segment-elevation myocardial infarction reperfusion care.

Which patients and where: a qualitative study of patient transfers from community hospitals

BACKGROUND

Interhospital transfer of patients is a routine part of the care at community hospitals, but the current process may lead to suboptimal patient outcomes. A microlevel analysis of the processes of patient transfer has not earlier been carried out.

RESEARCH DESIGN

We conducted semistructured qualitative interviews with care providers at 3 purposively sampled community hospitals to describe patient transfer mechanisms, focusing on perceptions of transfers and transfer candidates, choice of transfer destination, and perceived process. We interviewed physicians, nurses, and care technicians from emergency departments and intensive care units at the hospitals, and analyzed the resultant transcripts by content analysis.

RESULTS

Appropriate triage and the transfer of patients was a highly valued skill at the community hospitals. On the basis of participant accounts, the transfer process had 4 components: (1) Identifying transfer-eligible patients; (2) Identifying a destination hospital; (3) Negotiating the transfer; and (4) Accomplishing the transfer. There were common challenges at each component across hospitals. Protocolization of care was perceived to substantially facilitate transfers. Informal arrangements played a key role in the identification of the receiving hospital, but patient preferences and hospital quality were not discussed as important in decision making. The process of arranging a patient transfer placed a significant burden on the staff of community hospitals.

CONCLUSIONS

The patient transfer process is often cumbersome, varies by condition, and may not be focused on optimizing patient outcomes. Development of a more fluid transfer infrastructure may aid in implementing policies such as selective referral and regionalization.

Post-resuscitation care at the emergency department with critical care facilities--a length-of-stay analysis

AIM OF THE STUDY

An emergency department providing critical care will have an effect on outcome and intensive-care-units' resources by avoiding unnecessary or futile intensive-care admissions and thereby save hospital expenses. The study focussed on this result.

METHODS

The study employed a retrospective analysis of prospectively collected data of out-of-hospital cardiac arrest patients with return of spontaneous circulation, comatose on arrival. Outcomes and length of stay of patients who either stayed at the 'emergency department only' or were 'transferred in addition to an intensive care unit' were compared. Linear regression with log length of stay as outcome and 'emergency department only' as predictor with covariates was used for modelling.

RESULTS

From 1991 to 2008, out of 1236 patients (age 57 ± 15 years, female 31%), the 'emergency department only' group (n=349 (28%)) survived to discharge in 81(23%) cases, with a median length-of-stay in critical care of 1.7 (interquartile range 0.8; 3.1) days. The patients 'transferred in addition to an intensive care unit' (n=887 (72%)), with a survival rate of 55% (n=486, p<0.001) stayed 10 (5; 18) days (p<0.001). The length-of-stay in hospital was significantly shorter if patients were treated in the 'emergency department only' independent of other cardiac-arrest-related factors (regression coefficient -1.42, confidence interval -1.60 to -1.24).

CONCLUSIONS

An emergency department with critical care prevents admissions to intensive care units in 28% of patients with out-of-hospital cardiac arrest. It saves intensive-care-unit resources and shortens length of stay for comatose out-of-hospital cardiac-arrest survivors, regardless of their outcome.

Management of Acute ST-Elevation Myocardial Infarction: Reperfusion Options

Primary percutaneous coronary intervention and thrombolysis remain therapies of choice for patients presenting with ST-segment elevation myocardial infarction (STEMI). Clinical outcome in the management of acute STEMI is dependent on myocardial reperfusion time and reperfusion strategies. Optimisation of these strategies should take into consideration logistical limitations of the local medical systems and the various patient profiles. We review the reperfusion strategies and its history in Singapore, comparing its clinical application with that in some developed Western countries. Key words: Acute Myocardial Infarction, Primary Percutaneous Coronary Intervention, ST segment Elevation Myocardial Infarction, Thrombolysis

Regional cardiac resuscitation systems of care

PURPOSE OF REVIEW

Out-of-hospital cardiac arrest (OOHCA) is a common public health problem. Regional systems of care have improved provider experience and patient outcomes for those with ST-elevation myocardial infarction and life-threatening traumatic injury. We review evidence of the effectiveness of regional cardiac resuscitation systems and describe preliminary recommended elements of such systems.

RECENT FINDINGS

There is large and important regional variation in survival among patients treated with OOHCA by emergency medical services, or among patients transported to the hospital after return of spontaneous circulation (ROSC). Most regions lack a well coordinated approach to postcardiac arrest care. There is little evidence to show small increases in transport time or distance have an adverse impact on survival, so bypassing closer hospitals may be feasible. Hospitals that have facilities to provide a comprehensive package of postresuscitation care including percutaneous coronary intervention and therapeutic hypothermia appear to have better survival but further studies are needed. A well defined relationship between increased volume of patients or procedures of individual providers and hospitals and better outcomes has been observed for several clinical disorders and there are suggestions that this may also be true for patients with ROSC after cardiac arrest.

SUMMARY

Many more people could survive OOHCA if regional systems of cardiac resuscitation were established. The time has come to implement such systems whenever feasible.

Regional Systems of Care for Out-of-Hospital Cardiac Arrest

Out-of-hospital cardiac arrest continues to be an important public health problem, with large and important regional variations in outcomes. Survival rates vary widely among patients treated with out-of-hospital cardiac arrest by emergency medical services and among patients transported to the hospital after return of spontaneous circulation. Most regions lack a well-coordinated approach to post–cardiac arrest care. Effective hospital-based interventions for out-of-hospital cardiac arrest exist but are used infrequently. Barriers to implementation of these interventions include lack of knowledge, experience, personnel, resources, and infrastructure. A well-defined relationship between an increased volume of patients or procedures and better outcomes among individual providers and hospitals has been observed for several other clinical disorders. Regional systems of care have improved provider experience and patient outcomes for those with ST-elevation myocardial infarction and life-threatening traumatic injury. This statement describes the rationale for regional systems of care for patients resuscitated from cardiac arrest and the preliminary recommended elements of such systems. Many more people could potentially survive out-of-hospital cardiac arrest if regional systems of cardiac resuscitation were established. A national process is necessary to develop and implement evidence-based guidelines for such systems that must include standards for the categorization, verification, and designation of components of such systems. The time to do so is now.