P1746Prehospital logistics and therapy delays in urban vs. rural regions: implications for quality of acute ST-elevation myocardial infarction care

Background

Treatment and time goals for STEMI care are clearly defined in national and international guidelines. However, initiation of therapy relies in accurate diagnosis after first medical contact (FMC). Prehospital logistics with fast transfer to the next available 24/7 PCI-center can be challenging, especially in rural areas and for transfers across state-borders in Germany.

Objective

To analyze quality of STEMI care in a high volume PCI center serving a city and a large rural area with focus on EMS (emergency medical service) logistics. Two groups of patients admitted by EMS: (1) direct PCI-center admission vs. (2) secondary admission after transfer from a non-PCI hospital were compared.

Methods

Various administrative, procedural, therapeutic and clinical parameters were registered for each patient including timelines of acute treatment (tables). Inaccurate treatment delays were calculated as cumulative time in any prolongation in timely diagnosis or therapy after FMC.

Results

From 340 consecutive STEMI patients in or registry, 299 patients were transferred by EMS. Reperfusion therapy with PPCI was significantly delayed and required double of the time in patients secondary transferred from a non-PCI hospital (Contact-to-Balloon: 195.6±134.8 min vs. 99.6±45.3 min, p<0.001, table 1). An inaccurate delay in timely treatment (delay in correct diagnosis or deferred therapy) was determined in 45% of the patients transferred from non-PCI hospitals vs 26% of directly admitted patients (p=0.02, table 1). Accordingly, correct STEMI diagnosis was established by EMS physician prehospital only in 7.1% in the transfer group vs. 61.9% in the direct admission group (p<0.001, table 1). Our data suggest different reasons for STEMI patients falsely transferred to non-PCI hospitals: a) lower qualification of EMS personnel with ECG misinterpretation and/or false working diagnosis, b) inadequate prehospital logistics with transfer of patients to the next near-by hospital instead of next PCI-center, c) personal or system “thresholds” of EMS physicians in rural areas preventing a direct transfer to PCI-centers. Further analysis of the transfer group (table 2) showed even longer treatment times for patients transferred across state borders compared to transfers within a state (C2B: 264.8±142.2 vs. 143.7±107.0 min, p<0.05, table 2). Importantly, transfers across state borders were not associated with a longer absolute distance (km) to PCI center. However, a rescue helicopter was used for across-state transfers in one third of the cases.

Conclusion

Quality of acute STEMI care is significantly worse in rural areas predominantly due to suboptimal prehospital logistics and poor prehospital emergency care. Our data underline the importance to establish local STEMI networks irrespective of state borders with clearly defined prehospital transfer strategies, continuous medial education of EMS personnel and assessement of local quality of care.

Unscheduled return visits by patients to a german emergency department are a high risk group for initial wrong diagnosis

The aim was to classify patients who returned unscheduled to an emergency department within 7 days. We categorized the patients' cases arbitrarily according to the underlying cause of the return. The main causes for returning unscheduled were: "patient related" (24,2%), "illness related" (35,4%), "physician related" (18,3%), "system related" (3,8%) and "other" (21,7%). We also analyzed missed diagnoses, as the literature describes this special patient population as a high risk group. 15,4% of all return cases had a wrong diagnosis. No typical risk constellation/symptom could be found. Vital signs or blood values were within normal limits as well.

[Pyoderma gangrenosum following AICD implantation: differential diagnosis to necrotizing fasciitis]

Pyoderma gangrenosum is rarely seen in the surgical disciplines. In the described case the patient was initially diagnosed with necrotizing fasciitis and admitted to the intensive care unit suffering from septic shock. The automated implantable cardioverter defibrillator (AICD), the suspected focus for infection, had already been removed. Following weeks of broad spectrum antibiotics and wound debridement without clinical improvement the alternative diagnosis of pyoderma gangrenosum was reached. Consequently the patient was treated with immunosuppressive therapy and his condition improved rapidly such that he was ultimately discharged to rehabilitation.