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Kolls BJ, Ehrlich ME, Monk L, Shah S, Roettig M, Iversen E, Jollis JG, Granger CB, Graffagnino C. Regionalization of stroke systems of care in the stroke belt states: The IMPROVE stroke care quality improvement program. Am Heart J 2024; 269:72-83. [PMID: 38061683 DOI: 10.1016/j.ahj.2023.11.020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/17/2023] [Revised: 11/18/2023] [Accepted: 11/28/2023] [Indexed: 01/07/2024]
Abstract
BACKGROUND Despite guidelines and strong evidence supporting intravenous thrombolysis and endovascular thrombectomy for acute stroke, access to these interventions remains a challenge. The objective of the IMPROVE stroke care program was to accelerate acute stroke care delivery by implementing best practices and improving the regional systems of care within comprehensive stroke networks. METHODS The IMPROVE Stroke Care program was a prospective quality improvement program based on established models used in acute coronary care. Nine hub hospitals (comprehensive stroke centers), 52 regional/community referral hospitals (spokes), and over 100 emergency medical service agencies participated. Through 6 regional meetings, 49 best practices were chosen for improvement by the participating sites. Over 2 years, progress was tracked and discussed weekly and performance reviews were disseminated quarterly. RESULTS Data were collected on 21,647 stroke code activations of which 8,502 (39.3%) activations had a final diagnosis of stroke. There were 7,226 (85.0%) ischemic strokes, and thrombolytic therapy was administered 2,814 times (38.9%). There was significant overall improvement in the proportion that received lytic therapy within 45 minutes (baseline of 44.6%-60.4%). The hubs were more frequently achieving this at baseline, but both site types improved. A total of 1,455 (17.1%) thrombectomies were included in the data of which 401 (27.6%) were transferred from a spoke. There was no clinically significant change in door-to-groin times for hub-presenting thrombectomy patients, however, significant improvement occurred for transferred cases, 46 minutes (interquartile range [IQR] 36, 115.5) at baseline to 27 minutes (IQR 10, 59). CONCLUSIONS The IMPROVE program approach was successful at improving the delivery of thrombolytic intervention across the consortium at both spoke and hub sites through collaborative efforts to operationalize guideline-based care through iterative sharing of performance and best practices for implementation. Our approach allowed identification of both opportunities for improvement and operational best practices providing guidance on how best to create a regional stroke care network and operationalize the published acute stroke care guidelines.
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Affiliation(s)
- Brad J Kolls
- Department of Neurology, Duke University School of Medicine, Durham, NC; Duke Clinical Research Institute, Durham, NC.
| | - Matthew E Ehrlich
- Department of Neurology, Duke University School of Medicine, Durham, NC
| | - Lisa Monk
- Duke Clinical Research Institute, Durham, NC
| | - Shreyansh Shah
- Department of Neurology, Duke University School of Medicine, Durham, NC
| | | | - Edwin Iversen
- Department of Statistical Science, Duke University, Durham NC
| | - James G Jollis
- Duke Clinical Research Institute, Durham, NC; Division of Cardiology, Duke University School of Medicine, Durham, NC
| | - Christopher B Granger
- Duke Clinical Research Institute, Durham, NC; Division of Cardiology, Duke University School of Medicine, Durham, NC
| | - Carmelo Graffagnino
- Department of Neurology, Duke University School of Medicine, Durham, NC; Duke Clinical Research Institute, Durham, NC
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Hasan SA, Morsi M, Frakes BS, Bryson ME, Schmidt CW, Seshiah P, Choo J, Smith JM, Answini GA, Stewart-Dehner TL, Yasar SJ, Jollis JG, Berlacher MD, Ratajczak TM, Chung ES, Kereiakes DJ, Garcia S. Management strategies and prognosis of patients ineligible for transcatheter mitral valve replacement. Cardiovasc Revasc Med 2024:S1553-8389(24)00023-X. [PMID: 38355340 DOI: 10.1016/j.carrev.2024.02.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2023] [Revised: 01/08/2024] [Accepted: 02/05/2024] [Indexed: 02/16/2024]
Abstract
BACKGROUND Transcatheter mitral valve replacement (TMVR) faces anatomical challenges, currently limiting widespread adoption. OBJECTIVES To describe the natural history and prognosis of patients ineligible for various TMVR devices. METHODS During a 4-year period (2019-2023) 3 TMVR devices (SAPIEN M3, Intrepid and Alta Valve) became available at a single institution (The Christ Hospital, Cincinnati, OH) in the setting of pivotal clinical trials or early feasibility study. Consenting patients who were deemed ineligible ≥1 of these trials were prospectively studied to capture anatomical reasons for ineligibility, cross-over to alternative mitral valve therapies (surgery or high-risk mitral transcatheter edge to edge repair [M-TEER]), and clinical events. RESULTS A total of 61 patients (out of 71 consenting patients or 85.9 %) were deemed ineligible for TMVR during the study period. The mean age was 79.2 ± 8.8 years, 65.6 % were female, with elevated surgical risk (median STS 4.3, IQR: 2.7-7.3). The 2 most common anatomical reasons for ineligibility were increased risk of left ventricular outflow tract obstruction (LVOTO) (n = 24, 39.3 %) and annular size (n = 29, 47.5 %). During follow-up (median 277 [162-555] days) there were 7 deaths (11.5 %) and 12 (19.7 %) hospitalizations for heart failure. Management strategies included high-risk M-TEER in 11 patients (1 death [9.0 %], 0 HF hospitalizations [0 %]), surgery in 9 patients (0 deaths, 1 HF hospitalizations [11.1 %]), and medical management in 41 patients (6 deaths [14.6 %], 11 HF hospitalizations [26.8 %]) (p = 0.715 for mortality and p = 0.093 for HF hospitalizations). Residual MR ≥ moderate was 0 %, 50 %, and 100 % for surgery, M-TEER and medical treatment, respectively (p < 0.001). CONCLUSIONS One third of patients deemed ineligible for TMVR are candidates for high-risk M-TEER or surgery with acceptable morbidity and mortality. Our results have practical implications for patient management.
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Affiliation(s)
- Syeda A Hasan
- The Christ Hospital Heart and Vascular Institute and Lindner Center for Research and Education, Cincinnati, OH, United States of America
| | - Moustafa Morsi
- The Christ Hospital Heart and Vascular Institute and Lindner Center for Research and Education, Cincinnati, OH, United States of America
| | - Belinda S Frakes
- Lindner Center for Research and Education, Cincinnati, OH, United States of America
| | - Marien E Bryson
- Lindner Center for Research and Education, Cincinnati, OH, United States of America
| | - Christian W Schmidt
- The Christ Hospital Heart and Vascular Institute and Lindner Center for Research and Education, Cincinnati, OH, United States of America
| | - Puvi Seshiah
- The Christ Hospital Heart and Vascular Institute and Lindner Center for Research and Education, Cincinnati, OH, United States of America
| | - Joseph Choo
- The Christ Hospital Heart and Vascular Institute and Lindner Center for Research and Education, Cincinnati, OH, United States of America
| | - J Michael Smith
- The Christ Hospital Heart and Vascular Institute and Lindner Center for Research and Education, Cincinnati, OH, United States of America
| | - Geoffrey A Answini
- The Christ Hospital Heart and Vascular Institute and Lindner Center for Research and Education, Cincinnati, OH, United States of America
| | - Terri L Stewart-Dehner
- The Christ Hospital Heart and Vascular Institute and Lindner Center for Research and Education, Cincinnati, OH, United States of America
| | - Senan J Yasar
- The Christ Hospital Heart and Vascular Institute and Lindner Center for Research and Education, Cincinnati, OH, United States of America
| | - James G Jollis
- The Christ Hospital Heart and Vascular Institute and Lindner Center for Research and Education, Cincinnati, OH, United States of America
| | - Mark D Berlacher
- The Christ Hospital Heart and Vascular Institute and Lindner Center for Research and Education, Cincinnati, OH, United States of America
| | - Teresa M Ratajczak
- The Christ Hospital Heart and Vascular Institute and Lindner Center for Research and Education, Cincinnati, OH, United States of America
| | - Eugene S Chung
- The Christ Hospital Heart and Vascular Institute and Lindner Center for Research and Education, Cincinnati, OH, United States of America
| | - Dean J Kereiakes
- The Christ Hospital Heart and Vascular Institute and Lindner Center for Research and Education, Cincinnati, OH, United States of America
| | - Santiago Garcia
- The Christ Hospital Heart and Vascular Institute and Lindner Center for Research and Education, Cincinnati, OH, United States of America.
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3
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Garcia S, Ye J, Webb J, Reardon M, Kleiman N, Goel S, Hatab T, Fam N, Peterson M, Liauw S, Frisoli TM, Bashir H, Paige D, Rock D, Schmidt C, Jollis JG, Kereiakes DJ. Transcatheter Treatment of Native Aortic Valve Regurgitation: The North American Experience With a Novel Device. JACC Cardiovasc Interv 2023; 16:1953-1960. [PMID: 37212431 DOI: 10.1016/j.jcin.2023.05.018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/12/2023] [Revised: 05/04/2023] [Accepted: 05/09/2023] [Indexed: 05/23/2023]
Abstract
BACKGROUND Transcatheter treatment of patients with native aortic valve regurgitation (AR) has been limited by anatomical factors. No transcatheter device has received U.S. regulatory approval for the treatment of patients with AR. OBJECTIVES The aim of this study was to describe the compassionate-use experience in North America with a dedicated transcatheter device (J-Valve). METHODS A multicenter, observational registry was assembled of compassionate-use cases of J-Valve implantation for the treatment of patients with severe symptomatic AR and elevated surgical risk in North America. The J-Valve consists of a self-expanding Nitinol frame, bovine pericardial leaflets, and a valve-locating feature. The available size matrix (5 sizes) can treat a wide range of anatomies (minimum and maximum annular perimeters 57-104 mm). RESULTS A total of 27 patients (median age 81 years [IQR: 72-85 years], 81% at high surgical risk, 96% in NYHA functional class III or IV) with native valve AR were treated with the J-Valve during the study period (2018-2022). Procedural success (J-Valve delivered to the intended location without the need for surgical conversion or a second transcatheter heart valve) was 81% (22 of 27 cases) in the overall experience and 100% in the last 15 cases. Two cases required conversion to surgery in the early experience, leading to changes in valve design. At 30 days, there was 1 death, 1 stroke, and 3 new pacemakers (13%), and 88% of patients were in NYHA functional class I or II. No patient had residual AR of moderate or greater degree at 30 days. CONCLUSIONS The J-Valve appears to provide a safe and effective alternative to surgery in patients with pure AR and elevated or prohibitive surgical risk.
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Affiliation(s)
- Santiago Garcia
- The Christ Hospital Heart and Vascular Institute and Lindner Center for Research and Education, Cincinnati, Ohio, USA.
| | - Jian Ye
- Center for Heart Valve Innovation, St. Paul's Hospital, Vancouver, British Columbia, Canada
| | - John Webb
- Center for Heart Valve Innovation, St. Paul's Hospital, Vancouver, British Columbia, Canada
| | | | | | - Sachin Goel
- Houston Methodist Hospital, Houston, Texas, USA
| | - Taha Hatab
- Houston Methodist Hospital, Houston, Texas, USA
| | - Neil Fam
- St. Michael's Hospital and University of Toronto, Toronto, Ontario, Canada
| | - Mark Peterson
- St. Michael's Hospital and University of Toronto, Toronto, Ontario, Canada
| | - Samantha Liauw
- St. Michael's Hospital and University of Toronto, Toronto, Ontario, Canada
| | | | - Hanad Bashir
- The Christ Hospital Heart and Vascular Institute and Lindner Center for Research and Education, Cincinnati, Ohio, USA
| | - Debra Paige
- The Christ Hospital Heart and Vascular Institute and Lindner Center for Research and Education, Cincinnati, Ohio, USA
| | - Darlene Rock
- The Christ Hospital Heart and Vascular Institute and Lindner Center for Research and Education, Cincinnati, Ohio, USA
| | - Christian Schmidt
- The Christ Hospital Heart and Vascular Institute and Lindner Center for Research and Education, Cincinnati, Ohio, USA
| | - James G Jollis
- The Christ Hospital Heart and Vascular Institute and Lindner Center for Research and Education, Cincinnati, Ohio, USA
| | - Dean J Kereiakes
- The Christ Hospital Heart and Vascular Institute and Lindner Center for Research and Education, Cincinnati, Ohio, USA
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Osho A, Fernandes MF, Poudel R, de Lemos J, Hong H, Zhao J, Li S, Thomas K, Kikuchi DS, Zegre-Hemsey J, Ibrahim N, Shah NS, Hollowell L, Tamis-Holland J, Granger CB, Cohen M, Henry T, Jacobs AK, Jollis JG, Yancy CW, Goyal A. Race-Based Differences in ST-Segment-Elevation Myocardial Infarction Process Metrics and Mortality From 2015 Through 2021: An Analysis of 178 062 Patients From the American Heart Association Get With The Guidelines-Coronary Artery Disease Registry. Circulation 2023; 148:229-240. [PMID: 37459415 DOI: 10.1161/circulationaha.123.065512] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/07/2023] [Accepted: 06/13/2023] [Indexed: 07/20/2023]
Abstract
BACKGROUND Systems of care have been developed across the United States to standardize care processes and improve outcomes in patients with ST-segment-elevation myocardial infarction (STEMI). The effect of contemporary STEMI systems of care on racial and ethnic disparities in achievement of time-to-treatment goals and mortality in STEMI is uncertain. METHODS We analyzed 178 062 patients with STEMI (52 293 women and 125 769 men) enrolled in the American Heart Association Get With The Guidelines-Coronary Artery Disease registry between January 1, 2015, and December 31, 2021. Patients were stratified into and outcomes compared among 3 racial and ethnic groups: non-Hispanic White, Hispanic White, and Black. The primary outcomes were the proportions of patients achieving the following STEMI process metrics: prehospital ECG obtained by emergency medical services; hospital arrival to ECG obtained within 10 minutes for patients not transported by emergency medical services; arrival-to-percutaneous coronary intervention time within 90 minutes; and first medical contact-to-device time within 90 minutes. A secondary outcome was in-hospital mortality. Analyses were performed separately in women and men, and all outcomes were adjusted for age, comorbidities, acuity of presentation, insurance status, and socioeconomic status measured by social vulnerability index based on patients' county of residence. RESULTS Compared with non-Hispanic White patients with STEMI, Hispanic White patients and Black patients had lower odds of receiving a prehospital ECG and achieving targets for door-to-ECG, door-to-device, and first medical contact-to-device times. These racial disparities in treatment goals were observed in both women and men, and persisted in most cases after multivariable adjustment. Compared with non-Hispanic White women, Hispanic White women had higher adjusted in-hospital mortality (odds ratio, 1.39 [95% CI, 1.12-1.72]), whereas Black women did not (odds ratio, 0.88 [95% CI, 0.74-1.03]). Compared with non-Hispanic White men, adjusted in-hospital mortality was similar in Hispanic White men (odds ratio, 0.99 [95% CI, 0.82-1.18]) and Black men (odds ratio, 0.96 [95% CI, 0.85-1.09]). CONCLUSIONS Race- or ethnicity-based disparities persist in STEMI process metrics in both women and men, and mortality differences are observed in Hispanic White compared with non-Hispanic White women. Further research is essential to evolve systems of care to mitigate racial differences in STEMI outcomes.
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Affiliation(s)
- Asishana Osho
- Department of Surgery, Division of Cardiac Surgery, Massachusetts General Hospital, Boston (A.O.)
| | | | - Ram Poudel
- American Heart Association, Dallas, TX (R.P., H.H., J.Z., S.L., K.T., L.H.)
| | - James de Lemos
- University of Texas Southwestern Medical Center, Dallas (J.d.L.)
| | - Haoyun Hong
- American Heart Association, Dallas, TX (R.P., H.H., J.Z., S.L., K.T., L.H.)
| | - Juan Zhao
- American Heart Association, Dallas, TX (R.P., H.H., J.Z., S.L., K.T., L.H.)
| | - Shen Li
- American Heart Association, Dallas, TX (R.P., H.H., J.Z., S.L., K.T., L.H.)
| | - Kathie Thomas
- American Heart Association, Dallas, TX (R.P., H.H., J.Z., S.L., K.T., L.H.)
| | - Daniel S Kikuchi
- Osler Medical Residency, Johns Hopkins Hospital, Baltimore, MD (D.S.K.)
| | | | - Nasrien Ibrahim
- Harvard T.H. Chan School of Public Health, Boston, MA (N.I.)
| | - Nilay S Shah
- Department of Medicine, Division of Cardiology, Northwestern University Medical School, Chicago, IL (N.S.S., C.W.Y.)
| | - Lori Hollowell
- American Heart Association, Dallas, TX (R.P., H.H., J.Z., S.L., K.T., L.H.)
| | | | | | | | - Timothy Henry
- The Christ Hospital Heart and Vascular Institute, Cincinnati, OH (T.H., J.G.J.)
| | | | - James G Jollis
- The Christ Hospital Heart and Vascular Institute, Cincinnati, OH (T.H., J.G.J.)
| | - Clyde W Yancy
- Department of Medicine, Division of Cardiology, Northwestern University Medical School, Chicago, IL (N.S.S., C.W.Y.)
| | - Abhinav Goyal
- Department of Medicine, Division of Cardiology, Emory University School of Medicine, Atlanta, GA (A.G.)
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5
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Griffin ACG, Yildiz M, Bradley S, Smith JE, Garcia S, Schmidt CW, Garberich R, Walser-Kuntz E, Traverse J, Jollis JG, Sharkey SW, Henry TD. Frequency and outcomes of STEMI patients presenting between 12 and 24 h after symptom onset: Late-presenting STEMI. Catheter Cardiovasc Interv 2023; 101:1-10. [PMID: 36423258 DOI: 10.1002/ccd.30495] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/29/2022] [Revised: 11/01/2022] [Accepted: 11/04/2022] [Indexed: 11/27/2022]
Abstract
OBJECTIVES To assess the characteristics and prognosis of ST-elevation myocardial infarction (STEMI) patients, presenting between 12 and 24 h after symptom onset, in contemporary regional STEMI systems of care in the United States. BACKGROUND Previous observational studies have been inconsistent regarding the benefit of primary percutaneous coronary intervention (PCI) compared with conservative management for late-presenting STEMI patients and the majority of randomized trials are from the fibrinolytic era. METHODS Using a two-center registry-based cohort from March 2003 to December 2020, we evaluated the frequency, clinical characteristics, and outcomes of STEMI patients, stratified by symptom onset to balloon time: <3, 3-6, 6-12, and 12-24 h (late presenters). RESULTS Among 5427 STEMI patients with available symptom onset time, 6.2% were late presenters, which increased to 11% during the early phase of the Covid-19 pandemic. As symptom onset to balloon time increased, patients were more likely to be older, female, and have a history of hypertension and diabetes mellitus. Late presenters with an identifiable culprit lesion were less likely to be revascularized with PCI (96%, 96%, 95%, and 92%; p for trend = 0.004) and had a longer median door-to-balloon time (82, 109, 107, and 117 min; p for trend < 0.001). In-hospital and 1-year death risks were comparable between late and earlier presenters. CONCLUSION Despite the unfavorable risk profile and longer door-to-balloon time, clinical outcomes of late presenters were similar to those presenting within 12 h of symptom onset.
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Affiliation(s)
- Anna C Gonzalez Griffin
- Minneapolis Heart Institute Foundation at Abbott Northwestern Hospital, Minneapolis, Minnesota, USA
| | - Mehmet Yildiz
- The Carl and Edyth Lindner Center for Research and Education at The Christ Hospital, Cincinnati, Ohio, USA
| | - Steven Bradley
- Minneapolis Heart Institute Foundation at Abbott Northwestern Hospital, Minneapolis, Minnesota, USA
| | - Jenna E Smith
- Minneapolis Heart Institute Foundation at Abbott Northwestern Hospital, Minneapolis, Minnesota, USA
| | - Santiago Garcia
- Minneapolis Heart Institute Foundation at Abbott Northwestern Hospital, Minneapolis, Minnesota, USA
| | - Christian W Schmidt
- Minneapolis Heart Institute Foundation at Abbott Northwestern Hospital, Minneapolis, Minnesota, USA
| | - Ross Garberich
- Minneapolis Heart Institute Foundation at Abbott Northwestern Hospital, Minneapolis, Minnesota, USA
| | - Evan Walser-Kuntz
- Minneapolis Heart Institute Foundation at Abbott Northwestern Hospital, Minneapolis, Minnesota, USA
| | - Jay Traverse
- Minneapolis Heart Institute Foundation at Abbott Northwestern Hospital, Minneapolis, Minnesota, USA
| | - James G Jollis
- The Carl and Edyth Lindner Center for Research and Education at The Christ Hospital, Cincinnati, Ohio, USA
| | - Scott W Sharkey
- Minneapolis Heart Institute Foundation at Abbott Northwestern Hospital, Minneapolis, Minnesota, USA
| | - Timothy D Henry
- The Carl and Edyth Lindner Center for Research and Education at The Christ Hospital, Cincinnati, Ohio, USA.,The Christ Hospital Heart and Vascular Institute, The Christ Hospital, Cincinnati, Ohio, USA
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Jollis JG, Granger CB, Zègre-Hemsey JK, Henry TD, Goyal A, Tamis-Holland JE, Roettig ML, Ali MJ, French WJ, Poudel R, Zhao J, Stone RH, Jacobs AK. Treatment Time and In-Hospital Mortality Among Patients With ST-Segment Elevation Myocardial Infarction, 2018-2021. JAMA 2022; 328:2033-2040. [PMID: 36335474 PMCID: PMC9638953 DOI: 10.1001/jama.2022.20149] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
IMPORTANCE Recognizing the association between timely treatment and less myocardial injury for patients with ST-segment elevation myocardial infarction (STEMI), US national guidelines recommend specific treatment-time goals. OBJECTIVE To describe these process measures and outcomes for a recent cohort of patients. DESIGN, SETTING, AND PARTICIPANTS Cross-sectional study of a diagnosis-based registry between the second quarter of 2018 and the third quarter of 2021 for 114 871 patients with STEMI treated at 648 hospitals in the Get With The Guidelines-Coronary Artery Disease registry. EXPOSURES STEMI or STEMI equivalent. MAIN OUTCOMES AND MEASURES Treatment times, in-hospital mortality, and adherence to system goals (75% treated ≤90 minutes of first medical contact if the first hospital is percutaneous coronary intervention [PCI]-capable and ≤120 minutes if patients require transfer to a PCI-capable hospital). RESULTS In the study population, median age was 63 (IQR, 54-72) years, 71% were men, and 29% were women. Median time from symptom onset to PCI was 148 minutes (IQR, 111-226) for patients presenting to PCI-capable hospitals by emergency medical service, 195 minutes (IQR, 127-349) for patients walking in, and 240 minutes (IQR, 166-402) for patients transferred from another hospital. Adjusted in-hospital mortality was lower for those treated within target times vs beyond time goals for patients transported via emergency medical services (first medical contact to laboratory activation ≤20 minutes [in-hospital mortality, 3.6 vs 9.2] adjusted OR, 0.54 [95% CI, 0.48-0.60], and first medical contact to device ≤90 minutes [in-hospital mortality, 3.3 vs 12.1] adjusted OR, 0.40 [95% CI, 0.36-0.44]), walk-in patients (hospital arrival to device ≤90 minutes [in-hospital mortality, 1.8 vs 4.7] adjusted OR, 0.47 [95% CI, 0.40-0.55]), and transferred patients (door-in to door-out time <30 minutes [in-hospital mortality, 2.9 vs 6.4] adjusted OR, 0.51 [95% CI, 0.32-0.78], and first hospital arrival to device ≤120 minutes [in-hospital mortality, 4.3 vs 14.2] adjusted OR, 0.44 [95% CI, 0.26-0.71]). Regardless of mode of presentation, system goals were not met in most quarters, with the most delayed system performance among patients requiring interhospital transfer (17% treated ≤120 minutes). CONCLUSIONS AND RELEVANCE This study of patients with STEMI included in a US national registry provides information on changes in process and outcomes between 2018 and 2021.
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Affiliation(s)
- James G. Jollis
- Lindner Center for Research and Education, Cincinnati, Ohio
- Duke University, Durham, North Carolina
| | | | | | | | | | | | | | - Murtuza J. Ali
- Louisiana State University Health Sciences Center, New Orleans
| | | | - Ram Poudel
- American Heart Association, Dallas, Texas
| | - Juan Zhao
- American Heart Association, Dallas, Texas
| | | | - Alice K. Jacobs
- Boston University School of Medicine and Boston Medical Center, Boston, Massachusetts
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Taylor TG, Stickney RE, French WJ, Jollis JG, Kontos MC, Niemann JT, Sanko SG, Eckstein MK, Bosson N. Prehospital Predictors of Atypical STEMI Symptoms. PREHOSP EMERG CARE 2021; 26:756-763. [PMID: 34748467 DOI: 10.1080/10903127.2021.1987597] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
Introduction: Rapid prehospital identification of patients with ST-elevation myocardial infarction (STEMI) is a critical step to reduce time to treatment. Broad screening with field 12-lead ECGs can lead to a high rate of false positive STEMI activations due to low prevalence. One strategy to reduce false positive STEMI interpretations is to limit acquisition of 12-lead ECGs to patients who have symptoms strongly suggestive of STEMI, but this may delay care in patients who present atypically and lead to disparities in populations with more atypical presentations. We sought to assess patient factors associated with atypical STEMI presentation.Methods: We retrospectively analyzed consecutive adult patients for whom Los Angeles Fire Department paramedics obtained a field 12-lead ECG from July 2011 through June 2012. The regional STEMI receiving center registry was used to identify patients with STEMI. Patients were designated as having typical symptoms if paramedics documented provider impressions of chest pain/discomfort, cardiac arrest, or cardiac symptoms, otherwise they were designated as having atypical symptoms. We utilized logistic regression to determine patient factors (age, sex, race) associated with atypical STEMI presentation.Results: Of the 586 patients who had STEMI, 70% were male, 43% White, 16% Black, 20% Hispanic, 5% Asian and 16% were other or unspecified race. Twenty percent of STEMI patients (n = 117) had atypical symptoms. Women who had STEMI were older than men (74 years [IQR 62-83] vs. 60 years [IQR 53-70], p < 0.001). Univariate predictors of atypical symptoms were older age and female sex (p < 0.0001), while in multivariable analysis older age [odd ratio (OR) 1.05 per year, [95%CI 1.04-1.07, p < 0.0001] and black race (OR vs White 2.18, [95%CI 1.20-3.97], p = 0.011) were associated with atypical presentation.Conclusion: Limiting prehospital acquisition of 12-lead ECGs to patients with typical STEMI symptoms would result in one in five patients with STEMI having delayed recognition, disproportionally impacting patients of older age, women, and Black patients. Age, not sex, may be a better predictor of atypical STEMI presentation.
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Affiliation(s)
- Tyson G Taylor
- Stryker Corporation, Torrance, California (TGT, RES); Harbor-UCLA Medical Center, Torrance, California (WJF, JTN, NB); The Lundquist Institute, Torrance, California (WJF, JTN, NB); The David Geffen School of Medicine at UCLA, Los Angeles, California (WJF, JTN, NB); North Carolina Heart and Vascular, UNC Healthcare, Chapel Hill, North Carolina (JGJ); Internal Medicine, Virginia Commonwealth University, Richmond, Virginia (MCK); Los Angeles County-USC Medical Center, Los Angeles, California (SGS, MKE); Los Angeles Fire Department, Los Angeles, California (SGS); Emergency Medicine,USC School of Medicine, Los Angeles, California (MKE); Los Angeles County EMS Agency, Santa Fe Springs, California (MKE, NB)
| | - Ronald E Stickney
- Stryker Corporation, Torrance, California (TGT, RES); Harbor-UCLA Medical Center, Torrance, California (WJF, JTN, NB); The Lundquist Institute, Torrance, California (WJF, JTN, NB); The David Geffen School of Medicine at UCLA, Los Angeles, California (WJF, JTN, NB); North Carolina Heart and Vascular, UNC Healthcare, Chapel Hill, North Carolina (JGJ); Internal Medicine, Virginia Commonwealth University, Richmond, Virginia (MCK); Los Angeles County-USC Medical Center, Los Angeles, California (SGS, MKE); Los Angeles Fire Department, Los Angeles, California (SGS); Emergency Medicine,USC School of Medicine, Los Angeles, California (MKE); Los Angeles County EMS Agency, Santa Fe Springs, California (MKE, NB)
| | - William J French
- Stryker Corporation, Torrance, California (TGT, RES); Harbor-UCLA Medical Center, Torrance, California (WJF, JTN, NB); The Lundquist Institute, Torrance, California (WJF, JTN, NB); The David Geffen School of Medicine at UCLA, Los Angeles, California (WJF, JTN, NB); North Carolina Heart and Vascular, UNC Healthcare, Chapel Hill, North Carolina (JGJ); Internal Medicine, Virginia Commonwealth University, Richmond, Virginia (MCK); Los Angeles County-USC Medical Center, Los Angeles, California (SGS, MKE); Los Angeles Fire Department, Los Angeles, California (SGS); Emergency Medicine,USC School of Medicine, Los Angeles, California (MKE); Los Angeles County EMS Agency, Santa Fe Springs, California (MKE, NB)
| | - James G Jollis
- Stryker Corporation, Torrance, California (TGT, RES); Harbor-UCLA Medical Center, Torrance, California (WJF, JTN, NB); The Lundquist Institute, Torrance, California (WJF, JTN, NB); The David Geffen School of Medicine at UCLA, Los Angeles, California (WJF, JTN, NB); North Carolina Heart and Vascular, UNC Healthcare, Chapel Hill, North Carolina (JGJ); Internal Medicine, Virginia Commonwealth University, Richmond, Virginia (MCK); Los Angeles County-USC Medical Center, Los Angeles, California (SGS, MKE); Los Angeles Fire Department, Los Angeles, California (SGS); Emergency Medicine,USC School of Medicine, Los Angeles, California (MKE); Los Angeles County EMS Agency, Santa Fe Springs, California (MKE, NB)
| | - Michael C Kontos
- Stryker Corporation, Torrance, California (TGT, RES); Harbor-UCLA Medical Center, Torrance, California (WJF, JTN, NB); The Lundquist Institute, Torrance, California (WJF, JTN, NB); The David Geffen School of Medicine at UCLA, Los Angeles, California (WJF, JTN, NB); North Carolina Heart and Vascular, UNC Healthcare, Chapel Hill, North Carolina (JGJ); Internal Medicine, Virginia Commonwealth University, Richmond, Virginia (MCK); Los Angeles County-USC Medical Center, Los Angeles, California (SGS, MKE); Los Angeles Fire Department, Los Angeles, California (SGS); Emergency Medicine,USC School of Medicine, Los Angeles, California (MKE); Los Angeles County EMS Agency, Santa Fe Springs, California (MKE, NB)
| | - James T Niemann
- Stryker Corporation, Torrance, California (TGT, RES); Harbor-UCLA Medical Center, Torrance, California (WJF, JTN, NB); The Lundquist Institute, Torrance, California (WJF, JTN, NB); The David Geffen School of Medicine at UCLA, Los Angeles, California (WJF, JTN, NB); North Carolina Heart and Vascular, UNC Healthcare, Chapel Hill, North Carolina (JGJ); Internal Medicine, Virginia Commonwealth University, Richmond, Virginia (MCK); Los Angeles County-USC Medical Center, Los Angeles, California (SGS, MKE); Los Angeles Fire Department, Los Angeles, California (SGS); Emergency Medicine,USC School of Medicine, Los Angeles, California (MKE); Los Angeles County EMS Agency, Santa Fe Springs, California (MKE, NB)
| | - Stephen G Sanko
- Stryker Corporation, Torrance, California (TGT, RES); Harbor-UCLA Medical Center, Torrance, California (WJF, JTN, NB); The Lundquist Institute, Torrance, California (WJF, JTN, NB); The David Geffen School of Medicine at UCLA, Los Angeles, California (WJF, JTN, NB); North Carolina Heart and Vascular, UNC Healthcare, Chapel Hill, North Carolina (JGJ); Internal Medicine, Virginia Commonwealth University, Richmond, Virginia (MCK); Los Angeles County-USC Medical Center, Los Angeles, California (SGS, MKE); Los Angeles Fire Department, Los Angeles, California (SGS); Emergency Medicine,USC School of Medicine, Los Angeles, California (MKE); Los Angeles County EMS Agency, Santa Fe Springs, California (MKE, NB)
| | - Marc K Eckstein
- Stryker Corporation, Torrance, California (TGT, RES); Harbor-UCLA Medical Center, Torrance, California (WJF, JTN, NB); The Lundquist Institute, Torrance, California (WJF, JTN, NB); The David Geffen School of Medicine at UCLA, Los Angeles, California (WJF, JTN, NB); North Carolina Heart and Vascular, UNC Healthcare, Chapel Hill, North Carolina (JGJ); Internal Medicine, Virginia Commonwealth University, Richmond, Virginia (MCK); Los Angeles County-USC Medical Center, Los Angeles, California (SGS, MKE); Los Angeles Fire Department, Los Angeles, California (SGS); Emergency Medicine,USC School of Medicine, Los Angeles, California (MKE); Los Angeles County EMS Agency, Santa Fe Springs, California (MKE, NB)
| | - Nichole Bosson
- Stryker Corporation, Torrance, California (TGT, RES); Harbor-UCLA Medical Center, Torrance, California (WJF, JTN, NB); The Lundquist Institute, Torrance, California (WJF, JTN, NB); The David Geffen School of Medicine at UCLA, Los Angeles, California (WJF, JTN, NB); North Carolina Heart and Vascular, UNC Healthcare, Chapel Hill, North Carolina (JGJ); Internal Medicine, Virginia Commonwealth University, Richmond, Virginia (MCK); Los Angeles County-USC Medical Center, Los Angeles, California (SGS, MKE); Los Angeles Fire Department, Los Angeles, California (SGS); Emergency Medicine,USC School of Medicine, Los Angeles, California (MKE); Los Angeles County EMS Agency, Santa Fe Springs, California (MKE, NB)
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8
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Moeller S, Hansen CM, Kragholm K, Dupre ME, Sasson C, Pearson DA, Tyson C, Jollis JG, Monk L, Starks MA, McNally B, Thomas KL, Becker L, Torp-Pedersen C, Granger CB. Race Differences in Interventions and Survival After Out-of-Hospital Cardiac Arrest in North Carolina, 2010 to 2014. J Am Heart Assoc 2021; 10:e019082. [PMID: 34431375 PMCID: PMC8649293 DOI: 10.1161/jaha.120.019082] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background Following the implementation of the HeartRescue project, with interventions in the community, emergency medical services, and hospitals to improve care and outcomes for out‐of‐hospital cardiac arrests (OHCA) in North Carolina, improved bystander and first responder treatments as well as survival were observed. This study aimed to determine whether these improvements were consistent across Black versus White individuals. Methods and Results Using the Cardiac Arrest Registry to Enhance Survival (CARES), we identified OHCA from 16 counties in North Carolina (population 3 million) from 2010 to 2014. Temporal changes in interventions and outcomes were assessed using multilevel multivariable logistic regression, adjusted for patient and socioeconomic neighborhood‐level factors. Of 7091 patients with OHCA, 36.5% were Black and 63.5% were White. Black patients were younger, more females, had more unwitnessed arrests and non‐shockable rhythm (Black: 81.0%; White: 75.4%). From 2010 to 2014, the adjusted probabilities of bystander cardiopulmonary resuscitation (CPR) went from 38.5% to 51.2% in White, P<0.001; and 36.9% to 45.6% in Black, P=0.002, and first‐responder defibrillation went from 13.2% to 17.2% in White, P=0.002; and 14.7% to 17.3% in Black, P=0.16. From 2010 to 2014, survival to discharge only increased in White (8.0% to 11.4%, P=0.004; Black 8.9% to 9.5%, P=0.60), though, in shockable patients the probability of survival to discharge went from 24.8% to 34.6% in White, P=0.02; and 21.7% to 29.0% in Black, P=0. 10. Conclusions After the HeartRescue program, bystander CPR and first‐responder defibrillation increased in both patient groups; however, survival only increased significantly for White patients.
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Affiliation(s)
- Sidsel Moeller
- Duke Clinical Research Institute Durham NC.,Department of Cardiology Copenhagen University Hospital Herlev and Gentofte Hellerup Denmark
| | - Carolina M Hansen
- Duke Clinical Research Institute Durham NC.,Emergency Medical Services Copenhagen University of Copenhagen Denmark.,Department of Cardiology Nordsjaellands Hospital Hillerød Denmark
| | - Kristian Kragholm
- Duke Clinical Research Institute Durham NC.,Department of Cardiology North Denmark Regional Hospital &Aalborg University Hospital Aalborg Denmark
| | - Matt E Dupre
- Duke Clinical Research Institute Durham NC.,Department of Sociology Durham NC.,Department of Population Health Sciences Duke University Durham NC
| | - Comilla Sasson
- Department of Emergency Medicine University of Colorado School of Medicine Aurora CO
| | | | | | | | - Lisa Monk
- Duke Clinical Research Institute Durham NC
| | | | - Bryan McNally
- Emory University School of Medicine Atlanta Atlanta GA.,Rollins School of Public Health Atlanta Atlanta GA
| | | | - Lance Becker
- Department of Emergency Medicine Northwell HealthHofstra Northwell School of Medicine at Hofstra University Manhasset NY
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9
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Monk L, Ehrlich M, Shah S, Graffagnino C, Jollis JG, Granger C, Kolls B. Abstract P883: A Survey of Acute Stroke Blood Pressure Management Practices in the Southeastern US. Stroke 2021. [DOI: 10.1161/str.52.suppl_1.p883] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background:
IMPROVE Stroke Care is a regional implementation science study in the Southeastern US aimed at reducing acute stroke treatment times and improving outcomes through wide scale application of best practices. Optimal blood pressure in acute ischemic stroke (AIS) and acute intracerebral hemorrhage (ICH) remains controversial. Current guidelines lack specific targets for non-tPA treated AIS or ICH. We sought to evaluate current BP management processes for acute stroke within the 65 hospitals in the IMPROVE consortium.
Methods:
A 27-question survey was conducted using Qualtrics software. Topics covered existing protocols, guideline adherence, target BP in various settings, medication availability and use cases, and EMS practices. Simple proportions were calculated.
Results:
Overall survey completion rate was 71% (Hub 8/9 (89%) and Spoke 38/56 (68%)). The majority of participating sites (89%) have BP management protocols in place, as do their transport agencies (89%). Order sets are utilized for this in 87% of Emergency Departments and 83% of Intensive Care Units. Significant variation in practice was seen regarding goal BP in AIS patients who were not tPA candidates, with ‘provider discretion’, ‘unsure’ or ‘NA’ accounting for 63% of responses. Similarly, target BP prior to and following thrombectomy varied greatly. In tPA eligible AIS patients 76% (32/42) reported goal BP in line with the AHA guideline recommendation of <185/110mmHg; 21% (9/42) reported a goal <180/100mmHg. BP goals for ICH also vary widely, with systolic goals <150mmHg (46%) and <140mmHg (24%) the most common choices, with no difference in anticoagulated patients. The first-line drugs used in ED and EMS are labetalol (ED 83%/ EMS 35%), hydralazine (10%/26%), and nicardipine (8%/26%). In the ED, medications are obtained from a ‘cart or closet’ 62%, walked from pharmacy 27%, ‘tubed’ 17%, or ‘other’ 27%. Importantly, no participating sites indicated BP control as a common reason for stroke treatment delay.
Conclusion:
The survey demonstrates that many Southeastern US hospitals have BP management protocols in place that follow guidelines where available, and have tools to prevent treatment delays, yet no consensus exists on goal BP in thrombectomy, non-tPA treated AIS and ICH patients.
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Affiliation(s)
- Lisa Monk
- Outcomes, Duke Clinical Rsch Institute, Clemmons, NC
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10
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Affiliation(s)
- Timothy D Henry
- The Carl and Edyth Lindner Center for Research and Education, The Christ Hospital, Cincinnati, Ohio
| | - James G Jollis
- Department of Medicine, Duke University, Durham, North Carolina
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11
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Zeitouni M, Al-Khalidi HR, Roettig ML, Bolles MM, Doerfler SM, Fordyce CB, Hellkamp AS, Henry TD, Magdon-Ismail Z, Monk L, Nelson RD, O’Brien PK, Wilson BH, Ziada KM, Granger CB, Jollis JG. Catheterization Laboratory Activation Time in Patients Transferred With ST-Segment–Elevation Myocardial Infarction: Insights From the Mission: Lifeline STEMI Accelerator-2 Project. Circ Cardiovasc Qual Outcomes 2020; 13:e006204. [DOI: 10.1161/circoutcomes.119.006204] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background:
Catheterization laboratory (cath lab) activation time is a newly available process measure for patients with ST-segment–elevation myocardial infarction requiring inter-hospital transfers for primary percutaneous coronary intervention that reflects inter-facility communication and urgent mobilization of interventional laboratory resources. Our aim was to determine whether faster activation is associated with improved reperfusion time and outcomes in the American Heart Association Mission: Lifeline Accelerator-2 Project.
Methods and Results:
From April 2015 to March 2017, treatment times of 2063 patients with ST-segment–elevation myocardial infarction requiring inter-hospital transfer for primary percutaneous coronary intervention from 12 regions around the United States were stratified by cath lab activation time (first hospital arrival to cath lab activation within [timely] or beyond 20 minutes [delayed]). Median cath lab activation time was 26 minutes, with a delayed activation observed in 1241 (60.2%) patients. Prior cardiovascular or cerebrovascular disease, arterial hypotension at admission, and black or Latino ethnicity were independent factors of delayed cath lab activation. Timely cath lab activation patients had shorter door-in door-out times (40 versus 68 minutes) and reperfusion times (98 versus 135 minutes) with 80.1% treated within the national goal of ≤120 minutes versus 39.0% in the delayed group.
Conclusions:
Cath lab activation within 20 minutes across a geographically diverse group of hospitals was associated with performing primary percutaneous coronary intervention within the national goal of ≤120 minutes in >75% of patients. While several confounding factors were associated with delayed activation, this work suggests that this process measure has the potential to direct resources and practices to more timely treatment of patients requiring inter-hospital transfer for primary percutaneous coronary intervention.
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Affiliation(s)
- Michel Zeitouni
- Duke Clinical Research Institute, Durham, NC (M.Z., H.R.A.-K., M.L.R., S.M.D., A.S.H., L.M., C.B.G.)
| | - Hussein R. Al-Khalidi
- Duke Clinical Research Institute, Durham, NC (M.Z., H.R.A.-K., M.L.R., S.M.D., A.S.H., L.M., C.B.G.)
| | - Mayme L. Roettig
- Duke Clinical Research Institute, Durham, NC (M.Z., H.R.A.-K., M.L.R., S.M.D., A.S.H., L.M., C.B.G.)
| | | | - Shannon M. Doerfler
- Duke Clinical Research Institute, Durham, NC (M.Z., H.R.A.-K., M.L.R., S.M.D., A.S.H., L.M., C.B.G.)
| | | | - Anne S. Hellkamp
- Duke Clinical Research Institute, Durham, NC (M.Z., H.R.A.-K., M.L.R., S.M.D., A.S.H., L.M., C.B.G.)
| | - Timothy D. Henry
- The Carl and Edyth Lindner Center for Research and Education at The Christ Hospital, Cincinnati, OH (T.D.H.)
| | | | - Lisa Monk
- Duke Clinical Research Institute, Durham, NC (M.Z., H.R.A.-K., M.L.R., S.M.D., A.S.H., L.M., C.B.G.)
| | | | | | - B. Hadley Wilson
- Sanger Heart and Vascular Institute, Atrium Health, Charlotte, NC (B.H.W.)
| | - Khaled M. Ziada
- Gill Heart & Vascular Institute University of Kentucky, Lexington (K.M.Z.)
| | - Christopher B. Granger
- Duke Clinical Research Institute, Durham, NC (M.Z., H.R.A.-K., M.L.R., S.M.D., A.S.H., L.M., C.B.G.)
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12
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Jacobs AK, Ali M, Best PJ, Bieniarz M, Cohen MG, French WJ, Fonarow GC, Granger CB, Goyal A, Henry TD, Hollowell L, Jneid H, Jollis JG, Katz JN, Mason P, Menon V, Redlener M, Tamis-Holland JE, Zegre-Hemsey J. Temporary Emergency Guidance to STEMI Systems of Care During the COVID-19 Pandemic: AHA's Mission: Lifeline. Circulation 2020; 142:199-202. [PMID: 32363905 PMCID: PMC7365666 DOI: 10.1161/circulationaha.120.048180] [Citation(s) in RCA: 25] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Alice K. Jacobs
- Boston University School of Medicine and Boston Medical Center, MA (A.K.J)
| | - Murtuza Ali
- Louisiana State University School of Medicine, New Orleans (M.A.)
| | | | | | | | - William J. French
- Harbor-University of California, Los Angeles, Medical Center (W.J.F.)
| | - Gregg C. Fonarow
- University of California, Los Angeles, Division of Cardiology (G.C.F.)
| | | | - Abhinav Goyal
- Emory University Hospital Midtown, Atlanta, GA (A.G.)
| | | | | | - Hani Jneid
- Baylor College of Medicine, The Michael E. DeBakey VA Medical Center, Houston, TX (H.J.)
| | - James G. Jollis
- Duke University School of Medicine, Durham, NC (C.B.G., J.G.J., J.N.K.)
| | - Jason N. Katz
- Duke University School of Medicine, Durham, NC (C.B.G., J.G.J., J.N.K.)
| | - Peter Mason
- Medical College of Wisconsin, Milwaukee (P.M.)
| | - Venu Menon
- Cleveland Clinic, Lerner College of Medicine, Case Western Reserve University, OH (V.M.)
| | - Michael Redlener
- The Icahn School of Medicine at Mount Sinai, New York, NY (M.R.)
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13
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Ehrlich ME, Kolls BJ, Roettig M, Monk L, Shah S, Xian Y, Jollis JG, Granger CB, Graffagnino C. Implementation of Best Practices-Developing and Optimizing Regional Systems of Stroke Care: Design and Methodology. Am Heart J 2020; 222:105-111. [PMID: 32028136 DOI: 10.1016/j.ahj.2020.01.004] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/29/2019] [Accepted: 01/13/2020] [Indexed: 11/18/2022]
Abstract
The AHA Guidelines recommend developing multi-tiered systems for the care of patients with acute stroke.1 An ideal stroke system of care should ensure that all patients receive the most efficient and timely care, regardless of how they first enter or access the medical care system. Coordination among the components of a stroke system is the most challenging but most essential aspect of any system of care. The Implementation of Best Practices For Acute Stroke Care-Developing and Optimizing Regional Systems of Stroke Care (IMPROVE Stroke Care) project, is designed to implement existing guidelines and systematically improve the acute stroke system of care in the Southeastern United States. Project participation includes 9 hub hospitals, approximately 80 spoke hospitals, numerous pre-hospital agencies (911, fire, and emergency medical services) and communities within the region. The goal of the IMPROVE Stroke program is to develop a regional integrated stroke care system that identifies, classifies, and treats acute ischemic stroke patients more rapidly and effectively with reperfusion therapy. The project will identify gaps and barriers to implementation of stroke systems of care, leverage existing resources within the regions, aid in designing strategies to improve care processes, bring regional representatives together to agree on and implement best practices, protocols, and plans based on guidelines, and establish methods to monitor quality of care. The impact of implementation of stroke systems of care on mortality and long-term functional outcomes will be measured.
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Affiliation(s)
- Matthew E Ehrlich
- Department of Neurology, Duke University School of Medicine, Durham, NC.
| | - Brad J Kolls
- Department of Neurology, Duke University School of Medicine, Durham, NC; Duke Clinical Research Institute, Durham, NC
| | | | - Lisa Monk
- Duke Clinical Research Institute, Durham, NC
| | - Shreyansh Shah
- Department of Neurology, Duke University School of Medicine, Durham, NC
| | - Ying Xian
- Department of Neurology, Duke University School of Medicine, Durham, NC; Duke Clinical Research Institute, Durham, NC
| | - James G Jollis
- Duke Clinical Research Institute, Durham, NC; Division of Cardiology, Duke University School of Medicine, Durham, NC
| | - Christopher B Granger
- Duke Clinical Research Institute, Durham, NC; Division of Cardiology, Duke University School of Medicine, Durham, NC
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14
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Kontos MC, Gunderson MR, Zegre-Hemsey JK, Lange DC, French WJ, Henry TD, McCarthy JJ, Corbett C, Jacobs AK, Jollis JG, Manoukian SV, Suter RE, Travis DT, Garvey JL. Prehospital Activation of Hospital Resources (PreAct) ST-Segment-Elevation Myocardial Infarction (STEMI): A Standardized Approach to Prehospital Activation and Direct to the Catheterization Laboratory for STEMI Recommendations From the American Heart Association's Mission: Lifeline Program. J Am Heart Assoc 2020; 9:e011963. [PMID: 31957530 PMCID: PMC7033830 DOI: 10.1161/jaha.119.011963] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Affiliation(s)
- Michael C Kontos
- Pauley Heart Center Virginia Commonwealth University Richmond VA
| | | | | | - David C Lange
- The Permanente Medical Group Kaiser Permanente Santa Clara Santa Clara CA
| | - William J French
- Harbor-UCLA Medical Center and Los Angeles Biomedical Institute Torrance CA.,David Geffen School of Medicine at UCLA Los Angeles CA
| | - Timothy D Henry
- The Lindner Center for Research and Education at The Christ Hospital Cincinnati OH
| | - James J McCarthy
- Department of Emergency Medicine McGovern Medical School University of Texas Health Science Center at Houston TX
| | | | - Alice K Jacobs
- Section of Cardiology Department of Medicine Boston University Medical Center Boston MA
| | | | | | - Robert E Suter
- Department of Emergency Medicine UT Southwestern and Augusta University Dallas Texas.,Department of Military and Emergency Medicine Uniformed Services University Dallas TX
| | | | - J Lee Garvey
- Department of Emergency MedicineCarolinas Medical Center Charlotte NC
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15
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Granger CB, Bates ER, Jollis JG, Antman EM, Nichol G, O'Connor RE, Gregory T, Roettig ML, Peng SA, Ellrodt G, Henry TD, French WJ, Jacobs AK. Improving Care of STEMI in the United States 2008 to 2012. J Am Heart Assoc 2020; 8:e008096. [PMID: 30596310 PMCID: PMC6405711 DOI: 10.1161/jaha.118.008096] [Citation(s) in RCA: 61] [Impact Index Per Article: 15.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
Background We aimed to determine the change in treatment strategies and times to treatment over the first 5 years of the Mission: Lifeline program. Methods and Results We assessed pre‐ and in‐hospital care and outcomes from 2008 to 2012 for patients with ST‐segment–elevation myocardial infarction at US hospitals, using data from the National Cardiovascular Data Registry Acute Coronary Treatment and Intervention Outcomes Network Registry—Get With The Guidelines Registry. In‐hospital adjusted mortality was calculated including and excluding cardiac arrest as a reason for primary percutaneous coronary intervention delay. A total of 147 466 patients from 485 hospitals were analyzed. There was a decrease in the proportion of eligible patients not treated with reperfusion (6.2% versus 3.3%) and treated with fibrinolytic therapy (13.4% versus 7.0%). Median time from symptom onset to first medical contact was unchanged (≈50 minutes). Use of prehospital ECGs increased (45% versus 71%). All major reperfusion times improved: median first medical contact‐to‐device for emergency medical systems transport to percutaneous coronary intervention–capable hospitals (93 to 84 minutes), first door‐to‐device for transfers for primary percutaneous coronary intervention (130 to 112 minutes), and door‐in–door‐out at non–percutaneous coronary intervention–capable hospitals (76 to 62 minutes) (all P<0.001 over 5 years). Rates of cardiogenic shock and cardiac arrest, and overall in‐hospital mortality increased (5.7% to 6.3%). Adjusted mortality excluding patients with known cardiac arrest decreased by 14% at 3 years and 25% at 5 years (P<0.001). Conclusions Quality of care for patients with ST‐segment–elevation myocardial infarction improved over time in Mission: Lifeline, including increased use of reperfusion therapy and faster times‐to‐treatment. In‐hospital mortality improved for patients without cardiac arrest but did not appear to improve overall as the number of these high‐risk patients increased.
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Affiliation(s)
| | - Eric R Bates
- 2 Department of Internal Medicine University of Michigan Ann Arbor MI
| | - James G Jollis
- 1 Division of Cardiology Duke Clinical Research Institute Durham NC
| | | | - Graham Nichol
- 4 University of Washington-Harborview Center for Prehospital Emergency Care University of Washington Seattle WA
| | - Robert E O'Connor
- 5 Department of Emergency Medicine University of Virginia School of Medicine Charlottesville VA
| | | | - Mayme L Roettig
- 1 Division of Cardiology Duke Clinical Research Institute Durham NC
| | | | - Gray Ellrodt
- 8 Department of Medicine Berkshire Medical Center Pittsfield MA
| | | | - William J French
- 10 Department of Medicine Harbor-University of California at Los Angeles Medical Center Torrance CA
| | - Alice K Jacobs
- 11 Department of Medicine Boston University School of Medicine Boston MA
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16
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Malta Hansen C, Kragholm K, Dupre ME, Pearson DA, Tyson C, Monk L, Rea TD, Starks MA, Nelson D, Jollis JG, McNally B, Corbett CM, Granger CB. Association of Bystander and First-Responder Efforts and Outcomes According to Sex: Results From the North Carolina HeartRescue Statewide Quality Improvement Initiative. J Am Heart Assoc 2019; 7:e009873. [PMID: 30371210 PMCID: PMC6222952 DOI: 10.1161/jaha.118.009873] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background The Institute of Medicine has called for actions to understand and target sex‐related differences in care and outcomes for out‐of‐hospital cardiac arrest patients. We assessed changes in bystander and first‐responder interventions and outcomes for males versus females after statewide efforts to improve cardiac arrest care. Methods and Results We identified out‐of‐hospital cardiac arrests from North Carolina (2010–2014) through the CARES (Cardiac Arrest Registry to Enhance Survival) registry. Outcomes for men versus women were examined through multivariable logistic regression analyses adjusted for (1) nonmodifiable factors (age, witnessed status, and initial heart rhythm) and (2) nonmodifiable plus modifiable factors (bystander cardiopulmonary resuscitation and defibrillation before emergency medical services), including interactions between sex and time (ie, year and year2). Of 8100 patients, 38.1% were women. From 2010 to 2014, there was an increase in bystander cardiopulmonary resuscitation (men, 40.5%–50.6%; women, 35.3%–51.8%; P for each <0.0001) and in the combination of bystander cardiopulmonary resuscitation and first‐responder defibrillation (men, 15.8%–23.0%, P=0.007; women, 8.5%–23.7%, P=0.004). From 2010 to 2014, the unadjusted predicted probability of favorable neurologic outcome was higher and increased more for men (men, from 6.5% [95% confidence interval (CI), 5.1–8.0] to 9.7% [95% CI, 8.1–11.3]; women, from 6.3% [95% CI, 4.4–8.3] to 7.4% [95% CI, 5.5–9.3%]); while adjusted for nonmodifiable factors, it was slightly higher but with a nonsignificant increase for women (from 9.2% [95% CI, 6.8–11.8] to 10.2% [95% CI, 8.0–12.5]; men, from 5.8% [95% CI, 4.6–7.0] to 8.4% [95% CI, 7.1–9.7]). Adding bystander cardiopulmonary resuscitation and defibrillation before EMS (modifiable factors) did not substantially change the results. Conclusions Bystander and first‐responder interventions increased for men and women, but outcomes improved significantly only for men. Additional strategies may be necessary to improve survival among female cardiac arrest patients.
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Affiliation(s)
- Carolina Malta Hansen
- 1 Duke Clinical Research Institute Duke University Durham NC.,2 Division of Endocrinology and Nephrology North Zealand Hospital Copenhagen University Copenhagen Denmark.,3 Emergency Medical Services Capital Region of Denmark Copenhagen University Copenhagen Denmark
| | | | - Matthew E Dupre
- 1 Duke Clinical Research Institute Duke University Durham NC.,4 Department of Population Health Sciences Duke University Durham NC
| | | | - Clark Tyson
- 1 Duke Clinical Research Institute Duke University Durham NC.,6 Ctr for Educational Excellence Duke University Durham NC
| | - Lisa Monk
- 1 Duke Clinical Research Institute Duke University Durham NC
| | - Thomas D Rea
- 7 Department of Medicine University of Washington Seattle WA
| | | | | | - James G Jollis
- 1 Duke Clinical Research Institute Duke University Durham NC
| | - Bryan McNally
- 9 Emory University School of Medicine Atlanta GA.,10 Rollins School of Public Health Atlanta GA
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17
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Fordyce CB, Hansen CM, Kragholm K, Dupre ME, Jollis JG, Roettig ML, Becker LB, Hansen SM, Hinohara TT, Corbett CC, Monk L, Nelson RD, Pearson DA, Tyson C, van Diepen S, Anderson ML, McNally B, Granger CB. Association of Public Health Initiatives With Outcomes for Out-of-Hospital Cardiac Arrest at Home and in Public Locations. JAMA Cardiol 2019; 2:1226-1235. [PMID: 28979980 DOI: 10.1001/jamacardio.2017.3471] [Citation(s) in RCA: 65] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
Importance Little is known about the influence of comprehensive public health initiatives according to out-of-hospital cardiac arrest (OHCA) location, particularly at home, where resuscitation efforts and outcomes have historically been poor. Objective To describe temporal trends in bystander cardiopulmonary resuscitation (CPR) and first-responder defibrillation for OHCAs stratified by home vs public location and their association with survival and neurological outcomes. Design, Setting, and Participants This observational study reviewed 8269 patients with OHCAs (5602 [67.7%] at home and 2667 [32.3%] in public) for whom resuscitation was attempted using data from the Cardiac Arrest Registry to Enhance Survival (CARES) from January 1, 2010, through December 31, 2014. The setting was 16 counties in North Carolina. Exposures Patients were stratified by home vs public OHCA. Public health initiatives to improve bystander and first-responder interventions included training members of the general population in CPR and in the use of automated external defibrillators, teaching first responders about team-based CPR (eg, automated external defibrillator use and high-performance CPR), and instructing dispatch centers on recognition of cardiac arrest. Main Outcomes and Measures Association of resuscitation efforts with survival and neurological outcomes from 2010 through 2014. Results Among home OHCA patients (n = 5602), the median age was 64 years, and 62.2% were male; among public OHCA patients (n = 2667), the median age was 68 years, and 61.5% were male. After comprehensive public health initiatives, the proportion of patients receiving bystander CPR increased at home (from 28.3% [275 of 973] to 41.3% [498 of 1206], P < .001) and in public (from 61.0% [275 of 451] to 70.5% [424 of 601], P = .01), while first-responder defibrillation increased at home (from 42.2% [132 of 313] to 50.8% [212 of 417], P = .02) but not significantly in public (from 33.1% [58 of 175] to 37.8% [93 of 246], P = .17). Survival to discharge improved for arrests at home (from 5.7% [60 of 1057] to 8.1% [100 of 1238], P = .047) and in public (from 10.8% [50 of 464] to 16.2% [98 of 604], P = .04). Compared with emergency medical services-initiated CPR and resuscitation, patients with home OHCA were significantly more likely to survive to hospital discharge if they received bystander-initiated CPR and first-responder defibrillation (odds ratio, 1.55; 95% CI, 1.01-2.38). Patients with arrests in public were most likely to survive if they received both bystander-initiated CPR and defibrillation (odds ratio, 4.33; 95% CI, 2.11-8.87). Conclusions and Relevance After coordinated and comprehensive public health initiatives, more patients received bystander CPR and first-responder defibrillation at home and in public, which was associated with improved survival.
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Affiliation(s)
- Christopher B Fordyce
- Division of Cardiology, Department of Medicine, University of British Columbia, Vancouver, Canada.,Duke Clinical Research Institute, Durham, North Carolina
| | | | - Kristian Kragholm
- Duke Clinical Research Institute, Durham, North Carolina.,Department of Cardiology, Aalborg University Hospital, Aalborg, Denmark.,Department of Epidemiology and Biostatistics, Aalborg University Hospital, Aalborg, Denmark
| | - Matthew E Dupre
- Duke Clinical Research Institute, Durham, North Carolina.,Department of Sociology, Duke University, Durham, North Carolina
| | - James G Jollis
- Division of Cardiology, Department of Medicine, The University of North Carolina at Chapel Hill
| | | | - Lance B Becker
- Department of Emergency Medicine, Northwell Health, Hofstra Northwell School of Medicine at Hofstra University, Manhasset, New York
| | - Steen M Hansen
- Duke Clinical Research Institute, Durham, North Carolina
| | | | | | - Lisa Monk
- Duke Clinical Research Institute, Durham, North Carolina
| | - R Darrell Nelson
- Wake Forest University Health Sciences, Winston-Salem, North Carolina
| | - David A Pearson
- Department of Emergency Medicine, Carolinas Medical Center, Charlotte, North Carolina
| | - Clark Tyson
- Duke Clinical Research Institute, Durham, North Carolina
| | - Sean van Diepen
- Department of Critical Care, University of Alberta, Edmonton, Alberta, Canada.,Division of Cardiology, Department of Medicine, University of Alberta, Edmonton, Alberta, Canada
| | | | - Bryan McNally
- Department of Emergency Medicine, Emory University School of Medicine, Atlanta, Georgia
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18
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Pun PH, Dupre ME, Starks MA, Tyson C, Vellano K, Svetkey LP, Hansen S, Frizzelle BG, McNally B, Jollis JG, Al-Khatib SM, Granger CB. Outcomes for Hemodialysis Patients Given Cardiopulmonary Resuscitation for Cardiac Arrest at Outpatient Dialysis Clinics. J Am Soc Nephrol 2019; 30:461-470. [PMID: 30733235 PMCID: PMC6405155 DOI: 10.1681/asn.2018090911] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2018] [Accepted: 11/28/2018] [Indexed: 01/13/2023] Open
Abstract
BACKGROUND Out-of-hospital cardiac arrest, the leading cause of death among patients on hemodialysis, occurs frequently within outpatient dialysis centers. Practice guidelines recommend resuscitation training for all dialysis clinic staff and on-site defibrillator availability, but the extent of staff involvement in cardiopulmonary resuscitation (CPR) efforts and its association with outcomes is unknown. METHODS We used data from the Cardiac Arrest Registry to Enhance Survival and the Centers for Medicare & Medicaid Services dialysis facility database to identify patients who had cardiac arrest within outpatient dialysis clinics between 2010 and 2016 in the southeastern United States. We compared outcomes of patients who received dialysis staff-initiated CPR with those who did not until the arrival of emergency medical services (EMS). RESULTS Among 398 OHCA events in dialysis clinics, 66% of all patients presented with a nonshockable initial rhythm. Dialysis staff initiated CPR in 81.4% of events and applied defibrillators before EMS arrival in 52.3%. Staff were more likely to initiate CPR among men and witness cardiac arrests, and were more likely to provide CPR within larger dialysis clinics. Staff-initiated CPR was associated with a three-fold increase in the odds of hospital discharge and favorable neurologic status on discharge. There was no overall association between staff-initiated defibrillator use and outcomes, but there was a nonsignificant trend toward improved survival to hospital discharge in the subgroup with shockable initial cardiac arrest rhythms. CONCLUSIONS Dialysis staff-initiated CPR was associated with a large increase in survival but was only performed in 81% of cardiac arrest events. Further investigations should focus on understanding the potential facilitators and barriers to CPR in the dialysis setting.
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Affiliation(s)
- Patrick H. Pun
- Duke Clinical Research Institute,,Division of Nephrology, Department of Medicine, and
| | - Matthew E. Dupre
- Duke Clinical Research Institute,,Department of Population Health Sciences, Duke University School of Medicine, Durham, North Carolina
| | | | | | - Kimberly Vellano
- Department of Emergency Medicine, Emory University, Atlanta, Georgia
| | | | - Steen Hansen
- Unit of Epidemiology and Biostatistics, Aalborg University Hospital, Aalborg, Denmark; and
| | - Brian G. Frizzelle
- Carolina Population Center, University of North Carolina, Chapel Hill, North Carolina
| | - Bryan McNally
- Department of Emergency Medicine, Emory University, Atlanta, Georgia
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19
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Shavadia JS, Roe MT, Chen AY, Lucas J, Fanaroff AC, Kochar A, Fordyce CB, Jollis JG, Tamis-Holland J, Henry TD, Bagai A, Kontos MC, Granger CB, Wang TY. Association Between Cardiac Catheterization Laboratory Pre-Activation and Reperfusion Timing Metrics and Outcomes in Patients With ST-Segment Elevation Myocardial Infarction Undergoing Primary Percutaneous Coronary Intervention. JACC Cardiovasc Interv 2018; 11:1837-1847. [DOI: 10.1016/j.jcin.2018.07.020] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/03/2018] [Revised: 07/12/2018] [Accepted: 07/17/2018] [Indexed: 12/15/2022]
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20
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Kochar A, Al-Khalidi HR, Hansen SM, Shavadia JS, Roettig ML, Fordyce CB, Doerfler S, Gersh BJ, Henry TD, Berger PB, Jollis JG, Granger CB. Delays in Primary Percutaneous Coronary Intervention in ST-Segment Elevation Myocardial Infarction Patients Presenting With Cardiogenic Shock. JACC Cardiovasc Interv 2018; 11:1824-1833. [DOI: 10.1016/j.jcin.2018.06.030] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/22/2018] [Revised: 06/14/2018] [Accepted: 06/19/2018] [Indexed: 12/27/2022]
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21
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Jollis JG, Al-Khalidi HR, Roettig ML, Berger PB, Corbett CC, Doerfler SM, Fordyce CB, Henry TD, Hollowell L, Magdon-Ismail Z, Kochar A, McCarthy JJ, Monk L, O’Brien P, Rea TD, Shavadia J, Tamis-Holland J, Wilson BH, Ziada KM, Granger CB. Impact of Regionalization of ST-Segment–Elevation Myocardial Infarction Care on Treatment Times and Outcomes for Emergency Medical Services–Transported Patients Presenting to Hospitals With Percutaneous Coronary Intervention. Circulation 2018; 137:376-387. [DOI: 10.1161/circulationaha.117.032446] [Citation(s) in RCA: 81] [Impact Index Per Article: 13.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/17/2017] [Accepted: 11/08/2017] [Indexed: 11/16/2022]
Abstract
Background:
Regional variations in reperfusion times and mortality in patients with ST-segment–elevation myocardial infarction are influenced by differences in coordinating care between emergency medical services (EMS) and hospitals. Building on the Accelerator-1 Project, we hypothesized that time to reperfusion could be further reduced with enhanced regional efforts.
Methods:
Between April 2015 and March 2017, we worked with 12 metropolitan regions across the United States with 132 percutaneous coronary intervention–capable hospitals and 946 EMS agencies. Data were collected in the ACTION (Acute Coronary Treatment and Intervention Outcomes Network)-Get With The Guidelines Registry for quarterly Mission: Lifeline reports. The primary end point was the change in the proportion of EMS-transported patients with first medical contact to device time ≤90 minutes from baseline to final quarter. We also compared treatment times and mortality with patients treated in hospitals not participating in the project during the corresponding time period.
Results:
During the study period, 10 730 patients were transported to percutaneous coronary intervention–capable hospitals, including 974 in the baseline quarter and 972 in the final quarter who met inclusion criteria. Median age was 61 years; 27% were women, 6% had cardiac arrest, and 6% had shock on admission; 10% were black, 12% were Latino, and 10% were uninsured. By the end of the intervention, all process measures reflecting coordination between EMS and hospitals had improved, including the proportion of patients with a first medical contact to device time of ≤90 minutes (67%–74%;
P
<0.002), a first medical contact to device time to catheterization laboratory activation of ≤20 minutes (38%–56%;
P
<0.0001), and emergency department dwell time of ≤20 minutes (33%–43%;
P
<0.0001). Of the 12 regions, 9 regions reduced first medical contact to device time, and 8 met or exceeded the national goal of 75% of patients treated in ≤90 minutes. Improvements in treatment times corresponded with a significant reduction in mortality (in-hospital death, 4.4%–2.3%;
P
=0.001) that was not apparent in hospitals not participating in the project during the same time period.
Conclusions:
Organization of care among EMS and hospitals in 12 regions was associated with significant reductions in time to reperfusion in patients with ST-segment–elevation myocardial infarction as well as in in-hospital mortality. These findings support a more intensive regional approach to emergency care for patients with ST-segment–elevation myocardial infarction.
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Affiliation(s)
- James G. Jollis
- Duke Clinical Research Institute, Duke University, Durham, NC (J.G.J., H.R.A.-K., M.L.R., S.D., A.K., L.M., J.S., C.B.G.)
- University of North Carolina, Chapel Hill (J.G.J.)
| | - Hussein R. Al-Khalidi
- Duke Clinical Research Institute, Duke University, Durham, NC (J.G.J., H.R.A.-K., M.L.R., S.D., A.K., L.M., J.S., C.B.G.)
| | - Mayme L. Roettig
- Duke Clinical Research Institute, Duke University, Durham, NC (J.G.J., H.R.A.-K., M.L.R., S.D., A.K., L.M., J.S., C.B.G.)
| | | | | | - Shannon M. Doerfler
- Duke Clinical Research Institute, Duke University, Durham, NC (J.G.J., H.R.A.-K., M.L.R., S.D., A.K., L.M., J.S., C.B.G.)
| | | | | | | | | | - Ajar Kochar
- Duke Clinical Research Institute, Duke University, Durham, NC (J.G.J., H.R.A.-K., M.L.R., S.D., A.K., L.M., J.S., C.B.G.)
| | - James J. McCarthy
- McGovern School of Medicine, University of Texas Health Science Center at Houston (J.J.M.)
| | - Lisa Monk
- Duke Clinical Research Institute, Duke University, Durham, NC (J.G.J., H.R.A.-K., M.L.R., S.D., A.K., L.M., J.S., C.B.G.)
| | | | | | - Jay Shavadia
- Duke Clinical Research Institute, Duke University, Durham, NC (J.G.J., H.R.A.-K., M.L.R., S.D., A.K., L.M., J.S., C.B.G.)
| | | | - B. Hadley Wilson
- Sanger Heart and Vascular Institute, Carolinas HealthCare System, Charlotte, NC (B.H.W.)
| | | | - Christopher B. Granger
- Duke Clinical Research Institute, Duke University, Durham, NC (J.G.J., H.R.A.-K., M.L.R., S.D., A.K., L.M., J.S., C.B.G.)
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22
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Fordyce CB, Al-Khalidi HR, Jollis JG, Roettig ML, Gu J, Bagai A, Berger PB, Corbett CC, Dauerman HL, Fox K, Garvey JL, Henry TD, Rokos IC, Sherwood MW, Wilson BH, Granger CB. Association of Rapid Care Process Implementation on Reperfusion Times Across Multiple ST-Segment-Elevation Myocardial Infarction Networks. Circ Cardiovasc Interv 2017; 10:CIRCINTERVENTIONS.116.004061. [PMID: 28082714 DOI: 10.1161/circinterventions.116.004061] [Citation(s) in RCA: 36] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/06/2016] [Accepted: 11/17/2016] [Indexed: 01/21/2023]
Abstract
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.
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Affiliation(s)
- Christopher B Fordyce
- From the Division of Cardiology, University of British Columbia, Vancouver, Canada (C.B.F.); Duke Clinical Research Institute, Durham, NC (C.B.F., H.R.A.-K., M.L.R., J.G., K.F., M.W.S., C.B.G.); University of North Carolina, Chapel Hill (J.G.J.); St. Michael's Hospital, University of Toronto, ON, Canada (A.B.); Northwell Health, Great Neck, NY (P.B.B.); New Hanover Regional Medical Center, Wilmington, NC (C.C.C.); University of Vermont College of Medicine, Burlington (H.L.D.); Department of Emergency Medicine, Carolinas Medical Center, Charlotte, NC (J.L.G.); Cedars-Sinai Heart Institute, Los Angeles, CA (T.D.H.); UCLA-Olive View Medical Center, Los Angeles, CA (I.C.R.); and Sanger Heart & Vascular Institute, Carolinas Medical Center, Charlotte, NC (B.H.W.).
| | - Hussein R Al-Khalidi
- From the Division of Cardiology, University of British Columbia, Vancouver, Canada (C.B.F.); Duke Clinical Research Institute, Durham, NC (C.B.F., H.R.A.-K., M.L.R., J.G., K.F., M.W.S., C.B.G.); University of North Carolina, Chapel Hill (J.G.J.); St. Michael's Hospital, University of Toronto, ON, Canada (A.B.); Northwell Health, Great Neck, NY (P.B.B.); New Hanover Regional Medical Center, Wilmington, NC (C.C.C.); University of Vermont College of Medicine, Burlington (H.L.D.); Department of Emergency Medicine, Carolinas Medical Center, Charlotte, NC (J.L.G.); Cedars-Sinai Heart Institute, Los Angeles, CA (T.D.H.); UCLA-Olive View Medical Center, Los Angeles, CA (I.C.R.); and Sanger Heart & Vascular Institute, Carolinas Medical Center, Charlotte, NC (B.H.W.)
| | - James G Jollis
- From the Division of Cardiology, University of British Columbia, Vancouver, Canada (C.B.F.); Duke Clinical Research Institute, Durham, NC (C.B.F., H.R.A.-K., M.L.R., J.G., K.F., M.W.S., C.B.G.); University of North Carolina, Chapel Hill (J.G.J.); St. Michael's Hospital, University of Toronto, ON, Canada (A.B.); Northwell Health, Great Neck, NY (P.B.B.); New Hanover Regional Medical Center, Wilmington, NC (C.C.C.); University of Vermont College of Medicine, Burlington (H.L.D.); Department of Emergency Medicine, Carolinas Medical Center, Charlotte, NC (J.L.G.); Cedars-Sinai Heart Institute, Los Angeles, CA (T.D.H.); UCLA-Olive View Medical Center, Los Angeles, CA (I.C.R.); and Sanger Heart & Vascular Institute, Carolinas Medical Center, Charlotte, NC (B.H.W.)
| | - Mayme L Roettig
- From the Division of Cardiology, University of British Columbia, Vancouver, Canada (C.B.F.); Duke Clinical Research Institute, Durham, NC (C.B.F., H.R.A.-K., M.L.R., J.G., K.F., M.W.S., C.B.G.); University of North Carolina, Chapel Hill (J.G.J.); St. Michael's Hospital, University of Toronto, ON, Canada (A.B.); Northwell Health, Great Neck, NY (P.B.B.); New Hanover Regional Medical Center, Wilmington, NC (C.C.C.); University of Vermont College of Medicine, Burlington (H.L.D.); Department of Emergency Medicine, Carolinas Medical Center, Charlotte, NC (J.L.G.); Cedars-Sinai Heart Institute, Los Angeles, CA (T.D.H.); UCLA-Olive View Medical Center, Los Angeles, CA (I.C.R.); and Sanger Heart & Vascular Institute, Carolinas Medical Center, Charlotte, NC (B.H.W.)
| | - Joan Gu
- From the Division of Cardiology, University of British Columbia, Vancouver, Canada (C.B.F.); Duke Clinical Research Institute, Durham, NC (C.B.F., H.R.A.-K., M.L.R., J.G., K.F., M.W.S., C.B.G.); University of North Carolina, Chapel Hill (J.G.J.); St. Michael's Hospital, University of Toronto, ON, Canada (A.B.); Northwell Health, Great Neck, NY (P.B.B.); New Hanover Regional Medical Center, Wilmington, NC (C.C.C.); University of Vermont College of Medicine, Burlington (H.L.D.); Department of Emergency Medicine, Carolinas Medical Center, Charlotte, NC (J.L.G.); Cedars-Sinai Heart Institute, Los Angeles, CA (T.D.H.); UCLA-Olive View Medical Center, Los Angeles, CA (I.C.R.); and Sanger Heart & Vascular Institute, Carolinas Medical Center, Charlotte, NC (B.H.W.)
| | - Akshay Bagai
- From the Division of Cardiology, University of British Columbia, Vancouver, Canada (C.B.F.); Duke Clinical Research Institute, Durham, NC (C.B.F., H.R.A.-K., M.L.R., J.G., K.F., M.W.S., C.B.G.); University of North Carolina, Chapel Hill (J.G.J.); St. Michael's Hospital, University of Toronto, ON, Canada (A.B.); Northwell Health, Great Neck, NY (P.B.B.); New Hanover Regional Medical Center, Wilmington, NC (C.C.C.); University of Vermont College of Medicine, Burlington (H.L.D.); Department of Emergency Medicine, Carolinas Medical Center, Charlotte, NC (J.L.G.); Cedars-Sinai Heart Institute, Los Angeles, CA (T.D.H.); UCLA-Olive View Medical Center, Los Angeles, CA (I.C.R.); and Sanger Heart & Vascular Institute, Carolinas Medical Center, Charlotte, NC (B.H.W.)
| | - Peter B Berger
- From the Division of Cardiology, University of British Columbia, Vancouver, Canada (C.B.F.); Duke Clinical Research Institute, Durham, NC (C.B.F., H.R.A.-K., M.L.R., J.G., K.F., M.W.S., C.B.G.); University of North Carolina, Chapel Hill (J.G.J.); St. Michael's Hospital, University of Toronto, ON, Canada (A.B.); Northwell Health, Great Neck, NY (P.B.B.); New Hanover Regional Medical Center, Wilmington, NC (C.C.C.); University of Vermont College of Medicine, Burlington (H.L.D.); Department of Emergency Medicine, Carolinas Medical Center, Charlotte, NC (J.L.G.); Cedars-Sinai Heart Institute, Los Angeles, CA (T.D.H.); UCLA-Olive View Medical Center, Los Angeles, CA (I.C.R.); and Sanger Heart & Vascular Institute, Carolinas Medical Center, Charlotte, NC (B.H.W.)
| | - Claire C Corbett
- From the Division of Cardiology, University of British Columbia, Vancouver, Canada (C.B.F.); Duke Clinical Research Institute, Durham, NC (C.B.F., H.R.A.-K., M.L.R., J.G., K.F., M.W.S., C.B.G.); University of North Carolina, Chapel Hill (J.G.J.); St. Michael's Hospital, University of Toronto, ON, Canada (A.B.); Northwell Health, Great Neck, NY (P.B.B.); New Hanover Regional Medical Center, Wilmington, NC (C.C.C.); University of Vermont College of Medicine, Burlington (H.L.D.); Department of Emergency Medicine, Carolinas Medical Center, Charlotte, NC (J.L.G.); Cedars-Sinai Heart Institute, Los Angeles, CA (T.D.H.); UCLA-Olive View Medical Center, Los Angeles, CA (I.C.R.); and Sanger Heart & Vascular Institute, Carolinas Medical Center, Charlotte, NC (B.H.W.)
| | - Harold L Dauerman
- From the Division of Cardiology, University of British Columbia, Vancouver, Canada (C.B.F.); Duke Clinical Research Institute, Durham, NC (C.B.F., H.R.A.-K., M.L.R., J.G., K.F., M.W.S., C.B.G.); University of North Carolina, Chapel Hill (J.G.J.); St. Michael's Hospital, University of Toronto, ON, Canada (A.B.); Northwell Health, Great Neck, NY (P.B.B.); New Hanover Regional Medical Center, Wilmington, NC (C.C.C.); University of Vermont College of Medicine, Burlington (H.L.D.); Department of Emergency Medicine, Carolinas Medical Center, Charlotte, NC (J.L.G.); Cedars-Sinai Heart Institute, Los Angeles, CA (T.D.H.); UCLA-Olive View Medical Center, Los Angeles, CA (I.C.R.); and Sanger Heart & Vascular Institute, Carolinas Medical Center, Charlotte, NC (B.H.W.)
| | - Kathleen Fox
- From the Division of Cardiology, University of British Columbia, Vancouver, Canada (C.B.F.); Duke Clinical Research Institute, Durham, NC (C.B.F., H.R.A.-K., M.L.R., J.G., K.F., M.W.S., C.B.G.); University of North Carolina, Chapel Hill (J.G.J.); St. Michael's Hospital, University of Toronto, ON, Canada (A.B.); Northwell Health, Great Neck, NY (P.B.B.); New Hanover Regional Medical Center, Wilmington, NC (C.C.C.); University of Vermont College of Medicine, Burlington (H.L.D.); Department of Emergency Medicine, Carolinas Medical Center, Charlotte, NC (J.L.G.); Cedars-Sinai Heart Institute, Los Angeles, CA (T.D.H.); UCLA-Olive View Medical Center, Los Angeles, CA (I.C.R.); and Sanger Heart & Vascular Institute, Carolinas Medical Center, Charlotte, NC (B.H.W.)
| | - J Lee Garvey
- From the Division of Cardiology, University of British Columbia, Vancouver, Canada (C.B.F.); Duke Clinical Research Institute, Durham, NC (C.B.F., H.R.A.-K., M.L.R., J.G., K.F., M.W.S., C.B.G.); University of North Carolina, Chapel Hill (J.G.J.); St. Michael's Hospital, University of Toronto, ON, Canada (A.B.); Northwell Health, Great Neck, NY (P.B.B.); New Hanover Regional Medical Center, Wilmington, NC (C.C.C.); University of Vermont College of Medicine, Burlington (H.L.D.); Department of Emergency Medicine, Carolinas Medical Center, Charlotte, NC (J.L.G.); Cedars-Sinai Heart Institute, Los Angeles, CA (T.D.H.); UCLA-Olive View Medical Center, Los Angeles, CA (I.C.R.); and Sanger Heart & Vascular Institute, Carolinas Medical Center, Charlotte, NC (B.H.W.)
| | - Timothy D Henry
- From the Division of Cardiology, University of British Columbia, Vancouver, Canada (C.B.F.); Duke Clinical Research Institute, Durham, NC (C.B.F., H.R.A.-K., M.L.R., J.G., K.F., M.W.S., C.B.G.); University of North Carolina, Chapel Hill (J.G.J.); St. Michael's Hospital, University of Toronto, ON, Canada (A.B.); Northwell Health, Great Neck, NY (P.B.B.); New Hanover Regional Medical Center, Wilmington, NC (C.C.C.); University of Vermont College of Medicine, Burlington (H.L.D.); Department of Emergency Medicine, Carolinas Medical Center, Charlotte, NC (J.L.G.); Cedars-Sinai Heart Institute, Los Angeles, CA (T.D.H.); UCLA-Olive View Medical Center, Los Angeles, CA (I.C.R.); and Sanger Heart & Vascular Institute, Carolinas Medical Center, Charlotte, NC (B.H.W.)
| | - Ivan C Rokos
- From the Division of Cardiology, University of British Columbia, Vancouver, Canada (C.B.F.); Duke Clinical Research Institute, Durham, NC (C.B.F., H.R.A.-K., M.L.R., J.G., K.F., M.W.S., C.B.G.); University of North Carolina, Chapel Hill (J.G.J.); St. Michael's Hospital, University of Toronto, ON, Canada (A.B.); Northwell Health, Great Neck, NY (P.B.B.); New Hanover Regional Medical Center, Wilmington, NC (C.C.C.); University of Vermont College of Medicine, Burlington (H.L.D.); Department of Emergency Medicine, Carolinas Medical Center, Charlotte, NC (J.L.G.); Cedars-Sinai Heart Institute, Los Angeles, CA (T.D.H.); UCLA-Olive View Medical Center, Los Angeles, CA (I.C.R.); and Sanger Heart & Vascular Institute, Carolinas Medical Center, Charlotte, NC (B.H.W.)
| | - Matthew W Sherwood
- From the Division of Cardiology, University of British Columbia, Vancouver, Canada (C.B.F.); Duke Clinical Research Institute, Durham, NC (C.B.F., H.R.A.-K., M.L.R., J.G., K.F., M.W.S., C.B.G.); University of North Carolina, Chapel Hill (J.G.J.); St. Michael's Hospital, University of Toronto, ON, Canada (A.B.); Northwell Health, Great Neck, NY (P.B.B.); New Hanover Regional Medical Center, Wilmington, NC (C.C.C.); University of Vermont College of Medicine, Burlington (H.L.D.); Department of Emergency Medicine, Carolinas Medical Center, Charlotte, NC (J.L.G.); Cedars-Sinai Heart Institute, Los Angeles, CA (T.D.H.); UCLA-Olive View Medical Center, Los Angeles, CA (I.C.R.); and Sanger Heart & Vascular Institute, Carolinas Medical Center, Charlotte, NC (B.H.W.)
| | - B Hadley Wilson
- From the Division of Cardiology, University of British Columbia, Vancouver, Canada (C.B.F.); Duke Clinical Research Institute, Durham, NC (C.B.F., H.R.A.-K., M.L.R., J.G., K.F., M.W.S., C.B.G.); University of North Carolina, Chapel Hill (J.G.J.); St. Michael's Hospital, University of Toronto, ON, Canada (A.B.); Northwell Health, Great Neck, NY (P.B.B.); New Hanover Regional Medical Center, Wilmington, NC (C.C.C.); University of Vermont College of Medicine, Burlington (H.L.D.); Department of Emergency Medicine, Carolinas Medical Center, Charlotte, NC (J.L.G.); Cedars-Sinai Heart Institute, Los Angeles, CA (T.D.H.); UCLA-Olive View Medical Center, Los Angeles, CA (I.C.R.); and Sanger Heart & Vascular Institute, Carolinas Medical Center, Charlotte, NC (B.H.W.)
| | - Christopher B Granger
- From the Division of Cardiology, University of British Columbia, Vancouver, Canada (C.B.F.); Duke Clinical Research Institute, Durham, NC (C.B.F., H.R.A.-K., M.L.R., J.G., K.F., M.W.S., C.B.G.); University of North Carolina, Chapel Hill (J.G.J.); St. Michael's Hospital, University of Toronto, ON, Canada (A.B.); Northwell Health, Great Neck, NY (P.B.B.); New Hanover Regional Medical Center, Wilmington, NC (C.C.C.); University of Vermont College of Medicine, Burlington (H.L.D.); Department of Emergency Medicine, Carolinas Medical Center, Charlotte, NC (J.L.G.); Cedars-Sinai Heart Institute, Los Angeles, CA (T.D.H.); UCLA-Olive View Medical Center, Los Angeles, CA (I.C.R.); and Sanger Heart & Vascular Institute, Carolinas Medical Center, Charlotte, NC (B.H.W.)
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Hinohara TT, Al-Khalidi HR, Fordyce CB, Gu X, Sherwood MW, Roettig ML, Corbett CC, Monk L, Tamis-Holland JE, Berger PB, Burchenal JEB, Wilson BH, Jollis JG, Granger CB. Impact of Regional Systems of Care on Disparities in Care Among Female and Black Patients Presenting With ST-Segment-Elevation Myocardial Infarction. J Am Heart Assoc 2017; 6:JAHA.117.007122. [PMID: 29066448 PMCID: PMC5721895 DOI: 10.1161/jaha.117.007122] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND The American Heart Association Mission: Lifeline STEMI (ST-segment-elevation myocardial infarction) Systems Accelerator program, conducted in 16 regions across the United States to improve key care processes, resulted in more patients being treated within national guideline goals (time from first medical contact to device: <90 minutes for direct presenters to hospitals capable of performing percutaneous coronary intervention; <120 minutes for transfers). We examined whether the effort reduced reperfusion disparities in the proportions of female versus male and black versus white patients. METHODS AND RESULTS In total, 23 809 patients (29.3% female, 82.3% white, and 10.7% black) presented with acute STEMI between July 2012 and March 2014. Change in the proportion of patients treated within guideline goals was compared between sex and race subgroups for patients presenting directly to hospitals capable of performing percutaneous coronary intervention (n=18 267) and patients requiring transfer (n=5542). The intervention was associated with an increase in the proportion of men treated within guideline goals that presented directly (58.7-62.1%, P=0.01) or were transferred (43.3-50.7%, P<0.01). An increase was also seen among white patients who presented directly (57.7-59.9%, P=0.02) or were transferred (43.9-48.8%, P<0.01). There was no change in the proportion of female or black patients treated within guideline goals, including both those presenting directly and transferred. CONCLUSION The STEMI Systems Accelerator project was associated with an increase in the proportion of patients meeting guideline reperfusion targets for male and white patients but not for female or black patients. Efforts to organize systems of STEMI care should implement additional processes targeting barriers to timely reperfusion among female and black patients.
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Affiliation(s)
- Tomoya T Hinohara
- Duke University Medical Center, Durham, NC.,Duke Clinical Research Institute, Durham, NC
| | - Hussein R Al-Khalidi
- Duke University Medical Center, Durham, NC.,Duke Clinical Research Institute, Durham, NC
| | - Christopher B Fordyce
- Duke University Medical Center, Durham, NC.,Duke Clinical Research Institute, Durham, NC
| | | | - Matthew W Sherwood
- Duke University Medical Center, Durham, NC.,Duke Clinical Research Institute, Durham, NC
| | | | | | - Lisa Monk
- Duke Clinical Research Institute, Durham, NC
| | | | - Peter B Berger
- Cardiovascular Center for Clinical Research, Danville, PA
| | | | - B Hadley Wilson
- Sanger Heart and Vascular Institute, Carolinas HealthCare System, Charlotte, NC
| | | | - Christopher B Granger
- Duke University Medical Center, Durham, NC .,Duke Clinical Research Institute, Durham, NC
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24
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van Diepen S, Girotra S, Abella BS, Becker LB, Bobrow BJ, Chan PS, Fahrenbruch C, Granger CB, Jollis JG, McNally B, White L, Yannopoulos D, Rea TD. Multistate 5-Year Initiative to Improve Care for Out-of-Hospital Cardiac Arrest: Primary Results From the HeartRescue Project. J Am Heart Assoc 2017; 6:JAHA.117.005716. [PMID: 28939711 PMCID: PMC5634254 DOI: 10.1161/jaha.117.005716] [Citation(s) in RCA: 45] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
Background The HeartRescue Project is a multistate public health initiative focused on establishing statewide out‐of‐hospital cardiac arrest (OHCA) systems of care to improve case capture and OHCA care in the community, by emergency medical services (EMS), and at hospital level. Methods and Results From 2011 to 2015 in the 5 original HeartRescue states, all adults with EMS–treated OHCA due to a presumed cardiac cause were included. In an adult population of 32.8 million, a total of 64 988 OHCAs—including 10 046 patients with a bystander‐witnessed OHCA with a shockable rhythm—were treated by 330 EMS agencies. From 2011 to 2015, the case‐capture rate for all‐rhythm OHCA increased from an estimated 39.0% (n=6762) to 89.2% (n=16 103; P<0.001 for trend). Overall survival to hospital discharge was 11.4% for all rhythms and 34.0% in the subgroup with bystander‐witnessed OHCA with a shockable rhythm. We observed modest temporal increases in bystander cardiopulmonary resuscitation (41.8–43.5%, P<0.001 for trend) and bystander automated external defibrillator application (3.2–5.6%, P<0.001 for trend) in the all‐rhythm group, although there were no temporal changes in survival. There were marked all‐rhythm survival differences across the 5 states (8.0–16.1%, P<0.001) and across participating EMS agencies (2.7–26.5%, P<0.001). Conclusions In the initial 5 years, the HeartRescue Project developed a population‐based OHCA registry and improved statewide case‐capture rates and some processes of care, although there were no early temporal changes in survival. The observed survival variation across states and EMS systems presents a future challenge to elucidate the characteristics of high‐performing systems with the goal of improving OHCA care and survival.
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Affiliation(s)
- Sean van Diepen
- Department of Critical Care and Division of Cardiology, University of Alberta, Edmonton, Alberta, Canada
| | - Saket Girotra
- Department of Internal Medicine, University of Iowa Carver College of Medicine, Iowa City, IA
| | - Benjamin S Abella
- Center for Resuscitation Science, University of Pennsylvania, Philadelphia, PA
| | | | | | - Paul S Chan
- Saint Luke's Mid America Heart Institute and University of Missouri-Kansas, Kansas City, MO
| | - Carol Fahrenbruch
- Division of Emergency Services, Public Health-Seattle & King County, Seattle, WA
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25
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Kragholm K, Malta Hansen C, Dupre ME, Xian Y, Strauss B, Tyson C, Monk L, Corbett C, Fordyce CB, Pearson DA, Fosbøl EL, Jollis JG, Abella BS, McNally B, Granger CB. Direct Transport to a Percutaneous Cardiac Intervention Center and Outcomes in Patients With Out-of-Hospital Cardiac Arrest. Circ Cardiovasc Qual Outcomes 2017; 10:CIRCOUTCOMES.116.003414. [DOI: 10.1161/circoutcomes.116.003414] [Citation(s) in RCA: 41] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/20/2016] [Accepted: 05/02/2017] [Indexed: 01/13/2023]
Affiliation(s)
- Kristian Kragholm
- From the Duke Clinical Research Institute, Durham, NC (K.K., C.M.H., M.E.D., Y.X., C.T., L.M., C.B.F., E.L.F., J.G.J., C.B.G.); Departments of Cardiology and Epidemiology/Biostatistics, Aalborg University Hospital, Denmark (K.K.); Department of Community and Family Medicine (M.E.D.), Nicholas School of the Environment (B.S.), Duke University, Durham, NC; Department of Neurology, Duke University Medical Center, Durham, NC (Y.X.); Center for Educational Excellence, Durham, NC (C.T.); New Hanover
| | - Carolina Malta Hansen
- From the Duke Clinical Research Institute, Durham, NC (K.K., C.M.H., M.E.D., Y.X., C.T., L.M., C.B.F., E.L.F., J.G.J., C.B.G.); Departments of Cardiology and Epidemiology/Biostatistics, Aalborg University Hospital, Denmark (K.K.); Department of Community and Family Medicine (M.E.D.), Nicholas School of the Environment (B.S.), Duke University, Durham, NC; Department of Neurology, Duke University Medical Center, Durham, NC (Y.X.); Center for Educational Excellence, Durham, NC (C.T.); New Hanover
| | - Matthew E. Dupre
- From the Duke Clinical Research Institute, Durham, NC (K.K., C.M.H., M.E.D., Y.X., C.T., L.M., C.B.F., E.L.F., J.G.J., C.B.G.); Departments of Cardiology and Epidemiology/Biostatistics, Aalborg University Hospital, Denmark (K.K.); Department of Community and Family Medicine (M.E.D.), Nicholas School of the Environment (B.S.), Duke University, Durham, NC; Department of Neurology, Duke University Medical Center, Durham, NC (Y.X.); Center for Educational Excellence, Durham, NC (C.T.); New Hanover
| | - Ying Xian
- From the Duke Clinical Research Institute, Durham, NC (K.K., C.M.H., M.E.D., Y.X., C.T., L.M., C.B.F., E.L.F., J.G.J., C.B.G.); Departments of Cardiology and Epidemiology/Biostatistics, Aalborg University Hospital, Denmark (K.K.); Department of Community and Family Medicine (M.E.D.), Nicholas School of the Environment (B.S.), Duke University, Durham, NC; Department of Neurology, Duke University Medical Center, Durham, NC (Y.X.); Center for Educational Excellence, Durham, NC (C.T.); New Hanover
| | - Benjamin Strauss
- From the Duke Clinical Research Institute, Durham, NC (K.K., C.M.H., M.E.D., Y.X., C.T., L.M., C.B.F., E.L.F., J.G.J., C.B.G.); Departments of Cardiology and Epidemiology/Biostatistics, Aalborg University Hospital, Denmark (K.K.); Department of Community and Family Medicine (M.E.D.), Nicholas School of the Environment (B.S.), Duke University, Durham, NC; Department of Neurology, Duke University Medical Center, Durham, NC (Y.X.); Center for Educational Excellence, Durham, NC (C.T.); New Hanover
| | - Clark Tyson
- From the Duke Clinical Research Institute, Durham, NC (K.K., C.M.H., M.E.D., Y.X., C.T., L.M., C.B.F., E.L.F., J.G.J., C.B.G.); Departments of Cardiology and Epidemiology/Biostatistics, Aalborg University Hospital, Denmark (K.K.); Department of Community and Family Medicine (M.E.D.), Nicholas School of the Environment (B.S.), Duke University, Durham, NC; Department of Neurology, Duke University Medical Center, Durham, NC (Y.X.); Center for Educational Excellence, Durham, NC (C.T.); New Hanover
| | - Lisa Monk
- From the Duke Clinical Research Institute, Durham, NC (K.K., C.M.H., M.E.D., Y.X., C.T., L.M., C.B.F., E.L.F., J.G.J., C.B.G.); Departments of Cardiology and Epidemiology/Biostatistics, Aalborg University Hospital, Denmark (K.K.); Department of Community and Family Medicine (M.E.D.), Nicholas School of the Environment (B.S.), Duke University, Durham, NC; Department of Neurology, Duke University Medical Center, Durham, NC (Y.X.); Center for Educational Excellence, Durham, NC (C.T.); New Hanover
| | - Claire Corbett
- From the Duke Clinical Research Institute, Durham, NC (K.K., C.M.H., M.E.D., Y.X., C.T., L.M., C.B.F., E.L.F., J.G.J., C.B.G.); Departments of Cardiology and Epidemiology/Biostatistics, Aalborg University Hospital, Denmark (K.K.); Department of Community and Family Medicine (M.E.D.), Nicholas School of the Environment (B.S.), Duke University, Durham, NC; Department of Neurology, Duke University Medical Center, Durham, NC (Y.X.); Center for Educational Excellence, Durham, NC (C.T.); New Hanover
| | - Christopher B. Fordyce
- From the Duke Clinical Research Institute, Durham, NC (K.K., C.M.H., M.E.D., Y.X., C.T., L.M., C.B.F., E.L.F., J.G.J., C.B.G.); Departments of Cardiology and Epidemiology/Biostatistics, Aalborg University Hospital, Denmark (K.K.); Department of Community and Family Medicine (M.E.D.), Nicholas School of the Environment (B.S.), Duke University, Durham, NC; Department of Neurology, Duke University Medical Center, Durham, NC (Y.X.); Center for Educational Excellence, Durham, NC (C.T.); New Hanover
| | - David A. Pearson
- From the Duke Clinical Research Institute, Durham, NC (K.K., C.M.H., M.E.D., Y.X., C.T., L.M., C.B.F., E.L.F., J.G.J., C.B.G.); Departments of Cardiology and Epidemiology/Biostatistics, Aalborg University Hospital, Denmark (K.K.); Department of Community and Family Medicine (M.E.D.), Nicholas School of the Environment (B.S.), Duke University, Durham, NC; Department of Neurology, Duke University Medical Center, Durham, NC (Y.X.); Center for Educational Excellence, Durham, NC (C.T.); New Hanover
| | - Emil L. Fosbøl
- From the Duke Clinical Research Institute, Durham, NC (K.K., C.M.H., M.E.D., Y.X., C.T., L.M., C.B.F., E.L.F., J.G.J., C.B.G.); Departments of Cardiology and Epidemiology/Biostatistics, Aalborg University Hospital, Denmark (K.K.); Department of Community and Family Medicine (M.E.D.), Nicholas School of the Environment (B.S.), Duke University, Durham, NC; Department of Neurology, Duke University Medical Center, Durham, NC (Y.X.); Center for Educational Excellence, Durham, NC (C.T.); New Hanover
| | - James G. Jollis
- From the Duke Clinical Research Institute, Durham, NC (K.K., C.M.H., M.E.D., Y.X., C.T., L.M., C.B.F., E.L.F., J.G.J., C.B.G.); Departments of Cardiology and Epidemiology/Biostatistics, Aalborg University Hospital, Denmark (K.K.); Department of Community and Family Medicine (M.E.D.), Nicholas School of the Environment (B.S.), Duke University, Durham, NC; Department of Neurology, Duke University Medical Center, Durham, NC (Y.X.); Center for Educational Excellence, Durham, NC (C.T.); New Hanover
| | - Benjamin S. Abella
- From the Duke Clinical Research Institute, Durham, NC (K.K., C.M.H., M.E.D., Y.X., C.T., L.M., C.B.F., E.L.F., J.G.J., C.B.G.); Departments of Cardiology and Epidemiology/Biostatistics, Aalborg University Hospital, Denmark (K.K.); Department of Community and Family Medicine (M.E.D.), Nicholas School of the Environment (B.S.), Duke University, Durham, NC; Department of Neurology, Duke University Medical Center, Durham, NC (Y.X.); Center for Educational Excellence, Durham, NC (C.T.); New Hanover
| | - Bryan McNally
- From the Duke Clinical Research Institute, Durham, NC (K.K., C.M.H., M.E.D., Y.X., C.T., L.M., C.B.F., E.L.F., J.G.J., C.B.G.); Departments of Cardiology and Epidemiology/Biostatistics, Aalborg University Hospital, Denmark (K.K.); Department of Community and Family Medicine (M.E.D.), Nicholas School of the Environment (B.S.), Duke University, Durham, NC; Department of Neurology, Duke University Medical Center, Durham, NC (Y.X.); Center for Educational Excellence, Durham, NC (C.T.); New Hanover
| | - Christopher B. Granger
- From the Duke Clinical Research Institute, Durham, NC (K.K., C.M.H., M.E.D., Y.X., C.T., L.M., C.B.F., E.L.F., J.G.J., C.B.G.); Departments of Cardiology and Epidemiology/Biostatistics, Aalborg University Hospital, Denmark (K.K.); Department of Community and Family Medicine (M.E.D.), Nicholas School of the Environment (B.S.), Duke University, Durham, NC; Department of Neurology, Duke University Medical Center, Durham, NC (Y.X.); Center for Educational Excellence, Durham, NC (C.T.); New Hanover
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26
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Masoudi FA, Ponirakis A, de Lemos JA, Jollis JG, Kremers M, Messenger JC, Moore JW, Moussa I, Oetgen WJ, Varosy PD, Vincent RN, Wei J, Curtis JP, Roe MT, Spertus JA. Trends in U.S. Cardiovascular Care. J Am Coll Cardiol 2017; 69:1427-1450. [DOI: 10.1016/j.jacc.2016.12.005] [Citation(s) in RCA: 167] [Impact Index Per Article: 23.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/18/2016] [Revised: 12/08/2016] [Accepted: 12/16/2016] [Indexed: 11/30/2022]
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27
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Jollis JG, Al-Khalidi HR, Roettig ML, Berger PB, Corbett CC, Dauerman HL, Fordyce CB, Fox K, Garvey JL, Gregory T, Henry TD, Rokos IC, Sherwood MW, Suter RE, Wilson BH, Granger CB. Regional Systems of Care Demonstration Project: American Heart Association Mission: Lifeline STEMI Systems Accelerator. Circulation 2016; 134:365-74. [PMID: 27482000 DOI: 10.1161/circulationaha.115.019474] [Citation(s) in RCA: 69] [Impact Index Per Article: 8.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/11/2015] [Accepted: 06/01/2016] [Indexed: 11/16/2022]
Abstract
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.
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Affiliation(s)
- James G Jollis
- From University of North Carolina, Chapel Hill (J.G.J.); Duke Clinical Research Institute, Duke University, Durham, NC (H.R.A.-K., M.L.R., C.B.F., K.F., M.W.S., C.B.G.); Northwell Health, New Hyde Park, NY (P.B.B.); New Hanover Regional Medical Center, Wilmington, NC (C.C.C.); University of Vermont College of Medicine, Burlington (H.L.D.); Department of Emergency Medicine, Carolinas Medical Center, Charlotte, NC (J.L.G.); American Heart Association, Dallas, TX (T.G., R.E.S.); Cedars-Sinai Heart Institute, Los Angeles, CA (T.D.H.); UCLA-Olive View Medical Center, Los Angeles, CA (I.C.R.); and Sanger Heart and Vascular Institute, Carolinas HealthCare System, Charlotte, NC (B.H.W.)
| | - Hussein R Al-Khalidi
- From University of North Carolina, Chapel Hill (J.G.J.); Duke Clinical Research Institute, Duke University, Durham, NC (H.R.A.-K., M.L.R., C.B.F., K.F., M.W.S., C.B.G.); Northwell Health, New Hyde Park, NY (P.B.B.); New Hanover Regional Medical Center, Wilmington, NC (C.C.C.); University of Vermont College of Medicine, Burlington (H.L.D.); Department of Emergency Medicine, Carolinas Medical Center, Charlotte, NC (J.L.G.); American Heart Association, Dallas, TX (T.G., R.E.S.); Cedars-Sinai Heart Institute, Los Angeles, CA (T.D.H.); UCLA-Olive View Medical Center, Los Angeles, CA (I.C.R.); and Sanger Heart and Vascular Institute, Carolinas HealthCare System, Charlotte, NC (B.H.W.)
| | - Mayme L Roettig
- From University of North Carolina, Chapel Hill (J.G.J.); Duke Clinical Research Institute, Duke University, Durham, NC (H.R.A.-K., M.L.R., C.B.F., K.F., M.W.S., C.B.G.); Northwell Health, New Hyde Park, NY (P.B.B.); New Hanover Regional Medical Center, Wilmington, NC (C.C.C.); University of Vermont College of Medicine, Burlington (H.L.D.); Department of Emergency Medicine, Carolinas Medical Center, Charlotte, NC (J.L.G.); American Heart Association, Dallas, TX (T.G., R.E.S.); Cedars-Sinai Heart Institute, Los Angeles, CA (T.D.H.); UCLA-Olive View Medical Center, Los Angeles, CA (I.C.R.); and Sanger Heart and Vascular Institute, Carolinas HealthCare System, Charlotte, NC (B.H.W.)
| | - Peter B Berger
- From University of North Carolina, Chapel Hill (J.G.J.); Duke Clinical Research Institute, Duke University, Durham, NC (H.R.A.-K., M.L.R., C.B.F., K.F., M.W.S., C.B.G.); Northwell Health, New Hyde Park, NY (P.B.B.); New Hanover Regional Medical Center, Wilmington, NC (C.C.C.); University of Vermont College of Medicine, Burlington (H.L.D.); Department of Emergency Medicine, Carolinas Medical Center, Charlotte, NC (J.L.G.); American Heart Association, Dallas, TX (T.G., R.E.S.); Cedars-Sinai Heart Institute, Los Angeles, CA (T.D.H.); UCLA-Olive View Medical Center, Los Angeles, CA (I.C.R.); and Sanger Heart and Vascular Institute, Carolinas HealthCare System, Charlotte, NC (B.H.W.)
| | - Claire C Corbett
- From University of North Carolina, Chapel Hill (J.G.J.); Duke Clinical Research Institute, Duke University, Durham, NC (H.R.A.-K., M.L.R., C.B.F., K.F., M.W.S., C.B.G.); Northwell Health, New Hyde Park, NY (P.B.B.); New Hanover Regional Medical Center, Wilmington, NC (C.C.C.); University of Vermont College of Medicine, Burlington (H.L.D.); Department of Emergency Medicine, Carolinas Medical Center, Charlotte, NC (J.L.G.); American Heart Association, Dallas, TX (T.G., R.E.S.); Cedars-Sinai Heart Institute, Los Angeles, CA (T.D.H.); UCLA-Olive View Medical Center, Los Angeles, CA (I.C.R.); and Sanger Heart and Vascular Institute, Carolinas HealthCare System, Charlotte, NC (B.H.W.)
| | - Harold L Dauerman
- From University of North Carolina, Chapel Hill (J.G.J.); Duke Clinical Research Institute, Duke University, Durham, NC (H.R.A.-K., M.L.R., C.B.F., K.F., M.W.S., C.B.G.); Northwell Health, New Hyde Park, NY (P.B.B.); New Hanover Regional Medical Center, Wilmington, NC (C.C.C.); University of Vermont College of Medicine, Burlington (H.L.D.); Department of Emergency Medicine, Carolinas Medical Center, Charlotte, NC (J.L.G.); American Heart Association, Dallas, TX (T.G., R.E.S.); Cedars-Sinai Heart Institute, Los Angeles, CA (T.D.H.); UCLA-Olive View Medical Center, Los Angeles, CA (I.C.R.); and Sanger Heart and Vascular Institute, Carolinas HealthCare System, Charlotte, NC (B.H.W.)
| | - Christopher B Fordyce
- From University of North Carolina, Chapel Hill (J.G.J.); Duke Clinical Research Institute, Duke University, Durham, NC (H.R.A.-K., M.L.R., C.B.F., K.F., M.W.S., C.B.G.); Northwell Health, New Hyde Park, NY (P.B.B.); New Hanover Regional Medical Center, Wilmington, NC (C.C.C.); University of Vermont College of Medicine, Burlington (H.L.D.); Department of Emergency Medicine, Carolinas Medical Center, Charlotte, NC (J.L.G.); American Heart Association, Dallas, TX (T.G., R.E.S.); Cedars-Sinai Heart Institute, Los Angeles, CA (T.D.H.); UCLA-Olive View Medical Center, Los Angeles, CA (I.C.R.); and Sanger Heart and Vascular Institute, Carolinas HealthCare System, Charlotte, NC (B.H.W.)
| | - Kathleen Fox
- From University of North Carolina, Chapel Hill (J.G.J.); Duke Clinical Research Institute, Duke University, Durham, NC (H.R.A.-K., M.L.R., C.B.F., K.F., M.W.S., C.B.G.); Northwell Health, New Hyde Park, NY (P.B.B.); New Hanover Regional Medical Center, Wilmington, NC (C.C.C.); University of Vermont College of Medicine, Burlington (H.L.D.); Department of Emergency Medicine, Carolinas Medical Center, Charlotte, NC (J.L.G.); American Heart Association, Dallas, TX (T.G., R.E.S.); Cedars-Sinai Heart Institute, Los Angeles, CA (T.D.H.); UCLA-Olive View Medical Center, Los Angeles, CA (I.C.R.); and Sanger Heart and Vascular Institute, Carolinas HealthCare System, Charlotte, NC (B.H.W.)
| | - J Lee Garvey
- From University of North Carolina, Chapel Hill (J.G.J.); Duke Clinical Research Institute, Duke University, Durham, NC (H.R.A.-K., M.L.R., C.B.F., K.F., M.W.S., C.B.G.); Northwell Health, New Hyde Park, NY (P.B.B.); New Hanover Regional Medical Center, Wilmington, NC (C.C.C.); University of Vermont College of Medicine, Burlington (H.L.D.); Department of Emergency Medicine, Carolinas Medical Center, Charlotte, NC (J.L.G.); American Heart Association, Dallas, TX (T.G., R.E.S.); Cedars-Sinai Heart Institute, Los Angeles, CA (T.D.H.); UCLA-Olive View Medical Center, Los Angeles, CA (I.C.R.); and Sanger Heart and Vascular Institute, Carolinas HealthCare System, Charlotte, NC (B.H.W.)
| | - Tammy Gregory
- From University of North Carolina, Chapel Hill (J.G.J.); Duke Clinical Research Institute, Duke University, Durham, NC (H.R.A.-K., M.L.R., C.B.F., K.F., M.W.S., C.B.G.); Northwell Health, New Hyde Park, NY (P.B.B.); New Hanover Regional Medical Center, Wilmington, NC (C.C.C.); University of Vermont College of Medicine, Burlington (H.L.D.); Department of Emergency Medicine, Carolinas Medical Center, Charlotte, NC (J.L.G.); American Heart Association, Dallas, TX (T.G., R.E.S.); Cedars-Sinai Heart Institute, Los Angeles, CA (T.D.H.); UCLA-Olive View Medical Center, Los Angeles, CA (I.C.R.); and Sanger Heart and Vascular Institute, Carolinas HealthCare System, Charlotte, NC (B.H.W.)
| | - Timothy D Henry
- From University of North Carolina, Chapel Hill (J.G.J.); Duke Clinical Research Institute, Duke University, Durham, NC (H.R.A.-K., M.L.R., C.B.F., K.F., M.W.S., C.B.G.); Northwell Health, New Hyde Park, NY (P.B.B.); New Hanover Regional Medical Center, Wilmington, NC (C.C.C.); University of Vermont College of Medicine, Burlington (H.L.D.); Department of Emergency Medicine, Carolinas Medical Center, Charlotte, NC (J.L.G.); American Heart Association, Dallas, TX (T.G., R.E.S.); Cedars-Sinai Heart Institute, Los Angeles, CA (T.D.H.); UCLA-Olive View Medical Center, Los Angeles, CA (I.C.R.); and Sanger Heart and Vascular Institute, Carolinas HealthCare System, Charlotte, NC (B.H.W.)
| | - Ivan C Rokos
- From University of North Carolina, Chapel Hill (J.G.J.); Duke Clinical Research Institute, Duke University, Durham, NC (H.R.A.-K., M.L.R., C.B.F., K.F., M.W.S., C.B.G.); Northwell Health, New Hyde Park, NY (P.B.B.); New Hanover Regional Medical Center, Wilmington, NC (C.C.C.); University of Vermont College of Medicine, Burlington (H.L.D.); Department of Emergency Medicine, Carolinas Medical Center, Charlotte, NC (J.L.G.); American Heart Association, Dallas, TX (T.G., R.E.S.); Cedars-Sinai Heart Institute, Los Angeles, CA (T.D.H.); UCLA-Olive View Medical Center, Los Angeles, CA (I.C.R.); and Sanger Heart and Vascular Institute, Carolinas HealthCare System, Charlotte, NC (B.H.W.)
| | - Matthew W Sherwood
- From University of North Carolina, Chapel Hill (J.G.J.); Duke Clinical Research Institute, Duke University, Durham, NC (H.R.A.-K., M.L.R., C.B.F., K.F., M.W.S., C.B.G.); Northwell Health, New Hyde Park, NY (P.B.B.); New Hanover Regional Medical Center, Wilmington, NC (C.C.C.); University of Vermont College of Medicine, Burlington (H.L.D.); Department of Emergency Medicine, Carolinas Medical Center, Charlotte, NC (J.L.G.); American Heart Association, Dallas, TX (T.G., R.E.S.); Cedars-Sinai Heart Institute, Los Angeles, CA (T.D.H.); UCLA-Olive View Medical Center, Los Angeles, CA (I.C.R.); and Sanger Heart and Vascular Institute, Carolinas HealthCare System, Charlotte, NC (B.H.W.)
| | - Robert E Suter
- From University of North Carolina, Chapel Hill (J.G.J.); Duke Clinical Research Institute, Duke University, Durham, NC (H.R.A.-K., M.L.R., C.B.F., K.F., M.W.S., C.B.G.); Northwell Health, New Hyde Park, NY (P.B.B.); New Hanover Regional Medical Center, Wilmington, NC (C.C.C.); University of Vermont College of Medicine, Burlington (H.L.D.); Department of Emergency Medicine, Carolinas Medical Center, Charlotte, NC (J.L.G.); American Heart Association, Dallas, TX (T.G., R.E.S.); Cedars-Sinai Heart Institute, Los Angeles, CA (T.D.H.); UCLA-Olive View Medical Center, Los Angeles, CA (I.C.R.); and Sanger Heart and Vascular Institute, Carolinas HealthCare System, Charlotte, NC (B.H.W.)
| | - B Hadley Wilson
- From University of North Carolina, Chapel Hill (J.G.J.); Duke Clinical Research Institute, Duke University, Durham, NC (H.R.A.-K., M.L.R., C.B.F., K.F., M.W.S., C.B.G.); Northwell Health, New Hyde Park, NY (P.B.B.); New Hanover Regional Medical Center, Wilmington, NC (C.C.C.); University of Vermont College of Medicine, Burlington (H.L.D.); Department of Emergency Medicine, Carolinas Medical Center, Charlotte, NC (J.L.G.); American Heart Association, Dallas, TX (T.G., R.E.S.); Cedars-Sinai Heart Institute, Los Angeles, CA (T.D.H.); UCLA-Olive View Medical Center, Los Angeles, CA (I.C.R.); and Sanger Heart and Vascular Institute, Carolinas HealthCare System, Charlotte, NC (B.H.W.)
| | - Christopher B Granger
- From University of North Carolina, Chapel Hill (J.G.J.); Duke Clinical Research Institute, Duke University, Durham, NC (H.R.A.-K., M.L.R., C.B.F., K.F., M.W.S., C.B.G.); Northwell Health, New Hyde Park, NY (P.B.B.); New Hanover Regional Medical Center, Wilmington, NC (C.C.C.); University of Vermont College of Medicine, Burlington (H.L.D.); Department of Emergency Medicine, Carolinas Medical Center, Charlotte, NC (J.L.G.); American Heart Association, Dallas, TX (T.G., R.E.S.); Cedars-Sinai Heart Institute, Los Angeles, CA (T.D.H.); UCLA-Olive View Medical Center, Los Angeles, CA (I.C.R.); and Sanger Heart and Vascular Institute, Carolinas HealthCare System, Charlotte, NC (B.H.W.).
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Bosson N, Sanko S, Stickney RE, Niemann J, French WJ, Jollis JG, Kontos MC, Taylor TG, Macfarlane PW, Tadeo R, Koenig W, Eckstein M. Causes of Prehospital Misinterpretations of ST Elevation Myocardial Infarction. PREHOSP EMERG CARE 2016; 21:283-290. [DOI: 10.1080/10903127.2016.1247200] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
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Pearson DA, Darrell Nelson R, Monk L, Tyson C, Jollis JG, Granger CB, Corbett C, Garvey L, Runyon MS. Comparison of team-focused CPR vs standard CPR in resuscitation from out-of-hospital cardiac arrest: Results from a statewide quality improvement initiative. Resuscitation 2016; 105:165-72. [DOI: 10.1016/j.resuscitation.2016.04.008] [Citation(s) in RCA: 37] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2015] [Revised: 03/29/2016] [Accepted: 04/11/2016] [Indexed: 10/21/2022]
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Mathews R, Fonarow GC, Li S, Peterson ED, Rumsfeld JS, Heidenreich PA, Roe MT, Oetgen WJ, Jollis JG, Cannon CP, de Lemos JA, Wang TY. Comparison of performance on Hospital Compare process measures and patient outcomes between hospitals that do and do not participate in Acute Coronary Treatment and Intervention Outcomes Network Registry-Get With The Guidelines. Am Heart J 2016; 175:1-8. [PMID: 27179718 DOI: 10.1016/j.ahj.2016.01.008] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/23/2015] [Accepted: 01/20/2016] [Indexed: 11/26/2022]
Abstract
BACKGROUND Acute Coronary Treatment and Intervention Outcomes Network Registry-Get With The Guidelines (ACTION Registry-GWTG) was designed to measure and improve the treatment and outcomes of patients with acute myocardial infarction (AMI), yet it is unknown whether performance of Medicare Hospital Compare metrics and outcomes differ between hospitals participating versus those not participating in the registry. METHODS Using 2007 to 2010 Hospital Compare data, we matched participating to nonparticipating hospitals based on teaching status, size, percutaneous coronary intervention capability, and baseline (2007) Hospital Compare AMI process measure performance. We used linear mixed modeling to compare 2010 Hospital Compare process measure adherence, 30-day risk-adjusted mortality, and readmission rates. We repeated these analyses after stratification according to baseline performance level. RESULTS Compared with nonparticipating hospitals, those participating were larger (median 288 vs 139 beds, P < .0001), more often teaching hospitals (18.8% vs 6.3%, P < .0001), and more likely had interventional catheterization lab capabilities (85.7% vs 34.0%, P < .0001). Among 502 matched pairs of participating and nonparticipating hospitals, we found high levels of process measure adherence in both 2007 and 2010, with minimal differences between them. Rates of 30-day mortality and readmission in 2010 were also similar between both groups. Results were consistent across strata of baseline performance level. CONCLUSIONS In this observational analysis, there were no significant differences in the performance of Hospital Compare process measures or outcomes between hospitals in Acute Coronary Treatment and Intervention Outcomes Network Registry-Get With The Guidelines and other hospitals not in the registry. However, baseline performance on the Hospital Compare process measures was very high in both groups, suggesting the need for new quality improvement foci to further improve patient outcomes.
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Fordyce CB, Hansen CM, Kragholm K, Jollis JG, Roettig ML, Dupre ME, Becker LB, Corbett CC, Monk L, Nelson RD, Pearson DA, Tyson C, Van Diepen S, Anderson ML, McNally B, Granger CB. STATEWIDE INITIATIVES IMPROVE THE CARE AND OUTCOMES OF PATIENTS WITH OUT-OF-HOSPITAL CARDIAC ARREST AT HOME AND IN PUBLIC LOCATIONS: RESULTS FROM THE HEARTRESCUE PROJECT. J Am Coll Cardiol 2016. [DOI: 10.1016/s0735-1097(16)30807-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
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Rao MP, Dupre ME, Pokorney SD, Hansen CM, Tyson C, Monk L, Pearson DA, Nelson RD, Myers B, Jollis JG, Granger CB. Therapeutic Hypothermia for Patients with Out-of-Hospital Cardiac Arrest in North Carolina. PREHOSP EMERG CARE 2016; 20:630-6. [DOI: 10.3109/10903127.2016.1142627] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
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Malta Hansen C, Jollis JG, Granger CB. Initial Interventions for Out-of-Hospital Cardiac Arrest--Reply. JAMA 2015; 314:2414. [PMID: 26647268 DOI: 10.1001/jama.2015.13206] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Affiliation(s)
| | - James G Jollis
- Duke Clinical Research Institute, Durham, North Carolina
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Hansen CM, Kragholm K, Granger CB, Pearson DA, Tyson C, Monk L, Corbett C, Nelson RD, Dupre ME, Fosbøl EL, Strauss B, Fordyce CB, McNally B, Jollis JG. The role of bystanders, first responders, and emergency medical service providers in timely defibrillation and related outcomes after out-of-hospital cardiac arrest: Results from a statewide registry. Resuscitation 2015; 96:303-9. [DOI: 10.1016/j.resuscitation.2015.09.002] [Citation(s) in RCA: 75] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2015] [Revised: 08/17/2015] [Accepted: 09/08/2015] [Indexed: 10/23/2022]
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Neumar RW, Eigel B, Callaway CW, Estes NM, Jollis JG, Kleinman ME, Morrison LJ, Peberdy MA, Rabinstein A, Rea TD, Sendelbach S. American Heart Association Response to the 2015 Institute of Medicine Report on Strategies to Improve Cardiac Arrest Survival. Circulation 2015; 132:1049-70. [DOI: 10.1161/cir.0000000000000233] [Citation(s) in RCA: 42] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
The American Heart Association (AHA) commends the recently released Institute of Medicine (IOM) report,
Strategies to Improve Cardiac Arrest Survival: A Time to Act
(2015). The AHA recognizes the unique opportunity created by the report to meaningfully advance the objectives of improving outcomes for sudden cardiac arrest. For decades, the AHA has focused on the goal of reducing morbidity and mortality from cardiovascular disease though robust support of basic, translational, clinical, and population research. The AHA also has developed a rigorous process using the best available evidence to develop scientific, advisory, and guideline documents. These core activities of development and dissemination of scientific evidence have served as the foundation for a broad range of advocacy initiatives and programs that serve as a foundation for advancing the AHA and IOM goal of improving cardiac arrest outcomes. In response to the call to action in the IOM report, the AHA is announcing 4 new commitments to increase cardiac arrest survival: (1) The AHA will provide up to $5 million in funding over 5 years to incentivize resuscitation data interoperability; (2) the AHA will actively pursue philanthropic support for local and regional implementation opportunities to increase cardiac arrest survival by improving out-of-hospital and in-hospital systems of care; (3) the AHA will actively pursue philanthropic support to launch an AHA resuscitation research network; and (4) the AHA will cosponsor a National Cardiac Arrest Summit to facilitate the creation of a national cardiac arrest collaborative that will unify the field and identify common goals to improve survival. In addition to the AHA’s historic and ongoing commitment to improving cardiac arrest care and outcomes, these new initiatives are responsive to each of the IOM recommendations and demonstrate the AHA’s leadership in the field. However, successful implementation of the IOM recommendations will require a timely response by all stakeholders identified in the report and a coordinated approach to achieve our common goal of improved cardiac arrest outcomes.
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Malta Hansen C, Kragholm K, Pearson DA, Tyson C, Monk L, Myers B, Nelson D, Dupre ME, Fosbøl EL, Jollis JG, Strauss B, Anderson ML, McNally B, Granger CB. Association of Bystander and First-Responder Intervention With Survival After Out-of-Hospital Cardiac Arrest in North Carolina, 2010-2013. JAMA 2015. [PMID: 26197186 DOI: 10.1001/jama.2015.7938] [Citation(s) in RCA: 290] [Impact Index Per Article: 32.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
IMPORTANCE Out-of-hospital cardiac arrest is associated with low survival, but early cardiopulmonary resuscitation (CPR) and defibrillation can improve outcomes if more widely adopted. OBJECTIVE To examine temporal changes in bystander and first-responder resuscitation efforts before arrival of the emergency medical services (EMS) following statewide initiatives to improve bystander and first-responder efforts in North Carolina from 2010-2013 and to examine the association between bystander and first-responder resuscitation efforts and survival and neurological outcome. DESIGN, SETTINGS, AND PARTICIPANTS We studied 4961 patients with out-of-hospital cardiac arrest for whom resuscitation was attempted and who were identified through the Cardiac Arrest Registry to Enhance Survival (2010-2013). First responders were dispatched police officers, firefighters, rescue squad, or life-saving crew trained to perform basic life support until arrival of the EMS. EXPOSURES Statewide initiatives to improve bystander and first-responder interventions included training members of the general population in CPR and in use of automated external defibrillators (AEDs), training first responders in team-based CPR including AED use and high-performance CPR, and training dispatch centers in recognition of cardiac arrest. MAIN OUTCOMES AND MEASURES The proportion of bystander and first-responder resuscitation efforts, including the combination of efforts between bystanders and first responders, from 2010 through 2013 and the association between these resuscitation efforts and survival and neurological outcome. RESULTS The combination of bystander CPR and first-responder defibrillation increased from 14.1% (51 of 362; 95% CI, 10.9%-18.1%) in 2010 to 23.1% (104 of 451; 95% CI, 19.4%-27.2%) in 2013 (P < .01). Survival with favorable neurological outcome increased from 7.1% (82 of 1149; 95% CI, 5.8%-8.8%) in 2010 to 9.7% (129 of 1334; 95% CI, 8.2%-11.4%) in 2013 (P = .02) and was associated with bystander-initiated CPR. Adjusting for age and sex, bystander and first-responder interventions were associated with higher survival to hospital discharge. Survival following EMS-initiated CPR and defibrillation was 15.2% (30 of 198; 95% CI, 10.8%-20.9%) compared with 33.6% (38 of 113; 95% CI, 25.5%-42.9%) following bystander-initiated CPR and defibrillation (odds ratio [OR], 3.12; 95% CI, 1.78-5.46); 24.2% (83 of 343; 95% CI, 20.0%-29.0%) following bystander CPR and first-responder defibrillation (OR, 1.70; 95% CI, 1.06-2.71); and 25.2% (109 of 432; 95% CI, 21.4%-29.6%) following first-responder CPR and defibrillation (OR, 1.77; 95% CI, 1.13-2.77). CONCLUSIONS AND RELEVANCE Following a statewide educational intervention on rescusitation training, the proportion of patients receiving bystander-initiated CPR and defibrillation by first responders increased and was associated with greater likelihood of survival. Bystander-initiated CPR was associated with greater likelihood of survival with favorable neurological outcome.
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Affiliation(s)
| | | | | | - Clark Tyson
- Duke Clinical Research Institute, Durham, North Carolina3Center for Educational Excellence, Durham, North Carolina
| | - Lisa Monk
- Duke Clinical Research Institute, Durham, North Carolina
| | | | | | - Matthew E Dupre
- Duke Clinical Research Institute, Durham, North Carolina6Department of Community and Family Medicine, Duke University, Durham, North Carolina
| | - Emil L Fosbøl
- Duke Clinical Research Institute, Durham, North Carolina7The Heart Center, University Hospital of Copenhagen, Rigshospitalet, Denmark
| | - James G Jollis
- Duke Clinical Research Institute, Durham, North Carolina
| | - Benjamin Strauss
- Nicholas School of the Environment, Duke University, Durham, North Carolina
| | | | - Bryan McNally
- Emory University School of Medicine, Atlanta, Georgia10Rollins School of Public Health, Emory University, Atlanta, Georgia
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Kontos MC, Scirica BM, Chen AY, Thomas L, Anderson ML, Diercks DB, Jollis JG, Roe MT. Cardiac arrest and clinical characteristics, treatments and outcomes among patients hospitalized with ST-elevation myocardial infarction in contemporary practice: A report from the National Cardiovascular Data Registry. Am Heart J 2015; 169:515-22.e1. [PMID: 25819858 DOI: 10.1016/j.ahj.2015.01.010] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/04/2014] [Accepted: 01/20/2015] [Indexed: 12/22/2022]
Abstract
BACKGROUND Cardiac arrest (CA) is a major complication of patients with ST-elevation myocardial infarction (STEMI). Its prevalence and prognostic impact in contemporary US practice has not been well assessed. METHODS We evaluated STEMI patients included in the National Cardiovascular Data Registry (NCDR) Acute Coronary Treatment Intervention Outcomes Network Registry-Get With the Guidelines (ACTION Registry-GWTG) from 4/1/11 to 6/30/12. Patient clinical characteristics, treatments, and inhospital outcomes were compared by the presence or absence of CA on first medical contact-either before hospital arrival or upon presentation to the ACTION hospital. RESULTS Of the 49,279 STEMI patients included, 3,716 (7.5%) had CA. Cardiac arrest patients were more likely to have heart failure (15.5% vs 6.9%) and shock (42.9% vs 4.9%) on presentation and higher median (25th and 75th percentiles) ACTION Registry-GWTG mortality risk scores (42 [32, 54] vs 32 [26, 38]) than non-CA patients (all P < .001). Primary percutaneous coronary intervention was performed in most patients with and without CA (76.7% vs 79.1%). Inhospital mortality was significantly higher in patients with than without CA (28.8% vs 4.0%; P < .001), both in patients who presented with cardiogenic shock (46.9% vs 27.1%; P < .001) and those without shock (15.4% vs 2.9%; P < .001). The ACTION Registry-GWTG inhospital mortality model underestimated mortality risk in CA patients; however, prediction significantly improved after adding CA to the model. CONCLUSIONS Almost 8% of STEMI patients present with CA. More than 25% die during the hospitalization, despite high use of primary percutaneous coronary intervention. Cardiogenic shock and CA frequently coexist. Our results suggest that development of systems of care and treatments for both STEMI and CA is needed to reduce the high mortality in these patients.
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Ersboll M, Schulte PJ, Al Enezi F, Shaw L, Køber L, Kisslo J, Siddiqui I, Piccini J, Glower D, Harrison JK, Bashore T, Risum N, Jollis JG, Velazquez EJ, Samad Z. Predictors and progression of aortic stenosis in patients with preserved left ventricular ejection fraction. Am J Cardiol 2015; 115:86-92. [PMID: 25456876 DOI: 10.1016/j.amjcard.2014.09.049] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/12/2014] [Revised: 09/26/2014] [Accepted: 09/26/2014] [Indexed: 11/28/2022]
Abstract
We aimed to characterize the hemodynamic progression of aortic stenosis (AS) in a contemporary unselected cohort of patients with preserved left ventricular ejection fraction. Current guidelines recommend echocardiographic surveillance of hemodynamic progression. However, limited data exist on the expected rate of progression and whether clinical variables are associated with accelerated progression in contemporarily managed patients with AS. We conducted a retrospective analysis of patients presenting with AS and explored the trajectory of AS mean gradient over time using generalized estimating equations and fit a longitudinal linear regression model with adjustment for baseline clinical variables. A total of 1,558 patients (median age 72; interquartile range 65 to 79) having mild (n = 982), moderate (n = 363), or severe AS (n = 213) were included. In patients with mild AS at baseline (n = 983), 303 (31%) had progressed to moderate/severe AS/AVR within 5 years of the index echo. In patients with moderate AS, 159 of 363 (44%) had progressed to severe AS/AVR within 2 years of the index echo. The annual change in mean gradient was dependent on baseline AS severity. Average annual increases in mean gradient were 6.8% (95% confidence interval 6.0 to 7.6) and 7.1% (95% confidence interval 4.8 to 9.3) in patients with mild and moderate AS, respectively. In the subset of patients with mild AS at baseline, age (p = 0.0310) and gender (p = 0.0270) had significant interaction with change in mean gradient over time. In patients with moderate AS, age (p <0.0001), gender (p = 0.0346), renal dysfunction (p = 0.0036), and hyperlipidemia (p = 0.0010) demonstrated significant interaction with change in mean gradient over time. In conclusion, although average disease progression was slower than previously reported, a significant proportion of patients with mild and moderate AS progressed to higher grades within the currently recommended time windows for echocardiographic follow-up.
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Affiliation(s)
- Mads Ersboll
- Division of Cardiology, Department of Medicine, Duke University Medical Center, Durham, North Carolina; The Heart Center, Department of Cardiology, University of Copenhagen, Rigshospitalet, Denmark
| | - Phillip J Schulte
- The Duke Clinical Research Institute, Duke University Medical Center, Durham, North Carolina
| | - Fawaz Al Enezi
- Division of Cardiology, Department of Medicine, Duke University Medical Center, Durham, North Carolina
| | - Linda Shaw
- The Duke Clinical Research Institute, Duke University Medical Center, Durham, North Carolina
| | - Lars Køber
- The Heart Center, Department of Cardiology, University of Copenhagen, Rigshospitalet, Denmark
| | - Joseph Kisslo
- Division of Cardiology, Department of Medicine, Duke University Medical Center, Durham, North Carolina
| | - Irfan Siddiqui
- Division of Cardiology, Department of Medicine, Duke University Medical Center, Durham, North Carolina
| | - Jonathan Piccini
- Division of Cardiology, Department of Medicine, Duke University Medical Center, Durham, North Carolina
| | - Donald Glower
- Division of Cardiology, Department of Medicine, Duke University Medical Center, Durham, North Carolina
| | - J Kevin Harrison
- Division of Cardiology, Department of Medicine, Duke University Medical Center, Durham, North Carolina
| | - Thomas Bashore
- Division of Cardiology, Department of Medicine, Duke University Medical Center, Durham, North Carolina
| | - Niels Risum
- Division of Cardiology, Department of Medicine, Duke University Medical Center, Durham, North Carolina
| | - James G Jollis
- Division of Cardiology, Department of Medicine, Duke University Medical Center, Durham, North Carolina
| | - Eric J Velazquez
- Division of Cardiology, Department of Medicine, Duke University Medical Center, Durham, North Carolina; The Duke Clinical Research Institute, Duke University Medical Center, Durham, North Carolina
| | - Zainab Samad
- Division of Cardiology, Department of Medicine, Duke University Medical Center, Durham, North Carolina.
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Nicholson BD, Dhindsa HS, Roe MT, Chen AY, Jollis JG, Kontos MC. Relationship of the distance between non-PCI hospitals and primary PCI centers, mode of transport, and reperfusion time among ground and air interhospital transfers using NCDR's ACTION Registry-GWTG: a report from the American Heart Association Mission: Lifeline Program. Circ Cardiovasc Interv 2014; 7:797-805. [PMID: 25406204 DOI: 10.1161/circinterventions.113.001307] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND ST-segment myocardial infarction patients frequently present to non-percutaneous coronary intervention (PCI) hospitals and require interhospital transfer for primary PCI. The effect of distance and mode of transport to the PCI center and the frequency that recommended primary PCI times are met are not clear. METHODS AND RESULTS Data from the ACTION Registry(®)-GWTG™ were used to determine the distance between the Non-PCI and PCI center and first door time to balloon time based on transfer mode (ground and air) for patients having interhospital transfer for primary PCI. From July 1, 2008, to December 31, 2012, 17 052 ST-segment myocardial infarction patients were transferred to 413 PCI hospitals. The median distance from the non-PCI hospital to the primary PCI center was 31.9 miles (Q1, Q3: 19.1, 47.9; ground 25.2 miles; air 43.9 miles; P<0.001). At distances <40 miles, ground transport was the primary transport method, whereas at distances >40 miles air transport predominanted. Median first door time to balloon time time for patients transferred for primary PCI was 118 minutes (Q1, Q3: 95 152), with time for patients transported by air significantly longer (median 124 versus 113 minutes; respectively, P<0.001) than for patients transported by ground. Fifty-three percent of patients had a first door time to balloon time ≤120 minutes, with only 20% ≤90 minutes. A first door time to balloon time ≤120 minutes was more likely in ground than in air transport patients (57.0% versus 45.6%; P<0.001). CONCLUSIONS Interhospital transfer for primary PCI is associated with prolonged reperfusion times. These delays should prompt increased consideration of fibrinolytic therapy, emergency medical services hospital bypass protocols, and improved systems of care for ST-segment myocardial infarction patients requiring transfer.
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Affiliation(s)
- Benjamin D Nicholson
- From the Virginia Commonwealth University (B.D.N.), Department of Emergency Medicine (H.S.D.), and Department of Internal Medicine (M.C.K.), Richmond, VA; and Duke Clinical Research Institute, Duke University Medical Center, Durham, NC (M.T.R., A.Y.C., J.G.J.); and on behalf of the NCDR
| | - Harinder S Dhindsa
- From the Virginia Commonwealth University (B.D.N.), Department of Emergency Medicine (H.S.D.), and Department of Internal Medicine (M.C.K.), Richmond, VA; and Duke Clinical Research Institute, Duke University Medical Center, Durham, NC (M.T.R., A.Y.C., J.G.J.); and on behalf of the NCDR
| | - Matthew T Roe
- From the Virginia Commonwealth University (B.D.N.), Department of Emergency Medicine (H.S.D.), and Department of Internal Medicine (M.C.K.), Richmond, VA; and Duke Clinical Research Institute, Duke University Medical Center, Durham, NC (M.T.R., A.Y.C., J.G.J.); and on behalf of the NCDR
| | - Anita Y Chen
- From the Virginia Commonwealth University (B.D.N.), Department of Emergency Medicine (H.S.D.), and Department of Internal Medicine (M.C.K.), Richmond, VA; and Duke Clinical Research Institute, Duke University Medical Center, Durham, NC (M.T.R., A.Y.C., J.G.J.); and on behalf of the NCDR
| | - James G Jollis
- From the Virginia Commonwealth University (B.D.N.), Department of Emergency Medicine (H.S.D.), and Department of Internal Medicine (M.C.K.), Richmond, VA; and Duke Clinical Research Institute, Duke University Medical Center, Durham, NC (M.T.R., A.Y.C., J.G.J.); and on behalf of the NCDR
| | - Michael C Kontos
- From the Virginia Commonwealth University (B.D.N.), Department of Emergency Medicine (H.S.D.), and Department of Internal Medicine (M.C.K.), Richmond, VA; and Duke Clinical Research Institute, Duke University Medical Center, Durham, NC (M.T.R., A.Y.C., J.G.J.); and on behalf of the NCDR.
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Fosbøl EL, Dupre ME, Strauss B, Swanson DR, Myers B, McNally BF, Anderson ML, Bagai A, Monk L, Garvey JL, Bitner M, Jollis JG, Granger CB. Association of neighborhood characteristics with incidence of out-of-hospital cardiac arrest and rates of bystander-initiated CPR: Implications for community-based education intervention. Resuscitation 2014; 85:1512-7. [DOI: 10.1016/j.resuscitation.2014.08.013] [Citation(s) in RCA: 51] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2014] [Revised: 08/05/2014] [Accepted: 08/11/2014] [Indexed: 10/24/2022]
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Bagai A, Jollis JG, Dauerman HL, Peng SA, Rokos IC, Bates ER, French WJ, Granger CB, Roe MT. Response to letter regarding article, "Emergency department bypass for ST-segment-elevation myocardial infarction patients identified with a prehospital electrocardiogram: a report from the American Heart Association Mission: Lifeline Program". Circulation 2014; 129:e372. [PMID: 24589703 DOI: 10.1161/circulationaha.113.008027] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Akshay Bagai
- St. Michael's Hospital, University of Toronto, Toronto, ON, Canada
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Bagai A, Al-Khalidi HR, Sherwood MW, Muñoz D, Roettig ML, Jollis JG, Granger CB. Regional systems of care demonstration project: Mission: Lifeline STEMI Systems Accelerator: design and methodology. Am Heart J 2014; 167:15-21.e3. [PMID: 24332137 DOI: 10.1016/j.ahj.2013.10.005] [Citation(s) in RCA: 37] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/19/2013] [Accepted: 10/14/2013] [Indexed: 10/26/2022]
Abstract
ST-segment elevation myocardial infarction (STEMI) systems of care have been associated with significant improvement in use and timeliness of reperfusion. Consequently, national guidelines recommend that each community should develop a regional STEMI care system. However, significant barriers continue to impede widespread establishment of regional STEMI care systems in the United States. We designed the Regional Systems of Care Demonstration Project: Mission: Lifeline STEMI Systems Accelerator, a national educational outcome research study in collaboration with the American Heart Association, to comprehensively accelerate the implementation of STEMI care systems in 17 major metropolitan regions encompassing >1,500 emergency medical service agencies and 450 hospitals across the United States. The goals of the program are to identify regional gaps, barriers, and inefficiencies in STEMI care and to devise strategies to implement proven recommendations to enhance the quality and consistency of care. The study interventions, facilitated by national faculty with expertise in regional STEMI system organization in partnership with American Heart Association representatives, draw upon specific resources with proven past effectiveness in augmenting regional organization. These include bringing together leading regional health care providers and institutions to establish common commitment to STEMI care improvement, developing consensus-based standardized protocols in accordance with national professional guidelines to address local needs, and collecting and regularly reviewing regional data to identify areas for improvement. Interventions focus on each component of the reperfusion process: the emergency medical service, the emergency department, the catheterization laboratory, and inter-hospital transfer. The impact of regionalization of STEMI care on clinical outcomes will be evaluated.
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Heitner JF, Klem I, Rasheed D, Chandra A, Kim HW, Van Assche LMR, Parker M, Judd RM, Jollis JG, Kim RJ. Stress cardiac MR imaging compared with stress echocardiography in the early evaluation of patients who present to the emergency department with intermediate-risk chest pain. Radiology 2013; 271:56-64. [PMID: 24475814 DOI: 10.1148/radiol.13130557] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
PURPOSE To compare the utility and efficacy of stress cardiac magnetic resonance (MR) imaging and stress echocardiography in an emergency setting in patients with acute chest pain (CP) and intermediate risk of coronary artery disease (CAD). MATERIALS AND METHODS Written informed consent was obtained from all patients. This HIPAA-compliant study was approved by the institutional review board for research ethics. Sixty patients without history of CAD presented to the emergency department with intermediate-risk acute CP and were prospectively enrolled. Patients underwent both stress cardiac MR imaging and stress echocardiography in random order within 12 hours of presentation. Stress imaging results were interpreted clinically immediately (blinded interpretation was performed months later), and coronary angiography was performed if either result was abnormal. CAD was considered significant if it was identified at angiography (narrowing >50% ) or if a cardiac event (death or myocardial infarction) occurred during follow-up (mean, 14 months ± 5 [standard deviation]). McNemar test was used to compare the diagnostic accuracy of techniques. RESULTS Stress cardiac MR imaging and stress echocardiography had similar specificity, accuracy, and positive and negative predictive values (92% vs 96%, 93% vs 88%, 67% vs 60%, and 100% vs 91%, respectively, for clinical interpretation; 90% vs 92%, 90% vs 88%, 58% vs 56%, and 98% vs 94%, respectively, for blinded interpretation). Stress cardiac MR imaging had higher sensitivity at clinical interpretation (100% vs 38%, P = .025), which did not reach significance at blinded interpretation (88% vs 63%, P = .31). However, multivariable logistic regression analysis showed stress cardiac MR imaging to be the strongest independent predictor of significant CAD (P = .002). CONCLUSION In patients presenting to the emergency department with intermediate-risk CP, adenosine stress cardiac MR imaging performed within 12 hours of presentation is safe and potentially has improved performance characteristics compared with stress echocardiography. Online supplemental material is available for this article.
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Affiliation(s)
- John F Heitner
- From the Duke Cardiovascular Magnetic Resonance Center (J.F.H., I.K., H.W.K., L.M.R.V.A., M.P., R.M.J., R.J.K.) and Departments of Medicine (J.F.H., I.K., D.R., H.W.K., L.M.R.V.A., M.P., R.M.J., J.G.J., R.J.K.), Emergency Medicine (A.C.), and Radiology (R.M.J., R.J.K.), Duke University Medical Center, Box 3934, Durham, NC 27710
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Langabeer JR, Dellifraine J, Fowler R, Jollis JG, Stuart L, Segrest W, Griffin R, Koenig W, Moyer P, Henry TD. Emergency medical services as a strategy for improving ST-elevation myocardial infarction system treatment times. J Emerg Med 2013; 46:355-62. [PMID: 24268897 DOI: 10.1016/j.jemermed.2013.08.112] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2012] [Revised: 04/22/2013] [Accepted: 08/15/2013] [Indexed: 11/29/2022]
Abstract
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.
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Affiliation(s)
| | | | - Raymond Fowler
- University of Texas Southwestern Medical Center, Dallas, Texas
| | | | | | | | | | - William Koenig
- Los Angeles County Emergency Medical Services, University of California Los Angeles School of Medicine, Los Angeles, California
| | - Peter Moyer
- Boston University School of Medicine, Boston, Massachusetts
| | - Timothy D Henry
- Minneapolis Heart Institute Foundation at Abbott Northwestern Hospital, Minneapolis, Minnesota
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46
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Langabeer JR, Henry TD, Kereiakes DJ, Dellifraine J, Emert J, Wang Z, Stuart L, King R, Segrest W, Moyer P, Jollis JG. Growth in percutaneous coronary intervention capacity relative to population and disease prevalence. J Am Heart Assoc 2013; 2:e000370. [PMID: 24166491 PMCID: PMC3886741 DOI: 10.1161/jaha.113.000370] [Citation(s) in RCA: 64] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background The access to and growth of percutaneous coronary intervention (PCI) has not been fully explored with regard to geographic equity and need. Economic factors and timely access to primary PCI provide the impetus for growth in PCI centers, and this is balanced by volume standards and the benefits of regionalized care. Methods and Results Geospatial and statistical analyses were used to model capacity, growth, and access of PCI hospitals relative to population density and myocardial infarction (MI) prevalence at the state level. Longitudinal data were obtained for 2003–2011 from the American Hospital Association, the U.S. Census, and the Centers for Disease Control and Prevention (CDC) with geographical modeling to map PCI locations. The number of PCI centers has grown 21.2% over the last 8 years, with 39% of all hospitals having interventional cardiology capabilities. During the same time, the US population has grown 8.3%, from 217 million to 235 million, and MI prevalence rates have decreased from 4.0% to 3.7%. The most densely concentrated states have a ratio of 8.1 to 12.1 PCI facilities per million of population with significant variability in both MI prevalence and average distance between PCI facilities. Conclusions Over the last decade, the growth rate for PCI centers is 1.5× that of the population growth, while MI prevalence is decreasing. This has created geographic imbalances and access barriers with excess PCI centers relative to need in some regions and inadequate access in others.
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van Diepen S, Abella BS, Bobrow BJ, Nichol G, Jollis JG, Mellor J, Racht EM, Yannopoulos D, Granger CB, Sayre MR. Multistate implementation of guideline-based cardiac resuscitation systems of care: description of the HeartRescue project. Am Heart J 2013; 166:647-653.e2. [PMID: 24093843 DOI: 10.1016/j.ahj.2013.05.022] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/02/2012] [Accepted: 05/08/2013] [Indexed: 11/18/2022]
Abstract
BACKGROUND There is large and significant regional variation in out-of-hospital cardiac arrest (OHCA), and despite advances in treatment, survival remains low. The American Heart Association has called for the creation of integrated cardiac resuscitation systems of care capable of measuring and improving evidence-based care from bystanders through to hospital discharge. METHODS The HeartRescue Project was initiated in 2010 by the Medtronic Foundation in collaboration with 5 academic medical centers and American Medical Response. The HeartRescue Project aims to develop regional cardiac resuscitation systems of care that will implement guideline-based best practice bystander, prehospital, and hospital care with standardized data reporting linked to outcomes. The primary goal is to improve collective OHCA survival by 50% over 5 years. RESULTS The total population in the 5 participating states is 41.1 million. At baseline, the HeartRescue Project covers approximately 26.1 million people (63.6%) and has engaged 767 emergency medical services agencies and 269 hospitals. Data will be collected for quality improvement, to inform provider feedback, and serve to define effective strategies to improve cardiac arrest care. CONCLUSION The HeartRescue Project is the largest public health initiative of its kind focused entirely on cardiac arrest outcomes. The project is designed to significantly improve OHCA survival by implementing and measuring model systems of care for cardiac resuscitation.
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Affiliation(s)
- Sean van Diepen
- Divisions of Critical Care and Cardiology, University of Alberta, Edmonton, Alberta, Canada
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48
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Bagai A, McNally BF, Al-Khatib SM, Myers JB, Kim S, Karlsson L, Torp-Pedersen C, Wissenberg M, van Diepen S, Fosbol EL, Monk L, Abella BS, Granger CB, Jollis JG. Temporal differences in out-of-hospital cardiac arrest incidence and survival. Circulation 2013; 128:2595-602. [PMID: 24045044 DOI: 10.1161/circulationaha.113.004164] [Citation(s) in RCA: 79] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Understanding temporal differences in the incidence and outcomes of out-of-hospital cardiac arrest (OHCA) has important implications for developing preventative strategies and optimizing systems for OHCA care. METHODS AND RESULTS We studied 18 588 OHCAs of presumed cardiac origin in patients aged ≥18 years who received resuscitative efforts by emergency medical services (EMS) and were enrolled in the Cardiac Arrest Registry to Enhance Survival (CARES) from October 1, 2005, to December 31, 2010. We evaluated temporal variability in OHCA incidence and survival to hospital discharge. There was significant variability in the frequency of OHCA by hour of the day (P<0.001), day of the week (P<0.001), and month of the year (P<0.001), with the highest incidence occurring during the daytime, from Friday to Monday, in December. Survival to hospital discharge was lowest for OHCA that occurred overnight (from 11:01 pm to 7 am; 7.1%) versus daytime (7:01 am to 3 pm; 10.8%) or evening (3:01 pm to 11 pm; 11.3%; P<0.001) and during the winter (8.8%) versus spring (11.1%), summer (11.0%), or fall (10.0%; P<0.001). There was no difference in survival to hospital discharge between OHCAs that occurred on weekends and weekdays (9.5% versus 10.4%, P=0.06). After multivariable adjustment for age, sex, race, witness status, layperson resuscitation, first monitored cardiac rhythm, and emergency medical services response time, compared with daytime and spring, survival to hospital discharge remained lowest for OHCA that occurred overnight (odds ratio, 0.81; 95% confidence interval, 0.70-0.95; P=0.008) and during the winter (odds ratio, 0.81; 95% confidence interval, 0.70-0.94; P=0.006), respectively. CONCLUSIONS There is significant temporal variability in the incidence of and survival after OHCA. The relative contribution of patient pathophysiology, likelihood of the OHCA being observed, and prehospital and hospital-based resuscitative factors deserves further exploration.
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Affiliation(s)
- Akshay Bagai
- From St. Michael's Hospital, University of Toronto, Ontario, Canada (A.B.); Emory University School of Medicine, Rollins School of Public Health, Atlanta, GA (B.F.M.); Duke Clinical Research Institute, Durham, NC (S.M.A.-K., S.K., E.L.F., L.M., C.B.G., J.G.J.); Wake County Department of Emergency Medical Services, Raleigh, NC (J.B.M.); Department of Cardiology, University Hospital Gentofte, Gentofte, Denmark (L.K., M.W.); Institute of Health, Science and Technology, Aolborg University, Aolborg, Denmark (C.T.-P.); Division of Critical Care and Cardiology, University of Alberta, Alberta, Ontario, Canada (S.v.D.); and Center for Resuscitation Science, University of Pennsylvania, Philadelphia (B.S.A.)
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Bagai A, Al-Khalidi HR, Muñoz D, Monk L, Roettig ML, Corbett CC, Garvey JL, Wilson BH, Granger CB, Jollis JG. Bypassing the Emergency Department and Time to Reperfusion in Patients With Prehospital ST-Segment–Elevation. Circ Cardiovasc Interv 2013; 6:399-406. [DOI: 10.1161/circinterventions.112.000136] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background—
Among patients identified prehospital with ST-segment–elevation myocardial infarction, emergency medical service transport from the field directly to the catheterization laboratory, thereby bypassing the emergency department (ED), may shorten time to reperfusion.
Methods and Results—
We studied 1687 patients identified prehospital with ST-segment–elevation myocardial infarction from the Reperfusion in Acute Myocardial Infarction in Carolina Emergency Departments (RACE) project, transported via emergency medical service directly to 21 North Carolina hospitals for primary percutaneous coronary intervention between July 2008 and December 2009. Treatment time intervals were compared between patients evaluated in the ED (ED evaluation) and those transported directly to the catheterization laboratory (ED bypass). Emergency medical service transported 1401 (83.0%) patients to the ED, whereas the ED was bypassed for 286 (17.0%) patients. Overall, first medical contact to device activation within 90 minutes was achieved in 913 (54.1%) patients. Among patients evaluated in the ED, median time (25th–75th percentiles) from ED arrival to catheterization laboratory arrival was 30 (20–41) minutes. First medical contact to device activation occurred faster (75 [59–93] versus 90 [76–109] minutes;
P
<0.001) and was more frequently achieved within 90 minutes (74.1% versus 50.1%;
P
<0.001) among ED bypass patients.
Conclusions—
Among patients identified prehospital with ST-segment–elevation myocardial infarction and transported directly to a percutaneous coronary intervention hospital, only 1 in 2 achieve device activation within 90 minutes. A median of 30 minutes is spent in the ED, contributing significantly to the failure to achieve timely reperfusion. The strategy to bypass the ED is used infrequently and represents a potential opportunity to improve reperfusion times.
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Affiliation(s)
- Akshay Bagai
- From the Department of Cardiology, Duke Clinical Research Institute, Duke University, Durham, NC (A.B., H.R.A.-K, D.M., L.M., M.L.R., C.B.G., J.G.J.); New Hanover Regional Medical Center, Wilmington, NC (C.C.C.); and Departments of Emergency Medicine (J.L.G.), and Cardiology (B.H.W.), Carolinas Medical Center, Charlotte, NC
| | - Hussein R. Al-Khalidi
- From the Department of Cardiology, Duke Clinical Research Institute, Duke University, Durham, NC (A.B., H.R.A.-K, D.M., L.M., M.L.R., C.B.G., J.G.J.); New Hanover Regional Medical Center, Wilmington, NC (C.C.C.); and Departments of Emergency Medicine (J.L.G.), and Cardiology (B.H.W.), Carolinas Medical Center, Charlotte, NC
| | - Daniel Muñoz
- From the Department of Cardiology, Duke Clinical Research Institute, Duke University, Durham, NC (A.B., H.R.A.-K, D.M., L.M., M.L.R., C.B.G., J.G.J.); New Hanover Regional Medical Center, Wilmington, NC (C.C.C.); and Departments of Emergency Medicine (J.L.G.), and Cardiology (B.H.W.), Carolinas Medical Center, Charlotte, NC
| | - Lisa Monk
- From the Department of Cardiology, Duke Clinical Research Institute, Duke University, Durham, NC (A.B., H.R.A.-K, D.M., L.M., M.L.R., C.B.G., J.G.J.); New Hanover Regional Medical Center, Wilmington, NC (C.C.C.); and Departments of Emergency Medicine (J.L.G.), and Cardiology (B.H.W.), Carolinas Medical Center, Charlotte, NC
| | - Mayme L. Roettig
- From the Department of Cardiology, Duke Clinical Research Institute, Duke University, Durham, NC (A.B., H.R.A.-K, D.M., L.M., M.L.R., C.B.G., J.G.J.); New Hanover Regional Medical Center, Wilmington, NC (C.C.C.); and Departments of Emergency Medicine (J.L.G.), and Cardiology (B.H.W.), Carolinas Medical Center, Charlotte, NC
| | - Claire C. Corbett
- From the Department of Cardiology, Duke Clinical Research Institute, Duke University, Durham, NC (A.B., H.R.A.-K, D.M., L.M., M.L.R., C.B.G., J.G.J.); New Hanover Regional Medical Center, Wilmington, NC (C.C.C.); and Departments of Emergency Medicine (J.L.G.), and Cardiology (B.H.W.), Carolinas Medical Center, Charlotte, NC
| | - J. Lee Garvey
- From the Department of Cardiology, Duke Clinical Research Institute, Duke University, Durham, NC (A.B., H.R.A.-K, D.M., L.M., M.L.R., C.B.G., J.G.J.); New Hanover Regional Medical Center, Wilmington, NC (C.C.C.); and Departments of Emergency Medicine (J.L.G.), and Cardiology (B.H.W.), Carolinas Medical Center, Charlotte, NC
| | - B. Hadley Wilson
- From the Department of Cardiology, Duke Clinical Research Institute, Duke University, Durham, NC (A.B., H.R.A.-K, D.M., L.M., M.L.R., C.B.G., J.G.J.); New Hanover Regional Medical Center, Wilmington, NC (C.C.C.); and Departments of Emergency Medicine (J.L.G.), and Cardiology (B.H.W.), Carolinas Medical Center, Charlotte, NC
| | - Christopher B. Granger
- From the Department of Cardiology, Duke Clinical Research Institute, Duke University, Durham, NC (A.B., H.R.A.-K, D.M., L.M., M.L.R., C.B.G., J.G.J.); New Hanover Regional Medical Center, Wilmington, NC (C.C.C.); and Departments of Emergency Medicine (J.L.G.), and Cardiology (B.H.W.), Carolinas Medical Center, Charlotte, NC
| | - James G. Jollis
- From the Department of Cardiology, Duke Clinical Research Institute, Duke University, Durham, NC (A.B., H.R.A.-K, D.M., L.M., M.L.R., C.B.G., J.G.J.); New Hanover Regional Medical Center, Wilmington, NC (C.C.C.); and Departments of Emergency Medicine (J.L.G.), and Cardiology (B.H.W.), Carolinas Medical Center, Charlotte, NC
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Bagai A, Jollis JG, Dauerman HL, Peng SA, Rokos IC, Bates ER, French WJ, Granger CB, Roe MT. Emergency Department Bypass for ST-Segment–Elevation Myocardial Infarction Patients Identified With a Prehospital Electrocardiogram. Circulation 2013; 128:352-9. [DOI: 10.1161/circulationaha.113.002339] [Citation(s) in RCA: 80] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Affiliation(s)
- Akshay Bagai
- From the Duke Clinical Research Institute, Durham, NC (A.B., J.G.J., S.A.P., C.B.G., M.T.R.); University of Vermont, Burlington, VT (H.L.D.); University of California at Los Angeles–Olive View Medical Center, Geffen School of Medicine, Sylmar, CA (I.C.R.); University of Michigan, Ann Arbor, MI (E.R.B.); and Harbor–University of California at Los Angeles Medical Center, Torrance, CA (W.J.F.)
| | - James G. Jollis
- From the Duke Clinical Research Institute, Durham, NC (A.B., J.G.J., S.A.P., C.B.G., M.T.R.); University of Vermont, Burlington, VT (H.L.D.); University of California at Los Angeles–Olive View Medical Center, Geffen School of Medicine, Sylmar, CA (I.C.R.); University of Michigan, Ann Arbor, MI (E.R.B.); and Harbor–University of California at Los Angeles Medical Center, Torrance, CA (W.J.F.)
| | - Harold L. Dauerman
- From the Duke Clinical Research Institute, Durham, NC (A.B., J.G.J., S.A.P., C.B.G., M.T.R.); University of Vermont, Burlington, VT (H.L.D.); University of California at Los Angeles–Olive View Medical Center, Geffen School of Medicine, Sylmar, CA (I.C.R.); University of Michigan, Ann Arbor, MI (E.R.B.); and Harbor–University of California at Los Angeles Medical Center, Torrance, CA (W.J.F.)
| | - S. Andrew Peng
- From the Duke Clinical Research Institute, Durham, NC (A.B., J.G.J., S.A.P., C.B.G., M.T.R.); University of Vermont, Burlington, VT (H.L.D.); University of California at Los Angeles–Olive View Medical Center, Geffen School of Medicine, Sylmar, CA (I.C.R.); University of Michigan, Ann Arbor, MI (E.R.B.); and Harbor–University of California at Los Angeles Medical Center, Torrance, CA (W.J.F.)
| | - Ivan C. Rokos
- From the Duke Clinical Research Institute, Durham, NC (A.B., J.G.J., S.A.P., C.B.G., M.T.R.); University of Vermont, Burlington, VT (H.L.D.); University of California at Los Angeles–Olive View Medical Center, Geffen School of Medicine, Sylmar, CA (I.C.R.); University of Michigan, Ann Arbor, MI (E.R.B.); and Harbor–University of California at Los Angeles Medical Center, Torrance, CA (W.J.F.)
| | - Eric R. Bates
- From the Duke Clinical Research Institute, Durham, NC (A.B., J.G.J., S.A.P., C.B.G., M.T.R.); University of Vermont, Burlington, VT (H.L.D.); University of California at Los Angeles–Olive View Medical Center, Geffen School of Medicine, Sylmar, CA (I.C.R.); University of Michigan, Ann Arbor, MI (E.R.B.); and Harbor–University of California at Los Angeles Medical Center, Torrance, CA (W.J.F.)
| | - William J. French
- From the Duke Clinical Research Institute, Durham, NC (A.B., J.G.J., S.A.P., C.B.G., M.T.R.); University of Vermont, Burlington, VT (H.L.D.); University of California at Los Angeles–Olive View Medical Center, Geffen School of Medicine, Sylmar, CA (I.C.R.); University of Michigan, Ann Arbor, MI (E.R.B.); and Harbor–University of California at Los Angeles Medical Center, Torrance, CA (W.J.F.)
| | - Christopher B. Granger
- From the Duke Clinical Research Institute, Durham, NC (A.B., J.G.J., S.A.P., C.B.G., M.T.R.); University of Vermont, Burlington, VT (H.L.D.); University of California at Los Angeles–Olive View Medical Center, Geffen School of Medicine, Sylmar, CA (I.C.R.); University of Michigan, Ann Arbor, MI (E.R.B.); and Harbor–University of California at Los Angeles Medical Center, Torrance, CA (W.J.F.)
| | - Matthew T. Roe
- From the Duke Clinical Research Institute, Durham, NC (A.B., J.G.J., S.A.P., C.B.G., M.T.R.); University of Vermont, Burlington, VT (H.L.D.); University of California at Los Angeles–Olive View Medical Center, Geffen School of Medicine, Sylmar, CA (I.C.R.); University of Michigan, Ann Arbor, MI (E.R.B.); and Harbor–University of California at Los Angeles Medical Center, Torrance, CA (W.J.F.)
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