Clinical Investigation
Acute Ischemic Heart Disease
Developing an ST-elevation myocardial infarction system of care in Dallas County

https://doi.org/10.1016/j.ahj.2013.02.005Get rights and content

Background

The American Heart Association Caruth Initiative (AHACI) is a multiyear project to increase the speed of coronary reperfusion and create an integrated system of care for patients with ST-elevation myocardial infarction (STEMI) in Dallas County, TX. The purpose of this study was to determine if the AHACI improved key performance metrics, that is, door-to-balloon (D2B) and symptom-onset-to-balloon times, for nontransfer patients with STEMI.

Methods

Hospital patient data were obtained through the National Cardiovascular Data Registry Action Registry–Get With The Guidelines, and prehospital data came from emergency medical services (EMS) agencies through their electronic Patient Care Record systems. Initial D2B and symptom-onset-to-balloon times for nontransfer primary percutaneous coronary intervention (PCI) STEMI care were explored using descriptive statistics, generalized linear models, and logistic regression.

Results

Data were collected by 15 PCI-capable Dallas hospitals and 24 EMS agencies. In the first 18 months, there were 3,853 cases of myocardial infarction, of which 926 (24%) were nontransfer patients with STEMI undergoing primary PCI. D2B time decreased significantly (P < .001), from a median time of 74 to 64 minutes. Symptom-onset-to-balloon time decreased significantly (P < .001), from a median time of 195 to 162 minutes.

Conclusion

The AHACI has improved the system of STEMI care for one of the largest counties in the United States, and it demonstrates the benefits of integrating EMS and hospital data, implementing standardized training and protocols, and providing benchmarking data to hospitals and EMS agencies.

Section snippets

Eligibility and participation requirements

This research was funded by the W.W. Caruth, JR. Foundation/Communities Foundation of Texas. To implement a STEMI system of care in Dallas County, the AHA served as the organizing body and established a volunteer stakeholder group of representatives from hospitals and EMS agencies in the County. This was a 3-year program to organize a STEMI system supported by PCI hospitals and EMS agencies in Dallas County. Institutions eligible to participate in the project were restricted to those

Patient demographics

There were 3,853 AMI cases in Dallas County identified in the NCDR database from October 2010 through March 2012. Of these, 926 were nontransfer patients with STEMI who received primary PCI. Descriptive statistics of patient demographics and other control variables are presented in Table II.

Figure 1 shows the median times for the dependent variables, which are presented by quarter. Overall median D2B andS2B times for nontransfer patients with STEMI who received primary PCI decreased throughout

Discussion

The AHACI provided an opportunity to develop and improve a coordinated system of STEMI care in a large metropolitan area. The primary purpose of this research was to describe the preliminary results for the first 18 months of the project (which includes D2B and S2B times). Specifically, we sought to determine whether or not one integrated system of STEMI protocols and procedures for all participating PCI hospitals and EMS agencies in Dallas, along with feedback of performance metrics to these

Disclosures

This study was funded by the W.W. Caruth, Jr. Foundation/Communities Foundation of Texas.

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      The program expanded to then include all hospitals in North Carolina (21 PCI-capable, and 98 PCI noncapable), thus demonstrating the feasibility of regionalizing STEMI care to an entire state (Fig. 2).22 Early adopters in predominately urban US STEMI systems of care include Los Angeles and Dallas.23,24 Table 1 compares the Minneapolis, North Carolina, Los Angeles, and Dallas systems, and the 16-region American Heart Association (AHA) Accelerator Program, which aimed to rapidly implement systems of care across multiple STEMI networks (discussed in more detail later).25,26

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      2016, International Journal of Cardiology
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      Current care systems for STEMI, designed to optimize the interaction between the Emergency Medical System (EMS) and the interventional hospitals, have led to a progressive and significant improvement in time between initial medical contact to primary angioplasty [3–4]. Despite this major progress, many patients continue to show prolonged time from the symptom onset to reperfusion [4–6], as STEMI programs do not address the patient decision making, a major component of the overall ischemic time. Reducing the patient delay is thus a critical step to further shorten ischemic time and improve clinical outcomes.

    • Emergency Medical Services as a Strategy for Improving ST-Elevation Myocardial Infarction System Treatment Times

      2014, Journal of Emergency Medicine
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      This study is one of the first to systematically measure and analyze total systemic treatment time from symptom onset through reperfusion, and we believe that strengthening our ability to consistently define and measure symptom onset times will help drive improved clinical diagnosis and treatment. Greater details establishing the validity of the metric are described elsewhere (21). Regardless, we also explored D2B as our primary dependent variable, because this metric is more established and widely reported.

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    Kim A. Eagle, MD served as guest editor for this article.

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