Abstract 13349: Decreasing the EMS to Balloon Time for ST-Elevation Myocardial Infarction: A Model for Managing STEMI in Rural Communities
Primary percutaneous coronary intervention (PCI) has become the standard of care for the management of ST-elevation myocardial infarction (STEMI) patients when door-to-balloon (D2B) times can be achieved in <90 minutes. Rural communities have diverse challenges often preventing the use of primary PCI due to unacceptable delays in evaluation and transport. Bonner County (BC) in rural North Idaho is 50 miles from Kootenai Health (KH), the nearest cath-capable facility. STEMI management has traditionally employed thrombolytic therapy and urgent transport to KH. We describe a progressive STEMI Alert plan instituted in 11/10 wherein STEMI patients are transported by ground ambulance directly from the field to KH for primary PCI. Important elements of this plan include: cell phone transmission of EKGs, early activation of the PCI team, bypassing local and regional emergency departments (ED), and direct communication of the paramedic and the accepting cardiologist who may order oral and/or IV anti-platelet medications to be given en route. By protocol, critical care trained (CCT) medics may also administer ASA, heparin, beta-blockers, nitrates and narcotics. We evaluated the change in the EMS to balloon times (E2B), length of stay and mortality in 35 patients treated prior to this program, as compared to the first 15 persons managed with this program. Between 1/09 and 11/10, 35 STEMI patients were transported to KH from BC. For those requiring immediate cath (typically for failed thrombolysis) the average E2B was 198 minutes including an average time of 88 minutes in the local ED before transport could be mobilized. Average length of stay for STEMI patients was 4.5 days. There was one in-hospital and one 30-day mortality. In contrast, under the new STEMI Alert plan the E2B dropped to 109 minutes, which includes a 20 minute scene time. Transport times were similar (44 vs 47 minutes) as were D2B times once arriving at KH (24 vs 29 minutes). Length of stay decreased to 2.8 days with no mortality to date. Primary PCI for STEMI is a viable option when using early EKG transmission, early activation of the PCI team, pre-hospital care provided by CCT paramedics in communication with a cardiologist, and bypassing ED care. These strategies decrease E2B and in turn improve patient outcomes.
- © 2011 by American Heart Association, Inc.