Emergency Department Bypass for ST-Segment Elevation Myocardial Infarction Patients Identified with a Pre-Hospital Electrocardiogram: A Report From the American Heart Association Mission: Lifeline™ Program
Background—For patients identified pre-hospital with ST-segment elevation myocardial infarction (STEMI), bypassing the emergency department (ED) with direct transport to the catheterization laboratory may shorten reperfusion times.
Methods and Results—We studied 12,581 STEMI patients identified with a pre-hospital electrocardiogram (ECG), treated at 371 primary percutaneous coronary intervention (PCI)-capable U.S. hospitals participating in the ACTION Registry-Get With The Guidelines - Mission: Lifeline™ program from 2008-2011. Reperfusion times with primary PCI and in-hospital mortality rates were compared between patients undergoing ED evaluation versus those bypassing the ED. ED-bypass occurred in 1,316 (10.5%) patients. These patients had a lower frequency of heart failure and shock on presentation, and non-systems reasons for delay in PCI. ED-bypass occurred more frequently during working hours compared with off-hours (18.3% vs. 4.3%); ED-bypass rate varied significantly across hospitals (median, 3.3% [range, 0% to 71%]). First medical contact to device activation time was shorter (median, 68 [54, 85] vs. 88 [73, 106] minutes, p<0.0001) and achieved within 90 minutes more frequently (80.7% vs. 53.7%, p<0.0001) with ED-bypass. The unadjusted in-hospital mortality rate was lower among ED-bypass patients (2.7% vs. 4.1%, p=0.01), but the adjusted mortality risk was similar (adjusted OR=0.69, 95% CI: 0.45-1.03, p=0.07).
Conclusions—Among STEMI patients identified with a pre-hospital ECG, the rate of ED-bypass varied significantly across U.S. hospitals, but ED bypass occurred infrequently and was mostly isolated to working-hours. Since ED-bypass was associated with shorter reperfusion times and numerically lower mortality rates, further exploration and advocacy for implementation of this process appears warranted.
- emergency department bypass
- reperfusion time
- ST-segment elevation myocardial infarction
- primary percutaneous coronary intervention
- Received February 28, 2013.
- Revision received May 21, 2013.
- Accepted May 31, 2013.