Impact of Regionalization of ST Elevation Myocardial Infarction Care on Treatment Times and Outcomes for Emergency Medical Services Transported Patients Presenting to Hospitals with Percutaneous Coronary Intervention: Mission: Lifeline Accelerator-2
Background: Regional variations in reperfusion times and mortality in patients with ST-segment elevation myocardial infarction (STEMI) 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 PCI-capable hospitals and 946 EMS agencies. Data were collected in the ACTION-Get With The Guidelines Registry for quarterly Mission: Lifeline reports. The primary endpoint was the change in the proportion of EMS transported patients with first medical contact to device (FMC2D) time ≤90 minutes from baseline to final quarter. We also compared treatment times and mortality to 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 PCI-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 female, 6% had cardiac arrest and 6% had shock on admission; 10% were black, 12% 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 FMC2D time of ≤90 minutes (67% to 74%; P<0.002), a FMC to catheterization laboratory activation of <20 minutes (38% to 56%; P<0.0001), and emergency department dwell time of <20 minutes (33% to 43%; P<0.0001). Of the 12 regions, 9 reduced FMC2D time, and 8 met or exceeded the national goal of 75% of patients treated <90 minutes. Improvements in treatment times corresponded with a significant reduction in mortality (in-hospital death 4.4% to 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 STEMI, and in-hospital mortality. These findings support a more intensive regional approach to emergency care for patients with STEMI.
- acute myocardial infarction
- catheter-based coronary interventions
- CPR and emergency cardiac care
- health policy and outcome research
- Received October 26, 2017.
- Revision received November 7, 2017.
- Accepted November 8, 2017.