Quality of care for patients with ST-segment-elevation myocardial infarction (STEMI) has improved in hospitals participating in the American Heart Association’s Mission: Lifeline program, according to a new report.
The program aims to improve the application of guideline-recommended care for STEMI, which includes:
- Use of a 12-lead echocardiogram (ECG) by emergency medical services (EMS) personnel at the site of first medical contact (FMC);
- EMS transport directly to a percutaneous coronary intervention (PCI)-capable hospital for primary PCI, with an FMC-to-device time system goal of 90 minutes or less;
- Immediate transfer to a PCI-capable hospital for patients presenting to a non-PCI-capable hospital, with an FMC-to-device time system goal of 120 minutes or less; and
- Fibrinolytic therapy for patients at non-PCI-capable hospitals, unless contraindicated, when the anticipated FMC-to-device time at a PCI-capable hospital would exceed 120 minutes.
“This report of the first five years of Mission: Lifeline documents that very important improvements in regional care for heart attacks are possible with collaboration of emergency medical services and networks of hospitals,” Dr. Christopher Granger of the Duke Clinical Research Institute in Durham, North Carolina, told Reuters Health. “Those improvements appear to result in substantial reductions in deaths.”
Dr. Granger and colleagues studied pre- and in-hospital care and outcomes from 2008-2012 for close to 148,000 STEMI patients admitted to 485 U.S. hospitals in 46 states, representing 656 care systems registered with Mission: Lifeline. Patients had a median age of 60; 30 percent were women; and the median time from symptom onset to FMC was about 50 minutes.
As reported online December 31 in the Journal of the American Heart Association, outcomes over five years included:
- A decrease both in the proportion of eligible patients not treated with reperfusion (from 6.2 to 3.3 percent) and in the proportion treated with fibrinolytic therapy (from 13.4 to 7.0 percent).
- No change in median time from symptom onset to FMC.
- Increase in the use of prehospital ECGs (from 45 to 71 percent).
- Improvement in all major reperfusion times: median FMC-to-device for EMS transport to PCI-capable hospitals (93 to 84 minutes); first door-to-device for transfers for primary PCI (130 to 112 minutes); and door in-door-out at non-PCI-capable hospitals (76 to 62 minutes)
- Increase in rates of cardiogenic shock and cardiac arrest, and increase in overall in-hospital mortality (5.7 to 6.3 percent) as the number of these high-risk patients increased.
- Adjusted mortality—excluding patients with known cardiac arrest—decreased by 14 percent at three years and 25 percent at five years.
Dr. Granger noted, “A dominant feature of emergency medical care in the United States is fragmentation, (which) is a barrier to the coordinated care that is essential to providing timely and high-quality care from the prehospital to specialized hospital settings.”
“Another barrier,” he added, “is competition, which is often intense between regional hospitals that need patient referrals for financial survival and are thus wary of standardized protocols and sharing data regarding transporting patients to and between hospitals.”
“But the data now clearly show that such programs are essential for regional high-quality care to save lives,” he said.
The program has been extended to other cardiovascular emergencies, such as out-of-hospital cardiac arrest and stroke, Dr. Granger noted.
Interventional cardiologist Dr. Louai Razzouk of NYU Langone Health in New York City, commented by email, “Regional systems of care for myocardial infarctions are critical, as not all hospitals have the same capabilities, nor should they, as this would not be financially feasible.”
“Hospitals that can treat a heart attack right away and have a cardiac catheterization laboratory available on call 24/7 are encouraged to work closely with EMS and other hospitals with lesser capabilities, in order to optimize patients’ outcomes and minimize the delay in opening up a newly blocked coronary artery,” he told Reuters Health.
“Competition is always a factor when hospitals decide to participate in these national initiatives,” said Dr. Razzouk, who was not involved in the study. “But healthy competition is also a good way to encourage improvement in care and promote communication and learning from each other’s pitfalls and successes.”
NYU Langone Health is part of Mission: Lifeline and other cardiac regional systems and registries, and received a Lifeline Gold STEMI Award in June 2018, Dr. Razzouk noted. “A new focus of the Mission: Lifeline in 2019 will be the rate of cardiac rehabilitation referral for our STEMI patients.”