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Bypassing the emergency department (ED) and heading straight to the cath lab resulted in faster reperfusion times for more patients with a severe heart attack, a statewide analysis found.
Three-quarters of patients with ST-segment elevation myocardial infarction (STEMI) taken directly to the cath lab by emergency medical services were treated within the 90-minute recommended time frame, compared with only half of those who were evaluated in the ED first (P<0.001), according to Akshay Bagai, MD, of the Duke Clinical Research Institute, and colleagues.
Action Points
- Of patients identified prior to hospital admission with ST-segment elevation myocardial infarction (STEMI) and transported directly to a percutaneous coronary intervention hospital, only one in two achieved device activation within 90 minutes, a study found.
- A median of 30 minutes was spent in the emergency department, contributing significantly to the failure to achieve timely reperfusion.
The time from first medical contact to angioplasty was a median 75 minutes for those who bypassed the ED, versus 90 minutes for those triaged in the ED before going to the cath lab (P<0.001), they wrote in the study published online in Circulation: Cardiovascular Interventions.
The median time spent in the ED was 30 minutes, "which contributes significantly to the failure to achieve timely reperfusion," researchers noted.
"In Europe, chest pain patients call for an ambulance, but in the U.S., only half of them do. The remainder drive themselves to the ED or are driven by family members," said William O'Neill, MD, medical director of the Center for Structural Heart Disease at the Henry Ford Hospital in Detroit.
"That's a real problem, because it adds minutes to the time needed for the patient to be reperfused," O'Neill told 乌鸦传媒. "We can potentially save up to 90 minutes from the time of symptom onset to reperfusion if more chest pain patients called for an ambulance."
Even when investigators excluded patients who needed resuscitation or intubation before percutaneous coronary intervention (PCI), the transfer time from first medical contact to device activation remained faster for those who bypassed the ED (76 versus 89 minutes, P<0.001) and more of them were treated within the 90-minute guideline-recommended time frame (74% versus 52%, P<0.001).
In addition, Bagai and colleagues found that emergency medical services bypassed the ED more often during working hours compared with off-hours (28% versus 8%). And when patients were triaged in the ED, the lag time for landing in the cath lab was shorter during working hours (24 versus 34 minutes for off-hours).
Also, patients who bypassed the ED had a lower rate of in-hospital mortality (1.8% versus 4.6%, P=0.02), but this metric lost significance when researchers excluded those with cardiac arrest or intubation before PCI.
For the study, Bagai and colleagues included 1,687 patients who were identified by emergency medical services during pre-hospital transport as experiencing a STEMI. A total of 83% were triaged in the ED, while 17% went directly to the cath lab.
The patients were part of the RACE (Reperfusion in Acute Myocardial Infarction in Carolina Emergency Departments) project, which comprises 119 North Carolina hospitals and about 540 emergency medical service agencies.
Patients in the study were transported to 21 PCI-capable hospitals from July 2008 to December 2009, either directly to the cath lab or triaged first in the ED before being taken to the cath lab. Patients who were transferred from a non-PCI-capable hospital to a PCI-capable hospital were not included in the study.
The average age of patients was 60, the majority were men, and most were white.
Whether a hospital's ED was bypassed or not varied widely among the 21 hospitals in the study. The range of variation went from no patients bypassing the ED to nearly two-thirds (68%) of patients skipping the ED, depending on the hospital involved.
Whether a hospital was able to treat patients in less than 90 minutes also varied widely, ranging from 28% of patients at a particular hospital to 80%, despite the fact that emergency medical services was capable of transmitting ECGs to the ED in 15 hospitals and directly to the cath lab in eight hospitals.
They noted that the "30-30-30" rule has been suggested as a way to achieve the 90-minute benchmark: 30 minutes spent by emergency medical services, 30 minutes in the ED, and 30 minutes in the cath lab. But in this study, even when researchers excluded those who needed resuscitation or intubation before PCI, "patients still spent more than 30 minutes in the ED."
Researchers said the study is limited because it is observational and registry-based. Also, there were several limitations that precluded the ability to determine patient and system factors independently associated with the timing of reperfusion therapy.
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From the American Heart Association:
Disclosures
This work was supported by an award from the American Heart Association Pharmaceutical Roundtable and David and Stevie Spina.
Bagai disclosed he has no conflicts of interest. Other authors reported relationships with Philips Healthcare, Abiomed, Boston Scientific, Astellas Pharma, AstraZeneca, Boehringer Ingelheim, Bristol-Myers Squibb, Elsevier, GlaxoSmithKline, Hoffman LaRoche, McGraw-Hill Publishing, Medtronic, Merck Sharpe & Dohme, Otsuka, Pfizer, sanofi-aventis, UpToDate, WebMD, Blue Cross Blue Shield North Carolina, and United Healthcare.
Primary Source
Circulation: Cardiovascular Interventions
Bagai A, et al "Bypassing the emergency department and time to reperfusion in patients with prehospital ST-Segment elevation: findings from the reperfusion in acute myocardial infarction in Carolina emergency departments project" Circ Cardiovasc Interv 2013; DOI: 10.1161/CIRCINTERVENTIONS.112.000136.