Improving STEMI Care Will Come From Outside of the Hospital

Reed Miller

March 09, 2011

March 8, 2011 (Washington, DC) — Improving the outcomes of ST-elevation-MI patients in the future will depend more on treatment outside the hospital than within it, an expert panel at CRT 2011, the Cardiovascular Research Technologies conference, agreed [1].

"[Further effort to achieve] the door-to-balloon-time goal for the in-hospital system of care should be stopped," Dr Eric Bates (University of Michigan Medical Center, Ann Arbor) said during a panel discussion at the conference. "We need to stop, declare victory, and worry instead about the prehospital system of care and these transfer patients, where time to treatment is a big problem. . . . It's that [long] transfer time that is associated with worse outcomes."

Bates said improvement in STEMI outcomes can be achieved both by reducing the time from the onset of symptoms to treatment and ensuring consistent high quality of care throughout the system. "You need to [meet with] your referring hospitals, get face-to-face meetings and contracts written down, and [create] communication pathways."

Dr Timothy D Henry (Minneapolis Heart Institute Foundation at Abbott Northwestern Hospital, MN), one of the leaders of a STEMI system throughout Minnesota, agreed. "Door-to-balloon time is a marker of how well the system works, but it really needs to be far more than that. Having a standardized approach to myocardial infarction is far more important, so that includes guideline-based medication both on admission and on discharge and a plan to do cardiac rehab and the scheduled follow-up.

"All of that needs to be systematized, so that it happens for every patient," Henry added. "For a lot of reasons, with the door-to-balloon times, we've done really well in PCI centers, but we're not doing well in transfer centers. Every hospital in the United States should have a plan for how they treat STEMI, including how the patients are going to be transferred." Henry and the other panelists also emphasized the importance of each center collecting and reviewing its quality data to see where it can make improvements.

Despite the success stories, still only a little over half the US population is covered by a coordinated STEMI system, and only about one-third live in an area where the hospitals have set transfer protocols, according to Dr Alice Jacobs (Boston University School of Medicine, Boston, MA), one of the leaders of the American Heart Association's Mission: Lifeline. Mission: Lifeline is a consortium of hospitals and emergency-services systems that share best practices and data. Jacobs said it will soon yield data that will show where coordinated STEMI systems are reducing mortality and which geographic areas are not well-served by a STEMI system.

Bates commended the efforts of copanelists Dr Jonathan Reiner (George Washington University, Washington, DC) and Dr Lowell F Satler (Washington Cardiology Center, DC) on creating a coordinated STEMI system for the District of Columbia, an example of a system that is improving patient care. "They just reorganized a whole community, which is an amazing accomplishment."

Reiner described how the STEMI system in DC was very disjointed a few years ago, with patients being sent from whatever hospital they presented at to one of DC's three PCI centers without a set plan. Now DC has a coordinated system and a unified database to measure the quality of STEMI care for the whole city.

Reiner said his hospital reviews every STEMI case soon after it happens with the cardiologists, emergency-room staff, and paramedics. "Frankly, when our door-to-balloon time is long it's usually because [the patients] were sitting in the ER for a while and the MI hadn't been recognized. So it's very helpful to review individual cases with the docs who made the decisions and show them how, in retrospect, the decision could have been made earlier." This continuous quality-improvement process has improved the average door-to-balloon times in DC. Previously, less than 50% of STEMI patients had a door-to-balloon time under 90 minutes, and now it's 80%.

Jacobs pointed out that training more ambulance personnel to read ECGs could significantly improve STEMI-patient outcomes. The DC-area hospitals have made a particular effort to do this. Satler described an ongoing project, partially supported by AT&T, to give an iPhone to everyone who treats STEMI patients, including the emergency-room doctors and paramedics, and develop a special iPhone application that can securely transmit high-quality ECG information from the field to the hospital to speed the diagnosis of STEMI. The ECG data can also be easily stored in an electronic medical record. Satler's group is currently running a pilot study of the iPhone system in St Mary's County in southern Maryland, because St Mary's currently has no system for transmitting ECG data, he explained.

Improving STEMI care requires the cooperation of a lot of different personnel, so "you absolutely have to have administrative support from your hospital to empower the whole process and a STEMI coordinator who is empowered to make that system work," Henry concluded. "It won't work if you're fighting against your administration. . . . You need to all be on the same page."

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