North Carolina Pioneers 'Pit-Crew' Approach to STEMI Response That Can Work Anywhere

Reed Miller

June 06, 2012

June 5, 2012 (Durham, North Carolina) — The Regional Approach to Cardiovascular Emergencies (RACE) project led by Duke University researchers has improved the response to ST-elevation MI across the whole state of North Carolina, and the leaders say the same successful approach could be used in other states and for other types of cardiovascular emergencies [1].

"The RACE system is the largest statewide ST-elevation myocardial infarction system ever implemented in the United States, [and it] demonstrates that systematic barriers in timely reperfusion can be overcome with a broadly organized voluntary effort to fill leadership gaps in healthcare," Dr James Jollis (Duke Clinical Research Institute, Durham, NC) and colleagues explain in a paper published online June 4, 2012 in Circulation.

"North Carolina isn't unique at all," Jollis told heartwire . "There's no question that this can be implemented everywhere. It's just a matter of having somebody come in and mediate the competition [among medical centers]. It's a matter of organizing groups of hospitals and making sure that every hospital and ambulance has the same plan in place." Duke is currently working with the American Heart Association to implement coordinated STEMI systems in 20 new regions, including New York City, Philadelphia, Detroit, San Antonio, and Phoenix.

Jollis said his group is also trying to develop coordinated emergency-response systems for cardiac arrest and stroke. "It's all fairly simple stuff. Once you have all the groups working together, it's fairly easy to add on these other diseases," he said.

Everyone knows their role in North Carolina STEMI care

Jollis explained that the coordinated STEMI care initiative in North Carolina is called RACE in reference to North Carolina's rich tradition of stock-car racing and to analogize rapid STEMI response to a racecar pit crew, "where everyone knows what to do instead of trying to figure out who will do what" during each emergency.

The RACE program now covers every emergency medical service (EMS) and hospital in the state, including many hospitals that normally see each other as competitors, Jollis said. The 21 PCI hospitals in the state with on-site surgery serve as regional primary PCI centers and have agreed to collect data and share paramedics without the need for cardiology consultation. They also have agreed to keep beds open for STEMI patients and have their catheterization laboratory always available with an interventional cardiologist ready within 30 minutes of activation by an EMS call. All of the EMS organizations and hospitals have agreed upon a single treatment regimen. The 98 non-PCI centers designate themselves according to their reperfusion strategy for patients presenting with STEMI: either routine transfer for primary PCI, routine fibrinolytic therapy, or a mixed strategy including transfer for primary PCI of STEMI patients when transportation is readily available.

Jollis stressed that a key component of a successful STEMI program is equipping every ambulance that responds to a possible STEMI with an ECG and a paramedic who can read it to make a diagnosis. "Emergency departments are overwhelmed with huge numbers of patients, so there needs to be ways of finding these patients and getting them out of the waiting room and into the hospital," he explained. "If they are having a heart attack, there needs to be an ECG and somebody to read it without a cardiology consult or having to know who's on call and having it be according to somebody's preference."

Program makes a significant difference in a short period

The success of the RACE program is detailed in the paper in Circulation. It presents data from 6841 STEMI patients treated at 119 North Carolina hospitals with coordinated STEMI plans from July 2009 to December 2009, including 3907 patients presenting directly to 21 PCI hospitals and 2933 patients who were transferred from the 98 non-PCI hospitals to the PCI centers.

From before the coordinated program was implemented to the end of the study, the rate of patients not receiving reperfusion fell from 5.4% to 4.0% (p=0.04), and treatment times for hospital-transfer patients significantly improved in several measurements. "Door-to-device" times for the hospitals that always transferred STEMI patients fell from 117 minutes to 103 minutes (p=0.0008), while times at hospitals with a mixed strategy of transfer or fibrinolysis fell from 195 minutes to 138 minutes (p=0.002). The median door-to-device times for patients presenting directly to a PCI hospital dropped from 64 to 59 minutes (p < 0.001). Importantly, 91% of patients transported by ambulance met the door-to-device target of 90 minutes, including 52% treated within 60 minutes. Mortality was 2.2% in cases that met this target, compared with 5.7% for those exceeding the guideline recommendations (p < 0.001).

In the study, 39% of patients undergoing primary PCI after being transferred from one hospital to another had a door-to-device time under 90 minutes, the highest such rate reported in a multicenter study, according to Jollis et al. For comparison, they cite a Massachusetts study in which 15% of patients requiring hospital transfer in that state were treated within 90 minutes in 2008, the latest year data are available, and the National Cardiovascular Data Registry AR-G study, which reported that 24% of patients transferred for PCI in the fourth quarter of 2009 had device times within 90 minutes of first door.

A major impediment to coordination of STEMI care nationwide is a lack of national leadership, Jollis said. Right now, the Federal Office of Emergency Medical Services, which leads the creation of standards for EMS groups, is part of the National Highway Traffic Safety Administration, so the focus tends to be on response to motor-vehicle accidents and trauma, Jollis pointed out. "Emergency medical services are underfunded, locally funded, and very disjointed. There are over 15 000 EMS agencies, and we need more uniform national standards," he said. "We need much stronger leadership.

"Four times as many people die from myocardial infarction as motor-vehicle accidents, so if we have a trauma system, we can certainly have a system like this for medical emergencies like heart attacks and strokes," he said.

Jollis received research grants from Phillips, Sanofi, the Medtronic Foundation, and the Medicines Company. He also acted as a consultant for United Healthcare and BlueCross BlueShield of North Carolina. This study was supported by unrestricted grants from Phillips, Sanofi, and the Medtronic Foundation.

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