'Mission: Lifeline' Shows Collaborative Care Ups MI Survival

Marlene Busko

November 27, 2014

CHICAGO, IL — The Mission: Lifeline program of coordinated emergency response for patients with ST-segment-elevation MI (STEMI) resulted in shorter emergency-room (ER) wait times and better survival, new research shows[1].

"What we saw were significant improvements in times from first medical contact to primary PCI whether [patients] came in via emergency medical services (EMS), were direct presenters, or were transferred for primary PCI," said Dr Christopher Granger (Duke University Medical Center, Durham, NC), who presented the results during a late-breaking trial session at the American Heart Association (AHA) 2014 Scientific Sessions.

The study looked at results of the ACCELERATOR study, in which the Mission: Lifeline program was implemented in 16 metropolitan areas in the United States (including New York City, Houston, Atlanta, and St Louis), representing about 10% of the US population.

In the first year of the program, the number of STEMI patients treated within guideline-recommended times increased by about 3% to 5%, with increases of 20% in some regions.

Importantly, the improvements in timely care were associated with better survival. "We identified numerically lower mortality among participating regions compared with national rates, suggesting that regional STEMI programs can provide important improvements to public health," Granger said.

Early Results

Nearly half of the more than 250 000 patients who have a STEMI each year in the US aren't treated within the recommended 90 minutes at hospitals that have PCI capability or within 120 minutes if they require transfer to a hospital that can do PCI, previous studies have shown.

In 2007, the American Heart Association (AHA) created the Mission: Lifeline program to bring together hospitals and EMS agencies in different communities to overcome STEMI-treatment delays. The program has been implemented in 827 communities, covering 82.5% of the US population, according to an AHA statement.

"The [program] is an opportunity to establish common regional leadership and work on common protocols so that hospitals could work together to provide better care to patients," lead author Dr Matthew W Sherwood (Duke University) told heartwire .

The program aimed to increase timely coronary reperfusion by organizing coordinated STEMI care. Sherwood and colleagues organized meetings in each region with leaders of EMS services, ER physicians, and interventional cardiologists to identify areas of improvement. Participants collaborated to develop common, regional protocols.

The study included 171 PCI-capable hospitals, more than 200 other hospitals, and 1253 EMS agencies. From July 1, 2012 to March 31, 2014, nearly 24 000 patients had heart attacks; more than 18 000 presented to PCI-capable hospitals, and 5500 were transferred to PCI-capable hospitals from other hospitals.

Most patients (90%) were treated with PCI. The median time from symptom onset to first medical contact was only 47 minutes for patients who called 911 and arrived by ambulance vs nearly 2 hours for patients who presented on their own. 

At baseline, very few of the regions met the guideline recommendations for time from first medical contact until treatment. However, 18 months later, the percentage of STEMI patients who received timely treatment increased from 62% to 65% for those who went directly to the hospital, from 54% to 59% for those arriving by ambulance, and from 50% to 53% for those requiring hospital transfer. A total of 6% of patients died in hospital, which is consistent with other national data.

Although the overall changes were modest, in the five regions with the greatest improvements, the percentage of patients who received timely treatment increased from 49% to 61%.

Less time spent waiting in the ER (adjusted for covariates) was associated with improved survival (P<0.001). About one in 10 patients who waited in the ER for more than 45 minutes died at the hospital. However, fewer of those who waited 30 to 45 minutes (7%) or under half an hour (3.6%) died at the hospital.

Tremendous Collaborative Effort Can Save Lives

Session moderator Dr Robert Harrington (Stanford University, CA) commented that some European countries such as Sweden have a coordinated, fast emergency response, and the biggest barrier in the US is competition between hospitals. "We have to get over that," he said. "The best thing is to come up with standards and compare hospitals."

To heartwire, coauthor Dr James G Jollis (Duke University) pointed out that some of the challenges in the US healthcare system are that "We have more people in North Carolina or Los Angeles than all of Sweden," and it is quite a feat "to get 170 hospitals to agree, collect common data, and share protocols."

Researchers were successful in getting the collaboration by starting at a grass-roots level and identifying gaps in care or communication, he said.

New York City was one of the most improved regions. "In New York City, we got 16 hospitals to come together and share data, which was quite a process. For the first time, they agreed to allow patients to be taken from ambulances directly to a cath lab, and with that we saw a huge improvement in times," said Jollis.

When paramedics can make a diagnosis with a 12-lead ECG and activate a cath lab before a patient arrives at hospital, it saves the patient time in the ER waiting for the cath team to mobilized, he noted.

"These findings [from the ACCELERATOR study] validate the concept that the collaborative systems of care model we launched with our Mission: Lifeline initiative 7 years ago can speed heart-attack treatment and save lives," Dr Alice Jacobs (Boston University, MA), AHA past president and original chair of the Mission: Lifeline program advisory working group, said in a statement.

"Lessons from the demonstration project can be used to guide our future efforts to further improve heart-attack care in the United States and beyond."

Granger reports research grants from Bristol-Myers Squibb, Daiichi Sankyo, Bayer, the Medicines Company, AstraZeneca, and Janssen. Jollis reports research grants from the Medtronic Foundation, AstraZeneca, the Medicines Company, and Philips Healthcare. Sherwood has no disclosures.

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