For Earlier PCI in Acute STEMI, Sync Prehospital-Hospital Care Processes

December 01, 2017

ANAHEIM, CA — In a case of thinking globally and acting locally, a national program used input from providers in different communities to unify and coordinate their hospital and prehospital care processes for acute ST-segment elevation MI (STEMI). The results: more effective care, a streamlined route to the cath lab, and significantly better hospital survival[1].

"Every single process we measured improved," Dr James G Jollis (Duke Clinical Research Institute, Durham, NC) said about the STEMI ACCELERATOR-2 study, using local leaders in 12 metropolitan areas to engage area hospitals and emergency medical services (EMS) in improving their STEMI care processes.

The idea was to track which locally inspired process changes worked well within the framework of the national Get With the Guidelines (GWTG) quality initiative; to reduce times to PCI reperfusion by organizing care throughout the patient's EMS and hospital journey; and to provide a forum for feedback to help all centers and providers improve their game.

The delivery of acute STEMI care is fragmented not only by limited coordination between hospital emergency departments and EMS but also by varying practices among different hospitals and EMS services, even within the same regions—and that can worsen patient outcomes, Jollis told | Medscape Cardiology.

"Healthcare systems are amazingly different every place you live." In trying to bring more consistency to acute STEMI management, "we find time and time again that all the barriers and opportunities are local issues, regional issues. Most of our answers came from the local leaders," he said.

"We bridged the gaps between competing hospitals and health systems, and we bridged the gaps between emergency medical services and hospitals."

Jollis presented the STEMI ACCELERATOR 2 results here at the American Heart Association (AHA) 2017 Scientific Sessions and is lead author on its concurrent publication in Circulation.

Bypass Emergency Departments When Appropriate

As described in that report, process changes at each of the study's 946 EMS agencies and 132 hospitals with PCI capability focused on "prehospital activation of catheterization laboratories and bypassing emergency departments whenever appropriate, prespecified treatment protocols, measurement and feedback in regional reports, broad regional leadership to support these activities, and ongoing implementation and quality-improvement efforts by a dedicated regional coordinator."

The 2-year ACCELERATOR 2 project involving 10,730 patients saw significant improvements for several key end points in its final 3 months compared with its initial 3 months, including the proportion of patients with a <20-minute time from first medical contact (FMC) (that is, paramedic arrival) to cath-lab activation (P<0.0001); emergency-department time <20 minutes (P<0.0001); and the primary end point, time from FMC to PCI of <90 minutes (P<0.002). No such gains were seen in a cohort of hospitals not participating in ACCLERATOR 2.

Those gains by the final months of the study were accompanied by a drop in hospital mortality from 4.4% to 2.3% (P=0.001) and development of heart failure as a complication from 7.4% to 5.0% (P=0.031).

Estimates are that "Americans receive half or less of guideline-indicated care," observed Dr Larry A Allen (University of Colorado Hospital, Aurora) as discussant following the Jollis presentation of ACCELERATOR 2.

"There are many opportunities in STEMI care," he said. More than half of patients don't use EMS, and "the majority of EMS systems in the past have not used 12-lead ECGs." In other examples, "There are prolonged transfer times in rural settings and even actually within cities, and hospital emergency departments are frequently on diversion."

Furthermore, he said, "We should shift the focus from hospital door-to-balloon times, which are important but don't include the whole system of care, to first medical contact."

Proportion of Patients (%) With Emergency-Department and Cath-Lab Activation Times <20 min vs >30 min at Beginning and End of ACCELERATOR 2*

Parameter Mean <20 min in first 3 months (%) <20 min in final 3 months (%) >30 min in first 3 months (%) >30 min in final 3 months (%)
FMC to cath-lab activation 31.8 56.1 37.5 22.2
Patient time in emergency department 33.0 43.4 41.8 32.8
FMC=first medical contact
* P<0.0001 for all differences between first and final 3 months

Time in the emergency department, "an important indicator of coordination of care between paramedics and hospitals," should also be targeted, but "this really requires regional STEMI care, regional approaches, that have communities working together to deliver care," he said.

"Not to knock the fact that we continue to have another new stent, another new antiplatelet drug, another new LDL-lowering agent, but meanwhile there is a lot of low-hanging fruit out there in terms of getting people on the therapies that we know work."

From Regional to National

The current study follows the ACCELERATOR 1 pilot study and earlier quality initiatives, notably the RACE project in North Carolina, that by and large focused on in-hospital measures like door-to-balloon (D2B) time and were limited to one part of the US.

Regional coordination of acute STEMI care systems in RACE were associated with significant improvements in cath-lab activation times, D2B times, and other measures, but observers questioned whether the program could be scaled up to a national level.

People said, "How can you do this outside North Carolina?" Dr Gregg C Fonarow (Ronald Reagan University of California, Los Angeles Medical Center) said in an interview.

One answer, ACCELERATOR 2 found, is to tailor the program's implementation to local system needs. That depended on "the regional coordinator working with the local experts" as they "shared best practices and expertise," he said.  

"It's using the principle that those who know that community best all work together to achieve common goal," Fonarow said. "But how you achieve those goals, how the mechanism for deciding which hospitals patients will be transported to, which hospitals will be primary STEMI receiving center, what the protocol will be when there's snow on the ground and you need snow plows to get through—all of those things can very much vary. And there may be some politics with different EMS agencies that will vary by region."

Fonarow, a GWTG steering committee member, said hopes are that something like the ACCELERATOR program can be adopted across the US.

"What we've seen here is incredibly impressive, because overall this intervention has actually led to faster [FMC-to-PCI] times," he said. "Importantly, we see that this translated to an in-hospital mortality decline over time that was not seen to the same degree in regions that were not targeted for the ACCELERATOR program."

Hurdles to Faster Cath-Lab Activation

As described in the published report, the improvement efforts in ACCELERATOR 2 focused on STEMI diagnosis in the field and rapid activation of the cath lab. In fact, of the challenges in the study, Jollis said, "a big one was cath-lab activation—that is, allowing paramedics to activate it. There was a lot of pushback on that."

Getting more cardiologists at the hospital to accept a STEMI diagnosis from paramedics was another hurdle, he said. It helped for them to know that as part of the program, "the paramedics were better trained, so they were getting less of those false activations."

Sometimes there are delays due to confusion about whether the cath lab is ready to receive the patient, Jollis said. "We know of one hospital that put lights in the emergency department, a green and a red light. If cath lab was ready, the green light was switched on and they could go in. Red light, they stayed down in the emergency department."

Outcomes for Acute STEMI Patients Arriving by EMS at PCI-Capable Hospitals

End points Initial 3 months (%) Final 3 months (%) P
CABG during hospitalization 2.7 1.8 0.166
In-hospital death* 4.4 2.3 0.008
Congestive heart failure 7.4 5.0 0.031
Stroke 0.8 0.3 0.131
*P=0.013 after adjustment for demographic and clinical features

As evidence that shorter times from FMC to cath-lab activation make a difference to outcomes, in-hospital mortality when that time was <20 minutes was 2.2%, compared with 4.5% for when FMC to cath-lab activation took longer than 20 minutes (P<0.0001).

Jollis said the drop in overall in-hospital mortality from the trial's first 3 months to its final 3 months may seem disproportionately large for the observed improvement in FMC to cath-lab activation time.

"Part of this is likely due to the observational nature of the study," he said. But "better training of paramedics, ability to identify sick patients and get them to the cath lab, and communication in working as teams I think really makes a huge difference."

Fonarow agreed that the trial's steep drop in hospital mortality derives from more than just the shortened FMC-to-PCI times. "You're seeing a nice reduction from the accumulated improvements in all of the efforts. Not just on the time interval, but the whole component of care."

ACCELERATOR 2 was sponsored by AstraZeneca and the Medicines Company. Jollis had no relevant financial relationships. Fonarow discloses consulting or serving on an advisory board for Amgen, Janssen, Medtronic, Novartis, and St Jude Medical. Allen discloses consulting or serving on an advisory board for Janssen, Boston Scientific, and Novartis.

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