Barbara T. Unger

A Regional System to Provide Timely Access to Percutaneous Coronary Intervention for ST-Elevation Myocardial Infarction

Background— Percutaneous coronary intervention (PCI) for ST-elevation myocardial infarction (STEMI) is superior to fibrinolysis when performed in a timely manner in high-volume centers. Recent European trials suggest that transfer for PCI also may be superior to fibrinolysis and increase access to PCI. In the United States, transfer times are consistently long; therefore, many believe a transfer for PCI strategy for STEMI is not practical. Methods and Results— We developed a standardized PCI-based treatment system for STEMI patients from 30 hospitals up to 210 miles from a PCI center. From March 2003 to November 2006, 1345 consecutive STEMI patients were treated, including 1048 patients transferred from non-PCI hospitals. The median first door-to-balloon time for patients <60 miles (zone 1) and 60 to 210 miles (zone 2) from the PCI center was 95 minutes (25th and 75th percentiles, 82 and 116 minutes) and 120 minutes (25th and 75th percentiles, 100 and 145 minutes), respectively. Despite the high-risk unselected patient population (cardiogenic shock, 12.3%; cardiac arrest, 10.8%; and elderly [≥80 years of age], 14.6%), in-hospital mortality was 4.2%, and median length of stay was 3 days. Conclusions— Rapid transfer of STEMI patients from community hospitals up to 210 miles from a PCI center is safe and feasible using a standardized protocol with an integrated transfer system.

Therapeutic Hypothermia After Out-of-Hospital Cardiac Arrest Evaluation of a Regional System to Increase Access to Cooling

Background— Therapeutic hypothermia (TH) improves survival and confers neuroprotection in out-of-hospital cardiac arrest (OHCA), but TH is underutilized, and regional systems of care for OHCA that include TH are needed. Methods and Results— The Cool It protocol has established TH as the standard of care for OHCA across a regional network of hospitals transferring patients to a central TH-capable hospital. Between February 2006 and August 2009, 140 OHCA patients who remained unresponsive after return of spontaneous circulation were cooled and rewarmed with the use of an automated, noninvasive cooling device. Three quarters of the patients (n=107) were transferred to the TH-capable hospital from referring network hospitals. Positive neurological outcome was defined as Cerebral Performance Category 1 or 2 at discharge. Patients with non–ventricular fibrillation arrest or cardiogenic shock were included, and patients with concurrent ST-segment elevation myocardial infarction (n=68) received cardiac intervention and cooling simultaneously. Overall survival to hospital discharge was 56%, and 92% of survivors were discharged with a positive neurological outcome. Survival was similar in transferred and nontransferred patients. Non–ventricular fibrillation arrest and presence of cardiogenic shock were associated strongly with mortality, but survivors with these event characteristics had high rates of positive neurological recovery (100% and 89%, respectively). A 20% increase in the risk of death (95% confidence interval, 4% to 39%) was observed for every hour of delay to initiation of cooling. Conclusions— A comprehensive TH protocol can be integrated into a regional ST-segment elevation myocardial infarction network and achieves broad dispersion of this essential therapy for OHCA.Background— Therapeutic hypothermia (TH) improves survival and confers neuroprotection in out-of-hospital cardiac arrest (OHCA), but TH is underutilized, and regional systems of care for OHCA that include TH are needed. Methods and Results— The Cool It protocol has established TH as the standard of care for OHCA across a regional network of hospitals transferring patients to a central TH-capable hospital. Between February 2006 and August 2009, 140 OHCA patients who remained unresponsive after return of spontaneous circulation were cooled and rewarmed with the use of an automated, noninvasive cooling device. Three quarters of the patients (n=107) were transferred to the TH-capable hospital from referring network hospitals. Positive neurological outcome was defined as Cerebral Performance Category 1 or 2 at discharge. Patients with non–ventricular fibrillation arrest or cardiogenic shock were included, and patients with concurrent ST-segment elevation myocardial infarction (n=68) received cardiac intervention and cooling simultaneously. Overall survival to hospital discharge was 56%, and 92% of survivors were discharged with a positive neurological outcome. Survival was similar in transferred and nontransferred patients. Non–ventricular fibrillation arrest and presence of cardiogenic shock were associated strongly with mortality, but survivors with these event characteristics had high rates of positive neurological recovery (100% and 89%, respectively). A 20% increase in the risk of death (95% confidence interval, 4% to 39%) was observed for every hour of delay to initiation of cooling. Conclusions— A comprehensive TH protocol can be integrated into a regional ST-segment elevation myocardial infarction network and achieves broad dispersion of this essential therapy for OHCA. # Clinical Perspective {#article-title-40}

Explaining Anomalous High Performance in a Health Care Supply Chain

An implicit assumption in distributing and coordinating work among independent organizations in a supply chain is that a focal organization can use financial or contractual mechanisms to enforce compliance among the other organizations in meeting desired performance objectives. Absent contractual agreement or financial gain, there is little incentive for independent organizations to coordinate their process improvement activities. In this study, we examine a health care supply chain in which the work is distributed among independent organizations. We use a detailed case study and an abductive reasoning approach to understand how and why the independent organizations choose to coordinate and collaborate in their work. Our study makes two contributions to the literature. First, we use well-established lean principles to explain how independent organizations achieve superior performance despite highly uncertain and variable customer demand—a context considerably different from the origins of lean principles. Second, we forward relational coordination theory to explain why the organizations in this decentralized supply chain coordinate their work. Relational coordination includes the use of shared goals, shared knowledge, and mutual respect for one anothers work as primary mechanisms to explain process improvement in the absence of any contractual incentives. Our study constitutes a first step in generating theory for work design and its improvement in decentralized supply chains.

Effects of variation in temperature management on cerebral performance category scores in patients who received therapeutic hypothermia post cardiac arrest.

AIM To assess differences in cerebral performance category (CPC) in patients who received therapeutic hypothermia post cardiac arrest by time to initiation, time to target temperature, and duration of therapeutic hypothermia (TH). METHODS A secondary data analysis was conducted using hospital-specific data from the international cardiac arrest registry (INTCAR) database. The analytic sample included 172 adult patients who experienced an out-of-hospital cardiac arrest and were treated in one Midwestern hospital. Measures included time from arrest to ROSC, arrest to TH, arrest to target temperature, and length of time target temperature was maintained. CPC was assessed at three points: transfer from ICU, discharge from hospital, and post discharge follow-up. RESULTS Average age was 63.6 years and 74.4% of subjects were male. Subjects had TH initiation a mean of 94.4 min (SD 81.6) after cardiac arrest and reached target temperature after 309.0 min (SD 151.0). In adjusted models, the odds of a poor neurological outcome increased with each 5 min delay in initiating TH at transfer from ICU (OR=1.06, 95% C.I. 1.02-1.10). Similar results were seen for neurological outcomes at hospital discharge (OR=1.06, 95% C.I. 1.02-1.11) and post-discharge follow-up (OR=1.08, 95% C.I. 1.03-1.13). Additionally the odds of a poor neurological outcome increased for every 30 min delay in time to target temperature at post-discharge follow-up (OR=1.17, 95% C.I. 1.01-1.36). CONCLUSION In adults undergoing TH post cardiac arrest, delay in initiation of TH and reaching target temperature differentiated poor versus good neurologic outcomes. Randomized trials assessing the range of current recommended guidelines for TH should be conducted to establish optimal treatment protocols.

Multidisciplinary Standardized Care for Acute Aortic Dissection Design and Initial Outcomes of a Regional Care Model

> “No physician can diagnose a condition he never thinks about.” > > — Michael DeBakey Patients with acute aortic dissection (AAD) have an in-hospital mortality of 26%, and for those patients with type A AAD, the mortality risk is 1% to 2% per hour until emergency surgical repair is performed.1,2 It is therefore critical that AAD be recognized promptly and that surgical care be provided expeditiously. Data from the International Registry of Acute Aortic Dissection (IRAD) indicate that the median time from emergency department (ED) presentation to definitive diagnosis of AAD is 4.3 hours, with an additional 4 hours between diagnosis and surgical intervention for type A patients.2,3 A portion of the delay to surgery is often the result of the patients presenting to smaller community hospitals underequipped to manage emergent AAD. Transfer to high-volume aortic care centers with highly specialized facilities and expertise is routine, but even at such centers, current surgical mortality is 25%.4 In an effort to address factors that delay AAD recognition and optimal management, a standardized, quality-improvement protocol for the regional treatment of AAD was developed and implemented with the goal of providing consistent, integrated, and coordinated care for patients with AAD throughout all phases of care. Modeled, in part, after a successful regional program for ST-segment elevation myocardial infarction,5, the specific aims of the program were to decrease the time from hospital arrival to diagnosis and treatment and to improve clinical outcomes for patients with AAD. A collaborative team designed program elements directed at (1) increasing awareness and knowledge of AAD among emergency care providers, (2) standardizing optimal care for AAD through the use of a formal protocol, (3) improving care coordination and communication across disciplines, and (4) providing …

Neurologic Outcomes and Postresuscitation Care of Patients With Myoclonus Following Cardiac Arrest.

Objectives: To evaluate the outcomes of cardiac arrest survivors with myoclonus receiving modern postresuscitation care. Design: Retrospective review of registry data. Setting: Cardiac arrest receiving centers in Europe and the United States from 2002 to 2012. Patients: Two thousand five hundred thirty-two cardiac arrest survivors 18 years or older enrolled in the International Cardiac Arrest Registry. Interventions: None. Measurements and Main Results: Eighty-eight percent of patients underwent therapeutic hypothermia and 471 (18%) exhibited myoclonus. Patients with myoclonus had longer time to professional cardiopulmonary resuscitation (8.6 vs 7.0 min; p < 0.001) and total ischemic time (25.6 vs 22.3 min; p < 0.001) and less often presented with ventricular tachycardia/ventricular fibrillation, a witnessed arrest, or had bystander cardiopulmonary resuscitation. Electroencephalography demonstrated myoclonus with epileptiform activity in 209 of 374 (55%), including status epilepticus in 102 of 374 (27%). Good outcome (Cerebral Performance Category 1–2) at hospital discharge was noted in 9% of patients with myoclonus, less frequently in myoclonus with epileptiform activity (2% vs 15%; p < 0.001). Patients with myoclonus with good outcome were younger (53.7 vs 62.7 yr; p < 0.001), had more ventricular tachycardia/ventricular fibrillation (81% vs 46%; p < 0.001), shorter ischemic time (18.9 vs 26.4 min; p = 0.003), more witnessed arrests (91% vs 77%; p = 0.02), and fewer “do-not-resuscitate” orders (7% vs 78%; p < 0.001). Life support was withdrawn in 330 of 427 patients (78%) with myoclonus and poor outcome, due to neurological futility in 293 of 330 (89%), at 5 days (3–8 d) after resuscitation. With myoclonus and good outcome, median ICU length of stay was 8 days (5–11 d) and hospital length of stay was 14.5 days (9–22 d). Conclusions: Nine percent of cardiac arrest survivors with myoclonus after cardiac arrest had good functional outcomes, usually in patients without associated epileptiform activity and after prolonged hospitalization. Deaths occurred early and primarily after withdrawal of life support. It is uncertain whether prolonged care would yield a higher percentage of good outcomes, but myoclonus of itself should not be considered a sign of futility.

ST-Elevation Myocardial Infarction Which Patients Do Quality Assurance Programs Include?

Background—In the United States, efforts are underway to improve timely access to percutaneous coronary intervention in ST-elevation myocardial infarction (STEMI). The Joint Commission (TJC) and the American College of Cardiology National Cardiovascular Data Registry (NCDR) have developed standardized definitions and clinical performance measures for STEMI. The purpose of this study was to determine differences in 3 quality-assurance registries for STEMI patients. Methods and Results—STEMI patients presenting to the Minneapolis Heart Institute at Abbott Northwestern Hospital (Minneapolis, Minn) are tracked by 3 distinct quality assurance programs: NCDR, TJC, and the level 1 MI registry (a regional system for percutaneous coronary intervention in STEMI which includes transfer patients). Over 1 year, we examined consecutive STEMI patients in level 1 and compared them with individuals meeting NCDR and TJC inclusion criteria. Of 501 STEMI patients treated using the level 1 MI protocol, 422 patients had a clear culprit (402 percutaneous coronary intervention, 13 coronary artery bypass grafting, 7 medical management). In the same period, 282 patients met inclusion criteria for NCDR (56% of the level 1 population), and 66 met inclusion criteria for TJC (13% of the level 1 population). Transfer patients (n=380) accounted for 87% of the discrepancy between level 1 and TJC. Pharmacoinvasive percutaneous coronary intervention (n=102) accounted for 47% of the discrepancy between level 1 and NCDR. Conclusions—Current inclusion criteria for enrollment in STEMI registries are not uniform. This may lead to variable quality assurance outcomes for the same patient cohort and has important implications for standardized quality measurement.

Association of gender to outcome after out-of-hospital cardiac arrest – a report from the International Cardiac Arrest Registry

IntroductionPrevious studies have suggested an effect of gender on outcome after out-of-hospital cardiac arrest (OHCA), but the results are conflicting. We aimed to investigate the association of gender to outcome, coronary angiography (CAG) and adverse events in OHCA survivors treated with mild induced hypothermia (MIH).MethodsWe performed a retrospective analysis of prospectively collected data from the International Cardiac Arrest Registry. Adult patients with a non-traumatic OHCA and treated with MIH were included. Good neurological outcome was defined as a cerebral performance category (CPC) of 1 or 2.ResultsA total of 1,667 patients, 472 women (28%) and 1,195 men (72%), met the inclusion criteria. Men were more likely to receive bystander cardiopulmonary resuscitation, have an initial shockable rhythm and to have a presumed cardiac cause of arrest. At hospital discharge, men had a higher survival rate (52% vs. 38%, P <0.001) and more often a good neurological outcome (43% vs. 32%, P <0.001) in the univariate analysis. When adjusting for baseline characteristics, male gender was associated with improved survival (OR 1.34, 95% CI 1.01 to 1.78) but no longer with neurological outcome (OR 1.24, 95% CI 0.92 to 1.67). Adverse events were common; women more often had hypokalemia, hypomagnesemia and bleeding requiring transfusion, while men had more pneumonia. In a subgroup analysis of patients with a presumed cardiac cause of arrest (n = 1,361), men more often had CAG performed on admission (58% vs. 50%, P = 0.02) but this discrepancy disappeared in an adjusted analysis.ConclusionsGender differences exist regarding cause of arrest, adverse events and outcome. Male gender was independently associated with survival but not with neurological outcome.

Has the Time Come for a National Cardiovascular Emergency Care System

In 2007, there were ≈4 million visits to emergency departments in the United States with a primary diagnosis of cardiovascular disease.1 Current forecasts estimate that the direct medical costs for cardiovascular disease in the United States will triple by 2030 to

Safety, feasibility, and outcomes of induced hypothermia therapy following in-hospital cardiac arrest-evaluation of a large prospective registry*.

800 billion dollars.2 Acute cardiovascular emergencies, including ST-segment–elevation myocardial infarction (STEMI), non-STEMI/unstable angina, out-of-hospital cardiac arrest (OHCA), acute aortic dissection (AAD), abdominal aortic aneurysm (AAA), stroke, and acute decompensated heart failure/cardiogenic shock, require rapid, complex, and resource-intensive care and confer a high risk of mortality. Regionalized systems of care enable patients with complex and urgent medical needs to be systematically directed to hospitals that can provide the highest level of clinical expertise and resources (ie, designated centers). Historically, trauma systems have used this paradigm with improved outcomes. There is a growing focus on regionalized medical care as a strategy to leverage limited resources, to manage cost, and to improve outcomes for other medical emergencies. National cardiovascular organizations have already published recommendations for the establishment of centers and regional systems of care for STEMI,3–6 cardiac arrest,7–9 and stroke.10,11 The purpose of this article is to propose the concept of a cardiovascular emergency system, ie, a comprehensive regional system of care for cardiovascular emergencies led by a designated cardiovascular emergency receiving center. Over the past decade, the Minneapolis Heart Institute at Abbott Northwestern Hospital (MHI-ANW) has implemented regional systems of care for STEMI,12 OHCA,13 AAD,14 non-STEMI, and AAA. These initiatives provide a demonstration of the clinical programs and supportive network that reflect the burgeoning framework of a cardiovascular emergency system. Informed by this work, we discuss the historical perspective of, rationale for, and proposed principal elements of a cardiovascular emergency system. Trauma systems are the prototype for …