Christine M. Bjerke

Regional Systems of Care to Optimize Timeliness of Reperfusion Therapy for ST-Elevation Myocardial Infarction The Mayo Clinic STEMI Protocol

Background— Quality improvement efforts have focused on strategies to improve the timeliness of reperfusion therapy in ST-elevation myocardial infarction patients who present to hospitals with and without percutaneous coronary intervention (PCI) capability. We implemented and evaluated a protocol to optimize the timeliness of reperfusion therapy and to coordinate systems of care for a PCI center and 28 regional hospitals located up to 150 miles away across 3 states. Methods and Results— The present study focused on a prospective, observational cohort of 597 patients who presented with ST-segment elevation and within 12 hours of symptom onset to Saint Marys Hospital and 28 regional hospitals up to 150 miles away between May 2004 and December 2006. The Mayo Clinic ST-elevation myocardial infarction protocol implemented strategies to improve timeliness of reperfusion therapy and to coordinate systems of care for transfer between hospitals. The study sample consisted of 258 patients who presented to Saint Marys Hospital and were treated with primary PCI (group A), 105 patients who presented to a regional hospital with symptom onset >3 hours and then were transferred for primary PCI (group B), and 131 patients who presented to a regional hospital with symptom onset <3 hours and were treated with full-dose fibrinolytic therapy (group C). For groups A and B, median door-to-balloon times were 71 and 116 minutes, respectively. Door-to-balloon time <90 minutes was achieved in 75% of group A and 12% of group B. Median door-to-needle time was 25 minutes for group C, and 70% had door-to-needle time <30 minutes. Conclusions— The Mayo Clinic ST-elevation myocardial infarction protocol demonstrates the feasibility of implementing strategies to optimize the timeliness of reperfusion therapy and the times that can be achieved through coordinated systems of care for ST-elevation myocardial infarction patients presenting to a PCI center (Saint Marys Hospital) and 28 regional hospitals without PCI capability located up to 150 miles away across 3 states.

Systems of Care to Improve Timeliness of Reperfusion Therapy for ST-Segment Elevation Myocardial Infarction During Off Hours: The Mayo Clinic STEMI Protocol

OBJECTIVES We implemented the Mayo Clinic ST-segment elevation myocardial infarction (STEMI) protocol and evaluated the timeliness of reperfusion therapy during off hours versus regular hours. BACKGROUND Patients with STEMI who present during off hours have longer door-to-balloon times and door-to-needle times. METHODS The Mayo STEMI protocol was implemented in May 2004 to optimize timeliness of reperfusion therapy for STEMI patients presenting to Saint Marys Hospital, a tertiary facility with on-site percutaneous coronary intervention (PCI), and for those presenting to 28 regional hospitals located up to 150 miles away from Saint Marys Hospital. We compared door-to-balloon times and door-to-needle times for 597 consecutive patients who presented during off hours (weekdays from 5 pm to 7 am and any time on weekends or holidays) versus regular hours (weekdays from 7 am to 5 pm). In 2003, prior to implementing the protocol, median door-to-balloon time at Saint Marys Hospital was 85 min during regular hours and 98 min during off hours. RESULTS Among 258 patients who presented to Saint Marys Hospital, median door-to-balloon time was 65 min during regular hours versus 74 min during off hours (p = 0.085). Among 105 patients transferred from regional hospitals for primary PCI, median door-to-balloon time was 118 min during regular hours versus 114 min during off hours (p = 0.15). Among 131 patients treated with fibrinolytic therapy at regional hospitals, median door-to-needle time was 21 min during regular hours versus 26 min during off hours (p = 0.067). CONCLUSIONS The Mayo Clinic STEMI protocol demonstrates the rapid times that can be achieved through coordinated systems of care for STEMI patients presenting during off hours and regular hours.

Impact of Prehospital Electrocardiogram Protocol and Immediate Catheterization Team Activation for Patients With ST-Elevation–Myocardial Infarction

Guidelines recommend implementing prehospital electrocardiograms (PH ECG) into systems of care for patients with suspected ST-elevation–myocardial infarction to reduce door-to-balloon time (DTB). We developed a PH ECG protocol with an affiliated emergency medical service, combining 4 features: (1) PH ECG acquisition; (2) emergency medical service interpretation without PH ECG transmission; (3) prehospital activation of the cardiac catheterization team; and (4) emergency department bypass. We compared data from June 1, 2006, to August 31, 2007 (preimplementation group, n=50), with data from October 1, 2007, to June 30, 2010 (postimplementation group, n=82), analyzing all patients with ST-elevation–myocardial infarction transported by an affiliated EMS and treated with primary percutaneous coronary intervention. PH ECGs were acquired in 33 (66%) and 67 (82%) patients in the preimplementation and postimplementation groups, respectively ( P =0.041). Median DTB was 59 and 57 minutes for the preimplementation and postimplementation groups, respectively ( P =0.28). In a prespecified subgroup analysis of postimplementation patients (n=38) who had prehospital activation of catheterization team and emergency department bypass, median DTB was 32 minutes ( P <0.001 compared with preimplementation group). Our PH ECG protocol increased the frequency of PH ECG acquisition and decreased DTB for patients when all 4 features of our PH ECG protocol were carried out. Prehospital electrocardiograms (PH ECG) can decrease reperfusion times for patients with ST-elevation–myocardial infarction (STEMI) undergoing primary percutaneous coronary intervention (PCI).1–16 However, even when PH ECG are acquired, they may not be optimally utilized and integrated. A recent scientific statement by the American Heart Association (AHA) stated, “the central challenge for healthcare providers is not to simply perform PH ECG, but to use and integrate the diagnostic information from a PH ECG with systems of care.”17 The American College of Cardiology/AHA (ACC/AHA) guidelines for STEMI encourage a first medical contact-to-balloon time (FMCTB) within 90 …

Using prehospital electrocardiograms to improve door-to-balloon time for transferred patients with ST-elevation myocardial infarction: a case of extreme performance.

A 45-year-old man was walking his dog at 5:30 am in June 2009 and developed crushing 10/10 substernal chest pain. He called 911 at 6:05 am after his symptoms persisted for 35 minutes. Emergency medical services (EMS) paramedics arrived at the scene at 6:09 am and obtained a brief history and examination showing a diaphoretic man, pulse of 92 bpm, blood pressure of 170/140 mm Hg, normal respiratory rate, and no rales or murmurs. Treatment was initiated including supplemental oxygen, sublingual nitroglycerin, and aspirin. A 12-lead prehospital (PH) ECG was acquired at the scene at 6:16 am and interpreted by paramedics as showing acute ST-elevation myocardial infarction (STEMI) (Figure 1). On the basis of the PH ECG, paramedics made a single phone call to the closest community hospital emergency department and activated the PH ECG STEMI protocol at 6:17 am. The closest community hospital was located within 5 miles and did not have capability for percutaneous coronary intervention (PCI). The STEMI protocol activation consisted of autolaunching helicopter transport to intercept the patient at the community hospital and alerting the cardiac catheterization team at the tertiary PCI center located 50 miles away with the estimated patient arrival time. The patient arrived at the community hospital emergency department (door 1) by ground ambulance at 6:26 am. Helicopter transport picked up the patient and departed the community hospital at 6:37 am with a door 1 in–to–door 1 out time of 11 minutes. The patient arrived at the tertiary PCI center (door 2) at 7:10 am and was transported directly to the cardiac catheterization laboratory. During transport from the helipad to the cardiac catheterization laboratory, the patient had ventricular fibrillation in the elevator, and a shock was delivered with 120 J of selected energy. Coronary angiography showed a thrombotic occlusion of the …

Using Prehospital Electrocardiograms to Improve Door-to-Balloon Time for Transferred Patients With ST-Elevation Myocardial Infarction

A 45-year-old man was walking his dog at 5:30 am in June 2009 and developed crushing 10/10 substernal chest pain. He called 911 at 6:05 am after his symptoms persisted for 35 minutes. Emergency medical services (EMS) paramedics arrived at the scene at 6:09 am and obtained a brief history and examination showing a diaphoretic man, pulse of 92 bpm, blood pressure of 170/140 mm Hg, normal respiratory rate, and no rales or murmurs. Treatment was initiated including supplemental oxygen, sublingual nitroglycerin, and aspirin. A 12-lead prehospital (PH) ECG was acquired at the scene at 6:16 am and interpreted by paramedics as showing acute ST-elevation myocardial infarction (STEMI) (Figure 1). On the basis of the PH ECG, paramedics made a single phone call to the closest community hospital emergency department and activated the PH ECG STEMI protocol at 6:17 am. The closest community hospital was located within 5 miles and did not have capability for percutaneous coronary intervention (PCI). The STEMI protocol activation consisted of autolaunching helicopter transport to intercept the patient at the community hospital and alerting the cardiac catheterization team at the tertiary PCI center located 50 miles away with the estimated patient arrival time. The patient arrived at the community hospital emergency department (door 1) by ground ambulance at 6:26 am. Helicopter transport picked up the patient and departed the community hospital at 6:37 am with a door 1 in–to–door 1 out time of 11 minutes. The patient arrived at the tertiary PCI center (door 2) at 7:10 am and was transported directly to the cardiac catheterization laboratory. During transport from the helipad to the cardiac catheterization laboratory, the patient had ventricular fibrillation in the elevator, and a shock was delivered with 120 J of selected energy. Coronary angiography showed a thrombotic occlusion of the …

Using prehospital electrocardiograms to improve door-to-balloon time for transferred patients with st-elevation myocardial infarction a case of extreme perf

A 45-year-old man was walking his dog at 5:30 am in June 2009 and developed crushing 10/10 substernal chest pain. He called 911 at 6:05 am after his symptoms persisted for 35 minutes. Emergency medical services (EMS) paramedics arrived at the scene at 6:09 am and obtained a brief history and examination showing a diaphoretic man, pulse of 92 bpm, blood pressure of 170/140 mm Hg, normal respiratory rate, and no rales or murmurs. Treatment was initiated including supplemental oxygen, sublingual nitroglycerin, and aspirin. A 12-lead prehospital (PH) ECG was acquired at the scene at 6:16 am and interpreted by paramedics as showing acute ST-elevation myocardial infarction (STEMI) (Figure 1). On the basis of the PH ECG, paramedics made a single phone call to the closest community hospital emergency department and activated the PH ECG STEMI protocol at 6:17 am. The closest community hospital was located within 5 miles and did not have capability for percutaneous coronary intervention (PCI). The STEMI protocol activation consisted of autolaunching helicopter transport to intercept the patient at the community hospital and alerting the cardiac catheterization team at the tertiary PCI center located 50 miles away with the estimated patient arrival time. The patient arrived at the community hospital emergency department (door 1) by ground ambulance at 6:26 am. Helicopter transport picked up the patient and departed the community hospital at 6:37 am with a door 1 in–to–door 1 out time of 11 minutes. The patient arrived at the tertiary PCI center (door 2) at 7:10 am and was transported directly to the cardiac catheterization laboratory. During transport from the helipad to the cardiac catheterization laboratory, the patient had ventricular fibrillation in the elevator, and a shock was delivered with 120 J of selected energy. Coronary angiography showed a thrombotic occlusion of the …