EXECUTIVE SUMMARY
New findings from the Mission: Lifeline STEMI Systems Accelerator program suggest that a regionalized approach to ST-segment elevation myocardial infarctions (STEMI) can cut time-to-treatment for patients modestly, thereby improving the prospects for better outcomes. The approach encourages hospitals, emergency medical services (EMS), and cardiologists in a region to work together to optimize treatment and efficiency so that patients in need of percutaneous coronary intervention (PCI) receive this care more expeditiously.
- The research included 484 hospitals, 1,253 EMS agencies, and nearly 24,000 patients in 16 regions across the United States.
- The goal was to increase the number of STEMI patients who receive PCI within professionally prescribed time parameters.
- Overall, the percentage of STEMI patients receiving PCI in accordance with guidelines improved from 50% to 55% during the study period.
- Key to the Mission: Lifeline approach is a focus on starting the clock ticking on time-to-treatment at first medical contact (FMC) as opposed to the hospital door, but this requires coordination with EMS and other hospitals.
- Some observers question whether a push for regionalization is worth the effort, considering the modest results thus far.
Can EDs, cardiologists, and emergency medical service (EMS) providers do more to accelerate heart-saving care to patients with ST-segment elevation myocardial infarctions (STEMI)? An important new project, spearheaded by Duke Health and the American Heart Association (AHA), suggests the answer is yes. But findings from this work also reveal that such improvement requires a more regionalized approach to STEMI care, better coordination between emergency medicine and EMS, and a focus on more rigorous outcome indicators — a tall order in a healthcare system that is highly fragmented and influenced by competitive pressures. (See also: “Time to Move the Goal Posts on STEMI Care?” located in this issue.)
The new findings cover an 18-month period of outcomes from the Mission: Lifeline STEMI Systems Accelerator. The project included 484 hospitals, 1,253 EMS agencies, and nearly 24,000 patients in 16 regions across the United States.1 The goal was to increase the number of STEMI patients who receive percutaneous coronary intervention (PCI) within the time parameters recommended by prescribed guidelines: within 90 minutes of first medical contact with emergency responders if the patient is taken to a hospital that is capable of fully handling the PCI, or within 120 minutes if the patient must be transferred to a second hospital for PCI.
Currently, roughly 50% of STEMI patients do not receive PCI within the recommended time window. However, over the course of this project, that percentage improved among participating organizations. For patients who were brought by EMS to hospitals capable of performing PCI, the proportion receiving this intervention within 90 minutes increased from 50% to 55%. Among patients who needed to be transferred to a second hospital, the proportion grew from 44% receiving PCI within the recommended 120-minute window to 48% meeting this standard.
While not all observers are impressed with the modest improvements achieved in this large-scale project, the authors contend that additional benefits are possible as the coordination strategies leveraged at the demonstration sites are optimized in the coming years. Further, they note that the project provides a roadmap for other health systems to follow in improving care for STEMI patients as well as other time-sensitive cardiovascular conditions. Indeed, the Mission: Lifeline program now is setting its sights on accelerating brain-saving care to stroke patients. (See also: “An Alternative View on Regionalized STEMI Care,” located in this issue.)
Target Delays
Christopher Granger, MD, a professor of medicine at Duke University School of Medicine and chairman of the AHA’s Mission: Lifeline program to improve heart attack care nationally, states that a key roadblock for investigators in this area is the highly competitive nature of America’s healthcare system.
“Individual hospitals do a really good job with healthcare, but they are not really working together because part of their job in terms of administration is to be a successful business, and that means being better than the competition in terms of margin-generating patient care,” he explains. “It is not really in their best interests to do things that will help their competition, especially with something like cardiovascular care, which is fairly lucrative.”
Another challenge is the fragmentation between different healthcare services.
“In some states, like Maryland, there is one EMS system and it is pretty organized. In other states, like North Carolina and Georgia, EMS is not really part of the medical system. It is funded through state and local government in a fragmented way, and it is part of the highway transportation system,” he says. “In North Carolina, we have 640 different EMS agencies.”
Granger notes that this competition and fragmentation can slow down care when there are not common approaches or protocols to follow regarding what a paramedic, emergency physician, and an interventional cardiologist will do when someone is having a heart attack.
“The paramedic goes to the scene and diagnoses that the patient is having a heart attack, and then he or she has to decide where to go. Maybe there are two PCI-capable hospitals that are equidistant or the paramedic doesn’t know if one hospital is ready or not,” he says. “In the past, the paramedics have ended up having to call around or even to drive to the nearest ED before anything is really done, and then that ED might call in the catheterization lab, and that results in an additional delay. Pretty soon you’ve got these long delays, and every minute of delay after a heart attack begins there is irreversible injury to the heart muscle and greater likelihood of death and heart failure.”
Given that outcomes in the case of STEMI are highly dependent on providing rapid care, investigators have seized on a big opportunity to improve care by doing a better job of coordinating the various care elements involved, thereby improving efficiency and time to treatment.
“Most of our focus is starting when the paramedic arrives. That is when the clock starts. We call that first medical contact (FMC), or when the first medical provider arrives at the side of the patient,” Granger explains. “Then what we want the paramedic to do is within 10 minutes, and ideally within five minutes, to get an ECG, and that will diagnose if there is a STEMI heart attack.”
Under a proper regionalized system of care, there should be an effective training system that can assure the competency of paramedics to interpret 12-lead ECGs, Granger notes. However, he observes that even computers can diagnose STEMIs accurately about 90% of the time. Alternatively, some paramedics transmit ECGs to the closest appropriate ED or cardiologist.
“That provides a bit of an extra step, but if it is done in an efficient way, it can reduce the false positives,” he explains. “We try to keep the ‘seen’ time — the time that the paramedics are at the site of the patient before the ambulance rolls — to less than 15 minutes.”
Once a STEMI has been diagnosed, paramedics are instructed to call the closest hospital that is capable of performing the primary PCI so that the catheterization lab can be activated, Granger explains, noting that while healthcare providers can’t do anything about the distance between the patient and the hospital, they can take this step to insure that the patient receives PCI as quickly as possible.
“Then we try to minimize the time in the ED, and get the patient as quickly as possible to the cath lab,” says Granger. “Sometimes the cath lab [personnel] have not yet arrived, so the patient has to wait until that happens. Other times, the cath lab [and personnel] may be available, and in some regions like New York City, for example, they have a fairly robust program of completely bypassing the ED if the cath lab is ready. Then the patient goes straight from the EMS stretcher to the cath lab.”
Address Hospital Concerns
To chart improvements in treatment time, it is critical that health systems measure performance on STEMI care, beginning with FMC, Granger stresses. However, this requires cooperation and coordination across health systems and EMS service providers.
“I live in Durham, NC. We have three hospitals and three EMS systems, and unless we work together ... on improving heart attack care in Durham, and measure how we are doing across the whole region, we really don’t know how we are doing and we can’t move things forward,” he explains. “We really have to look at it as a regional problem, and that is what we did in this project.”
J. Lee Garvey, MD, the director of emergency cardiac care at Carolinas Medical Center in Charlotte, NC, and a co-chair of the Mission: Lifeline statewide program in North Carolina, agrees, noting that there are distinctive roles to play for EMS, emergency medicine, and cardiology.
“A lot of work is really depending on each of us in those different niches working cooperatively together, making sure we are each on the same page and we each have the same expectations in performance,” he explains. “We consider the EMS role to be critical. We would like more patients with STEMIs to come [to the ED] via EMS because we then in the ED can be the brokers of the information, apply some additional filters ... and then can activate the cath lab appropriately for the whole systems response.”
Making sure that patients who are diagnosed with STEMI heart attacks in the field are taken to a hospital capable of performing PCI is not a hard-sell to EMS providers, Garvey observes.
“There is a common desire by EMS to provide patients with the best care they can. That is entirely a non-political, non-business decision, and they have been doing this forever,” he explains.
However, hospitals that do not have PCI capability need to be reassured that their bottom line will not suffer. The issue certainly came up in Charlotte in the early stages of the Mission: Lifeline project, according to Garvey.
“The administrators of smaller hospitals were concerned that if their local populations were directed to go downtown for STEMIs, then these patients also might feel like they should also go downtown for chest pain not known to be a STEMI or abdominal pain,” he says.
However, Garvey notes that such concerns have turned out to be unfounded.
“The response of the patients has been that they are much more confident in their local hospitals doing the best they can for them because they would really prefer to be closer to home when it is appropriate, and they would prefer to be downtown [at a receiving PCI-capable hospital] when that level of care is appropriate,” he explains.
In fact, when the EMS agencies and hospitals work together to make the appropriate decision about where the patient will receive the right level of care, patients are more confident that their local hospital is looking out for them, Garvey observes. Such questions about bottom line impact are raised frequently when the Mission: Lifeline regional systems are being set up, he acknowledges.
“And it is a common response that patients express more confidence in their local hospital’s care strategy because they only filter the most severely ill and injured patients to go directly to their receiving centers,” he says.
Standardize EMS Protocols
Another aspect of the Mission: Lifeline model involves standardizing what hospitals require from EMS when a patient is diagnosed in the field with a STEMI.
“A lot of this regionalization is aimed at making sure the hospitals provide a singular type of information and share patient care in a well-defined manner with all the EMS agencies so that an EMS agency will have the same response, the same pattern of care, and the same pattern of communication no matter whether they are going to PCI center A, PCI center B, or PCI center C,” Garvey notes. “That took a lot of coordination [in Charlotte], and that is a lot of the work that is ongoing with Mission: Lifeline and the Accelerator program.”
To a large degree, the program focuses on taking advantage of pre-hospital and transport time, Garvey adds.
“The majority of the work that Mission: Lifeline is engaged in right now is ensuring that EMS agencies are doing the appropriate diagnostic work, and that they are communicating in an early and effective manner,” he says. “Then the hard part is making sure that hospitals act on the information at the earliest opportunity.”
Of course false-positives are a concern, Garvey notes.
“We are trying to figure out how we can do this so that the hospital’s response is early and appropriate, and that there are only very few inappropriate activations or cases that later get canceled that could have been sorted out ahead of time,” he explains.
Granger emphasizes the central role that emergency medicine plays in STEMI care and the Mission: Lifeline approach.
“Emergency medicine is at the center of this. Even though sometimes a patient might be able to bypass the ED, that is only with protocols in place and with the full support of emergency medicine,” he explains. “Emergency medicine is critical [to] the coordination of more efficient care.”
Involve a Neutral Third Party
Regionalizing STEMI care is one of the more difficult aspects of the Mission: Lifeline approach because it requires gathering all players and reassuring them this is not a scheme to increase hospital market share, Garvey notes.
“It may be necessary or important to get an influential outside group to help mediate the discussions — like the AHA or the state American College of Emergency Physicians chapter or the state American College of Cardiology chapter to help groups work cooperatively together rather than try to push this alone because most individuals are at least felt to be associated with and working with the interests of their home institution in mind,” Garvey explains. “People may be more likely to buy into a neutral third party as the promoter of this kind of cooperative work.”
While the point of such an initiative is to improve overall cardiovascular care in a region, this segment of care generally is very competitive, so the benefits to all the participating groups must be highlighted, Garvey suggests.
“We want to have all the groups’ patients benefit,” he says. “That is why we have engaged the AHA as the body that can assist regions to work together cooperatively.”
Hospitals or providers interested in getting their own regions involved in improving STEMI care now have resources they can tap into for guidance on how to proceed.
“We have a manual of operations that goes through every element of what we have done across these regions,” Granger observes. “It is publicly available for free on our website, so I would say take our manual, adapt it to your issues, and let us know if we can help.”
Editor’s Note: For links to the Mission: Lifeline manual of operations and other resources available through the STEMI Systems Accelerator project, please visit http://bit.ly/2dU5Hij and http://bit.ly/2dycwp7.
REFERENCE
- Jollis J, Al-Khalidi H, Roettig M, et al. Regional systems of care demonstration project, American Heart Association Mission: Lifeline STEMI Systems Accelerator. Circulation 2016;134:365-374.
SOURCES
- J. Lee Garvey, MD, Director, Emergency Cardiac Care, Carolinas Medical Center, Charlotte, NC, and Co-chair, Mission: Lifeline in North Carolina. Email: [email protected].
- Christopher Granger, MD, Professor of Medicine, Duke University School of Medicine, Durham, NC, and Chairman, American Heart Association Mission: Lifeline Program. Email: [email protected].
Investigators maintain that every minute of treatment delay leads to irreversible heart damage in patients suffering STEMI.
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