EXECUTIVE SUMMARY

A push to regionalize the care and treatment of patients with ST-elevation myocardial infarction (STEMI) gains steam. Investigators documented improved time to treatment results and a significant decline in mortality among patients treated at sites adopting a regionalized approach. The data come from the Regional Systems Accelerator-2 project in which key stakeholders in 12 regions pledged to work together to improve STEMI care.

  • In an improvement over the intervention used in the Accelerator-1 project, a neutral STEMI coordinator was funded at each site to oversee collaborative efforts to accelerate treatment and improve care.
  • Key to the overall concept was the development of regionalized STEMI care plans, the empowerment of EMS providers to diagnose patients with suspected STEMI, and the activation of catheterization lab teams from the field, thereby accelerating treatment.
  • Investigators reported that the faster treatment times produced by the Accelerator-2 intervention were in alignment with a significant 4.4% to 2.3% decrease in in-hospital mortality among STEMI patients by the end of the two-year intervention period.
  • Particularly compelling to investigators was the observation that when first medical contact to activation of the catheterization lab is less than 20 minutes, mortality is in the 2% range. However, if activation of the cath lab takes longer than 20 minutes, mortality is more than double that figure.

Reducing time to treatment makes a critical difference in patients experiencing an ST-elevation myocardial infarction (STEMI), the deadliest form of heart attack. In recognition of this reality, hospitals have made great strides in improving door-to-balloon times, or the time between a STEMI patient’s arrival in the ED to when he or she receives life-saving percutaneous coronary intervention (PCI) in a hospital’s catheterization lab, a procedure designed to unblock a clogged artery.

However, experts now make the case that to achieve further improvements in STEMI outcomes, it is not enough to start the clock ticking when a patient first arrives in the ED. Instead, they advise measuring time to treatment from first medical contact (FMC), thereby shifting the focus of improvement efforts further upstream to the prehospital environment.

Given the vast differences in the way EMS agencies are governed and funded across the country, there may be no one-size-fits-all approach to cobbling together a systems-level solution that will accelerate time to treatment for STEMI patients. But in the Regional Systems Accelerator-2 project, investigators have demonstrated that a regionalized approach to care is possible, and that it can significantly reduce mortality in STEMI patients.1

Empower EMS

In the Accelerator-2 project, researchers aimed to test whether appointing dedicated regional coordinators could make a difference in improving STEMI care and outcomes in 12 participating regions. Among other objectives, the coordinators were charged with overseeing collaboration among hospitals and EMS agencies, and working toward accelerating time to treatment for STEMI patients. An earlier STEMI Accelerator-1 project, which did not include dedicated coordinators, achieved just modest improvements in time to treatment results from efforts to regionalize care in 16 participating areas. However, investigators noted that not all the sites had implemented crucial steps in the improvement effort.2

The Accelerator-2 project included several improvements over Accelerator-1. Perhaps the most significant improvement was the funding of a STEMI coordinator in each participating region. However, in both projects, a key aspect of the regionalization push involved empowering EMS providers to obtain ECGs in the field and to activate catheterization lab teams based on the paramedic’s interpretation of the ECGs.

“That is the most crucial part. In doing that, you are able to mobilize the team and treat the patients quickly when they [arrive at the hospital], but that takes buy-in and support from the receiving hospitals, and it takes buy-in from EMS,” explains Claire Corbett, MMS, NREMT-P, the AMI and stroke programs manager at New Hanover Regional Medical Center in Wilmington, NC, and a faculty member/advisor on the Accelerator-2 project.

To secure appropriate buy-in from all stakeholders, ambulance teams need to be equipped with the necessary gear, and they need to be proficient in reading 12-lead ECGs. “Overall, that is now a national standard, and there is lots of great evidence out there that paramedics can read 12-lead ECGs and make these diagnoses,” explains James Jollis, MD, the lead author of the Accelerator-2 study and a professor of radiology at Duke University School of Medicine. “That being said, there are 15,000 [EMS agencies], and each one has independent direction. They rely on local funding. Often, that funding is inadequate.”

Build Relationships

There are going to be times when paramedics activate a catheterization lab team, and it turns out that the patient is not in fact experiencing a STEMI attack. However, there is no perfect test, Jollis, says, noting that improving proficiency among paramedic teams is a function of strong physician leadership. For example, Jollis observes that in Wake County, NC, where he practices, paramedic activation of the catheterization lab is cancelled in just one out of every 10 activations. However, he acknowledges that more leadership and training are needed in some regions to ensure that the ECGs are interpreted in the field with a high degree of proficiency. This is where emergency medicine clinicians can play a significant role in the development of effective, regionalized STEMI systems. “Emergency medicine is a very important part of this whole system,” Jollis says. “Emergency medicine physicians are running EMS agencies, they are writing state protocols, and they run EDs.”

Cardiologists also play a strong role in fostering ties with prehospital providers, Corbett offers. For example, she notes that a cardiologist might sit with paramedics and review some ECGs or case studies together. “It breaks down the barriers between cardiology [specialists] and paramedics, who usually don’t interface, and it builds trust,” she says. “That is a very important part of doing this successfully.”

Corbett is not just reflecting on her experience with the Accelerator-2 project. She also has been heavily involved in the Regional Approach to Cardiovascular Emergencies (RACE) in North Carolina, a statewide project that shares many of the same processes and goals and helped to inform the approach used in both Accelerator-1 and Accelerator-2.

From this work, Corbett notes that another helpful step in the relationship-building process involves asking paramedics to stick around in the catheterization lab so that they can see at least the beginning stages of the PCI procedure. “That gives them some instant feedback on what is going on with the patient, and it helps with that relationship-building between the various team members,” Corbett says. “That has very much been a part of the STEMI system being built in North Carolina as well as in the Accelerator-2 sites.”

Such steps are needed to pull all the different entities involved in STEMI care in the same direction. “Everybody wants to do a good job. But there is so much fragmentation in the system that if we don’t come together to focus on the patient and the system, none of us are going to be able to meet the end goal that we want, which is to provide the best possible care,” Corbett adds.

Establish Plans

In the Accelerator-2 project, each of the 12 sites worked with a neutral coordinator from the American Heart Association (AHA), someone who was not affiliated with one of the big hospitals in the region. The idea was to ensure that the person would not be perceived as biased for or against any participating hospital and could serve as a central broker, Corbett explains. However, she acknowledges that finding and employing a neutral coordinator may not always be possible.

Nonetheless, Corbett explains that the coordinator role can be filled in other ways. For example, she notes that in North Carolina’s RACE project, the STEMI coordinator’s role typically would be filled through partnering. “It would be myself from my hospital and another person like me from another PCI hospital. We would approach the process improvement, and we would approach the relationships with the hospitals and EMS [providers] together,” she says. “The concept was around the idea that the most important thing we can do is create a plan for the STEMI patient and keep the patient at the center [of that plan]. Then, people tend to get in line.”

The role of emergency providers in these STEMI systems of care may differ, depending on whether they work at a community hospital or a larger, PCI-capable hospital, Corbett says. “The emergency physician at a community hospital will see fewer STEMI patients, but will also have fewer resources, making the process of providing appropriate care even harder,” she says. This makes creating a good plan for such patients particularly important. “I would say every ED needs a physician and a nurse champion to own the process, look at the data, and make sure there is an ECG protocol so that [all appropriate patients] who walk in the door get an ECG.”

Corbett adds that the process needs to be hard-wired so that every emergency physician knows what the protocol is when they see a STEMI patient and what the process is for transferring the patient to a PCI-capable facility. “Community hospitals need to have those processes in place and to very much be an extension of the regional STEMI system,” she says.

Emergency physicians who practice at PCI-capable hospitals still see STEMI patients who come through the front door. These providers need to ensure that ECGs are performed on all appropriate patients and that their catheterization labs are activated within five minutes of an ECG indicating the patient is likely experiencing a STEMI heart attack, Corbett explains. “They also need to collaborate with EMS and cardiology continuously on all of these patients,” she adds.

Corbett reports that at her medical center and many others, STEMI patients do not bypass the ED, but rather make a quick pit stop there. “It is only for five minutes or less usually, but that is a point in which the ED physician is accepting the patient, receiving report[s] from EMS, and ensuring that the patient is appropriate to move on,” she says. “Although it is short, it is a very important role that emergency physicians play.”

The data around STEMI care are clear and convincing, Corbett stresses. “We know that by decreasing treatment time, you save lives. And who doesn’t want to be a part of that?” she says. “Everybody essentially wants to be a part of a winning team, and we know how to do STEMI well.”

Prioritize Timing

One aspect of accelerating care involves making sure that suspected STEMI patients are transported directly to PCI-capable hospitals so that life-saving care is not delayed by the need for transfer to a second hospital. Once EMS is accustomed to identifying STEMI patients and activating catheterization teams, this is a concept that takes hold pretty easily, Corbett suggests. “EMS has taken trauma patients to trauma centers for a long time ... so there were inklings of starting to do the same thing with STEMI patients, but we really solidified that in North Carolina with the RACE program and then with the Accelerator-2 project,” she says. Corbett says every region should determine how long it takes to travel to a PCI-capable facility. “If EMS can get [to a PCI hospital] within an hour or 45 minutes, then the most appropriate thing to do is to bypass [non-PCI-capable hospitals] and take the patient to the PCI center. If it is really far away, then the decision [should be] to take the patient to a community hospital that can provide thrombolytics.”

Such decision-making under many circumstances is all very much integrated into the plans that need to be developed as part of a regionalized STEMI system, Corbett explains. There is the need for early activation of catheterization labs, destination planning, and specifying when EMS needs to bypass community hospitals to get to a PCI-capable center.

There were no mandated laws as part of either the Accelerator-2 project or North Carolina’s RACE program, Corbett reports. “We pushed for grassroots efforts in having everyone step up and collectively make [appropriate] decisions,” she says. “We tried to use local resources and get local buy-in.”

These efforts proved highly successful during the Accelerator-2 study period, which took place from April 2015 to March 2017. By the end of the observational study, investigators reported that all the process measures concerning coordination between EMS and receiving hospitals had improved, including the proportion of patients experiencing FMC to PCI times within the national standard of 90 minutes. Specifically, investigators reported nine of the 12 participating regions reduced their FMC to PCI times and eight regions topped the national goal of treating 75% of patients within 90 minutes.

Most important, the faster treatment times were in alignment with a significant 4.4% to 2.3% in-hospital mortality decrease among STEMI patients by the end of the intervention period. Researchers also reported this reduction was not observed at a subset of hospitals that was not participating in the Accelerator-2 project during the same period.

Agree to Basic Tenets

Although investigators tracked a range of measures reflective of the coordination between medics and receiving hospitals, Jollis points to one observation that is particularly compelling. “Regarding first medical contact to activation [of the catheterization lab], we find that if that is less than 20 minutes, mortality is very low, in the 2% range. If it takes more than 20 minutes, then [mortality] is more than double that [figure],” he explains. “If you look at the mortality data, then having medics make the call [to activate the catheterization lab] makes a big difference.”

Although catheterization lab teams may grouse about activations that ultimately prove unnecessary, Jollis makes the case that there is nothing wrong with activating the catheterization lab when you have someone who looks like they are experiencing a heart attack. “Even if [the cath lab team] is cancelled, the benefit to those patients who are actually having [a STEMI heart attack] far outweighs the resource use for when such activations are cancelled.” Jollis adds that in roughly 10% of cath lab patients, no blockages are found, so no specialist or practitioner is perfect at determining when PCI is warranted. Nonetheless, Jollis stresses that the most important decisions in heart attack care come before someone arrives at the hospital. “A lot of things happen long before the ED. To be most effective, that [regional] coordination needs to take place, and our health system doesn’t have anything to do with that,” he says.

However, if all the different disciplines and agencies can agree to a common understanding of definitions as well as the diagnosis and treatment of STEMI patients, that will allow everyone to perform their jobs without worrying about delays, securing consultations, or figuring out who will take care of the patient, Jollis observes. “If you can just agree to basic tenets of how you are going to treat somebody, the system works much better,” he says.

Further, it is not too difficult to make the case for opening a blocked vessel that is causing the heart muscle to die, Jollis notes. “It clinically makes sense. There is also good evidence for it, so it is actually pretty easy to get agreement among healthcare providers beforehand about common plans,” he explains.

Identify Leaders

Corbett’s advice to clinicians or hospital administrators in other localities interested in taking advantage of the Accelerator-2 processes is to scour the literature about the project and then contact the champions. “Everybody that has been part of this work is so passionate about it that they will help and give guidance, share protocols, and share regional plans,” she says. “The bulk of the science is essentially there. We know how to do this well, and we know what the benefits are for patients. The hard part is actually doing the implementation.”

Leadership to develop such a system can come from cardiology, emergency medicine, governmental officials, and/or EMS, Jollis observes. Ultimately, no one wants to be left out of the system. “At every level, when we would go [to communities], have these meetings, and talk about patients, people would get pretty fired up,” Jollis says. “When you get up to leave these meetings, you actually find the leaders. It is really fulfilling to do this work as a healthcare professional.”

Now that the Accelerator 2 project has concluded, the focus has shifted to maintaining the gains that have been achieved, a tougher task than achieving the improvements in the first place, Corbett observes. “Working with the AHA and the regional leaders to sustain the improvements is very important,” she says. However, Corbett notes that project leaders also are looking for other ways they can apply the same steps and regionalized approach to achieve improvements in the care of other time-dependent diseases such as stroke.

In fact, Corbett notes that a new process improvement collaborative focused on stroke and thrombectomy, an interventional procedure used to remove blood clots from an artery, is underway in five states. The project, called IMPROVE Stroke, includes some of the same investigators who were involved in the Accelerator-2 project. The stroke project is focused on regionalizing care and accelerating treatment in a similar fashion.

(Editor’s Note: For more information and resources related to the STEMI projects, please visit: https://bit.ly/2ThqoGh. For more information about the new stroke initiative, please visit: https://bit.ly/2sJWJtx.)

REFERENCES

  1. Jollis JG, Al-Khalidi HR, Roettig ML, et al. Impact of regionalization of ST-segment-elevation myocardial infarction care on treatment times and outcomes for emergency medical services-transported patients presenting to hospitals with percutaneous coronary intervention. Mission: Lifeline Accelerator-2. Circulation 2018;137:376-387.
  2. Jollis JG, Al-Khalidi HR, Roettig ML, et al. Regional systems of care demonstration project, American Heart Association Mission: Lifeline STEMI Systems Accelerator. Circulation 2016;134:365-374.

EMS and Hospital Bypass Policies

There is ample consensus that when it comes to STEMI, time-to-treatment is a critical factor. The AHA and the American College of Cardiology guidelines recommend that STEMI patients receive PCI within 90 minutes of FMC when patients are taken directly to a PCI-capable hospital and within 120 minutes of FMC when patients are taken to a non-PCI-capable hospital first.

How does one go about improving performance in this area? For starters, investigators have found that it makes a difference whether one lives in a state that enables EMS providers to bypass hospitals that lack the capability to provide PCI and instead take patients directly to a PCI-capable hospital.1

Studying this issue specifically, investigators compared the time to treatment for STEMI patients in six states that had instituted relevant hospital bypass policies vs. six states that had not. In states with bypass policies, 57.9% of STEMI patients received PCI within 90 minutes of FMC and 82% received PCI within 120 minutes of FMC. In states without bypass policies, just 47.5% of patients received PCI within 90 minutes and 77% underwent the procedure within 120 minutes.

Jacqueline Green, MD, MPH, lead author, said that a policy that improves timely access to care for even just an additional 10% of patients could significantly affect the population level. She further noted that the results of the study bolster the case for state government leadership in developing strong systems of EMS care that can triage and transport patients with time-critical conditions.

REFERENCE

  1. Green JL, Jacobs AK, Holmes D, et al. Taking the reins on systems of care for ST-segment elevation myocardial infarction patients. Circ Cardiovasc Interv 2018 May;11:e005706. doi: 10.1161/CIRCINTERVENTIONS.117.005706.