ClinicalUse of emergency medical services expedites in-hospital care processes in patients presenting with ST-segment elevation myocardial infarction undergoing primary percutaneous coronary intervention
Introduction
Rapid reperfusion with percutaneous coronary intervention (PCI) is the gold standard therapy for patients presenting with ST-segment elevation myocardial infarction (STEMI) when promptly available [1]. Delays in door-to-balloon (DTB) times correlate with increased morbidity and mortality [2], [3]. Achieving a DTB time of < 90 minutes has become a quality measure of the hospital system performance dealing with STEMI care [1], [4]. With the identification of key strategies to enhance hospital system performances [5], [6], several programs have been successfully implemented to help meet the DTB < 90-minute time goals with timely access to primary PCI [7], [8], [9].
To address the continuum of care for STEMI patients from the onset of symptoms to arrival at the emergency department (ED), the use of emergency medical services (EMS) may potentially facilitate rapid transport, early assessment and treatment, and expedited communication of information with the accepting ED. However, EMS has been shown to be underutilized [10], [11], and a significant proportion of STEMI patients still arrive at the ED via their own transportation.
MedStar Washington Hospital Center (Washington, DC) is a primary PCI facility with around-the-clock cardiac catheterization capabilities catering to Washington, DC, a highly urbanized area with EMS coverage provided fully by the DC Fire and EMS. In addition, it serves as a referring PCI center for other facilities in DC, as well as parts of Maryland and Virginia. MedStar Washington Hospital Center is located in the heart of Washington, DC, and with DC Fire and EMS as the single EMS provider for Washington, DC, this offers us a unique opportunity to analyze modes of transport for STEMI patients within DC, and its impact on pre- and in-hospital care processes leading to reperfusion. Specifically, we aimed to determine if the use of EMS transport may actually reduce overall DTB times by reducing certain components of in-hospital processing times.
Section snippets
Patient population
This retrospective analysis included all patients from January 2007 to December 2012 who presented to the MedStar Washington Hospital Center ED with a STEMI and subsequently underwent primary PCI. Patients who were transferred from a referring institution, patients who suffered cardiac arrest, patients who were intubated, and patients who were given fibrinolytic therapy before the PCI were excluded. The patients were categorized into whether they were self-transported (“self”) or transported by
Results
A total of 309 consecutive STEMI patients who underwent primary PCI were analyzed, of which 226 arrived by self-transport, and 83 were transported by EMS. The baseline and procedural characteristics in both groups were similar. (Table 1, Table 2). The majority of patients from both groups presented to the ED during off hours. A significantly higher percentage of EMS-transported patients achieved the time goals of DTB < 90 minutes and DTB < 120 minutes compared to self-transported patients. (Fig. 2)
Discussion
With continued emphasis on shortening the symptom-to-treatment time in patients presenting with acute myocardial infarction, the present study detects important findings that may impact this mission: 1) compared to self-transport, EMS transport leads to faster in-hospital ED processing time, translating to reduction in DTB time in STEMI patients undergoing primary PCI; 2) EMS-transported patients experienced shorter delays to hospital care from symptom onset; and 3) self-transport and off hours
Conclusion
The use of EMS transport in STEMI patients significantly shortens time to reperfusion by primary PCI, mainly by expediting emergency department processes. Robust EMS programs should be supported with community education outreach efforts that focus not only on the importance of recognizing symptoms of myocardial infarction, but also on taking early decisive action by calling EMS.
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