Timely diagnosis and restoration of coronary artery flow remains the cor- nerstone of treatment for patients with ST-elevation myocardial infarction
(STEMI). During the past six years, enormous efforts by hospitals and medical
professionals have focused on a specific phase of coronary reperfusion, namely the
“door-to-balloon” process. As a result of this work, more than 90% of patients presenting to hospitals with percutaneous coronary intervention (PCI) facilities are
now treated within 90 minutes of hospital arrival.1
However, despite the improvements in door-to-balloon time, the current
emergency cardiac care system often performs well below its potential. In 2012,
more than half of the STEMI patients who called 9-1-1, and those transferred
from outside emergency departments (EDs), haven’t met the new guideline goals
for reperfusion: EMS arrival to device deployment within 90 minutes for EMS-transported patients, and first hospital door-to-device within 120 minutes for
transferred patients. 2, 3 Paramedics should play a pivotal role in coronary reperfusion. Pre-notification and laboratory activation can reduce door-to-balloon times
below 30 minutes.
These time goals can only be achieved with the expansion of STEMI protocols
beyond the 1,400 hospitals with PCI facilities to the 3,600 hospitals lacking such
capability and to the more than 15,000 EMS agencies in the U.S. Emergency cardiac care systems must evolve beyond the PCI hospital door with implementation
on a regional basis.
Following the examples of such models as Los Angeles County and North
Carolina, every hospital and EMS agency within a region should have a pre-specified and coordinated plan in which healthcare professionals know their role
in the identification, diagnosis and expediting treatment of patients experiencing
acute myocardial infarction. 4-7
In order to meet the full potential of emergency cardiac care, the Regional
Systems of Care Demonstration Project: Mission: Lifeline STEMI System
Accelerator Program, funded in part by two-year grants from Philips Healthcare,
The MEDICINES Company and Abiomed, has selected 20 regions across the
U.S. for sustained efforts to regionalize coronary reperfusion plans. These 20 sites
were selected based on leadership, organization and facilities, and their likelihood
of developing coordinated diagnosis and treatment plans in every hospital and
EMS agency in their region.
The STEMI Accelerator Program is designed to build on the experience of
successfully implemented regional systems. According to a national survey of 381
STEMI systems conducted by the American Heart Association (AHA), the single
most commonly cited barriers to system implementation were hospital and physician competition. 8 The program’s interventions are led by national faculty and
local AHA staff who will serve as neutral intermediaries between EMS agencies,
hospitals and physicians within a region.
A number of tenets are central to this accelerator intervention. It’s designed
to build or advance systems that are ultimately self-sustaining and use existing regional and national resources whenever possible, such as the ACTION
Registry®-GWTGTM data and regional system reports. The program focuses on
supporting leaders within each region to design, implement and sustain the system.
The ultimate goal is to establish rapid diagnosis and treatment of STEMI as
a uniformed standard of care across every EMS agency and hospital within a
region. When it comes to building emergency cardiac systems, a number of key
features are shared across regions, including implementing national guidelines,
similar ECG equipment and protocols, and having hospital systems to support
rapid PCI. Many issues are unique to specific regions, largely based on the
interplay of geography, government and market forces. Thus, the project will
be guided by EMS providers in each region regarding challenges and barriers.
The project’s intervention will follow an approach that was developed a num-
ber of regional STEMI systems. The initial focus will be on the establishment of
leadership, common data and funding. Funding is primarily required to support
data collection and analysis, and to provide a neutral “feet on the ground” regional
system coordinator/implementer. Next, all PCI hospitals in the region will be
organized to provide rapid intervention on a systematic basis that includes single
call catheterization laboratory activation by paramedics and emergency physicians
on a 24/7 basis, accepting all patients regardless of bed availability, participation in
the regional data registry, and adoption of regional reperfusion protocols. In develop-
ing these protocols, the focus has been directed toward three patient scenarios that
have the most potential to save time and lives: patients presenting by EMS, patients
transferred from hospitals lacking PCI facilities, and patients with early signs of
With pre-specified and uniform protocols, paramedics, nurses and emergency
physicians who first come into contact with patients can rapidly implement
treatment plans without delay for consultation or need to identify the accepting
Once PCI hospitals have adopted the above processes to rapidly provide
coronary reperfusion, coordinators and leaders will work with EMS agencies and
non-PCI hospitals to adopt a STEMI diagnosis and treatment plan consistent
with regional protocols and local resources. A final step involves ongoing measurement and feedback through Mission: Lifeline™ regional system reports, targeting
opportunities for continued improvement.
The Accelerator Program has a two-year time horizon from conception to
implementation. In order to measure the effects of the intervention, data will be
examined from all participating regions relative to changes in treatment times and
outcomes. Involving EMS on a regional basis will result in improved treatment
times and lower in-hospital mortality.
This clinical feature is ponsored by Philips.
BY JAMES JOLLIS, MD & MAYME ROETTIG, RN, MSN
James Jollis, MD, is a cardiologist at Duke University Medical Center.
He is co-medical director of the North Carolina RACE program. Contact him at firstname.lastname@example.org.
Mayme Roettig, RN, MSN, is the Assistant Director of
the Center for Educational Excellence (CEE), Duke Clinical Research Institute/Duke University. Contact her at
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Approach to Cardiovascular Emergencies (RACE) Investigators.
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