Abstract 258: A Novel Process to Reduce Mortality Associated with In-Hospital STEMI

Abstract

Background: According to recently published data mortality due to ST-elevation myocardial infarction (STEMI) occurring in hospitalized patients (pts) can be as high as 40%. Reasons for the high mortality are not completely understood, but delays in diagnosis and treatment, as depicted by prolonged (129 minutes) diagnostic ECG to first intra-coronary balloon inflation (E2B) time, may play a major role. The hospitals of the academic health center (AHC) of Indiana University Health put in place a process for the early identification and treatment of in-hospital ST-elevation Myocardial Infarction (i-STEMI). The process went into place in August of 2009 and consisted of three simple steps: 1) bedside nurses were empowered to obtain a 12 lead ECG on any patient with signs or symptoms of acute coronary syndrome, 2) Providers from the hospital rapid response team (RRT) interpreted the ECG within 10 minutes of acquisition, 3) The rapid responders were empowered to activate the cardiac catheterization laboratory as a Level 1 STEMI emergency. Prior to launch of the i-STEMI process, multiple approaches were employed in order to ensure nurses were adequately educated. We report on the mortality results from the first 40 months of the novel process. Methods: The emergent cardiac catheterization database was queried to identify 141 hospitalized pts for whom cardiac catheterization laboratory was activated emergently between August 2009 and 2013. Electronic health records were reviewed to record demographics, admission diagnosis, comorbidities, current cardiac medications, indication for obtaining diagnostic ECG, time of diagnostic ECG, time of first intra-coronary balloon inflation, post i-STEMI ejection fraction, and discharge disposition for each patient. Results: We found 52 confirmed cases of i-STEMI out of total 141 pts. Out of 52 i-STEMI pts 49 (94%) underwent emergent coronary angiography. The reason for not performing angiography in remaining pts was increased risk of bleeding and altered mental status. Percutaneous coronary intervention (PCI) was performed in 29 (56%) pts. Reasons for not performing PCI in remaining pts included: occlusion of saphenous vein graft and absence of critical stenosis in infarct-related coronary artery as predicted by diagnostic ECG. E2B time for i-STEMI pts at our AHC was 81 minutes. Overall in-hospital mortality was 17%. In-hospital mortality in pts who received PCI was 6.6%. Our E2B time and hospital mortality were much lower when compared with recently reported data i.e. 81 minutes vs. 129 minutes and 17% vs. 40% respectively. Conclusion: A simple protocol that empowers adequately trained bedside medical personnel can significantly reduce time to optimal treatment and in-hospital mortality associated with i-STEMI. For patients who receive timely intervention, i-STEMI can be managed with survival rates very similar to pts presenting to hospital with STEMI.