Development of Systems of Care for ST-Elevation Myocardial Infarction Patients

Abstract

As noted in the previous section of these conference proceedings,1 there are 3 potential strategies to increase the number of ST-segment myocardial infarction (STEMI) patients with timely access to primary percutaneous coronary intervention (PCI): (1) hospitals currently without PCI capability can develop primary PCI services without cardiac surgery on-site; (2) non–PCI-capable hospitals can rapidly expedite the transfer of STEMI patients to primary PCI-capable hospitals after diagnosis and thereby serve as STEMI referral hospitals; or (3) communities with emergency medical services (EMS) systems can develop prehospital transport protocols that bypass non–PCI-capable hospitals. The best approach for a given community will vary and will be heavily influenced by geographic location and available resources. In this article, we view these strategies from the perspective of the PCI-capable hospital that “receives” STEMI patients (STEMI-receiving hospital). A primary PCI center is defined as any hospital that performs primary PCI. Patients can present to PCI-capable hospitals through 1 of 3 pathways. Each of these modes of presentation offers opportunities for improving time to treatment and access to primary PCI. The Figure depicts the position of the primary PCI-capable hospital within the system. Figure. Primary PCI-capable hospital position in the system. ### The Current System #### Patient Presentation to a PCI-Capable Hospital Door-to-balloon time is a focus for improvement at many hospitals because it is a Centers for Medicare and Medicaid Services quality indicator for STEMI. An efficient emergency department (ED) triage system quickly acquires a 12-lead ECG to diagnose STEMI in patients with suggestive symptoms and rapidly activates the cardiac catheterization laboratory. Door-to-balloon times have been shown to be shorter when the emergency physician is able to activate the cardiac catheterization laboratory without consulting a cardiologist.2 #### Patient Presentation Directly to a PCI-Capable Hospital by EMS The use of EMS by patients provides the opportunity for prehospital ECG diagnosis of STEMI, as well as notification and activation of the cardiac catheterization laboratory to substantially accelerate …