Patient and System-Related Delays of Emergency Medical Services Use in Acute ST-Elevation Myocardial Infarction: Results from the Third Gulf Registry of Acute Coronary Events (Gulf RACE-3Ps).

Khalid F Alhabib,Wael Almahmeed,Salim Yusuf,Hussam F Alfaleh,Prashanth Panduranga,Robert C Welsh,Kadhim Sulaiman,Alawi A Alsheikh-Ali,Mohammed Al Jarallah,Zohair Al Aseri,Hani B Altaradi,Anhar Ullah,Jassim Al Suwaidi,Tarek Kashour,Ahmad Hersi,Haitham Amin,Kazi Nur Asfina,Raffaele Bugiardini

doi:10.1371/journal.pone.0147385

Abstract

BackgroundLittle is known about Emergency Medical Services (EMS) use and pre-hospital triage of patients with acute ST-elevation myocardial infarction (STEMI) in Arabian Gulf countries.MethodsClinical arrival and acute care within 24 h of STEMI symptom onset were compared between patients transferred by EMS (Red Crescent and Inter-Hospital) and those transferred by non-EMS means. Data were retrieved from a prospective registry of 36 hospitals in 6 Arabian Gulf countries, from January 2014 to January 2015.ResultsWe enrolled 2,928 patients; mean age, 52.7 (SD ±11.8) years; 90% men; and 61.7% non-Arabian Gulf citizens. Only 753 patients (25.7%) used EMS; which was mostly via Inter-Hospital EMS (22%) rather than direct transfer from the scene to the hospital by the Red Crescent (3.7%). Compared to the non-EMS group, the EMS group was more likely to arrive initially at a primary or secondary health care facility; thus, they had longer median symptom-onset-to-emergency department arrival times (218 vs. 158 min; p˂.001); they were more likely to receive primary percutaneous coronary interventions (62% vs. 40.5%, p = 0.02); they had shorter door-to-needle times (38 vs. 42 min; p = .04); and shorter door-to-balloon times (47 vs. 83 min; p˂.001). High EMS use was independently predicted mostly by primary/secondary school educational levels and low or moderate socioeconomic status. Low EMS use was predicted by a history of angina and history of percutaneous coronary intervention. The groups had similar in-hospital deaths and outcomes.ConclusionMost acute STEMI patients in the Arabian Gulf region did not use EMS services. Improving Red Crescent infrastructure, establishing integrated STEMI networks, and launching educational public campaigns are top health care system priorities.

Highlights

Acute reperfusion therapy is critical for improving the outcomes of patients with ST-elevation myocardial infarction (STEMI)
Unlike the well-developed emergency medical service (EMS) systems in western countries, the EMS in our region is quite dispersed, and it is under the authority of two main health care providers: (1) Red Crescent EMS: ambulances operated by the Red Crescent transfer patients directly from the scene to the nearest hospital (PCI or non-PCI); (2) Inter-Hospital EMS: ambulances under the authority of non-PCI hospitals that transfer patients to the nearest PCI hospital, or from a peripheral and small-sized nonPCI hospital to a larger non-PCI hospital that is equipped with an intensive care unit, subsequent transfer to a PCI hospital whenever possible
This study revealed that most patients with acute STEMI in the Arabian Gulf region did not use EMS

Summary

Introduction

Acute reperfusion therapy is critical for improving the outcomes of patients with ST-elevation myocardial infarction (STEMI). The guidelines have advocated that timely primary percutaneous coronary intervention (PPCI) in experienced centers is a superior mode of therapy compared to thrombolytic therapy (TT) [1,2]. Quality improvement initiatives, such as the “Stent for Life” in Europe, the “D2B Alliance” and the “Mission:Lifeline” in the USA, were established to improve the rate of timely PPCI for patients with STEMI [3,4,5,6,7]. Little is known about Emergency Medical Services (EMS) use and pre-hospital triage of patients with acute ST-elevation myocardial infarction (STEMI) in Arabian Gulf countries

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Discussion

Conclusion