Rural Inequity in STEMI Treatment Can Be Addressed by Implementation of the New Zealand National STEMI Pathway

Abstract

Background: Although timely reperfusion therapy is instrumental in determining treatment outcomes for ST-elevation myocardial infarction (STEMI) patients, the lack of a coordinated approach in regional Australasia leads to substantial delays in the delivery of time critical treatment. Methods: A collaborative treatment algorithm involving Emergency Medical Services (EMS) and secondary care aimed to deliver either primary percutaneous coronary intervention (PPCI) or pre-hospital thrombolysis with routine immediate transfer of eligible patients to a PCI centre was developed, trialled and evaluated in the predominantly rural Nelson and Marlborough region of New Zealand. Using data from ANZACS-QI and EMS; parameters including pre-hospital ECG transmission, fibrinolysis administration, device and transfer times were evaluated. Results: Sixty-seven of the 100 consecutive STEMI/presumed STEMI patients from February 2016 onwards met the eligibility criteria; the initial reperfusion strategy included PPCI (n = 36), fibrinolysis (n = 28), and medical treatment (n = 1). First medical contact (FMC) to device time for PPCI patients was 89 minutes (43-194, n = 36, 72.2% < 120 minutes), FMC to pre-hospital needle time was 44 minutes (16-78, n = 28, 23.8% < 30 minutes). FMC to arrival at a PCI centre was 75 minutes (27-278, n = 54, 66% < 90 minutes), however door-in-door-out time (DIDO) time for patients presenting to a non-PCI centre was 99 minutes (25-248, n = 9, 11.10% < 30 minutes). Conclusion: A coordinated STEMI pathway can lead to timely arrival at PCI centres and reperfusion therapy for patients that receive PPCI and reasonable FMC to pre-hospital fibrinolysis. However, poor DIDO from non-PCI centres times require further improvement to achieve equity.