American Heart Association Mission Research Articles

Maximizing Brain Health After Hemorrhagic Stroke: Bugher Foundation Centers of Excellence.

Maximizing Brain Health After Hemorrhagic Stroke: Bugher Foundation Centers of Excellence.

Examining the Timeliness of ST-elevation Myocardial Infarction Transfers.

IntroductionDespite large-scale quality improvement initiatives, substantial proportions of patients with ST-elevation myocardial infarction (STEMI) transferred to percutaneous coronary intervention centers do not receive percutaneous coronary intervention within the recommended 120 minutes. We sought to examine the contributory role of emergency medical services (EMS) activation relative to percutaneous coronary intervention center activation in the timeliness of care for patients transferred with STEMI.MethodsWe conducted a retrospective analysis of interfacility transfers from emergency departments (ED) to a single percutaneous coronary intervention center between 2011–2014. We included emergency department (ED) patients transferred to the percutaneous coronary intervention center and excluded scene transfers and those given fibrinolytics. We calculated descriptive statistics and used multivariable linear regression to model the association of variables with ED time intervals (arrival to electrocardiogram [ECG], ECG-to-EMS activation, and ECG-to-STEMI alert) adjusting for patient age, gender, mode of arrival, weekday hour presentation, facility transfers in the past year, and transferring facility distance.ResultsWe identified 159 patients who met inclusion criteria. Subjects were a mean of 59 years old (standard deviation 13), 22% female, and 93% White; 59% arrived by private vehicle, and 24% presented after weekday hours. EDs transferred a median of 9 STEMIs (interquartile range [IQR] 3, 15) in the past year and a median of 65 miles (IQR 35, 90) from the percutaneous coronary intervention center. Median ED length of stay was 65 minutes (IQR 51, 85). Among component intervals, arrival to ECG was 6%, ECG-to-EMS activation 32%, and ECG-to-STEMI alert was 49% of overall ED length of stay. Only 18% of transfers had EMS activation earlier than STEMI alert. ECG-to-EMS activation was shorter in EDs achieving length of stay ≤60 minutes compared to those >60 minutes (12 vs 31 minutes, P<0.001). Multivariable modeling showed that after-hours presentation was associated with longer ECG-to-EMS activation (adjusted relative risk [RR] 1.05, P<0.001). Female gender (adjusted RR 0.81, P<0.001), prior facility transfers (adjusted RR 0.84, P<0.001), and initial ambulance presentation (adjusted RR 0.93, P = 0.02) were associated with shorter ECG-to-EMS activation.ConclusionIn STEMI transfers, faster EMS activation was more likely to achieve a shorter ED length of stay than a rapid, percutaneous coronary intervention center STEMI alert. Large-scale quality improvement efforts such as the American Heart Association’s Mission Lifeline that were designed to regionalize STEMI have improved the timeliness of reperfusion, but major gaps, particularly in interfacility transfers, remain. While the transferring EDs are recognized as the primary source of delay during interfacility STEMI transfers, the contributions to delays at transferring EDs remain poorly understood.

Abstract P688: North Dakota Mission: Lifeline Stroke Public Awareness Survey Campaign Results Indicate Significant Improvements

The American Heart Association (AHA) Mission: Lifeline Stroke program is a 3-year initiative in North Dakota which aims to improve guideline-based care of stroke patients. Improving outcomes involves widespread awareness of stroke symptoms, early recognition, and timely access to emergency health care services. The purpose was to evaluate effectiveness of the public awareness campaign through a pre and post survey in 2018 and 2020 which assessed knowledge of the F.A.S.T acronym, actions and behaviors when stroke is suspected, and media preferences. The AHA commissioned Marketing &amp; Advertising Business Unlimited, Inc., to conduct four hundred phone interviews in 2018 and 2020. Residents were randomly selected from a list of 24,000 landlines and 8,000 mobile phones. Data was weighted by gender, age, and region to conform to the latest statewide census. The survey had a 4.9% margin of error and a 95% confidence interval. Respondents reported having learned the signs and symptoms of stroke increased from 47.0% in 2018 to 68.3% in 2020. Awareness of symptoms changed as follows from 2018 to 2020: face related 30.0% to 43.1%; arm related 17.0% to 32.8%; speech related 39.0% to 41.0%. When asked what they would do first if stroke was suspected “Call 9-1-1- immediately” 64.0% to 70.7%, assess for F.A.S.T. symptoms then call 9-1-1 3% to 14.2%, drive themselves to the hospital 14% to 7.3% respectively in 2018 to 2020 . When asked if It would be better to transport someone experiencing stroke symptoms to a hospital by personal vehicle because driving could be faster than an ambulance in 2020 65% urban and 46% rural respondents disagreed. Media preferences were: 1) F.A.S.T. acronym over other longer options, 2) visuals with real humans 3) tagline “Care Starts When You Call”. In 2020 60% of respondents recalled advertisements about stroke signs and symptoms in the past 12 months. They recalled seeing messaging on: TV: 74.1%, Facebook: 20.1%, Radio: 19.1%, Billboard: 14.1%. Overall, the ND M:L public awareness communications were shown to have improved stroke symptom awareness and inclination to activate emergency services during a potential stroke. A preference for private vehicle presentation was noted in the rural cohort where transport time appears to be an influencing factor.

Catheterization Laboratory Activation Time in Patients Transferred With ST-Segment-Elevation Myocardial Infarction: Insights From the Mission: Lifeline STEMI Accelerator-2 Project.

Catheterization laboratory (cath lab) activation time is a newly available process measure for patients with ST-segment-elevation myocardial infarction requiring inter-hospital transfers for primary percutaneous coronary intervention that reflects inter-facility communication and urgent mobilization of interventional laboratory resources. Our aim was to determine whether faster activation is associated with improved reperfusion time and outcomes in the American Heart Association Mission: Lifeline Accelerator-2 Project. From April 2015 to March 2017, treatment times of 2063 patients with ST-segment-elevation myocardial infarction requiring inter-hospital transfer for primary percutaneous coronary intervention from 12 regions around the United States were stratified by cath lab activation time (first hospital arrival to cath lab activation within [timely] or beyond 20 minutes [delayed]). Median cath lab activation time was 26 minutes, with a delayed activation observed in 1241 (60.2%) patients. Prior cardiovascular or cerebrovascular disease, arterial hypotension at admission, and black or Latino ethnicity were independent factors of delayed cath lab activation. Timely cath lab activation patients had shorter door-in door-out times (40 versus 68 minutes) and reperfusion times (98 versus 135 minutes) with 80.1% treated within the national goal of ≤120 minutes versus 39.0% in the delayed group. Cath lab activation within 20 minutes across a geographically diverse group of hospitals was associated with performing primary percutaneous coronary intervention within the national goal of ≤120 minutes in >75% of patients. While several confounding factors were associated with delayed activation, this work suggests that this process measure has the potential to direct resources and practices to more timely treatment of patients requiring inter-hospital transfer for primary percutaneous coronary intervention.

The Effect of Implementation of the American Heart Association Mission Lifeline PreAct Algorithm for Prehospital Cardiac Catheterization Laboratory Activation on the Rate of "False Positive" Activations.

Emergency Medical Services (EMS) systems have developed protocols for prehospital activation of the cardiac catheterization laboratory for patients with suspected ST-elevation myocardial infarction (STEMI) to decrease first-medical-contact-to-balloon time (FMC2B). The rate of "false positive" prehospital activations is high. In order to decrease this rate and expedite care for patients with true STEMI, the American Heart Association (AHA; Dallas, Texas USA) developed the Mission Lifeline PreAct STEMI algorithm, which was implemented in Los Angeles County (LAC; California USA) in 2015. The hypothesis of this study was that implementation of the PreAct algorithm would increase the positive predictive value (PPV) of prehospital activation. This is an observational pre-/post-study of the effect of the implementation of the PreAct algorithm for patients with suspected STEMI transported to one of five STEMI Receiving Centers (SRCs) within the LAC Regional System. The primary outcome was the PPV of cardiac catheterization laboratory activation for percutaneous coronary intervention (PCI) or coronary artery bypass graft (CABG). The secondary outcome was FMC2B. A total of 1,877 patients were analyzed for the primary outcome in the pre-intervention period and 405 patients in the post-intervention period. There was an overall decrease in cardiac catheterization laboratory activations, from 67% in the pre-intervention period to 49% in the post-intervention period (95% CI for the difference, -14% to -22%). The overall rate of cardiac catheterization declined in post-intervention period as compared the pre-intervention period, from 34% to 30% (95% CI, for the difference -7.6% to 0.4%), but actually increased for subjects who had activation (48% versus 58%; 95% CI, 4.6%-15.0%). Implementation of the PreAct algorithm was associated with an increase in the PPV of activation for PCI or CABG from 37.9% to 48.6%. The overall odds ratio (OR) associated with the intervention was 1.4 (95% CI, 1.1-1.8). The effect of the intervention was to decrease variability between medical centers. There was no associated change in average FMC2B. The implementation of the PreAct algorithm in the LAC EMS system was associated with an overall increase in the PPV of cardiac catheterization laboratory activation.

Prehospital Activation of Hospital Resources (PreAct) ST-Segment-Elevation Myocardial Infarction (STEMI): AStandardized Approach to Prehospital Activation and Directtothe Catheterization Laboratory for STEMI Recommendations From the American Heart Association's Mission: Lifeline Program.

Prehospital Activation of Hospital Resources (PreAct) ST-Segment-Elevation Myocardial Infarction (STEMI): AStandardized Approach to Prehospital Activation and Directtothe Catheterization Laboratory for STEMI Recommendations From the American Heart Association's Mission: Lifeline Program.

Abstract 190: North Dakota Mission: Lifeline Stroke Survey of Symptom Awareness Indicates Need for Public Education

Introduction: The American Heart Association (AHA) Mission: Lifeline Stroke program is a 3-year statewide initiative in North Dakota which aims to improve consistency of guideline-based care of stroke patients thereby improving outcomes. In year one a public awareness assessment of stroke awareness was completed. Purpose: The intent of this survey was to establish a baseline of symptom awareness related to the F.A.S.T acronym, actions and behaviors when stroke is suspected, and media preferences in ND. Methods: The AHA commissioned Marketing &amp; Advertising Business Unlimited, Inc., to conduct a telephone survey. Four hundred phone interviews were completed with ND residents by random selection from a list of 24,000 residential landlines and 8,000 mobile phones. Numbers were stratified into five distinct regions to ensure a proper urban/rural balance. Data was also weighted by gender, age, and region to conform to the latest statewide census projects. The telephone survey had a 4.9% margin of error and a 95% confidence interval. Results: Forty seven percent of respondents stated that they had learned the signs of stroke, however only 17% classified themselves as very familiar. The most common signs identified were “Speech/Slurred Words” and “Face/Drooping Face” at 39% and 30%, respectively. In terms of F.A.S.T. awareness, 46% of survey respondents correctly identified “Face” while only 15% identified “Time.” “Arm” and “Speech” were identified 32% and 23%, respectively. Respondents indicated they would call 9-1-1 64% of the time. When asked why it may be better to be transported by personal vehicle, 74% responded you may be able to get to the hospital faster. Men and those over 65 were far less likely to correctly identify the components of F.A.S.T. Media preferences expressed were: 1) F.A.S.T. acronym over other longer options, 2) visual examples with real humans versus icons, 3) the tagline “Care Starts When You Call”, and 4) television and Facebook were the preferred mediums. Conclusions: Overall, the survey data is encouraging and may provide guidance for future rural programs. A significant portion of the respondents were deficient in stroke symptom awareness, however most survey respondents expressed interested in learning these symptoms.

Delays in Primary Percutaneous Coronary Intervention in ST-Segment Elevation Myocardial Infarction Patients Presenting With Cardiogenic Shock

ObjectivesThis study sought to examine whether quality improvement initiatives across multiple ST-segment elevation myocardial infarction (STEMI) systems translated to faster first medical contact (FMC)-to-device times for patients presenting with cardiogenic shock (CS). BackgroundThere are limited data describing contemporary rates of achieving guideline-directed FMC-to-device times for STEMI patients with CS. MethodsFrom 2012 to 2014, the American Heart Association Mission: Lifeline STEMI Systems Accelerator project established a protocol-guided approach to STEMI reperfusion systems in 484 U.S. hospitals. The study was stratified by CS versus no CS at presentation and performed Cochrane-Armitage tests to evaluate trends of achieving FMC-to-device time targets. A multivariable logistic regression model assessed the association between achieving guideline-directed FMC-to-device times and mortality. ResultsAmong 23,785 STEMI patients, 1,993 (8.4%) experienced CS at presentation. For direct presenters, patients with CS were less likely to achieve the 90-min FMC-to-device time compared with no-CS patients (37% vs. 54%; p < 0.001). For transferred patients, CS patients were even less likely to reach the 120-min FMC-to-device time compared with no-CS patients (34% vs. 47%; p < 0.0001). The Accelerator intervention did not result in improvements in the FMC-to-device times for direct-presenting CS patients (p for trend = 0.53), although there was an improvement for transferred patients (p for trend = 0.04). Direct-presenting patients arriving within 90 min had lower mortality rates compared with patients who reached after 90 min (20.49% vs. 39.12%; p < 0.001). ConclusionsFewer than 40% of STEMI patients presenting with CS achieved guideline-directed FMC-to-device targets; delays in reperfusion for direct-presenting patients were associated with higher mortality.

Comprehensive electrocardiogram-to-device time for primary percutaneous coronary intervention in ST-segment elevation myocardial infarction: A report from the American Heart Association mission: Lifeline program

Assessing hospital-related network-level primary percutaneous coronary intervention (PCI) performance for ST-segment elevation myocardial infarction (STEMI) is challenging due to differential time-to-treatment metrics based on location of diagnostic electrocardiogram (ECG) for STEMI. STEMI patients undergoing primary PCI at 588 PCI-capable hospitals in AHA Mission: Lifeline (2008-2013) were categorized by initial STEMI identification location: PCI-capable hospitals (Group 1); pre-hospital setting (Group 2); and non-PCI-capable hospitals (Group 3). Patient-specific time-to-treatment categories were converted to minutes ahead of or behind their group-specific mean; average time-to-treatment difference for all patients at a given hospital was termed comprehensive ECG-to-device time. Hospitals were then stratified into tertiles based on their comprehensive ECG-to-device times with negative values below the mean representing shorter (faster) time intervals. Of 117,857 patients, the proportion in Groups 1, 2, and 3 were 42%, 33%, and 25%, respectively. Lower rates of heart failure and cardiac arrest at presentation are noted within patients presenting to high-performing hospitals. Median comprehensive ECG-to-device time was shortest at -9 minutes (25th, 75th percentiles: -13, -6) for the high-performing hospital tertile, 1 minute (-1, 3) for middle-performing, and 11 minutes (7, 16) for low-performing. Unadjusted rates of in-hospital mortality were 2.3%, 2.6%, and 2.7%, respectively, but the adjusted risk of in-hospital mortality was similar across tertiles. Comprehensive ECG-to-device time provides an integrated hospital-related network-level assessment of reperfusion timing metrics for primary PCI, regardless of the location for STEMI identification; further validation will delineate how this metric can be used to facilitate STEMI care improvements.

Self-Care for the Prevention and Management of Cardiovascular Disease and Stroke: A Scientific Statement for Healthcare Professionals From the American Heart Association.

Self‐care is defined as a naturalistic decision‐making process addressing both the prevention and management of chronic illness, with core elements of self‐care maintenance, self‐care monitoring, and self‐care management. In this scientific statement, we describe the importance of self‐care in the American Heart Association mission and vision of building healthier lives, free of cardiovascular diseases and stroke. The evidence supporting specific self‐care behaviors such as diet and exercise, barriers to self‐care, and the effectiveness of self‐care in improving outcomes is reviewed, as is the evidence supporting various individual, family‐based, and community‐based approaches to improving self‐care. Although there are many nuances to the relationships between self‐care and outcomes, there is strong evidence that self‐care is effective in achieving the goals of the treatment plan and cannot be ignored. As such, greater emphasis should be placed on self‐care in evidence‐based guidelines.

Abstract 038: American Heart Association Mission: Lifeline Breakthrough Series Collaborative Improving the Survival Rates for Out of Hospital Cardiac Arrest by Focusing on Early CPR With an Emphasis on Chest Compressions

Introduction: Out-of-hospital cardiac arrest (OHCA) remains a highly morbid public health problem. Despite improving practices and clear guidelines, mortality from this condition remains high at 90%, with survivors often suffering from poor neurologic outcomes. To determine the feasibility of quality improvement collaboratives to narrow gaps between evidence-based practice and patient care for OHCA, we conducted a pilot study of the AHA Resuscitation Collaborative. Methods: Eight emergency medical service agencies participated in the quality improvement collaborative pilot project. We identified several OHCA performance measures to assess the quality of care, guide collaborative activities, and monitor change in performance over time. Over the course of four learning sessions, participants were trained in quality improvement and performance measurement, analyzed performance measure results, and shared successes and challenges. Results: Five remaining agencies underwent the process outlined in Figure 1. Adherence to performance measures, including compression rate compliance (Figure 2), improved over the course of the collaborative. Compression rate compliance in Figure 2 corresponds to the process improvement efforts of the Chesapeake Fire Department with achievement of goals for optimal range of chest compression rate between 100 and 120 compressions per minute during resuscitations. Conclusion: As demonstrated in Virginia, the collaborative approach was an effective framework to improve OHCA care. Improvement in performance measures, the evident commitment of dedicated peers and colleagues, consistent collaboration, and the effective diffusion of best practices all support the continued use of this model.

The effect of high-risk ST elevation myocardial infarction transfer patients on risk-adjusted in-hospital mortality: A report from the American Heart Association Mission: Lifeline program

Hospital mortality is an important quality measure for acute myocardial infarction care. There is a concern that despite risk adjustment, percutaneous coronary intervention hospitals accepting a greater volume of high-risk ST elevation myocardial infarction (STEMI) transfer patients may have their reported mortality rates adversely affected. The STEMI patients in the National Cardiovascular Data RegistryAcute Coronary Treatment Intervention Outcomes Network Registry-Get With the Guidelines from April 2011 to December 2013 were included. High-risk STEMI was defined as having either cardiogenic shock or cardiac arrest on first medical contact. Receiving hospitals were divided into tertiles based on the ratio of high-risk STEMI transfer patients to the total number of STEMI patients treated at each hospital. Using the Action Coronary Treatment Intervention Outcomes Network Registry-Get With the Guidelines in-hospital mortality risk model, we calculated the difference in risk-standardized in-hospital mortality before and after excluding high-risk STEMI transfers in each tertile. Among 119,680 STEMI patients treated at 539 receiving hospitals, 37,028 (31%) were transfer patients, of whom 4,500 (12%) were highrisk. The proportion of high-risk STEMI transfer patients ranged from 0% to 12% across hospitals. Unadjusted mortality rates in the low-, middle-, and high-tertile hospitals were 6.0%, 6.0%, and 5.9% among all STEMI patients and 6.0%, 5.5%, and 4.6% after excluding high-risk STEMI transfers. However, risk-standardized hospital mortality rates were not significantly changed after excluding high-risk STEMI transfer patients in any of the 3 hospital tertiles (low, -0.04%; middle, -0.05%; and high, 0.03%). Risk-adjusted in-hospital mortality rates were not adversely affected in STEMI-receiving hospitals who accepted more high-risk STEMI transfer patients when a clinical mortality risk model was used for risk adjustment.

Emergency medical services management of ST-segment elevation myocardial infarction in the United States—a report from the American Heart Association Mission: Lifeline Program

ObjectiveST-segment elevation myocardial infarction (STEMI) is a major cause of morbidity and mortality in the United States. Emergency medical services (EMS) agencies play a critical role in its initial identification and treatment. We conducted this study to assess EMS management of STEMI care in the United States. MethodsA structured questionnaire was administered to leaders of EMS agencies to define the elements of STEMI care related to 4 core measures: (1) electrocardiogram (ECG) capability at the scene, (2) destination protocols, (3) catheterization laboratory activation before hospital arrival, and (4) 12-lead ECG quality review. Geographic areas were grouped into large metropolitan, small metropolitan, micropolitan, and noncore (or rural) by using Urban Influence Codes, with a stratified analysis. ResultsData were included based on responses from 5296 EMS agencies (36% of those in the United States) serving 91% of the US population, with at least 1 valid response from each of the 50 states and the District of Columbia. Approximately 63% of agencies obtained ECGs at the scene using providers trained in ECG acquisition and interpretation. A total of 46% of EMS systems used protocols to determine hospital destination, cardiac catheterization laboratory activation, and communications with the receiving hospital. More than 75% of EMS systems used their own agency funds to purchase equipment, train personnel, and provide administrative oversight. A total of 49% of agencies have quality review programs in place. In general, EMS systems covering higher population densities had easier access to resources needed to maintain STEMI systems of care. Emergency medical services systems that have adopted all 4 core elements cover 14% of the US population. ConclusionsThere are large differences in EMS systems of STEMI care in the United States. Most EMS agencies have implemented at least 1 of the 4 core elements of STEMI care, with many having implemented multiple elements.

Frequency of Nonsystem Delays in ST-Elevation Myocardial Infarction Patients Undergoing Primary Percutaneous Coronary Intervention and Implications for Door-to-Balloon Time Reporting (from the American Heart Association Mission: Lifeline Program)

The percentage of patients with primary percutaneous coronary intervention (PCI) with door-to-balloon (D2B) times ≤90minutes is used as a hospital performance measure for public reporting. Patients can be excluded from reporting for nonsystem-related delays. How exclusions impact D2B time reporting at the hospital level is unknown. The percentage of patients having nonsystem delays for primary PCI at the hospital level was calculated using data from the Acute Coronary Treatment Intervention Outcomes Network Registry-Get with the Guidelines Registry. Hospitals were categorized based on tertiles of percentage of excluded patients: low, ≤7.1%; intermediate, >7.1% to 11.2%; and high, >11.2%. From January 1, 2007, to March 31, 2011, 43,909 patients from 294 hospitals were included. The percentage of exclusions differed substantially among hospitals (0% to 68%, median 9.2% [interquartile range 5.6% to 13.5%]). Exclusion reasons included vascular access difficulty (7.6%), cardiac arrest/intubation (38%), and PCI procedural difficulties (20%). Including patients with nonsystem delays significantly increased D2B times by ≤2minutes for each group. The effect was larger on the proportion of patients having a D2B ≤90minutes (low 83.6% to 85%, intermediate 82.9% to 86.3%, high 82% to 87.5%, p<0.001, for all). If a criterion of having ≥90% of patients with D2B ≤90minutes was used, excluding patients with nonsystem delays significantly increased the proportion of patients meeting this goal for each group: low, 28% to 37%; intermediate, 17.7% to 37.5%; and high, 14% to 52% (all p <0.01). In conclusion, the proportion of patients excluded from D2B reporting varies substantially among hospitals. This has a greater impact on percentage of patients with D2B time ≤90minutes than on median D2B times.

Response to Letter Regarding Article, “Emergency Department Bypass for ST-Segment–Elevation Myocardial Infarction Patients Identified With a Prehospital Electrocardiogram: A Report From the American Heart Association Mission: Lifeline Program”

We thank Dr Maier and colleagues for their letter highlighting the importance of networks and systems of care to optimize early ST-segment–elevation myocardial infarction (STEMI) diagnosis and treatment.1 A system is typically defined as an integrated group of entities coordinating the provision of care within a region. A care system for STEMI includes emergency medical service providers, referral centers/non–percutaneous coronary intervention (PCI) hospital(s), and receiving centers/primary PCI hospital(s). Each party has a predefined action plan based on consensus on how to best implement guideline recommendations with the aim of providing optimal care to the maximum number of eligible patients. Establishing STEMI care systems has been associated with a significant improvement in the …

Letter by Maier et al Regarding Article, “Emergency Department Bypass for ST-Segment–Elevation Myocardial Infarction Patients Identified With a Prehospital Electrocardiogram: A Report From the American Heart Association Mission: Lifeline Program”

Bagai et al1 convincingly showed in their article that bypassing the emergency department (ED) in the United States reduces treatment times for patients with ST-segment–elevation myocardial infarction (STEMI). As part of a national effort for the improvement in STEMI treatment, one thing that contributed to this success was prehospital ECGs. One would assume that shorter treatment times translate directly into improved outcome. However, this did not occur. Astonishingly, only 10.5% of all patients actually bypassed the ED. Moreover, the mortality rate in all 12 581 patients included was rather low, with values between 2.7% and 4.1%. This also raises the question of whether all patients who would actually benefit from an early percutaneous intervention were transferred to a …

Predictors of Reperfusion Delay in Patients With ST Elevation Myocardial Infarction Self-Transported to the Hospital (from the American Heart Association's Mission: Lifeline Program)

Primary percutaneous coronary intervention for ST elevation myocardial infarction (STEMI) is beneficial if performed in a timely manner. Self-transport patients with STEMI have prolonged treatment times compared with Emergency Medical Services-transported patients. This study evaluated self-transport patients with STEMI undergoing primary percutaneous coronary intervention to identify factors associated with prolonged door-to-balloon (D2B) times. From January 2007 to March 2011, data for 13,379 self-transport patients with STEMI treated at 432 hospitals in the Acute Coronary Treatment Intervention Outcomes Network Registry-Get With The Guidelines Registry were evaluated. Patients with a D2B time >90 minutes were compared with those with D2B time ≤90 minutes. Factors associated with prolonged D2B (>90 minutes) were explored using logistic generalized estimating equations. The median (twenty-fifth, seventy-fifth percentiles) D2B time for the entire cohort was 72 minutes (58, 86), and 19% had a D2B time of >90 minutes. Over the study period, there was a significant increase in the percentage of patients achieving D2B time ≤90 minutes. There were significant baseline differences between patients with D2B time ≤ versus >90 minutes. The main factors associated with prolonged treatment time were off-hour presentation (weekends and 7 p.m. to 7 a.m. weekdays), not obtaining an electrocardiogram within 10 minutes of hospital arrival, previous coronary artery bypass surgery, black race, older age, and female gender. In conclusion, although prolonged delay from arrival to electrocardiographic acquisition is a modifiable factor contributing to prolonged D2B times among self-transport patients with STEMI, additional factors (age, race, and gender) indicate that historic disparities for cardiovascular care still persist in terms of contemporary metrics for STEMI reperfusion.

Emergency Department Bypass for ST-Segment-Elevation Myocardial Infarction Patients Identified with a Prehospital Electrocardiogram: A Report From the American Heart Association Mission: Lifeline Program: Bagai A, Jollis J, Dauerman H, et al. Circulation 2013;128:352–9.

Emergency Department Bypass for ST-Segment-Elevation Myocardial Infarction Patients Identified with a Prehospital Electrocardiogram: A Report From the American Heart Association Mission: Lifeline Program: Bagai A, Jollis J, Dauerman H, et al. Circulation 2013;128:352–9.

Circulation : Clinical Summaries

<i>Circulation</i> : Clinical Summaries

Emergency Department Bypass for ST-Segment–Elevation Myocardial Infarction Patients Identified With a Prehospital Electrocardiogram

Background— For patients identified before hospital arrival with ST-segment–elevation myocardial infarction, bypassing the emergency department (ED) with direct transport to the catheterization laboratory may shorten reperfusion times. Methods and Results— We studied 12 581 ST-segment–elevation myocardial infarction patients identified with a prehospital ECG treated at 371 primary percutaneous coronary intervention–capable US hospitals participating in the Acute Coronary Treatment and Intervention Outcomes Network Registry–Get With The Guidelines, including those participating in the American Heart Association Mission: Lifeline program from 2008 to 2011. Reperfusion times with primary percutaneous coronary intervention and in-hospital mortality rates were compared between patients undergoing ED evaluation and those bypassing the ED. ED bypass occurred in 1316 patients (10.5%). These patients had a lower frequency of heart failure and shock on presentation and nonsystem reasons for delay in percutaneous coronary intervention. ED bypass occurred more frequently during working hours compared with off-hours (18.3% versus 4.3%); ED bypass rate varied significantly across hospitals (median, 3.3%; range, 0%–71%). First medical contact to device activation time was shorter (median, 68 minutes [interquartile range, 54–85 minutes] versus 88 minutes [interquartile range, 73–106 minutes]; P &lt;0.0001) and achieved within 90 minutes more frequently (80.7% versus 53.7%; P &lt;0.0001) with ED bypass. The unadjusted in-hospital mortality rate was lower among ED bypass patients (2.7% versus 4.1%; P =0.01), but the adjusted mortality risk was similar (adjusted odds ratio, 0.69; 95% confidence interval, 0.45–1.03; P =0.07). Conclusions— Among ST-segment–elevation myocardial infarction patients identified with a prehospital ECG, the rate of ED bypass varied significantly across US hospitals, but ED bypass occurred infrequently and was mostly isolated to working hours. Because ED bypass was associated with shorter reperfusion times and numerically lower mortality rates, further exploration of and advocacy for the implementation of this process appear warranted.