Emergency Department Bypass Research Articles

Prehospital stroke care in Africa: The reality and potential solutions.

Prehospital stroke care in Africa: The reality and potential solutions.

High-resolution CT with arch/neck/head CT angiography on a mobile stroke unit

BackgroundMobile stroke units (MSUs) performance dependability and diagnostic yield of 16-slice, ultra-fast CT with auto-injection angiography (CTA) of the aortic arch/neck/circle of Willis has not been previously reported.MethodsWe performed a...

Impact of Emergency Medical System Transportation in ST-segment Elevation Myocardial Infarction: A Nationwide Retrospective Study

Emergency medical system transportation has been shown to reduce treatment times in ST-segment elevation myocardialinfarction. The authors studied the Portuguese National Registry of Acute Coronary Syndromes to determine the nationwide impactof the emergency medical system transportation in the treatment of ST-segment elevation myocardial infarction. A multicentric, nationwide, retrospective study of ST-segment elevation myocardial infarction patients insertedin the National Registry from 2010 to 2017 was performed. The patients were divided into: Group I, composed of patients transportedby emergency medical system, and Group II, patients arriving to the Emergency department by other means. Of the 5702 patients studied, 25.9% were transported via emergency medical system. Rates of emergency medical systemactivation increased by 17% in the last 7 years. The emergency medical system provided a higher rate of transport to a percutaneouscoronary intervention capable centre, of Emergency department bypass, of on-site fibrinolysis, and ensured a 59-minute reduction ofthe median reperfusion time (p < 0.001). There was no difference in in-hospital mortality. In this nationwide cohort, emergency medical system transportation is associated with a reduction in reperfusion times.It provides a higher amount of salvaged myocardium and reduces the incidence of acute heart failure. However, emergency medicalsystem use did not result in lower in-hospital mortality, probably due to confounding factors of higher disease severity and comorbidity. The benefits associated with emergency medical system based transportation of patients with ST-segment elevationmyocardial infarction do not translate into lower in-hospital mortality.

P6422Physician vs machine: an innovative ST-elevation myocardial infarction pathway through artificial intelligence

Abstract Background The diagnosis of ST-Elevation Myocardial Infarction (STEMI) has traditionally relied on a cardiologist's interpretation of an Electrocardiogram (EKG). This cumbersome process is costly, inefficient and out of date. Artificial Intelligence (AI) -guided algorithms can provide point-of-care, accurate STEMI diagnosis that will facilitate STEMI management. Purpose To demonstrate the feasibility of an automated AI-guided EKG analysis for STEMI diagnosis. Methods An observational, retrospective, case-control study. Sample: 8,511 EKG cardiologist-annotated records, including 4,255 STEMI cases. Records excluded patient and medical information. The sample was derived from the private International Telemedical Systems (ITMS) database. LUMENGT-AI Algorithm was employed. Preprocessing: detection of QRS complexes by wavelet system, segmentation of each EKG into individual heartbeats (90,592 total beats) with fixed window of 0.4s to the left and 0.9s to the right of main QRS; Classification: A 1-D convolutional neural network was implemented, “STEMI” and “Not-STEMI” classes were considered for each heartbeat, individual probabilities were aggregated to generate the final label for each record. Training &amp; Testing: 90% and 10% of the sample were used, respectively. Experiments: Intel PC i7 8750H processor at 2.21GHz, 16GB RAM, Windows 10 OS with NVidia GTX 1070 GPU, 8GB RAM. Results The model achieved an accuracy of 96.5%, with a sensitivity of 96.3%, and a specificity of 96.8%. Conclusion(s) 1) AI-guided interpretation of the EKG can reliably diagnose STEMI; 2) AI algorithms can be incorporated into ambulance systems for pre-hospital diagnosis, single page activation, emergency department bypass, facilitating more efficient STEMI pathways.

Prognostic significance of emergency department bypass in stable and unstable patients with ST-segment elevation myocardial infarction.

Background:In ST-segment elevation myocardial infarction (STEMI) patients treated with percutaneous coronary intervention, direct transport from the scene to the catheterisation laboratory bypassing the emergency department has been shown to shorten times to reperfusion. The aim of this study was to investigate the effects of emergency department bypass on mortality in both haemodynamically stable and unstable STEMI patients.Methods:The analysis is based on a large cohort of STEMI patients prospectively included in the German multicentre Feedback Intervention and Treatment Times in ST-Elevation Myocardial Infarction (FITT-STEMI) trial.Results:Out of 13,219 STEMI patients who were brought directly from the scene by emergency medical service transportation and were treated with percutaneous coronary intervention, the majority were transported directly to the catheterisation laboratory bypassing the emergency department (n=6740, 51% with emergency department bypass). These patients had a significantly lower in-hospital mortality than their counterparts with no emergency department bypass (6.2% vs. 10.0%, P<0.0001). The reduced mortality related to emergency department bypass was observed in both stable (n=11,594, 2.8% vs. 3.8%, P=0.0024) and unstable patients presenting with cardiogenic shock (n=1625, 36.3% vs. 46.2%, P<0.0001). Regression models adjusted for the Thrombolysis In Myocardial Infarction (TIMI) risk score consistently confirmed a significant and independent predictive effect of emergency department bypass on survival in the total study population (odds ratio 0.64, 95% confidence interval 0.56–0.74, P<0.0001) and in the subgroup of shock patients (OR 0.69, 95% CI 0.54–0.88, P=0.0028).Conclusion:In STEMI patients, emergency department bypass is associated with a significant reduction in mortality, which is most pronounced in patients presenting with cardiogenic shock. Our data encourage treatment protocols for emergency department bypass to improve the survival of both haemodynamically stable patients and, in particular, unstable patients.Clinical Trial Registration: NCT00794001ClinicalTrials.gov: NCT00794001

Abstract TP30: Risks and Benefits of Bypassing the Emergency Department for Ischemic Stroke Transferred in for Acute Endovascular Therapy

Background and Purpose: Minimizing time from symptom onset to recanalization is crucial to maximizing outcome. Approaches to save time in ET cases including processes to reduce door-to-recanalization times need to be explored. Methods: We performed a retrospective review of consecutive ischemic stroke patients transferred to our comprehensive stroke center (CSC) from March 2014 to April 2015. Demographic and clinical data were collected. We compared adverse events (hemorrhagic transformation [HT], DVT, PE, urinary tract infection [UTI], pneumonia [PNA], bacteremia), door-to-recanalization time, and short-term outcomes in patients that were evaluated in the emergency department (ED) prior to ET and patients that were transferred directly to the endovascular suite, bypassing the ED. Results: Among the 776 consecutive ischemic stroke patients admitted to our center during the 14-month period, 7% (n=49) received acute ET. Twenty-six of these patients (53%) were transferred to our CSC for ET. Among transfers, 58% (n=15) bypassed the ED. Patients that bypassed the ED had a higher frequency of adverse events (53% vs. 27%, p=0.246), but shorter arrival to recanalization times when compared to patients that did not skip the ED (median 89 vs. 109 minutes p=0.637). Poor functional outcome, as measured by modified Rankin scale (mRS) score of 4-6, was similar between groups (67% vs. 64%, p=1.000), but in-hospital mortality was more frequent in the ED bypass group (33% vs. 18%, p=0.658). Conclusions: In our sample of acute ischemic patients transferred for acute ET, nearly 60% of patients bypassed the ED, reducing time to recanalization. This time savings was associated with a clinically higher proportion of adverse events. Standardized protocols for patients transferred to acute ET are needed to reduce time to recanalization without increasing adverse event rates.

Abstract 17432: Specific Care Process Implementation Associated With Improved Reperfusion Times Across Multiple STEMI Networks: Insights From The AHA Mission: Lifeline STEMI Accelerator Program

Introduction: The STEMI Accelerator Program occurred in 16 U.S. metropolitan regions and resulted in more patients receiving timely reperfusion. We assessed whether implementing key care processes was associated with shorter reperfusion times. Methods: Hospitals (n=167 with 23,498 STEMI patients) were surveyed pre- (02/2012) and post- (08/2014) intervention with a standardized care process questionnaire. Survey data were then merged with patient-level clinical data over the same time period. For reperfusion times, hospitals were stratified by whether they implemented a specific process of care, had a pre-existing process, or never implemented the process. Results: Uptake of several care processes increased following intervention: pre-hospital activation (62% to 91% of hospitals; p&lt;0.001), single call transfer protocol from an outside facility (45% to 70%; p&lt;0.001) and emergency department (ED) bypass for both direct presenters via paramedics (48% to 59%; p=0.002) and transfer patients (56% to 79%; p=0.001). There were significant differences in median first medical contact-to-device (FMC) times (Figure) among patients treated at hospitals that implemented pre-activation compared to non-implementers (88 min for implementers; vs 89 min for pre-existing; vs 98 min for non-implementers; p&lt;0.001 for group comparisons). Similarly, patients treated at hospitals implementing single call transfer protocols had shorter median FMC times (112 min vs 128 min vs 152 min; p&lt;0.001). ED bypass was also associated with shorter FMC times for both direct presenters (84 min vs 88 min vs 94 min; p&lt;0.001) and transfers (123 min vs 127 min vs 167 min; p&lt;0.001). Conclusions: The STEMI Accelerator program increased the uptake of key care processes, which were in turn associated with shorter median reperfusion times. These findings support ongoing efforts to implement regional STEMI networks focused upon pre-hospital activation, single call transfer protocols and ED bypass.

Outcomes by day and night for patients bypassing the emergency department presenting with ST-segment elevation myocardial infarction identified with a pre-hospital electrocardiogram.

Pre-hospital ECG and emergency department (ED) bypass direct to the catheter laboratory may optimize reperfusion times for patients with ST-segment elevation myocardial infarction. Questions remain over feasibility and safety during off hours. To determine if presenting time of day is associated with differences in in-hospital and 30-day mortality and key reperfusion times. Seven hundred and twenty consecutive patients with STEMI triaged directly from the field to the catheter laboratory between June 2004-May 2013. Vital status was reported as of August 2013. The mean age was 65 ± 14 years, and 75.1% were male. Overall mortality (in-hospital/30 days) did not significantly differ for patients (3.4% in hours and 3.1% off hours; P = N/S). Symptom onset-to-arrival to the heart attack was non-significantly lower (100 minutes off hours (IQR 78-174) versus 110 minutes in hours (IQR 75-199), P = N/S). Call-to-balloon time was not significantly affected by the time of presentation: 150 min in hours (IQR 111-239) versus 154 minutes during off hours (IQR 115-225) P = N/S. Overall door-to-balloon time was 36 minutes (IQR 25-51), 34 minutes in hours (IQR 24-49) versus 40 minutes off hours (IQR 29-55) P = N/S. The overall false positive activation rate was only 13.1%, (in hours 12.2% vs. off hours 14.6%, respectively, P = N/S). In a unit with an established field triage system facilitating ED bypass, reperfusion times and mortality are not significantly influenced by whether the patient presents during standard working hours or outside of these hours.

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 …

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.

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.

Circulation : Clinical Summaries

<i>Circulation</i> : Clinical Summaries

Bypassing the Emergency Department and Time to Reperfusion in Patients With Prehospital ST-Segment–Elevation

Among patients identified prehospital with ST-segment-elevation myocardial infarction, emergency medical service transport from the field directly to the catheterization laboratory, thereby bypassing the emergency department (ED), may shorten time to reperfusion. We studied 1687 patients identified prehospital with ST-segment-elevation myocardial infarction from the Reperfusion in Acute Myocardial Infarction in Carolina Emergency Departments (RACE) project, transported via emergency medical service directly to 21 North Carolina hospitals for primary percutaneous coronary intervention between July 2008 and December 2009. Treatment time intervals were compared between patients evaluated in the ED (ED evaluation) and those transported directly to the catheterization laboratory (ED bypass). Emergency medical service transported 1401 (83.0%) patients to the ED, whereas the ED was bypassed for 286 (17.0%) patients. Overall, first medical contact to device activation within 90 minutes was achieved in 913 (54.1%) patients. Among patients evaluated in the ED, median time (25th-75th percentiles) from ED arrival to catheterization laboratory arrival was 30 (20-41) minutes. First medical contact to device activation occurred faster (75 [59-93] versus 90 [76-109] minutes; P<0.001) and was more frequently achieved within 90 minutes (74.1% versus 50.1%; P<0.001) among ED bypass patients. Among patients identified prehospital with ST-segment-elevation myocardial infarction and transported directly to a percutaneous coronary intervention hospital, only 1 in 2 achieve device activation within 90 minutes. A median of 30 minutes is spent in the ED, contributing significantly to the failure to achieve timely reperfusion. The strategy to bypass the ED is used infrequently and represents a potential opportunity to improve reperfusion times.

Impact of Prehospital Electrocardiogram Protocol and Immediate Catheterization Team Activation for Patients With ST-Elevation–Myocardial Infarction

Guidelines recommend implementing prehospital electrocardiograms (PH ECG) into systems of care for patients with suspected ST-elevation–myocardial infarction to reduce door-to-balloon time (DTB). We developed a PH ECG protocol with an affiliated emergency medical service, combining 4 features: (1) PH ECG acquisition; (2) emergency medical service interpretation without PH ECG transmission; (3) prehospital activation of the cardiac catheterization team; and (4) emergency department bypass. We compared data from June 1, 2006, to August 31, 2007 (preimplementation group, n=50), with data from October 1, 2007, to June 30, 2010 (postimplementation group, n=82), analyzing all patients with ST-elevation–myocardial infarction transported by an affiliated EMS and treated with primary percutaneous coronary intervention. PH ECGs were acquired in 33 (66%) and 67 (82%) patients in the preimplementation and postimplementation groups, respectively ( P =0.041). Median DTB was 59 and 57 minutes for the preimplementation and postimplementation groups, respectively ( P =0.28). In a prespecified subgroup analysis of postimplementation patients (n=38) who had prehospital activation of catheterization team and emergency department bypass, median DTB was 32 minutes ( P <0.001 compared with preimplementation group). Our PH ECG protocol increased the frequency of PH ECG acquisition and decreased DTB for patients when all 4 features of our PH ECG protocol were carried out. Prehospital electrocardiograms (PH ECG) can decrease reperfusion times for patients with ST-elevation–myocardial infarction (STEMI) undergoing primary percutaneous coronary intervention (PCI).1–16 However, even when PH ECG are acquired, they may not be optimally utilized and integrated. A recent scientific statement by the American Heart Association (AHA) stated, “the central challenge for healthcare providers is not to simply perform PH ECG, but to use and integrate the diagnostic information from a PH ECG with systems of care.”17 The American College of Cardiology/AHA (ACC/AHA) guidelines for STEMI encourage a first medical contact-to-balloon time (FMCTB) within 90 …

The Effects of Minimizing Ambulance Diversion Hours on Emergency Departments

This study explores the effects of minimizing Emergency Department (ED) bypass on individual hospital’s ED census, ambulance transports, and admissions. Five hospitals in a geographic area collected data over 3 weeks. The first and third week represented controls, whereas the second week hospitals minimized their usage of bypass. Data collected included hours on bypass, ED census, ambulance runs, hospital admissions, and inter-facility transfers. The total number of hours on bypass for all hospitals for pre-trial, trial, and post-trial weeks were 112.2, 0.3, and 47, respectively. There were several statistical shifts in the proportion of ambulance runs and admissions seen by individual hospitals. Clinically, these shifts in patients were minor and within ED capacity. Hospitals in a given geographic area may successfully reduce the number of hours on bypass with possible minor shifting in the number of ambulance runs and admissions that are within ED capacity.

Field triage to primary angioplasty combined with emergency department bypass reduces treatment delays and is associated with improved outcome

We investigated the net benefit in the outcome of reducing treatment delay through field triage and emergency department (ED) bypass in patients with ST-elevation myocardial infarction (STEMI) treated with primary angioplasty. In a prospective registry study, consecutive patients with suspected STEMI were assigned to: (i) pre-hospital ECG and triage or (ii) ECG and triage at the closest ED, solely based on ambulance availability. Four district hospitals and one regional heart centre serviced the 890,000 population metropolitan area and primary angioplasty was the only reperfusion strategy employed. Baseline characteristics were similar in STEMI patients triaged in the field (108) and the EDs (193). Symptom onset to balloon times: 154 [inter-quartile range (IQR) 120-233) vs. 249 (IQR 184-405) min (P<0.001) and peak creatine kinase in early presenters (<2 h): 1435 (95 %CI: 904-1966) U/L vs. 2320 (95% CI: 1881-2762) U/L (P=0.009) were lower in field- than in ED-triaged patients. Mortality in the PCI treated were 1.1 and 8.2% [P=0.025, RR 0.14 (95% CI: 0.01-1.08)] and overall mortality were 1.9 and 7.3% [P=0.046, RR 0.26 (95% CI: 0.05-1.11)]. Field-triage and ED bypass were feasible means of reducing treatment delay in patients with suspected STEMI and resulted in smaller infarct size in early presenters and a trend towards a reduction in mortality.