Impact of Regionalization of ST-Segment–Elevation Myocardial Infarction Care on Treatment Times and Outcomes for Emergency Medical Services–Transported Patients Presenting to Hospitals With Percutaneous Coronary Intervention
Authors: Jollis James G. , Al-Khalidi Hussein R. , Roettig Mayme L. , Berger Peter B. , Corbett Claire C. , Doerfler Shannon M. , Fordyce Christopher B. , Henry Timothy D. , Hollowell Lori , Magdon-Ismail Zainab , Kochar Ajar , McCarthy James J. , Monk Lisa , O’Brien Peter , Rea Thomas D. , Shavadia Jay , Tamis-Holland Jacqueline , Wilson B. Hadley , Ziada Khaled M. , Granger Christopher B. 
Published: November 2017

Background:
Regional variations in reperfusion times and mortality in patients with ST-segment–elevation myocardial infarction are influenced by differences in coordinating care between emergency medical services (EMS) and hospitals. Building on the Accelerator-1 Project, we hypothesized that time to reperfusion could be further reduced with enhanced regional efforts.

Methods:
Between April 2015 and March 2017, we worked with 12 metropolitan regions across the United States with 132 percutaneous coronary intervention–capable hospitals and 946 EMS agencies. Data were collected in the ACTION (Acute Coronary Treatment and Intervention Outcomes Network)-Get With The Guidelines Registry for quarterly Mission: Lifeline reports. The primary end point was the change in the proportion of EMS-transported patients with first medical contact to device time ≤90 minutes from baseline to final quarter. We also compared treatment times and mortality with patients treated in hospitals not participating in the project during the corresponding time period.

Results:

During the study period, 10 730 patients were transported to percutaneous coronary intervention–capable hospitals, including 974 in the baseline quarter and 972 in the final quarter who met inclusion criteria. Median age was 61 years; 27% were women, 6% had cardiac arrest, and 6% had shock on admission; 10% were black, 12% were Latino, and 10% were uninsured. By the end of the intervention, all process measures reflecting coordination between EMS and hospitals had improved, including the proportion of patients with a first medical contact to device time of ≤90 minutes (67%–74%;
P
<0.002), a first medical contact to device time to catheterization laboratory activation of ≤20 minutes (38%–56%;
P
<0.0001), and emergency department dwell time of ≤20 minutes (33%–43%;
P
<0.0001). Of the 12 regions, 9 regions reduced first medical contact to device time, and 8 met or exceeded the national goal of 75% of patients treated in ≤90 minutes. Improvements in treatment times corresponded with a significant reduction in mortality (in-hospital death, 4.4%–2.3%;
P
=0.001) that was not apparent in hospitals not participating in the project during the same time period.

Conclusions:
Organization of care among EMS and hospitals in 12 regions was associated with significant reductions in time to reperfusion in patients with ST-segment–elevation myocardial infarction as well as in in-hospital mortality. These findings support a more intensive regional approach to emergency care for patients with ST-segment–elevation myocardial infarction.