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”
Authors: Akshay Bagai, James G. Jollis, Harold L. Dauerman, S. Andrew Peng, Ivan C. Rokos, Eric R. Bates, William J. French, Christopher B. Granger, Matthew T. Roe
Journal: Circulation (2014)

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. 1A 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 overall use and timeliness of reperfusion. 2In 2009, the American College of Cardiology Foundation/American Heart Association STEMI guidelines added a new Class I recommendation that "each community should develop a STEMI system of care." 3 Recommended system features included regular multidisciplinary team meetings that include emergency medical services, data collection and sharing by non-PCI and PCI hospitals, prehospital STEMI identification and activation, destination protocols for PCI hospitals, and transfer protocols for patients who arrive at non-PCI hospitals.Dr Maier and colleagues 4 have demonstrated the impact of data collection, data sharing, and regular feedback to improve processes of care, timing of reperfusion, and clinical outcomes in STEMI.Such improvements are feasible only with emergency medical services, non-PCI hospitals, and PCI-hospitals working together with common, unified goals.Bypassing the emergency department with direct transfer from the field to the cardiac catheterization laboratory for patients diagnosed with a prehospital ECG is a good example of a process that requires collaboration between different entities within the system.Emergency department bypass requires performing ECG and diagnosing STEMI before hospital arrival by emergency medical services, bypassing non-PCI hospital(s) with transfer directly to a PCI-capable hospital, preactivation of the cardiac catheterization laboratory team before the patient arrives at the hospital, and availability of an off-hours urgent care team in the hospital to monitor the patient in case the patient arrives at the hospital before the catheterization laboratory team.Although at present emergency department bypass occurs infrequently in the United States, likely in part because of suboptimal coordination between entities providing care, large-scale efforts are being made to implement regional systems across the country.The Regional Systems of Care Demonstration Project: Mission: Lifeline STEMI Systems Accelerator 5 was designed in collaboration with the American Heart Association to identify regional gaps, barriers, and inefficiencies in STEMI care and to devise strategies to implement proven recommendations to enhance quality and consistency of care in 17 major metropolitan regions encompassing >1500 emergency medical services agencies and 450 hospitals in the United States.We believe that such efforts are a major step forward to regionalizing STEMI care and outcomes of our patients.