Improvement in STEMI Care Processes Possible on a Large Scale

Hospitals that implemented key processes of care as part of a broad American Heart Association (AHA) STEMI initiative over just a few years’ time had reperfusion times comparable to those seen in centers that were already adhering to those standards, a new analysis shows. Centers that failed to implement those approaches, on the other hand, continued to have poor treatment times.

“Hospitals have to recognize that these care processes are important, that if we implement them we can reduce reperfusion time,” lead author Christopher Fordyce, MD (University of British Columbia, Vancouver, Canada), told TCTMD. “The challenge lies in organizing these regions and getting cardiologists, emergency physicians, and EMS working together to improve these processes.”

He added that the study—published online January 12, 2017, ahead of print in Circulation: Cardiovascular Interventions—“is another piece of evidence that supports regionalization of STEMI care and shows that if you participate in care process implementation, you will improve your outcomes.”

Of note, however, in-hospital mortality in the current analysis was no different between centers that had and had not instituted these AHA-recommended changes to their STEMI care.

Umesh Khot, MD (Cleveland Clinic, OH), who was not involved in the study, pointed out that prior studies—mostly involving single centers or hospital systems—have shown that it is possible to make substantial improvements in processes of care for STEMI and that those gains are associated with shorter reperfusion times. What makes the current study unique, he told TCTMD, is that it involved a large number of centers across the country (171 hospitals in 16 metropolitan areas).

He said one of the unknowns in the study is how well participating centers who said they implemented a certain process of care actually put it into place, noting that there was probably a lot of variability. “One of my concerns is that in some of the places that said they did these processes . . . [implementation] may not have been as ideal,” Khot said. That may have played a role in the relatively modest differences in reperfusion times observed between centers who said they were adhering to the care processes and those that were not, he explained.

Khot said that overall the study is positive, showing “that multiple healthcare networks can work together to improve the process of care.”

Mission: Lifeline

The current study involved data from the AHA Mission: Lifeline STEMI Systems Accelerator program, which implemented common protocols in participating hospitals between March 2012 and July 2014. A prior analysis showed that the program had the overall effect of modestly reducing reperfusion times.

To get a better idea of the impact of implementing specific care processes, Fordyce et al surveyed 167 of the centers before and after the program and combined the responses with patient-level clinical data on nearly 24,000 people treated during the study period. Hospitals were divided into three groups: those that implemented the care processes, those that had them already in place, and those that never went through with implementation.

Each of the four key processes of care became used by a larger percentage of centers during the initiative:

• Prehospital cardiac catheterization laboratory activation for patients presenting by EMS to a PCI-capable hospital (62% to 91%; P < 0.001)
• Use of a single-call transfer protocol for patients presenting to non-PCI-capable centers (45% to 70%; P < 0.001)
• Emergency department bypass for patients presenting directly to a PCI-capable center (48% to 59%; P = 0.002)
• Emergency department bypass for transferred patients (56% to 79%; P = 0.001)

For each of the processes, first medical contact-to-device times at centers that implemented the protocols were shorter than reperfusion times at hospitals that failed to put them into place and similar to times at centers already adhering to the process. When looking at prehospital activation of the cath lab, for example, the interval was 88 minutes in implementing centers, 89 minutes in centers already using the process, and 98 minutes in the non-implementers.

Mortality Remains Unchanged

The relatively modest changes in reperfusion times did not, however, translate into lower in-hospital mortality.

Fordyce et al propose several reasons for the lack of a mortality difference, including the relatively small sample size and the short follow-up period. Also, Fordyce pointed out, there is evidence that STEMI patients as a whole are increasingly coming in with a higher risk profile, which would cancel out any gains expected from shorter reperfusion times. “There are some signals to say that as we’re improving the systems and the systems are maturing, we may be drawing in sicker patients” who in the past may have died before reaching the hospital, he said.

Khot added that the reductions in reperfusion times in the hospitals implementing the key care processes might not have been large enough to drive a decline in mortality. He said future studies should investigate how putting into place processes of care affects downstream patient outcomes.

Fordyce acknowledged that mortality is an important outcome, but stressed that improvement in patient outcomes starts with identifying and refining key processes of care. The lack of a difference in mortality in the current study “doesn’t mean that the care processes aren’t working,” he said. “It’s just that we need to be a little bit more thoughtful in terms of why that is.”

In an accompanying editorial, Harvey White, DSc (Auckland City Hospital, New Zealand), says: “The lack of reduction in mortality with implementation of four key rapid care processes should stimulate activities to improve all aspects of STEMI care such as transmission of ECGs, availability of catheterization laboratories 24/7, regular feedback on [first medical contact]-to-device times to emergency medical services and hospital personnel, and institution of high rates of evidence-based medicine.”