Langabeer James R, Prasad Sapna, Seo Munseok, Smith Derek T, Segrest Wendy, Owan Theophilus, Gerard Daniela, Eisenhauer Michael D
University of Texas Health Science Center, Houston, TX.
University of Texas Health Science Center, Houston, TX.
Am J Emerg Med. 2015 Jul;33(7):913-6. doi: 10.1016/j.ajem.2015.04.009. Epub 2015 Apr 10.
Regional myocardial infarction systems of care have been shown to improve timely access to primary percutaneous coronary intervention (PCI). However, there is a relatively sparse research on rural "frontier" regions. Arrival mode, high rates of interhospital transfers, long transport times, low population density, and mostly volunteer emergency medical services (EMS) distinguish this region from metropolitan systems of care. We sought to assess the effect of interhospital transfers, distance, and arrival mode on total ischemic times for patients with ST-elevation myocardial infarctions undergoing primary PCI.
We assessed patient data from our observational cohort of 395 patients with ST-elevation myocardial infarction with PCI as their primary treatment strategy. Data came from the 10 PCI hospitals participating in the Wyoming Mission: Lifeline program from January 2013 to September 2014. We performed both regression and tests of differences.
Median total ischemic time was nearly 2.7 times greater in transferred patients than those presenting directly (379 vs 140 minutes). Distance in miles traveled between patient's home and PCI facility was 2.5 times larger in transfer patients (51 vs 20 miles). Emergency medical services arrival was associated with 23% shorter total ischemic times than self-arrival.
Transfer patients from referral hospitals had significantly greater total ischemic time, and use of EMS was associated with significantly lower times. Transport distance was mixed in its effect. These findings suggest a continued focus on improving transitions between referral and receiving centers and enhancing coordination in rural systems of care to reduce the multiplier effect of transfers on total ischemic time.
已证明区域性心肌梗死护理系统可改善及时接受直接经皮冠状动脉介入治疗（PCI）的情况。然而，针对农村“边远”地区的研究相对较少。到达方式、较高的院间转运率、较长的转运时间、较低的人口密度以及大多为志愿性质的紧急医疗服务（EMS）使该地区与大城市护理系统有所不同。我们试图评估院间转运、距离和到达方式对接受直接PCI的ST段抬高型心肌梗死患者总缺血时间的影响。
我们评估了来自395例以PCI作为主要治疗策略的ST段抬高型心肌梗死观察队列患者的数据。数据来自2013年1月至2014年9月参与怀俄明生命线计划的10家PCI医院。我们进行了回归分析和差异检验。
转运患者的总缺血时间中位数比直接就诊患者长近2.7倍（379分钟对140分钟）。转运患者从家中到PCI机构的行驶英里数距离是直接就诊患者的2.5倍（51英里对20英里）。与自行到达相比，紧急医疗服务到达时的总缺血时间缩短了23%。
来自转诊医院的转运患者总缺血时间明显更长，而使用EMS与明显更短的时间相关。转运距离的影响好坏参半。这些发现表明应继续关注改善转诊中心与接收中心之间的衔接，并加强农村护理系统的协调，以减少转运对总缺血时间的倍增效应。
