Jollis James G, Al-Khalidi Hussein R, Roettig Mayme L, Berger Peter B, Corbett Claire C, Dauerman Harold L, Fordyce Christopher B, Fox Kathleen, Garvey J Lee, Gregory Tammy, Henry Timothy D, Rokos Ivan C, Sherwood Matthew W, Suter Robert E, Wilson B Hadley, Granger Christopher B
From University of North Carolina, Chapel Hill (J.G.J.); Duke Clinical Research Institute, Duke University, Durham, NC (H.R.A.-K., M.L.R., C.B.F., K.F., M.W.S., C.B.G.); Northwell Health, New Hyde Park, NY (P.B.B.); New Hanover Regional Medical Center, Wilmington, NC (C.C.C.); University of Vermont College of Medicine, Burlington (H.L.D.); Department of Emergency Medicine, Carolinas Medical Center, Charlotte, NC (J.L.G.); American Heart Association, Dallas, TX (T.G., R.E.S.); Cedars-Sinai Heart Institute, Los Angeles, CA (T.D.H.); UCLA-Olive View Medical Center, Los Angeles, CA (I.C.R.); and Sanger Heart and Vascular Institute, Carolinas HealthCare System, Charlotte, NC (B.H.W.).
Circulation. 2016 Aug 2;134(5):365-74. doi: 10.1161/CIRCULATIONAHA.115.019474.
Up to 50% of patients fail to meet ST-segment-elevation myocardial infarction (STEMI) guideline goals recommending a first medical contact-to-device time of <90 minutes for patients directly presenting to percutaneous coronary intervention-capable hospitals and <120 minutes for transferred patients. We sought to increase the proportion of patients treated within guideline goals by organizing coordinated regional reperfusion plans.
We established leadership teams, coordinated protocols, and provided regular feedback for 484 hospitals and 1253 emergency medical services (EMS) agencies in 16 regions across the United States.
Between July 2012 and December 2013, 23 809 patients presented with acute STEMI (direct to percutaneous coronary intervention hospital: 11 765 EMS transported and 6502 self-transported; 5542 transferred). EMS-transported patients differed from self-transported patients in symptom onset to first medical contact time (median, 47 versus 114 minutes), incidence of cardiac arrest (10% versus 3%), shock on admission (11% versus 3%), and in-hospital mortality (8% versus 3%; P<0.001 for all comparisons). There was a significant increase in the proportion of patients meeting guideline goals of first medical contact-to-device time, including those directly presenting via EMS (50% to 55%; P<0.001) and transferred patients (44%-48%; P=0.002). Despite regional variability, the greatest gains occurred among patients in the 5 most improved regions, increasing from 45% to 57% (direct EMS; P<0.001) and 38% to 50% (transfers; P<0.001).
This Mission: Lifeline STEMI Systems Accelerator demonstration project represents the largest national effort to organize regional STEMI care. By focusing on first medical contact-to-device time, coordinated treatment protocols, and regional data collection and reporting, we were able to increase significantly the proportion of patients treated within guideline goals.
高达50%的患者未达到ST段抬高型心肌梗死（STEMI）指南目标，该指南建议，对于直接前往有经皮冠状动脉介入治疗能力医院的患者，首次医疗接触至器械治疗时间应小于90分钟，对于转诊患者则应小于120分钟。我们试图通过组织协调的区域再灌注计划，提高在指南目标规定时间内接受治疗的患者比例。
我们在美国16个地区为484家医院和1253个紧急医疗服务（EMS）机构建立了领导团队，协调了方案，并定期提供反馈。
在2012年7月至2013年12月期间，23809例患者出现急性STEMI（直接前往经皮冠状动脉介入治疗医院：11765例由EMS转运，6502例自行前往；5542例为转诊）。由EMS转运的患者与自行前往的患者在症状发作至首次医疗接触时间（中位数分别为47分钟和114分钟）、心脏骤停发生率（10%对3%）、入院时休克发生率（11%对3%）以及院内死亡率（8%对3%；所有比较P<0.001）方面存在差异。达到首次医疗接触至器械治疗时间指南目标的患者比例显著增加，包括直接由EMS转运的患者（从50%增至55%；P<0.001）和转诊患者（从44%增至48%；P=0.002）。尽管存在区域差异，但在改善最明显的5个地区，患者获益最大，直接由EMS转运的患者从45%增至57%（P<0.001），转诊患者从38%增至50%（P<0.001）。
这项“使命：生命线STEMI系统加速器”示范项目是全国范围内组织区域STEMI护理的最大规模努力。通过关注首次医疗接触至器械治疗时间、协调治疗方案以及区域数据收集和报告，我们能够显著提高在指南目标规定时间内接受治疗的患者比例。
