Ground Emergency Medical Services Requests for Helicopter Transfer of ST-segment Elevation Myocardial Infarction Patients Decrease Medical Contact to Balloon Times in Rural and Suburban Settings
ABSTRACT ST-segment elevation myocardial infarction (STEMI) care is time-dependent. Many STEMI patients require interhospital helicopter transfer for percutaneous coronary intervention (PCI) if ground emergency medical services (EMS) initially transport the patient to a non-PCI center. This investigation models potential time savings of ground EMS requests for helicopter EMS (HEMS) transport of a STEMI patient directly to a PCI center, rather than usual transport to a local hospital with subsequent transfer.
Data from a multicenter retrospective chart review of STEMI patients transferred for primary PCI by a single HEMS agency over 12 months were used to model medical contact to balloon times (MCTB) for two scenarios: a direct-to-scene HEMS response and hospital rendezvous after ground EMS initiation of transfer.
Actual MCTB median time for 36 hospital-initiated transfers was 160 minutes (range = 116 to 321 minutes). Scene response MCTB median time was estimated as 112 minutes (range = 69 to 187 minutes). The difference in medians was 48 minutes (95% confidence interval [CI] = 33 to 62 minutes). Hospital rendezvous MCTB median time was estimated as 113 minutes (range = 74 to 187 minutes). The difference in medians was 47 minutes (95% CI = 32 to 62 minutes). No patient had an actual MCTB time of less than 90 minutes; in the scene response and hospital rendezvous scenarios, 2 of 36 (6%) and 3 of 36 (8%), respectively, would have had MCTB times under 90 minutes.
In this setting, ground EMS initiation of HEMS transfers for STEMI patients has the potential to reduce MCTB time, but most patients will still not achieve MCTB time of less than 90 minutes.
Full-textDOI: · Available from: Gregory J Fermann, May 29, 2015
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ABSTRACT: Most US hospitals lack primary percutaneous coronary intervention (PCI) capabilities to treat patients with ST-elevation myocardial infarction (STEMI) necessitating transfer to PCI-capable centers. Transferred patients rarely meet the 120-minute benchmark for timely reperfusion, and referring emergency departments (EDs) are a major source of preventable delays. We sought to use more granular data at transferring EDs to describe the variability in length of stay at referring EDs. We retrospectively analyzed a secondary data set used for quality improvement for patients with STEMI transferred to a single PCI center between 2008 and 2012. We conducted a descriptive analysis of the total time spent at each referring ED (door-in-door-out [DIDO] interval), periods that comprised DIDO (door to electrocardiogram [EKG], EKG-to-PCI activation, and PCI activation to exit), and the relationship of each period with overall time to reperfusion (medical contact-to-balloon [MCTB] interval). We identified 41 EDs that transferred 620 patients between 2008 and 2012. Median MCTB was 135 minutes (interquartile range [IQR] 114,172). Median overall ED DIDO was 74 minutes (IQR 56,103) and was composed of door to EKG, 5 minutes (IQR 2,11); EKG-to-PCI activation, 18 minutes (IQR 7,37); and PCI activation to exit, 44 minutes (IQR 34,56). Door-in door-out accounted for the largest proportion (60%) of overall MCTB and had the largest variability (coefficient of variability, 1.37) of these intervals. In this cohort of transferring EDs, we found high variability and substantial delays after EKG performance for patients with STEMI. Factors influencing ED decision making and transportation coordination after PCI activation are a potential target for intervention to improve the timeliness of reperfusion in patients with STEMI. Copyright © 2015 Elsevier Inc. All rights reserved.American Journal of Emergency Medicine 01/2015; 33(3). DOI:10.1016/j.ajem.2014.12.067 · 1.15 Impact Factor
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ABSTRACT: Introduction This study aimed to evaluate consistency/predictability of interfacility flight times (IFFTs) and accuracy of geographical information system (GIS) software packages for estimating IFFT. Methods This retrospective study conducted by a program using a Bell 206 assessed the first 1000 IF transports occurring on 137 “runs” (ie, referring-receiving hospital pairings) made at least twice. GIS IFFT estimates using Google Earth™ (GE) and ArcGIS™ (AG) were compared against actual IFFT using linear regression; univariate analysis included assessment of medians with 95% binomial exact confidence intervals (CIs). Interrater agreement for GIS was assessed with κ. Results GE and AG estimates fell, respectively, within 1 mile of actual in 136/137 runs (99%, 95% CI 96%–100%) and 130/137 runs (95%, 95% CI 90%–98%). GE- and AG-predicted IFFT strongly (P < .001) correlated with, underestimating by about 2 minutes, actual IFFT (GE: r2 0.93, coefficient 0.98, 95% CI .97–1.00; AG: r2 0.93; coefficient 0.98, 95% CI .96–1.0). GE and AG had statistically equivalent (κ > .8), “almost-perfect,” interrater agreement. Conclusion IFFTs for same-run helicopter EMS transports in our rural state setting are characterized by little variability. GIS is highly accurate in predicting IF logistics, with public-domain GE performing as well as more expensive AG.Journal of Air Medical Transport 08/2014; 33(4):165–171. DOI:10.1016/j.amj.2014.03.002
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ABSTRACT: Patients suffering ST segment elevation myocardial infarction (STEMI) requiring transfer from a non-percutaneous coronary intervention (PCI) hospital to a PCI-capable hospital often have prolonged treatment times. For STEMI transfers, we changed from air to ground transportation, and carefully documented the impact on treatment times. This is a retrospective report between two hospitals within one STEMI system. The referring facility controls both air and ground ambulance services. After a 2-year period of air transportation with suboptimal treatment times, the referring hospital switched to ground transport. All pertinent times were carefully recorded and are reported here. There were 43 patients included, approximately half were transported by air and half by ground. Comparing our early experience (air only) vs. our later experience (predominantly ground-transported patients), median door-in-door-out (DIDO) time at the first facility was 70 min vs. 35 min (p < 0.001), median transport time was 20 min vs. 30 min (p < 0.001), and median first medical contact to balloon time (FMC2b time) was 123 min vs. 90 min (p < 0.001). After changing mode of transport, achievement of the national FMC2b time goal of < 120 min rose from 47% to 92% (p < 0.001). We document a significantly reduced DIDO and FMC2b time after changing mode of transportation for STEMI patients transferred 30 miles for primary PCI. Utilizing ground rather than air transportation, the median FMC2b time was reduced from 123 to 90 min. We show that mode of transportation can dramatically reduce both DIDO time and FMC2b time.Journal of Emergency Medicine 04/2014; DOI:10.1016/j.jemermed.2014.02.003 · 1.18 Impact Factor