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Development of systems of care for ST-elevation myocardial infarction patients the patient and public perspective

Circulation (Impact Factor: 14.95). 08/2007; 116(2):e33-8. DOI: 10.1161/CIRCULATIONAHA.107.184045
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    ABSTRACT: Objective To determine whether door-to-balloon (DTB) times of patients presenting with ST-elevation myocardial infarction (STEMI) were reduced in patients transported by emergency medical services (EMS) compared to those who were self-transported. Background DTB time is an important measure of hospital care processes in STEMI. Use of EMS may expedite in-hospital processing and reduce DTB times. Methods A total of 309 consecutive STEMI patients who underwent primary percutaneous coronary intervention in our institution were analyzed. Excluded were patients who received fibrinolytics, presented in cardiac arrest, were intubated, or were transferred from another hospital. EMS-transported patients (n = 83) were compared to self-transported patients (n = 226). The primary outcome measure was DTB time and its component time intervals. Secondary end points included symptom-to-door and symptom-to-balloon times, and correlates for DTB > 90 minutes. Results A higher percentage of EMS-transported patients reached the time goal of DTB < 90 minutes compared to self-transported patients (83.1 versus 54.3%; p < 0.001). EMS-transported patients had shorter DTB times [median (IQR) minutes, 65 (50-86) versus 85 (61-126); p < 0.001] due to a reduction of emergency department processing (door-to-call) time, whereas catheterization laboratory processing (call-to-balloon) times were similar in both groups. EMS-transported patients had shorter symptom-to-door [median (IQR) hours, 1.2 (0.8-3.5) versus 2.3 (1.2-7.5); p < 0.001] and symptom-to-balloon [median (IQR) hours, 2.5 (1.9 -4.7) versus 4.3 (2.6-9.1); p < 0.001]. Independent correlates of DTB times > 90 minutes were self-transport (odds ratio 5.32, 95% CI 2.65-10.70; p < 0.001) and off-hours presentation (odds ratio 2.89, 95% CI 1.60-5.22; p < 0.001). Conclusion Use of EMS transport in STEMI patients significantly shortens time to reperfusion, primarily by expediting emergency department processes. Community education efforts should focus not only on the importance of recognizing symptoms of myocardial infarction, but also taking early action by calling the EMS.
    Cardiovascular Revascularization Medicine 06/2014; 15(4). DOI:10.1016/j.carrev.2014.03.011
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    ABSTRACT: Women with ST-elevation myocardial infarction (STEMI) tend to have longer treatment delays than men. This may partly be due to women delaying calling for help, difficulties for the emergency medical communication (EMC) service in interpreting a different constellation of presenting symptoms than men, or gender-specific ambulance delays due to differences in the management by the EMC service. We studied the EMC audio logs and medical records of 244 consecutive STEMI patients (65 women and 179 men) who contacted the EMC center at a single hospital directly. Patient demographics, clinical findings, and outcome after primary percutaneous coronary intervention were similar for the 2 genders. More women than men reported chest discomfort and discomfort in other areas of the upper body as debuting symptoms. The combined effects of longer patients delay and system delay led to longer total ischemic time in women (total ischemic time: median [interquartile range] 142 [180] vs 135 [83] minutes, women vs men, P = .024). Despite similar presentation, women had lower priority for emergent ambulance service (78.7% and 89.4% of women vs men, P = .035). Lower priority for ambulance service was associated with longer total ischemic time. Despite similar presentation and clinical findings, women with STEMI were given significantly lower priority for emergent ambulance service than men.
    American heart journal 11/2013; 166(5):839-45. DOI:10.1016/j.ahj.2013.07.034 · 4.56 Impact Factor
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    ABSTRACT: Background-Transfer for primary percutaneous coronary intervention (PCI) is superior to fibrinolysis if performed in a timely manner but frequently requires dislocation of patients and their families from their local community. Although patient satisfaction is increasingly viewed as an important quality indicator, there are no data on how emergent transfer for PCI affects patients with ST-segment-elevation myocardial infarction and their families.Methods and Results-The Minneapolis Heart Institute's Level 1 Regional ST-Segment-Elevation Myocardial Infarction program is designed to facilitate emergent transfer for PCI in patients with ST-segment-elevation myocardial infarction from 31 rural and community hospitals. To determine the effect of emergent transfer, questionnaires were given to 152 patients and their families who survived to hospital discharge with a 65.8% response rate (mean age, 63.9 years; 29% women). Ninety-five percent of patients felt the reasons and process of transfer were well explained, and 97% felt transfer for care was necessary. Despite this, 15% of patients would have preferred to stay in their local hospital. The majority of the families felt the transfer process (88%) and family member's condition (94%) were well explained. Although 99% felt it was necessary for their family member to be transferred for specialized care, 11% of families still would have preferred that their family members remain at the local community hospital.Conclusions-Our results suggest that ST-segment-elevation myocardial infarction patients and families can be informed, even in time-critical situations, about the transfer process for PCI and understand the need for specialized care. Still, a significant minority would prefer to stay at their local hospital, despite acknowledging transfer for PCI provided optimal care.
    Circulation Cardiovascular Quality and Outcomes 03/2014; 7(2). DOI:10.1161/CIRCOUTCOMES.113.000641 · 5.04 Impact Factor

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