Summary
Background
Primary percutaneous coronary intervention (PCI) is the preferred management for patients with acute ST-segment elevation myocardial infarction (STEMI) if performed in a timely manner by experienced providers. Patients can access a PCI facility by three routes: prehospital STEMI diagnosis by emergency medical services (EMS) and direct transport by EMS to a PCI facility (EMS-PCI); visit to a hospital emergency department (ED) followed by referral to an on-site PCI facility (ED-PCI); or transfer from the ED to a PCI facility in another hospital (ED-transfer-PCI).
Aims
To assess the implementation rate in France of the guidelines recommending that STEMI patients be transported by EMS to a PCI facility and to compare the times between symptom onset and PCI for these three routes.
Methods
We used the results of the pilot testing of a national quality indicator programme on STEMI in 64 hospitals, providing data on patient characteristics, referral route and symptom-onset-to-needle time. We compared delays for each route in a Cox proportional-hazard model.
Results
In a population of 1217 patients, median symptom-onset-to-needle time was 186 minutes (Q1 133; Q3 292) for the EMS-PCI route, 237 minutes (Q1 165; Q3 368) for the ED-PCI route and 305 minutes (Q1 230; Q3 570) for the ED-transfer-PCI route. A total of 70.8% of patients were transported by EMS as recommended. After adjustment for age, symptom onset period (weekends/nights) and history of cardiovascular disease, the EMS-PCI route was associated with the shortest symptom-onset-to-needle times. The hazard ratio was 0.71 [0.59–0.86] for the ED-PCI route and 0.67 [0.52–0.86] for the ED-transfer-PCI route.
Conclusion
STEMI patients receive prompter care after prehospital diagnosis and direct transport to a PCI facility by EMS than by visiting a hospital ED. Use of this referral route should be further encouraged in France as approximately one-third of STEMI patients are still presenting directly to the ED.
Résumé
Contexte
La prise en charge de l’infarctus du myocarde (IDM) sur la mise en œuvre d’une stratégie de reperfusion coronaire la plus précoce possible, en générale par angioplastie si elle peut être accomplie à temps par des opérateurs entraînés. En France, plusieurs filières de prise en charge ont été identifiées. La filière recommandée s’appuie sur l’appel au samu-centre 15, déclenchant l’envoi d’un effecteur qui effectue un diagnostic pré-hospitalier et amène le patient dans un établissement hospitalier avec une salle de coronarographie diagnostique et interventionnelle (SCDI). Cependant, d’autres filières existent. En effet, certains patients se présentent directement aux urgences des établissements hospitaliers et sont soit pris en charge dans l’établissement lorsque celui-ci dispose d’une SCDI, soit transféré dans un établissement en disposant.
Objectifs
L’objectif de cette étude est de comparer les délais de prise en charge entre les symptômes et la ponction d’angioplastie selon la filière empruntée par le patient.
Méthodes
Les données issues de l’évaluation de la qualité de la prise en charge de l’IDM dans 64 établissements hospitaliers ont été utilisées. Celles-ci comportaient les caractéristiques des patients prises en charge, les filières suivies, et les délais de prise en charge définis comme le délai entre les symptômes et la ponction d’angioplastie. Les filières ont été comparées à l’aide d’un modèle à risque proportionnel.
Résultats
Parmi les 1217 patients inclus, le délai moyen de prise en charge était de 186 minutes (Q1 133 ; Q3 292) pour la filière recommandée comparée à 237 minutes (Q1 165 ; Q3 368) et 305 minutes (Q1 230 ; Q3 570) pour les patients se présentant directement aux urgences respectivement d’un établissement hospitalier avec et sans SCDI. Au total, 70,8 % des patients ont suivi la filière recommandée. Après avoir ajusté sur l’âge, la période de prise en charge (week-end et nuit) et les antécédents cardiovasculaires, la filière recommandée était associée au délai de prise en charge le plus court comparé aux filières passant par les urgences des établissements avec et sans SCDI ( Hazard ratio de 0,71 [0,59–0,86] et 0,67 [0,52–0,86] respectivement).
Conclusion
Les patients pris en charge dans la filière recommandée reçoivent des soins plus précoces comparés aux autres filières. Cependant, dans notre étude, un tiers des patients n’ont pas suivi la filière recommandée, ce qui suggère que davantage d’efforts d’éducation doivent être fait auprès de la population.
Introduction
Primary percutaneous coronary intervention (PCI) is the preferred management strategy for patients with ST-segment elevation myocardial infarction (STEMI) if it can be performed in a timely manner by experienced providers; the shorter the delay to PCI, the higher the likelihood of survival . It is therefore essential that patients with STEMI symptoms be diagnosed and referred to a PCI facility as quickly as possible. In international studies, prehospital STEMI diagnosis and direct access to a PCI facility reduced delays and improved clinical outcomes .
In France, patients with symptoms of STEMI can be referred to a PCI facility by calling an emergency phone number and, on instructions from the call-centre physician, be transported directly to a PCI facility by the emergency medical services (EMS). A mobile intensive care unit manned by a nurse and emergency physician who can carry out the prehospital diagnosis of STEMI is dispatched on site. Alternatively, patients can arrive directly at the emergency department (ED) of a nearby hospital for a diagnosis of STEMI. From there, they can be referred to an on-site PCI facility, if available, or be transferred to a PCI facility in another hospital. Current guidelines recommend that patients call the emergency number in order to be transported by the mobile intensive care unit to the closest available PCI facility . To our knowledge, however, no studies have compared times taken to access PCI by each of these routes in the French context.
The results of the pilot testing of the national quality indicator programme for STEMI care provide the opportunity to confirm that prehospital diagnosis leads to reduced delays in France. Furthermore, it provides an evaluation of the implementation rate in France of the guidelines recommending that STEMI patients be transported by EMS to a PCI facility.
Methods
Context
The Haute Autorité de Santé is currently implementing a national indicator programme on quality of care for several pathologies, including STEMI. A pilot test of the STEMI quality indicators, developed by COMPAQHPST , the Haute Autorité de Santé and the French College of Cardiology, took place in 2010 in a sample of French hospitals. A total of 64 PCI-capable volunteer hospitals took part in the quality assessment (16 public teaching hospitals, 27 public general hospitals, 21 private hospitals). The hospitals were located throughout France.
Study population
Our study was based on data obtained during the assessment of the quality of care delivered to patients with acute myocardial infarction (AMI) in the hospital sample. Patients were included in our study if they were diagnosed with STEMI, if < 12 hours had elapsed from symptom onset to diagnosis and if they underwent primary PCI. Patients were excluded if the PCI referral route and data for calculating symptom-onset-to-needle time had not been recorded in their file. For eligibility, patients had to be hospitalized for > 24 hours in 2010 with a diagnosis of AMI (diagnosis codes I21 or I22 ICM-10). A random sample of 80 patient files was selected in each hospital or, if there were fewer than 80 files available in any hospital, all available files were selected. The sample size was chosen to limit the burden of data collection . Anonymized data were collected retrospectively from the files by hospital staff. Informed consent was waived because the data were analysed anonymously.
Measures
The primary endpoint was time elapsed between STEMI symptom onset and PCI needle time (“symptom-onset-to-needle time”) for: direct transportation to a PCI facility by EMS (EMS-PCI); referral by the ED to an on-site PCI facility (ED-PCI); and transfer from ED to PCI facility in another hospital (ED-transfer-PCI).
We defined needle time as the time of the arterial puncture for PCI. Symptom-onset-to- contact and contact-to-needle times were calculated for the EMS-PCI and ED-PCI routes, considering first medical contact time as EMS arrival time or patient arrival time at the hospital ED (data unavailable for ED-transfer-PCI route patients). Other recorded variables were patient age, period of onset (weekends [Saturday or Sunday] or nights [6.00 pm to 8.00 am on following day]) and history of cardiovascular disease as given by any ongoing antiplatelet treatment (aspirin or clopidogrel).
Statistical analysis
Continuous variables are reported as means with standard deviations and categorical variables as numbers with percentages. Times are given as medians with first and last quartiles. Differences in patients’ characteristics between included and excluded patients and between referral routes were tested by univariate analysis using Student’s t test or Pearson’s chi-square test, as appropriate.
We first analysed symptom-onset-to-needle time using the PCI referral route as covariate in a Cox proportional-hazard model after stratification on the hospital where PCI was performed. Analyses were adjusted for age, weekend or night onset and history of cardiovascular disease. No data were censored as all patients underwent PCI. We calculated a point estimate and two-sided 95% confidence interval for the hazard ratio (HR). We then added symptom-onset-to-contact time for the EMS-PCI and ED-PCI routes as a covariate to the model.
We also tested for potential differences in symptom-onset-to-needle time and symptom-onset-to-contact time between hospital status and activity level using Student’s t test.
All P values are two-sided. A P value < 0.05 was considered significant. We used SAS software, version 9.2 (SAS Institute, Cary, NC, USA).
Results
Characteristics of patients and features of STEMI
A total of 4290 patients with a diagnosis of AMI were randomly selected for a quality of care assessment in the 64 participating hospitals. Of these 4290 patients, only 1754 met the inclusion criteria (diagnosis of STEMI, time of symptom onset or interval between onset and diagnosis < 12 hours, PCI as primary treatment). Of these patients, 537 were excluded because of missing data (unavailable symptom-onset-to-needle time or referral route). This left 1217 included patients (69% of eligible patients) for the analysis.
Compared with the 537 excluded patients, the 1217 included patients were younger ( Table 1 ). There was no significant difference between included and excluded patients in terms of medical history of cardiovascular disease. The percentage of patients transported directly to a PCI facility by EMS was higher among included patients (70.8% vs 63.1%) and the percentage making their way to the ED was lower ( Table 1 ). A higher percentage experienced symptom onset at weekends (30.2% vs 23.7%) and a lower percentage at nights (50.9% vs 70.6%).
| Included patients ( n = 1217) | Excluded patients ( n = 537) | P | |
|---|---|---|---|
| Mean age (years) | 63.1 ± 13.7 | 65.4 ± 14.9 | 0.001 |
| PCI referral route | |||
| EMS-PCI | 862 (70.8) | 316 (63.1) | 0.005 |
| ED-PCI | 192 (15.8) | 106 (21.2) | |
| ED-transfer-PCI | 163 (13.4) | 79 (15.8) | |
| Onset period | |||
| Weekend | 367 (30.2) | 127 (23.7) | 0.005 |
| Night | 620 (50.9) | 379 (70.6) | < 0.001 |
| History of cardiovascular disease | |||
| Yes | 221 (18.2) | 116 (21.6) | 0.09 |
| No | 996 (81.8) | 421 (78.4) | |
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