A community-based push to create standardized response systems could decrease mortality and streamline acute care for patients suffering an ST-elevation myocardial infarction.
The American Heart Association's ambitious “Mission: Lifeline” program will go far beyond past efforts at improving treatment times through public outreach and education, Dr. Alice Jacobs said during a press conference. “Regrettably, prior public awareness campaigns and community-based interventions have not yet been effective in reducing the time from symptom onset to first medical contact, or in increasing the number of patients who use emergency medical services [EMS] to get to hospitals where they can receive the appropriate care. We must have a system in place that will do this.”
The need for systematic reform, beginning with patient education and continuing through emergency response and hospital systems, is sadly obvious, she said. “Despite the proven benefits of quickly restoring blood flow to the heart muscle during a heart attack, 30% of STEMI patients do not receive any reperfusion therapy,” neither fibrinolytics nor primary percutaneous coronary intervention (PCI), said Dr. Jacobs, director of the cardiac catheterization lab at Boston Medical Center. “And only 50% of those who get fibrinolytics and 40% of those who undergo PCI do so within the recommended time frames.”
Last year, the AHA convened a conference to devise an organized method of addressing these issues. The group's recommendations are published in the journal Circulation (DOI:10.1161/CIRCULATIONAHA.107.184043).
The ideal system would combine several key elements, she said.
▸ Public education. “We must start with patient education,” Dr. Jacobs said. “People need to understand the signs and symptoms of a heart attack, and the importance of activating the EMS system as quickly as possible.” Half of STEMI patients drive themselves to the hospital or get a ride from family or friends, “resulting in a delay of the treatment that EMS could provide.
▸ Improving EMS diagnosis of STEMI. “In the ideal scenario, the cath lab would be activated by EMS from the field, or by the emergency physician from the hospital, and the patient would be brought directly to the cath lab without wasting time in the emergency room,” Dr. Jacobs said. “If EMS systems have the personnel, training, and appropriate resources, they can acquire, interpret, and transmit 12-lead electrocardiograms that can show the patient is having a STEMI heart attack.”
▸ Quick, efficient transfer to hospitals equipped with cardiac catheterization teams. The majority of STEMI patients go to hospitals without on-site primary PCI capabilities, Dr. Jacobs said. Unfortunately, transfer delays are all too common. “Transfers are often a matter of the patient waiting for the next available ambulance. Under this system, patients transported to a non-PCI-capable hospital would remain on the stretcher with EMS personnel in attendance until the decision is made about whether to transport to a PCI-capable receiving hospital, which is always available and never on diversion, 24 hours a day, and 7 days a week.”
▸ Hospital incentives and certification. “We will be working with payers and policy makers to ensure that mechanisms are in place for appropriate reimbursement,” Dr. Jacobs said. This may eventually translate into one treatment fee that is split between the transporting, referring, and receiving organizations. A STEMI Center Certification program will establish treatment and accountability protocols for both referring and receiving hospitals.
Achieving these goals won't be quick or easy, said Dr. Raymond Gibbons, president of the American Heart Association. Stakeholders on every level—from patients in the community to local hospitals, legislators, insurance companies, and the federal government—will have to cooperate before Mission: Lifeline can become a reality.
The AHA will play a pivotal role in bringing these parties together, Dr. Gibbons said, beginning with an assessment of EMS effectiveness for STEMI patients. The AHA will use this information to construct a basic response system that can be tailored to different regions. The group will also convene meetings at the state and local levels to identify ways to implement the system, and to evaluate pilot programs.
Funding these systems, Dr. Gibbons said, will be largely left to localities. AHA will provide support in seeking the money necessary for implementation—industry grants, for example—but the group won't be contributing financially to any individual project.
“As an example, there may be a need to purchase the 12-lead equipment and train EMS staff,” Dr. Gibbons said. “The AHA can look for mechanisms to support that. In the past, we have placed automatic external defibrillators with first-responder units by advocating for state grants or donor support. We're confident that similar tactics can be employed with Mission: Lifeline.”