Mission: Lifeline Project Expanded Ranks of Patients Getting Guidelines-Based STEMI Care

Larry Hand

August 04, 2016

DURHAM, NC — In the largest national project to organize regional care for ST-segment-elevation MI (STEMI), the proportion of patients treated within guideline goals increased modestly but significantly, according to a new report published in the August 2, 2016 issue of Circulation[1].

Under the Mission: Lifeline STEMI Systems Accelerator project, a collaborative program between Duke Clinical Research Institute and the American Heart Association, 484 hospitals and 1253 emergency medical service (EMS) agencies in 16 US geographic regions participated in an effort to organize coordinated regional reperfusion plans. Most reported to the ACTION Registry–Get With The Guidelines (AR-G) program.

Seven-year-old national guidelines call for PCI within 90 minutes for patients who arrive by EMS at PCI-capable hospitals and within 120 minutes of first medical contact for patients from interhospital transfer. Yet for up to 50% of STEMI patients, this guideline is not met.

"It is possible, in large and complex metropolitan areas in the US, to establish integrated regional STEMI systems of care that will significantly improve timely STEMI reperfusion,"senior author Dr Christopher B Granger (Duke University Medical Center, Durham, NC) told heartwire from Medscape by email.

"This involves having all PCI centers entering data in AR-G, having regional reports to review in regional leadership meetings, protocols for each hospital in the region, and common protocols for EMS," he said. "The materials, such as sample protocols for hospitals and EMS, are available on the American Heart Association Mission: Lifeline website. This type of regional approach is critical to overcome the barriers of a fragmented EMS system and poor coordination between hospitals."

During this intervention, between July 2012 and December 2013, clinical centers established leadership teams, coordinated protocols, and provided regular feedback on how patients were treated when presenting with STEMI. The current study covers the 24 months after initiation of the project.

Of 23,809 patients (median age 60) presenting during this time, EMS transported 11,765 patients, 6502 self-transported, and 5542 transferred from non–PCI-capable centers.

EMS-transported patients had a median time of 47 minutes for symptom onset to first medical contact, compared with 114 minutes for self-transported patients. EMS-transported patients also had significantly higher rates of cardiac arrest (10% vs 3%) and shock (11% vs 3%) on admission, as well as in-hospital mortality (8% vs 3%, P<0.001 for all differences).

Overall, the proportion of patients presenting directly to PCI-capable centers who received treatment within guideline goals increased from 59% to 61% (P=0.005) during the intervention. The increase went from 50% to 55% (P<0.001) for EMS-transported patients and from 44% to 48% (P=0.002) for transferred patients.

Substantial regional variability occurred, the researchers noted, with the most improved region showing an increase from 56% to 76% for EMS-transported patients receiving treatment within 90 minutes and the five most improved regions showing an increase of 45% to 57% (P<0.001 for both).

The proportion treated within 120 minutes among transferred patients increased from 38% to 50% overall and from 33% to 56% in the most improved region.

Overall in-hospital mortality came to 6.1%, with no significant change in in-hospital mortality during the intervention.

The authors did not specify regions by name, but they included New York, Atlanta, Houston, and St Louis.

In an accompanying editorial[2], Dr Alice K Jacobs (Boston University School of Medicine and Boston Medical Center, MA) writes that the authors "have shown that, despite the challenges (including the variable time to implementation among regions that diluted the potential improvement in process metrics and outcomes), by organizing leadership, using common protocols, fostering data collection, and promoting ongoing review and timely feedback, they were able to modestly increase the percentage of patients treated within guideline goals.

"What is clear, however," she continued, "is that we must continue to meet the challenges of the realities of reperfusion therapy and the barriers to implementation of STEMI systems. The quality of care and outcomes for our patients with time-sensitive cardiovascular disorders depend on it."

Granger told heartwire , "We have a forthcoming manuscript that will detail what features of the intervention appeared to be important to success. More complete implementation of the protocols by EMS and hospitals appeared to be very important—for example, protocols to ensure prehospital catheterization laboratory activation once the 12-lead electrocardiogram showed STEMI."

A STEMI Accelerator II program is under way now, he said, "extending to new regions eager to participate and including the transition from hospital and postdischarge phases of care to improve adherence and reduce preventable rehospitalizations."

The regional demonstration product is supported by the ACTION Registry-Get With the Guidelines and by Abiomed, AstraZeneca, Phillips Healthcare, and the Medicines Company. Granger has received research support from Armetheon, AstraZeneca, Bayer, Boehringer Ingelheim, Bristol-Myers Squibb, Daiichi Sankyo, the US Food and Drug Administration, GlaxoSmithKline, Janssen Pharmaceuticals, the Medicines Company, Medtronic Foundation, Novartis, Pfizer, Sanofi, and Takeda, as well as fees for consulting or other services from AstraZeneca, Bayer, Boehringer Ingelheim, Bristol-Myers Squibb, Eli Lilly, Daiichi Sankyo, Gilead, GlaxoSmithKline, Hoffmann-La Roche, Janssen Pharmaceuticals, the Medicines Company, Medtronic, the National Institutes of Health, Novartis, Pfizer, Sanofi, and Takeda. Disclosures for the coauthors are listed in the article.

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