A Pilot Rapid Triage Process for Prehospital ST-Segment Myocardial Infarction Patients Direct to the Catheterization
Matthew J Levy1,2, Asa Margolis1,3, Victoria Collins1
1Department of Emergency Medicine, Johns Hopkins University School of Medicine, Baltimore, USA.
Insights
Implementing a "Direct to Lab" workflow significantly reduced treatment times for ST-elevation myocardial infarction (STEMI) patients arriving via Emergency Medical Services (EMS). This streamlined approach, prioritizing rapid percutaneous coronary intervention (PCI), improved key metrics without increasing complications.
Area of Science:
- Cardiology
- Emergency Medicine
- Health Systems Management
Background:
- ST-elevation myocardial infarction (STEMI) requires rapid treatment with primary percutaneous coronary intervention (PCI) to minimize morbidity and mortality.
- Reducing total ischemic time is critical, with first-medical-contact-to-balloon (FMCTB) time serving as a key performance indicator.
- Optimizing workflows for Emergency Medical Services (EMS) STEMI patients presenting to the Emergency Department (ED) is essential for timely reperfusion.
Purpose of the Study:
- To evaluate the impact of a pilot "Direct to Lab" (DTL) workflow on reducing FMCTB times for EMS-STEMI patients.
- To compare treatment times and complication rates between the DTL workflow and the standard ED triage process.
Main Methods:
- A pre/post analysis was conducted at a community hospital, comparing a DTL workflow pilot to the standard STEMI patient management.
- Data from the hospital's STEMI database (2/1/2021–3/1/2024) included EMS STEMI alert activations.
- Inclusion criteria focused on hemodynamically stable STEMI patients arriving via EMS during weekday daytime hours; exclusions applied to off-hours arrivals or those requiring extensive ED stabilization.
Main Results:
- The DTL workflow resulted in significantly faster times: 8.4 minutes faster in the ED, 19.6 minutes faster for door-to-balloon (DTB), and 24.3 minutes faster for FMCTB.
- Complication rates were comparable between the DTL and standard workflow groups.
- The primary reasons stable patients did not utilize DTL included the need for further clinical evaluation or lab unavailability.
Conclusions:
- The pilot "Direct to Lab" workflow significantly reduced total ED, DTB, and FMCTB times for EMS-STEMI patients.
- This streamlined approach demonstrated patient-centered benefits without an increase in procedural complications.
- Effective collaboration between EMS, ED, and Interventional Cardiology is crucial for optimizing STEMI care pathways.
Abstract:
Background Rapid treatment of ST-elevation myocardial infarction (STEMI) patients with primary percutaneous coronary intervention (PCI) significantly reduces morbidity and mortality rates. Recent studies emphasize the importance of reducing total ischemic time, making first-medical-contact-to-balloon (FMCTB) time a key performance indicator. To improve FMCTB times in patients brought to the Emergency Department (ED) by Emergency Medical Services (EMS), we implemented a "Direct to Lab" (DTL) workflow during the following conditions: weekday daytime hours, when the lab is fully staffed, and for hemodynamically stable STEMI patients presenting via EMS. Methods We performed a pre/post analysis following the implementation of a pilot workflow for EMS STEMI patients to be rapidly triaged to the cardiac catheterization lab as compared to those patients who underwent the standard workflow before program implementation at a 225-bed community hospital in a suburban setting in Maryland, USA. The hospital's STEMI database was queried from 2/1/2021 through 3/1/2024, including all EMS STEMI alert activations during the study period. Cases were excluded if the patient arrived after program operating hours, declined PCI, or if clinical circumstances (such as cardiac arrest or the need for other resuscitative or diagnostic interventions) necessitated additional ED stabilization before PCI. Results A total of 30 patients met the inclusion criteria. The analysis revealed significantly reduced ED, door-to-balloon (DTB), and FMCTB times for patients under the "Direct to Lab" workflow, including a total ED time of 8.4 minutes faster, an average DTB time of 19.6 minutes faster, and an average FMCTB time of 24.3 minutes faster than those triaged via the standard workflow. Complication rates were similar among both groups. The most common reason that stable patients were not taken directly to the lab was the need for further clinical evaluation before cardiac catheterization or the lab not being immediately available. Conclusion In this pilot single-center analysis, STEMI patients who were expeditiously triaged "Direct to Lab" experienced significantly lower total ED, DTB, and FMCTB times with no difference in procedural complications. This study highlights the patient-centered benefits of a robust collaboration between EMS, ED, and Interventional Cardiology teams.
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