Optimizing prehospital ST-segment elevation myocardial infarction pathways, medical dispatch types and acute
Emilie Lesaine1, Sahal Miganeh-Hadi1, Mathilde Borg2
1CIC-EC 14-01, Inserm U1219, BPH, Institut Bergonié, CHU de Bordeaux, 33000 Bordeaux, France.
Insights
Efficient emergency medical services are vital for ST-segment elevation myocardial infarction (STEMI) patients. Mistriage and delays in emergency departments (EDs) significantly hinder optimal care pathways, impacting patient outcomes.
Area of Science:
- Cardiology
- Emergency Medicine
- Health Services Research
Background:
- Effective emergency medical services (EMS) management is critical for ST-segment elevation myocardial infarction (STEMI) patients.
- Directing STEMI patients to the fastest pathway, bypassing emergency departments (EDs) when appropriate, improves outcomes.
- Analysis of EMS pathways can identify improvements in patient care and outcomes.
Purpose of the Study:
- To describe initial STEMI pathways focusing on dispatch management.
- To analyze acute management times and revascularization strategies for different STEMI pathways.
- To compare pathways: medical intensive care unit, PCI-capable hospital ED, and PCI-incapable hospital ED.
Main Methods:
- Multicentre retrospective study of 8344 adult STEMI patients (2017-2021).
- Inclusion criteria: STEMI diagnosis by emergency physicians within 24 hours of symptom onset.
- Primary endpoint: proportion of patients missing the fastest pathway due to mistriage; Secondary endpoints: time intervals from symptom onset to balloon inflation.
Main Results:
- 57% of patients followed the fastest pathway; 21% missed it due to mistriage.
- Median ED time was 78 minutes (PCI-capable) vs. 109 minutes (PCI-incapable).
- Only 11% received fibrinolysis in PCI-incapable EDs; 79% exceeded 120 minutes for primary PCI.
Conclusions:
- Findings highlight the need for improved dispatch accuracy and dedicated STEMI networks in French EDs.
- Time lost due to ED delays or mistriage represents significant missed opportunities for STEMI patients.
- The role and effectiveness of fibrinolysis in STEMI management require re-evaluation.
Background:
Efficient management of emergency medical services is crucial, particularly during dispatch, to direct patients with ST-segment elevation myocardial infarction (STEMI) to the fastest medical intensive care unit pathway, bypassing emergency departments (EDs) at hospitals capable and incapable of percutaneous coronary intervention (PCI). A detailed analysis of emergency pathways may reveal key actions to improve patient care and outcomes.
Aim:
To describe the initial STEMI pathways, with a focus on dispatch management, acute management times and revascularization strategies for each pathway: medical intensive care unit; ED at PCI-capable hospital; and ED at PCI-incapable hospital.
Methods:
Multicentre retrospective study of all adult patients with STEMI diagnosed by emergency physicians within 24hours of symptom onset, and managed in any of the 19 medical intensive care units, seven PCI-capable hospitals and 25 PCI-incapable hospitals in the Aquitaine region from 1st January 2017 to 31st December 2021. The primary endpoint was the proportion of patients who missed the fastest pathway because of mistriage. The secondary endpoints focused on time intervals from symptom onset to balloon inflation.
Results:
The study sample comprised 8344 patients: 57% (95% confidence interval [CI] 56-58%) followed the fastest pathway; and 21% (95% CI 20-22%) missed it because of mistriage. The median (interquartile range) time spent in the ED was 78 (48-150) minutes at PCI-capable hospitals and 109 (71-178) minutes at PCI-incapable hospitals. Only 11% (95% CI 10-12%) of patients managed in EDs at PCI-incapable hospitals received fibrinolysis, and 79% (95% CI 76-82%) exceeded the recommended 120minutes from first medical contact to balloon for the primary PCI strategy.
Conclusions:
These findings should prompt French policymakers to improve the accuracy of dispatch and develop specific STEMI networks in EDs. Time lost in EDs or because of mistriage represents a considerable loss of opportunity for patients. The role of fibrinolysis should be reconsidered.
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