Journal Wrap: Should We Bypass the ER in STEMI?
When a patient presents at the hospital with STEMI, time is of the essence. Given the various system components that can delay time to reperfusion, several strategies have been proposed to optimize and shorten reperfusion times. In an analysis of PCI-capable hospitals participating in the ACTION Registry-Get With The Guidelines-Mission: Lifeline program, Akshay Bagai, MD, MHS, and colleagues questioned whether bypassing the emergency department with direct transport to the cath lab would accomplish this goal.
According to data from Mission: Lifeline (an initiative to improve the quality of care and outcomes for patients with STEMI and health care system readiness and response to STEMI), uptake of the ED-bypass strategy has been relatively low: compared to the 11,265 patients who underwent ED-evaluation, only 1,316 (10.5%) of patients bypassed the ED, although it has steadily increased since 2008.
ED-bypass was more likely to occur during working hours rather than off-hours (18.3% vs. 4.3%), and these patients were less likely to have had a previous MI and HF or cardiogenic shock on presentation. Presentation during working hours was the factor that most strongly influenced the use of ED-bypass—a finding, the authors wrote, "that is likely explained by the proximity and availability of the primary PCI team when the hospital is first notified of the incoming STEMI patient by EMS."
Current ACCF/AHA guidelines recommend that device activation occur within 90 minutes of first medical contact (FMC) by emergency service providers for STEMI patients being transported to a PCI-capable hospital. In the current study, the time from FMC to hospital arrival was longer with ED-bypass, but the median FMC-to-device activation time was 20 minutes shorter, compared with ED-evaluation. After excluding high-risk patients and those with documented non-system reasons for delay in PCI from the analysis, the median FMC-to-device time remained shorter and guideline-recommended time was achieved more frequently among ED-bypass patients.
In-hospital mortality rates were lower among ED-bypass patients (2.7% vs. 4.1%; p = 0.01), however the adjusted mortality risk was similar between the two groups (OR = 0.69; 95% CI 0.45-1.03; p = 0.07), showing that bypassing the ED had no adverse impact on patient outcomes.
Although their study presented some evidence for the increased utilization of ED-bypass, Dr. Bagai and colleagues listed some factors that need to be addressed before ED-bypass can be more widely adopted across the United States. Among these:
- increased use of pre-hospital ECG among EMS-transported patients;
- better infrastructure to support transmission of pre-hospital ECGs (and to avoid false activation of the cath lab);
- the lack of reliable triage protocols for ED-bypass to help EMS providers identify appropriate patients; and
- the risk of performing ED-bypass PCI off-hours, without the primary PCI team present.
In an accompanying editorial, Elliott M. Antman, MD, also questioned what the next phase of optimizing STEMI systems will look like. Rather than focusing on a single component of system delay like ED-bypass, he suggested, PCI-capable centers should engage in comprehensive care improvement programs that address all steps between admission and discharge. After all, Dr. Antman asked, "How can we reconcile the fact that ED-bypass was associated with a lower system delay but did not translate into improved in-hospital outcomes?
"Ultimately, we need to see a reduction in total ischemic time, which involves recognition of STEMI symptoms by patients," he wrote, adding that health care providers should treat office visits with high-risk patients as teachable moments to review and rehearse the appropriate actions to be taken when the symptoms of STEMI appear. "Even the best organized system will not work effectively if patients delay in recognizing their symptoms and 50% of STEMI patients are not transported by EMS," he concluded.
Antman EM. Circulation. 2013 June 20. [Epub ahead of print]
Bagai A, Jollis JG, Dauerman HL, et al. Circulation. 2013 June 20. [Epub ahead of print]
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