The Impact of Regional ST-Elevation Myocardial Infarction Systems of Care on the Use of Protocols and Quality The Impact of Regional ST-Elevation Myocardial Infarction Systems of Care on the Use of Protocols and Quality Improvement Initiatives in Community Hospitals Without Cardiac Catheterization LaboratoriesImprovement Initiatives in Community Hospitals Without Cardiac Catheterization Laboratories

Chauncy B. Handran, Kelsey L. Baron, Jason T. Henry, Monique G. Ross, Ross F. Garberich, David M. Larson, Scott W. Sharkey, Timothy D. HenryMinneapolis Heart Institute Foundation at Abbott Northwestern Hospital, Minneapolis, MN

Background: Since the 1990s, the ACC/AHA STEMI guidelines recommended all hospitals develop protocols and standing orders (reperfusion strategy, adjunctive medications, transfer criteria) for STEMI and monitor quality measures (time to treatment and adjunctive medications). In 2003, a Minnesota survey of hospitals without cardiac catheterization labs (CCL) found <70% of hospitals had any protocols and <50% had a formal quality improvement (QI) process and many were incomplete or inadequate. (Acad Emerg Med 2005;12:522) The 2003 survey results stimulated the development of regional STEMI systems in Minnesota. We examined the contemporary use of STEMI protocols and QI practices.Methods: In late 2009, we mailed the identical 2003 survey to emergency department medical directors and nurse mangers to all 108 Minnesota hospitals without CCL.Results: Of the 108 hospitals surveyed, 94 (87%) responded (compared to 104/111 (94%) in 2003). Survey results 2003 and 2009 are compared in the table.Conclusions: Since 2003, implementation of STEMI guidelines, protocols and standing orders in Minnesota community hospitals without CCL has dramatically improved. Hospitals without specific STEMI protocols are now <10%. The majority of STEMI patients are now transferred for PCI and most hospitals have a formal QI process. This improvement was stimulated by regional STEMI systems which support the recent class I recommendation for STEMI systems of care in the 2009 focused update of the ACC/AHA guidelines.

To assess the impact of the development of regional STEMI systems on the use of protocols, adherence to guidelines, quality assessment methods and decision making regarding treatment and transfer criteria in non-PCI hospitals throughout Minnesota

MethodsMethods

In 2009, >90% of non PCI hospitals have guidelines and standing orders to treat STEMI

A significant improvement was seen in quality improvement programs

Regional STEMI systems have improved the use of guidelines, protocols, standing orders and transfer criteria for Minnesota non PCI hospitals

Primary PCI is the optimal reperfusion strategy for STEMI, however, only 25% of US hospitals have PCI capability

AHA Mission: Lifeline program and ACC/AHA STEMI guidelines recommend non PCI hospitals participate in regional STEMI systems in order to improve quality and timely access to PCI

2003 Minnesota survey demonstrated inadequate protocols, standing orders and quality improvement initiatives in non PCI hospitals

Multiple regional STEMI systems have been developed in Minnesota since 2003

PurposePurpose

AbstractAbstract

BackgroundBackground

ResultsResults

ConclusionsConclusions

Surveys were mailed to emergency department medical directors and nurse managers in 108 Minnesota hospitals that did not have cardiac catheterization labs

The survey was identical to the 2003 survey with questions regarding protocols/guidelines, standing orders, quality assurance, decision making and indications for transfer of patients with STEMI

A second letter was sent with follow-up phone calls to hospitals not responding to the initial survey

94/108 (87%) hospitals surveyed responded

89% of responding hospitals had specific written protocols or guidelines regarding the management of STEMI patients

88% of responding hospitals had standing orders for the treatment of STEMI

Less than 10% of responding hospitals did not have protocols/guidelines or standing protocols compared to 33% in 2003

Of the responding hospitals, 67% now have triage and transfer criteria compared to only 8% of responding hospitals in 2003

In 2009 decisions were more likely to be made by the emergency physician and/or protocols and less likely by cardiologists and primary physicians

In 2009, 56% of hospitals transferred all STEMI patients compared to only 23% in 2003 (p <0.001)

SurveySurvey

31 Community hospitals without PCI capability31 Community hospitals without PCI capability

BLUE- Zone 1 (<90 minutes)BLUE- Zone 1 (<90 minutes)

RED- Zone 2 (90-120 minutes)RED- Zone 2 (90-120 minutes)

DisclosuresDisclosures

There are no conflicts of interest related to this presentation

2007 Focused Update of the ACC/AHA Guidelines for the Management of Patients with STEMI. Antman et al. (2008)2007 Focused Update of the ACC/AHA Guidelines for the Management of Patients with STEMI. Antman et al. (2008)

Quality Assessment 2003 vs. 2009Quality Assessment 2003 vs. 2009

19%

35%

46%

36%

53%50%

80%80%

85%

65%

78%

71%

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

Formal QA Monitor door-drug interval Utilize lytics Utilize aspirin Utilize beta-blockers Utilize IV Nitro

2003 2009

p=0.003

p=<0.001

p=<0.001

p=<0.001 p=<0.001

p=0.006

Guideline/Protocol 2003 vs. 2009Guideline/Protocol 2003 vs. 2009

57%

33%

9% 8%

89% 88%

9%

87%

67%

63%

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Protocol and Guidelines Standing Orders No Guidelines, Protocols,Standing Orders

Specific Protocols forTransfer to PCI

Triage and Transfer Criteria

2003 2009

p<0.001

p<0.001

p<0.001

p<0.001

p<0.001

Decision Making 2003 vs. 2009Decision Making 2003 vs. 2009

17.3%

47.1%

1.0%

34.6%

15.1%

44.1%

35.5%

4.3%

0.0%

5.0%

10.0%

15.0%

20.0%

25.0%

30.0%

35.0%

40.0%

45.0%

50.0%

Emergency MD Protocol Cardiologist Primary MD

Transfer 2003 Transfer 2009p=0.174

p<0.001

p=0.006

p=0.098