Original Article
Care Processes Associated With Quicker Door-In–Door-Out
Times for Patients With ST-Elevation–Myocardial Infarction
Requiring Transfer
Results From a Statewide Regionalization Program
Seth W. Glickman, MD, MBA; Barbara L. Lytle, MS; Fang-Shu Ou, MS; Greg Mears, MD;
Sean O’Brien, PhD; Charles B. Cairns, MD; J. Lee Garvey, MD; David J. Bohle, MD;
Eric D. Peterson, MD, MPH; James G. Jollis, MD; Christopher B. Granger, MD
Downloaded from http://circoutcomes.ahajournals.org/ by guest on June 14, 2017
Background—The ability to rapidly identify patients with ST-segment elevation–myocardial infarction (STEMI) at
hospitals without percutaneous coronary intervention (PCI) and transfer them to hospitals with PCI capability is critical
to STEMI regionalization efforts. Our objective was to assess the association of prehospital, emergency department
(ED), and hospital processes of care implemented as part of a statewide STEMI regionalization program with
door-in– door-out times at non-PCI hospitals.
Methods and Results—Door-in– door-out times for 436 STEMI patients at 55 non-PCI hospitals were determined before (July
2005 to September 2005) and after (January 2007 to March 2007) a year-long implementation of standardized protocols as
part of a statewide regionalization program (Reperfusion of Acute Myocardial Infarction in North Carolina Emergency
Departments, RACE). The association of 8 system care processes (encompassing emergency medical services [EMS], ED,
and hospital settings) with door-in– door-out times was determined using multivariable linear regression. Median door-in–
door-out times improved significantly with the intervention (before: 97.0 minutes, interquartile range, 56.0 to 160.0 minutes;
after: 58.0 minutes, interquartile range, 35.0 to 90.0 minutes; P⬍0.0001). Hospital, ED, and EMS care processes were each
independently associated with shorter door-in– door-out times (⫺17.7 [95% confidence interval, ⫺27.5 to ⫺7.9]; ⫺10.1 [95%
confidence interval, ⫺19.0 to ⫺1.1], and ⫺7.3 [95% confidence interval, ⫺13.0 to ⫺1.5] minutes for each additional hospital,
ED, and EMS process, respectively). Combined, adoption of EMS processes was associated with the shortest median
treatment times (44 versus 138 minutes for hospitals that adopted all EMS processes versus none).
Conclusions—Prehospital, ED, and hospital processes of care were independently associated with shorter door-in– doorout times for STEMI patients requiring transfer. Adoption of several EMS processes was associated with the largest
reduction in treatment times. These findings highlight the need for an integrated, system-based approach to improving
STEMI care. (Circ Cardiovasc Qual Outcomes. 2011;4:382-388.)
Key Words: STEMI care 䡲 emergency medical services 䡲 outcomes
G
that only 4% of patients with STEMI transferred for PCI had
first door-to-device times of ⬍90 minutes.3 Although this has
improved to 17% in the latest National Cardiovascular Data
Registry Acute Coronary Treatment Intervention Outcomes
Network Registry–Get With The Guidelines (ACTION Registry, GWTG) data, shortening transfer delays remains a top
priority to improve care and, ultimately, to save lives.4
uidelines published by the American College of Cardiology and American Heart Association state that, as a
systems goal, patients with ST-segment elevation myocardial
infarction (STEMI) should be treated with primary percutaneous coronary intervention (PCI) within 90 minutes of their
first medical contact.1 Only 1200 of 5000 acute care hospitals
in the United States are capable of performing PCI, and the
logistical challenges to rapidly identify and transfer patients
from non-PCI hospitals to PCI-capable facilities are significant.2 Notably, a study of 4278 STEMI patients in the
National Registry of Myocardial Infarction (NRMI) found
Editorial see p 376
Recent national efforts have focused on prompt recognition
and treatment of STEMI, including geographic regionaliza-
Received October 18, 2010; accepted April 27, 2011.
From the Duke Clinical Research Institute and the Department of Medicine, Duke University School of Medicine, Durham, NC (S.W.G., C.B.G., F.O.,
S.O., B.L., E.D.P., J.G.J.); the Department of Emergency Medicine, Carolinas Medical Center, Charlotte, NC (J.L.G.); the Division of Cardiology, Forsyth
Medical Center, Winston-Salem, NC, (D.J.B.); and the Department of Emergency Medicine, University of North Carolina School of Medicine, Chapel
Hill, NC (S.W.G., C.B.C., G.M.).
Correspondence to Seth Glickman, MD, MBA, Department of Emergency Medicine, University of North Carolina, 170 Manning Dr, CB #7594, Chapel
Hill, NC, 27599. E-mail [email protected]
© 2011 American Heart Association, Inc.
Circ Cardiovasc Qual Outcomes is available at http://circoutcomes.ahajournals.org
382
DOI: 10.1161/CIRCOUTCOMES.110.959643
Glickman et al
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tion programs to integrate care between hospitals with and
without PCI capability to minimize time to reperfusion.5,6
Current national recommendations are that reperfusioneligible patients should be transferred to PCI centers with a
door-in– door-out time within 45 minutes.7 Previous studies
have evaluated system factors associated with faster door-todevice times at PCI hospitals.8,9 Nevertheless, there exists a
paucity of data regarding specific factors that contribute to
shorter door-in– door-out times among patients evaluated at
non-PCI hospitals, who are transferred out for primary PCI.
In 2006, the state of North Carolina implemented a statewide
STEMI regionalization program called the Reperfusion of Acute
Myocardial Infarction in North Carolina Emergency Departments (RACE).10,11 As part of this program, a coronary reperfusion plan and an overall set of recommendations was established for each hospital, including a plan for patients transferred
for primary PCI. Using data from RACE, the objectives of the
current study were to assess the association of 8 specific
prehospital, emergency department (ED), and hospital processes
of care implemented at 55 non-PCI hospitals on door-in– doorout times for patients with STEMI.
WHAT IS KNOWN
●
●
Shortening transfer delays from hospitals without
percutaneous coronary intervention (PCI) to hospitals with PCI capability remains a top priority to
improve ST-segment elevation–myocardial infarction (STEMI) care and patient outcomes.
There are few data identifying factors that contribute
to shorter door-in– door-out times among STEMI
patients evaluated at non-PCI hospitals.
WHAT THE STUDY ADDS
●
●
●
Prehospital, emergency department, and hospital
processes of care adopted as part of a statewide
STEMI regionalization program were each independently associated with shorter door-in– door-out
times for STEMI patients requiring transfer.
Adoption of several emergency medical services
care processes was associated with the largest absolute reduction in treatment times.
Integrated, system-based approaches are promising strategies with which to improve regionalized STEMI care.
Methods
This study analyzed data collected as part of the RACE regionalization
program. The design and methods for this study and data collection have
been previously published.10,11 Briefly, the RACE program was a
coordinated statewide system of STEMI reperfusion therapy that was
implemented in 2006 and comprised 65 hospitals, including 10 PCI and
55 non-PCI hospitals. The RACE program focused on the coordination
of each aspect of care from the initial emergency medical response to
reperfusion itself (eg, fibrinolytic therapy or primary PCI)—whichever
was most appropriate for a given setting. Non-PCI hospitals adopted 1
of 3 primary reperfusions strategies—fibrinolysis, transfer for PCI, or
mixed— depending on whether expedient transfer was possible according to geography, local weather, and equipment availability. The
program had institutional review board approval for analyses and
Care Processes
383
Table 1. Recommendations to Improve Door-In–Door-Out Times
Percentage of Hospitals
(n⫽55)
Before
After
Intervention Intervention
Hospital processes
Dedicated STEMI reperfusion team
with committed leadership
Hospital-specific reperfusion protocol
ED processes
System for obtaining ECGs within 10
min of ED arrival
Single call No. to activate PCI
center cardiac catheterization lab
EMS processes
EMS has equipment to perform
prehospital ECGs
Program for paramedics to recognize
STEMI on 12-lead ECGs
Use local ambulance to transport
patients within 50 miles
Keep patient on local stretcher as
part of AMI
P
Value
25.5
65.4
⬍0.001
20.0
89.1
⬍0.001
27.3
36.4
0.41
16.4
96.2
⬍0.001
74.5
88.2
0.12
45.4
80.4
⬍0.001
34.2
56.0
0.07
3.9
27.5
0.02
AMI indicates acute myocardial infarction.
publication of the findings and the study was monitored by an independent oversight board.
The RACE paramedics, nurses, physicians, administrators, and
technicians used practice guidelines, published reports, and quality
improvement principles to create a RACE operations manual containing a set of recommendations for each point in care. Recommendations were established for reducing time delays for each component of the reperfusion process: emergency medical services (EMS),
ED, catheterization laboratory, and interhospital transfer. An important principle was to create, as much as possible, a single plan for
each hospital that would be systematically applied to each patient.
These systematic plans were established and supported through
numerous local, regional, and statewide meetings and conference
calls with local leaders involved in plan components.
The RACE coordinators at each hospital were surveyed both before
and after the RACE intervention about which of the recommendations
from the operations manual were adopted. If the RACE coordinator was
unsure as to whether or not a specific recommendation had been
uniformly applied, then the answer was set to “missing.”
Study Population
The starting study population included all STEMI patients treated at 55
non-PCI hospitals both before (July 2005 to September 2005) and after
(January 2007 to March 2007) the RACE intervention (n⫽925).
Because our focus was on door-in– door-out among STEMI patients
transferred for primary PCI, patients who were not transferred for PCI
(eg, received fibrinolytic therapy) (n⫽445) or who were missing
door-in– door-out times (n⫽44) were excluded, leaving a total of 436
patients.
Statistical Analysis
Hospital-Level Process Data
Hospital care processes adopted at each hospital both before and
after the RACE intervention were abstracted from the hospital survey
of RACE administrators. Because of colinearity among use of
individual care processes, the care processes were reviewed and
organized into broad factors by the research team to form taxonomy
for classifying quality improvement efforts according to a previously
defined methodology.12 Eight individual care processes targeting
384
Table 2.
Circ Cardiovasc Qual Outcomes
July 2011
Patient Characteristics
Variable
Level
(n⫽436)
Overall
(n⫽217)
Before
(n⫽219)
After
P Value
Age, y
Median
25th
75th
436
61.00
50.00
72.00
217
62.00
51.00
72.00
219
60.00
49.00
72.00
0.5191
Sex
Male
Female
295
141
67.66
32.34
139
78
64.06
35.94
156
63
71.23
28.77
0.1096
Self-transport
Ambulance
263
171
60.32
39.22
129
86
59.45
39.63
134
85
61.19
38.81
0.3522
Systolic blood pressure, mm Hg
Median
25th
75th
434
140.00
121.00
161.00
217
142.00
123.00
161.00
217
138.00
117.00
160.00
0.2060
Pulse, bpm
Median
25th
75th
434
78.00
66.00
93.00
217
79.00
67.00
90.00
217
77.00
65.00
94.00
0.8270
Killip class
No CHF
Rales, JVD
Pulmonary edema
Cardiogenic shock
Median
25th
75th
Yes
Median
25th
75th
398
22
5
11
436
91.28
5.05
1.15
2.52
74.00
43.50
125.50
16.74
10.00
4.00
20.00
203
11
2
1
217
93.55
5.07
0.92
0.46
97.00
56.00
160.00
16.13
13.00
5.00
32.00
195
11
3
10
219
89.04
5.02
1.37
4.57
58.00
35.00
90.00
17.35
7.50
3.00
15.00
0.0527
199
134
45.64
30.73
89
81
41.01
37.33
110
53
50.23
24.20
99
22.71
43
19.82
56
25.57
4
0.92
4
1.84
0
0.00
Demographics
Presentation/physical examination
Arrival model
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First door-in to 1st door-out (among
transfer for primary PCI patients)
Prehospital ECG
Door-to-ECG (among patients
without prehospital ECG)
Transfer method to next hospital
(overall)
EMS (dispatched locally)
Ground (dispatched from
PCI center)
Air (dispatched from
PCI center)
Other
73
357
35
179
38
178
⬍0.0001
0.6749
⬍0.0001
0.0033
CHF indicates congestive heart failure; JVD, jugular venous distension.
door-in– door-out times among patients transferred for primary PCI
were organized into the following 3 categories of care: (1) EMS, (2)
ED, and (3) hospital-level (Table 1). Emergency medical services
processes included (1) having ECG equipment to do prehospital
ECGs for patients with chest pain, (2) developing a formal program
for paramedics to recognize ST-elevation on 12-lead ECGs, (3) using
local ambulances to transport patients if destination is within 50
miles, and (4) keeping patients on local ambulance stretchers. ED
processes included having a separate system for obtaining ECGs
within 10 minutes of ED arrival and using a single call number to
activate PCI center catheterization laboratory teams. Hospital processes included creation of a dedicated cross-functional RACE team
with committed leadership and establishing a single designated
hospital-specific reperfusion plan and protocol.
The 8 variables were mathematically combined and allocated to 1
of 3 categories. For each care process that was adopted within a
given category, the hospital was assigned 1 point to the category. For
example, for the hospital category, if a hospital implemented a
RACE leadership team but did not establish a designated hospitalspecific reperfusion plan, then this hospital received 1 point for this
category. Similarly, incorporation of a reperfusion plan but not a
RACE leadership team would also result in a single point. Implementation of both care processes would result in 2 points. In cases in
which the RACE administrator at a hospital was unsure whether a
hospital process had been universally adopted, the variable was set to
missing, and multiple imputation with 10 imputations was used to
impute the missing values.
Patient-Level Data
Patients who were transferred for primary PCI and had recorded
door-in– door-out times were included in the analysis, as described
above. Hospital-level data (care processes) and patient-level data
(treatment times) were merged on the basis of time period (before or
after RACE).
Descriptive Data for Individual Factors
Next, we examined the association between the individual care
process and the door-in– door-out time. The median (interquartile
range) door-in– door-out times were calculated according to whether
each care process was present or absent. Statistical analyses were
performed separately for each of the 10 imputed data sets. The 10
sets of results were then aggregated (ie, combined) into a single
result. A single probability value was generated for comparison of
door-in– door-out times for each individual factor (present or absent).
This single probability value was obtained from the 10 ␹2 values that
were generated from Wilcoxon rank-sum tests.13
We repeated the analysis described above after combining the 8
different care processes into the 3 a priori categories (EMS, ED, and
hospital). Similarly, analyses were performed separately for each of
the 10 imputed data sets. The 10 sets of results for each category
Glickman et al
Care Processes
385
Figure 2. Number and type of processes adopted at non-PCI
hospitals. This figure displays the overall number and type of
practices, including EMS, ED, and hospital, adopted by non-PCI
hospitals after the RACE program.
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Figure 1. Changes in door-in– door-out times with the RACE
intervention. Among the 436 patients in this study, median doorin– door-out times improved significantly with the RACE intervention (before: 97.0 minutes [interquartile range, 56 to 160];
after: 58.0 minutes [interquartile range, 35 to 90]; P⬍0.0001).
were then aggregated (ie, combined) into a single result. A single
probability value was obtained from the 10 ␹2 values that were
generated from Kruskal-Wallis tests.13
Median Regression
Finally, multivariable regression was used to look at the number of
processes adopted within each category with median door-in– doorout times. Median regression was used because door-in– door-out
times were not normally distributed. For the unadjusted model, the 3
categories were entered in the model as continuous variables. The
interpretation of the regression model estimate is the reduction in
median door-in– door-out time associated with a 1-point increase in
the number of care processes adopted within each category. The
model adjusted for patient-level factors known to be associated with
STEMI treatment times, including age, sex, and cardiogenic shock at
presentation. Time period (pre- versus post-RACE intervention) was
also included as a covariate. We also tested for interactions between
time and each category of care process.
A probability value of ⬍0.05 was considered significant for all tests.
No adjustments were made for multiple comparisons because all
analyses were exploratory in nature. All statistical analyses were
performed using SAS software (version 9.0, SAS Institute, Cary, NC).
Results
Patient demographics, presenting clinical characteristics, and
transfer characteristics for STEMI patients treated at the 55
non-PCI hospitals are shown in Table 2. Among the 436
patients in this study, median door-in– door-out times improved significantly with the RACE intervention (before:
97.0 minutes [interquartile range, 56 to 160]; after: 58.0
minutes [interquartile range, 35 to 90]; P⬍0.0001) (Figure 1).
Table 1 shows the proportion of non-PCI hospitals that
adopted each of the care process recommendations from the
RACE operations manual. Individual care processes are displayed according to whether they were implemented for the
prehospital, ED, or hospital settings. Overall use of the 8
recommended care processes increased significantly as part of
the RACE program. Figure 2 displays the overall number and
type of practices adopted by non-PCI hospitals after the RACE
program. In general, hospitals that adopted more EMS processes
tended to implement the recommended ED and hospital processes as well. However, there was heterogeneity among the
hospitals in terms of both the number and type of processes
adopted.
Table 3 displays the association between each of the individual care processes and median door-in– door-out times. In the
univariable analysis, each care process was associated with
significantly shorter door-in– door-out times. When the individual processes were grouped into the 3 categories (prehospital,
ED, and hospital), adoption of additional processes within each
category was associated with shorter door-in– door-out times
(P⬍0.001 for all comparisons) (Figure 3). Median door-in–
door-out times among hospitals that adopted 0, 1, 2, 3, or 4
recommended EMS care processes were 138, 102, 85, 65, and
44 minutes, respectively. Median door-in– door-out times among
hospitals that adopted 0, 1, or 2 recommended ED care processes
were 110, 75, and 54 minutes, respectively. Median door-toballoon times associated with hospitals that adopted 0, 1, or 2
recommended care hospital processes were 110, 95, and 48
minutes, respectively. Overall, if all processes were adopted,
then the category of care that was associated with the greatest
reduction in delay was EMS. That is, the adoption of all EMS
processes was associated with the shortest median treatment
times (44 minutes for hospitals which adopted all 4 EMS
processes versus 138 minutes for hospitals which adopted none)
compared with ED and hospital processes. Median-door-toballoon times associated with hospitals that adopted 0 to 2, 3 to
5, versus 6 to 8 total care processes were 119, 91, and 45
minutes, respectively.
In a multivariable analysis, each of the 3 categories of care
processes (prehospital, ED, and hospital) was independently
associated with shorter door-in– door-out times (Table 4). Adoption of 1 additional care process within each of the categories
was associated with shorter door-in– door-out times (17.7 minutes shorter for each additional hospital process, 10.1 minutes
shorter for each additional ED process, and 7.2 minutes shorter
for each additional EMS process). There was a significant
interaction between time and ED care processes (P⫽0.007),
386
Table 3.
Circ Cardiovasc Qual Outcomes
July 2011
Patient Door-In–Door-Out Times According to Hospital Processes
Before Intervention
Processes
Hospital leadership
RACE team
Single designated reperfusion plan
ED processes
Separate system for ECGs
Single call No. for PCI centers
EMS processes
Equipment for prehospital ECGs
Paramedic program for ECGs
Keep patient on local ambulance stretcher
Local ambulance for transfer ⬍50 miles
After Intervention
Yes
No
Dif, P Value
Yes
No
Dif, P Value
63 (42–96)
67 (43–104)
111 (68–192)
115 (68–192)
⬍0.001
⬍0.001
48 (32–80)
55 (36–90)
87 (58–141)
73 (35–98)
⬍0.001
0.351
79 (48–162)
79 (49–166)
110 (67–160)
108 (62–160)
0.013
0.079
40 (27–66)
55 (35–90)
74 (48–112)
150 (74–166)
⬍0.001
0.082
90 (55–153)
77 (45–122)
67 (47–87)
81 (47–125)
137 (95–235)
117 (70–213)
101 (56–166)
104 (60–191)
0.006
⬍0.001
0.024
0.040
55 (35–89)
55 (35–86)
43 (29–64)
48 (33–79)
149 (86–167)
78 (39–113)
77 (44–118)
84 (46–127)
0.002
0.189
⬍0.001
⬍0.001
Values are median (interquartile range).
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suggesting that the RACE program played an important role in
optimizing ED-related STEMI care. There was no significant
interaction with time and hospital or EMS care processes
(P⫽0.398 and 0.658, respectively).
Discussion
To the best of sour knowledge, our study is the first to
evaluate the association of specific care process and system
factors with better time to reperfusion therapy for STEMI
patients requiring transfer. First, we found that median
door-in– door-out times among transferred patients improved
nearly 30 minutes overall among STEMI patients participating in a statewide regionalization program (P⬍0.0001).
Second, we identified 8 care processes that were each
individually associated with significant reductions in doorin– door-out times among patients treated at non-PCI hospitals. In a multivariable analysis, EMS, ED, and hospital care
processes were all independently associated with shorter
door-in– door-out times, thus highlighting the need for an
integrated, system-based approach to improving STEMI
treatment times at non-PCI hospitals. Third, we identified
EMS processes as the most important single focus for
reducing transfer delay.
Hospitals without PCI capability play a critical role in
STEMI regionalization efforts, yet there are unique challenges to providing timely STEMI care at non-PCI hospitals
and rural EMS settings. Rural hospitals and EMS systems
have more limited financial and personnel resources than
Figure 3. Median door-in– door-out times for hospital, ED, and EMS. A total of 8 individual processes were grouped into hospital (n⫽2),
ED (n⫽2), and EMS (n⫽4) categories. The figure shows median door-in– door-out times according to number of quality processes
adopted within each category and in aggregate.
Glickman et al
Table 4. Change in Door-In–Door-Out Times Among
Patients Transferred for Primary PCI for Each Additional
Quality Process Adopted
STEMI Care Process
Change in
Treatment Time
95% CI
P Value
Hospital
ED
EMS
Time (before vs after)
⫺17.69
⫺10.07
⫺7.25
⫺1.86
⫺27.51 to ⫺7.88
⫺19.03 to ⫺1.12
⫺13.04 to ⫺1.45
⫺14.99 to 11.3
0.0004
0.0275
0.0148
0.7806
Times are in minutes and are adjusted for patient age, sex, and presenting
characteristics.
CI indicates confidence interval.
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their urban counterparts as well as fewer standardized hospital clinical protocols for acute myocardial infarction care.14,15
Furthermore, as illustrated by RACE, smaller non-PCI hospitals generally care for a relatively small number of STEMI
patients. This lack of experience and formal quality management may contribute to uncertainty about how to arrange for
urgent coronary interventions at tertiary centers. The RACE
program addressed these challenges by working directly with
EMS and hospital administrators, nurses, and physicians.
Although previous studies have described system factors
associated with faster door-to-device times at PCI hospitals,
comparatively fewer studies have quantified specific factors
that contribute to quicker door-in– door-out times among
patients transferred for primary PCI. Our findings are consistent with those of other regionalized systems of STEMI care.
These systems, such as the Stat Heart Program and Minneapolis Heart Institute, have used similar strategies to facilitate
timely transfer for patients with STEMI, including having a
single call activation system, use of prehospital ECGs, rapid
availability of ECGs to the ED physician, standardized
algorithms for STEMI care, and immediate access to EMS
ground transportation.16 –19 A unique feature of our study is
quantifying the improvement attributed to each process and
finding that EMS, ED, and hospital processes are all independent predictors of faster door-in– door-out times. This
finding highlights the need for a coordinated approach to
STEMI care at non-PCI hospitals.
We also found that time delays at referring institutions
accounted for approximately 50% of total door-to-device
time for transfer patients, a proportion similar to other recent
studies.19 Therefore, it is not surprising that the RACE
processes aimed at reducing transport time in the EMS (using
local stretchers and ambulances), ED (having a single call
number), and hospital (dedicated reperfusion plan and protocol) were associated with significantly shorter door-in– doorout times. In addition, hospitals that had a committed leadership team and a dedicated reperfusion protocol had the
fastest treatment times (17.7-minute reduction; 95% confidence interval, 5.0 to 27.5 for each process in multivariable
analysis). This finding reinforces the importance of hospital
leadership as well as the integrated efforts from EMS,
cardiology, nursing, and emergency medicine.
Overall, comprehensive adoption of EMS processes versus
those of the ED or hospital was associated with the shortest
median treatment times (44 minutes for hospitals that adopted
Care Processes
387
all 4 EMS processes versus 138 minutes for hospitals that
adopted none). For the 50% of patients with chest pain who
arrive to the hospital by EMS, earliest identification of
STEMI depends on EMS obtaining and accurately interpreting a prehospital ECG.20 –22 Increasing the availability of
prehospital ECG equipment and formal training programs for
paramedics to learn how to interpret the ECGs were key
components of the RACE intervention. Indeed, previous
studies have shown that paramedics with formal training can
interpret prehospital ECGs with a high degree of accuracy,
with a sensitivity ranging from 71% to 97% and a specificity
ranging from 91% to 100%.23 Expanding access to prehospital ECG capability is a critical need, particularly in underresourced or rural EMS systems.
Limitations
The present study has several limitations. First, there was no
regional or national comparator by which to judge the relative
improvement in STEMI care. The NRMI registry closed in
December 2006, before the postintervention data collection
period. Comparison with NRMI reports was further limited
by the lack of continuous data distribution availability and the
reporting of treatment times in a rolling 12-month fashion.
With these caveats in mind, a comparison with NRMI during
a similar period suggests larger improvements with the
RACE intervention. Second, because data from PCI hospitals
were obtained from a voluntary registry and non-PCI hospital
data were collected by independent study personnel, we
cannot exclude the possibility of selection bias in the reporting of patient data. Nevertheless, the data collected in this
study are consistent with overall estimates of STEMI prevalence in North Carolina. Finally, our analysis used multiple
imputations to address missing information about whether
care processes were adopted. However, the overall rate of
missing data was low, and any missing data create a bias
against finding a statistically significant association between
care processes and treatment times.
Conclusions
Prehospital, ED, and hospital processes of care were independently associated with shorter door-in– door-out times for
STEMI patients requiring transfer. Adoption of several EMS
processes was associated with the largest reduction in treatment times. These findings highlight the need for an integrated, system-based approach to improving STEMI care,
including a special focus on EMS.
Sources of Funding
This work was supported by an award from the American Heart
Association Pharmaceutical Roundtable. RACE was supported by
grants from Blue Cross and Blue Shield of North Carolina, Genentech, and Sanofi Aventis and is endorsed by the North Carolina
Chapter of the American College of Cardiology and the North
Carolina Office of Emergency Medical Services. Dr Glickman was
supported by a Physician Faculty Scholar Award from the Robert
Wood Johnson Foundation.
Disclosures
Dr Bohle received funding as a speaker for AstraZeneca (modest)
until September 2010. Dr Peterson received funding for research
grants from Schering Plough (modest), Bristol Myers Squibb (mod-
388
Circ Cardiovasc Qual Outcomes
July 2011
est), Merck/Schering Plough (modest), Sanofi Aventis (modest),
Saint Jude, Inc (modest), and funding for serving as a consultant/
participant on advisory board for Pfizer (modest) and Bayer Corporation (significant). Dr Jollis received funding for research grants
from Genentech and Sanofi Aventis (modest). Dr Granger received
funding for research grants from AstraZeneca (modest), Boehringer
Ingelheim (modest), Bristol Myers Squibb (modest), deCode Genetics (modest), GlaxoSmithKline (modest), Novartis Pharmaceutical
Co (modest), Sanofi Aventis (modest), The Medicines Company
(modest), and funding for serving as a consultant/participant on
advisory board for INO Therapeutics (modest).
13.
14.
15.
16.
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Care Processes Associated With Quicker Door-In−Door-Out Times for Patients With
ST-Elevation−Myocardial Infarction Requiring Transfer: Results From a Statewide
Regionalization Program
Seth W. Glickman, Barbara L. Lytle, Fang-Shu Ou, Greg Mears, Sean O'Brien, Charles B.
Cairns, J. Lee Garvey, David J. Bohle, Eric D. Peterson, James G. Jollis and Christopher B.
Granger
Circ Cardiovasc Qual Outcomes. published online June 28, 2011;
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