The Perfectly Integrated STEMI Model: Commentary

Author(s): 

Sameer Mehta, MD, FACC, MBA

Sameer Mehta, MD, FACC, MBA, is studying ST-elevation myocardial infarction interventions in his work with short door-to-balloon time primary PCI and the Single INdividual Community Experience REgistry for Primary PCI (SINCERE) database at 5 community hospitals in Miami, Florida, now over 365 patients. A past chief of interventional cardiology and director of the cardiovascular laboratory at Cedars Medical Center in Miami, as well as former President of the American Heart Association (Miami Dade Division), Dr. Mehta is a Voluntary Associate Clinical Professor of Medicine at the University of Miami-School of Medicine. Dr. Mehta is also president of the Indo-American Society of Interventional Cardiologists (ISIC) and a course director for LUMEN 2009: The Symposium on Optimal Treatments for Acute MI (www.lumenAMI.com). He has recently published the Textbook of STEMI Interventions (available through HMP Communications at http://www. stemiinterventions.com).

Dr. Mehta will be commenting on the important work going on around the world as societies and their hospitals struggle to educate patients about the importance of timely intervention in ST-elevation myocardial infarction, and work collaboratively to decrease the time from patient arrival to intervention.

In this issue of the Cath Lab Digest, we present an outstanding STEMI dissertation by Reneé Akins and Sharon Ellis from the WellStar Cobb Hospital in Austell, Georgia.

In my commentary of this article, I would like to emphatically state that the submitted work probably represents the best STEMI work reviewed in the Cath Lab Digest! The work represents a perfectly integrated STEMI model that enables very early triage and transfer of the STEMI patient with superb pre-hospital activation of the STEMI protocol and very effective bypass protocols that eliminate the needless duplication that occurs from the STEMI patient being transferred from the referral hospital.

This work is an ideal transition from innovative work that is being done at the Mayo Clinic, at Abbott Northwestern Hospital, and by the RACE and SOCAL investigators.1-4 These robust STEMI triage and transfer systems have created excellent models of population-based STEMI programs. These systems demonstrate a superb backward integration between the cardiovascular laboratory (CVL), emergency department (ED) and emergency medical services (EMS).

The Citywide Ottawa Protocol5 perhaps goes even a step beyond these solid programs. It has the lowest published mortality for a pure STEMI strategy that was achieved by the active role played by the advanced paramedics. These paramedics performed critical STEMI diagnosis and early management and laid the foundation for a pure STEMI strategy that was delivered to the 800,000 residents of metropolitan Toronto.

The success of these excellent STEMI programs is largely dependent on the following important principles:

1. Effective triage and transfer of STEMI patients;

2. Pre-hospital activation;

3. Effective transfer protocols;

4. Incorporation of the essential criteria recognized for reducing door-to-balloon (D2B) times.

Nevertheless, the critical and final component of the backward integration of the STEMI model that involves the 911 operator has been best captured by the investigators of WellStar Cobb Hospital. With their innovative Field STEMI project, they were able to begin the effective triage process with the 911 dispatchers – this translated to very early STEMI diagnosis and transfer to the appropriate STEMI facility and bypassing the nearest hospital.

Herein lays the most pragmatic method of eliminating the redundancies that occur from involvement of two hospitals and from the duplication of the management strategies.

In my opinion, this is the essential and missing step that is needed for deconstruction of the STEMI chaos that is inherent at most STEMI facilities. The investigators in Ottawa noted the wide disparity that occurs when a second hospital is involved in the care of the STEMI patient and found that the D2B times are greatly prolonged in this situation. Innovative work in Denmark and in other parts of Europe is essentially trying to establish similar protocols of very early activation and bypass protocols.

Importantly too, in addition to the very early activation of the STEMI process, the team at WellStar was able to incorporate various other enhancements: IT penetration to boost diagnosis and critical simplification of the admission process. Pragmatic solutions were aplenty too and included administrative support, teamwork, feedback and quality assurance.

I congratulate WellStar Cobb Hospital, its STEMI team and its administrators, for developing an excellent program – one that will go a long way in demonstrating the need for establishing a National Heart Attack Policy and STEMI centers.6

Dr. Mehta can be contacted at mehtas@bellsouth.net

References: 
<br>1. Henry TD, Sharkey SW, Burke MN, et al. A regional system to provide timely access to percutaneous coronary intervention for ST-elevation myocardial infarction. Circulation 2007 Aug 14; 116(7): 721-728. </br><br> 2. Ting HH, Rihal CS, Gersh BJ, et al. Regional systems of care to optimize timeliness of reperfusion therapy for ST-elevation myocardial infarction: the Mayo Clinic STEMI Protocol. Circulation 2007 Aug 14; 116(7):729-736. </br><br> 3. Jollis JG, Mehta RH, Roettig ML, et al. Reperfusion of Acute Myocardial Infarction in North Carolina Emergency Departments (RACE): study design. Am Heart J 2006; 152:851: e1-11. </br><br> 4. Rokos I. on behalf of the Southern California STEMI Consortium. Regional STEMI Networks in Southern California Reduce Door-to-Balloon Times: Pooled Data from 4 Counties. October 22, 2007, at Transcatheter Cardiovascular Therapeutics 2007. </br><br> 5. Le May MR, So DY, Dionne R, et al. A Citywide Protocol for Primary PCI in ST-segment Elevation Myocardial Infarction. N Engl J Med 2008; 358:231-240. </br><br> 6. Mehta S, Briceño R, Alfonso C. Practical Guidelines for Performing STEMI Interventions. In: Mehta S, ed. Textbook of STEMI Interventions. Malvern, Pennsylvania: HMP Publications; 2008. </br><br>

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