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A system of care for STEMI
Reducing time to reperfusion for patients with
ST-segment elevation myocardial infarction
Foreword
On 22 September 2011, the National Heart Foundation of Australia hosted a roundtable
discussion on Reducing systems delay for patients with ST-segment elevation myocardial
infarction (STEMI).
Attendees of the roundtable discussion included representatives from:
• state and territory cardiac and cardiovascular clinical networks
• the Australian Commission on Safety and Quality in Health Care
• ambulance, emergency and cardiology national peak bodies.
This consensus statement reflects the key outcomes from the roundtable discussion, with a
particular focus on the core principles that underpin systems of care that deliver prompt access
to reperfusion therapy for patients with STEMI. These core principles have been categorised under three key themes:
1. Fostering a system of care
2. Activating a system of care
3. Supporting a system of care.
Throughout this document, Case in point examples are provided from across state and territory jurisdictions that highlight
the core principles described. The Heart Foundation recommends that the core principles described within this consensus
statement should underpin all system-based strategies to achieve prompt reperfusion for patients with STEMI.
Professor James Tatoulis MB, BS, MS, MD, FRACS, FCSANZ
Chief Medical Advisor
National Heart Foundation of Australia
Any enquiries regarding this report should be directed to:
Christopher Poulter
Policy Project Officer
National Heart Foundation of Australia
Email: [email protected]
© 2012 National Heart Foundation of Australia ABN 98 008 419 761
This work is copyright. No part of this publication may be reproduced in any form or language without prior written permission
from the National Heart Foundation of Australia (national office). Enquiries concerning permissions should be directed to
[email protected].
ISBN 978-1-74345-018-5
PRO-135
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A system of care for STEMI
National Heart Foundation of Australia
Contents
Recommendations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2
Background: a system of care for patients with STEMI . . . . . . . . . . . . . . . . . . . . . . . . . . 3
1. Fostering a system of care . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4
Clinical leadership and collaboration across traditional service-delivery boundaries . . . . . . . . . . . . . . 4
2. Activating a system of care . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5
Early patient recognition of warning signs and calling Triple Zero (000) . . . . . . . . . . . . . . . . . . . . . . . 5
Earliest possible diagnosis of STEMI . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6
Prioritising catheterisation laboratory access for patients with STEMI . . . . . . . . . . . . . . . . . . . . . . . . . 6
Prioritising ‘door-in/door-out’ patients with STEMI . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8
3. Supporting a system of care . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10
An appropriately trained workforce and access to cardiology support . . . . . . . . . . . . . . . . . . . . . . . . 10
Performance monitoring and feedback mechanisms informing systems of care . . . . . . . . . . . . . . . . . 10
Conclusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13
Acknowledgements . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14
Appendix . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15
Glossary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17
National Heart Foundation of Australia
A system of care for STEMI
1
Recommendations
The recommendations outlined in Table 1 are based upon the set of core principles primarily informed by the
roundtable discussion Reducing systems delay for patients with ST-segment elevation myocardial infarction (STEMI).
These principles and recommendations have been categorised under three key themes:
1. Fostering a system of care
2. Activating a system of care
3. Supporting a system of care.
Table 1: Themes, principles and recommendations
Theme
Principle
Recommendation
1. Fostering a
system of care
Clinical leadership and
collaboration across
traditional service-delivery
boundaries.
1.1 Support state/territory clinical networks to continue leading the
development of local systems of care.
Early patient recognition of
warning signs and calling
Triple Zero (000).
2.1 Implement public awareness–raising programs to educate
the community on early recognition of warning signs and the
importance of calling Triple Zero (000) without delay.
Earliest possible diagnosis of
STEMI.
2.2 Train all paramedic officers in 12-lead electrocardiogram
(ECG) acquisition, STEMI interpretation and digital
transmission.
2. Activating a
system of care
1.2 Closely engage clinical networks in the development and
implementation of future national quality improvement strategies
relating to STEMI and acute coronary syndromes (ACS).
Prioritising catheterisation
2.3 Develop systems within hospitals capable of percutaneous
laboratory access for patients
coronary intervention (PCI) to minimise delay to
with STEMI.
catheterisation laboratory activation following diagnosis of
STEMI.
2.4 Establish system protocols and pathways prioritising ‘door-in/
door-out’ (DIDO) patients with STEMI for rapid transfer for
primary PCI, where clinically appropriate.
3. Supporting a
system of care
Appropriately trained
workforce with access to
on-call cardiology support.
3.1 Develop and implement training programs that provide
health professionals with the expertise and confidence to
deliver fibrinolysis in areas where primary PCI is unavailable
within optimal timeframes, supported by access to a 24-hour
cardiology telephone advice service.
Performance monitoring
and feedback mechanisms
informing systems of care.
3.2 Establish a national ACS registry, including universal data
definitions for STEMI.
3.3 Develop a national set of indicators and standards to evaluate,
inform and improve systems of care.
Call to action
The Heart Foundation strongly encourages government, policy-makers, clinical networks and clinicians to
adopt these core principles where gaps are identified by implementing the recommendations described.
2
A system of care for STEMI
National Heart Foundation of Australia
Background: a system of care
for patients with STEMI
An ST-segment elevation myocardial infarction (STEMI)
(acute heart attack) requires prompt restoration of blood
flow to the affected area of heart muscle by either
primary percutaneous coronary intervention (PCI) or
fibrinolytic therapy. Prompt reperfusion minimises the
likelihood of death or long-term disability in these
patients.
Systems of care facilitating prompt reperfusion for
patients with STEMI are traditionally developed at a
jurisdictional level, congruent with local circumstances.
Broadly speaking, a ‘system-based’ approach to
reperfusion can be defined as a coordinated and
seamless series of activated events that transcend
traditional service-delivery boundaries. A system of
care encompasses the system-based principles of
synergy, integration, collaboration and networks.1 The
effectiveness of a system of care for STEMI is significantly
influenced by the following variables:
• an early diagnosis
• communication between services
• collaboration across service boundaries
• in-hospital response processes.2
Some regions within Australia are currently operating
effective systems of care for STEMI, led by cardiacfocused clinical networks and championed by clinical
leaders at the practice level.
This consensus statement describes the core principles
that underpin quality of care for patients with STEMI, and
draws upon the experiences from across jurisdictions.
(See the appendix for an overview of the components
of a system of care for STEMI.)
• leadership, support and guidance from clinical and
local health area networks
• patient recognition of symptoms and calling
Triple Zero (000)
National Heart Foundation of Australia
A system of care for STEMI
3
1. Fostering a system of care
Collaboration and integration across service boundaries
are core principles that underpin an effective system of
care for STEMI. Collaboration in particular is essential
to effectively implement rapid reperfusion strategies.
Clinical networks will need to foster the necessary
collaboration for STEMI systems of care, particularly
across:
Clinical leadership and collaboration
across traditional service-delivery
boundaries
Within Australia, clinical networks (i.e. cardiac,
emergency) with a focus on acute coronary syndromes
(ACS) exist across a number of jurisdictions (see Case
in point, below). The importance of clinical networks
is increasingly being recognised. It is clear they have
significant influence in improving the overall quality of
care received by patients with STEMI by:
• health service area boundaries:
– local health area networks
– Local Hospital Networks
– primary healthcare organisations (e.g Medicare
Locals)
• fostering awareness, communication and partnerships
across service-delivery boundaries (i.e. ambulance,
emergency, cardiology)
• health service delivery boundaries:
• engaging policy-makers and key stakeholders by
contributing to state-wide service planning, policy and
clinical reforms
– inter-service (i.e. ambulance, emergency
departments)
– intra-hospital (i.e. emergency and cardiology)
• promoting links between rural, remote and metropolitan
health services
– inter-hospital (i.e. geographical boundaries
such as rural and metropolitan).
• engaging clinical leaders at the service-delivery level to
support the implementation of evidence-based care
• challenging clinicians to consider their current
practice processes
• contributing to clinical networking at a
national level.
Case in point
State and territory
clinical networks:
fostering better
systems of care
NT (Network currently
in development)
QLD State-wide Cardiac
Clinical Network
NSW Agency for Clinical
Innovation – Cardiac
Network
VIC Cardiac Clinical
Network
WA Cardiovascular
Health Network
4
SA State-wide Cardiology
Network and Integrated
Cardiovascular Clinical
Network CHSA
A system of care for STEMI
• Leadership: Developing
reperfusion strategies,
appropriate to local
geographical circumstances.
• Collaboration: Bringing together
multi-disciplinary expertise
across cardiology, emergency,
ambulance, rural, nursing,
general practice, allied health
and policy.
• Clinical governance:
Establishing sub-committees
and working groups to develop
targeted system strategies across
various settings (rural, regional
and metropolitan).
National Heart Foundation of Australia
2. Activating a system of care
Early patient recognition of warning
signs and calling Triple Zero (000)
A prolonged patient delay time, the time from the onset
of warning signs of heart attack to the activation of
emergency medical services (i.e. calling Triple Zero),
is a significant issue within Australia. Recent data
estimates the median patient delay for patients who
present with chest pain is between four and five hours.3
Early patient recognition of symptoms and subsequent
prompt activation of the ambulance by calling Triple
Zero (000) are vital for getting the patient ‘into the
system’.4 However, currently within Australia, only about
50% of patients presenting with chest pain to emergency
departments (ED) arrive by ambulance.3
The Heart Foundation, through the ‘Warning Signs’
strategy, has invested significant funds to raise awareness
of the warning signs of a heart attack and the importance
of calling Triple Zero (000), in a concerted effort to
reduce patient delay (see Case in point, below).5 As
the shift across jurisdictions moves towards a systems
approach to STEMI care, it is crucial that people with
warning signs of heart attack engage the ambulance
service (as an entry point) to ensure they receive the best
possible care.
Case in point
‘Will you
recognise your
heart attack?’
campaign5
• Aboriginal and Torres Strait Islander peoples
• culturally and linguistically diverse (CALD)
communities.
The campaign has significantly increased awareness
of both typical and less common heart attack warning
signs within the community.
The Heart Foundation’s ‘Will you recognise your heart
attack?’ campaign aims to increase public awareness
and knowledge about the warning signs of heart attack.
It also encourages people to respond promptly by
calling Triple Zero (000). Key target groups include:
• men and women aged 45 to 65
•p
eople with a known history of coronary heart
disease, and their families
National Heart Foundation of Australia
The Heart Foundation has engaged a number of EDs to
act as ‘sentinel sites’ to assist in monitoring the impact
of the campaign. In particular, ‘time from symptom
onset (TFSO) to ED presentation’ data (determined at
ED triage) has been reliably monitored and collected.
The median ‘TFSO to ED presentation’ for patients
presenting with chest pain is four to five hours, and
more than 30% of patients present after eight hours.3
These outcomes highlight that more work needs
to be done to improve patient response time on a
population level. Data for the campaign are also
being sourced from ambulance services to monitor
the number of calls and dispatches for patients with
suspected heart attack.
A system of care for STEMI
5
Earliest possible diagnosis of STEMI
Delivering optimal care to patients with STEMI depends
on an early diagnosis, which requires the application
and analysis of a 12-lead electrocardiogram (ECG).
Within Australia, the clinical and time-saving benefits
of paramedics conducting a 12-lead ECG in the prehospital environment, as part of a planned reperfusion
system, have been well described (see Case in point,
opposite).6,7
Many ambulance services across Australia use 12lead ECG technology as part of their clinical protocol
to assess patients with signs/symptoms of a suspected
STEMI. To date, this clinical practice has largely been
limited to intensive care paramedic officers. Appreciably,
ambulance services recognise the value of 12-lead ECG
application in the pre-hospital space, and some services
plan to extend this practice to all paramedic officers.8,9
As the demand for ambulance care increases and
the practice of pre-hospital 12-lead ECG broadens,
training for all paramedic officers in ECG acquisition
and interpretation will be essential to ensure a timely
diagnosis. Overseas research demonstrates that, with
appropriate training, paramedics are able to identify
STEMI using ECG with accuracy comparable to that of
cardiologists and ED physicians.10,11 Anecdotal reports
from South Australia and Queensland also support this
conclusion.12
6
Furthermore, validated 12-lead ECG units with
algorithmic interpretation functionality should be
considered to provide additional support to paramedics
and other health professionals in the assessment of
STEMI.13
Prioritising catheterisation laboratory
access for patients with STEMI
Systems within PCI-capable facilities have been
developed to minimise delay to catheterisation laboratory
activation, following a diagnosis of STEMI. The door to
balloon (D2B) initiative in the United States identified
several core strategies that reduce catheterisation
laboratory activation times in PCI-capable hospitals:
• ED activation of the catheterisation laboratory
• single call activation of the catheterisation laboratory
• prompt data feedback to the ED
• senior management commitment (both ED and
cardiology)
• team-based approach.14
In Australia, considerable improvements have been made
across some jurisdictions in reducing in-hospital delay
times by implementing these strategies.15 However, broad
variations in practice still exist, indicating opportunities
for more widespread implementation of these practices
locally.16
A system of care for STEMI
National Heart Foundation of Australia
Case in point
MonAMI 12-lead
ECG field triage
strategy6
The MonAMI protocol, developed by MonashHEART
and Ambulance Victoria, is a systematic strategy that
aims to deliver rapid reperfusion (primary PCI) for
patients with STEMI. The protocol consists of:
• 12-lead ECG performed by a paramedic in
the field
•1
2-lead ECG electronically transmitted to receiving
hospital ED
•d
ecision to proceed to primary PCI made by the
emergency physician within 5 minutes of the ECG
being received
•d
irect activation of the catheterisation laboratory
team prior to patient arrival.
Time (median)
NonMonAMI
MonAMI
p value
D2B
102.5 mins
56.5 mins
p < 0.001
Time at
scene
20.3 mins
24.0 mins
p > 0.001
Transport
time
16.5 mins
17.8 mins
p = 0.31
Field 12-lead ECG and pre-hospital activation of
the catheterisation laboratory team significantly
improves D2B times, resulting in a greater proportion
of patients achieving guideline-recommended inhospital treatment times.
National Heart Foundation of Australia
A system of care for STEMI
7
Prioritising ‘door-in/door-out’ patients
with STEMI
Significant challenges exist to reduce delays for patients
with STEMI who present at a non-PCI facility and require
prompt transfer to a PCI facility. This process is commonly
termed the ‘door-in/door-out’ (DIDO) time. Expert
consensus indicates a DIDO time of 30 minutes or less is
optimal.17 Patients often do not receive the rapid attention
they need for prompt transfer due to:
• lack of urgency by staff in identifying the requirement for
prompt transfer
• lack of established communication and referral channels
between ‘STEMI referring’ and ‘STEMI receiving’
hospitals, resulting in prolonged delay in the decision to
transfer patients
8
Unfortunately, DIDO times are not currently reported
within Australia. A recent analysis of DIDO processes
within the United States showed the majority of
patients with STEMI who require transfer from a non-PCI
facility to a PCI facility are not transferred within clinically
optimal timeframes.18
Patients diagnosed with STEMI, who require prompt transfer
to a PCI facility, must be given Triple Zero (000) priority by
ambulance services. Additionally, hospital-specific DIDO
protocols should be established to facilitate the prompt and
systematic transfer of patients with STEMI from a non-PCI
facility to a PCI facility. Similarly to D2B protocols, DIDO
protocols should incorporate:
• clinical indications for patients with STEMI who are
considered candidates for immediate transfer
• lengthy administrative processes in arranging transfer
• established communication channels and formal referral
pathways between the referring and receiving centre
• resistance from the receiving hospital (i.e. no capacity to
accept the patient for reasons such as no available beds)
• tools for facilitating the transfer process (i.e. DIDO
transfer checklist).19
• challenges faced by the ambulance service to prioritise
DIDO patients with STEMI.
Hospital and ambulance staff should receive specific
education of the STEMI DIDO protocol to ensure it is
routinely followed (see Case in point, opposite).
A system of care for STEMI
National Heart Foundation of Australia
Case in point
Improving DIDO
time for transfer
of patients with
STEMI19
Joondalup health campus, a peripheral metropolitan hospital in Western Australia,
developed and implemented a specific protocol (in conjunction with Sir Charles
Gardner Hospital, a tertiary PCI centre) for patients with STEMI requiring transfer for
primary PCI. The protocol includes:
• performing the first ECG on the ambulance stretcher
• ensuring first contact is with the on-call cardiologist for transfer confirmation (i.e.
bypassing junior medical staff)
• treating patients with STEMI on the stretcher while immediate transfer is arranged
• a medication checklist of standard treatments for rapid administration by nursing staff
• educating paramedics, nursing staff, cardiology and ED medical staff to ensure
adherence to the protocol.
Time (mean ± standard deviation)
Pre-protocol
Post-protocol
p value
D2B
137 ± 25 mins
107 ± 22 mins
p < 0.001
DIDO
66 ± 25 mins
36 ± 16 mins
p < 0.001
National Heart Foundation of Australia
A system of care for STEMI
9
3. Supporting a system of care
An appropriately trained workforce
and access to cardiology support
A functioning system of care for STEMI requires an
appropriately skilled workforce to effectively implement
the system across various settings. Significant barriers to
delivering prompt STEMI care, particularly within some
rural and remote areas of Australia, have been identified,
including:
• limited clinical expertise
• low patient numbers (i.e. lack of consistent exposure to
patients with suspected STEMI)
• a lack of confidence among healthcare workers.20
Healthcare workers who are involved in the management
of patients presenting with chest pain (including
paramedics, general practitioners and registered nurses
across various settings) should confidently and readily be
able to:
• a cquire a 12-lead ECG reading and identify a
possible STEMI
• provide appropriate pain relief and anticoagulation
• a ccess cardiology support for guidance and confirmation
of ECG diagnosis and/or management
• a dminister a fibrinolytic agent (as indicated by local
protocols)
•o
rganise appropriate and timely patient transfer,
supported by formal referral pathways (where indicated).
Pre-hospital fibrinolysis should be considered as a
component of a comprehensive reperfusion strategy,
particularly in areas where primary PCI is not readily
accessible within optimal timeframes.*,21 Healthcare
workers involved in the acute management of patients
with STEMI require the appropriate skills to promptly
provide these patients with the best possible care. Training
programs that are designed to equip healthcare workers
with the necessary skills, such as administering fibrinolysis,
need to be implemented, particularly across rural and
remote settings.
Such training programs have been highly effective in
safely reducing time to reperfusion for patients within rural
settings where primary PCI is not optimally accessible
(see Case in point, opposite).22 In addition, prompt oncall access to clinical support from a cardiologist (i.e. a
designated telephone service) is vital to provide real-time
support to clinicians, particularly within regions where
patients with STEMI may not commonly present.
Finally, a pre-hospital fibrinolysis strategy should be
supported by strong referral pathways and linkages to PCI
facilities to allow prompt rescue PCI if required.
Performance monitoring and feedback
mechanisms informing systems of care
Monitoring current practice is vital to assess trends in
quality of care. A national ACS registry would enable
system performance to be monitored, which ultimately
would lead to improvements in the care of patients with
STEMI. Previous clinical registry initiatives such as the
Global Registry of Acute Coronary Events (GRACE), the
Acute Coronary Syndrome Prospective Audit (ACACIA)
and current initiatives such as CONCORDANCE (see
Case in point, page 12), have provided some important
insights into the gaps in practice, particularly regarding
system care processes for patients with STEMI.23 The
national Snapshot ACS initiative (May 2012) has also
collected important data on services, workforce and
systems of care. This data will provide important
information about real-time gaps in service delivery
and show how different models impact upon patient
management.24 Unfortunately, all these initiatives are
restricted in the value they can add over a sustainable
period given their time-limited nature and relatively
small sample size.
* The 2011 addendum to the National Heart Foundation of Australia/Cardiac Society of Australia and New Zealand Guidelines for the Management of Acute Coronary
Syndromes (ACS) 2006 recommends the initiation of pre-hospital fibrinolysis by appropriately trained healthcare workers in settings where PCI is unavailable. The
optimal time period to reperfusion for STEMI is within 60 to 90 minutes of symptom onset. Therefore, consideration of the most appropriate and readily available
reperfusion therapy is paramount to reducing delay.
10
A system of care for STEMI
National Heart Foundation of Australia
Case in point
Up-skilling
paramedics to
deliver pre-hospital
fibrinolysis22
In 2008, the Ambulance Service of NSW successfully implemented a ‘proof-of-concept’ project within
a rural region of NSW. The aim was to test the ability to implement a proven intervention for STEMI into
pre-hospital clinical practice. Training was provided to 130 paramedics to manage patients with STEMI
more effectively through:
•p
atient assessment and acquisition and transmission of 12-lead ECG
• c linical decision-making and practice to support administration of thrombolytics and anticoagulants.
Safely delivering reperfusion therapy faster
•P
atients receiving fibrinolysis within 60 minutes from symptoms onset: 26.8%
•P
atients receiving fibrinolysis within 120 minutes from symptoms onset: 73.2%
Of 94 patients diagnosed with STEMI, 54 were indicated for pre-hospital fibrinolysis. With no adverse patient
outcomes reported to date (until February 2012), this project has demonstrated that, with appropriate training,
fibrinolysis can be safely and effectively incorporated into paramedic clinical practice. As a result, the quality
of care received by patients with STEMI, particularly across rural settings, has improved. The rate of rescue PCI
was 19%, highlighting the need for strong referral pathways to PCI hospitals to facilitate rescue PCI (e.g. the
‘drip and ship’ model operating in Queensland).
National Heart Foundation of Australia
A system of care for STEMI
11
A universal set of clinical indicators and standards is
required to support a national ACS registry. A key system
indicator for delivery of reperfusion therapy is ‘time to
treatment’. Ideally, this should encompass the various
stages across the time to treatment continuum, consistent
with clinical guideline recommendations.21 This includes:
• time from symptom onset to first medical contact
Case in point
CONCORDANCE
registry26
• time from first medical contact to fibrinolysis
• time from first medical contact to primary PCI
• time from arrival at PCI referral centre to discharge from
PCI referral centre (DIDO time)
• time from arrival at PCI referring centre to primary PCI.
The development of appropriate standards for STEMI
care should build upon the preliminary work conducted
by the Australian Institute of Health and Welfare.25
Clinical networks, professional representative bodies
and clinicians will need to reach a consensus to define
the key points across the time to treatment continuum
(i.e. defining ‘first medical contact’) to ensure universal
consistency of data collection and reporting. As
previously discussed, cardiac-focused clinical networks
should have significant input into the development of
system and clinical indicators and standards for STEMI, as
well as the ongoing monitoring of performance.
As evidenced by current system practices across
jurisdictions, a concurrent focus on organisational
structure and a cross-sectoral approach are important
when implementing clinical standards. To minimise the
collection and reporting burden, data collection should
be integrated into existing networked system databases
(e.g. ambulance and ED information systems) and other
clinical information systems as they emerge.
The Cooperative National Registry of Acute Coronary
Care, Guideline Adherence and Clinical Events
(CONCORDANCE) was established in 2009. From a
system of care perspective, CONCORDANCE is designed
to identify:
• the association between systems delivery of care as
determined at government, area and individual hospital
levels and implementation of evidence-based guidelines
• the patient and system level determinants of the barriers
and enablers to the implementation of evidence-based
guidelines.
Centres participating in CONCORDANCE reflect
different levels of ACS service provision across the
country, in relation to resources and systems of care.
CONCORDANCE, along with the national Snapshot
ACS, will significantly inform future quality improvement
initiatives and models of care for STEMI. Data gathering
initiatives of this type should be supported accordingly by
government.
Patients with STEMI arriving within 12 hours of
symptom onset who received fibrinolysis or PCI
Door-to-needle
(fibrinolysis)
(D2N)
D2B
(PCI)
Time (median)
46 mins
87 mins
Patients receiving
reperfusion within
recommended
timeframes*
68.3%
46.2%
*Recommended timeframes: D2N = < 30 mins, D2B = < 90 mins.
Source: CONCORDANCE Registry, Quarter 4 data 2011 (20 sites).
The above ‘time to reperfusion’ data shows that more than
50% of patients currently receive PCI therapy outside of
clinically optimal timeframes.
12
A system of care for STEMI
National Heart Foundation of Australia
Conclusion
STEMI is a time-critical emergency requiring prompt
reperfusion with current therapies. Patients diagnosed
with STEMI who do not receive reperfusion within
optimal timeframes, and survive, are likely to experience
long-term disability, ongoing hospital visits and
decreased quality of life.
If the quality of care received by patients with STEMI is
to be improved on a national scale, purpose-designed
system strategies tailored to local circumstances are
needed that seamlessly integrate across service delivery
borders. Australia must adopt a universal approach to
STEMI management, rather than the current landscape,
in which a patchwork of confined system models
exist in some regions, and ad hoc, facility-dependent
treatment strategies operate across others.
Responsibility for the planning, implementation and
funding of systems of care for STEMI rests with the
government. State and territory-based clinical networks
have proven their value in providing clinical leadership,
guidance and fostering service collaboration and should
be better consulted and utilised by governments to
implement evidence-based healthcare systems.
The Heart Foundation strongly encourages government
and policy-makers to adopt the core principles
presented in this consensus statement to improve the
quality of care delivered and ultimately reduce death
and disability from STEMI.
National Heart Foundation of Australia
A system of care for STEMI
13
Acknowledgements
Attendees at the roundtable discussion Reducing systems delay for patients with STEMI, held on 22 September 2011
in Melbourne, are listed below.
14
Attendee
Representing organisation/body
Professor David Brieger (facilitator)
Chair, ACS Implementation and Advocacy Working Group (ACSIAWG),
National Heart Foundation of Australia
Professor Leonard Arnolda
Cardiology Department, The Canberra Hospital and ACT Acute Coronary
Syndrome Reference Group
Mr Stephen Bloomer
Cardiovascular Health Network (WA)
Associate Professor Omar Farouque
Cardiac Society of Australia and New Zealand
Dr Paul Garrahy
State-wide Cardiac Clinical Network (QLD)
Dr John Gunning
Agency for Clinical Innovation – Cardiac Network (NSW)
Professor Richard Harper
Cardiac Clinical Network (VIC)
Associate Professor Matthew Hooper
South Australian Ambulance Service (SAAS)
Dr Will Parsonage
State-wide Cardiac Clinical Network (QLD)
Associate Professor Philip RobertsThomson
Royal Hobart Hospital and Hobart Heart Centre
Dr Michael Smith
Australian Commission on Safety and Quality in Health Care
Mr Michael Stephenson
Council of Ambulance Authorities
Mr Paul Stewart
Ambulance Service of NSW
Dr Phil Tideman
Integrated Cardiovascular Clinical Network CHSA
Dr John Vinen
Australasian College for Emergency Medicine
Associate Professor Darren Walters
ACS Implementation and Advocacy Working Group (ACSIAWG),
National Heart Foundation of Australia
Mr Christopher Poulter
National Heart Foundation of Australia
Ms Jacqui Williams
National Heart Foundation of Australia
Ms Rachelle Foreman
National Heart Foundation of Australia
Dr Rob Grenfell
National Heart Foundation of Australia
A system of care for STEMI
National Heart Foundation of Australia
Appendix
Chart 1: System of care for STEMI
System of care for STEMI
Optimising time to reperfusion
Activating the
system
Symptom
recognition
and calling
Triple Zero
(000)
Pre-hospital
12-lead ECG
Priority cath
lab access,
including
DIDO patients
National Heart Foundation of Australia
Fostering the
system
Central role
of clinical
networks
Collaboration
across service
boundaries
A system of care for STEMI
Supporting the
system
24-hour
cardiology
support
Trained
workforce
Standards and
performance
monitoring
15
Glossary
Acute coronary syndromes (ACS) The spectrum of acute
clinical presentations resulting from underlying coronary
heart disease, including heart attack and angina.
Anticoagulation The prevention of blood clotting within
an artery, by administering an anticoagulant drug.
Door to balloon (D2B) time The duration of time from
the point of arrival at a PCI facility to the first inflation
of a balloon inside the blocked coronary artery during
a PCI procedure. A D2B time of 90 minutes or less is
recommended to expedite time to reperfusion.
Door-in/door-out (DIDO) time The duration of time
from the point of arrival at the first or STEMI referring
hospital to discharge. A DIDO time of 30 minutes or less
is recommended to expedite time to reperfusion.
Electrocardiogram (ECG) A non-invasive test that records
the electrical activity of the heart. A 12-lead ECG records
12 different electrical ‘views’ of the heart simultaneously.
This test is performed to diagnose a STEMI.
Fibrinolysis Specialised drug treatment to dissolve a
blood clot blocking a coronary artery during a heart
attack. If given early enough, this treatment can reduce
damage to the heart muscle.
Non-PCI facility A hospital that does not have the
necessary infrastructure and/or resources to provide a PCI
service onsite. Can be referred to as a ‘STEMI referring’
hospital when referring patients with STEMI to a PCI
facility.
Percutaneous coronary intervention (PCI) An invasive
procedure that restores blood flow through a blocked
coronary artery. A special balloon is used to open the
blocked artery at the point of narrowing, without the
need for heart surgery. After PCI is performed, a stent (an
expandable metal tube such as a coil or wire mesh) is
delivered to the newly dilated site where it is expanded
and left in place to keep the artery open.
Reperfusion The restoration of blood flow (and therefore
oxygen supply) to an area of heart muscle that has been
deprived of circulation for a period of time (e.g. as a
result of a heart attack).
Rescue PCI Describes a PCI procedure performed
as soon as possible after failed fibrinolysis therapy to
establish reperfusion.
ST-segment elevation myocardial infarction (STEMI)
An acute heart attack for which the diagnosis has been
made by a 12-lead ECG test. A heart attack occurs when
an area of plaque within a coronary artery ruptures
and forms a blood clot, suddenly blocking the supply
of blood to part of the heart muscle and depriving it of
oxygen.
Triage The rapid systematic process used by healthcare
services to determine a patient’s level of urgency at
point-of-entry to the service.‘Field triage’ refers to the
assessment of a patient for STEMI (by 12-lead ECG)
and is conducted by paramedics prior to arrival at the
hospital.
PCI facility A hospital that has the necessary
infrastructure and resources to provide a PCI service
onsite. Can be referred to as a ‘STEMI receiving’ hospital
when accepting patients with STEMI from a non-PCI
facility.
16
A system of care for STEMI
National Heart Foundation of Australia
References
1. de Savigny D, Adam T (eds). Systems thinking for health systems
strengthening. Alliance for Health Policy and Systems Research: World
Health Organization, 2009.
2. Breiger D, 2011, ‘Systems of care in STEMI’, presentation at the
CSANZ conference, Perth, August 2011.
3. National Heart Foundation of Australia. Warning Signs: sentinel site
data analysis. 2009–2011. Melbourne: National Heart Foundation of
Australia, 2011.
4. Finn JC, Bett JH, Shilton TR, et al. Patient delay in responding to
symptoms of possible heart attack: can we reduce time to care? Med J
Aust 2007; 187(5):293–298.
5. National Heart Foundation of Australia. Championing Hearts –
Warning Signs strategic theme. 2008–2012. Melbourne: National Heart
Foundation of Australia, 2008.
6. Hutchison AW, Malaiapan Y, Jarvie I, et al. Prehospital 12-lead ECG
to triage ST-elevation myocardial infarction and emergency department
activation of the infarct team significantly improves door-to-balloon
times: ambulance Victoria and MonashHEART Acute Myocardial
Infarction (MonAMI) 12-lead ECG project. Circ Cardiovasc Interv 2009;
2(6):528–534.
7. Sivagangabalan G, Ong A, Narayan A, et al. Effect of prehospital
triage on revascularization times, left ventricular function, and survival
in patients with ST-elevation myocardial infarction. Am J Card 2009;
103(7):907–912.
8. Ambulance Victoria. Strategic plan 2010–2012. Available at: http://
www.ambulance.vic.gov.au/Media/docs/Ambulance%20Victoria%20
Strategic%20Plan-f2b7ef6d-5ba1-48d4-80c2-91df87d1869b-0.pdf.
Accessed 12 June 2012.
9. Ambulance Service of NSW. Excellence in care. December
2009. Available at: http://www.ambulance.nsw.gov.au/Media/
docs/100320excellence-f461b5a2-5021-45fd-854e-48dd714cf2a9-0.
pdf. Accessed 12 June 2012.
10. Whitebread M, Leah V, Bell T, et al. Recognition of ST elevation by
paramedics. Emerg Med J 2002; 19:66–67.
11. Bright H, Pocock J. Prehospital recognition of acute MI. Can J Emerg
Med 2002; 4:212.
12. National Heart Foundation of Australia. ‘Reducing systems delay for
patients with STEMI’, roundtable discussion, Melbourne, Victoria, 22
September 2011.
13. O’Connor RE, Bossaert L, Arntz HR, et al. Part 9: Acute coronary
syndromes: 2010 International Consensus on Cardiopulmonary
Resuscitation and Emergency Cardiovascular Care Science With
Treatment Recommendations. Circulation 2010; 122:S422–S465.
15. Wilson AB, Mountain D, Jeffers JM, et al. Door-to-balloon times are
reduced in ST-elevation myocardial infarction by emergency physician
activation of the cardiac catheterisation laboratory and immediate
patient transfer. Med J Aust 2010; 193:207–212.
16. Huynh LT, Rankin JM, Tideman P, et al. Reperfusion therapy in
the acute management of ST-segment-elevation myocardial infarction
in Australia: findings from the ACACIA registry. Med J Aust 2010;
193:496–501.
17. Jollis JG, Roettig ML, Aluko AO, et al. Implementation of a statewide
system for coronary reperfusion for ST-segment elevation myocardial
infarction. JAMA 2007; 298(20):2371–2380.
18. Herrin J, Miller LE, Dima F, et al. National performance on door-in
to door-out time among patients transferred for primary percutaneous
coronary intervention. Arch Intern Med 2011; 171(21):1879–1886.
19. Finn C, Bailey P, Lye V, et al, 2007, ‘Improving the door-to-balloon
time for patients with ST elevation myocardial infarction transferred
from a peripheral metropolitan hospital to a tertiary hospital for PCI’
poster presented at the Cardiac Society of Australia and New Zealand
conference, 2007.
20. Bloe C, Mair C, Call A, et al. Identification of barriers to
the implementation of evidence-based practice for pre-hospital
thrombolysis. Rural Remote Health 2009; 9(1):1100.
21. Chew DP, Aroney CN, Aylward PE, et al. 2011 Addendum to the
National Heart Foundation of Australia/Cardiac Society of Australia
and New Zealand Guidelines for the management of acute coronary
syndromes (ACS) 2006. Heart Lung Circ 2011; 20(8):487–502.
22. Ambulance Service of New South Wales. Pre-hospital thrombolysis
– an overview of the Hunter proof-of-concept July 2008–February 2012.
Ambulance Service of New South Wales: New South Wales, 2012.
23. Data Sub-commitee of the ACS Implementation and Advocacy
Working Group (ACSIAWG), National Heart Foundation of Australia.
Measuring performance and outcomes of acute coronary syndromes
(ACS) management in Australia. Med J Aust. Accepted for publication:
3 April 2012.
24. Snapshot ACS group. Snapshot Acute Coronary Syndrome Registry.
Information for public hospitals in Australia, 2012.
25. Australian Institute of Health and Welfare. Towards national
indicators of safety and quality in health care. Canberra: Australian
Institute of Health and Welfare, 2009; cat. no. HSE 75.
26. Brieger D. Chairman, The Cooperative National Registry of Coronary
care Guideline Adherence and Clinical Events (CONCORDANCE) Steering
Committee. Quarter 4, 2011 data. Sydney, 2011 (unpublished data).
14. Bradley EH, Herrin J, Wang Y, et al. Strategies for reducing the
door-to-balloon time in acute myocardial infarction. N Engl J Med 2006;
355:2308–2320.
National Heart Foundation of Australia
A system of care for STEMI
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