A Novel Survey Tool to Quantify the Degree and Duration of STEMI Regionalization Across California.

IntroductionCalifornia has been a global leader in regionalization efforts for time-critical medical conditions. A total of 33 local emergency medical service agencies (LEMSAs) exist, providing an organized EMS framework across the state for almost 40 years. We sought to develop a survey tool to quantify the degree and duration of ST-elevation myocardial infarction (STEMI) regionalization over the last decade in California.MethodsThe project started with the development of an 8-question survey tool via a multi-disciplinary expert consensus process. Next, the survey tool was distributed at the annual meeting of administrators and medical directors of California LEMSAs to get responses valid through December, 2014. The first scoring approach was the Total Regionalization Score (TRS) and used answers from all 8 questions. The second approach was called the Core Score, and it focused on only 4 survey questions by assuming that the designation of STEMI Receiving Centers must have occurred at the beginning of any LEMSA's regionalization effort. Scores were ranked and grouped into tertiles.ResultsAll 33 LEMSAs in California participated in this survey. The TRS ranged from 15 to 162. The Core Score range was much narrower, from 2 to 30. In comparing TRS and Core Score rankings, the top-tertiles were quite similar. More rank variation occurred between mid- and low-tertiles.ConclusionThis study evaluated the degree and duration of STEMI network regionalization from 2004 to 2014 in California, and ranked 33 LEMSAs into tertiles based upon their TRS and their Core Score. Successful application of the 8-item survey and ranking strategies across California suggests that this approach can be used to assess regionalization in other states or countries around the world

Regional Systems of Care Demonstration Project: American Heart Association Mission: Lifeline STEMI Systems Accelerator.

BACKGROUND: Up to 50% of patients fail to meet ST-segment-elevation myocardial infarction (STEMI) guideline goals recommending a first medical contact-to-device time of <90 minutes for patients directly presenting to percutaneous coronary intervention-capable hospitals and <120 minutes for transferred patients. We sought to increase the proportion of patients treated within guideline goals by organizing coordinated regional reperfusion plans. METHODS: We established leadership teams, coordinated protocols, and provided regular feedback for 484 hospitals and 1253 emergency medical services (EMS) agencies in 16 regions across the United States. RESULTS: Between July 2012 and December 2013, 23 809 patients presented with acute STEMI (direct to percutaneous coronary intervention hospital: 11 765 EMS transported and 6502 self-transported; 5542 transferred). EMS-transported patients differed from self-transported patients in symptom onset to first medical contact time (median, 47 versus 114 minutes), incidence of cardiac arrest (10% versus 3%), shock on admission (11% versus 3%), and in-hospital mortality (8% versus 3%; P<0.001 for all comparisons). There was a significant increase in the proportion of patients meeting guideline goals of first medical contact-to-device time, including those directly presenting via EMS (50% to 55%; P<0.001) and transferred patients (44%-48%; P=0.002). Despite regional variability, the greatest gains occurred among patients in the 5 most improved regions, increasing from 45% to 57% (direct EMS; P<0.001) and 38% to 50% (transfers; P<0.001). CONCLUSIONS: This Mission: Lifeline STEMI Systems Accelerator demonstration project represents the largest national effort to organize regional STEMI care. By focusing on first medical contact-to-device time, coordinated treatment protocols, and regional data collection and reporting, we were able to increase significantly the proportion of patients treated within guideline goals

Association of Rapid Care Process Implementation on Reperfusion Times Across Multiple ST-Segment–Elevation Myocardial Infarction Networks

BACKGROUND: The Mission: Lifeline STEMI Systems Accelerator program, implemented in 16 US metropolitan regions, resulted in more patients receiving timely reperfusion. We assessed whether implementing key care processes was associated with system performance improvement. METHODS AND RESULTS: Hospitals (n=167 with 23 498 ST-segment-elevation myocardial infarction patients) were surveyed before (March 2012) and after (July 2014) program intervention. Data were merged with patient-level clinical data over the same period. For reperfusion, hospitals were grouped by whether a specific process of care was implemented, preexisting, or never implemented. Uptake of 4 key care processes increased after intervention: prehospital catheterization laboratory activation (62%-91%; P<0.001), single call transfer protocol from an outside facility (45%-70%; P<0.001), and emergency department bypass for emergency medical services direct presenters (48%-59%; P=0.002) and transfers (56%-79%; P=0.001). There were significant differences in median first medical contact-to-device times among groups implementing prehospital activation (88 minutes implementers versus 89 minutes preexisting versus 98 minutes nonimplementers; P<0.001 for comparisons). Similarly, patients treated at hospitals implementing single call transfer protocols had shorter median first medical contact-to-device times (112 versus 128 versus 152 minutes; P<0.001). Emergency department bypass was also associated with shorter median first medical contact-to-device times for emergency medical services direct presenters (84 versus 88 versus 94 minutes; P<0.001) and transfers (123 versus 127 versus 167 minutes; P<0.001). CONCLUSIONS: The Accelerator program increased uptake of key care processes, which were associated with improved system performance. These findings support efforts to implement regional ST-segment-elevation myocardial infarction networks focused on prehospital catheterization laboratory activation, single call transfer protocols, and emergency department bypass

A Novel Survey Tool to Quantify the Degree and Duration of STEMI Regionalization Across California.

INTRODUCTION: California has been a global leader in regionalization efforts for time-critical medical conditions. A total of 33 local emergency medical service agencies (LEMSAs) exist, providing an organized EMS framework across the state for almost 40 years. We sought to develop a survey tool to quantify the degree and duration of ST-elevation myocardial infarction (STEMI) regionalization over the last decade in California. METHODS: The project started with the development of an 8-question survey tool via a multi-disciplinary expert consensus process. Next, the survey tool was distributed at the annual meeting of administrators and medical directors of California LEMSAs to get responses valid through December, 2014. The first scoring approach was the Total Regionalization Score (TRS) and used answers from all 8 questions. The second approach was called the Core Score, and it focused on only 4 survey questions by assuming that the designation of STEMI Receiving Centers must have occurred at the beginning of any LEMSAs regionalization effort. Scores were ranked and grouped into tertiles. RESULTS: All 33 LEMSAs in California participated in this survey. The TRS ranged from 15 to 162. The Core Score range was much narrower, from 2 to 30. In comparing TRS and Core Score rankings, the top-tertiles were quite similar. More rank variation occurred between mid- and low-tertiles. CONCLUSION: This study evaluated the degree and duration of STEMI network regionalization from 2004 to 2014 in California, and ranked 33 LEMSAs into tertiles based upon their TRS and their Core Score. Successful application of the 8-item survey and ranking strategies across California suggests that this approach can be used to assess regionalization in other states or countries around the world

Trends in Regionalization of Care for ST-Segment Elevation Myocardial Infarction

The article of record as published may be found at http://dx.doi.org/10.5811/westjem.2017.8.34592Introduction California has led successful regionalized efforts for several time-critical medical conditions, including ST-segment elevation myocardial infarction (STEMI), but no specific mandated protocols exist to define regionalization of care. We aimed to study the trends in regionalization of care for STEMI patients in the state of California and to examine the differences in patient demographic, hospital, and county trends. Methods Using survey responses collected from all California emergency medical services (EMS) agencies, we developed four categories – no, partial, substantial, and complete regionalization – to capture prehospital and inter-hospital components of regionalization in each EMS agency’s jurisdiction between 2005–2014. We linked the survey responses to 2006 California non-public hospital discharge data to study the patient distribution at baseline. Results STEMI regionalization-of-care networks steadily developed across California. Only 14% of counties were regionalized in 2006, accounting for 42% of California’s STEMI patient population, but over half of these counties, representing 86% of California’s STEMI patient population, reached complete regionalization in 2014. We did not find any dramatic differences in underlying patient characteristics based on regionalization status; however, differences in hospital characteristics were relatively substantial. Conclusion Potential barriers to achieving regionalization included competition, hospital ownership, population density, and financial challenges. Minimal differences in patient characteristics can establish that patient differences unlikely played any role in influencing earlier or later regionalization and can provide a framework for future analyses evaluating the impact of regionalization on patient outcomes.Emergency Medical Services agencies in the state of Californi

Trends in Regionalization of Care for ST-Segment Elevation Myocardial Infarction

Introduction: California has led successful regionalized efforts for several time-critical medical conditions, including ST-segment elevation myocardial infarction (STEMI), but no specific mandated protocols exist to define regionalization of care. We aimed to study the trends in regionalization of care for STEMI patients in the state of California and to examine the differences in patient demographic, hospital, and county trends. Methods: Using survey responses collected from all California emergency medical services (EMS) agencies, we developed four categories – no, partial, substantial, and complete regionalization – to capture prehospital and inter-hospital components of regionalization in each EMS agency’s jurisdiction between 2005–2014. We linked the survey responses to 2006 California non-public hospital discharge data to study the patient distribution at baseline. Results: STEMI regionalization-of-care networks steadily developed across California. Only 14% of counties were regionalized in 2006, accounting for 42% of California’s STEMI patient population, but over half of these counties, representing 86% of California’s STEMI patient population, reached complete regionalization in 2014. We did not find any dramatic differences in underlying patient characteristics based on regionalization status; however, differences in hospital characteristics were relatively substantial. Conclusion: Potential barriers to achieving regionalization included competition, hospital ownership, population density, and financial challenges. Minimal differences in patient characteristics can establish that patient differences unlikely played any role in influencing earlier or later regionalization and can provide a framework for future analyses evaluating the impact of regionalization on patient outcomes

Trends in Regionalization of Care for ST-Segment Elevation Myocardial Infarction

Introduction: California has led successful regionalized efforts for several time-critical medical conditions, including ST-segment elevation myocardial infarction (STEMI), but no specific mandated protocols exist to define regionalization of care. We aimed to study the trends in regionalization of care for STEMI patients in the state of California and to examine the differences in patient demographic, hospital, and county trends. Methods: Using survey responses collected from all California emergency medical services (EMS) agencies, we developed four categories – no, partial, substantial, and complete regionalization – to capture prehospital and inter-hospital components of regionalization in each EMS agency’s jurisdiction between 2005–2014. We linked the survey responses to 2006 California non-public hospital discharge data to study the patient distribution at baseline. Results: STEMI regionalization-of-care networks steadily developed across California. Only 14% of counties were regionalized in 2006, accounting for 42% of California’s STEMI patient population, but over half of these counties, representing 86% of California’s STEMI patient population, reached complete regionalization in 2014. We did not find any dramatic differences in underlying patient characteristics based on regionalization status; however, differences in hospital characteristics were relatively substantial. Conclusion: Potential barriers to achieving regionalization included competition, hospital ownership, population density, and financial challenges. Minimal differences in patient characteristics can establish that patient differences unlikely played any role in influencing earlier or later regionalization and can provide a framework for future analyses evaluating the impact of regionalization on patient outcomes

This Article Corrects: “Trends in Regionalization of Care for ST-Segment Elevation Myocardial Infarction”

The article of record as published may be found at http://dx.doi.org/10.5811/westjem.2018.5.3843