Patient and System Time Delay

Transcription

1 Quality Indicators in the Management of ST-elevation Myocardial Infarction Patient and System Time Delay Jacob Thorsted Sorensen, MD, PhD Department of Cardiology Aarhus University Hospital, Denmark

2 Disclosures Speakers honorarium Roche Diagnostics Astra Zeneca Advisory boards: Roche Diagnostics Research grants: Falck Denmark EMS

3 Acute Myocardial Infarction

4 Time is muscle - Fibrinolysis Boersma et al. Lancet Sep 21;348(9030):771-5.

5 Time is muscle Primary PCI De Luca et al. Circulation Mar 16;109(10):

6 Treatment delay in STEMI Patient delay Pre-hospital system delay In-hospital system delay Patient delay EMS call to arrival On scene delay Transport delay Door-to-balloon delay First Medical Contact to PPCI = System delay

7 Treatment delay in STEMI Patient delay System delay Pre-hospital system delay In-hospital system delay

8 Patient delay Time from symptom onset until first medical contact (FMC) How can this be influenced? Media campaigns Education of high-risk groups Mandatory courses at certain ages or life events

9

10

11 Patient delay Very difficult to modify despite aggressive campaigns Patient delay as a quality indicator? Patient delay hampered by: 1. Recall bias: When was the actual symptom onset? 2. Measurement error: Is symptom onset equal to AMI onset? Hours of UAP or spontaneous opening and closure of the culprit vessel? 3. Survivor cohort effect: Late incomers are survivors of the prehospital phase

12 Treatment delay in STEMI Patient delay System delay Pre-hospital system delay In-hospital system delay

13 Pre-hospital system delay From first medical contact to arrival at PPCI hospital Includes transportation Can be decreased by early ECG diagnosis and field triage

14 The Danish prehospital strategy PCI center ECG If not STEMI: Alerting Interview If STEMI: Re-routing Local hospital

15 Pre-hospital system delay Terkelsen et al. EHJ 2005 LeMay et al. NEJM 2008 Pedersen et al. JACC 2009 Dieker et al. JACC Card int 2010 Martinoni et al. G Ital Cardiol 2010 Sorensen et al. EHJ 2011 System delay (min) Symptom onset to balloon (min) Field triage No field triage Field triage No field triage N/A N/A

16 Pre-hospital system delay Distance to PCI-center (km) FMC to balloon (System delay) Regional University hospital Hospital 40 (30-49) 10 (6-19) 93 min 84 min (p<0.001) (p<0.001) Sorensen et al. EHJ 2011 Feb; 32(4)

17 Pre-hospital system delay Sorensen et al. EHJ 2011 Feb; 32(4)

18 Treatment delay in STEMI Patient delay System delay Pre-hospital system delay In-hospital system delay

19 In-hospital system delay Time from arrival at PPCI hospital to balloon inflation/angiography Door-to-balloon time Where s the door? Hot Topic: ACC D2B alliance 2006 AHA Mission:Lifeline 2007

20 In-hospital system delay D2B alliance recommendations: ED physician activates the cath lab Single-call system activates the cath lab Cath lab team available within 30 min (24/7) Prompt data feedback Pre-hospital activation of the cath lab Bradley Circulation 2006; 113:

21 Does size matter? What is the optimal size of a PPCI center? No clear answer, but: Registries suggest longer D2B times with smaller centers

22 PCI volume and delay Nallamothu Circulation 2006; 113

23 PCI volume and delay Nallamothu Circulation 2006; 113

24 In-hospital system delay ED physician activates the cath lab Single-call system activates the cath lab Cath lab team available within 30 minutes Prompt data feedback Pre-hospital activation the cath lab High volume PPCI centers?

25 System delay and outcome

26 System delay and mortality

27 System delay and morbidity

28 System delay as a quality indicator

29 Why focus on system delay? Door-to-balloon delay not ideal because: Easy to quantify No recall bias 1. It only comprise a minor part of the system delay D2B delay constitute 30% of FMC to PCI in Denmark Less bias by survivor cohort effect 2. Long system delay can be associated with short D2B in transfer patients Contains more information than D2B time More time to activate the cath. lab. in transfer patients The only predictor of outcome that is modifiable in the acute phase of STEMI Terkelsen et al. JAMA Does not consider the prehospital phase

30 Recommendations for clinical use

31 Guidelines Both US and European guidelines on STEMI and revascularization recommend PPCI within minutes from FMC Otherwise: Fibrinolysis Is this based on solid evidence?

32 System delay = PCI related delay?

33 PCI related delay The extra time used to perform PPCI instead of administering fibrinolysis Introduced by Nallamothu in 2003 Nallamothu et al. Am J Cardiol 2003; 92

34 PCI related delay Study year PCIrelated delay Mortality benefit from PPCI, 30 day / inhospital Mortality benefit from PPCI, 1 year Metaanalyses of RCTs PCAT-a min 5.4% 1417 PCAT-b min 1.4% 1292 PCAT-c min 0.6% 1425 PCAT-d % 1280 PCAT-e % 1349 PCAT-total min 2.6% 6763 RCTs ASSENT-IV min 1.7%* 1667 FINESSE min 0.7% 2452 Registries FAST-MI 170 min -1.0% 1030 RIKS-HIA-a min 6.5% 3.6% RIKS-HIA-b min 2.7% 2.7% Vienna min 0.1% 912 N

35 PCI related delay Prehospital fibrinolysis Patient delay EMS call to arrival on scene EMS arrival to needle PCI-related delay Field-triage for PPCI Patient delay EMS call to arrival on scene On scene delay Transport delay Door-to-balloon (D2B) delay First Medical Contact (FMC) to PPCI = System delay FMC to prehospital fibrinolysis: Approx. 30 min FMC to in-hospital fibrinolysis: Approx. 60 min FMC to PPCI (time to fibrinolysis + PCI-related delay): (30-60 min min) = min

36 System delay PCI related delay

37 Conclusions II Rapid reperfusion is pivotal in STEMI care Optimal logistics are crucial to achieve this Patient delay is difficult to reduce and often biased System delay can be reduced by: Improved prehospital care Improved in-hospital logistics and team work

38 Conclusions II System delay is associated with mortality System delay is an important quality indicator For clinical use PCI related delay may be better System delay PCI related delay PPCI superior/equal to fibrinolysis even with a delay of 120 minutes

39 Thank You!

40

41 Pre-hospital system delay Can be reduced by pre-hospital diagnosis and field triage for PPCI Results are consistent across varying geographical settings and infrastructure A reduction of pre-hospital system delay is associated with lower mortality

42

43 Transfer from local hospital Field-triaged to a PCI centre Treatment delay in STEMI Symptom onset EMS call Arrival at PCI centre PPCI Patient delay Transportation delay D2B delay Health Care System delay Treatment delay Arrival at local hospital Departure from local hospital Arrival at PCI centre PPCI Patient delay Transportation delay Local hospital delay Interhospital delay D2B delay Health Care System delay Treatment delay

44 Measurement error Patient delay Health Care System delay Treatment delay σ 2 treatment delay σ 2 patient delay + σ 2 system delay Treatment delay Patient delay System delay σ h 5.1 h 1.0 h Mean 4.2 h 2.3 h 2.2 h Terkelsen JAMA 2011; 304(7)

45 PCI volume and delay Pinto Circulation 2006; 114

46 PCI volume and delay Pinto Circulation 2006; 114

47 System delay and mortality Terkelsen JAMA 2011; 304(7)

48 Time is muscle! Modified from Löwel et al. Dtsch Med Wochenschr May 10;116(19):

49 PCI related delay