Lower mortality after prehospital recognition and treatment followed by fast tracking to coronary care compared with admittance via emergency department in patients with ST-elevation myocardial infarction

https://doi.org/10.1016/j.ijcard.2007.09.001Get rights and content

Abstract

Objectives

To describe the short-and long-term outcome among patients with an ST-elevation myocardial infarction (STEMI), assessed and treated by the emergency medical services (EMS) in relation to whether they were fast tracked to a coronary care unit (CCU) or admitted via the emergency department (ED).

Methods

Consecutive patients admitted to the CCU at Sahlgrenska University Hospital with ST elevations on admission ECG were analysed with respect to whether they by the EMS were fast tracked to the CCU or the adjacent coronary angiography laboratory (direct CCU group; n = 261) or admitted via the ED (ED group; n = 235).

Results

Whereas the two groups were similar with regard to age and previous history, those who were fast tracked to CCU were more frequently than the ED patients diagnosed and treated as STEMI already prior to hospital admission. Reperfusion therapy was more commonly applied in the CCU group compared with the ED group (90% vs 67%; < 0.0001). The delay times (median) were shorter in the direct CCU group than in the ED group, with a difference of 10 min from the onset of symptoms to arrival in hospital and 25 min from hospital arrival to the start of reperfusion treatment (primary PCI or in-hospital fibrinolysis).

Patients in the direct CCU group had lower 30-day mortality (7.3% vs. 15.3%; p = 0.004), as well as late mortality (> 30 days to five years) (11.6% vs. 20.6%; p = 0.008).

Conclusion

Among patients transported with ambulance due to STEMI there was a significant association between early recognition and treatment followed by fast tracking to the CCU and long term survival. A higher rate of and a more rapid revascularisation were probably of significant importance for the outcome.

Introduction

In Göteborg, two-thirds of patients who are hospitalized due to suspected acute myocardial infarction (AMI) are transported by ambulance [1]. Patients who call the emergency medical services (EMS) dispatch centre due to chest pain, and who are subsequently transported by the EMS (ambulance), have been shown to be older and to have a higher prevalence of a previous AMI, angina pectoris, hypertension, diabetes mellitus and congestive heart failure, as well as larger infarct sizes and higher mortality than those patients who transport themselves to hospital [1]. Furthermore, patients with chest pain who choose the EMS system for transport have a higher incidence of cardiac arrest during transport, develop AMI more frequently and are more frequently diagnosed with an acute coronary syndrome compared with patients using private transportation [2], [3], [4]. Based on the high-risk pattern for patients with chest pain who call the EMS dispatch centre, it is therefore an alarming sign per se when patients or their relatives decide to call for an ambulance.

Early reperfusion is crucial in ST-elevation myocardial infarction (STEMI) [5]. In major clinical trials, the median time from the onset of symptoms until the start of fibrinolytic treatment has remained at approximately three hours [6], [7]. Among patients undergoing percutaneous coronary interventions (PCI), it has been shown that each 30 min of delay is associated with an 8% increase in the risk of death during one year [8]. A substantial part of the delay in STEMI patients takes place in hospital. One study analysing the reasons for hospital delay revealed extended time intervals caused by delays in the decision by the emergency department (ED) nurse or physician to call a cardiologist, as well as delays in the arrival of the cardiologist at the ED. The other component was the interval between the cardiologist's decision to admit patients to the CCU and patients' departure from the ED [9].

The objective of the present study was to describe the outcome among patients with STEMI assessed and treated by the EMS in relation to whether they were fast tracked to the CCU (bypassing the emergency department) or admitted via the ED. The hypothesis was that patients who were fast tracked to the CCU have a shorter time interval from hospital arrival to the start of reperfusion therapy and thereby an improved outcome.

Section snippets

Study setting

Göteborg is the second largest city in Sweden with a population of approximately half a million. At the time of the study, Sahlgrenska Hospital was one of three Göteborg city hospitals to which emergency patients with suspected AMI were admitted.

All medical emergencies are handled and dispatched by one EMS dispatch centre according to a two-tier EMS response system for the Municipality of Göteborg. For calls assessed as a life-threatening condition, an advanced life support unit (ALS unit) and

Results

Two hundred and sixty-one patients constituted the direct CCU group, while the ED group comprised 235 patients.

Discussion

Our study suggests a substantially improved outcome in STEMI patients when fast tracked to the CCU as compared to those who are hospitalised via the ED. There are other studies that report that fast tracking and revascularisation at “point of entry” is more effective and that a chain of care that requires the transportation of patients between wards within the hospital steals valuable time [11], [12]. However, the difference in the delay to treatment between groups in this study does not

Conclusions

Among patients transported with ambulance due to STEMI there was a significant association between early recognition and treatment followed by fast tracking to the CCU and long term survival. A higher rate of and a more rapid revascularisation were probably of significant importance for the outcome.

References (18)

There are more references available in the full text version of this article.

Cited by (43)

  • Clinical decision-making described by Swedish prehospital emergency care nurse students – An exploratory study

    2016, International Emergency Nursing
    Citation Excerpt :

    The RNs in Sweden are responsible for the care delivered by the ambulance services, and they make the decisions on their own since there is seldom a physician at the scene of the illness or injury (Lindström et al., 2015). Emergency situations that arise in the prehospital context require quick assessment and a fast response to increase the survival of patients (Bang et al., 2008), and there is little margin for error or misjudgement. Previous studies have found that the RNs working in the ambulance services are sometimes worried about specific emergencies as well as situations related to the environment where the illness or injury has occurred (Abelsson and Lindwall, 2012; Svensson and Fridlund, 2008).

View all citing articles on Scopus
View full text