Acute Care/Hospitalization

Sending high-risk heart attack patients to certain hospitals reduces deaths, minimizes hospital volume shifts

Certain heart attack victims fare better with immediate surgery (primary percutaneous coronary intervention, PCI) than with clot-busting drugs (thrombolytic therapy, TT). These are patients with acute ST-segment elevation myocardial infarctions (STEMIs) and other high-risk features such as advanced age, diabetes, accelerated heart rates, larger infarcts (areas of cardiac tissue death), and noninferior infarcts. When emergency transport personnel take these patients directly to hospitals capable of full-time PCIs, even if they are not the closest hospitals, this approach reduces mortality while minimizing major shifts in hospital patient volumes.

Researchers evaluated three alternatives for the triage of heart attack patients to hospitals in one county:

1. Transport all patients to the closest hospital and treat with PCI if available and TT if not.
2. Transport all patients to the closest PCI-capable hospital and treat with PCI.
3. A targeted PCI strategy, in which patients who are closest to TT-only hospitals are evaluated for their expected mortality benefit with PCI and transported or transferred to PCI-capable hospitals, only if the expected benefit exceeds the expected risk of delay.

They used these strategies to simulate emergency transport for 2,000 patients with STEMIs from one large study using Dallas County, Texas, as the geospatial model.

The first strategy yielded a 5.2 percent 30-day mortality rate. The second strategy of universal PCI yielded a 4.4 percent mortality rate, but an increase in patient volume at two full-time PCI hospitals of more than 1,000 percent. The targeted PCI strategy yielded a 4.5 percent mortality rate if transfers were decided in the emergency department (ED), but 4.2 percent if the hospital destination was decided by ambulance personnel. This approach increased patient volumes at full-time PCI hospitals by about 700 percent. The study was supported in part by the Agency for Healthcare Research and Quality (T32 HS00060).

See "A geospatial analysis of emergency transport and inter-hospital transfer in ST-segment elevation myocardial infarction," by Thomas W. Concannon, Ph.D., David M. Kent, M.D., M.S., Sharon-Lise Normand, Ph.D., and others, in the January 2008 American Journal of Cardiology 101, pp. 69-74.

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