• Scenario #1: Emergency medical services (EMS) personnel are summoned to a college graduation event after the presenter suddenly faints during her presentation. Upon their arrival, the presenter, a 78-year-old minister, complains of weakness and dizziness. An electrocardiogram (ECG) performed on-site by EMS personnel reveals prominent anterior ST-segment elevation. EMS immediately contacts the local emergency department. The emergency physician on duty discusses the patient and ECG findings with the EMS personnel, and the decision is made to bypass the local ED (a non-percutaneous coronary intervention) facility and drive directly to the closest PCI facility, 20 minutes down the road. Having been activated prior to arrival, the catheterization lab at the PCI facility is waiting for the patient, who undergoes emergency PCI despite the event’s occurrence on a busy Sunday afternoon.
• Scenario #2: A 48-year old man, manager of a local auto parts store in a rural Kansas town, develops severe “heartburn” while stacking bales of hay on his farm. Despite his protests, his son rushes him to the local hospital, which is 42 miles away. The emergency physician working in the nine-bed ED that day correctly diagnoses the patient with an acute inferior wall myocardial infarction. Knowing that the closest PCI hospital is 82 miles away, the emergency physician quickly administers a fibrinolytic agent to the patient while at the same time arranging ground EMS transport to the nearest PCI hospital.

An estimated 400,000 adults in the United States annually experience prehospital and inhospital STEMI (ST-segment elevation myocardial infarction).¹ As illustrated, it often occurs without warning and can present with a variety of symptoms. The benefits of reperfusion therapy are time dependent, and the appropriate reperfusion strategy varies from location to location. In those systems that utilize interfacility transfers for STEMI patients, topography, weather conditions, and variable EMS availability further complicate the picture.

Among the vast population of patients transported by EMS, STEMI is an uncommon event, rarely encountered by most EMS providers. This infrequency impairs prompt recognition of the STEMI patient and is an impediment to the goal of rapid reperfusion. Each participant in the “STEMI continuum of care,” including the patient (by activating EMS), is integral to the process. During an acute STEMI, all members of the team must know their role, and each segment of the process must flow smoothly.

Emergency physicians are at the center of a vital intersection in the STEMI process of care. In nearly all systems, the ED functions as the connection point, serving to integrate and connect EMS with processes and personnel within hospital walls. The ED is the gateway into most hospitals. The tight relationships formed between EMS and ED staff (fostered by working closely together, day after day) are important in developing sustainable systems of STEMI care. Regardless of the reperfusion strategy selected (fibrinolysis, on-site PCI, or transfer for PCI), it is likely that an emergency physician is involved, either as direct participant or in the construction and development of that particular STEMI system of care.

Given their role as the primary connection point within the STEMI continuum of care, emergency physicians should be familiar with the immediate and future importance of the American Heart Association’s Mission: Lifeline, a national, community-based initiative to improve the health care system’s readiness for and response to STEMI.

This bold initiative, launched in May 2007, seeks to improve the quality of care for STEMI patients nationwide, with a specific focus on increasing the number of patients with timely access to primary PCI and minimizing time to reperfusion for all STEMI patients.

To accomplish these goals, the AHA has gathered providers from the entire STEMI continuum of care, including physicians, nurses, EMS and ED personnel, cardiologists and cath lab staff, hospital administrators, quality improvement specialists, payers, policy-makers, and others. The goal: integrated teams across the country working together at multiple levels within each community to improve STEMI systems of care.

Mission: Lifeline is an all-encompassing effort to improve each facet of STEMI care, realistically recognizing existing barriers. Mission: Lifeline is working to optimize STEMI recognition and response, both prehospital and inhospital; remove barriers to patient entry into the system; facilitate guideline-based reperfusion strategies at each site; develop regional systems of care involving EMS, STEMI referral hospitals (non-PCI centers), and STEMI receiving hospitals (PCI centers); and develop mechanisms for measurement of outcomes, utilizing efficient and accurate data collection.

Apart from improving the actual day-to-day processes of STEMI care, Mission: Lifeline also seeks to address closely related issues such as patient (and family) education, development of financial reimbursement models for EMS and hospitals, acquisition of sustainable funding sources, implementation of legislation related to improvement of STEMI care, and the distribution of applicable and useful knowledge.

In recognition of the enormous collaborative efforts such an endeavor will require, the AHA has wisely reached out to hundreds of individuals, organizations, and institutions in an effort to improve the entire nation’s quality of acute cardiovascular emergency care. In particular, Mission: Lifeline is reaching out to emergency medicine. Emergency medicine and EMS are particularly poised to be major leaders (and beneficiaries) of these massive efforts.

For example, the attention and assistance that EMS systems are receiving in this effort are substantial. Pre-hospital ECG has been recognized as a key to moving recognition of STEMI ever earlier into the infarct process. It is also critically important to encourage our patients and the public to call EMS (and to call earlier).

We must then be certain EMS has the tools and training to respond appropriately. For example, the AHA (in collaboration with EMS and EM organizations) has conducted an EMS/EM survey encompassing all 50 states to gain a better understanding of existing EMS/EM systems and availability of resources across the country and how best to support and augment these systems.

Just as EMS is being promoted as the new frontier of STEMI diagnosis, the ED must respond to our role as arbiters and real-time coordinators of our nation’s emerging STEMI systems of care. Development of such systems must be a joint effort of multiple contributors. Once in place, however, day-to-day oversight and adjustment of such systems (often on a case-by-case basis) is most easily directed from the ED.

Indeed, it appears that AHA has clearly recognized (and taken to heart) a crucial fact: The key to success (or failure) in improving STEMI care in this country (or any other) is an appreciation for the differing (but equal) contributions of emergency physicians, EMS personnel, and cardiologists to the STEMI continuum of care.

The word “regionalization” often brings to mind uncomfortable associations with perceptions of inefficiency and inflexibility that often accompany large-scale efforts at standardization and regulation. EM and EMS are particularly sensitive to the perceptions of excessive “top down” regulation and oversight, no matter how well intentioned.

For STEMI care, however, regionalization implies something positive: a concerted effort to improve and link existing systems of care, not necessarily creating new and competing models. This optimization can occur at all levels of STEMI systems. For example, on a conceptual level, the smallest functional STEMI system can be viewed in terms of just three components that each facility must work to optimize:

1. STEMI patients who present “at the front door” of an institution.
2. STEMI patients brought to that institution from the field via EMS (encouraged).
3. STEMI patients transferred to or from another institution (encouraged).

Intuitively (from the facility’s perspective), maximal improvement in the quality of local STEMI care could thereby be accomplished by optimizing as few as three key processes:

1. Standardizing the institution’s “in house” STEMI treatment processes.
2. Optimizing the institution’s EMS linkages.
3. Streamlining transfers of STEMI patients to or from that institution.

Application of the “Pareto² principle” or “80/20 rule” to this process has important implications. Identifying the sources of error or delay within each individual STEMI system and then prioritizing efforts to find precise solutions are important for efficient attainment of success.

At this level of “regionalization,” emergency physicians have the ability, knowledge, and leadership skills to lead the way in refining local STEMI systems. These highly efficient and interlinked local systems can then provide an effective starting point for complementary (not competing) larger-scale efforts.

The AHA fully recognizes the importance of these local efforts, and it is developing the tools, communication strategies, and networks to facilitate local-level regionalization. This complements current AHA efforts to provide a framework for national, state, and regional efforts. “Thinking globally and acting locally” will allow EM to help shape these efforts at all levels.

At times, the specialty of EM has been noted to be particularly sensitive to other specialties or authorities dictating or “recommending” guidelines on how we should best practice within our specialty. The AHA is clearly offering an alternative, inviting and encouraging EM to become as involved as we want to be and showcase what we do best.

With that in mind, we encourage you to become involved in Mission: Lifeline and offer your expertise in helping improve STEMI care for our friends, neighbors, and families. Take this opportunity to become involved through your local AHA affiliate or state chapter of ACEP and visit the Mission: Lifeline Web site at www.americanheart.org/missionlifeline.

In summary, Mission: Lifeline is a “calls to arms” for the specialty of emergency medicine. Our prominent participation will afford our specialty (and us as individuals) the opportunity to become involved (at multiple levels) in developing reasonable, evidence-based systems of care for STEMI patients in each community and throughout the United States.

References

1. AHA Consensus Statement: Recommendation to Develop Strategies to Increase the Number of ST-Segment-Elevation Myocardial Infarction Patients With Timely Access to Primary Percutaneous Coronary Intervention. Circulation 2006;113:2152-63.
2. Italian economist Vilfredo Federico Damaso Pareto observed in 1906 that 80% of the land in Italy was owned by 20% of the population. Joseph M. Juran, a pioneer in the field of quality management, suggested the principle that 80% of effects stem from 20% of causes and named it after Pareto.

This article was written by members of the American Heart Association’s ECC-STEMI Task Force, a key element of Mission: Lifeline. Dr. Robert O’Connor, chair of emergency medicine at the University of Virginia, leads the task force. Dr. Robert Solomon, medical editor-in-chief of ACEP News, is ACEP’s formal representative on the task force, which also includes several other emergency physicians.